SECTION I Aesthetic Surgery of the Face Surgical anatomy of the face, SMAS, facial spaces and retaining ligaments 79

6 Anatomy of the aging face

Bryan Mendelson and Chin-Ho Wong

intraoperative map for the surgeons to safely navigate to the SYNOPSIS area of interest to correct aging changes. This is most impor- ᭿ Aging of the face is a multifactorial process that can be explained tant in addressing the overriding concern, being the course of on an anatomical basis. the facial nerve branches. An anatomical approach to surgical ᭿ The face is constructed of five basic layers that are bound together rejuvenation of the face provides the way to obtaining a by a system of facial retaining ligaments. “natural” result that is lasting and with minimal morbidity. Fig. 6.1 Regions of the face. The mobile anterior face is functionally adapted for ᭿ To facilitate the mobility needed for facial expression independent facial expressions and is separated from the relatively fixed lateral face (shaded), of the basic functions of the face, particularly of mastication, a which overlies masticatory structures. A vertical line of retaining ligaments (red) separates the anterior and lateral face. These ligaments are, from above: temporal, series of soft tissue spaces are incorporated into the architecture Regions of the face lateral orbital, zygomatic, masseteric, and mandibular ligaments. In the anterior Fig. 6.2 The face is constructed of five basic layers. This five-layered construct of the face. face, the mid-cheek is split obliquely into two separate functional parts by the is most evident in the scalp but exists in the rest of the face, with significant ᭿ This arrangement, most clearly seen in the scalp, also exists in mid-cheek groove (dotted line) related to two cavities: the periorbital part above modification and compaction for functional adaptation. Layer 4 is the most The traditional approach to assessing the face is to consider the rest of the face, although with significant compaction and (blue) and the perioral part below (yellow). (© Dr Levent Efe, CMI.) significantly modified layer, with alternating facial soft tissue spaces and retaining the face in thirds (upper, middle, and lower thirds).2 While ligaments. Facial nerve branches also transition from deep to superficial in modifications. useful, this approach limits conceptualization, as it is not association with the retaining ligaments through layer 4. (© Dr Levent Efe, CMI.) ᭿ This chapter will describe, in detail, the five-layered construct of based on the function of the face. From a functional perspec- fascial layer for support. Accordingly, support does not come the face, including the spaces and retaining ligaments, and will tive, the face has an anterior aspect and a lateral aspect. The from within the cavity beneath, but from the rim of the cavi- highlight the relevance of these structures in the aging face. across the supraorbital rim, the scalp and the forehead are anterior face is highly evolved beyond the basic survival ties. The transitions between these areas, while not seen in firmly anchored by ligamentous attachments. Vital structures, ᭿ In addition, the profound impact of aging of the facial skeleton needs, specifically, for communication and facial expression. youth, become increasingly evident with aging. the nerves and vessels are always located in close proximity should be appreciated. In contrast, the lateral face predominantly covers the struc- to the retaining ligaments. In the face proper, while the prin- ᭿ 3 Understanding these principles will help not only in understanding tures of mastication. A vertical line descending from the ciples of construction remain the same, there is considerably the aging process but also in designing procedures that are logical lateral orbital rim is the approximate division between the Surgical anatomy of the face, SMAS, greater complexity. This is due to the compaction resulting and effective in reversing the stigmata of the aging face. anterior and lateral zones of the face. Internally, a series of from the absence of forward projection of the midface, as facial retaining ligaments are strategically located along this facial spaces and retaining ligaments occurs in other species, and the predominance of the orbital line to demarcate the anterior from the lateral face (Fig. 6.1). and oral cavities that limit the availability of a bony platform Introduction The mimetic muscles of the face are located in the superficial The soft tissue of the face is arranged concentrically into the 5,6 for attachment of ligaments and muscles. To secure the super- fascia of the anterior face, mostly around the eyes and the five basic layers : (1) skin; (2) subcutaneous; (3) musculo- ficial fascia to the facial skeleton, a system of retaining liga- Facial aging is a complex process that is the cumulative effect mouth. This highly mobile area of the face is designed to aponeurotic layer; (4) areola tissue; and (5) deep fascia. This ments bind the dermis to the skeleton, and the components of simultaneous changes of the many components of the face allow fine movement and is prone to develop laxity with five-layered arrangement is most clearly seen in the scalp and of this system pass through all layers (Figs 6.3, 6.4).7,8 as well as the interaction of these components with each other. aging. In contrast, the lateral face is relatively immobile as it forehead as a result of evolutionary expansion of the underly- The structure and composition of each of the 5 layers will An understanding of the anatomical changes associated with overlies the structures to do with mastication, the temporalis, ing cranial vault necessary to accommodate the highly devel- now be described in turn. aging is required in order to design effective procedures to masseter, the parotid gland and its duct, all located deep to oped frontal lobe in humans. Accordingly, the scalp is an rejuvenate various aspects of the aging face. Fundamental to the deep fascia. The only superficial muscle in the lateral face excellent place to study the principles of the layered anatomy understanding these changes is a firm grounding in the prin- is the platysma in the lower third, which extends to the level (Fig. 6.2). Layer 4 (the loose areolar tissue) is the layer that Layer 1: skin ciples on which the facial soft tissue layers are constructed.1 of the oral commissure. allows the superficial fascia (defined as the composite flap of This is important because the pathogenesis of facial aging is Importantly, the soft tissues of the anterior face are subdi- layers 1 through 3) to glide over the deep fascia (layer 5). The The epidermis is a cell-rich layer composed mainly of differ- explained on an anatomical basis, particularly the variations vided into two parts; that which overlies the skeleton and the simplified anatomy over the scalp gives the basic prototype entiating keratinocytes and a smaller number of pigment pro- in the onset and outcome of aging seen in different indi- larger part that comprises the highly specialized sphincters of layer 4. There are not any structures crossing this plane, ducing melanocytes and antigen-presenting Langerhans cells. viduals. Understanding the principles on which the facial soft overlying the bony cavities.4 Where the soft tissues overlie the which is essentially an avascular potential space. At the The dermis is the outer layer of the structural superficial fascia tissues are constructed is the basis for an accurate and reliable orbital and oral cavities they are modified, as there is no deep boundaries of the scalp along the superior temporal line and and comprises predominantly the extracellular matrix secreted ©2013, Elsevier Inc. All rights reserved. 80 SECTION I • 6 • Anatomy of the aging face Surgical anatomy of the face, SMAS, facial spaces and retaining ligaments 81

Fig. 6.3 The retaining ligaments of the face can Fig. 6.5 The density and strength of the retinacular cutis fibers in the subcutaneous be likened to a tree. The ligaments attach the soft layer varies in different areas of the face. Where it overlies the retaining ligaments, tissues to the facial skeleton or deep muscle fascia, the fibers are denser and oriented more vertically. In these areas, sharp release is passing through all five layers of the soft tissues. It usually necessary to raise a subcutaneous flap. In contrast, in areas overlying a fans out in a series of branches and inserts into the space, the fibers are less dense and oriented more horizontally. Here, it is relatively dermis. At different levels of dissection, it is given easy to elevate a subcutaneous facelift flap. (© Dr Levent Efe, CMI.) different names, such as the retinacular cutis in the A B subcutaneous layer and ligaments in the subSMAS compart mentalize the subcutaneous fat. These areas, such as level. (© Dr Levent Efe, CMI.) the so-called McGregor’s patch over the body of the zygoma, often require sharp release to mobilize. In between these Fig. 6.6 Topographical anatomy of layer 4 over the lateral face. Spaces (blue), The thinner the dermis, the more susceptible it is to qualita- retaining ligaments in layer 4 are located the soft tissue spaces ligaments (red) and the areas of important anatomy (stippled). The largest area tive deterioration aging changes. of the face, that facilitate the mobility of the superficial fascia of ligamentous attachment, the platysma-auricular fascia (PAF), dominates the posterior part of level 4 at the least mobile part of the face. The lateral face over the deep fascia. Where the subcutaneous fat overlies transitions into the anterior face at the vertical line of retaining ligaments. Layer 2: subcutaneous tissue a space, the retinacular fibers are less dense and orientated Immediately above and below the arch of the zygoma are the triangular-shaped more horizontally, as a result of which, the tissues tend to areas that contain the important anatomy proceeding from the lateral into the The subcutaneous layer has two components: the subcutane- separate with relative ease, often with just simple blunt finger anterior face. (© Dr Levent Efe, CMI.) ous fat, which provides volume, and the fibrous retinacular dissection (Fig. 6.5). This variation in the density and orienta- cutis that binds the dermis to the underlying SMAS.9 Of note, tion of the retinacular cutis fibers in the subcutaneous fat is lateral orbital thickening and the main zygomatic ligament at the retinacular cutis is the name given to that portion of the anatomical basis for the compartmentalization of the sub- its inferolateral border and the platysma at its upper border the retaining ligament that passes through the subcutaneous cutaneous fat into discrete compartments, described in detail by the lower masseteric ligament. The deeper muscles in layer 10,11 tissues. The amount, proportion and arrangement of each in Chapter 11.1. 3 provide greater functional control of the sphincters over the component vary in different regions of the face. In the scalp, bony cavities. For the upper third, these are the corrugators the subcutaneous layer has uniform thickness and consistency Layer 3: musculo-aponeurotic layer and procerus, and around the oral cavity, the elevators (zygo- of fixation to the overlying dermis. In contrast, in the face maticus major and minor, levator labii superioris, levator proper, the subcutaneous layer has significant variation in The muscles of facial expression are unique and fundamen- anguli oris), and the depressors (depressor anguli oris, depressor thickness and attachments. In specialized areas such as the tally different from skeletal muscles beneath the deep fascia labii inferioris) around the oral sphincter and the mentalis. eyelids and lips, this layer is significantly compacted such that because they are situated within the superficial fascia and fat may appear non-existent. In other areas, such as the nasola- they move the soft tissues of which they are a part. All muscles Layer 4 bial segment, it is very thick.4 In areas with thick subcu- of facial expression have either all or the majority of their taneous tissue, the retinacular cutis lengthens significantly, course within layer 3 and they are predominantly located over Layer 4 is the plane in which dissection is performed in predisposing its fibers to weakening and distension with and around the orbital and oral cavities. In the prototype subSMAS facelifts. It is an area of significant complexity and aging. Within the subcutaneous tissue, the overall attachment scalp, the occipital-frontalis moves the overlying soft tissue of contains the following structures: (1) soft tissue spaces; to the overlying dermis is stronger and denser than the attach- the forehead, while its undersurface glides over the subap- (2) retaining ligaments; (3) deep layers of the intrinsic muscles ment to the underlying SMAS.9 This is a result of the tree-like oneurotic space (layer 4). Layer 3 is continuous over the entire passing from their bone attachment to their more superficial arrangement of the retinacular cutis fibers (Fig. 6.3), with face, although for descriptive purposes, different names are soft tissue origin; and (4) facial nerve branches, passing from fewer but thicker fibers deep as its rises through the SMAS given to certain parts according to the superficial muscle deep to superficial. Functionally, a series of soft tissue spaces that progressively divide into multiple fine microligaments as within. It is called the galea over the scalp, the temporo- exist in layer 4 to allow independent movement of the peri- they reach the dermis. This explains why it is easier to perform parietal (superficial temporal) fascia over the temple, the orbital and perioral muscle of facial expressions over the deep subcutaneous dissection in the deeper subcutaneous level orbicularis fascia in the periorbital region, the superficial mus- fascia responsible for mastication directly beneath the muscles (just on the surface of the underlying SMAS) than more super- culoaponeurotic system (SMAS) over the mid- and lower face of facial expression.13 The retaining ligaments of the face are ficially nearer the dermis, as there are fewer retinacular cutis and platysma in the neck.5,12 strategically placed within the boundaries between the soft Fig. 6.4 Three morphological forms of retaining ligaments of the face. (© Dr Levent fibers and the subcutaneous fat here does not attach directly Within layer 3, the facial muscles themselves have a layered tissue spaces and functions to reinforce the boundaries (Fig. Efe, CMI.) to the outer surface of the underlying SMAS. configuration, with the broad, flat muscles forming the super- 6.6). In the lateral face, immediately in front of the ear, extend- Furthermore, the retinacular cutis fibers are not uniform ficial layer that covers the anterior aspect of the face. The ing 25–30 mm forward of the ear cartilage to the posterior by fibroblasts. Type I collagen is the most abundant protein. across the face, but vary in orientation and density according frontalis covers the upper, orbicularis oculi, the middle and border of the platysma, is a diffuse area of ligamentous attach- Other collagen types (III, V, VII), elastin, proteoglycans and to the anatomy of the underlying deeper structures. As will the platysma, and lower thirds, respectively. The muscles of ment, described by Furnas as the platysma auricular fascia fibronectins are present in smaller quantities. A rich vascular be apparent when the anatomy of the underlying Layer 4 is this layer have minimal direct attachment to the bone, stabi- (PAF).7 As no facial expression occurs here, the dermis, sub- plexus is an important component of the dermis. The thick- described, at the location of the retaining ligaments, the verti- lized to the skeleton at their periphery indirectly by the verti- cutaneous tissue, SMAS and the underlying parotid capsule ness of the dermis relates to its function and tends to be cally orientated retinacular cutis fibers are the most dense cally orientated retaining ligaments as noted earlier. The (layers 1–5) are bound together as an area of retaining liga- inversely proportionate to its mobility. The dermis is thinnest and are the most effective in supporting for the overlying frontalis is fixed along the superior temporal line by the supe- ment. Layer 4 is reduced to a layer of fusion here, without a in the eyelids and thickest over the forehead and the nasal tip. soft tissues and in so doing, forms boundaries that rior temporal septum, the orbicularis oculi laterally by the soft tissue space. The ligamentous character of this immobile 82 SECTION I • 6 • Anatomy of the aging face Facial spaces 83 area makes it surgically useful for suture fixation. Furnas had retaining ligament, which stabilizes the orbicularis oculi to the originally described the lower part of the PAF, the platysma orbital rim periosteum. Around the oral cavity where the auricular ligament,7 also named by Stuzin and colleagues, the boundary is less distinct, the ligaments arise mainly from the parotid cutaneous ligament5 and this ligament was subse- platform of the body of the zygoma, and from the deep fascia quently named the tympanoparotid fascia.14 The part of the over the masseter.15–17 PAF immediately in front of the lower tragus has been labeled, The deeper component of the eyelid and lips are derived Lore’s fascia.14 from the origin of the cavity and are not an extension of In contrast, in the anterior face where there is considerable the facial soft tissues. In the eyelid, the deeper lid muscles movement over and around the bony cavities, the ligaments with their related aponeurosis (levator and capsulopalpebral are significantly compacted and arranged around the edges fasciae) and fat are retained by the fascial system of the septum of the bony cavities. These boundaries provide the last posi- orbitale. The free edges of the upper and lower eyelids obtain tion where there is underlying deep fascia for the mobile their ligamentous support from the tarsal plates, with their shutters of the lids and lips to be supported. Importantly for canthal tendon attachments to the medial and lateral orbital the surgeon, the retaining ligaments also act as transition rims. In the pretarsal area, the superficial and deep lid struc- points for the facial nerve branches to pass from deep to tures, the anterior and posterior lamellae, merge. But between superficial, on their way to innervate their target muscles. the pretarsal area of the lid and the orbital rim the lamellae Soft tissue spaces of the face are in two forms: (1) those remain quite separate, i.e., the preseptal orbicularis does not overlying bony cavities, such as the preseptal space of the have an attachment to the septum orbitale. This is the ana- eyelid over the orbit and the vestibule of the oral cavity, under tomical basis for the, surgically significant, preseptal space of the lips and the lower nasolabial segment of the cheek and the lower lid. In the upper lid, there is not an equivalent space (2) those overlying the bone, where soft tissue spaces allow as the submuscular fat pad over the superior orbital rim con- the overlying superficial fascia to glide freely over the bone. tinues on the outer surface of the septum orbitale where it is adherent to the overlying fascia on the underside of the Layer 5 orbicularis almost down to where the levator crosses into the orbicularis. Fig. 6.9 The upper temporal space and the retaining ligaments of the temple. The The deep fascia, the deepest soft tissue layer of the face, is The extent of the vestibule of the oral cavity covering the boundaries of the space are the superior temporal septum (STS) and the inferior formed by the periosteum where it overlies bone. Over the maxilla and the mandible has a major impact on the suscep- temporal septum (ITS), which are extensions of the temporal ligament adhesion (TLA). No structures cross the temporal space. The TLA continues medially as the lateral face, where the muscle of mastication (temporalis and tibility to aging of the overlying soft tissue. The skeleton underlying the space is not available to provide ligamentous supraorbital ligamentous adhesion (SLA). Inferior to the temporal space is the masseter) overlie the bone, the deep fascia is instead the fascial triangular-shaped area of important anatomy (stippled). Crossing level 4 in this covering of the muscles, the deep temporal fascia above the attachment for support of the soft tissues that cover this large area are the medial and lateral branches of the zygomatic temporal nerve (ZTN) and zygomatic arch, and masseteric fascia below the arch. The Fig. 6.7 The anatomy over the skeleton and over bony cavities (1–5), showing area. The extreme mobility of the lip and adjacent part of the the sentinel vein. The temporal branches of the facial nerve (TFN) course on the parotid fascia is also part of the deep fascia. The investing the relationship of the soft tissue spaces to bony cavity spaces. (© Dr Levent Efe, cheek renders it susceptible to aging changes and the indica- underside of the temporal-parietal fascia over the area immediately inferior to the CMI.) deep cervical fascia is the corresponding layer in the neck tion for a lower facelift is largely to correct aging changes in inferior temporal septum. The periorbital septum (PS, green) is on the orbital rim at this unsupported tissue. the boundary of the orbital cavity. The lateral orbital thickening (LOT) and the lateral where it covers the supraomohyoid muscles and splits to form row thickening (LBT) are parts of the periorbital septum. SON, supraorbital nerve; the submandibular space that contains the submandibular ZFN, zygomaticofacial nerve. (© Dr Levent Efe, CMI.) gland. The deep fascia, although thin, is tough and unyielding and gives attachment to the retaining ligaments of the face. In Facial spaces the mobile shutters over the bony cavities, the deep fascia is the lower triangular shaped temporal area that contains absent, being replaced by a mobile lining derived from the A large part of the subSMAS layer 4 consists of soft tissue important anatomy, by the inferior temporal septum (ITS). cavities, that of the conjunctiva or oral mucosa. These septi merge at the triangular-shaped zone of adhesion “spaces.” These spaces have defined boundaries that are stra- 15 tegically reinforced by retaining ligaments.18 Significantly, called the temporal (orbital) ligament. The upper temporal these areas are by definition anatomically “safe spaces” to space provides safe surgical access to the lateral brow and Anatomy over the cavities dissect, as no structures crosses within and all branches of the upper mid-cheek. The space can be readily opened by blunt facial nerve are outside these spaces. As the roof of each space dissection to its boundaries. Once identified, the boundaries in the skeleton is the least supported part, it is more prone to developing are then released by precise sharp dissection. The superior laxity with aging, compared with the ligament-reinforced temporal septum can be released sharply, taking care only to The general pattern of the five-layered anatomy is modified preserve the lateral (deep) branch of the supraorbital nerve, boundaries. This differential laxity accounts for much of the 19 where the soft tissues overlie the orbital, oral and nasal cavi- characteristic changes that occur with aging of the face. Once which runs parallel to the septum about 0.5 cm medial to it. ties over the anterior face (Fig. 6.7). Only the outer three layers a space has been surgically defined to its boundaries, the The inferior temporal septum provides a marker to the impor- of the composite continue from the periphery as the soft tissue retaining ligaments in the boundary can then be precisely tant anatomy here as the temporal branches of the facial nerve over the cavities. The SMAS layer within this composite released under direct vision to achieve the desired mobiliza- are located parallel to and immediately inferior to this septum. includes the sphincteric orbicularis muscles that extend right tion, while preserving the vital structures closely associated To release the inferior temporal septum, the roof of the space to the free edge of the soft tissue aperture of the eyelids and with the ligaments. A brief description of surgically signifi- is gently lifted off the deep temporal fascia floor, which three- lips. The retaining ligaments, which are such a key feature of cant facial soft tissue spaces is given below. dimensionalizes the septum in preparation for its gentle the five-layered anatomy, are not present over the cavities. release at the level of the floor, bearing in mind the frontal There are thus anatomical variations associate with thee func- Upper temporal space branches are located under the roof of the lower temporal area tional transitions from the relative stability of the “fixed” where they travel in the ceiling within the layer of fat sus- areas to the high mobility of the soft tissue shutters over the The upper temporal space separates the temporoparietal pended on the underside of the temporoparietal fascia. Once cavities. At the transition, to support the shutters, the retain- fascia (superficial temporal fascia) from the (deep) temporal released, the sentinel vein comes into view. The sentinel vein ing ligaments are condensed along the bony orbital rim (Fig. fascia and is separated from the forehead by the superior tem- is not a good landmark for locating the temporal branches as 6.8). This is the anatomical basis for the periorbital ligament Fig. 6.8 The system of retaining ligaments situated around the bony cavities poral septum (STS) along the superior temporal line (Fig. 6.9). they course cephalad to the vein, that is, inferior to the inferior around the orbit, of which the lower lid part is the orbicularis stabilizes the soft tissue over the cavities. (© Dr Levent Efe, CMI.) Anteroinferiorly, the upper temporal space is separated from temporal septum. This anatomy is also reviewed in Chapter 7. 84 SECTION I • 6 • Anatomy of the aging face Facial nerve branches 85

being less firmly bound to the masseter. This allows the space surgical transection of the SMAS here, so-called high SMAS to enlarge and also allows the buccal fat to prolapse inferiorly, transection (i.e., at or above the arch) has been generally dis- below the level of the commissure into the lower face. As the couraged. It is now apparent that the nerve is deeper than was buccal fat comes to overlie the anterior border of the lower previously thought as it crosses the zygomatic arch.30 A histo- masseter it results in increased prominence of the labioman- logical study confirmed that the frontal branches are in transi- dibular fold and jowl. tion from where they exit the parotid below the zygomatic arch, to where they enter the underside of the temporoparietal fascia some 2 cm above the arch. They course in a tissue layer Facial nerve branches (layer 4), just deep to the temporoparietal fascia (layer 3) and immediately superficial to the periosteum and above that, the The danger zone for facial nerve injury has been well described temporalis fascia (layer 5), all along protected by a fascial, in the literature, but is of limited value to the surgeon due to fatty layer, which is an upward prolongation of the parotid- the two-dimensional perspective that gives the expected masseteric fascia and named the parotid-temporal fascia.27 course of the nerve relative to surface landmarks.22–24 Another study noted the temporal branch to transition to Confidence when approaching the nerve surgically comes under the temporoparietal fascia (layer 3) at a distance of from an understanding the three-dimensional course of the 1.5–3 cm above the zygomatic arch.31 The temporal branch nerve relative to the layered anatomy as described above and completes the transition to the underside of the temporopari- visually identifying the nerves in relation to defined land- etal fascia well before the nerve crosses cephalad to the senti- marks (Fig. 6.12). The facial nerve branches exit the parotid nel vein.15 Accordingly, once the sentinel vein is visualized gland and remain deep to layer 5 in the lateral face. As they from the temporal aspect, the temporal branches would approach the anterior face, the branches traverse layer 4 to already be located in the roof of the lower temporal area. reach the underside of mimetic muscles of the face. It is at The zygomatic branch exits the parotid gland deep to the Fig. 6.11 The rhomboidal-shaped premasseter space overlies the lower half of the these transition points across layer 4 that the nerves are at deep fascia just below the zygoma and cephalad to the parotid masseter. The roof of the space is formed by the platysma. The posterior border is greatest risk of injury.1,25 The transitions occur at predictable duct. It travels horizontally on the masseter with the trans- defined by the anterior edge of the strong PAF and the anterior border is reinforced locations, in close association with retaining ligaments that verse facial artery.32,33 At the lateral border of the origin of by the masseteric ligaments near the anterior edge of the masseter. The inferior zygomaticus major muscle is the substantive zygomatic boundary is mesenteric-like and does not contain any ligament. Weakness of provide stability and protection for the nerves. The surgical attachment of the platysma roof at the inferior boundary leads to the formation release of these ligaments to gain the needed mobility should retaining ligament (that attaches to the body of the zygoma). of the jowl directly behind the strong mandibular ligament. The buccal space be performed with extreme care on account of the proximity At the lateral border of zygomaticus major, after a branch containing the buccal fat is anterior to the upper masseteric ligaments. All facial of the nerves. is given off to supply the orbicularis oculi, entering the nerve branches course around and outside the space. The surgically important The surface marking of the temporal branch of the facial muscle at its inferolateral corner, the zygomatic nerve con- mandibular branch, after leaving the fixed PAF, courses under the inferior boundary Fig. 6.10 The prezygomatic space overlies the body of the zygoma. The origin nerve is along the Pitanguy line, from a point 0.5 cm below tinues medially and then transitions to the underside of the of the space, then rises onto the highly mobile outer surface of the mesenteric the tragus to a point 1.5 cm lateral to the supraorbital rim.26,27 muscles it innervates zygomaticus major and minor, and of the zygomatic muscles extends under the floor. The roof is formed by the inferior border before reaching the mandibular ligament. (© Dr Levent Efe, CMI.) orbicularis oculi line by the suborbicularis oculi fat (SOOF). The upper ligamentous It is traditional teaching that once the temporal branch exits supplies them from the deep aspect in close association border formed by the orbicularis retaining ligament is not as strong as the the parotid, it immediately runs superficially from the deep with the zygomatic ligaments. Careful dissection by vertical zygomatic ligament reinforced lower border. (© Dr Levent Efe, CMI.) fascia and comes to lie just deep to the SMAS as it crosses the spreading of the scissors is crucial to avoid damaging this arch of the zygoma.5,28,29 Because of its superficial location, branch here.16,24,34 Prezygomatic space plane allows opening of the jaw without restriction and avoids The upper buccal trunk exits the parotid, about in line with, excessive distortion of the overlying soft tissues. The roof of but superficial to, the parotid duct and continues deep to the This triangular-shaped space overlies the body of the zygoma, this space is formed by the platysma. The lower premasseter investing masseter fascia. Approaching the anterior edge of its floor covering the origins of the zygomatic muscles. The space has profound clinical significance, as it is the anatomical the masseter, this branch leaves the floor under the masseter space allows the independent displacement of the orbicularis basis for the development of jowls with aging. Laxity in the fascia in close association with the upper key masseteric liga- 5,35 oculi (pars orbitale) in the roof from the zygomatic muscles roof of the space, particularly where it has a weakened attach- ment. The lower buccal trunk leaves the parotid lower under the floor. Contraction of the overlying orbicularis ment to the anterior masseter by the masseteric ligaments and down, at about the level of the earlobe and remains under the elevates the prezygomatic soft tissues, which results in its inferior boundary where there is no ligament, manifests as masseter fascia as it crosses under the floor of the premasseter zygomatic smile lines (below the crow’s feet) (Fig. 6.10). With the labiomandibular fold and jowl, respectively. The relatively space . Similarly, upon approaching the anterior edge of the the laxity of aging the roof of the space rests at a lower level stable fixation at the anteroinferior corner of the premasseter masseter, in the upper membranous boundary of the premas- than in youth. As a result, there is a now a greater amplitude space provided by the mandibular ligament accounts for the seter space, the lower buccal trunk transitions from deep to of movement on orbicularis contraction that has the effect of dimple that is commonly seen separating the labiomandibular gain the underside of the SMAS in close association with the 18 exaggerating the zygomatic lines with aging.13,16 This aging fold above and the jowl below. upper surface of the lower key masseteric ligament. After of the prezygomatic space, with bulging over its roof accen- the nerves reach level 3, the zygomatic, upper and lower tuated by its well-supported boundaries, is the anatomical Buccal space buccal trunks, and mandibular branch connect with each basis for the clinical entity variously described as malar other before continuing their course to innervate the mimetic mounds, bags or malar crescent. These deformities indicate This is one of the deep facial spaces, being, like the sub- muscles. This accounts for the overlap in muscles innervated the presence of significant laxity and the treatment is directed mandibular space (which contains the submandibular gland), by these nerves. to tightening the laxity of the roof and upper ligamentous deep to the deep fascia (layer 5). The buccal space is located The temporal and mandibular branches are the most sig- boundary. in the anterior face, medial to the anterior border of the mas- nificant in terms of surgical risks because of the lack of cross seter above the level of the oral commissure in youth.20,21 The innervation of their target muscle. The marginal mandibular space and its contents, the buccal fat, facilitates movement of nerve is at risk where it is fixed by its close association with Premasseter space Fig. 6.12 The relationship between facial nerve branches, spaces and retaining the overlying nasolabial segment of the mid-cheek as well as ligaments. The nerves stay deep to and outside of the spaces at all times in the the retaining ligaments. Early in its course, around the angle This space overlies the lower half of the masseter and is analo- buffering this area from excessive motion from jaw move- lateral face. In the boundary between the lateral and anterior face, the facial nerve of the mandible, this is within the PAF, and then well anteri- gous to the temporal space, in that it overlies the deep fascia ment. Aging and attrition of the boundaries, particularly of branches transition from under layer 5 to enter layer 3, always in close association orly by the mandibular ligament. Over most of its course, the of a muscle of mastication (Fig. 6.11).18 This gliding soft tissue the masseteric ligaments inferiorly result in the platysma with the retaining ligaments of the face. (© Dr Levent Efe, CMI.) mandibular branch is mobile, being in relation to the inferior 86 SECTION I • 6 • Anatomy of the aging face Facial spaces and retaining ligaments 87 boundary of the premasseter space. It is not necessary to fibroblasts and decreased levels of collagen (especially types dissect in the vicinity of the nerve because of the inherent I and III) and elastin in the dermis. While chronological mobility of the platysma where it overlies the jaw and sub- skin aging and photo-aging can be readily distinguished mandibular area. The mobility of the nerve as it travels within and considered separate entities, both share important the inferior membranous boundary of the lower premasseter molecular features, that of altered signal transduction that space accounts for the reported variability of the location of promote matrix-metalloproteinase (MMP) expression, decr- this part of its course (occasionally below the mandible).36–38 eased pro-collagen synthesis and connective tissue damage. Oxidative stress is considered of primary importance in driving the aging process, resulting in increased hydrogen Aging changes of the face peroxide and other reactive oxygen species (ROS) and decreased anti-oxidant enzymes.42,43 These changes result in gene and protein structure alterations. Other environmental The youthful face has the general appearance of high rounded Fig. 6.13 In youth, the spaces are tight. The factors notably smoking accelerates skin aging, by between 10 fullness, while the aging process is characterized by a look of retaining ligaments are stout and the transition and 20 years.44 Increased collagenase and decreased skin cir- depletion and sagging, suggestive of tiredness. Changes with between spaces is not discernible. With aging, culation has been suggested as possible mechanisms. The aging occur at every level of the facial anatomy, starting with spaces expand to a greater extent than the laxity muscles of facial expression flex the skin in a specific pattern. that develops in ligaments within their boundaries, the facial skeleton. A key unresolved question is how much As the underlying collagen weakens and the skin thins, resulting in bulges between areas of relative of the change at each level is intrinsic aging and how much is the dermis loses its capacity to resist the constant force of fixations. These spaces open with relative ease with secondary to the changes from adjacent layers. This is not easy the muscles and these lines become etched in the skin and blunt dissection. (© Dr Levent Efe, CMI.) to quantitate due to the difficulties of measurement of a single ultimately even at rest. layer in the context of the complicated and interrelated layered structure. Current understanding of the aging process remains Subcutaneous tissue largely empirical, given that it is based on the effectiveness of treatments designed to satisfy the requirements of patients The fibrous and fat components in the subcutaneous tissue Facial spaces and retaining ligaments for a younger appearance. Historically, stretching of loose are not a uniform but arranged in discrete compartments.10 facial skin (traditional facelift), removal of apparent tissue Over specific sites, due to the prominence of the subcutaneous The multi-linked fibrous system attenuates with aging, with excess (traditional blepharoplasty), tightening the dermis and fat it has been given specific names such as the malar fat pad decreasing strength of the ligaments and increasing laxity. The evening the complexion (early phenol peels and CO2 laser and nasolabial fat. The boundary of these subcutaneous com- spaces expand with aging as well, to a greater extent than the resurfacing) and, in recent years, soft tissue volume augmen- partments corresponds to the location of the retaining liga- laxity that develop in the ligaments within their boundaries, tation (lipofilling and soft tissue fillers) have all had a positive ments, which pass superficially to insert into the dermis. In resulting in bulges between areas of relative fixations.18 impact on rejuvenating appearance. The success of each is youth, transition between compartments is smooth and non- Accordingly, the spaces dissect easily in older patients, and attributed to having reversed a cause of facial aging. Yet, discernible. With aging, a series of concavities and convexities the boundaries widen as the ligaments weaken.13 In young when each of these modalities is continued as the sole treat- develop which separates these compartments. These changes people, the spaces are more potential that real and do not ment, to further reverse the aging appearance, the results tend have been attributed to a number of causes including fat open quite so easily with blunt dissection (Fig. 6.13). to be bizarre, leading to the conclusion that multimodal descent, selective atrophy and hypertrophy and attenuation therapy is required to further reverse, what must be, multiple of the retaining ligaments that causes fat compartments mal- components of the aging process. positioning.9,10,45,46 It is now apparent that fat descends mini- Bone changes An understanding of the changes that occur in the layered mally with aging.47 As noted the subcutaneous fat is not a The facial skeleton changes dramatically with aging (Fig. 6.14) anatomy forms the basis for logical treatment. Changes of the confluent layer that can descend with aging. Distinct compart- and this has a profound impact on the appearance of the face skin are readily observable and changes in the skeleton effect- mentalization by the retaining ligaments holds the fat in its with aging (Fig. 6.15). At birth, the facial skeleton is under- ing layer 5 can also be observed radiologically. Because the relative positions. developed and rudimentary. This explains why infants and changes within the superficial fascia (layers 2 and 3) are not toddlers often transiently have distinct mid-cheek segments directly measurable, empiricism has remained prevalent. A (despite excellent tissue quality), which disappear as they correlation of the surface anatomy changes of aging with the Muscle aging grow older with the expansion of the mid-cheek skeleton.51 anatomy of layers 2, 3, and 4 indicates that bulging occurs Skeletal muscles, in general, have been noted to atrophy up Peak skeletal projection is probably attained in early adult- over the roof of soft tissue spaces, which stand out in contrast to 50% with age.48 This may be applicable to the muscle of hood. Thereafter, while certain areas continue to expand,4,52–55 to the absence of bulging of the adjacent cutaneous grooves. mastication such as the temporalis and masseter (compounded selective areas of the facial skeleton undergoes significant The grooves reflect the restriction imposed by the dermal by the decreased demand and deterioration of the dentition resorption. Areas with strong predisposition to resorption insertions of the retaining ligaments at the boundaries of the with aging) although no specific study on the effect of aging include the superomedial and inferolateral aspects of the spaces. The degree to which the bulging reflects true elonga- on these muscles has been done to date. The mimetic muscle orbital rim, the midface skeleton, particularly that part con- tion from primary tissue degeneration and laxity and how of the face, in contrast to skeletal muscles, may not undergo tributed by the maxilla including the pyriform area of the nose much it is ‘apparent’ laxity secondary to loss of volume (skel- Fig. 6.14 Arrows indicate the areas of the craniofacial skeleton that are susceptible the same degree of degeneration with aging because of their and also the prejowl area of the mandible.56–64 The resultant etal and soft tissue) remains unanswered. to resorption with aging. (© Dr Levent Efe, CMI.) constant use with facial expression. The orbicularis oculi has deficiencies in the skeletal foundation have a significant effect been noted to remain histologically unchanged with no loss on the overlying soft tissues. In the mid-cheek in particular, Skin of muscle fibers aging.49 The upper lip elevators, zygomaticus retrusion of the maxilla causes increased prominence of the of tissue descent with aging. Some patients have a congeni- major and levator labii superioris were also noted to remained tear-trough and the nasolabial folds.59 The retrusion of the tally weak or inadequate skeletal structure. In such cases, the Skin aging is influenced by genetics, environmental exposure, unchanged with aging, based on magnetic resonance imaging facial skeleton causes the origin of the multi-linked fibrous skeleton may be the primary cause of the manifestations of hormonal changes and metabolic processes.39–41 With aging, (MRI) of their length, thickness and volume.45 In contrast, the retaining ligaments to be displaced posteriorly. This pulls the premature aging. Accordingly, patients who suffer premature the supple skin of youth becomes thinned and flattened, with upper lip orbicularis atrophies with aging, with decreased skin inwards, exaggerating the concavity between the areas facial aging, a weakness of the relevant part of the underlying loss of elasticity and architectural regularity. Atrophy of the muscle thickness, smaller muscle fascicles and increase in of relative convexity that develop with aging. Retrusion of the skeleton is immediately suspect and should be addressed in extracellular matrix is reflected by the decreased number of surrounding epimysium.50 mid-cheek with loss of projection gives the visual impression order to obtain better aesthetic results. 88 SECTION I • 6 • Anatomy of the aging face Considerations for correcting aging changes of the face based on the anatomy of the aging face 89

orbicularis oculi act in concert to depress the medial brow and explained by difference in the tissue layers. In level 4, the produce oblique glabella frown lines. The procerus, also a orbicularis retaining ligament is not rigid where it is over the brow depressor causes transverse nasal skin lines. Laterally, center of the inferior orbital rim, so distension results in rela- the action of the lateral fibers of the orbicularis oculi with the tive sliding between it and layer 3, the orbicularis oculi. As transverse head of the corrugator supercilii promotes lateral the lid-cheek junction becomes more prominent, it visually brow ptosis. The ptosis of the lateral brow together and to a takes over from the infratarsal groove and becomes the new lesser extent, the laxity of the skin with aging produces separation between the lower eyelid and the cheek. This is the a pseudoexcess of the upper eyelid skin. Frontalis muscle basis for the commonly used but misleading phrase “length- hypertonicity from lateral brow skin hooding and its reaction ening of the lid cheek junction with aging”, which is in fact to the action of antagonistic muscles (corrugator supercilii, the result of a visual shift from the prominence of the infra- orbicularis oculi and procerus) results in the development tarsal groove in youth to the lid-cheek junction with age. of transverse forehead skin lines.18,65 The medial brow in con- Correction of the aging of the lid cheek segment of the mid- trast, seldom descends with aging and in fact, may rise.66,67 cheek, the visibly descended contour of the lid cheek junction The mechanism responsible for this includes the chronic acti- and long lower lid, has gained the colloquial name of “blend- vation of the frontalis muscle. This may either be to elevate ing the lid cheek junction.” the brow/eyelid complex associated with clinical or subclini- cal levator system weakness or to relieve visual field obstruc- Lower face tion due to excess lateral upper eyelid skin.65 Anatomically, the frontalis muscle ends at approximately the temporal The jowl and the labiomandibular fold in the lower face are fusion line (superior temporal septum). Lateral to this, there not present in youth, and develop with aging. With the is no upward vector to counteract the downward pull of brow description of the concept of soft tissue spaces of the face, and depressors and gravity on the lateral brow. This may explain specifically the premasseter space, the mechanism for the for- why descent preferentially occurs at the lateral brow. Fig. 6.16 The mid-cheek has three segments, the lid-cheek segment (blue) and mation of the jowl can now be understood on an anatomical the malar segment (green) are within the periorbital part and are adjacent to the basis.68 With the onset of aging, laxity develops in the roof of The mid-cheek nasolabial segment (yellow) in the perioral part, which overlies the vestibule of the premasseter space associated with attenuation of the ante- the oral cavity. The three grooves define the boundaries of the three segments rior and inferior boundaries. The major retaining ligaments 4 and interconnect like the italic letter Y. The palpebromalar groove (1) overlies the The mid-cheek is the anterior part of the midface. It is trian- (the key masseteric and mandibular) in contrast remain gular in shape and bounded superiorly by the pretarsal part inferomedial orbital rim and the nasojugal groove (2) which overlies the inferolateral orbital rim, then continues into the mid-cheek groove (3). (© Dr Levent Efe, CMI.) relatively strong and at these locations the superficial fascia of the lower eyelid, medially by the side of the nose and remains firmly fixed to the underlying deep fascia. Distension the nasolabial groove below, and laterally around the lateral of the weaker masseteric ligaments at the anterior border of cheek where the arch of the zygoma meets the body. A smooth cheek), now becomes revealed, especially the underside of the the lower premasseter space (below the key masseteric liga- rounded mid-cheek is a powerful image of youth and gives a lid fat bulge over the middle part. The visual impression is of ment) and inferior displacement of the buccal fat (within the 47 certain freshness to the face. With aging, the three mid-cheek a ‘lengthened’ lower lid. At the same time, the increased buccal space) is the anatomical basis for the development of segments become clearly discernible, as they become sepa- thickness of the soft tissue mass over the lower cheek tends the labiomandibular fold. The mandibular ligament demar- rated by the three cutaneous grooves of the mid-cheek; the to conceal the degree of maxillary resorption and gives the 4 cates the transition from the labiomandibular fold above and nasojugal, palpebromalar and mid-cheek grooves. This ‘seg- profound visual impression that the soft tissue mass has the jowl below. The jowl develops as a result of distension of Fig. 6.15 The darker areas denote areas of greatest bone loss. Note how the mentation’ of the mid-cheek has a profound impact on appear- descended into the lower part of the mid-cheek. the roof of the lower premasseter space with resultant descent stigmata of aging as manifested by the facial soft tissues correspond to the areas ance that is responsible for giving the ‘tired’ look we associate Of the three segments of the mid-cheek, the lower lid of weakened skeletal support due to bone loss. (© Dr Levent Efe, CMI.) of the tissues below the body of the mandible. The more with aging. segment changes the most dynamically with aging. It has two prominent the jowl, the more apparent will be the cutaneous The soft tissues of the mid-cheek are structurally composed distinct grooves across its surface, which vary in their expres- tethering provided by the mandibular ligament. Accordingly, of three segments or “modules”, with each overlying a spe- sion during the aging process, often co-existing. The upper is the anatomical solution to correcting these aging changes is Regional changes observed with cific part of the mid-cheek skeleton (Fig. 6.16). The lid-cheek the infratarsal groove at the junction of the pretarsal and to reduce the inferiorly displaced buccal fat and to tighten the segment overlies the prominence of the inferior orbital rim, preseptal parts of the eyelid. The groove is defined by the roof of the premasseter space. the aging face the malar segment overlies the body of the zygoma and the lower boundary of the pretarsal muscle bulge. The pretarsal nasolabial segment overlies the anterior surface of the maxilla. bulge in youth is the visual separation of the lid above and Temple and forehead The skeletal foundation of the mid-cheek borders the three the cheek below. This so-called “high lid-cheek junction” is bony cavities of the anterior face, the orbital, nasal and oral located well above the infraorbital rim and is a characteristic Considerations for correcting aging The skin of the temple differs from that of the forehead, being cavities. Because of the many spaces and limited bony support of youth. The infratarsal groove location does not change with changes of the face based on the thinner and less firmly supported to the underlying layers. available, the mid-cheek has some intrinsic structural weak- aging, although its contour usually fades. The lower groove The loose attachment reflects the underlying temporal space, nesses. Three factors make the mid-cheek susceptible to aging is the lid-cheek junction that relates to the lower edge of the anatomy of the aging face which is extensive, and the nature of the surrounding tempo- changes. These are: (1) the wedge shape of the soft tissue preseptal part of the lid. It is not usually present in youth and ral ligaments that are septal like and do not continue through of the mid-cheek, which are thin above and thicker below; appears with aging and then progressively deepens and Dissection planes the thin, loose subcutaneous layer over the temple to fix to the (2) the natural posterior incline of the mid-cheek skeleton, descends slightly over time. Its shape when it first appears is dermis as do facial ligaments elsewhere. This explains why from the relative prominence of the infra-orbital rim; and a gentle C contour but as it “descends”, particularly in its The subcutaneous plane of dissection (level 2) is the most com- deep layer procedures in the temple are not as effective in (3) the significant retrusion as a result of resorption of the central portion, its shape changes to a progressively more monly used plane in facelifts, either in isolation or more com- toning the overlying skin as they are, for example, in the maxilla with aging. This is not uniform, as the maxilla recedes angulated V shape with the medial side being formed by the monly with some form of SMAS management from the cheek. more medially and inferiorly.58–61 With early aging, the retru- developing nasojugal groove and the lateral side by the palpe- superficial aspect (Fig. 6.17).69–71 A distinction should be drawn Corrugator muscle contraction is associated with the sion of the maxilla, along with a slight descent of the wedge bromalar groove. The center of the V, the lowest and deepest between subcutaneous dissection over the lateral face from emotional states of grief and sadness.65 The transverse head shaped cheek soft tissue results in an appreciable reduction part has the nasojugal groove continuing down the cheek as that over the anterior face. This plane of dissection is per- of corrugator supercilii moves the eyebrow medially and of volume of the upper cheek. The result is that the small the mid cheek groove that separates the cheek into the malar ceived to be “safe” as dissection remains superficial to the produce vertical glabella lines. The oblique head of the cor- amount of orbital fat over the prominent edge of the infraor- and nasolabial segments. The reason why this contour demar- facial nerve branches at all times and is the main appeal of rugator, the depressor supercilii and the medial fibers of the bital rim, (originally concealed by the volume of the upper cation changes while the skin itself does not descend is level 2 dissection. The subcutaneous dissection can be 90 SECTION I • 6 • Anatomy of the aging face Summary 91

orientated, dislodge out of the way, unaffected by the control- and tenacity of the superficial fascia is not uniform. The areas led stretching. The subSMAS spaces can be used to safely where the retaining ligaments are located have inherent liga- and atraumatically access various part of the face, the mentous reinforcement, making them ideal for suture place- deep temporal space to the lateral brow,13 the preseptal space ment. It is also the location in which traction gives the most to the lower eyelid, and the prezygomatic space to the natural appearance, as these are the natural suspension sites mid-cheek.15,16 of the face. Accordingly, the suture fixation should be placed Level 5: subperiosteal “lifts” have the appeal of safety as far where the retaining ligaments are located. Where fixation as the facial nerve risk is concerned as they are superficial and sutures are placed in the anterior face in subSMAS surgery, the remote nerves never cross this plane.77–79 However, there they function as replacements for the retaining ligaments that are inherent limitations to subperiosteal lifts.. The accumu- have weakened or have been divided in order to mobilize the lated aging changes across all five layers are elevated as part composite flap. Accordingly, the replacement sutures should of the subperiosteal lift. Overcorrection is required to effect replicate the quality of support provided by the original liga- the desired changes of soft tissue shape and skin tone, to ments as the “mobile” spaces remain. In this respect braided compensate for the “lift-lag” phenomenon, which is in pro- permanent sutures are advantageous as they stimulate colla- Fig. 6.17 Alternative levels for dissection and portion to the soft tissue thickness and laxity. Accordingly, gen and elastic deposition within the suture similar to a liga- redraping in facelifts. Dissection can be performed subperiosteal lifts work best in areas where the layers are ment.81 The platysma auricular fascia, a diffuse ligamentous through any one of three alternative layers, namely more compacted as the lift-lag is minimized. An example area on the lateral face, provides an ideal area both anatomi- subcutaneous (level 2), subSMAS (level 4) and being in the brow where subperiosteal lifts are effective and cally and physically to fix the facelift flap, due to its inherent subperiosteal for the upper two-thirds of the face. 80 (© Dr Levent Efe, CMI.) popular. Where the layers are thicker, such as the nasolabial strength. segment of the mid-cheek, the lift-lag phenomenon signifi- cantly limits the improvement that can be achieved. Because performed either in the superficial subcutaneous or deep sub- of the unyielding nature of the periosteum, extensive under- cutaneous level. In the former, there is more density of the mining beyond the target area is needed or alternatively a Summary retinacular cutis fibres as the multi-linked ligaments branches “periosteal release” immediately beyond the area that requires out before inserting into the dermis. In the latter on the outer lifting to isolate the area to a limited island of periosteum This chapter has been structured to assist the reader to develop surface of the SMAS, there are fewer fibres, which tend to be a conceptual understanding of facial anatomy and how it thicker and stronger. The deep subcutaneous layer is not Placement of sutures changes with aging. It is the framework that unifies the uniform in its tenacity: some areas, as over the facial spaces 2 detailed anatomical information now available in the litera- are inherently easier to dissect, while others that overlie the While adequate surgical release is needed for mobility, it is ture. Once understood, this knowledge provides the anatomi- ligament are more adherent and require sharp release.7,72 For 1 the surgical fixation that achieves the desired effect by holding cal foundation for the logical and sound selection of surgical example, over the malar eminence at McGregor’s patch, the mobilized soft tissue in its new position.76 The strength techniques for rejuvenation of the aging face. where the zygomatic ligaments are located, sharp release is 3 often needed as is required over the mandibular ligament. In contrast, in the lower face over the premasseter space, the subcutaneous layer separates quite readily, requiring only Access the complete references list online at http://www.expertconsult.com blunt finger dissection. SubSMAS dissection (level 4): in the scalp, this is the pre- 4. Mendelson BC, Jacobson SR. Surgical anatomy of the 14. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy ferred tissue plane for dissection as the scalp readily separates mid-cheek; facial layers, spaces, and mid-cheek of the ligamentous attachments in the temple and from the underlying periosteum (level 5) through the avascu- Fig. 6.18 Using the facial spaces for safe and anatomical access to subSMAS segments. Clin Plast Surg. 2008;35:395–404. periorbital regions. Plast Reconstr Surg. 2000;105(4): lar areolar tissue with ease and inherent safety. Bruising and dissection in facelifts. (1) Premasseter space. (2) Prezygomatic space. (3) Upper 5. Stuzin JM, Baker TJ, Gordon HL. The relationship of 1475–1490. temporal space. swelling is kept to a minimum because of this anatomy. In the the superficial and deep facial fascias: relevance to A thorough description of the retaining ligaments of the face proper, while the anatomical principles remain the same, rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3): temporal and periorbital regions is given. The term level 4 is potentially the most risky plane to dissect because the PAF intact is that it is strong and can be used for suture 441–449. “ligamentous adhesion” is introduced to increase the 75 of the facial nerve branches which transition through this fixation. Once dissection has proceeded beyond the PAF A discussion of the concept of facial soft tissue being arranged understanding of the system, and there is emphasis on the level, from level 5, to supply the facial muscles in level 3. (indicated by the posterior border of the platysma), the SMAS in concentric layers, and the SMAS as the “investing” layer relations of the temporal branch of the facial nerve and the However, it should be noted that similar to the situation in should then be incised to gain direct access into the lower of the superficial mimetic muscles of the face. The relationship trigeminal branches to structures visualized in surgery rather the scalp where raising the flap at level 4 gives a robust and premasseter space. The space can then be opened by gentle between the deep and superficial fascias is described, with than to less useful landmarks which are not. A discussion of structurally integrated composite flap that can be effectively blunt dissection only, to define the boundaries of the space. acknowledgement of “areola” planes and areas of dense age related changes to the region compliments one of surgical tightened, subSMAS dissection in the face has the same The premasseter space below and the prezygomatic space approach with respect to the anatomy described. 73,74 fibrous attachments, including true osteocutaneous ligaments advantages and potential benefits. Dissection can be per- above form a series of spaces in the anterior face (Fig. 6.18). and other coalescences representing the retaining ligamentous 16. Mendelson BC, Muzaffar AR, Adams WP Jr. Surgical formed safely in level 4 by applying the understanding of the The boundaries of the spaces, reinforced by retaining liga- boundaries of the face. Age-associated laxity of the retaining anatomy of the mid-cheek and malar mounds. Plast three-dimensional anatomy of the face described earlier; the ments, are where the important anatomy is located. These ligament was noted to be a key component of facial aging. Reconstr Surg. 2002;110(3):885–911. key being the facial spaces, which provide safe access through need to be precisely released to eliminate their tethering effect this layer. Because these spaces are ‘pre-dissected’, access is on the soft tissues,76 which is more difficult in younger patients 7. Furnas DW. The retaining ligaments of the cheek. Plast 18. Knize DM. Anatomic concepts for brow lift procedures. quick, atraumatic, and easy. An example of this is the lower as the ligaments are denser and stronger. Clear visualization, Reconstr Surg. 1989;83:11. Plast Reconstr Surg. 2009;124(6):2118–2126. premasseter space. Subcutaneous dissection is performed to optimized by lifting the opened adjacent facial spaces, is ben- 10. Rohrich RJ, Pessa JE. The fat compartments of the face: 68. Mendelson BC, Freeman ME, Wu W, et al. Surgical approximately 30 mm anterior to the tragus through the zone eficial. When blunt scissors are used with gentle vertical anatomy and clinical implications for cosmetic surgery. anatomy of the lower face: the premasseter space, the of fixation, the platysma auricular fascia (PAF), where the spreading of the blades the surrounding fat and areolar tissue Plast Reconstr Surg. 2007;119(7):2219–2227. jowl, and the labiomandibular fold. Aesthetic Plast Surg. SMAS is fused to the deep fascia including the parotid capsule. separate to reveal the ligaments and the facial nerve branches 13. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical 2008;32 (2):185–195. Because the objective of the surgery is to correct laxity in the in relation to them. With further lifting, the ligaments become anatomy of the ligamentous attachments of the lower Introduces the concept of the “premasseter” space, mobile anterior face, the level of dissection used in the lateral more certainly defined as they tighten further, at which time lid and lateral canthus. Plast Reconstr Surg. 2002;110(3): age-related changes, and utility for safe subSMAS face is of secondary importance. A further benefit of leaving they can be safely released while the nerves, being obliquely 873–884. dissection. Distinction is made between this space, 92 SECTION I • 6 • Anatomy of the aging face References 92.e1

over the lower part of the masseter, and another space This article highlights the importance of adequate release periorbital regions. Plast Reconstr Surg. 2000;105(4): overlying the upper part of the masseter where the of retaining ligaments of the SMAS in repositioning of the References 1475–1490. neurovascular structures, the accessory lobe of the parotid composite flap. Inadequate release can lead to suboptimal A thorough description of the retaining ligaments of gland and duct are located. The true shape of the anterior advancement of the flap, and worse, distortion of the flap if 1. Mendelson BC. Facelift anatomy, SMAS, retaining the temporal and periorbital regions is given. The term border of the masseter muscle is described, with the border the direction of pull is incorrect, due to unwanted rotation ligaments and facial spaces. In: Aston J, Steinbrech DS, “ligamentous adhesion” is introduced to increase the ending anteroinferiorly at the mandibular ligament. This about the parts of the retaining ligamentous system which Walden JL, eds. Aesthetic plastic surgery. London: understanding of the system, and there is emphasis on the description completes the picture of the retaining ligaments have been left intact. The biomechanical function of the Saunders Elsevier; 2009:53–72. relations of the temporal branch of the facial nerve and the as a continuous border separating the anterior and lateral retaining ligaments is described as “quarantining” sections 2. Nahai F, ed. Clinical decision making in face lift and trigeminal branches to structures visualized in surgery rather parts of the face. The relations of the facial nerve branches, of the SMAS with less substantial fixation (areas now neck lift. In: The art of aesthetic surgery: principles and than to less useful landmarks which are not. A discussion of particularly that of the lower buccal trunk, to the masseter appreciated as subSMAS facial soft tissue spaces), preventing techniques. St Louis: Quality Medical; 2005:898–926. age related changes to the region compliments one of surgical and its fascia is described. unwanted traction on areas of the face distant to the desired approach with respect to the anatomy described. action in facial expression. There is discussion on the 3. Mendelson BC. Correction of the nasolabial fold: 75. Mendelson BC. Surgery of the superficial 15. Ghavami A, Pessa JE, Janis J, et al. The orbicularis advantage of extensive SMAS mobilization in allowing extended SMAS dissection with periosteal fixation. musculoaponeurotic system: principles of release, retaining ligament of the medial orbit: closing the circle. multiple and varied force vectors to be applied, which allows Plast Reconstr Surg. 1992;89(5):822–833. vectors and fixation. Plast Reconstr Surg. 2001;107(6): Plast Reconstr Surg. 2008;121(3):994–1001. 1545–1552. proper anatomical repositioning of the soft tissue of the face. 4. Mendelson BC, Jacobson SR. Surgical anatomy of the mid-cheek; facial layers, spaces, and mid-cheek 16. Mendelson BC, Muzaffar AR, Adams WP Jr. Surgical segments. Clin Plast Surg. 2008;35:395–404. anatomy of the mid-cheek and malar mounds. 5. Stuzin JM, Baker TJ, Gordon HL. The relationship of Plast Reconstr Surg. 2002;110(3):885–911. the superficial and deep facial fascias: relevance to 17. Yousif NJ, Mendelson BC. Anatomy of the midface. rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3): Clin Plast Surg. 1995;22(2):227–240. 441–449. 18. Knize DM. Anatomic concepts for brow lift procedures. A discussion of the concept of facial soft tissue being arranged Plast Reconstr Surg. 2009;124(6):2118–2126. in concentric layers, and the SMAS as the “investing” layer 19. Kahn JL, Wolfram-Gabel R, Bourjat P. Anatomy and of the superficial mimetic muscles of the face. The relationship imaging of the deep fat of the face. Clin Anat. 2000;13(5): between the deep and superficial fascias is described, with 373–382. acknowledgement of “areola” planes and areas of dense 20. Zhang HM, Yan YP, Qi KM, et al. Anatomical structure fibrous attachments, including true osteocutaneous ligaments of the buccal fat pad and its clinical adaptations. and other coalescences representing the retaining ligamentous Plast Reconstr Surg. 2002;109(7):2509–2518. boundaries of the face. Age-associated laxity of the retaining ligament was noted to be a key component of facial aging. 21. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy: anatomic variations and pitfalls. 6. Mendelson BC. Advances in the understanding of the Plast Reconstr Surg. 1979;64:781. surgical anatomy of the face. In: Eisenmann-Klein M, Neuhann-Lorenz C, eds. Innovations in plastic and 22. Gosain AK. Surgical anatomy of the facial nerve. aesthetic surgery. New York: Springer Verlag; 2007: Clin Plast Surg. 1995;222:241. 141–145. 23. Seckel BR. Facial danger zones. Avoiding nerve injury in 7. Furnas DW. The retaining ligaments of the cheek. Plast facial plastic surgery. St Louis: Quality Medical; 1994. Reconstr Surg. 1989;83:11. 24. Owsley JQ, Agrawal CA. Safely navigating around 8. Furnas D. The superficial musculoaponeurotic plane the facial nerve in three-dimensions. Clin Plast Surg. and the retaining ligaments of the face. In: Psillakis JM, 2008;35:469–477. ed. Deep face-lifting techniques. New York: Thieme 25. Lowe JB 3rd, Cohen M, Hunter DA, et al. Analysis of Medical; 1994. the nerve branches to the orbicularis oculi muscle of 9. Rohrich RJ, Pessa JE. The retaining system of the face: the lower eyelid in fresh cadavers. Plast Reconstr Surg. histologic evaluation of the septal boundaries of the 2005;116(6):1743–1749. subcutaneous fat compartments. Plast Reconstr Surg. 26. Furnas DW. Landmarks for the trunks and the 2008;121(5):1804–1809. temporofacial division of the facial nerve. Br J Surg. 10. Rohrich RJ, Pessa JE. The fat compartments of the face: 1965;52:694–696. anatomy and clinical implications for cosmetic surgery. 27. Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy Plast Reconstr Surg. 2007;119(7):2219–2227. of the frontal branch of the facial nerve: the significance 11. Rohrich RJ, Pessa JE. The anatomy and clinical of the temporal fat pad. Plast Reconstr Surg. 1989;83(2): implications of perioral submuscular fat. Plast Reconstr 265–271. Surg. 2009;124(1):266–271. 28. Ramirez OM, Maillard GF, Musolas A. The extended 12. Mitz V, Peyronie M. The superficial musculo- subperiosteal face lift: a definitive soft-tissue remodeling aponeurotic system (SMAS) in the parotid and cheek for facial rejuvenation. Plast Reconstr Surg. 1991;88(2): area. Plast Reconstr Surg. 1976;58:80. 227–236. 13. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical 29. Trussler AP, Stephan P, Hatef D, et al. The frontal anatomy of the ligamentous attachments of the lower branch of the facial nerve across the zygomatic arch: lid and lateral canthus. Plast Reconstr Surg. 2002;110(3): anatomical relevance of the high-SMAS technique. 873–884. Plast Reconstr Surg. 2010;125(4):1221–1229. 14. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of 30. Agarwal CA, Mendenhall SD 3rd, Foreman KB, et al. the ligamentous attachments in the temple and The course of the frontal branch of the facial nerve in 92.e2 SECTION I • 6 • Anatomy of the aging face References 92.e3

relation to fascial planes: an anatomic study. 49. Penna V, Stark GB, Eisenhardt SU, et al. The aging 67. Jelks GW, Jelks EB. The influence of orbital and eyelid vectors and fixation. Plast Reconstr Surg. 2001;107(6): Plast Reconstr Surg. 2010;125(2):532–537. lip: a comparative histological analysis of age-related anatomy on the palpebral aperture. Clin Plast Surg. 1545–1552. 31. Montagna W, Carlisle K. Structural changes in the aging changes in the upper lip complex. Plast Reconstr Surg. 1991;18(1):183–195. This article highlights the importance of adequate release skin. Br J Dermatol. 1990;122(Suppl 35):61–70. 2009;124(2):624–628. 68. Mendelson BC, Freeman ME, Wu W, et al. Surgical of retaining ligaments of the SMAS in repositioning of the 32. Ramirez OM, Santamaria R. Spatial orientation of motor 50. Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and anatomy of the lower face: the premasseter space, the composite flap. Inadequate release can lead to suboptimal innervation of the lower orbicularis oculi muscle. facial aging: nonlinear aspects of youthfulness and jowl, and the labiomandibular fold. Aesthetic Plast Surg. advancement of the flap, and worse, distortion of the flap if Aesthetic Surg J. 2000;20:107. skeletal remodeling, and why, perhaps, infants have 2008;32(2):185–195. the direction of pull is incorrect, due to unwanted rotation 33. Ruess W, Owsley JQ. The anatomy of the skin and jowls. Plast Reconstr Surg. 1999;103(2):635–644. Introduces the concept of the “premasseter” space, age-related about the parts of the retaining ligamentous system which fascial layers of the face in aesthetic surgery. Clin Plast 51. Schwartz GE, Fair PL, Mandel MR, et al. Facial changes, and utility for safe subSMAS dissection. Distinction have been left intact. The biomechanical function of the Surg. 1987;14(4):677–682. electromyography in the assessment of improvement in is made between this space, over the lower part of the retaining ligaments is described as “quarantining” sections of the SMAS with less substantial fixation (areas now 34. Byrd HS, Andochick SE. The deep temporal lift: a depression. Psychosom Med. 1978;40:355. masseter, and another space overlying the upper part of the appreciated as subSMAS facial soft tissue spaces), preventing multiplanar, lateral brow, temporal, and upper face lift. 52. Hellman M. Changes in the human face brought about masseter where the neurovascular structures, the accessory unwanted traction on areas of the face distant to the desired Plast Reconstr Surg. 1996;97(5):928–937. by development. Int J Orthod. 1927;13:475. lobe of the parotid gland and duct are located. The true shape of the anterior border of the masseter muscle is described, action in facial expression. There is discussion on the 53. Todd TW. Thickness of the white male cranium. 35. Dingman RO, Grabb WC. Surgical anatomy of the with the border ending anteroinferiorly at the mandibular advantage of extensive SMAS mobilization in allowing Anat Rec. 1924;27:245. mandibular ramus of the facial nerve based on the ligament. This description completes the picture of the multiple and varied force vectors to be applied, which allows dissection of 100 facial halves. Plast Reconstr Surg. 54. Lasker GW. The age factor in bodily measurements of retaining ligaments as a continuous border separating the proper anatomical repositioning of the soft tissue of the face. 1962;29:266. adult male and female Mexicans. Hum Biol. 1953;25:50. anterior and lateral parts of the face. The relations of the 76. Le Louarn C. The concentric malar lift: malar and lower 36. Conley J, Baker DC. Paralysis of the mandibular branch 55. Garn SM, Rohmann CG, Wagner B, et al. Continuing facial nerve branches, particularly that of the lower buccal eyelid rejuvenation. Aesthetic Plast Surg. 2004;28(6): of the facial nerve. Plast Reconstr Surg. 1982;70:569. bone growth during adult life: A general phenomenon. trunk, to the masseter and its fascia is described. 359–372. Am J Phys Anthropol. 1967;26:313. 37. Nelson DW, Gingrass RP. Anatomy of the mandibular 69. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 77. Sullivan SA, Dailey RA. Endoscopic subperiosteal branches of the facial nerve. Plast Reconstr Surg. 1979; 56. Kahn DM, Shaw RB Jr. Aging of the bony orbit: a 1997;100:509–513. midface lift: surgical technique with indications and 63:479. three-dimensional computed tomographic study. 70. Tonnard P, Verpaele A. The MACS-lift short scar outcomes. Ophthal Plast Reconstr Surg. 2002;18(5): 38. Pitanguy I, Ramos AS. The frontal branch of the facial Aesthet Surg J. 2008;28(3):258–264. rhytidectomy. Aesthet Surg J. 2007;27(2):188–198. 319–330. nerve: the importance of its variations in facelifting. 57. Pessa JE, Chen Y. Curve analysis of the aging orbital 71. Aston SJ, Walden JL. Facelift with SMAS techniques 78. Ramirez OM. Three-dimensional endoscopic midface Plast Reconstr Surg. 1966;38:352–356. aperture. Plast Reconstr Surg. 2002;109(2):751–755. and FAME. In: Aston SJ, Steinbrech DS, Walden JL, eds. enhancement: a personal quest for the ideal cheek 39. Wulf HC, Sandby-Moller J, Kobayashi T, et al. Skin 58. Pessa JE, Zadoo VP, Mutimer KL, et al. Relative Aesthetic plastic surgery. London: Saunders Elsevier; rejuvenation. Plast Reconstr Surg. 2002;109(1):329–340. aging and natural photoprotection. Micron. 2004;35: maxillary retrusion as a natural consequence of aging: 2009;73–86. 79. Rowe DJ, Guyuron B. Optimizing results in endoscopic 185–191. combining skeletal and soft-tissue changes into an 72. Labbé D, Franco RG, Nicolas J. Platysma suspension forehead rejuvenation. Clin Plast Surg. 2008;35(3): 40. Hall G, Phillips TJ. Estrogen and skin: the effects of integrated model of midfacial aging. Plast Reconstr Surg. and platysmaplasty during neck lift: anatomical 355–360. estrogen, menopause and hormone replacement therapy 1998;102(1):205–212. study and analysis of 30 cases. Plast Reconstr Surg. on the skin. J Am Acad Dermatol. 2005;53; 555–568. 80. Huggins RJ, Freeman ME, Kerr JB, et al. Histologic and 59. Pessa JE. An algorithm of facial aging: verification of 2006;117(6):2001–2007. ultrastructural evaluation of sutures used for surgical 41. Sander CS, Chang H, Salzmann S, et al. Photoaging is Lambros’s theory by three-dimensional 73. Hamra ST. Deep-plane rhytidectomy. Plast Reconstr fixation of the SMAS. Aesthetic Plast Surg. 2007;31(6): associated with protein oxidation in human skin in stereolithography, with reference to the pathogenesis of Surg. 1990;86:53. 719–724. vivo. Invest Dermatol. 2002;118(4):618–625. midfacial aging, scleral show, and the lateral suborbital 74. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 81. Freilinger G, Gruber H, Happat W, et al. Surgical 42. Chung JH, Seo JY, Choi HR, et al. Modulation of skin trough deformity. Plast Reconstr Surg. 2000;106(2): 1992;90:1. anatomy of the mimic muscle system and the facial collagen metabolism in aged and photoaged human 479–488. 75. Mendelson BC. Surgery of the superficial nerve: Importance for reconstructive and aesthetic skin in vivo. J Invest Dermatol. 2001;117(5):1218–1224. 60. Shaw RB Jr, Kahn DM. Aging of the midface bony musculoaponeurotic system: principles of release, surgery. Plast Reconstr Surg. 1987;80:686. 43. Freiman A, Bird G, Metelitsa AI, et al. Cutaneous effects elements: a three-dimensional computed tomographic of smoking. J Cutan Med Surg. 2004;8(6):415–423. study. Plast Reconstr Surg. 2007;119(2):675–681. 44. Gosain AK, Klein MH, Sudhakar PV, et al. A volumetric 61. Mendelson BC, Hartley W, Scott M, et al. Age-related analysis of soft-tissue changes in the aging midface changes of the orbit and mid-cheek and the implications using high-resolution MRI: implications for facial for facial rejuvenation. Aesthetic Plast Surg. 2007;31(5): rejuvenation. Plast Reconstr Surg. 2005;115(4):1143–1155. 419–423. 45. Gosain AK, Amarante MT, Hyde JS, et al. A dynamic 62. Zadoo VP, Pessa JE. Biological arches and changes to analysis of changes in the nasolabial fold using the curvilinear form of the aging maxilla. Plast Reconstr magnetic resonance imaging: implications for facial Surg. 2000;106(2):460–466. rejuvenation and facial animation surgery. Plast Reconstr 63. Pessa JE, Slice DE, Hanz KR, et al. Aging and the shape Surg. 1996;98(4):622–636. of the mandible. Plast Reconstr Surg. 2008;121(1): 46. Lambros V. Observations on periorbital and midface 196–200. aging. Plast Reconstr Surg. 2007;120(5):1367–1376. 64. Shaw RB Jr, Katzel EB, Koltz PF, et al. Aging of the 47. Faulkner JA, Larkin LM, Claflin DR, et al. Age-related mandible and its aesthetic implications. Plast Reconstr changes in the structure and function of the skeletal Surg. 2010;125(1):332–342. muscles. Clin Exp Phamacol Physiol. 2007;34:1091–1096. 65. Knize DM. Muscles that act on glabella skin: A closer 48. Pottier F, El-Shazly NZ, El-Shazly AE. Aging of look. Plast Reconstr Surg. 2000;105:350. orbicularis oculi: anatomophysiologic consideration in 66. Matros E, Garcia JA, Yaremchuk MJ. Changes in upper blepharoplasty. Arch Facial Plast Surg. 2008;10(5): eyebrow position and shape with aging. Plast Reconstr 346–349. Surg. 2009;124(4):1296–1301. SECTION I Aesthetic Surgery of the Face History 93.e1

making a concerted effort to elevate the lateral portion of the History brow. He also described a local method of direct brow lifting for certain patients. In 1984, Papillon and colleagues pre- The history of aesthetic brow surgery was thoroughly sented a subcutaneous dissection plane from the anterior hair- 9 reviewed by Paul in 2001.1 line approach. In 1989, Paul described a transblepharoplasty 10 The first description of brow elevation surgery was a pub- approach. lication by the French surgeon Passot in 1919.2 His technique The original description of endoscopic brow lifting is 7 attributed to two surgeons, Isse and Vasconez, both of whom involved the removal of multiple small skin ellipses, position- 11,12 ing scars in the forehead crease lines and at the frontal hair- presented their method at different venues in 1992. The 13 line. In 1926, Hunt described what appears to have been a full first publication of this method was by Chajchir in 1993. anterior hairline incision for brow lifting access.3 In 1931, In 1996, Knize published his “limited incision forehead 14 Forehead rejuvenation Lexer published a combined forehead and open brow lift with lift”, using a short temple incision without endoscopic assist. a hairline incision,4 and in 1933, Claoue published a similar By 2003, a reduction in the number of endoscopic brow lifts extensive approach.5 Interestingly, forehead lifting then fell being done was documented due to uncertainty over the sta- 15 into disfavor for several decades until 1962 when Gonzalez- bility of endoscopic brow lifting. In the first part of the 21st Richard J. Warren Ulloa published in the English literature an open coronal century, other methods appeared to deal with lateral brow 16 brow lift combined with facelift.6 Shortly thereafter, in Brazil, relapse. Numerous reports demonstrated the success of Vinas presented (1965)7 and subsequently described (1976)8 endoscopic brow lifting using measurements from the brow 17–21 his advanced concepts of brow elevation. He suggested to the pupil.

profoundly affect facial appearance. The aesthetic balance SYNOPSIS created by surgery can project strong human emotions, ᭿ Detailed knowledge of forehead anatomy is the basis for ranging from joy to sadness and from restfulness to fatigue. rejuvenation strategies of the forehead region. In the younger individual, aesthetic alteration of the fore- ᭿ Eyebrow position is the net result of forces which depress the head is generally limited to the nonsurgical alleviation of brow, forces which raise the brow and the structures which tether glabellar frown lines and lateral orbital wrinkles. These issues the eyebrow in place. are discussed in Chapters 3 and 4. Occasionally, surgery is ᭿ Brow depression is caused by glabellar frown muscles, the indicated to change the basic shape of a youthful eyebrow. In orbicularis and gravity. Frontalis is the only effective brow elevator. the older individual, the forehead typically becomes ptotic laterally, while in the orbit, there is a relative loss of orbital ᭿ Attractiveness of the periorbital region is intimately related to fat together with an accumulation of loose eyelid skin. eyebrow shape and eyebrow position as it relates to the upper Understanding the interplay between these complex anatomi- eyelid and the upper lid sulcus. cal changes is critical in choosing an appropriate surgical ᭿ Aging causes enlargement of the orbital aperture as well as strategy to rejuvenate the upper third of the face. changes in eyebrow shape. In a subset of individuals there is ptosis of the entire forehead complex. ᭿ Key elements of forehead rejuvenation are the attenuation of frown muscle action and the repositioning of ptotic eyebrow elements. Anatomy The lateral eyebrow is often the only portion requiring elevation. ᭿ Forehead rejuvenation can be accomplished using a combination The frontal bone is crossed laterally by a curved ridge called of surgical and non-surgical techniques. the temporal crest (also called the temporal ridge or the supe- ᭿ If surgical elevation of the brow complex fails early, it is usually rior temporal fusion line of the skull). This is a palpable land- due to lack of soft tissue release. If it fails late, is usually due to mark which separates the temporal fossa and the origin of the failure of fixation. temporalis muscle from the forehead portion of the frontal ᭿ Many methods of soft tissue fixation and bony fixation have been bone (Fig. 7.1). It also marks a change in nomenclature as proven effective in maintaining the position of the surgically tissue planes transition from lateral to medial. The deep tem- elevated brow. poral fascia covering the temporalis muscle attaches along the temporal ridge and continues medially as the periosteum Access the Historical Perspective section online at which covers the frontal bone. Similarly, the superficial tem- http://www.expertconsult.com poral fascia (also known as the temporal parietal fascia) con- tinues medially as the galea aponeurotica which encompasses the frontalis muscle. The surgical significance of the temporal crest line is that Introduction all fascial layers are tethered to bone in a band approximately 5 mm wide immediately medial to the palpable ridge. This The periorbital region is the most expressive part of the has been called the zone of fixation.22,23 Where this zone human face. The eyes are central, framed above by the eye- approaches the orbital rim at its inferior end, the fascial attach- brows, and below by the cheek. Alteration in components ment widens and becomes more dense, forming the orbital of the orbital frame, as well as the eyelids themselves, will ligament (Fig. 7.2). All fascial attachments in this region must ©2013, Elsevier Inc. All rights reserved. 94 SECTION I • 7 • Forehead rejuvenation Anatomy 95

Fontalis muscle Superior temporal Galeal aponeurosis fusion line Subgaleal space Galeal Zone of fixation Periosteum fat pad (zone of adhesion) Galeal attachment Superficial galea Fontalis muscle Temporal ridge Obicularis (temporal crest) oculi muscle

Deep galea Preseptal fat Orbital septum Galeal fat pad Lateral orbital rim with Lateral orbital rim with A B deep galeal attachment no galeal attachment Fig. 7.3 Endoscopic view of the inferior temporal septum, right side. Glide plane space Fig. 7.6 Lateral orbital rim variation. On the left, galeal attachment tethers the Fig. 7.1 Bony anatomy of the forehead and temporal fossa. The palpable temporal Corrugator supercilii muscle overlying brow. On the right, the galeal fat pad is contiguous with retro orbicularis ridge separates the temporal fossa from the forehead. The zone of fixation (aka zone oculi fat, potentially making the lateral brow prone to ptosis. of adhesion, superior temporal septum) is a 5 mm wide band along the temporal ridge where all layers are bound down to periosteum. Orbital rim Depressor supercilii Corrugator supercilii

Periosteum

Superior temporal septum Preseptal fat (ROOF) Zone of fixation (zone of adhesion) Suborbital fascia Obicularis oculi muscle Orbital ligament Sentinel vein Orbital septum

Inferior temporal septum Fig. 7.5 Relationship of galea to surrounding tissue as it splits to encompass the frontalis muscle, the galeal fat pad, and the glide plane space. The corrugator supercilii traverses through the galeal fat pad as it courses from its deep bony origin to its superficial insertion in the orbicularis and dermis. Orbicularis oculi Procerus

Temporal branches Fig. 7.7 Glabellar frown muscles. of the facial nerve Fig. 7.4 Endoscopic view of the medial zygomaticotemporal vein (sentinel vein), right side. Lateral orbital thickening Periorbital septal of periorbital septum attachment layer encompassing the frontalis muscle (Fig. 7.5). Inferiorly, by a reflected layer of galea. Laterally, this separation is describe the criss-crossing white fibers which loosely attach the deep galea layer separates further into three separate thought to be variable, with some individuals having a con- Fig. 7.2 Fascial attachments around the orbital rim. The inferior end of the zone of the superficial to the deep temporal fascia. layers: one layer immediately deep to the frontalis forming tinuous layer of fat from galeal fat pad to the preseptal fat fixation is the orbital ligament. The lateral orbital thickening is a lateral extension of The inferior temporal septum is a useful landmark during the roof of the galeal fat pad, a second layer forming the (Fig. 7.6).26 the septum which extends across the lateral orbital rim onto deep temporal fascia. endoscopic dissection from above, because it separates the floor of the galeal fat pad but not adherent to bone, and a third safe upper zone containing no vital structures from the lower layer adherent to periosteum. The two deepest layers define zone where facial nerve branches travel in the cavity’s roof. the glide plane space between the galeal fat pad and the Muscle be released from bone when a full thickness forehead flap is The medial zygomatic temporal vein (sentinel vein) is also skull. Inferiorly, the septum orbitale divides orbital fat from being repositioned. present in this lower zone, adjacent to the lateral orbital rim. PreSeptal fat (also known as retro orbicularis oculi fat or Eyebrow level is the result of a balance between the mus- Some fascial structures in this area have been named by The temporal branches pass immediately superior to this vein ROOF). cular forces which elevate the brow, the muscular forces different authors, generating some confusion. The superior (Figs 7.3, 7.4). When the eyebrow is raised by frontalis contraction, the which depress the brow, and the universal depressor: gravity temporal septum24 and the zone of adhesion16 are alternate soft tissue slides over the glide plane space. The galeal fat pad (Fig. 7.7). terms used to describe the zone of fixation. The temporal Galea extends across the entire width of the lower 2 cm of the fore- Brow depressors in the glabella originate from bone medi- ligamentous adhesion24 describes the lower portion of the head; medially it surrounds the supra orbital and supra tro- ally, inserting into soft tissue. The procerus runs vertically, the zone of fixation and the orbital ligament. The inferior tempo- Knize has described galeal anatomy in detail.26 In the fore- chlear nerves as well as portions of the frown musculature. depressor supercilii and orbiculars run obliquely, and the cor- ral septum24 and the orbicularis-temporal ligament25 both head, the galea aponeurotica splits into a superficial and deep The galeal fat pad is separated from the preseptal fat (ROOF) rugator mostly runs transversely. The transverse corrugator 96 SECTION I • 7 • Forehead rejuvenation Anatomy 97

Supratrochlear nerve

Infratrochlear nerve

Superficial branch of supraorbital nerve

Deep branch of supraorbital nerve Supraorbital nerve, deep branch Supraorbital Zygomatico- nerve, temporal nerve superficial branches Fig. 7.8 Lateral orbicularis acts like a sphincter, depressing the lateral brow.

Zygomatico- facial nerve Frontalis muscle Fig. 7.11 The deep branch of the supraorbital nerve travels in a 1 cm wide band between 5 and 15 mm medial to the temporal ridge. Temporal crest line Infraorbital nerve The supraorbital nerve immediately divides into two dis- Orbicularis occuli Facial nerve, temporal branch muscle tinct segments: superficial and deep. The superficial branch Fig. 7.10 Sensory nerves. pierces orbicularis and frontalis, dividing into several smaller branches which travel on the superficial surface of the fronta- lis to innervate the central forehead as far posteriorly as the Sensory nerves first 2 cm. of hair. The rest of the scalp, as far back as the vertex, is innervated by the deep branch. The deep branch Innervation to the upper periorbita is supplied by the supraor- courses superiorly in a more lateral location, remaining bita and supratrochlear nerves, as well as two lesser nerves, between the periosteum and the deepest layer of galea. As it the infratrochlear, and zygomaticotemporal (Fig. 7.10). travels superiorly, it becomes more superficial, piercing fron- The infratrochlear nerve exits the orbit medially supplying talis to innervate the skin. sensation to the nasal dorsum and medial orbital rim. It is It is a double branch approximately 60% of the time.29 An seldom damaged and rarely a cause of postoperative concern. important fact during endoscopic brow lifting is that the deep The zygomaticotemporal nerve exits posterior to the lateral branch runs in a 1 cm wide band, which is between 5 mm and Fig. 7.9 Frontalis acts to raise the eyebrow complex. On contraction, most orbital rim piercing the deep temporal fascia just inferior to movement occurs in the lower third of the muscle, and action is strongest on the 15 mm medial to the palpable temporal ridge (Fig. 7.11). medial and central eyebrow. the sentinel vein. In brow lifting, with complete release of the lateral orbital rim, it is often avulsed. Consequences of this are minimal and temporary. Motor nerves supercilii is the largest and most powerful of these muscles. The supratrochlear nerve usually exits the orbit superome- The temporal branch of the facial nerve is the only motor It originates from the orbital rim at its most supero-medial dially although this is variable, and it occasionally will exit nerve of concern in this area. Loss of this branch would result corner, with the large transverse head later passing through near the supraorbital nerve. It immediately divides into 4–6 in a brow ptosis and asymmetry due to impaired frontalis galeal fat becoming progressively more superficial until branches which can pass superficial (anterior) to the corruga- Facial nerve, zygomatic branch action (Fig. 7.12). The anatomy of this nerve has been well it interdigitates with the orbicularis and frontalis at a skin tor, or more frequently, directly through the substance of the described.30–33 Fig. 7.12 Facial nerve branches in the periorbital region. Note the corrugator has dimple which is visible when the patient frowns.27 corrugator. These branches then become more superficial, The temporal branch enters the temporal fossa as multiple dual innervation from the temporal branch and the zygomatic branch. The temporal The orbicularis encircles the orbit acting like a sphincter. innervating the central forehead. (2–4) fine branches which lie on the periosteum of the middle branch crosses the middle third of the zygomatic arch as 2–4 branches. Medially and laterally the orbicularis fibers run vertically and The supraorbital nerve exits the superior orbit either third of the zygomatic arch. Between 1.5 cm and 3.0 cm above act to depress brow level. Laterally, orbicularis is the only through a notch in the rim, or through a foramen superior to the arch, these branches become more superficial, entering the muscle which depresses brow position (Figs 7.8, 7.9). the rim. Much variation occurs with foramina present about superficial temporal fascia (temporoparietal fascia), traveling 3. Parallel and adjacent to the inferior temporal septum Frontalis is the only elevator of the brow. It originates from 20% of the time.28 The location of the notch or foramen is on to innervate the frontalis, superior orbicularis and glabellar the galea aponeurotica superiorly, and interdigitates inferiorly between 16 and 42 mm from the midline, with a mean of 4. Immediately superior to the sentinel vein (medial muscles.34 with the orbicularis. Contraction raises this muscle mass, 25 mm. A useful landmark for this is a palpable notch, or zygomaticotemporal vein). A number of different landmarks are commonly used to and in so doing, lifts the overlying skin which contains the failing that, the mid-papillary line. When a foramen is present, In all forehead lift procedures, dissection planes are predict the course of the temporal branches. These include: eyebrow. Due to its deficiency laterally, the primary effect of it has been found as far as 19 mm above the rim. Because of designed to protect the temporal branches. This can be done frontalis contraction is on the medial and central portions of such variation, blind dissection from above should be discon- 1. The middle third of the palpable zygomatic arch by staying deep to them, which requires dissecting directly on the eyebrow. tinued at least 2 cm above the orbital rim. 2. 1.5 cm lateral to the tail of the eyebrow deep temporal fascia in the temple and in the subgaleal or 98 SECTION I • 7 • Forehead rejuvenation Patient presentation 99 subperiosteal planes over the frontal bone. Alternatively, dis- facts are not so clear. Some studies actually suggest that eye- section can be kept superficial to the frontalis, the orbicularis, brows may rise with age, at least in the medial and central and the superficial temporal fascia. portions (Figs 7.15, 7.16).35–37 Logically, the medial and central eyebrows could rise over time through the action of frontalis. This may be caused by Patient presentation a subconscious reaction to excess upper lid skin or to early eyelid ptosis caused by senile levator disinsertion. Both phe- nomena will stimulate frontalis contraction to open the line Forehead aging of sight. Also at play is personal habit, exhibited by the brow elevation seen when most individuals are confronted with a Historically, the visible signs of forehead aging have been Fig. 7.17 Orbital changes with age: orbital mirror, or on facing a camera. Closing the eyes will usually, described in two ways. First, and most obvious are the furrows volume expands, most marked superomedial and but not always, relax the frontalis, causing the eyebrows to inferolateral. (With permission from Kahn DM, Shaw caused by the repetitive action of underlying muscles: trans- drop. Frontalis paralysis due to facial nerve injury or botuli- RB. Aging of the bony orbit. A three-dimensional verse lines are due to the eyebrow lifting action of the fron- num toxin will always drop the level of the eyebrow, indicat- A B computed tomographic study. Aesthet Surg J 2008; talis, while glabellar frown lines are due to the corrugator, ing that some resting tone is normal. 28(3):258–264.) depressor supercilii, and the procerus. The corrugator, being A final factor is the shape of the orbital aperture which the most transverse of these muscles causes vertical frown appears to enlarge with age, the superomedial brow rising, lines, the depressor supercilii, being oblique, causes oblique and the inferolateral orbital rim dropping and receeding.38,39 folds which cut across the orbital rim, and the vertically Another effect of a dropping lateral brow is a bunching up This could contribute to a rising medial brow, because of soft running procerus causes transverse lines at the radix (Figs or a pseudoexcess of lateral upper eyelid skin. In response to tissue attachment and the soft tissue support provided by the 7.13, 7.14). this, Flowers and Duval have described the phenomenon of trunk of the supraorbital nerve (Fig. 7.17). Second, it has been assumed that the forehead/eyebrow compensated brow ptosis where patients subconsciously con- As described earlier, the level and shape of the eyebrow is 42 complex becomes ptotic with age, encroaching on the orbit, tract the frontalis to open their line of sight. This further the result of a balancing act between the many forces of brow causing a pseudo-excess of upper eyelid skin. While consist- exacerbates the appearance of a downturned lateral brow. depression and the only elevator, which is the frontalis muscle. ent with the age-related ptosis of most other body parts, the Many patients recognize these changes and treat them- The lateral portion of the brow is particularly sensitive to this selves to eyebrow plucking, make-up or tattooing in order to interplay because frontalis action is attenuated laterally.40 make the lateral brow appear higher. Alternatively, they may Against the unrelenting force of gravity and the lateral orbicu- seek blepharoplasty to deal with lateral soft tissue hooding, laris oculi, the principle resistance to lateral brow decent is unaware that the ptotic lateral brow is the most significant soft tissue attachment. This attachment is variable and may factor. The unsuspecting surgeon who performs blepharo- be absent, leaving the lateral brow free to move.41 The result plasty in this circumstance will see the frontalis relax, unmask- is often a gradual ptosis of the lateral third of the brow, rela- ing the compensated brow ptosis, causing the medial and tive to the medial brow. This effect will be accentuated if a central brow to fall. patient also has a rising medial brow. The resulting down- turned lateral brow imparts a look of sadness, tiredness and age. Aesthetics

Traditional teaching has been that the correct eyebrow posi- Fig. 7.18 An oval formed by the eyebrow above, and the nasojugular fold below, tion is at or above the supra orbital rim. While usually true, should have the pupil at its equator. (Adapted from: Gunter J, Antrobus S. Aesthetic this axiom is overly simplistic, because eyebrow height is only analysis of the eyebrows. Plast Reconstr Surg 1997; 99:1808–1816.) one of many variables. In many individuals, the lateral brow Fig. 7.13 Patient frowning. The paired vertical folds are caused by the corrugator becomes more ptotic than the medial brow, altering brow supercilii and the transverse lines at the nasal radix are caused by the procerus. shape. Studies have demonstrated that our impression of The paired oblique lines are caused by the depressor supercilii and the medial people can be affected by altering the shape of their eyebrows, orbicularis oculi. Laterally the “crow’s feet” lines are caused by the vertically running fibers of the orbicularis oculi. implying that the shape of the brow is more important than its absolute height.43,44 Also, age related changes in eyebrow position do not occur in isolation. The upper lid sulcus may become more hollow as fat is lost, upper lid skin may become Fig. 7.15 more redundant, and there may be a modest degree of senile eyelid ptosis. As mentioned earlier, reflex brow raising is often the result, with a rising medial brow in relation to the lateral brow (Fig 7.16). Gunter observed that the eyebrow and naso-jugular fold create an oval shape, and that in an attractive eye, the pupil will lie at the equator of that oval (Fig. 7.18).45 Applying this analysis is a useful exercise to determine if brow position is an issue (Fig. 7.19). Ovals which are vertically wide look aged, while vertically narrow ovals look youthful. There is an intimate relationship between eyebrow position and the eyelid. The ratio of the visible eyelid from the lashes Fig. 7.19 On oval analysis of this case, the pupil lies above the natural equator of Fig. 7.14 Patient raising eyebrows. The transverse forehead lines are caused by the Fig. 7.16 From age 25–50, photographs demonstrate a 3–4 mm rise in the medial to the palpebral fold should be one-third, and at most one the oval. This confirms a low lying eyebrow plus or minus a low lying nasojugular frontalis. and central brows. half the distance from the lashes to the lower border of the fold. 100 SECTION I • 7 • Forehead rejuvenation Surgical techniques 101

Peak that reason, identifying the main component of every patient’s periorbital aging is important. Old photographs are very helpful in determining which aging changes predominate. Such a review will also help to focus patients’ perspectives on 2 exactly how they have aged, and what, if any, rejuvenation /3 they would like to undergo. 1 /3 Assessment of the patient should be done with the patient’s head in the vertical position; the patient will be sitting or standing. The following issues are evaluated: visual acuity; eyebrow and orbital symmetry; position of anterior hairline; thickness of scalp hair; transverse forehead lines; glabellar frown lines; thickness of eyebrow hair; eyebrow height; axis of the eyebrow (downward or upward lateral tilt); shape of the eyebrow (flat or peaked); passive and active eyebrow mobility, and the presence of old scars or tattoos. The upper eyelids should be assessed for soft tissue redundancy, for hol- lowness and for lid level (ptosis versus lid retraction). The Fig. 7.23 Coronal approach showing corrugator muscles. Fig. 7.20 The modern ideal brow/upper eyelid complex. patient should be examined with eyes open and eyes closed. With the eyes closed, the frontalis can usually be made to relax, revealing the true position and shape of the eyebrows. to leave some galeal attachment medially to prevent over- Fig. 7.21 Coronal and anterior hairline approaches. elevation of the medial scalp. Otherwise, for proper brow eyebrow (Fig. 7.20).45 A number of different factors may If the brow is held in this position when the patient opens elevation, there must be a thorough release of the galeal change this ratio: their eyes, the eyebrow/eyelid relationship without frontalis effect will be revealed. The surgeon can then manually reposi- attachments along the central and lateral orbital rims. The • Changing eyebrow height tion the eyebrows, experimenting with various positions and zone of fixation will be released as dissection progresses later- • Lid ptosis or lid retraction different vectors of mobilization. ally over the deep temporal fascia. The trunk of the supraor- • Redundant upper eyelid soft tissue Patients may be a candidate to have their entire brow bital nerve is identified and preserved. To reposition the • Loss of upper sulcus fat. complex lifted, or more commonly to have only part of the brows, the flap is drawn supero-laterally, and a full-thickness Any one of these issues can be treated independently or in eyebrow raised, thus improving eyebrow shape. Occasionally, strip of scalp is excised. Laterally, scalp excision will range conjunction with a brow lift. Brow repositioning is a powerful this may involve raising the medial brow only, but most from 1 to 3 cm, but centrally, little or no scalp is excised. The tool but it must be considered in the context of other possibili- typically it involves raising the lateral third to half of the scalp is closed directly, approximating galea and skin. ties such as ptosis repair, blepharoplasty, and fat grafting to brow, with little or no lift of the medial portion. Weakening Although deeper fixation can be added, the classic open the upper lid sulcus. or eliminating the glabellar frown muscles is a useful parallel coronal lift relies on scalp excision alone to maintain brow Individualization is a key component to any periorbital objective. Numerous methods are available, ranging from position. rejuvenation. Gender, ethnicity, eye prominence and overall botulinum toxin, to surgical techniques which may weaken, Disadvantages of the open coronal approach include scalp facial proportions must be considered. For example, Oriental or completely eliminate the glabellar frown muscles. numbness, which may be permanent, a long scar, disruption faces look attractive with higher eyebrows than would seem of hair follicles, and scalp dysesthesia. Inevitably, the anterior appropriate for the Caucasian face. Complicating matters, the hairline will be raised and some hair-bearing scalp will be “ideal” eyebrow has also changed over time. Renaissance sacrificed. This technique should be used cautiously or not at painters tended to portray their subjects with normal eye- Surgical techniques all in patients with a high anterior hairline, with thin hair, or brows and relatively hollow upper sulci, while in the 1950s, in patients who may eventually lose their hair. eyebrows became very high and arched.44 Individual varia- Surgical rejuvenation of the forehead has changed dramati- tion aside, there are certain themes which define “the ideal cally from the one-size-fits-all approach of an earlier era. As Anterior hairline approach eyebrow” (Fig. 7.20) in the era when this text is being written: our understanding of anatomy and aging has improved, our available surgical techniques have also evolved. Alongside Fig. 7.22 Open coronal flap dissection shown in the subgaleal plane. This incision is usually placed along the anterior hairline, 1. The medial eyebrow level should lie over the medial this evolution, the introduction of botulinum toxin for aes- orbital rim until it reaches the hairline laterally, where it transitions into thetic indications has changed many of our fundamental the hair-bearing temporal scalp. Alternatively, it can follow 2. The medial border of the eyebrow should be vertically in concepts. will be at the watershed between posterior and anterior the hairline over its entire extent (Fig. 7.21). Certain technical line with the medial canthus running sensory nerves, thus reducing scalp numbness. details help minimize scar visibility. These include placing the 3. The eyebrow should rise gently, peaking slightly at least Open coronal approach However, a more anterior incision involves less scalp dissec- incision within or just posterior to the fine hair of the anterior two-thirds of the way to its lateral end; typically this tion, better visibility, and a closer point of traction on the hairline, and beveling the incision parallel to the hair follicles. peak lies vertically above the lateral limbus The coronal approach was long considered the “gold stand- eyebrows (Figs 7.21–7.23). Alternatively, the principle of cutting across the hair follicles 4. The lateral tail of the brow should be higher than the ard” against which other techniques must be measured. Many The incision is made full-thickness down to periosteum, may be used in order to promote growth of hairs through the medial end surgeons still consider it to be the most effective method for and the anterior flap can then be raised in either the subperio- resulting scar.46 The incision, when made as a slightly wavy 5. The male brow should be lower and less peaked. modification of the forehead. The principal advantage of this steal, or more commonly, the subgaleal plane. Under direct line, tends to create a less visible scar. Skin tension is mini- approach is the unparalleled surgical exposure which facili- vision, the flap is elevated down to the orbital rim. If glabellar mized by approximating the galea, and doing a meticulous tates release and mobilization of brow soft tissues, as well as muscles are to be exposed, the galea must be breached on its skin closure. the modification of glabellar muscles under direct vision. deep surface, entering the galeal fat pad for access to the From the anterior hairline incision, dissection of the fore- Patient selection Surgical results are stable, and long lasting. muscles (Fig. 7.22). The frown muscles, corrugator, depressor head flap can be done in one of three different planes: subpe- The technique involves an incision over the top of the head, supercillii and procerus can be removed or weakened as nec- riosteal, subgaleal, and subcutaneous. Regardless of the plane Most patients are not aware of the many variables involved classically about 6–8 cm behind the anterior hairline, although essary (Fig. 7.23). Typically, resection of the corrugator requires being used, the anterior hairline approach offers the same in periorbital rejuvenation, and they may not want the multi- this incision can be placed almost anywhere in the hair- dissection of the supratrochlear nerve branches which course advantage as the coronal approach, namely excellent surgical ple procedures required to treat all of these components. For bearing scalp (Fig. 7.21). An incision as far back as the vertex through the substance of this muscle. It is often advantageous exposure, without the disadvantage of moving the anterior 102 SECTION I • 7 • Forehead rejuvenation Surgical techniques 103

Fibers of frontalis muscle Temporal pocket – against deep temporal fascia

Frontal pocket – subperiosteal

Fig. 7.25 Anterior hairline incision to lower the anterior hairline. Fig. 7.24 Limited hairline subcutaneous approach. hairline posteriorly. In addition, there are two unique advantages. Because there is no undermining of hair follicles, the Fig. 7.27 Five port endoscopic approach. surgeon has the option of a subcutaneous dissection plane Fig. 7.28 Temple approach. which is done on the superficial surface of the frontalis muscle. This allows brow elevation without the need to divide any sensory nerves, and also provides a potential effacement of supercilii. Care is taken to avoid excessive release of the flap Transpalpebral approach – deep transverse forehead lines. A popular modification of this medially to prevent over-elevation medially and to avoid muscle modification method is a short incision in the widow’s peak, which is used separation of the eyebrows. Once dissected, the forehead flap 47 is drawn superiorly and somewhat laterally. Specific vectors to target only the lateral brow (Fig. 7.24). Using the upper lid blepharoplasty approach, the glabellar have been described in this regard,51 but the surgeon can make The anterior hairline approach can also be used to lower frown muscles can be approached directly.54,55 This is an excel- an artistic decision during preoperative planning, with appro- an excessively high anterior hairline or to lower overly high lent method to attenuate glabellar frown lines in patients who priate vectors customized for each individual patient. While eyebrows. These problems may be congenital but often are the do not require a forehead lift. It can also be used as an adjunct some authors have suggested that no fixation is necessary,17 result of previous brow lift surgery. Hairline lowering involves to the patient undergoing an isolated elevation of the lateral two methods of fixation are usually employed: suture fixation a posterior dissection past the vertex of the skull, in order to third of the brow. The advantage of this method is a hidden in the lateral dissection pocket from the superficial to the deep extensively mobilize the scalp. Releasing incisions are made incision, which may be used for two purposes, blepharoplasty temporal fascia, and bony fixation in the medial dissection in the galea, and the scalp is advanced, utilizing bony fixation and frown muscle ablation. pocket. In an attempt to make the operation more predictable, to maintain the new hairline position (Figs 7.25, 7.26). If the Through an upper blepharoplasty incision, dissection pro- Fig. 7.26 Hairline lowering. a wide variety of fixation devices and techniques have been anterior approach is used to lower the eyebrows, bony fixa- 52 ceeds superiorly deep to the orbicularis oculi, but superficial 48–50 described. tion is done at the supraorbital rim (Figs 7.25, 7.26). to the orbital septum. Over the supraorbital rim, the trans- The main disadvantages of endoscopic brow lifting are: The main disadvantage of the anterior hairline incision is verse running fibers of the corrugator supercilii will be found. view, and short, undetectable incisions. In addition, the scalp the technical demands of using endoscopic equipment, the the presence of a permanent scar along the anterior hairline. The muscle becomes more superficial as it coursed laterally denervation associated with the open coronal approach is potential of overly elevating or separating the medial eye- In addition, if the scalp incision is full-thickness, the resulting through the galeal fat pad, eventually combining with the largely avoided (Fig. 7.27). brows, and some uncertainty about maintaining adequate scalp denervation will be worse than with the coronal orbicularis oculi and the lower frontalis. The muscle can be Access for the procedure is through 3–5 small (1–2 cm) fixation.15 approach because the posterior running sensory nerves are incisions placed within the hair-bearing scalp. Forehead flap removed, although care must be taken to protect supra troch- transected closer to their origin. Lastly, a full dissection of dissection is done to the same extent as with the open coronal lear nerve branches which travel through the substance of the forehead skin may compromise cutaneous blood flow leading lift. Medial to the zone of fixation, the dissection plane can be Temple approach muscle or around its inferior border. Medially in the wound, to partial skin necrosis. subgaleal, or the more popular subperiosteal approach. Flap the depressor supercilii can be seen coursing almost vertically, dissection can be done blindly at first, but is completed under A temple approach involves a full-thickness scalp incision in and the orbicularis oculi courses obliquely. Portions of these Endoscopic approach endoscopic control when approaching the orbital rim in order the temple, lateral to the temporal crest line.53 Knize improved muscles are removed. The procerus can be transected by dis- to avoid damaging the supraorbital nerve. Lateral to the zone and popularized this approach with dissection on the deep secting across the root of the nose. More than any other innovation, the introduction of endos- of fixation, dissection is done against the deep temporal fascia, temporal fascia, releasing of the lateral orbital rim, the The main disadvantages of this approach include potential copy to facial aesthetic surgery stimulated the quest for better with the inferior temporal septum and the sentinel vein used supraorbital rim, and the zone of fixation with using an endo- damage to sensory nerves (supraorbital and supratrochlear), understanding of forehead and temple anatomy. Basic ana- as landmarks for the position of the overlying temporal nerve scope (Fig. 7.28).14 After flap mobilization, fixation is done and increased bruising and edema compared to an isolated tomic principles are integral to the theory of endoscopic brow branches. The medial and lateral dissection pockets are then with sutures between the superficial and deep temporal upper lid blepharoplasty (Fig. 7.29). lifting. Laterally, brow lifting is accomplished by releasing all joined by going from lateral to medial. Soft tissue attachments fascia. If surgical modification of glabellar frown muscle mod- galeal attachments and relying on some method of mechani- along the lateral orbital rim and the supraorbital rim are then ification is desired, a transpalpebral approach can be used. Lateral brow approach cal fixation to maintain the scalp in a higher position. Medially, visualized and released. Dissection down the lateral orbital Disadvantages of this method include limited visibility of Video brow lifting happens passively by removing muscular depres- rim may be preperiosteal or subperiosteal. The supraorbital the central and medial supraorbital rim, and the fact that the The lateral brow approach utilizes a more medial incision 1 sors, and allowing the frontalis to lift unopposed. nerve is visualized during orbital rim release. If glabellar mus- fixation vector applied to the lateral eyebrow is oblique, rather than the temple approach. Its location is based on the observa- The principle advantages of the endoscopic brow lift are a culature is to be removed, the supratrochlear nerves are visu- than vertical, which may be inappropriate for some patients tion that the most effective vector for lateral brow lifting very good surgical exposure, magnification of the surgeon’s alized as they pass through the substance of the corrugator (Fig. 7.28). seems to be directly along the temporal crest line (Fig. 7.30). 104 SECTION I • 7 • Forehead rejuvenation Outcomes and complications 105

of planned fixation. Several sutures are then used to tether the mobilized brow in a more superior position, fixating the underside of the orbicularis to the periosteum. Alternate methods of fixation to bone can also be used. Overly tight Septum sutures must be avoided because of suture dimpling in the orbitale eyebrow. A more modest pexy is achieved if the cut edge of orbicularis oculi is simply suture to the orbital rim, with no superior dissection at all.59 Advantages of transpalpebral Corrugator supercilli browpexy are the ease of the procedure and a hidden scar. The principle disadvantage is the limited effect achieved and questionable longevity. Depressor supercilli Suture suspension browpexy

A number of methods have been developed to elevate the brow only using sutures, with no dissection at all. Methods Supratrochlear Fig. 7.31 The neurovascular bundle of the deep branch of the supraorbital nerve. include barbed sutures or suture loops which are placed nerve branches The subperiosteal pocket has been developed medially and the temporal pocket blindly through subcutaneous tunnels. The obvious advan- against the deep temporal fascia has been developed laterally. The two pockets are tage of these methods is extreme simplicity and relative safety, Supraorbital joined along the temporal crest line. When the lateral brow is raised, the while the principle drawback is their limited effect, and poor nerve branches neurovascular bundle will telescope up under the scalp closure. longevity.60

Fig. 7.29 Transpalpebral exposure of the frown musculature. galeal closure. The main advantages of this method are those Postoperative care of the endoscopic approach, plus the same strength of fixation provided by a coronal lift. The main disadvantage, compared Postoperative care for minor brow procedures is limited with the pure endoscopic approach, is a slightly longer to head elevation, cold packs, ointment application, and incision (Fig. 7.31). Fig. 7.32 Scar alopecia after coronal brow lift. analgesics. More extensive procedures (e.g., open coronal lift, endo- Direct suprabrow approach scopic lift) will require dressings and the possibility of drains for 24 h. Use of bupivacaine to block the supraorbital and Because the eyebrow is a cutaneous structure, the most effec- diagnosis. Once the decision has been made to raise all or part supratrochlear nerves is very helpful in decreasing the inci- of the brow complex, a myriad number of surgical procedures tive method to lift it would theoretically be a subcutaneous dence of postoperative headache. Patients can shower after approach done adjacent to the eyebrow itself. This simple are available. No one method can be considered best, but 48 h, with scalp suture removal in 7–10 days. rather, the surgical procedures must be chosen based on the technique was described almost a century ago. An excision After initial healing, measures can be adopted to prevent of full-thickness skin is done along the upper margin of individual patient’s needs. In addition, every surgeon will relapse of lateral brow ptosis. The use of botulinum toxin in have greater comfort with some procedures compared with the eyebrow, or alternatively within a deep forehead crease. the lateral orbicularis is helpful, as is the use of sunglasses On closure, there is initially a 1 : 1 relationship between the others, and it is incumbent on surgeons to carefully analyze and sun avoidance to prevent squinting in the first postopera- their results in order to give patients a realistic idea of what amount of skin removed and brow elevation, but the surgeon tive month. should plan for a 50% relapse in the first few months follow- can be expected. ing the procedure. The closer the incision is to the eyebrow, In addition to the aesthetic issues mentioned above, sur- gical complications of brow rejuvenation include scar alo- Fig. 7.30 Preoperative marking for modified lateral brow lift. The planned vector the less will be the relapse. The principle advantages of this technique are: the surgery is easy; it is well tolerated by the Outcomes and complications pecia, hematomas, infections, contour deformities, and nerve of pull is marked. Laterally, the purple dashed lines mark the expected course of damage (Fig. 7.32). the facial nerve temporal branches. The purple dot represents the sentinel vein. The patient; there is no scalp denervation; there is no risk to motor Significant problems with brow positioning and shape may curved purple line marks the temporal crest line which is accentuated when the nerves, and the result is relatively predictable. The surgical result of forehead rejuvenation depends on the patient clenches her teeth, contracting the temporalis. Medial to the crest line, The principle disadvantages of this method are the visible type of deformity, the procedure done and the quality of its be treated with secondary procedures. Alopecia due to hair the black cross hatched band is the expected course of the deep branch of the scar it creates and that fact that over time, brow depressing execution. follicle damage may be temporary, but if permanent can be supraorbital nerve, in purple. The corrugator supercilii, depressor supercilii and forces will once again stretch out the skin, causing a recur- Lesser procedures generally produce lesser results, but for treated with scar excision or hair grafting. procerus are marked in black. rence of brow ptosis. Certain individuals, especially older the individual patient with appropriate expectations, this may Hematomas are uncommon, but if they occur, are treated men with deep forehead creases, or thick eyebrows may be adequate. with drainage. Infections are rare, consistently reported at less More involved procedures afford the opportunity for than 1%, and are treated with wound care and appropriate be good candidates for this procedure, which can easily be 18 A variety of fixation methods can then be used including repeated if necessary. greater anatomic intervention, more dramatic results and antibiotics. Contour deformities can occur in areas of muscle simple scalp excision, deep temporal sutures, or fixation to potentially greater longevity. However, as our understanding excision; these problems are ideally prevented by the intraop- bone.56 The modified lateral brow lift is a hybrid procedure of the aging brow has progressed, it is clear that brow ptosis erative utilization of filling material such as fat or temporal utilizing a 5–6 cm incision in the scalp, approximately 1 cm Transpalpebral browpexy is not as significant a factor as was once thought, and there- fascia. If identified late, similar tissue can be added at a sepa- behind the hairline.16 Because the desired vector is directly fore, overly aggressive surgery can produce an exaggerated, rate procedure. along the course of the deep branch of the supraorbital nerve, During upper lid blepharoplasty, the ptotic lateral brow can un-aesthetic result. Historically, the main problems encoun- Sensory nerve damage is a common problem, and is uni- this procedure is designed to be nerve sparing. Orbital rim be addressed through the same upper lid incision.57,58 The tered by surgeons performing browlift procedures have been versal with some types of procedures. With coronal incisions, release can be done with or without an endoscope. A full- lateral portion of the superior orbital rim is easily exposed, aesthetic – in some cases overdoing the surgery and in other all posterior running sensory nerves are routinely transected. thickness excision of scalp is done (like an open coronal lift), and dissection proceeds superiorly over the frontal bone, cases, failing to achieve a predictable long term result. The resulting scalp denervation will extend to the vertex, but nerve branches are preserved as a neurovascular bundle. superficial to the periosteum. Dissection should continue for Every patient presents with a different set of challenges, the but will gradually improve, sometimes over several years. Fixation is accomplished with deep temporal sutures and by 2–4 cm above the orbital rim, or at least 1 cm above the level most important of which is to first make a proper aesthetic With limited incisions, sensory nerves may be traumatized 106 SECTION I • 7 • Forehead rejuvenation Secondary procedures 107

layers in the temple. A number of anatomic terms are 36. Matros E, Garcia JA, Yaremchuk MJ. Changes in introduced for the first time. eyebrow shape and position with aging. Plast Reconstr 26. Knize DM. Galea aponeurotica and temporal fascias. In: Surg. 2009;124(4):1296–1301. Knize DM, ed. Forehead and temporal fossa: anatomy and 41. Knize DM. Muscles that act on glabellar skin: A closer technique. Philadelphia: Lippincott Williams & Wilkins; look. Plast Reconstr Surg. 2000;105:350. 2001:45. 45. Gunter J, Antrobus S. Aesthetic analysis of the This text thoroughly presents the anatomy of the temporal eyebrows. Plast Reconstr Surg. 1997;99:1808–1816. fossa, the forehead and the soft tissues which relate The authors analyze the features of periorbital attractiveness. to the eyebrows. Knize combines several anatomical They conclude that eyebrow aesthetics must be considered in studies to summarize this anatomy, while several concert with the entire periorbital area, including the eyelids. additional authors contribute to the technique portions They describe novel ways to analyze eyes for attractiveness of the book. and identify eight features of attractive eyes.

Fig. 7.34 Over elevated medial brow after endoscopic brow lift.

Fig. 7.33 Temporary neurapraxia of left temporal branch after coronal brow lift.

due to traction, cautery, or instrumentation. Temporary neu- overly aggressive brow lift surgery can create an unaesthetic rapraxia of the supratrochlear nerves after frown muscle eyebrow shape, most frequently an over-elevation of the ablation is almost universal, with sensory return typically medial brow (Fig. 7.34). appearing by 2–3 weeks. Similarly, temporary neurapraxia of Minimal deformities can be corrected with botulinum the supraorbital rim is very common after a thorough release toxin in the central frontalis. If the medial brow has been of the supraorbital rim. aesthetically over-elevated, but the lateral brow remains The only motor nerve in the forehead is the temporal unelevated, the lateral brow can be elevated as a separate branch of the facial nerve, and damage to this nerve is the maneuver. most worrisome complication. Temporary neurapraxias are Alternatively, the medial brow can be lowered, a procedure relatively common, but permanent damage to the temporal which involves a full release of the scalp’s attachment to the branch is fortunately very rare. Should a neurapraxia develop, underlying skull, lowering of the medial brow, and bone watchful waiting is a must (Fig. 7.33). anchoring to the medial orbital rim.50 If there is simply a loss of effect from brow lift surgery, the situation can often be resolved to the patient’s satisfaction with a conservative upper lid blepharoplasty. However, if the Secondary procedures loss of effect is significant, repeat brow lifting may be neces- sary, preferably using a different technique and a different As mentioned above, minor issues such as areas of alopecia dissection plane. and contour deformities in the glabella, can be treated with In the case of a temporal branch palsy which does not simple procedures. improve with time, treatment options include applying botu- The most common reason for revision surgery after brow linum toxin to the normal side, or alternatively, performing surgery is to correct aesthetic deformities. Not infrequently, another brow lift on the affected side.

Access the complete references list online at http://www.expertconsult.com

1. Paul, MD. The evolution of the brow lift in aesthetic 22. Knize DM. An anatomically based study of the plastic surgery. Plast Reconstr Surg. 2001;108(5): mechanism of eyebrow ptosis. Plast Reconstr Surg. 1409–1424. 1996;97(7):1321–1333. In this paper, the author thoroughly reviews the published In this paper, the author presents the results of careful history of brow lift surgery, from 1919 to 2001. anatomic dissections to delineate the fascial structures which 14. Knize DM. Limited incision foreheadplasty. Plast govern eyebrow stability. Surgical implications are described Recontstr Surg. 1999;103:271–284. in the second paper in the same journal. 16. Warren RJ. The modified lateral brow lift. Aesthetic Surg 24. Moss CJ, Mendelson BC, Taylor I. Surgical anatomy J. 2009;29(2):158–166. of the ligamentous attachments in the temple and 20. Guyuron B, Kopal C, Michelow BJ. Stability after periorbital regions. Plast Reconstr Surg. 2000;105:4: endoscopic forehead surgery using single-point 1475–1490. fascia fixation. Plast Reconstr Surg. 2005;116: The authors describe a different way of describing fascial 1988. structures surrounding the orbit and creating structural References 107.e1 107.e2 SECTION I • 7 • Forehead rejuvenation

20. Guyuron B, Kopal C, Michelow BJ. Stability after relation to fascial planes: an anatomic study. 47. Miller TA, Rudkin G, Honig J, et al. Lateral References endoscopic forehead surgery using single-point fascia Plast Reconstr Surg. 2010;125:532. subcutaneous brow lift and interbrow muscle resection: fixation. Plast Reconstr Surg. 2005;116:1988. 35. Van Den Bosch W, Leenders I, Mukler P. Topographic clinical experience and anatomic studies. Plast Reconstr 1. Paul MD. The evolution of the brow lift in aesthetic 21. Graf RM, Tolazzi ARD, Mansur AEC, et al. Endoscopic anatomy of the eyelids and the effects of sex and age. Surg. 2000;105(3):1120–1127. plastic surgery. Plast Reconstr Surg. 2001;108(5): periosteal brow lift: evaluation and follow-up of Br J Ophthamol. 1999;83:348–352. 48. Guyuron B, Belmand RA, Green R. Shortening the long 1409–1424. eyebrow height. Plast Reconstr Surg. 2008;121(2):609. 36. Matros E, Garcia JA, Yaremchuk MJ. Changes in forehead. Plast Reconstr Surg. 1990;103; 218–223. In this paper, the author thoroughly reviews the published 22. Knize DM. An anatomically based study of the eyebrow shape and position with aging. Plast Reconstr 49. Marten T. Hairline lowering during foreheadplasty. history of brow lift surgery, from 1919 to 2001. mechanism of eyebrow ptosis. Plast Reconstr Surg. Surg. 2009;124(4):1296–1301. Plast Reconstr Surg. 1999;103:224–236. 2. Passot R. La chururgie esthetique dew rides du visage. 1996;97(7):1321–1333. 37. Lambros V. Observations on periorbital and midface 50. Yaremchuk MJ, O’Sullivan N, Benslimane F. Reversing Presse Med. 1919;27:258. In this paper, the author presents the results of careful aging. Plast Reconstr Surg. 2007;120:1367–1376. brow lifts. Aesthetic Surg J. 2007;27:367–375. 3. Hunt HL. Plastic surgery of the head, face, and neck. anatomic dissections to delineate the fascial structures which 38. Pessa JE, Chen Y. Curve analysis of the aging orbital 51. Eaves FF. Endoscopic brow lift surgery. In: Bostwick J, Philadelphia: Lea & Febiger; 1926. govern eyebrow stability. Surgical implications are described aperture. Plast Reconstr Surg. 2002;109:751–755. Eaves FF, Nahai F, et al., eds. Endoscopic plastic surgery. in the second paper in the same journal. 4. Lexer E. Die Gesamte Wiederherstellungs-Chirurgie. 39. Kahn DM, Shaw RB. Aging of the bony orbit: St Louis, MO: Quality Medical; 1994. Vols. 1 and 2. Leipzig: Jahann Ambrosius Barth; 1931. 23. Knize DM. Limited-incision forehead lift for eyebrow a three-dimensional computed tomographic study. 52. Rohrich RJ, Beran SJ, Evolving fixation methods elevation to enhance upper blepharoplasty. Plast 5. Claoue C. La ridectomie cervico-faciale par accrochage Aesthetic Surg J. 2008;28(3):258–264. in endoscopically assisted forehead rejuvenation: Reconstr Surg. 1996;97(7):134. parieto-temporo-occipital et resection cutanee. Bull Acad 40. Lemke BN, Stasior OG. The anatomy of eyebrow controversies and rationale. Plast Reconstr Surg. Med (Paris). 1933;109:257. 24. Moss CJ, Mendelson BC, Taylor I. Surgical anatomy optosis. Arch Ophthalmol. 1982;100:981. 1997;100(6):1575. of the ligamentous attachments in the temple and 6. Gonzalez-Ulloa M. Facial wrinkles: integral elimination. 41. Knize DM. Muscles that act on glabellar skin: A closer 53. Gleason MC. Brow lifting through a temporal scalp periorbital regions. Plast Reconstr Surg. 2000;105:4: Plast Reconstr Surg. 1962;29:658. look. Plast Reconstr Surg. 2000;105:350. approach. Plast Reconstr Surg. 1973;52:141–144. 1475–1490. 7. Vinas JC. Plan general de la ritidoplastia y zona tabu. 54. Knize DM. Transpalpebral approach to the corrugator The authors describe a different way of describing fascial 42. Flowers RS, Duval C. Blepharoplasty and periorbital Transactions of the 4th Brazilian Congress on Plastic supercilii and procerus muscles. Plast Reconstr Surg. structures surrounding the orbit and creating structural aesthetic surgery. In: Aston SJ, Beasley RW, Thorne Surgery, Porto Alegre, October 5–8, 1965:32. 1995;95(1):52–62. layers in the temple. A number of anatomic terms are CH, eds. Grabb and Smith’s plastic surgery. 5th ed. 8. Vinas JC, Caviglia C, Cortinas JL. Forehead introduced for the first time. Philadelphia: Lippincott-Raven; 1997:612. 55. Guyuron B, Michlow BJ, Thomas T. Corrugator rhytidoplasty and brow lifting. Plast Reconstr Surg. supercilii muscle resection through blepharoplasty 25. Isse N. Endoscopic anatomy of the forehead and 43. Knoll BI, Attkiss KJ, Persing JA. The influence of 1976;57:445. incision. Plast Reconstr Surg. 1995;96:691. temporal fossa. In: Knize DM, ed. Forehead and temporal forehead, brow, and periorbital aesthetics of perceived 9. Papillon J, Perras C, Tirkanits B. A comparative analysis of fossa: anatomy and technique. Philadelphia: Lippincott expression in the youthful face. Plast Reconstr Surg. 56. Tucillo F, Jacovella P, Zimman O, et al. An alternative forehead lift techniques. Presented at the Annual Meeting Williams & Wilkins; 2001:73. 2008;121:1793–1802. approach to brow lift fixation: temporoparietalis fascia, galeal, and periosteal imbrication. Plast Reconstr Surg. of the American Society for Aesthetic Plastic Surgery, 26. Knize DM. Galea aponeurotica and temporal fascias. In: 44. Warren RJ. Endoscopic Brow lift: Five-portal approach. 2007, 120(5):1433–1434. Boston, 1984. Knize DM, ed. Forehead and temporal fossa: anatomy and In: Nahai F, Saltz R, eds. Endoscopic plastic surgery. 2nd 10. Paul MD. The surgical management of upper eyelid technique. Philadelphia: Lippincott Williams & Wilkins; ed. St Louis, MO: Quality Medical; 2008:212. 57. Sokol AB, Sokol TP. Transblepharoplasty brow hooding. Aesthetic Plast Surg. 1989;13:183. 2001:45. 45. Gunter J, Antrobus S. Aesthetic analysis of the suspension. Plast Reconstr Surg. 1982;69:940. 11. Isse NG. Endoscopic forehead lift. Presented at the Annual This text thoroughly presents the anatomy of the temporal eyebrows. Plast Reconstr Surg. 1997;99:1808–1816. 58. McCord CD, Doxanas MT. Browplasty and browpexy: Meeting of the Los Angeles County Society of Plastic fossa, the forehead and the soft tissues which relate to the The authors analyze the features of periorbital attractiveness. an adjunct to blepharoplasty. Plast Reconstr Surg. Surgeons, Los Angeles, September 12, 1992. eyebrows. Knize combines several anatomical studies to They conclude that eyebrow aesthetics must be considered in 1990;86(2):248–254. 12. Vasconez LO. The use of the endoscope in brow lifting. summarize this anatomy, while several additional authors concert with the entire periorbital area, including the eyelids. 59. Zarem HA, Resnick RM, Carr DG. Browpexy: Lateral A video presentation at the Annual Meeting of the contribute to the technique portions of the book. They describe novel ways to analyze eyes for attractiveness orbicularis muscle fixation as an adjunct to upper American Society of Plastic and Reconstructive 27. Janis JE, Ghavami A, Lemmon JA, et al. Anatomy of and identify eight features of attractive eyes. blepharoplasty. Plast Reconstr Surg. 1997;100(5): Surgeons, Washington, DC, 1992. the corrugator supercilii muscle: Part I. Corrugator 46. Camirand A, Doucet J. A comparison between parallel 1258–1261. 13. Chajchir A. Endoscopia en cirugia plastica y estetica. topography. Plast Reconstr Surg. 2007;120(6):1647–1653. hairline incisions and perpendicular incisions when 60. Ruff GL. Suture suspension for face and neck. In: Aston In: Gonzalez Montaner LJ, Huriado Hoyo E, Altman R, 28. Beer GM, Putz R, Mager K, et al. Variations of the performing a face lift. Plast Reconstr Surg. 1997;99(1): SJ, Steinbrech DS, Walden JL, eds. Aesthetic plastic et al. eds. El Libro de Oro en Ho- menaje al Doctor Carlos frontal exit of the supraorbital nerve: an anatomic study. 10–15. surgery. London: Saunders Elsevier; 2009. Reussi. Buenos Aires: Associacion Medica Argentina; Plast Reconstr Surg. 1998;102(2):334–341. 1993:74. 29. Knize DM. A study of the supraorbital nerve. 14. Knize DM. Limited incision foreheadplasty. Plast Reconstr Surg. 1995;96:564. Plast Recontstr Surg. 1999;103:271–284. 30. Furnas DW. Landmarks for the trunk and the 15. Chiu ES, Baker DC. Endoscopic brow lift: A temporofacial division of the facial nerve. Br J Surg. retrospective review of 628 consecutive cases 1965;52:694. over 5 years. Plast Rectonstr Surg. 2003;112:628. 31. Pitanguy I, Ramos AS. The frontal branch of the facial 16. Warren RJ. The modified lateral brow lift. Aesthetic Surg nerve: the importance of its variation in face lifting. J. 2009;29(2):158–166. Plast Reconstr Surg. 1966;38:352. 17. Troilius C. Subperiosteal brow lifts without fixation. 32. Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy Plast Reconstr Surg. 2004;114:1595. of the frontal branch of the facial nerve: the significance 18. Jones BM, Grover R. Endoscopic brow lift: a personal of the temporal fat pad. Plast Reconstr Surg. 1989;83:256. review of 538 patients and comparison of fixation 33. Gosain AK, Sewall SR, Yousif NJ. The temporal branch techniques. Plast Reconstr Surg. 2004;113(4):1242–1250. of the facial nerve: how reliably can we predict its path? 19. Swift RW, Nolan WB, Aston SJ, et al. Endoscopic brow Plast Reconstr Surg. 1997;99:1224. lift: objective results after 1 year. Aesthetic Surg J. 34. Agarwa CA, Mendenhall MS, Foreman KB, et al. The 1999;19:287–292. course of the frontal branch of the facial nerve in SECTION I Aesthetic Surgery of the Face History 108.e1

applying these reconstructive principles and publishing the History first, reproducible cases of upper blepharoplasty. The con- cepts of herniated orbital fat pads were described shortly As far back as the 10th and 11th centuries, Arabian surgeons, thereafter by Sichel and Bourguet, respectively. Orbital fat Avicenna and Ibn Rashid, described the significance of excess pads were originally considered to be “circumscribed tumors” skin folds in impairing eyesight.1 Even at an early date, sur- of fat that made movement of the upper lid more difficult. It 8 geons had excised upper eyelid skin to improve vision. Texts was a rare condition found “most often in children”. Cosmetic published in the 18th and 19th centuries were the first to blepharoplasty entered a period of rapid growth and research describe and illustrate the upper eyelid aging deformities. The in the 1920–1930s. Contributions were made that described term, blepharoplasty, was coined by Von Graefe in 1818 to nearly 13 different approaches and closure methods. Recent describe reconstructive procedures employed following onco- variations in technique appear to have a basis in these early Blepharoplasty logic excisions. Several European surgeons developed recon- techniques, which have cycled in popularity over the last structive techniques for eyelid defects in the latter half of the decade. 19th century. Graefe and Mackenzie would be credited with Julius Few Jr. and Marco Ellis

traditional techniques may soon be deviating from a new SYNOPSIS standard of surgical care. It is this new standard that is advo- ᭿ Blepharoplasty is a vital part of facial rejuvenation. The traditional cated in this chapter. When they are understood and adopted, removal of tissue may or may not be the preferred approach when these new standards eliminate the classic complications and assessed in relation to modern cosmetic goals. risks associated with traditional techniques. ᭿ A thorough understanding of orbital and eyelid anatomy is Instead of the common practice of excising precious upper necessary to understand aging in the periorbital region, and to and, to a somewhat lesser degree, lower eyelid tissue, it is devise appropriate surgical strategies. preferable to focus on restoration of attractive, youthful ᭿ Preoperative assessment includes a review of the patient’s anatomy. To expect that the simple removal of tissue will perceptions, assessment of the patient’s anatomy, and an always result in beautiful or youthful eyes is unrealistic appropriate medical and ophthalmologic examination. because this may not fully correct the aging eye deformity. One should first conceptualize the desired outcome, then ᭿ Surgical techniques in blepharoplasty are numerous and should select and execute procedures accurately designed to achieve be tailored to the patient’s own unique anatomy and aesthetic those specific goals. For this task to be accomplished, several diagnosis. important principles are advocated (Box 8.1). Enthusiastically ᭿ Interrelated anatomic structures including the brow and the embraced, this approach is likely to result in excellent aes- infraorbital rim may need to be surgically addressed for an optimal thetic quality of surgical outcomes. outcome.

Access the Historical Perspective section online at http://www.expertconsult.com Basic science/disease process Essential and dynamic anatomy

Introduction It is an absolute necessity that the surgeon understands the essential and dynamic periorbital anatomy to effect superior Properly performed aesthetic periorbital surgery is one of the aesthetic and functional surgical results. No surgeon should most rejuvenating of all facial surgeries performed today. perform surgery without fully understanding the aesthetic Properly conceived and executed, it proves a tremendous and functional consequences of the choices.2–5 source of joy for both surgeon and patient. Done poorly, it can lead to a lifetime of disfigurement and functional problems Osteology and periorbita for the patient, sleepless nights for the surgeon, and dissatis- faction for both participants. The problem is magnified The orbits are pyramids formed by the frontal, sphenoid, because aesthetic periorbital surgical procedures are among maxillary, zygomatic, lacrimal, palatine, and ethmoid bones the most commonly performed in plastic surgery practices. (Fig. 8.1). The periosteal covering or periorbita is most firmly Traditional methods of aesthetic periorbital surgery often attached at the suture lines and the circumferential anterior produce suboptimal results. A departure from the standard orbital rim. The investing orbital septum in turn attaches to techniques of the past is recommended. Most plastic surgeons the periorbita of the orbital rim, forming a thickened perim- know there is a better way, and those who persist with eter known as the arcus marginalis. This structure reduces the ©2013, Elsevier Inc. All rights reserved. Basic science/disease process 109 110 SECTION I • 8 • Blepharoplasty

Supraorbital fissure Frontal bone Supraorbital foramen Medial canthal tendon Orbicularis fascia Temporalis Superior orbital ridge Medial check retinaculum Orbicularis Lateral orbital thickening Fossa for lacrimal sac Zygomatic bone Lateral canthal tendon Lateral canthal tendon Lateral check retinaculum

Optic foramen Greater wing Frontal bone of sphenoid Ethmoid Tenon’s capsule Whitnall’s tubercle Zygomatic Lacrimal bone Lateral canthal tendon Infraorbital and fossa Medial rectus and sheath fissure Maxilla ‘Tarsal strap’ Lateral rectus and sheath Periorbita

Coronoid process of mandible Maxilla bone Tarsal plates Infraorbital foramen Fig. 8.2 Horizontal section of the orbit showing the lateral retinaculum formed by Orbital septum Zygomaticofacial foramen the lateral horn of the levator, lateral canthal tendon, tarsal strap, the Lockwood Fig. 8.3 Lateral canthal tendon has separate superficial and deep components. The suspensory ligament, and lateral rectus check ligaments. deep component attaches inside the orbital rim at Whitnall’s tubercle. The superficial component passes from the tarsal plates to the periosteum of the lateral orbital rim and lateral orbital thickening. Both components are continuous with both superior and inferior lid tarsal plates. (Adapted from Muzaffar AR, Mendelson BC, Tarsus Fig. 8.1 Orbital bones. Frontal view of the orbit with foramina. Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002; 110(3):873–884.) Fig. 8.4 The deep portion of the lateral canthal tendon inserts securely into the thickened periosteum overlying Whitnall’s tubercle. The tarsal strap is a distinct Lateral retinaculum anatomic structure that suspends the tarsus medial and inferior to the lateral canthal Box 8.1 Principles for restoration of youthful eyes tendon to lateral orbital wall, approximately 4–5 mm from the orbital rim. • Control of periorbital aesthetics by proper brow positioning, Anchored to the lateral orbit is a labyrinth of connective tissues that are crucial to maintenance of the integrity, posi- Posterior limb, medial canthal tendon corrugator muscle removal, and lid fold invagination when Superciliary corrugator beneficial. tion, and function of the globe and periorbital. Understanding Frontalis Procerus • Restoration of tone and position of the lateral canthus and, along how to effectively restore these structures is key to periocular Superior limb, medial canthal tendon with it, restoration of a youthful and attractive intercanthal axis tilt. rejuvenation by canthopexy. These structures, known as the • Restoration of the tone and posture of the lower lids. lateral retinaculum, coalesce at the lateral orbit and support • Preservation of maximal lid skin and muscle (so essential to lid the globe and eyelids like a hammock (Fig. 8.2).8–10 The lateral Anterior limb, medial canthal tendon function and aesthetics) as well as orbital fat. retinaculum consists of the lateral canthal tendon, tarsal strap, Lacrimal fossa • Lifting of the midface through reinforced canthopexy, preferably lateral horn of the levator aponeurosis, the Lockwood suspen- Anterior and posterior lacrimal crests Orbicularis oculi enhanced by composite malar advancement. sory ligament, Whitnall’s ligament, and check ligaments of • Correction of suborbital malar grooves with tear trough (or the lateral rectus muscle. They converge and insert securely Pretarsal suborbital malar) implants, obliterating the deforming tear trough orbicularis (bony) depressions that angle down diagonally across the cheek, into the thickened periosteum overlying the Whitnall which begin below the inner canthus. tubercle. Controversy exists surrounding the naming of the • Control of orbital fat by septal restraint or quantity reduction. components of the lateral canthal tendon. Recent cadaveric Preseptal orbicularis • Removal of only that tissue (skin, muscle, fat) that is truly dissections suggest that the lateral canthal tendon has dual excessive on the upper and lower lids, sometimes resorting to insertions. A superficial component is continuous with the Fig. 8.5 The medial canthal tendon envelops the lacrimal sac. It is tripartite, with unconventional excision patterns. orbicularis oculi fascia and attaches to the lateral orbital rim anterior, posterior and superior limbs. Like the lateral canthal tendon, its limbs are continuous with tarsal plates. The components of this tendon along with its lateral • Modification of skin to remove prominent wrinkling and excision and deep temporal fascia by means of the lateral orbital thick- counterpart are enveloped by deep and superficial aspects of the orbicularis of small growths and blemishes. ening. A deep component connects directly to the Whitnall muscle. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular tubercle is classically known as the lateral canthal tendon Surgery. Philadelphia: Saunders; 2004:13.) (Fig. 8.3).11 In addition, the tarsal strap is a distinct anatomic structure Fig. 8.6 Facial muscles of the orbital region. Note that the preseptal and pretarsal orbicularis muscles fuse with the medial and lateral canthal tendons. that inserts into the tarsus medial and inferior to the lateral perimeter and diameter of the orbital aperture and is thickest canthal tendon.12 In contrast to the canthal tendon, the thick in the superior and lateral aspects of the orbital rim.6 tarsal strap is relatively resistant to laxity changes seen with Medial orbital vault Forehead and temporal region Certain structures must be avoided during upper lid aging. The tarsal strap attaches approximately 3 mm inferi- surgery. The lacrimal gland, located in the superolateral orbit orly and 1 mm posteriorly to the deep lateral canthal tendon, A hammock of fibrous condensations suspends the globe The forehead and brow consist of four layers: skin, subcutane- deep to its anterior rim, often descends beneath the orbital approximately 4–5 mm from the anterior orbital rim. It short- above the orbital floor. The medial components of the appa- ous tissue, muscle, and galea. There are four distinct brow rim, prolapsing into the postseptal upper lid in many persons. ens in response to lid laxity, benefiting from release during ratus include medial canthal tendon, the Lockwood suspen- muscles: frontalis, procerus, corrugator superciliaris, and During surgery, the gland can be confused with the lateral surgery to help achieve a long-lasting restoration or elevation sory ligament and check ligaments of the medial rectus. The orbicularis oculi (Fig. 8.6). The frontalis muscle inserts pre- extension of the central fat pad destined for removal during canthopexy (Fig. 8.4). Adequate release of the tarsal strap medial canthal tendon, like the lateral canthal tendon, has dominately into the medial half or two-thirds of the eyebrow aesthetic blepharoplasty. The trochlea is located 5 mm poste- permits a tension-free canthopexy, minimizing the downward separate limbs that attach the tarsal plates to the ethmoid and (Fig. 8.7), allowing the lateral brow to drop hopelessly ptotic rior to the superonasal orbital rim and is attached to the tethering force of this fibrous condensation. This release along lacrimal bones.13 Each limb inserts onto the periorbital of the from aging, while the medial brow responds to frontalis acti- periorbital. Disruption of this structure can cause motility with a superior reattachment of the lateral canthal tendon is apex of the lacrimal fossa. The anterior limb provides the bulk vation and elevates, often excessively in its drive to clear the problems.7 key to a successful canthopexy. of the medial globe support (Fig. 8.5). lateral overhand. Constant contraction of the frontalis will Basic science/disease process 111 112 SECTION I • 8 • Blepharoplasty

Frontalis The levator palpebrae superioris muscle originates above of the capsulopalpebral fascia during lower lid procedures, Levator palpebrae the annulus of Zinn. It extends anteriorly for 40 mm before particularly transconjunctival blepharoplasty, releases the Superior rectus becoming a tendinous aponeurosis below Whitnall’s liga- retractors of the lower eyelid, which can reduce downward ment.7,16 The aponeurosis fans out medially and laterally to traction and allow the position of the lower lid margin to rise. attach to the orbital retinacula. The aponeurosis fuses with the orbital septum above the superior border of the tarsus and at Retaining ligaments Orbicularis oculi the caudal extent of the sling, sending fibrous strands to the Muller’s muscle dermis to form the lid crease. Extensions of the aponeurosis A network of ligaments serves as a scaffold for the skin and finally insert into the anterior and inferior tarsus. As the subcutaneous tissue surrounding the orbit. The orbital retain- levator aponeurosis undergoes senile attenuation, the lid ing ligament directly attaches the orbicularis at the junction Upper tarsal plate crease rises into the superior orbit from its remaining dermal of its orbital and preseptal components to the periosteum of attachments while the lid margin drops. the orbital rim and, consequently, separates the prezygomatic Müller’s muscle, or the supratarsal muscle, originates on space from the preseptal space. This ligament is continuous the deep surface of the levator near the point where the muscle with the lateral orbital thickening, which inserts onto the becomes aponeurotic and inserts into the superior tarsus. lateral orbital rim and deep temporal fascia. It also has attach- Capsulopalpebral fascia Dehiscence of the attachment of the levator aponeurosis to the ments to the superficial lateral canthal tendon (Figs 8.3, 8.12, Lockwood’s ligament tarsus results in an acquired ptosis only after the Müller’s 8.13).20 Attenuation of these ligaments permit descent of muscle attenuates and loses its integrity.14 orbital fat onto the cheek. A midfacelift must release these In the Asian eyelid, fusion of the levator and septum com- ligaments to achieve a supported, lasting lift.21 monly occurs at a lower level, allowing the sling and fat to Inferior rectus descend farther into the lid.15,16 This lower descent of fat Blood supply creates the characteristic fullness of their upper eyelid. In addition, the aponeurotic fibers form a weaker attachment The internal and external carotid arteries supply blood to the Fig. 8.9 Eyelid anatomy. Each eyelid consists of an anterior lamella of skin and to the dermis, resulting in a less distinct lid fold (Fig. 8.10). orbit and eyelids (Fig. 8.14). The ophthalmic artery is the first orbicularis muscle and a posterior lamella of tarsus and conjunctiva. The orbital intracranial branch of the internal carotid; its branches supply septum forms the anterior border of the orbital fat. Septal extension the globe, extraocular muscles, lacrimal gland, ethmoid, upper eyelids, and forehead. The external carotid artery the horizontal wrinkles at the root of the nose. More com- Fig. 8.7 The frontalis muscle inserts predominantly into the medial half or The orbital septum has an adhesion to the levator aponeurosis branches into the superficial temporal and maxillary arteries. monly, these wrinkles result from brow ptosis and correct two-thirds of the eyebrow. The medial brow responds to frontalis activation and above the tarsus. The septum continues beyond this adhesion The infraorbital artery is a continuation of the maxillary artery elevates, often excessively, in its drive to clear lateral overhang. spontaneously with brow elevation. and extends to the ciliary margin. It is superficial to the and exits 8 mm below the inferomedial orbital rim to supply The obliquely oriented corrugators muscle arises from preaponeurotic fat found at the supratarsal crease. The septal the lower eyelid.22 the frontal bone and inserts into the brow tissue laterally, Diagonal lines extension is a dynamic component to the motor apparatus, as The arcade of the superior and inferior palpebral arteries with some extensions into orbicularis and frontalis muscula- traction on this fibrous sheet reproducibly alters ciliary margin gives a rich blood supply to the eyelids. The superior palpe- ture, forming vertical glabellar furrows during contraction. position (Fig. 8.11). The septal extension serves as an adjunct bral artery consists of a peripheral arcade located at the Wrinkles from procerus and corrugators contraction can to, and does not operate independent of, levator function, as superior tarsal border – the area where surgical dissection worsen significantly after upper lid tissue excision as a result mistaking the septal extension for levator apparatus and pli- occurs to correct lid ptosis and to define lid folds. Damage to of the frontalis muscle’s relaxing after being relieved of the 17 cating this layer solely results in failed ptosis correction. a vessel within this network commonly results in a hema- need to clear the obstructing lid skin.14 toma of Müller’s muscle, causing lid ptosis for 2–8 weeks Eyelids Lower eyelid postoperatively. Likewise, on the lower lid, the inferior palpe- bral artery lies at the inferior border of the inferior tarsus. The eyelids are vital, irreplaceable structures that serve to The anatomy of the lower eyelid is somewhat analogous to The supratrochlear, dorsal nasal, and medial palpebral protect the globes. Their shutter-like mechanism is essential that of the upper eyelid. The retractors of the lower lid, the arteries all traverse the orbit medially. Severing these arteries to clean, lubricate, and protect the cornea. Any disruption or capsulopalpebral fascia, correspond to the levator above. The during fat removal, without adequately providing hemosta- restriction of eyelid closure will have significant consequences capsulopalpebral head splits to surround and fuse with sis, may lead to a retrobulbar hematoma, a vision-threatening for both the patient and the surgeon. the sheath of the inferior oblique muscle. The two heads fuse complication of blepharoplasty. There is much similarity between upper and lower eyelid to form the Lockwood suspensory ligament, which is analo- anatomy. Each consists of an anterior lamella of skin and gous to Whitnall’s ligament. The capsulopalpebral fascia Innervation: trigeminal nerve and facial nerve orbicularis muscle and a posterior lamella of tarsus and con- fuses with the orbital septum 5 mm below the tarsal border 15 and then inserts into the anterior and inferior surface of the The trigeminal nerve along with its branches provides sen- junctiva (Fig. 8.9). 18 Fig. 8.8 Frontalis action. The frontalis muscle inserts into the medial two thirds of The orbicularis muscle, which acts as a sphincter for the tarsus. The inferior tarsal muscle is analogous to Muller’s sory innervations to the periorbital region (Fig. 8.15). The the brow. Exaggerated medial brow elevation is required to clear the lateral eyelids, consists of orbital, preseptal, and pretarsal segments. muscle of the upper eyelid and also arises from the sheath of ophthalmic division enters the orbit and divides into the overhang and to eliminate visual obstruction. Constant contraction of the frontalis The pretarsal muscle segment fuses with the lateral canthal the inferior rectus muscle. It runs anteriorly above the inferior frontal, nasociliary, and lacrimal nerves. The terminal branch will give the appearance of deep horizontal creases in the forehead. This necessarily tendon and attaches laterally to Whitnall tubercle. Medially it oblique muscle and also attaches to the inferior tarsal border. of the nasociliary nerve, the infratrochlear nerve, supplies means that when the lateral skin is elevated or excised, the over-elevated and The combination of the orbital septum, orbicularis, and the medial conjunctiva, and lacrimal sac. The lacrimal nerve distorted medial brow drops profoundly. forms two heads, which insert into the anterior and posterior lacrimal crests (Fig. 8.6). skin of the lower lid acts as the anterior barrier of the orbital supplies the lateral conjunctiva and skin of the lateral upper fat. As these connective tissue properties relax, the orbital fat eyelid. The frontal nerve, the largest branch, divides into give the appearance of deep horizontal creases in the forehead Upper eyelid is allowed to herniate forward, forming an unpleasing, full the supraorbital and supratrochlear branches. The supraor- (Fig. 8.8).3 lower eyelid. This relative loss of orbital volume leads to a bital nerve exits through either a notch or a foramen and The vertically oriented procerus is a medial muscle, often The orbital septum originates superiorly at the arcus and commensurate, progressive hollowing of the upper lid as provides sensory innervations to the skin and conjunctiva continuous with the frontalis, arising from the nasal bones forms the anterior border of the orbit. It joins with the levator upper eyelid fat recesses.19 of the upper eyelid and the scalp. The supratrochlear nerve and inserting into the subcutaneous tissue of the glabellar aponeurosis, just superior to the tarsus. The sling formed by The capsulopalpebral fascia and its overlying conjunctiva innervates the skin of the glabella, forehead, medial upper region. It pulls the medial brow inferiorly and contributes to the union of these two structures houses the orbital fat. form the posterior border of the lower orbital fat. Transection eyelid, and medial conjunctiva. A well-placed supraorbital 114 SECTION I • 8 • Blepharoplasty

Orbicularis retaining ligament Corrugator supercilii Maxilla bone Orbicularis oculi 6–8mm Frontal bone Nasal bone Occidental

Orbicularis

Orbital A septum

Muller’s muscle

Levator aponeurosis 8–13mm Septal Deep set extension (levator dehiscence) Tarsus Lateral orbital thickening Zygomatic bone Orbicularis retaining ligament

Fig. 8.12 The orbicularis muscle fascia attaches to the skeleton along the orbital rim by the lateral orbital thickening (LOT) in continuity with the orbicularis retaining ligament (ORL). (Adapted from Ghavami A, Pessa JE, Janis J, et al. The orbicularis B retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg 2008; 121(3):994–1001.)

Fig. 8.11 The orbital septum has an adhesion to the levator aponeurosis above the tarsus. The septal extension begins at the adhesion of the orbital septum to the Medial palpebral artery (superior) 1. Peripheral arcade levator and extends to the ciliary margin. It is superficial to the preaponeurotic fat Supraorbital artery 2. Marginal arcade found at the supratarsal crease. (Adapted from Reid RR, Said HK, Yu M, et al. Revisiting upper eyelid anatomy: introduction of the septal extension. Plast Reconstr Baggy eyelid Surg 2006; 117(1):65–70.) Superficial temporal Supratrochlear artery 0 to minimum artery Lacrimal artery Dorsal nasal artery Angular artery Medial palpebral artery (inferior) Lateral nasal artery Zygomaticofacial artery Inferior palpebral artery C Transverse facial artery

Infraorbital artery Facial artery Globe Fig. 8.14 Arterial supply to the periorbital region.

Asian Lacrimal nerve Supraorbital nerve 0 to minimum Supratrochlear nerve Septum orbitale Orbitomalar ligament

Zygomaticotemporal Infratrochlear nerve Pre-zygomatic space nerve D Orbicularis oculi

Zygomaticofacial Fig. 8.10 The anatomic variations in the upper eyelid displayed by different ethnic groups and the changes associated with senescence within each group allow for a nerve convergence of anatomy. (A) The occidental upper eyelid has levator extensions inserting onto the skin surface to define a lid-fold that averages 6–8 mm above the lid Fig. 8.13 The orbital retaining ligament (ORL) directly attaches the orbicularis oris Infraorbital nerve margin. The position of the levator-skin linkage and the anteroposterior relationship of the preaponeurotic fat determine lid-fold height and degree of sulcus concavity or (OO) at the junction of its pars palpebrarum and pars orbitalis to the periosteum convexity (as shown on the right half of each anatomic depiction). (B) In the case of levator dehiscence from the tarsal plate, the upper lid crease is displaced superiorly. of the orbital rim and, consequently, separates the prezygomatic space from the The orbital septum and preaponeurotic fat linked to the levator are displaced superiorly and posteriorly. These anatomic changes create a high lid crease, a deep superior preseptal space. (Adapted from Muzaffar AR, Mendelson BC, Adams WP Jr. sulcus, and eyelid ptosis. (C) In the aging eyelid, the septum becomes attenuated and stretches. The septal extension loosens, and this allows orbital fat to prolapsed Surgical anatomy of the ligamentous attachments of the lower lid and lateral forward and slide over the levator into an anterior and inferior position. Clinically, this results in an inferior displacement of the levator skin attachments and a low and canthus. Plast Reconstr Surg 2002; 110(3):873–884.) Fig. 8.15 Sensory nerves of the eyelids. anterior position of the preaponeurotic fat pad. (D) The youthful Asian eyelid anatomically resembles the senescent upper lid with a low levator skin zone of adhesion and inferior and anteriorly located preaponeurotic fat. The characteristic, but variable, low eyelid crease and convex upper eyelid and sulcus are classic. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:59.) Basic science/disease process 115 116 SECTION I • 8 • Blepharoplasty

Temporal branches (facial nerve VIII) African-American populations. Such upward tilt of the lateral canthal axis may give the eye a youthful appearance, which Diagnosis/patient presentation is aesthetically pleasing in any ethnic group. The lower lid that droops in its lateral aspect and the eye with a downward Evaluation basics 3–5X tilt generally convey to the viewer an aging, ill-health distor- tion or unattractiveness.25 X The first essential step is to look at the patient carefully, thor- oughly, and critically. The surgeon should be seated directly in front of the prospective patient with the patient’s eyes at Etiology of aging his or her eye level. Note the general impression and feeling generated from looking at this person (Fig. 8.19). In the upper lid, excessive skin due to loss of elasticity and One should also look for areas of symmetry or asymmetry. sun damage is one of the major causes of an aged appearance Notice the shape of the eye; the prominence or asymmetry of in the periorbital area. If there is an excess of skin that hangs the globes; and evidence of exposure, dryness, or injection of over the lid or the upper eyelid appears to have multiple vessels. Look for evidence of decreased tone and dropped folds, it is difficult to have a rejuvenated appearance with posture of the lower lids. What is the posture of the upper lid? cosmetics alone. In addition to relaxed skin changes, excessive Are the upper lids symmetric? Is there lid ptosis? At what fat herniation can cause bulging, resulting in a heavy appear- level does the upper lid traverse the globe? What levels do Zygomatic branches (facial nerve VIII) ance to the upper lid area. Although this fat is normal orbital the upper and lower lids sit in relation to the limbus? fat, it appears to be protruding outward because of the laxity Next, have the patient relax the brow and close the eyes. Fig. 8.16 Anatomy of the brow and temporal region. The light green opaque area Fig. 8.17 On relaxed forward gaze, the ideal upper lid should rest approximately of the orbital septum, which holds the fat in place. Theoretically, Do the lids close? Then ask the patient to open the eyes. Is it denotes the deep temporal fascia and the periosteum where sutures may be used to 2 mm below the upper limbus. The lower lid ideally covers 0.5 mm of the lower replacement of the fat into a position that maintains a normal necessary to raise the brows to effect comfortable forward suspend soft tissue. Wide undermining, soft tissue suspension and canthopexy are limbus. The ratio of distance from the lower edge of the eyebrow to the open lid level of fat in the orbital area seems an optimal solution. vision? Does the corrugator frown increase in prominence safely performed here. margin to the pretarsal skin ratio should be greater than 3. However, this is not easily accomplished and may result in with the eyes closed and the forehead relaxed? Is there trans- complications that are difficult to correct. Therefore, the skin verse brow wrinkling? Is one brow lower? Which one and and fat that seem to be in apparent excess should be treated how much? Is there a prominent frown? block will anesthetize most of the upper lid and the central surgical maneuvers. Attractive, youthful eyes are bright eyes. accordingly. Assess the lower lid tone by pulling the lid away from the 6,14,23 precoronal scalp. Bright eyes have globes framed in generously sized horizontal The etiology of aging changes in the lower lids is similar globe and releasing, making sure the patient does not blink The maxillary division exits the orbit through one to three apertures (from medial and lateral), often accentuated by a in some ways but quite different in others. Aging changes (modified snap test). Does each lid spring back immediately, infraorbital foramina. It provides sensation to the skin of the slight upward tilt of the intercanthal axis (Fig. 8.17). The aper- include relaxation of the tarsal margin with scleral show, reluctantly, or not at all? Is it held against the globe by only nose, the lower eyelids, and the upper lid. Dissection is neces- ture length should span most of the distance between the rhytides of the lower lid, herniated fat pads resulting in the tear seal? Most people presenting for blepharoplasty sary lateral to the infraorbital nerve for successful midface- orbital rims. In a relaxed forward gaze, the vertical height of bulging in one or all of the three fat pocket areas, and hollow- have a significant decrease in their lower lid tone, often lifting and around the nerve for placement of tear trough the aperture should expose at least three-quarters of the ing of the nasojugal groove and lateral orbital rim areas. asymmetric. implants. cornea with the upper lid extending down at least 1.5 mm Hollowing of the nasojugal groove area appears as dark What, if anything, would improve the aesthetic appearance The facial nerve exits the stylomastoid foramen and divides below the upper limbus (the upper margin of the cornea) but circles under the eyes, mostly because of lighting and the 26 of the eyes and periorbital region? Are there festoons or deep in the substance of the parotid gland into the superior tempo- no more than 3 mm. The lower lid ideally covers 0.5 mm of shadowing that result from this defect (Fig. 8.18). It is clear grooves (i.e., nasojugal grooves or tear trough deformities)? 4,15 rofacial and inferior cervicofacial branches (Fig. 8.16). The the lower limbus but no more than 1.5 mm. that evaluation of all aspects of aging changes in the lids is Is there excess skin, muscle, or fat? Quantitate any excess soft temporofacial nerve divides into the frontal, zygomatic, and In the upper lid, there should be a well-defined lid crease important so the surgeon can plan the most effective operative tissue on a simple eye diagram. Does restoration of lateral buccal nerves; the cervicofacial nerve divides into the buccal, lying above the lid margin with lid skin under slight stretch, procedure. canthal posture correct the illusion of excess skin on the lower mandibular, and cervical nerves. There are significant varia- slightly wider laterally. Ideally, the actual pretarsal skin visu- eyelid? Does it diminish it? Does the orbital septum appear tions in the branching of the facial nerve, which is responsible alized on relaxed forward gaze ranges from 3 to 6 mm in to be excessively relaxed? Note the tilt of the intercanthal axis for facial expression. Innervation of facial muscles occurs on European ethnicities. The Asian lid crease is generally 2–3 mm or lack thereof. their deep surfaces. Interruption of the branches to the orbicu- lower, with the distance from lid margin diminishing as The “four-finger lift” is performed by encircling the outer laris muscle from the periorbital surgery or facial surgery may the crease moves toward the inner canthus. Patients of Indo- orbit with the tips of the index, middle, ring and little fingers result in atonicity due to partial denervation of the orbicularis European and African decent show 1 to 2 mm lower than on one hand. With the index and middle fingers above the with loss of lid tone or anomalous reinnervation and possibly European ethnicities. The ratio of distance from the lower lateral brow, place the ring finger lateral to the canthus and 15 undesirable eyelid twitching. edge of the eyebrow (at the center of the globe) to the open little finger beneath the lateral canthus just lateral to the malar The frontal branch of the facial nerve courses immedi- lid margin to the visualized pretarsal skin should never be prominence. Gently move the four fingers posteriorly and ately above and attached to the periosteum of the zygomatic less than 3–1 (Fig. 8.1), preferably more. superiorly to lift the lateral brow, canthus, and cheek. If this bone. It then courses medially approximately 2 cm above the Scleral show is the appearance of white sclera below test restores youthfulness and attractiveness, a canthopexy, superior orbital rim to innervate the frontalis, corrugators, the lower border of the cornea and above the lower eyelid brow lift, and midfacelift may be beneficial. and procerus muscles from their deep surface. A separate margin. In general, sclera show is contradictory to optimal branch travels along the inferior border of the zygoma to aesthetics and may be perceived as a sign of aging, previous innervate the inferior component of orbicularis oculi.24 The blepharoplasty, or orbital disease (e.g., thyroid disease). Medical and ophthalmic history surgeon should take great care when operating in this area More than 0.5 mm of sclera show beneath the cornea on to avoid damaging this nerve during endoscopic and open direct forward gaze begins to confer a sad or melancholy A thorough history and physical examination should be brow lifts. aura to one’s appearance. However, in some youthful per- performed before surgery (Box 8.2). In addition, an adequate sons, the largeness of these apertures gives dramatic emphasis eye history encourages positive outcomes and reduces eye to the eyes and may be considered a strong and positive complications. Youthful, beautiful eyes Fig. 8.18 Morphed digital photography (split right half = current preoperative feature. photograph, split left half = photograph 20 years ago), demonstrating descent of Contact lens wear poses particular risks when eyelid The characteristics of youthful, beautiful eyes differ from one The intercanthal axis is normally tilted slightly upward periorbital fat and skin during the aging process. (From Odunze MO, Reid RR, Yu M, surgery is performed. The natural progression of aging dries population to another but generalizations are possible and (from medial to lateral) in most populations. Exaggerated et al. Periorbital rejuvenation and the African-American patient: a survey approach. the eyes out, and long-term contact lens wearing hastens this provide a needed reference to judge the success of various tilts are encountered in some Asian, Indo-European and Plast Reconstr Surg 2006; 118:1011–1018.) process considerably. Traditional blepharoplasty techniques Diagnosis/patient presentation 117 118 SECTION I • 8 • Blepharoplasty

and can increase the tension of the lid against the cornea, lesions about the eyes, especially those that rise above the lid affecting corneal curvature. It can cause conjunctival chemosis margin. Any cancerous (or precancerous) lesions must be or produce corneal erosion early postoperatively. Dry eye removed before any aesthetic procedure is performed to pre- exposure problems are most prevalent in patients who have serve eyelid skin for reconstruction, if needed. undergone LASIK surgery because the flap disrupts corneal Eyelid measurements are documented for use during ptosis innervations, forming an anesthetic effect that suppresses surgery and, if necessary, for insurance purposes. In the tear production. When in doubt, such patients should be eyelid of the white individual, the aperture (distance between reviewed by their refractive surgeon before undergoing the upper and lower eyelids) average 10–12 mm. The margin blepharoplasty. reflex distance (MRD), measured from the light reflex on the One should check for a history of other eye procedures, center of the cornea to the upper eyelid margin, ranges from Laxity of the orbital septum including glaucoma surgery (forms a bleb of conjunctival 3 to 5 mm. True blepharoptosis is defined by the degree tissue on the superior limbus), retinal, strabismus, and cata- of upper lid infringement upon the iris and pupil. As the ract surgery. Evaluate carefully for a history as well as physi- MRD decreases towards zero, the severity of blepharoptosis Laxity and descent of the orbicularis oculi cal evidence of facial muscle weakness, extraocular muscle increases. Before method selection, the levator function must imbalance, Bell palsy, or trauma in addition to orbicularis be determined by measuring the upper eyelid excursion from hyperactivity such as blepharospasm or hemifacial spasm. extreme downward gaze to extreme upward gaze; it generally Descent of the lid-cheek junction Any ocular condition may affect the type or result of eyelid ranges from 10 to 12 mm. If ptosis exists, the type of repair surgery.29 depends upon the severity of the ptosis and the reliability Superior or lateral visual field loss suggests functional of the levator to recreate smooth, upper lid elevation. A deep Descent of the check fat pad with laxity of the orbitomalar ligament ptosis or pseudoptosis. A 12–20 degree or a 30% improvement upper lid sulcus with a high lid fold in the presence of a of the superior visual field, between a taped and untaped droopy eyelid usually indicated a levator dehiscence, which Laxity of the SMAS covering zygomaticus muscles 31,32 and other elevators of the upper lip upper lid, may qualify for medical necessity. is often unilateral or asymmetric. Chronic eye irritation, such as tearing, dryness, excessive Pseudoptosis occurs when excess upper lid skin covers the Deepening of the nasolabial fold blinking, discharge, eyelid margin inflammation, crusting, eyelid, depressing the eyelashes, forming hooding and simu- burning, or itching, must be brought under control before any lating ptosis. It is easily differentiated from true ptosis by surgery. Dry eyes should be aggressively sought out and simply elevating the brow or the hooded skin itself to deter- 33 Jowl formation treated before surgery. mine the true resting lid level. Photographic evidence of this Dry irritated eyes before surgery will lead to irritated eyes is often necessary for insurance purposes when a levator after surgery, and the surgeon may be blamed. On question- aponeurosis repair or a excisional blepharoplasty is planned. ing, most patients will rarely admit to dry eyes, although it is When the hooded skin hangs over the lashes, the lashes turn known that the eyes dry out considerably throughout our downward and sometimes interfere with vision or rub against lifetime. Treatment options include artificial tears, ointment, the cornea. True trichiasis (misdirected lashes) may also exist, anti-inflammatory drops, and punctal plugs or punctal but inward-turning lashes can be trained to return to their closure.29,30 natural posture after eyelid repair with lash rotation. Exophthalmos, unilaterally or bilaterally, associated with a Brow ptosis is a common aspect of facial aging. It adds thyroid disorder should be completely stabilized for approxi- weight and volume to the upper eyelid to develop, or exacer- mately 6 months before elective aesthetic surgery. However, bate, eyelid ptosis. The more ptotic brow is often selectively Fig. 8.19 Mid cheek deflation due to loss of superficial and deep fat. SMAS, superficial musculoaponeurotic system. (Adapted from Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219-2227.) there may be an urgent requirement in active Graves’ disease elevated or over-elevated by frontalis muscle contraction, to perform procedures to protect the globe or the vision.13 which may confuse the surgeon as to whether eyelid ptosis or retraction exists. The ability to differentiate the causes of Ocular examination droopy eyelids – brow ptosis (brow weight resting on the consistently produce vertical dystopia with increased scleral eyelids), dermatochalasis (excess skin), and blepharoptosis exposure, making the lens wear difficult if not dangerous. An ocular examination before elective periorbital aesthetic (levator attenuation or dehiscence) – will enable the surgeon Ptosis and canthopexy surgery may alter the corneal curva- surgery should include all of the elements covered in the to select the proper correction. Box 8.2 Important information to obtain during history following sections (Fig. 8.20). and physical examination ture and require that contacts be refitted. The patient should Unilateral as well as bilateral upper eyelid retraction is discontinue contact lens wear in the perioperative period to commonly associated with prominent globes, which are often Visual acuity • Medication use: particularly anticoagulants, anti-inflammatory allow healing without the need to manipulate the eyelids. asymmetrically proptotic. Most commonly, it is the result of and cardiovascular drugs, and vitamins (especially vitamin E). Levator dehiscence or attenuation commonly accompanies The most essential preoperative test is assessment of visual Graves’ ophthalmopathy, which can lift the lid above the • Herbal supplement use: herbs represent risks to anesthesia long-term hard contact lens wear, caused by the mechanical acuity, by the surgeon or ophthalmic colleague. Document the superior limbus. A thyroid evaluation is appropriate before and surgery, particularly those affecting blood pressure, blood stresses posteriorly from the rigid lens rubbing against the vision with patient wearing glasses or contact lenses if they any surgery to correct retraction. If it is stable for more than coagulation, the cardiovascular system, and healing. posterior lamella of the lid.27 are needed. Note any vision deficits and have them evaluated 6 months, levator recession surgery can be combined with fat • Allergies: medication and type. The same population that seeks aesthetic surgery also grav- before surgery. The most common cause of unrecognized loss reduction blepharoplasty, but lid skin should rarely if ever • Past medical history: especially hypertension, diabetes, itates toward refractive surgery, such as LASIK (laser-assisted of vision is amblyopia (lazy eye), which is present in 2% of removed. cardiovascular and cerebrovascular disease, hepatitis, liver disease, heart disease or arrhythmias, cancer, thyroid disease, in situ keratomileusis). A history of such surgery is necessary the general population. A patient may often be unaware of the Long-term soft contact lens wear is also a common cause and endocrine disease. information because periorbital surgery particularly can- unilateral amblyopia (or any loss of vision) until the eyes are of lid retraction that raises the lid to the superior limbus or • Bleeding disorders or blood clots. thopexies and levator surgery, can affect the refractive char- tested individually. above. Congenitally shallow or traumatically small orbits are 27 • Psychiatric disease. acteristics, cause mechanical irritation of the conjunctiva also a cause of lid retraction, as is idiopathic retraction. If the 28 External examination • Alcohol and smoking history. and cornea, or affect the corneal flap. Ptosis repair or debulk- retraction persists in spite of taping the brow or lid tissue out • Recreational drug use, which may interact with anesthesia. ing of heavy upper lids can change the corneal curvature, The periorbital skin and tissues are examined for benign or of the way of vision, the surgery to correct the retraction must • Exposure to human immunodeficiency virus and hepatitis virus. resulting in the need for a new prescription for eyeglasses. malignant lesions, including xanthelasma, syringoma, basal either precede or accompany the eyelid or brow surgery. • Any history of facial herpes zoster or simplex. Canthopexy normally raises the contact point of the lid with cell carcinoma, benign moles, skin tags, and chalazia. Marked Retraction can also be accompanied contralateral blepharop- the globe and can increase the tension of the lid with the globe anesthetic improvement results from removal of benign tosis according to Hering’s Law. Diagnosis/patient presentation 119 120 SECTION I • 8 • Blepharoplasty

Orbicularis oculi

Tear trough

Tear trough

Levator labii superioris alaeque nasi

Levator labii superioris

A Visual acuity via Snellen chart

B Schirmer’s test Fig. 8.21 The anatomy of the tear trough deformity demonstrates the muscular triangle formed by the orbicularis oculi, levator labii superioris, and levator labii superioris alaeque nasi. (Adapted from Hirmand H. Anatomy and nonsurgical correction of tear trough deformity. Plast Reconstr Surg 2010; 125(2):699–708.)

Fig. 8.22 Tear trough test. The ability to place the side of a finger into the bony furrow under the nasojugal groove suggests a potential benefit from tear trough augmentation. Orbits and malar eminence The relative position of the globe to orbital anatomy greatly influences appropriate surgical technique. There is a normal 10–12 mm projection of the globe seen in a lateral, as meas- Extraocular muscles ured from the lateral orbital rim at the level of the canthal The extraocular muscles are tested for deviations, motility tendon to the pupil. Proptosis and enophthalmos are relative problems, or restrictions. Eye deviations often present with anterior and posterior displacement of the globe, respectively. C Snap back lost amblyopia unilaterally and corresponding reduced vision. Hertel exophthalmometry can be used to quantitate the degree One should examine the patient for the presence of an intact of relative projection for documentation purposes.15,24 Bell’s phenomenon, an upward and outward rotation of the The tear trough is at the inferior orbital rim most medially, cornea with lid closure. This can be accomplished by gently triangulated by the orbicularis, levator labii superioris alaeque forcing the upper eyelids open during closure. The presence nasi and levator labii superioris muscles (Fig. 8.21). The of an intact Bell reflex affords protection for the eye and cornea indentation is at the junction of the thin eyelid skin above and in the event of incomplete eyelid closure. If the eyelid fails to the thicker and different nasal and cheek skin below, with close during sleep, the cornea may remain uncovered and dry attenuated subcutaneous tissue overlying the maxillary bone. out. Thus, the absence of Bell phenomenon raises the risk for It is the deepening of this groove that leads to true indentation postoperative problems, especially in those with preexisting and significantly impacts facial appearance. The relative lack problems or dry eyes.29 of subcutaneous tissue in this area is subject to worsening concavity with aging. The cause of the deformity is due to a Globe combination of orbital fat herniation, skin laxity and malar The globe is examined for clarity of the cornea, iris, and lens. 26 volume loss and ptosis of skin and subcutaneous tissue. The The corneal light reflex should be sharp and no lesions noted ability to place the side of the finger into the bony furrow E Tear film break up time anywhere on the globe. If there is any question of a corneal under the nasojugal grooves suggests a potential benefit from defect, a slit-lamp examination is needed, either by a surgeon Positive vector Negative vector a tear trough implant or the addition of soft tissue augmenta- or by an ophthalmologist on referral. Any whitening of the 34 D Malar support tion (Fig. 8.22). cornea is possibly an infectious infiltrate and should be treated aggressively with antibiotics. Fig. 8.20 (A–E) Evaluation of the patient should include an appreciation of visual acuity (with and without correction), baseline tear production, intrinsic lid tone, lower Pupils eyelid support, and tear film quality. The tests performed and their interpretation should be tailored by the clinician within the context of each patient and applied on an The pupils are evaluated for direct and consensual response Tear film individual basis. (Adapted from Spinelli HM. Atlas of aesthetic eyelid and periocular surgery. Philadelphia: Saunders; 2004:31.) to light. An abnormal result indicates a problem behind the Assessment of tear production is a necessary but unreliable globe (i.e., the optic nerve or brain). Refractive errors, amblyo- task. Schirmer testing consists of placing filter paper strips in pia, and corneal or retinal problems will not present with an the lateral third of the lower eyelid. The irritation of any abnormal papillary response. foreign object against the globe stimulates reflex tearing, Patient selection 121 122 SECTION I • 8 • Blepharoplasty

consequence of Hering’s law, both levators are energized Box 8.3 Recommended photographic views Box 8.4 Preoperative periorbital plan Tear trough deformities equally in an attempt to clear the visual axis of the ptotic lid, • Full face, upright (at rest) frontal, oblique, and lateral views. The preoperative periorbital plan should include the following: thereby making the normal lid appear retracted. Covering The tear trough deformity is a type of relative infraorbital • Full face, upright and smiling. • The patient’s specific concerns and desires for improvement each eye separately and observing the lid position often lead malar hypoplasia, where there is an asymmetric bony depres- • Direct periorbital views in upward gaze and downward gaze and • Brow position to the discovery of the ptotic eye as the pathologic source. The sion along the medial infraorbital rim. Tear trough implants with eyes gently closed. • Lower eyelid tonicity retracted eye will drop to its normal position once the ptotic (Fig. 8.19) are reserved for severe deformities where the • A view with a finger slightly elevating the brows with the eyes • Eyelid ptosis, retraction, or levator dehiscence eye is covered, only to have the ptotic eye rise when it is volume of surgical fat repositioning is inadequate and cost of open and another with the eyes closed. 34,40 • Exophthalmos or enophthalmos uncovered. Symmetric elevation of the brow is similarly filler exceptional. • Supraorbital rim prominence or hypoplasia helpful in patients in whom asymmetric brow pseudoptosis If the surgeon can place the side of his or her finger into • Suborbital malar and tear trough deformities obstructs peripheral vision. this diagonally recessed bone, augmentation of the concavity • Excision of necessary skin, muscle, and fat – only if necessary. It is easy to correct existing true ptosis, or true retraction, should be considered. Factors such as age, skin quality and possibly yielding a deceptively good test result. A topical at the time of blepharoplasty surgery. Even when ptosis is severity of the hollowing dictate the appropriate procedure. anesthetic (tetracaine or proparacaine) eases discomfort and mild, correction avoids the probable worsening of the ptosis Young patients with good skin quality will benefit from reflex tearing, giving a better assessment of basal tear secre- by the additional insults of a weakened levator due to surgical hyaluronic acid fillers placed between the deep dermis and tion. After 5 min, normal tear production should be greater trauma, an edematous or bruised lid, a hematoma in the orbicularis oculi fascia. This outpatient procedure can be per- than 15 mm; 5–10 mm indicates borderline tear secretion, and maneuvers required be organized in a meaningful way levator muscle, a cicatrix associated with even the smallest formed concomitantly or weeks after blepharoplasty once below 5 mm is hyposecretion. (Box 8.4).35 Preoperative planning should take place with the amount of orbital bleeding, or a simple asymmetric surgical perioperative swelling subsides (Fig. 8.23). Older patients Basal tear production diminishes with age in all persons to patient upright under good lighting and with complete facial rendering.37,38 require orbital fat repositioning from the medial and central a degree that usually becomes symptomatic by 50 years of relaxation. It is also important to document the brow, canthus, compartments during a transconjunctival blepharoplasty. age. In contact lens wearers, allergy sufferers, arthritics, and and upper and lower eyelid posture and position and all other Alternative soft tissue injectables include autogenous fat, people with autoimmune diseases, this process accelerates desired alterations preoperatively. The preoperative photo- Globe position and malar prominence hydroxyapatite and micronized acellular dermis. and often becomes symptomatic in their 30s. It is important graphs and surgical plan should be easily visible to the for patients to be aware of this age-related decrease in tear surgeon during the entire surgery. The position of the globe greatly affects the procedural choices Optimal brow positioning production preoperatively. Skin and muscle are quantified for excision in millimeters and quality of outcome in periorbital surgery. The high fre- or any standardized system comfortable to the surgeon. Fat quency of asymmetry in globe prominence is often not appre- Aesthetic surgery of the forehead is thoroughly reviewed in Photographic documentation excision is measured in terms of cubic centimeters (cc) or ciated in aesthetic periorbital surgery. Unless it is recognized Chapter 7. Brow positioning is a cornerstone of blepharo- milliliters (mL). A pea-sized amount is roughly equivalent and treated appropriately, unfortunate outcomes are almost plasty surgery. The majority of aesthetic improvement of the No other area of cosmetic surgery is more dependent on accu- to 0.5 ccs or 0.5 mL. Determination of fat excision should inevitable. upper orbital region comes from proper brow positioning and rate photography than the periorbital region (Box 8.3). It is be approximated in multiples of this standard measure. In patients with infraorbital malar hypoplasia or tear canthopexy. When advocating periorbital rejuvenation, it is essential in documenting existing anatomy and pathologic Measurements should be consistent with the patient in a verti- trough deformity, it is not possible to achieve optimal aes- therefore appropriate to consider repositioning the resting 41 changes. Accurate photography assists in surgical planning, cal position to avoid lid hollowness or concave depressions. thetic results without some contour correction. If the globe brow position when considering blepharoplasty. intraoperative decision-making, and documentation of results, In proptotic patients, more aggressive fat excision offers the extends anteriorly past the inferior orbital rim, lower lid A low resting brow is extremely common and occurs in and it may be necessary for legal protection.35 possibility of reduction of globe projection, but skin removal, surgery will increase scleral show and lid deformity unless people of all ages. The lateral overhang of the eyebrow, upper of any quantity, is most likely contraindicated. the lid and canthal posture are raised, the orbital rim-malar eyelid and juxtabrow skin can cause visual field obstruction. complex is enhanced, or the prominent globe is retroposi- These tissues progress downward from degenerative changes Unintentional deception in eye appearance tioned. This bone deficit of the lower orbit, which occurs resulting in stretching of the forehead and brow tissues. The Anatomic-directed therapy most commonly in men, creates an exophthalmos of the recurring pull of the orbicularis, corrugator, and procerus There is a natural phenomenon that prevents surgeons from lower half of the globe. The patients can be described as muscles contributes to descent of the brow. Many adults fully appreciating the potential adverse effects of the surgery. Upper eyelid position vector-negative or having hemiexophthalmos. A youthful, presenting for aesthetic surgery have significant – but often Women, and some men to whom appearance is important, vector-positive profile consists of an inferior orbital rim and undetected – “resting” brow ptosis. This phenomenon has subconsciously and automatically modify their appearance In the typical person with the brow in an aesthetically pleas- malar soft tissue that are in the same plane of the globe (see been termed “compensated brow ptosis”, where brow ptosis when they are confronted with a mirror, a camera, or someone ing position, 20 mm of upper lid skin must remain between Fig. 8.20).39 remains undetected because of the compensatory activation of carefully examining their appearance. They lift the chin, tilt the bottom of the central eyebrow and the upper lid margin When a vector-negative profile exists, there is a relative the frontalis muscles to clear the obstructing lid overhang.42 the head backwards, elevate the eyebrows, and smile slightly. to allow adequate lid closure during sleep, a well-defined lid scarcity of lower eyelid skin. Lids must not be shortened If the brow is simply elevated to its proper position, the This gives the illusion of elevated lower eyelids (although it crease, and an effective and complete blink. either by blepharoplasty. To do so causes the lid margins to seemingly elevated upper lid tissue either disappears or alters the intercanthal axis, turning it downward), and it ride down the globe surface, resulting in more scleral show diminishes dramatically, leaving most if not all of the irre- cleans the upper lids. These unintentional changes simulate a and pathologic exposure. Similar to proptotic patients, sus- placeable eyelid skin. Furthermore, any scars resulting from brow lift, although the medial brow is typically dispropor- Lower eyelid tonicity pension canthopexy must be placed more superiorly and skin excision, when it is required, remain short and need not tionately elevated. This disguises from the surgeon, both on The presence of atonic lower lids and lateral canthal laxity anteriorly to prevent scleral show. This relative lack of lower extend beyond the orbital rim. direct inspection and in photographs, the accurate preopera- may give the impression that there is excess skin requiring lid skin can also increased with lower lid spacers, canthal If a blepharoplasty alone is performed in these patients, the tive appearance and true outcome of the surgery. When the removal. However, lower lid posture and optimal lateral tendon elongation or orbital fat reduction. visual incentive to elevate the brow disappears. The frontalis mirror and camera disappear, the brow drops, the corrugators canthal position should be restored manually before deter- In exophthalmos, tightening the lower lid, even when it is relaxes and the brow drops – exaggerating the aged, tired look contract, and the lower lids drop to their natural posture. This mining the amount of skin and other tissues to be removed. repositioned with a canthopexy or a lid shortening, may cause that the blepharoplasty was supposed to correct (Fig. 8.24). In then, is the face the real world is seeing. Lid and canthal restoration frequently eliminates skin excess. some severe potential problems. When it is horizontally tight- addition, the weakened frontalis now fails to oppose the cor- When skin removal is indicated, the surgeon will often need ened, the lid takes the course of least resistance and migrates rugators and relaxes its pull on the glabellar and interbrow to remove skin more centrally than laterally.9,36 under the proptotic globe, especially when the canthal attach- skin, thereby accentuating the glabellar crease and frown – a Patient selection ment is not lifted. To overcome this, the canthopexy attach- heavy price to pay for an aesthetic procedure designed to Eyelid ptosis or retraction ment commonly needs to be placed higher than is aesthetically rejuvenate the face. These features can be prevented by a Operative planning most desirable. In addition, the canthal fixation must be concomitant or preceding temporal brow lift that restores In patients with unilateral eyelid ptosis, one may be tempted placed more anteriorly to accommodate the proptotic globe, the eyebrows to their proper position and checks against Before surgical planning, one must have a meaningful con- to operate on the normal eye, which may appear to be and occasionally the canthus needs an extension to reach the a profound drop in the resting posture of the brow after ceptualization of the desired result. Only then can the surgical retracted, instead of the “disguised” ptotic eye. As a bone or augmentation of the orbital rim. blepharoplasty. Treatment/technique 123 124 SECTION I • 8 • Blepharoplasty

lid skin excision performed as standard procedure is both a Key components of the anchor blepharoplasty include functionally and aesthetically harmful form of upper eyelid minimal skin excision (2–3 mm) extending cephalad from the blepharoplasty. tarsus. A 1–2 mm sliver of orbicularis must be removed in proportion to the amount of skin removed. A small pretarsal Simple skin blepharoplasty skin and muscle flap are dissected from the aponeurosis and septum adhesion. After sharply disinserting the aponeurosis Preserving orbicularis muscle and preaponeurotic fat has from the tarsus, pretarsal fatty tissue can be removed to been shown to enhance aesthetic outcomes for a variety of debulk the pretarsal skin. Key components of the anchor presentation. Many who present for upper blepharoplasty blepharoplasty include minimal skin excision (2–3 mm) hope for a result that is aesthetically enhancing yet avoids extending cephalad from the tarsus. A 1–2 mm sliver of orbic- a “surgical appearance” or hollowed upper periorbital. ularis must be removed in proportion to the amount of skin Volume-maintaining methods by preserving the orbicularis removed. A small pretarsal skin and muscle flap are dissected muscle can be used to preserve or restore a youthful convex- from the aponeurosis and septum adhesion. After sharply ity of the upper eyelid-brow junction. Excessive skin and detaching the septal extension from the tarsus, pretarsal fatty facial soft-tissue descent may rest more on the deflationary tissue can be removed to debulk the pretarsal skin. Mattressed effects of regional volume loss rather true, gravitational anchor sutures are placed connecting the tarsus to the apone- descent. urosis and pretarsal skin (Fig. 8.27). Finally, a running suture A youthful appearance is gained with maintenance or approximates the preseptal skin incision. enhancement of volume, and a shorter pretarsal fold. Closure of the skin ellipse after skin resection and orbicularis preser- Orbital fat excision vation can improve supratarsal and infrabrow volume. The A B effects of muscle preservation can be similar to results achieved A relative excess of retroseptal fat may be safely excised by soft-tissue filler. Muscle resection should be reserved for through an upper eyelid blepharoplasty incision. A small sep- totomy is made at the superior aspect of the skin excision into Fig. 8.23 (A) Preoperative and (B) postoperative photograph demonstrating tear trough augmentation with fillers. patients with orbicularis redundancy or relative hypertrophy. The primary indication for selective myectomy is upper eyelid each fat compartment in which conservative resection of fold disparities and mild lid ptosis. redundant fat has been planned. The fat is teased out bluntly When skin-only excision is elected, it should occur above and resected using pinpoint cautery. This fat usually includes the supratarsal fold or crease, leaving that structure intact. the medial or nasal compartment, which contains white fat. This retains most of the definition of an existing lid fold. If Yellow fat in the central compartment is usually more super- eyelid skin containing the crease is part of the excision, the ficial and lateral. Gentle pressure on the patient’s globe can lid fold becomes ill-defined, indistinct, and irregular. The reproduce the degree of excess while the patient lies recum- supratarsal fold is located approximately 7–8 mm above the bent on the operating room table (Fig. 8.28). Overall, under- ciliary margin in women and 6–7 mm in men. The upper correction is preferred to prevent hollowing, which can be marking must be at least 10 mm from the lower edge of the dramatic and recognized as an A-frame abnormality. brow and should not include any thick brow skin. The use of The attenuated orbital septum may be addressed by using a pinch test for redraping the skin is helpful. selective diathermy along the exposed caudal septum. The shape of the skin resection is lenticular in younger Inflammation-mediated tightening can enhance septal integ- patients and more trapezoid-shaped laterally in older patients. rity. Septal plication aid is unnecessary and may induce a The incision may need to be extended laterally with a larger brisk, restrictive inflammatory response. extension, but extension lateral to the orbital rim should be avoided if possible, to prevent a prominent scar (Fig. 8.25). Blepharoptosis Similarly, the medial markings should not be extended medial to the medial canthus because extensions onto the During upper blepharoplasty, with the septum open and the nasal side wall result in webbing. At the conclusion of aponeurosis and superior tarsus exposed, there is an ideal Fig. 8.24 Compensated brow ptosis – continuous obligatory frontalis muscle contraction to clear the periorbital tissues (and to affect comfortable and unobstructed forward the case, the patient should have approximately 1–2 mm of opportunity to adjust the level of the aperture. Inappropriate vision). lagophthalmos bilaterally. Figure 8.26 displays the predict- aperture opening can be due to upper lid ptosis or upper lid able, restorative outcomes that can be achieved with skin retraction. It is not uncommon for there to be ptosis of only excision alone. the medial portion or retraction of only the lateral portion. A along the lateral orbital rim. Fillers, which range in cost and surgeon should not hesitate to take advantage of this oppor- Treatment/technique resorption rates, can augment the infraorbital rim in negative Anchor (or invagination blepharoplasty) tunity for repair. True ptosis repair involves reattachment vector patients. Photodynamic and laser therapy are alterna- of the levator aponeurosis to the tarsus, with or without short- Continuum of aesthetic enhancement tives to treat minor skin excess. It is prudent to develop lasting Anchor blepharoplasty involves the creation of an upper ening of applicable structures (e.g., aponeurosis, Müller’s relationships with patients and provide the least invasive, eyelid crease by attaching pretarsal skin to the underlying muscle, and tarsus).32,33 The goal of the eyelid surgeon when evaluating patients is to targeted procedure needed for rejuvenation. aponeurosis. The advantage of an anchor blepharoplasty is a Approximately half of all patients presenting for perior- develop an individualized treatment plan for the classic crisp, precise, and well-defined eyelid crease that persists bital aesthetic surgery have one brow that is several symptoms of periorbital aging. While surgical techniques Upper eyelid surgery indefinitely. Such lids are more desirable in women than in millimeters lower than the other. Half of those have signi- deliver the most dramatic and lasting results, these proce- Video men because they tend to glamorize the orbital region. The ficant unilateral ptosis on the side of the lower brow from dures are not without inherent risks and postoperative recov- The most common approach to upper blepharoplasty has 1 disadvantage is that it is more time-consuming, requires the “mechanical weight” of the excess skin. Half of those ery. Surgery is not always the first and immediate response. been the en block excision of skin, muscle, and fat in an attempt greater surgical skills and expertise, and encourages greater patients’ ptosis will be corrected by manually raising the brow Patients in their 30s and 40s will frequently benefit from to debulk the eyelid. However, traditional blepharoplasty frontalis relaxation as a result of more effective correction of on the affected side. The other half have true ptosis, which office-based, nonsurgical care. Chemodenervation can mini- may not always fulfill the promise of producing youthful, the overhanging pseudoptotic skin. It accomplishes that task most likely has gone undiagnosed because of overhanging mize the early appearance of brow ptosis and fine-line rhytides aesthetically pleasing eyelids. In particular, aggressive upper while minimizing upper lid skin removal.43 tissue. Treatment/technique 125 126 SECTION I • 8 • Blepharoplasty

Levator aponeurosis Whitnall’s ligament

Levator aponeurosis

Incision

Orbital septum

A B

Skin and orbicularis muscle resection A Medial fat pad removed Central fat pad (preaponeurotic) on levator aponeurosis Intracuticular running Interrupted sutures suture

Fig. 8.27 Anchor blepharoplasty technique. Attaching the dermis of the pretarsal skin flap to the superior aspect of the tarsus and to the free edge of the aponeurosis. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:69.)

Surgical technique Fig. 8.25 Simple skin excision blepharoplasty. (A) Digital traction and light pressure There are a variety of techniques to address blepharoptosis by the surgeon allow smooth quick incisions. (B) The skin may be elevated with the but they are outside the scope of this chapter. We will thus orbicularis muscle in one maneuver, proceeding from present our preferred technique for uncomplicated involu- lateral to medial. (C) The orbital septum is then opened, exposing the preaponeurotic Pressure on globe causes tional ptosis. A ptosis repair may be undertaken in combina- medial fat pad bulge space. The underlying levator aponeurosis is protected by opening the septum as cephalad as possible. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and tion with a skin excision upper blepharoplasty. The difference C Periocular Surgery. Philadelphia: Saunders; 2004:64.) is adjusting (or advancing) the point of attachment of the levator aponeurosis to the tarsus. There is a significant learn- B Closure ing curve to performing a ptosis repair, and even then, the Fig. 8.28 Simple skin excision blepharoplasty. (A) The medial fat pad may require ability to get perfect symmetry is elusive. digital pressure to expose and grasp; however, care should be taken not to overly In the setting of mild upper eyelid ptosis (approx. 1 mm), resect fat when using digital pressure techniques. (B) Closure may then be where the decision has been made to avoid a formal lid ptosis performed with a combination of interrupted and running intracuticular sutures. procedure, selective myectomy of the upper eyelid orbicularis (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. can be performed to widen the lid aperture. The amount of Philadelphia: Saunders; 2004:65.) muscle to be resected depends on a host of factors, including the severity of relative lid ptosis, brow position, and fold disparity (Fig. 8.29). The orbicularis muscle is then resected and/or lowering the upper eyelid margin. Placing the upper selectively using cautery that strips orbicularis muscle from eyelid incision and crease 2 mm or higher on the relatively the underlying orbital septum. The amount of resection is retracted side can also reduce the need for formal lid retrac- titrated depending on the amount of effect desired. For 1 mm tion surgery.38 or less of relative upper lid ptosis, resection of at least 3–4 mm The key components of formal lid ptosis correction include of orbicularis is required. The effects are more powerful the correct identification of the distal extensions of the aponeuro- closer the resection is to the inferior edge of the elliptical sis and the orbital septal extension.12 The superior edge of wound. No attempt is made to close orbicularis muscle in the tarsus is freed from any dermal or tendinous extensions. A B this resection, which could increase the risk of lagophthalmos. Leaving a small cuff of filmy connective tissue (approx. 1 mm) On the opposite side, which is likely retracted, a slight ptosis on the tarsus will minimize bleeding from the richly vascular- can be induced by resecting a larger degree of orbicularis ized area. Ensure that there is complete hemostasis by use of Fig. 8.26 (A) Preoperative and (B) postoperative photograph depicting predictable results with simple skin excision blepharoplasty anchor technique in addition to levator advancement with reinsertion into tarsus. Treatment/technique 127 128 SECTION I • 8 • Blepharoplasty

Transconjunctival blepharoplasty be excised through small incisions in the septum. The fat can also be retropositioned using capsulopalpebral fascia placa- Transconjunctival blepharoplasty is the preferred procedure tion, or it can be transferred into the naso-jugular fold. for fat reduction in patients without excess skin and with Orbicularis muscle fibers and skin can be excised at closure. good canthal position. A transconjunctival approach is less However, care must be taken with muscle excision, which can likely to lead to lower lid malposition than is a transcutaneous lead to orbicularis denervation and lid malposition. Levator plication approach. It minimizes but does not eliminate postoperative lower lid retraction; transection of the lower lid retractors Orbital fat Orbital septum can cause a temporary rise in the lid margin, especially if and underlying they are suspended during the healing period. Previously The relative excess of orbital fat may be handled in several (preaponeurotic) fat suspected septal scarring through transconjunctival fat exci- ways. Most commonly, surgeons choose to excise the herni- sion has not been shown to significantly alter lid posture or ated fat with meticulous attention to hemostasis. Additional 45 tonicity. techniques exist to reposition the fat to create periorbital The lower lid retractors (capsulopalpebral fascia and harmony. inferior tarsal muscle) and overlying conjunctiva lie directly posterior to the three fat pads of the lower lid. A broad and Orbital fat transposition deep transconjunctival incision severs both conjunctiva and retractors but typically should not incise the orbital septum, An alternative to excising prominent orbital fat is to redrape orbicularis, or skin. The conjunctival incision is made with a the pedicled fat onto the arcus marginalis. Patients with tear monopolar cautery needle tip at least 4 mm below the inferior trough deformities who have prominent medial fat pads are border of the tarsus – never through the tarsus (Fig. 8.30). A excellent candidates.46 Access to the medial and central fat preseptal approach is obtained by entering the conjunctiva pads is by the subciliary or transconjunctival incision.47 The above the level of septal attachment to the capsulopalpebral minor degree of lateral fat pad prominence is generally fascia. A retroseptal approach involves a 1.5–2 cm incision insufficient to affect any change with repositioning. A supra- lower down in the fornix, and is typically used to excise fat. periosteal or a subperiosteal dissection for 8–10 mm caudal to There are differences of opinion about whether to leave the the inferior orbital rim permits tension-free placement. The fat Levator aponeurosis transconjunctival incision open or to close it; however, it is can be secured in place with interrupted absorbable sutures. preferable to leave it open. Suturing the wound may trap This technique can be used as an alternative to fat grafting or bacteria or cause corneal irritation. Conjunctival closure, filler injection. Patients must be warned that various degrees A B when it is elected, is simplified by a monofilament pull-out of fat loss and hardening are possible. There is also a rare suture that enters the eye externally, closes the conjunctiva, but described possibility of restrictive strabismus related to and exits through the skin and is taped. aggressive fat mobilization and fixation. Fig. 8.29 (A,B) Once the upper lid is incised, the levator may be modified (shortened/lengthened) in a number of ways, including simple plication. A suborbicularis skin The incision through the conjunctiva and retractors gives flap can also be developed allowing access to preaponeurotic fat. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; excellent access to the orbital fat. A 6–0 silk traction suture Plication techniques 2004:69.) passed through the inferior conjunctival wound and retracted The fundamental agreement among surgeons who practice over the globe gives wide access to the orbital fat, even helping plication is that bulging of orbital fat is the major component to prolapse the fat into the wound. The thin film of synovium- in most cases of eyelid aging deformity. The conclusion is that appearing capsule encasing the orbital fat is opened, releasing a fine forceps cautery, lifting all lid tissues away from the Lower lid blepharoplasty most cases of baggy eyelids occur from a true herniation the fat to bulge into the operative field (Fig. 8.31). cornea and globe before cauterizing. Anchor the upper third of the orbital fat out of the bony orbit. Consequently, rejuvena- Once fat is removed or repositioned through a transcon- of the tarsus to the remaining levator with 5–0 silk suture, Lower blepharoplasty has evolved substantially. There are tion centers on re-establishing the normal position of the junctival incision, excess skin can be removed through a sub- placed as a horizontal mattress. The lid should be flipped to two trends in blepharoplasty, one towards more aggressive globe orbital fat. Plication offers the advantages of prevention ciliary position. Fat reduction may leave skin excess, leading ensure that the suture is not exposed posteriorly on the tarsus, techniques to maximize the aesthetic outcome and the of depletion of the orbita, achievement of a homogeneous to wrinkling. A conservative “skin pinch” can be done to which could cause a troublesome corneal abrasion. The level other towards more conservative techniques to minimize the and natural eyelid, avoiding local hollowing and sunken lid estimate skin removal, or alternatively, skin can be tightened should be checked by having the patient open the eye. Some risk of complications. Although excellent aesthetic results appearance, and no risk of infraorbital hematomas. Access is by skin resurfacing with chemical or laser peels (Fig. 8.32). coaxing helps the patient open the eye gently rather than can be achieved with transcutaneous lower blepharoplasty, through a transcutaneous approach, which gives superior One should be careful not to incise the orbital septum, which maximally, which the patient has been used to doing consist- lid retraction and ectropion are concerning complications. exposure. ently to compensate for ptosis. The patient should blink fre- Conservative excisional techniques center on the concept leads to increased postoperative retraction. This procedure quently and look superiorly to ensure that the lid never rises of fat preservation. Transconjunctival lower blepharoplasty, works particularly well when there is an isolated fat pad, above the superior limbus. For cases under general anesthetic, although more conservative, does not eliminate the risk of lid especially medially, accessed through a single stab incision Orbital septum plication one should attempt to create one to two times the amount of malposition. An effective, lasting procedure should address through the conjunctiva. In this procedure, the herniated septum is plicated and repo- lagophthalmos relative to the preoperative ptosis. the extrinsic and intrinsic support of the eye, which is weak- sitioned to its normal anatomic site within the orbit. The fat If there is any medial or lateral retraction or ptosis, the ened during the aging process. Transcutaneous blepharoplasty is replaced in the retroseptal position to regain its original central suture should be repositioned medially or laterally as In the classic concept of lower lid blepharoplasty, the anatomic integrity (Fig. 8.33). Three to four 5–0 polyglycolic many times as needed, with adjustment to a pleasing lid concern of the surgeon who resects lid fat is the difficulty of A subciliary incision can be used to develop a skin flap or a acid sutures are placed in a vertical fashion from medial to height and contour. Both sides should be completed before estimating the correct amount of fat to remove.44 If this is not skin-muscle flap. With either method, pretarsal orbicularis lateral. The protruding fat pads are invaginated and the integ- the suture is permanently tied. Once the desired lid height done correctly, this miscalculation may lead to asymmetry, fibers should remain intact. For the skin-muscle flap, skin and rity of the thin, flaccid septum is restored. Additional support and contour of both eyes are achieved, the patient should be hollowing, or a sunken lid appearance. Relative enophthal- preseptal orbicularis are elevated as one flap, while with a may be gained with septo-orbitoperiostoplasty variation.48 asked to open and close the eyes to ensure symmetry. mos is an obvious sign of aging because the volume of fat skin flap, the muscle and its innervation can be preserved.14 This technique plicates the flaccid septum and secures it to Anchoring the tarsus, dermis, and aponeurosis at the right decreases due to involution and herniation within the bony Periorbital fat, muscle, and skin can be addressed with either the periosteum of the inferior orbital rim. Because of no dis- level keeps the pretarsal skin taut and flat, prevents lash ever- orbit. By extension, rejuvenation proceeds by maintaining the approach. Once the plane deep to the orbicularis is entered, ruption of the eyelid anatomy occurs, complications of related sion, and forms a neat, crisp lid crease that will persevere for fatty volume and strengthening the globe’s extrinsic support dissection continues between the muscle and the orbital to lid malposition such as lid retraction, scleral show, and many years. by canthopexy and orbicularis and midface suspension. septum down to the level of the orbital rim. Periorbital fat can ectropion are reduced.49 Treatment/technique 129 130 SECTION I • 8 • Blepharoplasty

Retroseptal approach Inferior oblique muscle Pretroseptal (suborbicularis) approach

Nonconductive retractor Conjunctiva retracted superiorly Orbital septum opened

A Lateral, central and medial fat pads (left to right)

Conjunctiva is tented and secured with a stay suture A

Remove fat pads if they bulge

Orbital septum

Conjunctiva is divided longitudinally just below the tartsal plate Inferior tarsal plate B C B Fig. 8.30 (A) The transconjunctival approach to the retroseptal space may be in one of two ways: preseptal or retroseptal. The preseptal route requires entry into the suborbicularis preseptal space above the fusion of the lower lid retractors and the orbital septum. This will allow direct visualization of the septum, and each fat pad can be Reposition fat pads transconjunctivally addressed separately in a controlled fashion. (B) A conjunctival stay suture is placed deep in the fornix and traction is applied superiorly while the lid margin is everted. This causes the inferior edge of the tarsal plate to rise toward the surgeon. (C) The conjunctiva and lower lid retractors are incised just below the tarsal plate entering the suborbicularis preseptal space. This plane is developed to the orbital rim with the assistance of the traction suture and a nonconductive instrument. (Adapted from Spinelli Fig. 8.31 (A) The orbital septum may then be punctured and the inferior oblique muscle identified and preserved. (B) The fat pad may be addressed individually in-keeping HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:86.) with preoperative plans with either resection, repositioning, conservation or any combination of the these techniques. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:87.)

Capsulopalpebral fascia plication 6–0 nonabsorbable suture. The conjunctival gap of a few Orbicularis suspension Anatomical dissection suggests that the Lockwood suspen- the transcutaneous method, dissection is carried out between millimeters is allowed to reepithelialize (Fig. 8.34).50–52 One sory ligament descends with aging that leads to relative the orbicularis and the septum down to the orbital rim; the advantage of the transconjunctival approach is the division of Orbicularis repositioning can be used to eliminate hypotonic enophthalmos and fat herniation. Moreover, simply plicating capsulopalpebral fascia is then sutured to the orbital rim. In lower eyelid depressors, which helps maintain the lower and herniated orbicularis muscle, soften palpebral depres- the orbital septum, which is an acellular membrane with little the transconjunctival method, the capsulopalpebral fascia is eyelid at an elevated level due to the unopposed action of sions, and shorten the lower lid to cheek distance. The main tensile strength, will not restore the globe’s position. The cap- divided from the tarsus, and orbital fat is retroplaced, its posi- the pretarsal orbicularis. Several series have shown this steps include elevation of a skin muscle flap, release of the sulopalpebral fascia can be plicated to the orbital rim either tion maintained by suturing the capsulopalpebral fascia to disruption does not interfere with lower eyelid or globe orbicularis retaining ligament and resuspension of the orbicu- through a transcutaneous or a transconjunctival approach. In the periosteum of the orbital rim using a continuous running function.48,50 laris – frequently after lateral canthopexy. Along the entire Treatment/technique 131 132 SECTION I • 8 • Blepharoplasty

A B Upper (ciliary) flap

Fig. 8.32 (A) Simple skin excision lower eyelid blepharoplasty. (B) Typical removal of redraped skin or skin-muscle from the lower lid, which can be the shape of an Inferior orbital septum obtuse triangle, with the largest amount sacrificed laterally. Lower (ocular) flap made up Fascioseptal triangular space of conjunctiva inferior tarsal muscle capsulopalpebral fascia

A B

Capsulopalpebral fascia Capsulopalpebral fascia Fig. 8.34 (A,B) Suturing the lower capsulopalpebral flap to the arcus marginalis to reduce and contain the herniated fat. (Adapted from Camirand A, Doucet J, Harris J. Anatomy, pathophysiology, and prevention of senile enophthalmia and associated herniated lower eyelid pads. Plast Reconstr Surg 1997; 100(3):1535–1538.) Protruding inferior orbital fat Inferior orbital septum Inferior orbital septum

Inferior orbital rim Inferior orbital rim The degree of laxity predetermines the type of lateral support of the lateral canthus. While the standard position of A B canthal support. A lateral canthopexy is recommended for the lateral canthopexy suture is most commonly at the lower moderate lid laxity, which is considered <6 mm of lid level of the pupil, patients with prominent eyes or negative distraction away from the globe. This technique takes advan- vectors require additional vertical positioning of the lateral tage of a bluntly dissected tunnel extending from the lateral canthal support suture at the superior aspect of the pupil. Fig. 8.33 (A,B) Schematic representation of procedure for lower eyelid. Note that only the inferior orbital septum is plicated and sutured to the inferior orbital rim. (Adapted upper lid blepharoplasty incision into the lateral aspect of a from Sensöz O, Unlu RE, Percin A, et al. Septoorbitoperiostoplasty for the treatment of palpebral bags: a 10-year experience. Plast Reconstr Surg 1998; 101(6):1657–1663.) Lateral canthoplasty, which includes surgical division of lower lid incision. Next, the lateral retinaculum and tarsal the lateral canthus, is recommended for more significant strap are bluntly dissected off the periosteum 5 mm in both lower lid laxity, defined by lid distraction >6 mm away from infraorbital rim, the orbicularis retaining ligament is divided. excess lower lid skin as the tissues accordion inferiorly. With directions (Figs 8.4, 8.37). the globe. Lateral canthotomy, cantholysis of the inferior limb Additional medial dissection is performed to release the restoration of the normal intercanthal axis tilt, lid tone, and A double-armed 4–0 Prolene or Mersilene is used to suture of the lateral canthal tendon, and release of the tarsal strap are levator labii when a tear trough deformity is present. septal integrity, the appearance of excess skin and herniated the tarsal plate and lateral retinaculum to the inner aspect of performed. This dissection is followed by a 2–3 mm full- The skin muscle flap is draped in a superior lateral vector fat disappears with minimal tissue excision and, in many the lateral orbital rim periosteum above the Whitnall tubercle. thickness lid margin resection, depending on the degree of rather than a pure vertical vector. Excision of skin and muscle patients, without the need for any muscle, skin, or fat excision Periosteum is thickest at the superior and lateral orbital rim, tarsoligamentous laxity. The lateral commissure is carefully are performed by removing a triangle of tissue lateral to the (Fig. 8.35).37,53 making it a secure suture site. The mattress suture is placed reconstructed by aligning the anatomical grey line with 6–0 canthus, thereby minimizing the amount of tissue removed A lateral canthopexy can establish an aesthetically and through the periosteum within the lateral orbital rim to plain gut. Final fixation to the lateral orbital periosteum can along the actual lid margin. The lateral suspension of the functionally youthful eyelid and reduce the incidence of lower maintain the posterior position of the lid margin against be as described above. orbicularis is to the orbital periosteum. Lower lid support is lid malposition and scleral show (Fig. 8.36). It has become the globe. gained by resuspension of the anterior (skin and muscle) and an integral part of a lower lid blepharoplasty and midface- Bone canthopexy is technically possible through upper Midfacelifting posterior lamellae (tarsus by canthopexy). lifting.36 It is increasingly appreciated that good and long- and lower lid incisions but is technically demanding. Wide This technique is best suited for patients with scleral show, lasting surgical results in lower lid surgery are rarely possible exposure through a coronal brow lift provides the ideal envi- Patients will frequently complain that they would like the lid laxity, and a negative vector, which put them at risk for lid without an effective canthopexy. ronment and access. Bone fixation gives a profoundly longer lower skin to be smoother and tighter, the fatty pads to be malposition in the postoperative period. Its drawback is that A lasting canthopexy involves more than a simple stitch lasting result than does periosteal fixation. Drill holes (1.5 mm eliminated, and the tissues of the malar eminence to be fuller. it inherently disrupts the orbicularis, which may lead to den- into the periosteum. A properly executed canthopexy restores drill bit) are placed 2–3 mm posterior to the lateral orbital rim. Midface descent occurs in the spectrum of periorbital aging, ervation. Mobilization of the levator labii muscles also may the tone, posture, and tilt to the lower lid and serves as the The inferior and superior holes are separated by 5–10 mm to clinically apparent in the 4th decade (Fig. 8.39). The orbicula- put the buccal branch of the facial nerve at risk. fulcrum point for rejuvenation of the entire midface. In addi- allow suture separation and ligation (Fig. 8.38). ris muscle and suborbicularis oculi fat (SOOF) descend in tion, it raises the Lockwood suspensory ligament (and the The vertical position of the lateral canthal suture is depend- an inferonasal direction and, in conjunction with descent Canthopexy entire retinacular complex), lifting orbital structures upward, ent on eye prominence and preexisting canthal tilt. Patients of the malar fat pad, results in the fullness of the nasolabial reducing lower lid fat herniation, and reducing upper lid with prominent eyes and negative vector morphology are at fold frequently seen with the aging face. This inferonasal As the lateral canthal tendon lengthens, it shortens the aper- hollowing – all an essential part of a youthful periorbital higher risk for lid malposition and require additional vertical vector of aging also creates a visual lengthening of the lower ture and allows the lid posture to drop to give the illusion of restoration. Treatment/technique 133 134 SECTION I • 8 • Blepharoplasty

0˚ -10 - 15˚

A

A A

A

B

C

0˚ +10 - 15˚ B

B Fig. 8.36 (A) Preoperative and (B) 5-year postoperative photograph of a patient with a lower lid blepharoplasty and canthopexy.

B D includes the lateral canthal tendon, the medial canthal tendon, the skin, fat, and orbicularis oculi muscle of the lower eyelids, E the sub–orbicularis oculi fat pad, the malar fat pad, the orbito- Fig. 8.35 (A) Attenuation with aging produces a descent of the lateral canthus. malar ligament (orbicularis ligament), the orbital septum, (B) The end result is a lateral canthus that is linear or declined compared with the and origins of the zygomaticus major and minor muscles Fig. 8.38 The canthopexy suture series for a two-layered canthopexy. (A) The medial canthus. As the lateral canthus sags, the intercommissure distance shortens and levator labii superioris. When evaluating the midface canthopexy suture fixating the tarsal tail into the drilled hole. (B) The second-layer and the lower lid and inferior lateral septum become lax. This produces sclera for aesthetic surgery, all the structures listed above must be orbicularis suture. (C) Lateral sutures fix the lateral orbicularis to the deep temporal show, lid malposition and orbital fat prominence laterally and tear drainage considered. fascia. (D) If a midfacelift is elected, an inferior drill hole can be made to fixate the problems. With restoration of the normal intercanthal axis tilt, lid tone, and septal The author’s preferred technique includes approaching midface tissues. (E) Bury the knot into drill hole. integrity, the appearance of excess skin and herniated fat disappears with minimal tissue excision and, in many, without the need for any muscle, skin, or fat excision. the midface through a transconjunctival incision. After repo- (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. sitioning or resection of orbital fat, the midface is elevated in C Philadelphia: Saunders; 2004:35.) a supraperiosteal plane. The attachment of the orbicularis oculi muscle to the orbital septum is preserved. Adequate release of the remaining, lax orbitomalar ligament then lids beyond the orbital margin. Lastly, relative loss of soft permits malar fat pad suspension in a superolateral vector to tissue secondarily skeletonizes the inferior orbital rim and the lateral orbital rim and temporoparietal fascia (Fig. 8.40). Postoperative care Fig. 8.37 (A–C) Periosteal canthopexy. The inferior ramus of the lateral canthal zygoma, deepening the tear trough and diminishing the malar Canthopexy is then performed to redrape lower eyelid skin 54,55 tendon is secured and elevated to a raised position inside the orbital rim. Tension prominence. and recreate a youthful intercanthal angle. Finally, a skin only free suspension occurs with release of the tarsal strap and lateral orbital thickening. All patients are advised to expect swelling, bruising, some The middle third of the face, or midface, lies between the resection of the lower lid may be necessary to address any degree of ptosis, and tugging sensation on gazing upward. lateral canthal angle and the top of the nasolabial fold. It redundancy. Although complete recovery takes months, patients generally look presentable approximately 2–3 weeks after surgery.

tahir99 - UnitedVRG vip.persianss.ir Complications 135 136 SECTION I • 8 • Blepharoplasty

When no canthopexy is performed, half-inch Steri-Strips, retracted superiorly, are applied as a “cast” (with benzoin or Mastisol for security). This treatment tends to reduce lid Access via upper or lower blepharoplasty incision retraction. Alternatively, a Frost suture placed in the lower lid margin and fixed to the brow suspends the lid during early healing. Temporary medial or lateral limbus tarsorrhaphies were previously popular after aggressive skin excision blepha- roplasty techniques. These sutures were primarily used to minimize chemosis during the first 48 h. Discomfort, restricted vision and secondary office visits for suture removal have led Orbital fat to their limited use today. However, the best support during Orbital septum healing is a secure extended canthopexy.45 Orbicularis oculi

A Complications Malar bag Orbitomalar ligament Even the most carefully planned procedures will have a small SOOF percentage of complications. The possibility of such complica- Malar fat pad tions and a realistic appraisal of likely outcome should be discussed with the patient before surgery. Zygomaticus Asymmetry is common postoperatively and can be caused by edema, bruising, and asymmetric sleep posture, but it also SMAS Extent of sub-orbicularis muscle/ malar fat pad/SMAS undermining predictably follows undiagnosed preoperative asymmetry, Buccal fat pad A including mild ptosis, made worse by the weight of postop- erative edema. Patients should be advised that no reopera- tions are indicated before 8 weeks, and then only if the lids B have stabilized and no edema or bruising is seen. The need for reoperations is infrequent, but when ptosis or exophthalmos B is involved, incidence increases significantly to 10–30%.45 Retrobulbar hemorrhage is the most feared complication of Fig. 8.39 (A) Preoperative and (B) postoperative photograph demonstrating the eyelid surgery. Any complaint of severe orbital pain needs to benefit of midfacelift in the setting of blepharoplasty. be examined immediately, especially that of sudden onset. Acute management involves immediate evaluation, urgent ophthalmologic consultation and a return to the operation for evacuation of the hematoma. Medical treatments, in addition Surgical literature has not advocated compression bandag- to operative exploration, include administration of high flow ing of the eyes after surgery. The concern is an undetected oxygen, topical and systemic corticosteroids and mannitol. retrobulbar hemorrhage that results in vision loss. However, Acute loss of vision mandates bedside suture removal and the reality is that the risk for hemorrhage, chemosis, and other decompressive lateral canthotomy. Hospitalization with head problems is more likely in an eye that has no compression. elevation and close observation may be necessary to supple- Retrobulbar hemorrhage is likely to induce orbital pain, which ment the described measures.29 Peribulbar hematoma, in con- should never be ignored, alerting the surgeon to the potential trast, does not threaten vision. It usually results from bleeding Single mattress suture repair vision-threatening complication. If one chooses not to use of an orbicularis muscle vessel. Small hematomas may resolve gently compressive bandages, postoperative edema can be spontaneously, though larger hematomas can be evacuated in reduced with cool compresses for up to 20 min intermittently the office. during the initial 36 hours postoperatively. Patients are Visual changes, including diplopia, are generally tempo- advised against using frozen compresses directly over their rary and can be attributed to wound reaction, edema and face in the setting of previous anesthetic use and pain hematoma. Any damage to the superficial lying oblique 29 C Cheek flap is elevated and medication. muscles can be permanent and lead to postoperative strabis- sutured to deep temporal fascia or Additional recommendations include having the patient lie mus. Conservative management is recommended; refractory periosteum of lateral orbital rim in a semi-recumbent position while resting and to avoid cases should be referred to an ophthalmologist. bedrest. Prescriptions for rewetting drops, Lacri-Lube® and The most common complication after blepharoplasty is Fig. 8.40 Midfacelift. (A) The arrow in red depicts the plane of dissection to the midfacial structures in the cheek in a supraperiosteal approach. (B) Wide undermining of antibiotic ophthalmic ointment can be given to reduce the chemosis. Disruption of ocular and eyelid lymphatic drainage the periorbital ligamentous structures and lateral retinaculum may be transconjunctival or through the upper blepharoplasty incision. (C) Canthopexy and cheek suspension incidence of exposure keratoconjunctivitis and dry eye symp- leads to development of milky, conjunctival and corneal then proceed sequentially. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:129.) toms in the immediate postoperative period. Patients are per- edema. Chemosis can be limited by atraumatic dissection, mitted to shower the next day and use antibiotic ointments as cold compresses, elevation and massage. It is usually self- needed, for routine incisional care. Avoiding direct sun expo- limited and resolves spontaneously, though prolonged chem- dry eyes may be aggravated by postoperative lagophthalmos. ptosis all require careful observation and photographic sure with sunglasses may reduce the severity of sunburn and osis can be treated with topical steroids. Ocular protection can achieved medically with liberal use of documentation. Reoperation should be performed no earlier the formation of irregular, darkened pigmentation. It is also Dry eye symptoms are also frequently cited in the post corneal lubricants. than 3 months later. Secondary blepharoplasty can range suggested that patients refrain from using contacts and to operative phase. Patients may complain of foreign body sen- Additional complications such as lower lid malposition, from simple office-based procedures to extremely challenging minimize the use of prescription eyeglasses.30 sation, burning, secretions and frequent blinking. Preexisting lagophthalmos, undercorrection, asymmetry, and iatrogenic interventions.

tahir99 - UnitedVRG tahir99 - UnitedVRG vip.persianss.ir vip.persianss.ir Special considerations 137 References 137.e1

American Society for Aesthetic Plastic Surgery, there was a 19. Hawes MJ, Dortzbach RK. The microscopic anatomy Special considerations 293% increase in the number of African-American patients References of the lower eyelid retractors. Arch Ophthalmol. who underwent cosmetic plastic surgery from 1997 to 2004.58 1982;100(8):1313–1318. Male blepharoplasty The awareness of the benefits of cosmetic plastic surgery is 1. Dupuis, C, Rees, TD. Historical notes on blepharoplasty. 20. Gioia VM, Linberg JV, McCormick S. The anatomy becoming ever-present to a patient population which tran- Plast Reconstr Surg. 1971;47(3):246–251. of the lateral canthal tendon. Arch Ophthalmol. In the United States, 16% of blepharoplasties are performed scends cultural and racial boundaries. 2. Flowers RS. The art of eyelid and orbital aesthetics. Clin 1987;105(4):529–532. African-American patients pursuing eyelid rejuvenation on men, and blepharoplasty is the second most common Plast Surg. 1987;14(4):709–721. 21. Muzaffar AR, Mendelson BC, Adams Jr WP. Surgical 56 have preconceived notions and concerns distinct from their cosmetic surgery performed on male patients. Men tend to 3. Nesi FA, Levine MR, Lisman RD. Smith’s Ophthalmic anatomy of the ligamentous attachments of the Caucasian counterparts, thereby demanding a different seek out blepharoplasty more for functional reasons than Plastic and Reconstructive Surgery. ed 2. St. Louis, MO: lower lid and lateral canthus. Plast Reconstr Surg. surgical strategy. African-Americans are twice as likely as women, but this difference has become less and less distinct Mosby; 1997. 2002;110(3):873–884. in recent years. A more natural look is preferred, and the Caucasians to be afraid of losing their ethnic identity and 10 4. Putterman AM. Cosmetic Oculoplastic Surgery: Eyelid, Ophthalmic Plastic “operated look” will not be tolerated well by most male times as likely to choose a surgeon with special interests in 22. Jones LT, Mustarde JC, Callahan A. Forehead, and Facial Techniques. ed 3. Philadelphia: WB patients. Men typically do not use cosmetics, so all scars ethnic plastic surgery. There are several features that make the Surgery. New York: Aesculapius; 1970. Saunders; 1999. must be carefully concealed. This also makes male patients African-American eye ethnically unique. The lateral canthus 23. Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. suboptimal candidates for laser resurfacing. The lateral inci- is cephalad to the medial canthus in great frequency. In addi- 5. Flowers RS. Advanced blepharoplasty: principles of Philadelphia: WB Saunders; 1994. sion should rarely be extended beyond the later orbital rim. tion, there is a tendency for a more oval, Asian-like palpebral precision. In: Zaoli G, Meyer R, Gonzales-Ulloa M, et al, 24. Beard C, Quickert MH. Anatomy of the Orbit. New York: In men with heavy brows, resection of upper eyelid skin only aperture, as opposed to the more rounded Caucasian palpe- eds. Aesthetic Plastic Surgery. vol II. Padova: Piccin Press; Aesculapius; 1969. bral fissure. The supratarsal fold distance tends to be shorter 1987. will result in profoundly ptotic brows. Therefore, one should 25. Odunze MO, Reid RR, Yu M, et al. Periorbital than in the Caucasian eyelid but longer than the Asian eyelid. consider combined brow surgery with upper blepharoplasty. 6. Wolff E. The Anatomy of the Eye and Orbit. Philadelphia: Rejuvenation and the African American Patient: The lateral orbit and cheek skin is more sebaceous, and there Many men are reluctant to have cosmetic surgery to correct WB Saunders; 1976. A Survey Approach. Plast Reconstr Surg. is a decreased tendency toward rhytid formation. Finally, brow ptosis, so careful preoperative counseling is needed to 7. Doxanas MT, Anderson RL. Clinical Orbital Anatomy. 2006;118(4):1011–1018. prevent a dissatisfied patient with worse brow ptosis postop- African-Americans tend to be poor candidates for lower Baltimore, MD: Williams & Wilkins; 1984. 30,57 eyelid resurfacing because of pigmentation risk. The preferred 26. Hirmand H. Anatomy and nonsurgical correction eratively. Often, conservative eyelid resection is all that is 8. Stewart TD. The points of attachment of the palpebral surgical approach includes canthopexy to restore lateral of tear trough deformity. Plast Reconstr Surg. required. ligaments: their use in facial reconstructions of the skull. canthal position, preservation of the majority of orbicularis to 2010;125(2):699–708. J Forensic Sci. 1983;28(4):858–863. restore supratarsal contour and avoidance of cephalad mal- 27. Zinkernagel MS, Ebneter A, Ammann-Rauch D. Effect Blepharoplasty in people of color position of the upper eyelid incision to preserve limited pre- 9. Jelks GW, Jelks EB. The influence of orbital and eyelid of upper eyelid surgery on corneal topography. Arch tarsal show. These subtleties are discussed preoperatively, anatomy of the palpebral aperture. Clin Plast Surg. Ophthalmol. 2007;125(12):1610–1612. 1991;18:183–195. Patients who identify themselves other than Caucasian now often with the aid of youthful photographs, to appropriately 28. Lee WB, McCord Jr CD, Somia N, et al. Optimizing 25,59 account for 27% of all cosmetic procedures. Hispanics, African- plan surgery. 10. Couly G, Hureau J, Tessier P. The anatomy of the blepharoplasty outcomes in patients with previous Americans and Asian-Americans have seen a steady rise in The unique characteristics of the Asian blepharoplasty will external palpebral ligament in man. J Maxillofac Surg. laser vision correction. Plast Reconstr Surg. their market share over the last 10 years. According to the be thoroughly discussed in Chapter 10. 1976;4(4):195–197. 2008;122(2):587–594. 11. Whitnall SE. Anatomy of the Human Orbit and Accessory 29. Rohrich RJ, Trussler AP. MOC-PS CME article: Organs of Vision. New York: Oxford University Press; Blepharoplasty. Plast Reconstr Surg. 2008;1:1–10. 1932. Access the complete references list online at http://www.expertconsult.com 30. Rohrich RJ, Coberly DM, Fagien S, et al. Current 12. Flowers RS, Nassif JM, Rubin PA, et al. A key to concepts in aesthetic upper blepharoplasty. Plast canthopexy: the tarsal strap. A fresh cadaveric study. 12. Flowers RS, Nassif JM, Rubin PA, et al. A key to 30. Rohrich RJ, Coberly DM, Fagien S, et al. Current Reconstr Surg. 2004;3:32e–42e. canthopexy: the tarsal strap. A fresh cadaveric study. concepts in aesthetic upper blepharoplasty. Plast Plast Reconstr Surg. 2005;116(6):1752–1758. This continuing medical education article provides a concise Plast Reconstr Surg. 2005;116(6):1752–1758. Reconstr Surg. 2004;3:32e–42e. Flowers and colleagues detail the anatomy of the lateral description of upper eyelid aging and a step-by-step guide to orbital retinaculum and highlight the importance of full Flowers and colleagues detail the anatomy of the lateral This continuing medical education article provides a concise popular rejuvenation techniques. orbital retinaculum and highlight the importance of full description of upper eyelid aging and a step-by-step guide to dissection to achieve a tension-free canthopexy. 31. McCord CD, Tanenbaum M. Oculoplastic Surgery. New dissection to achieve a tension-free canthopexy. popular rejuvenation techniques. 13. Ghavami A, Pessa JE, Janis J, et al. The orbicularis York: Raven Press; 1987. 14. Spinelli HM. Atlas of aesthetic eyelid and periocular 36. Flowers RS. Canthopexy as a routine blepharoplasty retaining ligament of the medial orbit: closing the circle. 32. Beard C. Ptosis. St. Louis, MO: Mosby; 1976. surgery. Philadelphia: Saunders; 2004. component. Clin Plast Surg. 1993;20(2):351–365. Plast Reconstr Surg. 2008;121(3):994–1001. 15. Zide BM. Surgical anatomy around the orbit: the system 44. Mendelson BC. Fat preservation technique of lower-lid 14. Spinelli HM. Atlas of aesthetic eyelid and periocular 33. Anderson RL, Dixon RS. Aponeurotic ptosis surgery. of zones. ed 2. Philadelphia: Lippincott, Williams & blepharoplasty. Aesthet Surg J. 2001;21(5):450–459. surgery. Philadelphia: Saunders; 2004. Arch Ophthalmol. 1979;97(6):1123–1128. Wilkins; 2006. Results shown in Mendelson’s article demonstrate the safe, 15. Zide BM. Surgical anatomy around the orbit: the system 34. Flowers RS. Tear trough implants for correction of tear 17. Reid RR, Said HK, Yu M, et al. Revisiting upper eyelid reproducible outcomes of a skin-only blepharoplasty and help of zones. ed 2. Philadelphia: Lippincott, Williams & trough deformity. Clin Plast Surg. 1993;20(2):403–415. anatomy: introduction of the septal extension. Plast swing the pendulum away from aggressive, fat excisional Wilkins; 2006. 35. Flowers RS. Precision planning in blepharoplasty: the Reconstr Surg. 2006;117(1):65–70. techniques. 16. Fralick FB. Anatomy and physiology of the eyelid. importance of preoperative mapping. Clin Plast Surg. This cadaveric and histologic study identifies an extension of 45. Codner MA, Wolfi J, Anzarut A. Primary transcutaneous Ophthalmology. 1962;66:575–581. 1993;20(2):303–310. the orbital septum that must be identified and spared when lower blepharoplasty with routine lateral canthal 17. Reid RR, Said HK, Yu M, et al. Revisiting upper eyelid 36. Flowers RS. Canthopexy as a routine blepharoplasty performing a levator advancement for blepharoptosis. support: a comprehensive 10-year review. Plast Reconstr anatomy: introduction of the septal extension. Plast component. Clin Plast Surg. 1993;20(2):351–365. 21. Muzaffar AR, Mendelson BC, Adams Jr WP. Surgical Surg. 2008;121(1):241–250. Reconstr Surg. 2006;117(1):65–70. 37. Ortiz-Monasterio F, Rodriguez A. Lateral canthoplasty anatomy of the ligamentous attachments of the lower 59. Few JW. Rejuvenation of the African American This cadaveric and histologic study identifies an extension of to change the eye slant. Clin Plast Surg. 1985;75(1):1–10. lid and lateral canthus. Plast Reconstr Surg. Periorbital Area: Dynamic Considerations. Semin Plast the orbital septum that must be identified and spared when 38. Fagien S. The role of the orbicularis oculi muscle and 2002;110(3):873–884. Surg. 2009;23(1):198–206. performing a levator advancement for blepharoptosis. the eyelid crease in optimizing results in aesthetic upper 26. Hirmand H. Anatomy and nonsurgical correction of Few’s survey-based study shows that one must prioritize a 18. Jones LT. The anatomy of the lower eyelid and its blepharoplasty: a new look at the surgical treatment of tear trough deformity. Plast Reconstr Surg. 2010;125(2): patient’s ethnic identity and heritage when approaching the relation to the cause and cure of entropion. Am J mild upper eyelid fissure and fold asymmetries. Plast 699–708. periorbital area in African-Americans. Ophthalmol. 1960;49:29–36. Reconstr Surg. 2010;125(2):653–656.

tahir99 - UnitedVRG tahir99 - UnitedVRG vip.persianss.ir vip.persianss.ir • • Blepharoplasty 137.e2 SECTION I 8 SECTION I Aesthetic Surgery of the Face

39. Flowers RS. Orbital rim contouring. In: Ousterhout D, 51. de la Plaza R, Arroyo JM. A new technique for the ed. Aesthetic Contouring of the Craniofacial Skeleton. treatment of palpebral bags. Plast Reconstr Surg. Boston, MA: Little, Brown; 1991. 1998;81(5):677–687. 40. Yaremchuk MJ. Secondary malar implant surgery. Plast 52. Parsa AA, Lye KD, Radcliffe N, et al. Lower Reconstr Surg. 2008;121(2):620–628. blepharoplasty with capsulopalpebral fascia 41. Flowers RS. Blepharoplasty and brow lifting. In: hernia repair for palpebral bags: a long-term Roenigk RK, Roenigk HH, eds. Principles of Dermatologic prospective study. Plast Reconstr Surg. 2008;121(4): 9 Surgery. New York: Marcel Dekker; 1989. 1387–1397. 42. Flowers RS. The biomechanics of brow and frontalis 53. Jelks GW, Glat PM, Jelks EB, et al. The inferior function and its effect on blepharoplasty. Clin Plast Surg. retinacular lateral canthoplasty: a new technique. Plast 1993;20(2):255–268. Reconstr Surg. 1997;100(8):1262–1266. Secondary blepharoplasty: Techniques 43. Flowers RS. Upper blepharoplasty by eyelid 54. Patipa M. Transblepharoplasty lower eyelid and invagination: anchor blepharoplasty. Clin Plast Surg. midface rejuvenation: Part I. Avoiding complications 1993;20(2):303–307. by utilizing lessons learned from the treatment of 44. Mendelson BC. Fat preservation technique of lower-lid complications. Plast Reconstr Surg. 2004;113(5): Glenn W. Jelks, Elizabeth B. Jelks, Ernest S. Chiu, and Douglas S. Steinbrech blepharoplasty. Aesthet Surg J. 2001;21(5):450–459. 1459–1468. Results shown in Mendelson’s article demonstrate the safe, 55. Paul MP, Calvert JW, Evans GR. The evolution of the reproducible outcomes of a skin-only blepharoplasty and help midface lift in aesthetic plastic surgery. Plast Reconstr swing the pendulum away from aggressive, fat excisional Surg. 2006;117(7):1809–1827. techniques. 56. American Society of Plastic Surgeons. Gender 45. Codner MA, Wolfi J, Anzarut A. Primary transcutaneous distribution: cosmetic surgery 2008. Arlington Heights: lower blepharoplasty with routine lateral canthal American Society of Plastic Surgeons; 2010. Online. individualized postoperative management. Although rare, support: a comprehensive 10-year review. Plast Reconstr Available at: http://www.plasticsurgery.org/Media/ SYNOPSIS complications and unfavorable results may occur following Surg. 2008;121(1):241–250. stats/2008-top-5-male-cosmetic-surgery-procedures- ᭿ Serious complications of primary blepharoplasty surgery are rare, blepharoplasty. It has been estimated that the complication 46. Loeb R. Naso-jugal groove leveling with fat tissue. Clin graph.pdf 2–21 but should they occur, can be difficult to correct and be potentially rate following blepharoplasty is 2%. Minor complications Plast Surg. 1993;20(2):393–400. 57. Flowers RS. Periorbital aesthetic surgery for men: disastrous. are temporary and self-limiting with minimal visual distur- eyelids and related structures. Clin Plast Surg. 47. Goldberg RA. Transconjunctival orbital fat ᭿ bance or aesthetic consequence (Table 9.1). Major complica- 1991;18(4):689–729. Some serious complications which develop early, such as corneal repositioning: transposition of orbital fat pedicles exposure, require aggressive treatment, but lesser complications tions are definitely undesirable and potentially disastrous. into a subperiosteal pocket. Plast Reconstr Surg. 58. American Society of Plastic Surgeons. Cosmetic such as minor lid malpositions should be dealt with after time has They include visual loss, fixed eyelid deformities, corneal 2000;105(2):743–748. demographics 2008. Arlington Heights: American passed to allow for scar maturation. decomposition, and significant aesthetic compromise (Table Society of Plastic Surgeons; 2010. Online. Available at: 9.2) 48. Sensöz O, Unlu RE, Percin A, et al. Septo- ᭿ The eyelids can be divided into four anatomic zones. . In addition, an apparent technically successful operation orbitoperiostoplasty for the treatment of palpebral http://www.plasticsurgery.org/Media/stats/ may produce a very unhappy patient. ᭿ Upper eyelid problems include ptosis and lid retraction. An bags: a 10-year experience. Plast Reconstr Surg. 2008-cosmetic-procedure-demographics-ethnicity.pdf; Once the complication is discovered, a careful and thor- understanding of Herring’s law is necessary to diagnose the 1998;101(6):1657–1663. http://www.plasticsurgery.org/Media/stats/ ough evaluation of the patient’s anatomical deformity and its problem responsible for lid level asymmetry. 2008-cosmetic-procedure-demographics-ethnicity.pdf prognosis is essential. If impending visual compromise is 49. Huang T. Reduction of lower palpebral bulge by ᭿ (Accessed March 1). Lower lid malposition is a common problem after primary apparent, early emergent intervention may be warranted. plicating attenuated orbital septa: a technical blepharoplasty, and is due to an interplay between the patient’s 59. Few JW. Rejuvenation of the African American Most lid malpositions are temporary and resolve within 4–6 modification in cosmetic blepharoplasty. Plast Reconstr unique orbital and eyelid anatomy, and the cicatricial forces. There Periorbital Area: Dynamic Considerations. Semin Plast weeks postoperatively. It is important to protect the cornea Surg. 2000;105(7):2552–2558. are a number of predisposing factors. Surg. 2009;23(1):198–206. during this time. If the lid malpositions aggravate and con- 50. Camirand A, Doucet J, Harris J. Anatomy, ᭿ Lower lid evaluation should address the presence of cicatricial tribute to corneal decompensation, they should be corrected pathophysiology, and prevention of senile enophthalmia Few’s survey-based study shows that one must prioritize a contraction, a vector analysis of the globe in relation to the malar as soon as possible. However, lid malpositions that do not and associated herniated lower eyelid pads. Plast patient’s ethnic identity and heritage when approaching the eminence, a soft tissue to bone distance at the lateral canthus, compromise visual function may be corrected after scar matu- Reconstr Surg. 1997;100(3):1535–1538. periorbital area in African-Americans. tarsoligamentous integrity (distraction and snap tests), lower lid ration. In general, a delay in secondary surgical procedures to eversion, and the level of the malar fat pad. address the problem is recommended. Secondary surgery is ᭿ Lower lid malposition can be treated with various methods, more predictable in a surgical environment that is less inflam- including a wide variety of canthopexy and canthoplasty matory. Better results are obtained if secondary surgery can procedures, vertical spacer grafts and midface elevation. be postponed for at least 6 months and preferably 1 year fol- In severe cases, a combination of modalities is often indicated. lowing the initial surgery. The effect of blepharoplasty procedure complications on patient and physician can be profound. When the results of an elective aesthetic surgical procedure are suboptimal, the patient usually becomes more difficult to manage. It is easier Introduction to manage a dissatisfied patient when there has been a thor- ough preoperative discussion of risks resulting in a signed Each year, over 200 000 people in the United States have informed consent to the procedure. It is imperative to have a a blepharoplasty operation.1 These operations are generally handwritten note by the operating surgeon in the patient’s very successful with a high level of patient satisfaction. chart documenting the explanation of the proposed surgical Successful operations are the result of thorough preoperative procedures including any risks or complications to their evaluation, skillfully performed customized surgical proce- surgery. In addition, the alternatives to surgery should be dures, uneventful anesthesia, proper surgical venue and discussed. ©2013, Elsevier Inc. All rights reserved. tahir99 - UnitedVRG tahir99 - UnitedVRG vip.persianss.ir vip.persianss.ir Introduction 139 140 SECTION I • 9 • Secondary blepharoplasty: Techniques

Table 9.1 Minor blepharoplasty complications Table 9.2 Major blepharoplasty complications

Retrobulbar hemorrhage without visual loss Eyelid malposition Visual loss or alteration Contour changes Upper eyelid Globe penetration Margin abnormalities Pupil changes Ptosis Retrobulbar hemorrhage Lower eyelid Glaucoma Retraction Glaucoma Scleral show Extraocular muscle disorder Retraction Extraocular muscle disorder Contour change Marginal rotation Corneal Laxity Corneal changes Lower eyelid Exposure Paralysis Exposure Scleral show Ulcer Margin abnormalities Keratitis Lid retraction Filaments Ectropion Erosion Lid paresis Scar Entropion Ulcer Neovascularization Marginal rotation Eyelid deformities Refractive Refractive Ectropion or entropion Palpebral aperture asymmetry Astigmatism Astigmatism Unveiled pre-existing condition Edema Eyelid deformities Tear film abnormality Iatrogenic Tear film abnormality Hematoma Contact lens intolerance Upper eyelid fold Basement membrane disorder Epicanthal folds Basement membrane disorder Cysts Asymmetric Lacrimal disorder Wound separation Permanent eyelid deformities and functional disorders Absent Dry eye Eyelid numbness Lacrimal disorders High Epiphora Eyelid discoloration Dry eye Low Tear film abnormality Scars Epiphora Multiple Reflexly stimulated tears Loss of eyelashes Tear film abnormalities (reflexly stimulated) Epicanthal folds Tear distribution abnormalities Tear distribution abnormalities Cicatrix Lid margin eversion Inflammatory conditions Lid eversion Inadequate fat removal Lid retraction Infectious Lid retraction Excessive fat removal Lid ectropion Cellulitis Ectropion Suture tunnels Lid entropion Abscess Entropion Dermal pigmentary changes Lid paresis Hordeolum Tear drainage abnormalities Festoons Tear drainage abnormalities Chalazion Lid paralysis Malar pads Punctal eversion Blepharitis Medial punctal eversion Obstruction of nasolacrimal system Noninfectious Obstruction of nasolacrimal system Lid paresis Allergic Eyelid malpositions Dacryocystitis Chemical Upper eyelid Blepharitis Conjunctival changes Ptosis Chemosis Retraction Prolapse From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.27 Incarceration Hemorrhage From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.27

Anatomical zones Corneal protection

To facilitate complete and thorough anatomical analysis, the In both primary and secondary surgery of the eyelids and eyelids are divided into zones (Fig. 9.1).22,26 Zone 0 includes orbital region, protection of the cornea is essential. Specially Once a complication occurs, more time and effort by the (3) anatomical variations that may be accentuated after the ocular globe and orbital structures behind the arcus mar- designed, protective contact lenses should be routine (Fig. physician and his support staff will be required. This often eyelid skin, muscle; and fat removal and, most importantly, ginalis, posterior lacrimal crest, and lateral retinaculum. 9.3).27 Colored lenses are preferred as they filter bright operat- translates into arranging for more frequent office visits. The (4) the psychological status of the patient and assessment Zones I and II include the upper eyelid and lower eyelid, ing light if the procedure is performed under local anesthesia, physician must devote more time to help the patient through of their expectations of surgery. The presence of a pre- respectively, from the lateral commissure to the temporal and they are also less often inadvertently left on the cornea this disappointing situation. Reassurance by the surgeon in existing condition does not preclude cosmetic blepharoplasty; aspect of canalicular puncti. Zone III is the medial canthus postoperatively. The contact shell prevents desiccation and the face of temporary complications will aid in patient accep- however, the surgical timing, venue, and technique may have with the lacrimal drainage system. Zone IV is the lateral inadvertent corneal injury by an instrument or gauze. In order tance of prolonged healing. to be altered. retinaculum. Zones I–IV are further subdivided into struc- to avoid postoperative corneal abrasions, deep sutures on or The easiest complication to avoid is failure to recognize a The following discussion contains relevant information tures that are anterior (preseptal) or posterior (postseptal) to near the conjunctival surface should be placed in such a pre-existing condition that would increase the likelihood of regarding anatomical zones of the eyelids as well as preven- the orbital septum. Zone V includes the contiguous periorbital manner that the knots are buried in the tissue or placed exter- an unfavorable result from standard blepharoplasty (Table tion, diagnosis, and management of complications in the post- structures of nasal, glabella, brow, forehead, temple, malar, nally. A continuous buried suture that may be pulled out after 9.3).22–25 The pre-existing conditions include: (1) medical or blepharoplasty patient. Although malposition of both the and nasojugal regions which merge with zones I–IV (Fig. 9.2). healing is particularly useful in the approximation of tissue ophthalmological conditions that may increase the risk of upper and lower eyelid are presented, a particular emphasis The diagnosis and management of upper eyelid (zone I) and over the cornea. Skin grafts should not be placed in the con- visual impairment; (2) morphological variants that predispose is placed on unnatural distortion of the lower eyelid as these lower eyelid (zone II) complications that occur as a result of junctival sac if they are to be in contact with the cornea; only the patient to post-blepharoplasty eyelid malpositions; are the most common types of defects encountered. blepharoplasty procedures will be discussed in detail. conjunctival or other mucosal tissue is tolerated by the cornea.

tahir99 - UnitedVRG tahir99 - UnitedVRG vip.persianss.ir vip.persianss.ir Corneal protection 141 142 SECTION I • 9 • Secondary blepharoplasty: Techniques

Table 9.3 Prevention of blepharoplasty complications: preoperative evaluation Upper eyelid Pre-existing conditions Morphology Medical conditions Negative vector Hypertension Malar hypoplasia Upper eyelid malposition: evaluation Diabetes High myopia and management Bleeding disorders Small orbital volume Inflammatory skin condition Horizontal lid laxity A thorough evaluation of the upper eyelid (zone I) level is Asthma Involutional facilitated by dividing the structure into anterior, middle, and Sulfite allergy Cicatricial posterior lamella (Table 9.4). The anterior lamella is composed Venous thrombosis Ectropion of upper lid skin and orbicularis muscle. The middle lamella Cardiac disorders Entropion is composed of the tarsus, levator mechanism, orbital septum, Atherosclerosis and fat. The posterior lamella consists of the conjunctiva. The Anatomical variations COPD palpebral aperture is primarily influenced by the upper eyelid Tear trough deformity Emphysema levels (Fig. 9.4). The palpebral aperture usually varies in Malar pads Sleep apnea shape, size, and obliquity due to hereditary, racial, traumatic, Festoons Ophthalmological conditions or other acquired situations. The surrounding bony orbital Cheek-lid interface deformity Amblyopia anatomy, the internal orbital volume, and the integrity of the True ptosis Diplopia eyelids, with their muscular and tarsoligamentous supports, Look ptosis Fig. 9.3 Corneal protective shields manufactured with a steep central radius of Strabismus are some of the factors that influence the palpebral aperture Frontalis spasm curvature and a flat peripheral radius of curvature. This configuration prevents direct Glaucoma (Figs 9.5, 9.6). It is also influenced by the relative amount of Corrugator hyperactivity contact. Colored lenses are preferred as they filter bright operating light if the Corneal disease procedure is performed under local anesthesia, and they are also less often associated periorbital skin, fat, and soft tissues. Unique indi- Crow’s feet Eyelid disorder inadvertently left on the cornea postoperatively. (From Jelks GW, Jelks EB. vidual combinations of eyelid and orbital anatomy can cause Punctal eversion High myopia Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic variations in the palpebral aperture (Fig. 9.4).28 Ectropion surgery. New York: Gower Medical Publishing; 1992.) Contact lens wearer The eyelid fold position should also be evaluated. In the Entropion Retinal disorders occidental patient, the upper eyelid fold is normally 8–10 mm Uveitis Psychological above the lid margin. This corresponds to the superior attach- Dry eye Realistic outcome expectations ments of the levator aponeurosis to the subcutaneous tissue Tear film dysfunction Ability to deal with vision loss, deformity of the eyelid. Above the lid fold, the aponeurosis does not Refractive surgery Body dysmorphic disorder attach to the preseptal or orbital subcutaneous tissue, and the Body image overhanging skin forms a fold. Inferior to the lid fold there

Table 9.4 Secondary blepharoplasty candidate evaluation: upper eyelid

Anterior lamella Lagophthalmos Absent Present V 1 Skin Normal Abnormal Over-resection Excess I Scars Normal Abnormal Position Quality 2 3 4 Lid fold position Normal Abnormal High Low III IV Absent Multiple 5 Lash position Normal Abnormal Palpebral aperture Symmetric Asymmetric

II Fig. 9.2 Topographic anatomy of the eyelids and cheeks. (1) Superior eyelid fold; Middle lamella Lid levels Equal Ptosis Retraction (2) inferior eyelid fold; (3) malar fold; (4) nasojugal fold; (5) nasolabial fold. Unilateral Physiologic (Modified from Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications V and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; Bilateral Thyroid 1992.) Cicatricial Bell’s Mechanical Cicatricial Involutional Levator function (measurement) 0–3 mm 3–10 mm >10 mm Fig. 9.1 Surgical zones of the eyelids and periocular structures. Zone I, upper eyelid; zone II, lower eyelid; zone III, medial canthal structures including the Fat Normal Abnormal Excess lacrimal drainage system; zone IV, lateral canthal area; zone V, periocular removal contiguous area-glabella, eyebrow, forehead, temple, malar, nasojugal and nasal Retention areas. (From Spinelli HM, Jelks GW. Periocular reconstruction: a systematic Posterior lamella Palpebral conjunctiva Normal Abnormal approach. Plast Reconstr Surg 1993;91:1017.)

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Levator Skin Obicularis Superior rectus Orbital septum Levator aponeurosis

Globe Müller’s smooth muscle Lateral horn of Conjunctiva levator aponeurosis

Lateral rectus A Normal B Ptosis C Lid retraction Fig. 9.6 Sagittal section illustrating the structures of Fig. 9.4 (A) Normal palpebral aperture. The upper eyelid is normally 1–2 mm below the superior corneal limbus. (B) Ptosis is seen when the upper eyelid level is below the upper eyelid, including the levator muscle, its that seen in (A), interfering with the superior visual field. (C) Lid retraction is seen when the elevation of the upper lid is at or above the superior corneal limbus. (Modified Lateral canthal tendon Tarsus aponeurosis, and its relationship with Mueller’s muscle from Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.) and the septum orbitale. (Modified from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1990:1671.)

are levator attachments to the subcutaneous tissue overlying the tarsus. In the Asian patient, the orbital septum inserts more inferiorly onto the distal expansion of the levator apone- urosis, which allows more preaponeurotic fat to descend into the upper eyelid and the resultant lower eyelid crease. Blepharoplasty in Asians requires the identification of subor- bicular fat. Dissection through this fat layer provides access Skin to the orbital septum and the retroseptal (preaponeurotic) fat. Ptosis and lid retraction are conditions that alter the palpe- bral aperture by affecting the anatomic position of the upper Obicularis eyelid. Localization of any major eyelid pathology facilitates the delineation of corrective procedures. The most commonly seen upper eyelid complications requiring secondary correc- A B C tion are ptosis and lid retraction. Fig. 9.7 (A) Patient with acquired ptosis of the left upper lid. (B,C) Levator function of 15 mm was measured with a ruler from down gaze to up gaze while manually Ptosis blocking brow elevation of the upper eyelid. Levator function >10 mm is considered good. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.) Ptosis is the abnormally low level of the upper eyelid.28–31 Orbital septum Ptosis of the upper eyelid can result from damage to the Levator tendon levator complex during retroseptal dissection by direct trauma, hematoma, edema, or septal adhesions.28,32–38 The Müller’s muscle normal upper eyelid level covers 2–3 mm of the superior Cul-de-sac of limbus or lies at the level midway between the superior edge placed too high. The medial and lateral retinaculae become Aponeurosis disinsertion, or dehiscence, is the most conjunctiva of a 4 mm pupil and the superior corneal limbus (Fig. 9.4). tense and lower the upper lid level. Treatment consists of common form of acquired ptosis. The typical clinical presen- Preoperative variations in upper eyelid levels may result from observation and massage of the upper eyelid. If ptosis persists tation is a mild (1–2 mm) to moderate (2–3 mm) case of ptosis the level of alertness, pharmacologic agents, direction of gaze, more than several weeks, removal of the supratarsal fixation associated with thin upper eyelids, high lid folds, and good Attachments size of the ocular globe, orbital volume, visual acuity, and sutures is necessary. Ptosis may also occur when adhesions levator excursion (Figs 9.8, 9.9).28 The levator muscle origi- to tarsus extraocular muscle balance.28 Occasionally, unrecognized develop between the orbital septum and the levator aponeu- nates from the apex of the orbit and passes anteriorly, becom- Attachments ptosis manifests itself in the postoperative blepharoplasty rosis at a level higher than the original septal origin. ing aponeurotic at the superior orbital margin to insert onto to skin patient. Review of the preoperative examination records and Ptosis is classified as mild at 1–2 mm, moderate at 2–3 mm, the anterior two-thirds of the anterior tarsal surface. Some medical photography usually reveals the etiology. When no and severe at ≥4 mm.4,22,28 The amount of ptosis is documented fibers of the aponeurosis extend to the orbicularis fascia to Tarsus presenting condition can be documented, a surgical mis- by measuring the vertical dimensions of the palpebral aper- attach to the dermis of the upper eyelid, forming the upper adventure is implicated in the etiology. tures at the midpupillary line. The amount of levator function lid crease. The anterior orbital fat removed during upper Mechanical ptosis due to postoperative edema is symmet- in millimeters is measured whenever ptosis is diagnosed in blepharoplasty lies posterior to the septum and anterior to ric and transient and usually resolves spontaneously within order to plan a surgical correction. The test is performed by the levator aponeurosis. Inadvertent penetration or detach- 48–72 h. A hematoma in the retroseptal space can cause examining the upper eyelid excursion from complete down ment injury to the levator aponeurosis can occur during impairment of levator muscle function, maintaining the upper gaze to up gaze, while blocking any contribution to upper removal of the preseptal orbicularis oculi muscle or retrosep- eyelid in a ptotic position. Resorption of the hematoma may eyelid elevation by the eyebrow (Fig. 9.7). Asymmetric or tal fat (Fig. 9.9A). Fig. 9.5 Sagittal section through the upper eyelid showing the relationship of the orbicularis oculi muscle, septum orbitale, levator palpebrae superioris, and produce secondary fibrosis of the levator with persistent absent lid creases must be identified, because asymmetry can The condition is repaired by levator exploration and Mueller’s muscle. (Modified from Jelks GW, Smith BC. Reconstruction of the ptosis. Attempts to create high upper eyelid supratarsal be accentuated with standard blepharoplasty techniques. The advancement of the aponeurotic structures to the anterior eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. folds involve fixing the skin muscle edges to the levator vertical dimensions of the palpebral apertures at the midpu- tarsus.32–38 Patients with levator detachment should be Philadelphia: WB Saunders; 1990:1671.) aponeurosis. This can lead to tractional ptosis if the lid fold is pillary line are also measured.23 repaired by levator advancement to the anterior tarsus. The Upper eyelid 145 146 SECTION I • 9 • Secondary blepharoplasty: Techniques

Fasanella–Servat38 technique and its various modifications (Fig. 9.10), or variations of a tarso-mullerectomy are also excellent approaches to correct minimal ptosis.

Retraction Obicularis oculi Lid retraction of the upper eyelid is an elevation of the upper Levator eyelid margin above the superior corneal limbus. Lid retrac- aponeurosis tion may be unilateral or bilateral, giving the patient a staring appearance and the illusion or accentuation or exophthalmos. Excessive skin removal from the upper eyelid may result in Preaponeurotic fat lagophthalmos and lid retraction which prevents complete closure of the eyelids (Fig. 9.11A). Varying amounts of lid C D Orbital septum margin eversion may also be present (Fig. 9.11B). Surgical High lid fold correction requires release of the retraction through applica- Fig. 9.9, cont’d (C,D) Patients with left upper eyelid cicatricial ptosis due to adhesions between the levator aponeurosis, orbital septum, and skin. (From Jelks GW, Jelks Levator aponeurosis tion of a retro- or preauricular full-thickness skin graft (Fig. EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.) 9.11C,D).37–42 Müller’s smooth Adhesion, fibrosis, and foreshortening of the mid-lamellar muscle structures of the upper lid (levator aponeurosis, orbital Conjunctiva septum, and tarsus) can cause upper eyelid retraction (Fig. Thin lid 9.12A). Treatment requires surgical release of the adhesion, levator aponeurosis recession, interpositional fascial grafts, Tarsus and lid traction sutures, which should establish a minimal Skin amount of ptosis of the involved lids (Fig. 9.12B).27,37–42 Subsequent ptosis correction by a levator aponeurosis Ptosis advancement or partial tarso-mullerectomy usually produces an acceptable result (Fig. 9.12C).27,37 Herring’s law Retraction in the upper eyelid may also present as a result of ptosis in the contralateral eye (Fig. 9.13). This type of retrac- tion can be explained by Herring’s law of equal innervation,43 Fig. 9.8 Levator aponeurosis dehiscence produces a high upper lid fold, thin upper which states that both the levator palpebrae muscles receive eyelid, and ptosis. (Modified from Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, the same level of innervation (for motor power), regardless of A B C ed. Complications and problems in aesthetic plastic surgery. New York: Gower whether they are asymmetric. Therefore, if one eyelid is ptotic, Medical Publishing; 1992.) when the body produces a reflex action to overstimulate the eyelid to improve the ptotic eyelids position, the contralateral eye will then appear retracted. Herring’s law is an important consideration in both ptosis repair and lid retraction repair. By covering each eye independently during evaluation, the true amount of retraction may be revealed. Treatment consists of repair of the ptotic eyelid which should ultimately correct the asymmetry (Fig. 9.13).

D E

Fig. 9.10 The Fasanella–Servat technique. (A) The eyelid is everted. (B) Two thin, curved hemostatic forceps are placed on the lower edge of the everted lid ≤3 mm from the upper border of the tarsus. The first of the interrupted incisions is made. The interrupted incisions are extended in steps of 4–5 mm. A mattress suture is placed after each incision. (C) The sutures are tied so as to hold the tissues firmly yet allow the lid to be returned to its normal position at the end of the procedure. (D) Fasanella’s alternative method of suturing a running continuous or “serpentine” fashion. (E) The running continuous or “serpentine” suture is returned, and the suture is tied on the temporal side. (Modified from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1990:1671.)

A B

Fig. 9.9 (A) Patient who underwent cosmetic blepharoplasty with inadvertent disinsertion of the right levator aponeurosis during orbicularis oculi and retroseptal fat removal resulting in a right upper eyelid ptosis. (B) Patient following cosmetic blepharoplasty with a left upper eyelid ptosis from inadvertent levator aponeurosis detachment. Upper eyelid 147 148 SECTION I • 9 • Secondary blepharoplasty: Techniques

Lateral horn of levator Upper tarsus

Upper preseptal Orbital Lateral canthal tendon Upper preseptal Upper Upper pretarsal pretarsal Lateral palpebral raphe Lower pretarsal

B A Lower preseptal

A B

Fig. 9.14 (A) The lateral palpebral raphe. (B) The lateral canthal tendon and the anatomy of the structures of the lateral canthus. (Modified from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1990:1671.)

Lower eyelid Lower eyelid malposition C D Evaluation Fig. 9.11 (A) Patient with excessive skin removal from the upper eyelid and lagophthalmos. Bell’s reflex is fair. (B) Patient with upper eyelid retraction, lid margin eversion, Superior rectus and exposure keratopathy due to excessive upper eyelid skin excision. Note the surgical marking for the proposed incision to release the scar and establish a wide defect. The complications of primary blepharoplasty have been (C) Retroauricular full-thickness skin graft sutured to the defect. (D) Patient 9 months postoperatively. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. described in Chapter 6. Asymmetry is a common problem and Levator palpebrae superioris Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.) distortion of lower lid position is a common contributor to this phenomenon.2–4,7–10,13,18–21 This malposition is often due to an interplay of the patient’s unique periorbital anatomy with mechanical distraction due to gravitational and cicatricial forces of the skin, muscle, and Upper septum displacing the lid inferiorly following blepharoplasty preseptal procedures.22,23 Canthal and eyelid laxity, edema, hematoma, Upper pretarsal excessive resection of skin and fat, or impaired orbicularis oculi muscle function may also contribute to the disruptive forces. Lateral rectus B A C The lower eyelids (zone II) extend from the lid margin to Lateral horn of levator the cheek area (Fig. 9.1). The medial canthus zone (zone III), Fig. 9.12 (A) Patient 2 months postoperatively with right upper eyelid cicatricial retraction of the midlamellar structures (tarsus, orbital septum, and levator aponeurosis. (B) is a complex region containing the origins of the orbicularis Patient 6 months after the release of lid adhesions and a levator recession of the right upper eyelid. Minimal ptosis of the right upper eyelid was deliberately produced. (C) oculi muscle, the lacrimal collecting system, and associated Lateral canthal tendon Patient 6 months after ptosis correction by tarso-mullerectomy. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic neurovascular structures. The lateral canthus (zone IV) is an surgery. New York: Gower Medical Publishing; 1992.) Lower integral anatomic unit of the temporal aspects of the eyelids. pretarsal The lateral canthus zone, which is more correctly termed Lower preseptal lateral retinaculum, consists of: (1) the lateral horn of the levator palpebrae superioris muscle; (2) the continuation of the preseptal and pretarsal orbicularis oculi muscle (the lateral canthal tendon); (3) the inferior suspensory ligament of the globe (Lockwood’s ligament); and (4) the check ligaments of Fig. 9.15 The lateral extension or horn of the levator aponeurosis (upper arrow) 22,23,26,27 the lateral rectus muscle (Fig. 9.14). The lateral retinacu- splits the lacrimal gland into its orbital (O) and palpebral (P) lobes and extends lum structures attach to a confluent region of the lateral bony inferolaterally to join the lateral retinaculum. The lateral portion of Whitnall’s orbital wall on a small promontory just within the lateral ligament (W) inserts into the orbital lobe of the gland by way of the interglandular orbital rim known as Whitnall’s tubercle (Figs 9.2, 9.15).23,27 fascial septa. The inferolateral pole of the palpebral lobe of the lacrimal gland A B C Similar to the upper lid, the lower lid is also divided usually rests at the level of the lateral retinaculum (lower arrow). The lateral retinaculum is a confluence of the lateral horn of the levator, the lateral canthal into structural layers, consisting of the anterior, middle, and tendon, Lockwood’s suspensory ligament of the globe, and check ligaments from Fig. 9.13 (A) Patient presents with left t upper lid retraction and right lid ptosis secondary to purulent granulation tissue in the right upper eyelid. (B) By covering the right posterior lamella. The anterior lamella is composed of the the lateral retinaculus muscle. (Modified from Jelks GW, Smith BC. Reconstruction ptotic eye, the retracted eye exhibits a normal lid level due to Herring’s law of equal innervation. (C) Following excision of granulation tissue and correction of ptosis, the lower lid skin and orbicularis muscle. The middle lamella (or of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. patient exhibits normal lid levels bilaterally. midlamellar) structures include the tarsus, capsulopalpebral Philadelphia: WB Saunders; 1990:1671.) Lower eyelid 149 150 SECTION I • 9 • Secondary blepharoplasty: Techniques

Table 9.5 Secondary blepharoplasty candidate evaluation: lower eyelid

Anterior lamella Pretarsal orbicularis oculi function Absent Present Scars Absent Present Position Severity Skin Normal Abnormal Over-resection Excess Lateral canthal tendon Tarsus Lid margin eversion Absent Present LME I Orbital septum Lower pretarsal LME II (w/scleral show) Conjunctiva obicularis oculi LME III (w/lash rotation) Mid-lamellar cicatrix Ectropion Inferior oblique Lower preseptal obicularis oculi Lagophthalmos Absent Present Orbital rim Middle lamella Vertical cicatricial midlamellar retraction Present Absent Fat Normal Abnormal Excess removal Retention Posterior lamella Palpebral conjunctiva Normal Abnormal Fig. 9.16 Midlamellar cicatricial retraction is one of the most common indications for secondary blepharoplasty. Correction requires lysis of adhesions in conjunction with lateral canthoplasty with or without spacer grafts. Scarring of the pretarsal orbicularis oculi muscle to the middle Table 9.6 Lateral canthal zone evaluation lamella can result in lower lid malposition and scleral show. Anatomical morphology Denervation of the orbicularis oculi muscle leads to flattening of this area resulting in an aged, unnatural look. More impor- Vector analysis Positive Neutral Negative tantly, denervation or damage to orbicularis oculi muscle can Soft tissue: bone <1 cm <1 cm >1 cm lead to an incomplete blink mechanism, lack of tone, laxity of distance the lower lid and scleral show. Tarsoligamentous integrity During the evaluation of the patient with lower eyelid mal- position it is important to determine if there is any element of Distraction test Normal Abnormal midlamellar (tarsus, capsulopalpebral fascia, orbital septum) > ( 8 mm) cicatricial retraction (Fig. 9.16). If lid retraction is present, then Snap test Normal Abnormal surgical management may require lysis of the adhesions, interpositional grafts (cartilage, palatal mucosal), and other Lateral canthal laxity No Yes grafts, flaps, and procedures for correction. Ordinarily, when Medial canthal laxity No Yes upward traction is placed on the lower eyelid, it is easily A B Medial to lateral canthal Equal Abnormal High displaced to the level of the mid-pupil or above. When mid- position lamellar retraction is present, the eyelid will have restricted Fig. 9.17 (A) Patient with vertical displacement of the right lower eyelid demonstrates movement of the eyelid to the mid-pupillary level. (B) Same patient with upward mobility (Fig. 9.17). displacement of the left lower eyelid demonstrating midlamellar cicatricial changes preventing movement of the lid (lid retraction). (From Jelks GW, Jelks EB. Blepharoplasty. Palpebral aperture Symmetric Asymmetric The lateral view reveals the vector relationship of the (1) In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.) ocular globe to (2) the lower lid and (3) the malar eminence (Fig. 9.18).22,44–46 A positive vector relationship is when the most fascia, and orbital septum. The posterior lamella is the anterior projection of the globe lies behind the lower eyelid the patient usually presents with deep set eyes (i.e., positive/ with a slow snap back or a persistent eversion may have conjunctiva. margin, which lies behind the anterior projection of the malar neutral vector). Tarsal strip lateral canthoplasty and inferior eyelid and canthal laxity requiring correction (Fig. 9.22). If the Anatomical analysis, especially of the lateral canthal region, eminence. It is a favorable anatomic situation because there is retinacular lateral canthoplasty/canthopexy are effective pro- lateral canthus is higher than or equal to the level of the and a thorough understanding of lower eyelid malposition good bony, eyelid, and tarsoligamentous support with normal cedures to address this problem. If the distance is >1 cm and medial canthus, one may elect to perform horizontal lid short- etiology are required to choose and perform the appro- eyelid contours and levels. A neutral vector relationship is the patient presents with prominent eyes (i.e., negative vector), ening with a wedge resection alone or in combination with priate, corrective secondary blepharoplasty procedure in when the most anterior projection of the globe is in a vertical inferior retinacular lateral canthoplasty, dermal orbicular lateral canthoplasty. If, however, the lateral canthus is lower the lower lid (Tables 9.5, 9.6). Predisposing factors for post- relationship with the lower lid and malar eminence. Like the pennant lateral canthoplasty, and midfacial elevation are than the medial canthus, a lateral canthoplasty procedure is blepharoplasty eyelid malposition include: hypotonicity/ positive vector relationship, it has minimal risk for lower effective procedures in the surgical armamentarium to correct necessary for optimal correction. involutional changes, malar hypoplasia, shallow orbit, thyroid eyelid malposition following aesthetic blepharoplasty. The lower lid malposition in these patients. Another component of the evaluation of the secondary ophthalmopathy, unilateral high myopia, and patients under- negative vector relationship is when the most anterior projec- The tarsoligamentous integrity is determined by three com- blepharoplasty patient involves lower lid eversion, which is going secondary blepharoplasty.3,22 tion of the globe lies anterior to the lower lid and malar emi- ponents: lower lid laxity, medial canthal laxity, and lateral divided into four subtypes. The four types of lower lid ever- A thorough clinical assessment should include evaluation nence These patients often have scleral show. They have a canthal laxity. Horizontal lower lid laxity is diagnosed by sion are as follows: (I) lid margin eversion (LME) with scleral of: (1) pretarsal orbicularis oculi muscle function; (2) presence hypoplastic malar relationship which increases the risk for an “distraction” and “snap” test (Fig. 9.21).3,22,37 In the distraction show; (II) LME with scleral show and horizontal lid laxity; of vertical midlamellar cicatricial lid retraction/excessive skin unfavorable result, and requires alteration in the aesthetic test, the lower lid is grasped with the thumb and index finger (III) LME with lash rotation; and (IV) ectropion – involutional resection; (3) morphology: vector analysis and soft tissue to blepharoplastic procedure to prevent postoperative lower and displaced anteriorly. In the post-blepharoplasty patient, or cicatricial (Fig. 9.23). The term ectropion denotes an outward bone distance; (4) tarsoligamentous integrity; (5) presence eyelid malposition (Fig. 9.19). when the lower lid can be distracted laterally >8 mm, there turning or eversion of the eyelid. Ectropion may be classified of lower margin eversion; (6) posterior lamellar integrity; The soft tissue to bone distance is measured from the lateral should be concern for compromised tarsoligamentous integ- as either involutional or cicatricial.5,22,37 A common factor and (7) presence of malar fat pad descent. canthus to orbital rim (Fig. 9.20). This distance is important rity. The snap test is performed by pulling the eyelid inferiorly in all forms of ectropion is conjunctival hyperemia or kerati- Significant deformities may occur when excess skin and for determining what type of lower lid support procedure is to the level of the inferior orbital margin and then releasing it nization, punctual occlusion, and inflammatory changes muscle are excised during a blepharoplasty procedure. necessary to deliver acceptable results. If the distance is <1 cm, to judge the speed at which it returns to a normal level. A lid that become progressively worse. Involutional ectropion (aka, Lower eyelid 151 152 SECTION I • 9 • Secondary blepharoplasty: Techniques

1 2 3 A B C A

1 1 2 2

D 3 E F 3

B

1 2

G H 3

Fig. 9.18 Comparison of the variable anatomic relationships of the orbital region that influence the palpebral aperture. (1) Ocular globe; (2) lower lid; (3) malar eminence. Cosmetic blepharoplasty may have to be combined with other surgical procedures to prevent complications. (A,B) Young woman with high lid folds, deep set eyes (large, C D bony orbital volume with small ocular globes), and well-developed malar eminences. The most anterior projection of the ocular globe lies behind the lower eyelid margin and the malar eminence. This positive vector relationship is a favorable anatomic situation as there is good eyelid and tarsoligamentous integrity with normal eyelid contours Fig. 9.19 Eyelid malpositions following lower eyelid blepharoplasty. (A) Patient with bilateral lid margin eversion, round of the lateral canthi, and scleral show. (B) Patient and levels. (C,D) Woman presenting for cosmetic blepharoplasty with prominent ocular globes and increased periorbital skin and fat. The most anterior projection of her with lower eyelid horizontal laxity as well as the findings shown in (A). Note the malar hypoplasia. (C,D) Patient with marked lower eyelid malpositions and corneal exposure. ocular globes are posterior to the lower eyelid margin and inferior orbital margin (malar eminence). This is a neutral vector relationship with a minimum risk for lower eyelid Note the malar hypoplasia with inadequate bony support to the lower eyelid and ocular globe. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and malposition. (E,F) Woman with prominent ocular globes, slight scleral show, and malar hypoplasia. The lateral view demonstrates the influence of the globe on the lower problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.) eyelid position and the lack of eyelid support from the inferior orbital rim. This patient has a negative vector relationship with the most anterior portion of portion of the globe anterior to the lower lid and malar eminence. This negative vector relationship requires alterations in the cosmetic blepharoplastic procedure to prevent lower eyelid malposition. (G,H) Middle-aged woman with excess eyelid skin and fat, normal ocular globe position, marked inferior scleral show, lower eyelid laxity, and malar hypoplasia. This woman has a negative vector relationship and is at risk for an unfavorable result from lower eyelid surgery. A lower eyelid and lateral canthal tightening with repositioning (lateral canthalplasty) should be combined with the cosmetic blepharoplasty. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

senile ectropion) is caused by horizontal lid laxity of the eyelid thickness skin grafting requirement. This is partially covered supportive structures and usually begins with scleral show in Chapter 11.1.22,47 (Fig. 9.24). Cicatricial ectropion is caused by a deficiency of Finally, examination of the inner component of the poste- the skin or skin and muscle of the lid. In secondary blepharo- rior lamella should be conducted to determine if fibrosis, plasty patients, cicatricial ectropion is seen following excess infection, inadequate blood supply, etc., is present. skin removal and/or multiple previous blepharoplasty proce- dures and resultant scarring (Fig. 9.24). Management Patients with lower lid retraction often have a descent of the malar fat pad.7,9 A procedure such as a subperiosteal Several surgical procedures are available to provide excellent midface suspension techniques may be required to elevate lower eyelid function and contour in the secondary blepharo- the malar fat pad to a position that will assist in supporting plasty patient requiring correction of lower lid derformi- the lower eyelids. A transblepharoplasty subperiosteal ties.2,3,8,9,16,48–57 As mentioned previously, careful evaluation of midface elevation in conjunction with lateral canthoplasty the etiology of the lower eyelid defect as well as a thorough (with or without a spacer graft) may be required in patients morphological anatomical examination will assist the surgeon A B who present with lagophthalmos from multiple procedures in determining the optimal procedure(s) to perform to best and excessive skin resection to obviate or reduce a full address the defect or defects (Fig. 9.25, Table 9.7). Fig. 9.20 Lateral bone to canthus relationship. (A) Patients with <1 cm distance exhibit a positive/neutral vector. (B) Patients with >1 cm exhibit an negative vector. Lower eyelid 153 154 SECTION I • 9 • Secondary blepharoplasty: Techniques

A B

A B

Fig. 9.21 Distraction and snap test. (A) In the distraction test, the lower lid is grasped with the thumb and index finger and displaced anteriorly. In the post-blepharoplasty patient, when the lower lid can be distracted laterally >8 mm there should be concern for compromised tarsoligamentous integrity. (B) The snap test is performed by pulling the eyelid inferiorly to the level of the inferior orbital margin and then releasing it to judge the speed at which it returns to a normal level. A lid with a slow snap back or a persistent eversion may have eyelid and canthal laxity. C D

Fig. 9.23 Lower lid eversion divided into four types subtypes: (A) lid margin eversion (LME) with scleral show; (B) LME with scleral show and horizontal lid laxity; (C) LME with lash rotation; (D) ectropion – involutional or cicatricial.

We already know the trends

severe lid malposition with mid face decent severe horizontal lid laxity & retraction horizontal lid laxity

mild lid margin eversion Increasing severity of defect

Increasing technical complexity pexy alone plasty +/- tarsal stripplasty + vertical plasty + spacer + spacer graft cheek suspension

A B

A B Fig. 9.24 Classification of ectropion: (A) cicatricial or (B) involutional. (Modified from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. Fig. 9.25 Etiology of the lower eyelid defect versus the optimal procedure to In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1990:1671.) address the defect. Fig. 9.22 Medial canthus to lateral canthus relationship. (A) If the lateral canthus is higher than or equal to the level of the medial canthus, one may elect to perform horizontal lid shortening with a wedge resection alone or in combination with lateral canthoplasty. (B) If, however, the lateral canthus is lower than the medial canthus, a lateral canthoplasty procedure is necessary for optimal correction. It is not advisable to rely on horizontal lid shortening with lateral orbital rim periosteum. However, in some patients, the The lateral canthoplasty and its various modifications are portion of lateral retinaculum, the lid is elevated far enough simple wedge resections for lower lid support or to preserve soft, connective tissue of the periosteum has lost its integrity useful in addressing lower eyelid malposition.48–57 The proce- to cover 1–2 mm of the inferior limbus (Fig. 9.26B). The level the lateral canthal anatomy. Pentagonal resection of the lower due to damage from scarring or trauma. In patients with dures described in the following text require a precise knowl- of fixation to the inner aspect of the orbital rim should cor- eyelid only addresses one aspect of the lower lid malposition, milder damage, the fixation may be supplemented with a edge of the orbital anatomy and the desire to preserve the respond to a point level with the superior aspect of the pupil namely excess horizontal length. Optimal correction should local periosteal flap58–60 or a fascial graft.61 However, patients external commissure. There are key surgical points that should in primary position (Fig. 9.26C). Finally, upon closure of the address all aspects of the pathology, in particular the who have undergone multiple procedures with extensive be kept in mind when performing a lateral canthoplasty to lateral canthal skin incisions, the angle of the divergence from restoration/preservation of canthal anatomy to maximize damage to the orbital rim periosteum may require drill hole achieve symmetric lateral canthal repositioning. The lateral the original horizontal orientation must be equal and sym- postoperative success. fixation.52,62 Drill hole fixation of the lateral canthus is accom- canthal and lower eyelid incision should be horizontal (Fig. metric from one side to the other to ensure lateral canthal and Fixation of a lateral canthoplasty or canthopexy may be plished by determining the desired point of fixation in the 9.26A). After selective release of the lower eyelid with its lower eyelid symmetry (Fig. 9.26D). accomplished by directly suturing the lateral canthus to the lateral orbital rim. The point of fixation is determined by Lower eyelid 155 156 SECTION I • 9 • Secondary blepharoplasty: Techniques tucking the lateral canthus against the orbital rim until it cor- a canthoplasty procedure (lysis of the lateral canthus) a single remaining fatty tissue excised, it is sutured into the lower canthoplasty contour complications (Fig. 9.31).3,54 This proce- responds with the vertical level of the superior aspect of the loop of suture is brought through the canthal edges of the lids, eyelid. A 6–0 mild chromic suture is used to attach the graft(s) dure uses an extension of the lower lid in the form of a deepi- pupil. This position is marked with surgical ink, and a single and the arms are brought out through the single hole. Both to the inferior tarsal edge and the recessed conjunctiva and thelialized pennant of skin and underlying orbicularis muscle, drill hole with is made no less than 1 mm and generally arms of the suture are secured to the deep temporal fascia.62 capsulopalpebral fascia. but it does not divide the lateral palpebral commissure (Fig. approximately 4 mm posterior to the lateral orbital rim. A 9.32). This method maintains the horizontal dimension of the double-armed 4–0 Mersilene (ME-2) suture is used for fixa- Tarsal strip lateral canthoplasty and vertical spacer grafts Dermal orbicular pennant lateral canthoplasty palpebral aperture while allowing for tightening of the lower tion. In a canthopexy procedure (no lysis of the lateral canthus) Early in the senior author’s experience, the procedure of The dermal orbicular pennant lateral canthoplasty (DOPLC) was lid as well as lateral suspension (Fig. 9.33). the suture is double-looped into the canthal tissue and both choice for post-blepharoplasty lower lid malposition was developed to reduce the incidence of tarsal strip lateral The DOPLC is useful in post-blepharoplasty patients with suture arms are brought through the single hole (Fig. 9.27). In the tarsal strip lateral canthoplasty48–51,54 combined with hori- lower lid malposition, especially in patients with a bone to zontal lid shortening and lateral support with or without soft tissue relationship (Fig. 9.20) of >1 cm. However, because vertical spacer grafts of skin, cartilage, or mucosa (Fig. 9.28). the incision between the upper and lower lids has a very Table 9.7 Canthoplasty techniques and indications The tarsal strip lateral canthoplasty procedure divides the narrow skin bridge, persistent edema between the upper and lower lids may occur laterally with this technique. Canthoplasty technique Indications lateral palpebral commissure and selectively releases the lower lid. The amount of horizontal lid shortening can be Tarsal strip lateral canthoplasty Lower lid canthal malposition varied with the suture placement and fixation in the orbital Inferior retinacular lateral canthoplasty/canthopexy without lid laxity or ectropion periosteum. The tarsal strip procedure, and its many varia- and midface elevation tions is useful for secondary correction of the lax lower eyelid, Tarsal strip lateral canthoplasty Lid laxity or ectropion however, this technique produces a decrease in the horizontal The inferior retinacular lateral canthoplasty/canthopexy with horizontal lid shortening dimension of the palpebral aperture which may cause deform- (IRLC) was developed for secondary blepharoplasty patients Dermal-orbicular pennant Bone to soft tissue distance of ities of the lower lid and a rounding of the external commis- requiring correction of lower lid malposition and lateral lateral canthoplasty >1 cm sure (Fig. 9.29). canthal deformities without the problems associated with the tarsal strip lateral canthoplasty and DOPLC (Fig. 9.34).55 Inferior retinacular lateral Bone to soft tissue distance of If midlamellar cicatricial retraction is present, then surgical The IRLC is indicated in the secondary or primary blepharo- canthoplasty <1 cm correction may only require incising the midlamellar cicatricial adhesion. However, if the vertical lid defect is exces- plasty patient with a negative vector analysis, but with a Inferior retinacular lateral Bone to soft tissue distance of sive, an interpositional graft composed of palatal mucosa, canthopexy <1 cm, minimal distraction, + cartilage, or a flap of de-epithelialized lateral canthal dermis snap test (dermal pennant flap) may be required (Fig. 9.30).3,53,54 The 3,27,37 Vertical spacer graft Vertical deficiency from release preferred graft is palatal mucosa. The graft donor site is of midlamellar cicatrix or skin between the gingival and the midline which is a location of deficiency well-defined submucosa for easy separation of the graft from the fat and periosteum. When performing bilateral retraction Subperiosteal midface Multiple previous procedures repair, it is preferable to take two grafts from both sides of the elevation – recruitment of skin and mouth rather than one large graft; this will encourage more tissue rapid healing. Once the graft has been thinned and all

A B

Lateral canthal tendon

Horizontal incision Lid elevation Fig. 9.27 Drill hole fixation of a lateral canthopexy. Following determination of the proper point of fixation, a single drill hole is made no less than 1 mm and generally Fig. 9.28 Tarsal strip lateral canthoplasty. The lower portion of the lateral approximately 4 mm posterior to the lateral orbital rim. A double-armed 4–0 retinaculum is divided and development of a tarsal element for fixation is formed by Mersilene (ME-2) suture is used for fixation. In a canthopexy procedure (no lysis excising the temporal lid margin, cilia, conjunctiva, and skin. The tarsal strip is then of the lateral canthus) the suture is double-looped into the canthal tissue and both fixed in position to the lateral orbital periosteum with sutures. (Modified from Jelks C D suture arms are brought through the single hole. (From Aston, Aesthetic Plastic GW, Smith BC. Reconstruction of the eyelids and associated structures. In: Surgery, 2009, Saunders.) McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1990:1671.)

Level of fixation Symmetry of closures

A B C Fig. 9.26 Key points to achieve symmetric lateral canthal repositioning. (A) The lateral canthal and lower eyelid incision should be horizontal. (B) The lid is elevated to cover 1–2 mm of the inferior limbus. (C) The level of fixation to the lateral orbital periosteum is at a level corresponding to the superior aspect of the pupil in primary position. (D) On closure of the lateral canthal skin incisions, the angle of divergence from the original horizontal orientation must be equal and symmetric to ensure lateral Fig. 9.29 (A) Patient exhibiting post-blepharoplasty complications of scleral show, temporal bowing, and mild ectropion that is greater on the right side than on the left. (B) canthal and lower eyelid symmetry. (Modified from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. The tarsal strip ready for periosteal fixation. (C) At 6 months after bilateral tarsal strip procedures. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications Philadelphia: WB Saunders; 1990:1671.) and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.) Lower eyelid 157 158 SECTION I • 9 • Secondary blepharoplasty: Techniques

Strumming inferior retinaculum Scratch through dermis with Colorado needle to release lower lid

Protective contact lens Suture fixation is to lateral rim corresponding to the upper level of the pupil with the patient in the primary gaze

A Spacer graft B Dermal pennant as spacer graft

Fig. 9.30 Lower eyelid spacer grafts. (A) A spacer graft of autogenous palatal mucosal or auricular cartilage, or a (B) vascularized, de-epithelialized lateral canthal dermal pennant flap may be used to increase vertical height of the retracted or deficient lower eyelid in conjunction with a lateral canthoplasty. Spacer grafts are useful in enhancing the results in post-blepharoplasty patients with defects secondary to cicatricial retraction or excessive skin resection.

favorable bone to soft-tissue relationship (<1 cm discrepancy) malposition with a deficiency of lower lid skin.9,47,56,63 Proper 3,54–57 (Figs 9.18, 9.20). midface fixation and canthoplasty prevent lower lid descent A De-epithelialized dermal flap D The IRLC is performed through the lateral aspect of the in the first critical weeks of postoperative healing. upper eyelid blepharoplasty incision. A skin-muscle flap is Subperiosteal midface elevation is achieved through a elevated along the lateral orbit extending onto the lateral lower blepharoplasty incision. A skin-muscle flap is dissected Cut to fascia Spacer graft aspect of the inferior orbital rim. This maneuver exposes the down to the infraorbital rim. Periosteum at the anterior lower lid lateral fat pad that lies behind the orbital septum. margin of the infraorbital rim is elevated with a subperiosteal The inferior aspect of the lateral retinaculum lies immediately pocket. The periosteum is released laterally over the inferior superior to this fat. The lateral fat pad can be removed to lateral rim followed by release of the entire subperiosteal better expose the lateral retinaculum. Following removal of flap so it can be mobilized superiorly. The midfacial flap is Dermis the fat pad, the suborbicularis plane will be elevated to the suspended with using two 4–0 Vicryl sutures on half-circle level of the lateral retinaculum. The lower lid component of cutting needles that are used to purchase the suborbicularis the lateral retinaculum may then be identified. oculi fat and the malar fat pad. The sutures are then tied to a In the canthoplasty procedure, the lateral retinaculum is titanium screw placed on the anterior surface of the lateral released completely from all lateral attachments to the orbit orbital bone (zygomatic bone) (Fig. 9.35). The screw is tight- B and allows free movement of the lower orbit. A canthopexy ened until the head is flush with the bone surface. Alternate Canthal angle remains intact procedure is a non-lysis canthoplasty in which the lower methods which can be used to elevate the midface include a E lid component of the lateral retinaculum is plicated and preperiosteal dissection from the lower lid,64 the concentric anchored to the lateral orbital rim. A canthopexy is only malar lift,65 and the endoscopic, subperiosteal approach from Mobilize flap to pretarsal muscle appropriate for those patients with minimal distensibility and the temple (covered further in Chapter 11.8). Orbicularis muscle a firm snap test. The elevated and stabilized structures support the reposi- Both needles of a 4–0 Polydek suture are then passed into tioned lower lid and the recruited and elevated cheek skin a hitching stitch. The suture is passed through the lateral and tissue help replace deficient posterior lamella. orbital rim periosteum at a level corresponding to the supe- rior edge of the pupil with the globe in primary gaze. The Choosing the appropriate technique(s) Polydek suture is adjusted and tightened so that the lower lid Careful evaluation of specific indications in regard to the covers 1–2 mm of the inferior cornea. The lower lid compo- patient’s anatomy as well as their specific defect, enable the Periorbital fascia nent of the lateral retinaculum is fixed in its newly elevated surgeon to choose the optimal lateral canthoplasty procedure position on the lateral orbital rim. The position of the lateral (Table 9.7). In patients with a bony (lateral orbital rim) to soft- C canthus will appear over-corrected, and there may be some tissue (external commissure) distance of ≥1 cm, the dermal initial bunching of the soft tissue at the lateral canthal region. orbicular pennant lateral canthoplasty has become the pro- This relaxes to a normal contour over 2–4 weeks postopera- cedure of choice for correction of lower lid malposition. tively as the lateral canthus settles inferiorly. The dermal orbicular pennant lateral canthoplasty (DOPLC) allows for correction of the lateral canthal angle, while pre- Fig. 9.31 Dermal-orbicular pennant lateral canthoplasty (DOPLC). (A) Patient is illustrated with a protective, colored contact lens in place. The dermal-orbicular flap is Midface elevation and fixation 54 outlined at the lateral canthus. Note the horizontal alignment and the maintenance of the external commissure. An incision is made through the superficial layers. (B) The serving the external commissure. Lid laxity or ectropion are flap is de-epithelialized preserving the underlying dermis. The superficial border of the flap is incised to the suborbicularis muscle plane. (C) The inferior border of the Transblepharoplasty subperiosteal midface elevation is useful indications for canthoplasty, however, it is still preferable to dermal-orbicular pennant is elevated to the external commissure, which remains intact. The lower lid component of the lateral retinaculum is divided by “strumming” in conjunction with lateral canthoplasty with or without utilize some form of horizontal lid shortening (usually with a the structure with a Colorado needle. (D) The fixation of the suture is to the lateral orbital rim corresponding to the upper level of the pupil with the patient in primary gaze. spacer grafts for patients who have undergone multiple cos- tarsal strip). This maneuver allows for correction of the laxity (E) A spacer graft can be added as necessary. (Modifed from Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg 1993; 20:417–421.) metic procedures who present with lower eyelid and midface while allowing for canthal resuspension. Lower eyelid 159 160 SECTION I • 9 • Secondary blepharoplasty: Techniques

A Fixation suture inside periosteum of orbital rim

ME-2 needles

B Canthopexy Cave from inside orbit Alternate suture placement A Removal of fat pad to reveal ‘cave’ A

B Canthoplasty

Suture into tarsus

C

B Closure

Fig. 9.33 (A) Patient with bilateral lower eyelid malposition after blepharoplasty. D (B) The patient is seen 9 months following bilateral dermal-orbicular pennant lateral canthoplasties. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. D Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.) C

Fig. 9.34 Inferior retinacular lateral canthoplasty (IRLC) technique. (A) The IRLC is performed through the lateral aspect of an upper eyelid blepharoplasty incision. A skin-muscle flap is elevated along the lateral orbit exposing the lower lid lateral fat pad. The inferior aspect of the lateral retinaculum lies immediately superior to this fat. The lateral fat pad can be removed to better expose the lateral retinaculum. Inset: following removal of the fat pad, a “cave” is revealed superior to the lateral retinaculum. The illustration reveals this area as it would be visualized from inside the orbit. (B) Canthoplasty procedure with lysis of the lateral retinaculum. Inset: canthopexy, or non-lysis procedure in which the lower lid component of the lateral retinaculum is plicated and anchored to the lateral orbital rim. (C) Both needles of 4–0 Polydek suture Bilaterally symmetrical angles have been passed into a hitching stitch. The suture has been passed through the lateral orbital rim periosteum (as denoted by the arrow) at a level corresponding to the superior edge of the pupil with the globe in primary gaze. (D) The Polydek suture is adjusted and tightened so the lower lid covers 1–2 mm of the inferior cornea. The lower Fig. 9.32 Dermal-orbicular pennant lateral canthoplasty (DOPLC) fixation and lid component of the lateral retinaculum is then fixed in its elevated position to the lateral orbital rim. (Modifed from Jelks GW et al. The inferior retinacular lateral closure. (A) Both arms of an ME-2 4–0 Polydek suture are passed through canthoplasty: a new technique. Plast Reconstr Surg 1997; 100:1262–1265.) periosteum from the inner to the outer aspect of the orbital rim. The needles are passed through the loop, and cinched tightly down, hugging the inner aspect of the orbital rim. (B) Most commonly, periosteal fixation is to the lateral edge of the tarsus. Fixation of the lower lid to the orbital rim should result in an over-correction such that the lower lid covers 1–2 mm of the inferior cornea. (C) Upon closure, elevation causes inferior angulation of the original horizontal incision. (D) When < bilateral procedures are performed, care is taken to obtain symmetry of closure. In patients with lid retraction, a DOPLC may be sufficient favorable bony to soft-tissue relationships ( 1 cm), the infe- (Modifed from Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg to correct the problem if there is associated soft-tissue to rior retina cular lateral canthoplasty/canthopexy (IRLC) is 1993; 20:417–422.) bony disparity. If release of midlamellar (orbital septum, lid recommended.22,44,45,54–57 The IRLC procedure avoids the pit- retractors) cicatricial retraction is the cause of the vertical defi- falls of horizontal lid shortening and the edema associated ciency, the use of autogenous palatal mucosal or auricular with DOPLC. cartilage as a spacer graft is recommended. Spacer grafts should also be utilized when release of the posterior lamella Miscellaneous complications (conjunctiva) produces a vertical deficit. In patients with mul- tiple previous procedures presenting with deficient lower Excessive fat resection is a most disturbing problem, especially eyelid skin and tissue, midface elevation techniques may also when associated with lower eyelid malposition. Autogenous be necessary for an optimal result. Finally, for secondary or fat pad sliding, fat grafting (Fig. 9.36), and fat injection primary ble pharoplasty patients with negative vectors and have been utilized to correct this deformity with variable Lower eyelid 161 162 SECTION I • 9 • Secondary blepharoplasty: Techniques

results.66–72 A lateral canthoplasty should be performed at the time of fat augmentation. Inadequate fat resection most commonly occurs in the upper and lower medial and lower lateral compartments. A small stab incision through the skin, muscle, and septum can be utilized to deliver the residual fat for excision (Fig. 9.37).27 In the lower lid, the transconjunctival approach may also X be used. Persistent malar bags, or excess skin that presents without Fig. 9.35 Mitek screw fixation in subperiosteal midface lower lid cicatricial retraction can be directly excised and care- 27 X elevation. Following elevation of the subperiosteal midface flap, fully closed to produce acceptable results (Fig. 9.38). Mitek screw fixation is achieved by suspending the flap using two 4-0 Vicryl Chemosis is a milky edema of the subconjunctival tissues. It sutures on half-circle cutting needles. The sutures are then tied results from obstruction of the lymphatic drainage channels X Cutting edge to a titanium screw placed on the anterior surface of the lateral of the periorbital area (Fig. 9.39). Repositioning the eyelids X on outside of curve orbital bone (zygomatic bone). The screw is tightened until the Cutting edge head is flush with the bone surface. The elevated and stabilized over the chemotic conjunctiva and patching usually resolve on outside structures support the repositioned lower lid and the recruited the situation. If the chemosis becomes more marked or there and elevated cheek skin and tissue help replace deficient is actual incarceration by the eyelids, temporary suture tarsor- Fig. 9.39 Patient with persistent chemosis. posterior lamella. (From Aston, Aesthetic Plastic Surgery, 2009, rhaphy may be required.3,27,37 Screw locations Saunders.)

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3. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin 45. Pessa JE, Desvigne LD, Lambros VS, et al. Changes Plast Surg. 1993;20:417. in ocular globe-to-orbital rim position with age: 5. Jelks GW, Jelks EB. Preoperative evaluation and implications for aesthetic blepharoplasty of the lower A B C treatment of lower lid ectropion following eyelids. Aesthetic Plast Surg. 1999;23(5):337–342. blepharoplasty. Plast Reconstr Surg. 1990;85: The authors present findings from CT scans assessing the Fig. 9.36 (A) Patient with excessive lower lid fat resection with associated lower eyelid malposition. (B) The supplementary submental autogenous fat grafts are shown 971. relationship of the globe to surrounding anatomy throughout before their placement into a retroseptal position through a lateral canthal incision. Lateral canthoplasties were also performed. (C) Patient seen one year postoperatively. Preoperative identification of a predisposition to ectropion is the aging process. Their findings inform recommendations for (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.) the first step in preventing this complication after lower lid blepharoplasty and are incorporated into a model of blepharoplasty. The authors discuss surgical techniques to craniofacial aging. avoid this common adverse outcome and address procedures 51. Rees TD. Prevention of ectropion by horizontal designed to reverse ectropion if it does occur. shortening of the lower lid during blepharoplasty. 7. Patipa M. The evaluation and management of lower Ann Plast Surg. 1983;11:17. eyelid retraction following cosmetic surgery. Plast 57. Fagien S. Algorithm for Canthoplasty. The lateral Reconstr Surg. 2000;106:438. retinacular suspension: a simplified suture canthopexy. Causes of lower eyelid retraction are discussed from an Plast Reconstr Surg. 1999;103:2042. anatomical perspective. The author then presents etiology- Methods to provide canthal support and avoid lower lid based corrective procedures. malposition in midface/lower eyelid rejuvenation are 12. Lisman RD, Hyde K, Smith B. Complications of presented. The author describes his novel transpalpebral A B C blepharoplasty. Clin Plast Surg. 1988;15:309. lateral retinacular suspension in this context. 24. Zide BM, Jelks GW. Surgical anatomy of the orbit. Plast 61. McCord CD Jr, Ellis DS. The correction of lower lid Fig. 9.37 (A) Blepharoplastic patient preoperatively. (B) At 2 months postoperatively with evidence of inadequate resection of fat from the right lower eyelid medial Reconstr Surg. 1984;74:301. compartment. (C) The fat is removed via a small stab incision through skin, muscle, and orbital septum. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. malposition following lower lid blepharoplasty. Plast Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.) 43. Carraway JH. The impact of Herring’s law on Reconstr Surg. 1993;92:1068. blepharoplasty and ptosis surgery. Aesthetic Surg J. Methods to correct lower lid malposition are presented based 2004;24:275. on the underlying anatomical pathology.

A B C

Fig. 9.38 (A) Patient seen following blepharoplasty with persistent malar excess skin. (B) Immediately after direct excision. (C) A satisfied patient seen 9 months postoperatively. (From Jelks, GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.) References 162.e1 162.e2 SECTION I • 9 • Secondary blepharoplasty: Techniques

18. Jelks GW, Jelks EB. Prevention of ectropion in following blepharoplasty. Plast Reconstr Surg. 57. Fagien S. Algorithm for Canthoplasty. The lateral References reconstruction of facial defects. Clin Plast Surg. 2003;112:1444. retinacular suspension: a simplified suture canthopexy. 2001;28(2):297. 40. Baylis HI, Cies WA, Kamin DF. Correction of upper Plast Reconstr Surg. 1999;103:2042. 1. ASAPS. Statistical data for 2003. Online. Available at: 19. Edgerton MT. Causes and prevention of lower lid eyelid retraction. Am J Ophthalmol. 1976;82:790. Methods to provide canthal support and avoid lower lid http://www.surgery.org ectropion following blepharoplasty. Plast Reconstr Surg. 41. Fagien S. Advanced rejuvenative upper blepharoplasty: malposition in midface/lower eyelid rejuvenation are 2. McCord CD Jr. The correction of lower lid malposition 1972;49:367. enhancing aesthetics of the upper periorbita. Plast presented. The author describes his novel transpalpebral following blepharoplasty. Plast Reconstr Surg. 1999;102: 20. Tenzel RR. Complications of blepharoplasty: orbital Reconstr Surg. 2002;110:278. lateral retinacular suspension in this context. 2471. hematoma, ectropion, and scleral show. Clin Plast Surg. 42. Gradinger GP. Cosmetic upper blepharoplasty. Clin Plast 58. Dryden RM, Edelstein JP. Lateral palpebral tendon 3. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin 1981;7:797. Surg. 1988;15:289. repair for lower eyelid ectropion. Ophthalmol Plast Plast Surg. 1993;20:417. 21. Tenzel RR. Surgical treatment of complications of 43. Carraway JH. The impact of Herring’s law on Reconstr Surg. 1988;4:115. 4. Gradinger GP, Jelks GW. Blepharoplasty: anatomic cosmetic blepharoplasty. Clin Plast Surg. 1978;5:517. blepharoplasty and ptosis surgery. Aesthetic Surg J. 59. McCord CD Jr. Lateral canthal reconstruction. In: considerations and common problems. Perspect Plast 22. Jelks GW, Jelks EB. Preoperative evaluation of the 2004;24:275. McCord CD, Codner MA, Hester TR, eds. Eyelid surgery: Surg. 1992;6:90. blepharoplasty patient: bypassing the pitfalls. Clin Plast 44. Pessa JE, Chen Y. Curve analysis of the aging orbital principles and techniques. Philadelphia: Lippincott-Raven; 5. Jelks GW, Jelks EB. Preoperative evaluation and Surg. 1993;20:213. aperture. Plast Reconstr Surg. 2002;109(2):751–755. 1995:294. treatment of lower lid ectropion following 23. Zide BM, Jelks GW. Surgical anatomy of the orbit. New 45. Pessa JE, Desvigne LD, Lambros VS, et al. Changes 60. Sassoon E, McCord CD Jr, Codner MA, et al. Periosteal blepharoplasty. Plast Reconstr Surg. 1990;85:971. York: Raven Press; 1985. in ocular globe-to-orbital rim position with age: strip for correction of complications following lower Preoperative identification of a predisposition to ectropion 24. Zide BM, Jelks GW. Surgical anatomy of the orbit. Plast implications for aesthetic blepharoplasty of the lower lid blepharoplasty. Paper presented at the Aesthetic is the first step in preventing this complication after Reconstr Surg. 1984;74:301. eyelids. Aesthetic Plast Surg. 1999;23(5):337–342. Meeting of the American Society for Aesthetic Plastic Surgery, San Diego, California, 2000. blepharoplasty. The authors discuss surgical techniques to 25. Doxanas MT, Anderson RL. Clinical orbital anatomy. The authors present findings from CT scans assessing the avoid this common adverse outcome and address procedures Baltimore: Williams and Wilkins; 1984. relationship of the globe to surrounding anatomy throughout 61. McCord CD Jr, Ellis DS. The correction of lower lid designed to reverse ectropion if it does occur. the aging process. Their findings inform recommendations for malposition following lower lid blepharoplasty. Plast 26. Spinelli HM, Jelks GW. Periocular reconstruction: a Reconstr Surg. 1993;92:1068. 6. Bartley GB. The differential diagnosis and classification systematic approach. Plast Reconstr Surg. 1993;91:1017. lower lid blepharoplasty and are incorporated into a model of of eyelid retraction. Ophthalmology. 1996;103:168. craniofacial aging. Methods to correct lower lid malposition are presented based 27. Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. on the underlying anatomical pathology. 7. Patipa M. The evaluation and management of lower Complications and problems in aesthetic plastic surgery. 46. Yaremchuk MJ. Improving periorbital appearance eyelid retraction following cosmetic surgery. Plast New York: Gower Medical Publishing; 1992. in the “morphologically prone.” Plast Reconstr Surg. 62. McCord CD Jr, Boswell CB, Hester TR. Lateral canthal Reconstr Surg. 2000;106:438. anchoring. Plast Reconstr Surg. 2003;112:222. 28. Jelks GW, Jelks EB. The influence of orbital and eyelid 2004;114(4):980–987. Causes of lower eyelid retraction are discussed from an anatomy on the palpebral aperture. Clin Plast Surg. 47. Hester TR, Codner MA, McCord CD. The centrofacial 63. Hester TR, Codner MA, McCord CD. Subperiosteal anatomical perspective. The author then presents etiology- 1991;18:183. approach for correction of facial aging using the malar cheek lift with lower blepharoplasty. In: McCord based corrective procedures. CD, Codner MA, Hester TR, eds. Eyelid surgery: 29. de la Tore JL, Martin SA, De Cordier B, et al. Aesthetic transblepharoplasty subperiosteal cheek lift. Aesthetic 8. Patipa M. Transblepharoplasty lower eyelid and Surg Quart. 1996;16:51. principles and techniques. Philadelphia: Lippincott-Raven; eyelid ptosis correction: a review of technique and 1995. midface rejuvenation: part I. Avoiding complications cases. Plast Reconstr Surg. 2003;112:655. 48. Anderson RL, Gordy DD. The tarsal strip procedure. by utilizing lesson learned from the treatment of 64. Moelleken B. The superficial subciliary cheek lift, a 30. Beard C. Ptosis, 3rd ed. St. Louis: CV Mosby; 1981. Arch Ophthalmol. 1979;97:2192. complications. Plast Reconstr Surg. 2004;113(5): 49. Jordan DR, Anderson RL. The lateral tarsal strip technique for rejuvenating the infraorbital region and 1459–1468. 31. Frueh BR. The mechanistic classification of ptosis. nasojugal groove: a clinical series of 71 patients. Plast Ophthalmology. 1980;87:1019. revisited: The enhanced tarsal strip. Arch Ophthalmol. 9. Yaremchuk MJ. Restoring palpebral fissure shape after 1989;107:604. Reconstr Surg. 1999;104(6):1863–1876. previous lower blepharoplasty. Plast Reconstr Surg. 32. Patipa M. Levator ptosis in patients undergoing upper 65. Le Louarn C. The concentric malar lift: malar and lower lid blepharoplasty. Ann Ophthalmol. 1984;16:270. 50. Marsh JL, Edgerton MT. Periosteal pennant lateral 2003;111(1):441–450. canthoplasty. Plast Reconstr Surg. 1979;64:24. eyelid rejuvenation. Aesthetic Plast Surg. 2004;28(6): 10. Carraway JH, Mellow CG. The prevention and 33. Anderson RL, Dixon RS. Aponeurotic ptosis surgery. 359–374. Arch Ophthalmol. 1979;97:1123. 51. Rees TD. Prevention of ectropion by horizontal treatment of lower lid ectropion following shortening of the lower lid during blepharoplasty. Ann 66. Loeb R. Fat pad sliding and fat grafting for leveling lid blepharoplasty. Plast Reconstr Surg. 1990;85:971. 34. Flowers RS. Comments on blepharoplasty – Plast Surg. 1983;11:17. depression. Clinics in plastic surgery, Vol. 8, No. 4. 11. Levine MR, Boynton J, Tenzel RR, et al. Complications management of complications and patient Philadelphia: WB Saunders; 1981. dissatisfaction. In: Goldwyn RN, ed. The unfavorable 52. Flowers RS. Canthopexy as a routine blepharoplasty of blepharoplasty. Ophthal Surg. 1975;6:53. component. Clin Plast Surg. 1993;20:351. 67. Silkiss RZ, Baylis HI. Autogeneous fat grafting 12. Lisman RD, Hyde K, Smith B. Complications of result in plastic surgery, 2nd ed. Boston: Little, Brown; by injection. Ophthal Plast Reconstr Surg. 1987;3: 1984. 53. Patel BC, Patipa M, Anderson RL, et al. Management of 71–75. blepharoplasty. Clin Plast Surg. 1988;15:309. postblepharoplasty lower eyelid retraction with hard 13. McCord CD Jr, Shore JW. Avoidance of complications 35. McCulley TJ, Kersten RC, Kulwin DR, et al. Outcomes 68. Coleman SR. Structural fat grafts: the ideal filler? Clin and influencing factors of external levator palpebrae palate grafts and lateral strip. Plast Reconstr Surg. in lower lid blepharoplasty. Ophthalmology. 1983;90: 1997;99(5):1251–1260. Plast Surg. 2001;28(1):111–119. 1039. superioris aponeurosis advancement for blepharoptosis. 69. Coleman SR. Facial recontouring with lipostructure. Ophthal Plast Reconstr Surg. 2003;19:388. 54. Jelks GW, Glat PM, Jelks EB, et al. The evolution of the 14. McCord CD Jr. Complications of upper lid Clin Plast Surg. 1997;24(2):347–367. 36. Rohrich RJ, Coberly DM, Fagien S, et al. Current lateral canthoplasty: techniques and indications. Paper blepharoplasty. In: Putterman AM, ed. Cosmetic presented at the American Association of Plastic 70. Coleman SR. Long-term survival of fat transplants: oculoplasty surgery. New York: Grune & Stratton; 1982. concepts in aesthetic upper blepharoplasty. Plast controlled demonstrations. Aesthetic Plast Surg. Reconstr Surg. 2004;113(3):32e. Surgeons, 74th Annual Meeting, San Diego, April 30 15. Rafety FM. Complications of cosmetic blepharoplasty. to May 3, 1995. 1995;195(5):421–425. 37. Jelks GW, Smith BC. Reconstruction of the eyelids and Cos Surg. 1983;2:17. 55. Jelks GW, Glat PM, Jelks EB, et al. The inferior 71. Kanchwala SK, Bucky LP. Facial fat grafting: the search associated structures. In: McCarthy JG, ed. Plastic for predictable results. Facial Plast Surg. 2003;19(1): 16. Kim YW, Park HJ, Kim S. Secondary correction of surgery. Philadelphia: WB Saunders; 1990:1671. retinacular lateral canthoplasty: a new technique. Plast unsatisfactory blepharoplasty: removing multilaminated Reconstr Surg. 1997;100:1262. 137–146. 38. Fasanella RM, Servat J. Levator resection for minimal septal structures and grafting of preaponeurotic fat. 56. Hester R Jr, Codner MA, McCord CD. Discussion: 72. Ellenbogen R. Free autogenous pearl fat grafts in the Plast Reconstr Surg. 2000;106(6):1399–1404. ptosis: another simplified operation. Arch Ophthalmol. face-a preliminary report of a rediscovered technique. 1961;65:493. The inferior retinacular lateral canthoplasty: a new 17. Rocca R, Nesi FA, Lisman RD, eds. Ophthalmic plastic technique. Plast Reconstr Surg. 1997;100:1271. Ann Plast Surg. 1986;16:3. and reconstructive surgery. St. Louis: CV Mosby; 39. Shorr N, Goldberg, RA, McCann JD, et al. Upper eyelid 1987. skin grafting, an effective treatment for lagophthalmos • SECTION I Aesthetic Surgery of the Face 164 SECTION I 10 • Asian facial cosmetic surgery

which are not traditional to “Asian” beauty but have been and lack of supratarsal folds. However, this is not true of all influenced by Western countries. It is incorrect to simply Asians. About 50% of women in East Asia have these fea- assume that Asians seek to “westernize” their faces. Although tures.1,2 Many Asian women wish to enhance their appearance westernization of the Asian face seemed to be a goal in the but they do not want Caucasian eyelids.1,2,7 Asian blepharo- past, most patients now want to preserve their ethnic identity, plasty or “double eyelid” surgery is the most common cos- while at the same time improving their appearance.1,2,5 This metic operation in Asia, with some reports suggesting that has reached a point where people wonder if the concept of 30–60% of Asians undergo this procedure.8 If these women 10 traditional beauty no longer exists in these Asian countries have deep-set, large eyelids with high folds like Caucasians, and traditional beauty is no longer deemed beautiful. Some they look unnatural, as such eyelids do not match the patients in cosmetic surgery clinics want to look like celebri- shape of their faces. Therefore, ethnic differences should be ties in their respective countries. These celebrities have beauti- considered. Asian facial cosmetic surgery ful and attractive faces that are popular not only in their own The first procedure to create a supratarsal fold or “double countries but in neighboring countries. Patients seeking cos- eyelid” was described by Mikamo in 1896.9 The procedure metic surgery must be properly counseled in order to avoid was performed on a patient who lacked a fold in one of her disappointment from unrealistic expectations. upper eyelids. Shirakabe et al. made a historical review of 32 Kyung S. Koh, Jong Woo Choi, and Clyde H. Ishii Following the introduction of Western medicine in Asia, surgical techniques reported in Japan.10 In the western coun- aesthetic surgery was disorganized and sporadic. Although tries, Sayoc reported anatomic differences of upper eyelids the history of aesthetic surgery in Japan has been described, between Caucasians and East Asians. The anatomic differ- the exact details are not known due to lack of documentation. ences and their implications regarding double eyelid surgery This is also true in other Asian countries. Modern concepts of were discussed.11 Fernadez and Flowers in Hawaii, where facial cosmetic surgery, including double fold and augmenta- East meets West, published papers about double eyelid tion rhinoplasty, began and were developed in Japan in the surgery for Asians.4,12 Newer techniques seeking to be more late 19th and 20th centuries. In South Korea, facial cosmetic refined and less invasive while imitating the natural fold are from other Asians. Although there are some constants, the surgery flourished following the Seoul Olympics in 1988. being reported.13 SYNOPSIS standard of beauty varies among countries. Anatomic charac- With economic development, cosmetic surgery in China has ᭿ The Asian’s concept of beauty has changed over time. Currently, teristics and cultural differences, including trends in each grown rapidly. Due to the increased scientific knowledge and Anatomic considerations most Asians want to improve their appearance while preserving ethnic group, should be considered before performing facial training of board-certified plastic surgeons in East Asia, facial their ethnic identity. cosmetic surgery. cosmetic surgery has advanced rapidly. These plastic sur- Multiple theories exist regarding the formation of the supra- ᭿ Asian cosmetic surgery is not simply Western cosmetic surgery Much controversy surrounds the concept of universal geons have also played a key role in introducing new ideas tarsal crease or fold (Fig. 10.1). First, Sayoc explained the applied to Asians. Rather, cosmetic surgery in Asians must beauty. Humans, even babies, have an innate affinity for beau- and techniques about Asian facial plastic surgery. presence of double fold based on anatomic differences between 3 account for the underlying differences in anatomy and aesthetic tiful people. Symmetry and a healthy, young-looking appear- Double eyelid surgery and augmentation rhinoplasty are Caucasian and East Asian eyelids. Expansions of the levator proportions between Asians and Caucasians. ance make a face more attractive, regardless of ethnic two of the most popular facial cosmetic procedures through- palpebrae superioris muscle penetrating through the septum ᭿ Asian blepharoplasty and augmentation rhinoplasty are two of the background. A key feature of beautiful faces is the quality out Asia. Facial bone contouring is also becoming another and orbicularis oculi muscle to the overlying dermis were known as youthfulness.4 In Caucasian women, high cheek- common procedure in East Asia. Experience with ortho- thought to be present in Caucasian eyelids and less so in most popular facial cosmetic procedures in Asia today. Facial bone 14 contouring and aesthetic orthognathic surgery are also becoming bones are an important factor, whereas Asian women with gnathic surgery/craniofacial surgery initiated facial bone Asians (Fig. 10.2A). The presence of such attachments more common in certain parts of Asia. round or oval-shaped faces are considered more beautiful. operations like mandible angle contouring and zygoma between the levator aponeurosis and skin was established by When Asians see facial photographs of themselves alongside reduction. Development of special bone surgery tools, such as Cheng and Xu through scanning electron microscopy studies.15 ᭿ Since there is no perfect way to define beauty, one must use both Caucasians, they, especially younger individuals, are some- a variety of electrical saws and burrs has expanded the scope Another concept is the role of fibrous septa between the tarsal subjective and objective tools for analyzing facial profiles according times disappointed with their appearances. In general, Asian of cosmetic facial bone surgery, with favorable results. plate and pretarsal skin. The adherence between the tarsal to ethnic standards. faces tend to look broader with a flatter contour to their eyes, Some Asians have attractive facial traits, including large plate and pretarsal skin is loose in the single eyelid and tight nose, and face. We live in a three-dimensional world, and the eyes, a well-balanced nose with a good profile, and small in the double eyelid.4,16 Therefore, both explanations focus on faces we observe directly are three-dimensional. Facial cos- lower faces.6 Individuals who regard their facial features as the connection between the levator mechanism and the pre- Everything is in the face metic surgery is a three-dimensional procedure, and more falling short of the mainstream ideals of beauty are willing to tarsal skin. (Cicero) emphasis is being placed on facial contour changes. undergo facial cosmetic surgery. Younger individuals, for An important factor contributing to supratarsal crease for- Over the past two decades, many countries in East Asia, example, wish to undergo facial bone contouring to make mation is the level of fusion of the orbital septum and the including South Korea, China, Taiwan, and Japan, have their faces smaller. These individuals do not have “below levator aponeurosis. The supratarsal crease is formed by the emerged as strong economies. More people in these countries average faces”.1 Rather, they want to look above average, dermal insertion at the confluence of the septum and levator Introduction can now afford to spend money on items that are not consid- sometimes chic and stylish, not merely natural. Most patients aponeurosis.13 The level of adhesion between the orbital ered basic necessities, including cosmetic and luxury items. who want facial cosmetic procedures like double eyelids and septum and levator aponeurosis defines the superior palpe- The face, while only a single part of the body, is the icon of These items usually come from wealthier countries with well- augmentation rhinoplasty are women, but these cosmetic pro- bral crease in most Caucasian eyelids,17 whereas lower fusion self-identity and can be easily recognized among hundreds established economies, mostly located in Europe and North cedures are also requested by men. of the orbital septum to levator aponeurosis results in a low of thousands of faces. Asian and Caucasian faces each have America. People in East Asia have adopted Western habits, as lying or absent crease in the Asian eyelid (Fig. 10.2B). Asians unique features. It is generally accepted that Asians have “westernization” has progressed into these countries. Among with naturally occurring superior palpebral folds have a rela- small, puffy eyes with an epicanthal fold, shallow orbits, a the items brought to East Asia is a new concept of beauty for tively higher fusion of the orbital septum and levator aponeu- low profile nasal dorsum with thick skin, flat faces with large young female adults and teenagers. Due to globalization, Asian blepharoplasty rosis (Fig. 10.3).18 The preaponeurotic orbital fat present in the cheekbones and broad width. This is especially true for East Western and Eastern cultures interact to a greater degree than pretarsal space eliminates the formation of double fold in Asians, including people from China, Japan, Mongolia, North ever before, indirectly or directly. Thus, people from both Introduction Asians. Among Asians, it is not unusual for the upper lids to Korea, South Korea and Taiwan.1 Asia is the largest continent, cultures have become familiar with each other’s looks. vary, being double and single in the same individual, depend- and has numerous ethnic groups.1,2 Southern Asians have Young female Asians have become acutely interested in Few young Caucasians undergo cosmetic procedures for their ing on such variables as fatigue, diurnal variations of eyelid darker, thicker skin, larger eyes with double folds and smaller, their appearance, creating a boom in cosmetic surgery. This upper eyelids. Most of these individuals have large eyes with swelling, and weight change. narrower facial skeletons compared to northern Asians, phenomenon has created a new standard of beauty. Females crisp, tall upper lid creases. In contrast, Asians are described The epicanthal fold is also a characteristic feature of Asian whereas western Asians have quite different facial features in East Asia seek larger eyes, a higher nose, and a smaller face, by westerners as having puffy, small eyes, epicanthal folds, upper lid. It hides the medial part of eye, including the ©2013, Elsevier Inc. All rights reserved. Asian blepharoplasty 165 166 SECTION I • 10 • Asian facial cosmetic surgery

Orbital fat Preoperative considerations and diagnosis Müller muscle Most Asian patients desiring double eyelids no longer want Septum orbitale a westernized appearance, but rather an appearance more Submuscular fat Orbicularis oculi appropriate for Asians. Because the anatomy of the orbit differs greatly between Asians and Caucasians, Asian blepha- Orbital fat roplasty should be performed in accordance with the orbital Levator aponeurosis anatomy of Asians. Previously, most young Asians seeking Orbital septum upper blepharoplasty have done so only for double fold for- Orbicularis muscle mation. More recently, Asians have undergone upper blepha- roplasty to achieve a more attractive eyelid shape by reducing Dermal attachment of Retromuscular fat the puffiness in their eyelids, obtaining a double fold, and levator apon 18 Müller muscle increasing the palpebral fissure length. These patients also prefer a flat upper eyelid which looks young and stylish, not Tarsal plate 4 Levator aponeurosis sunken or deflated. Conjunctiva The height of double eyelid is an important issue. In young Caucasians, the superior palpebral fold is small and the height Tarsal plate of the pretarsal skin exposure is similar to te height of the superior palpebral crease.18 In contrast, the Asian lid crease is generally 2–3 mm lower, and a large superior palpebral fold hangs over the pretarsal skin.7 Thus, exposure of pretarsal Caucasian Asian skin is less than in Caucasians. The lower border of the fold is called the double eyelid line, and the distance between this Fig. 10.1 Anatomy of upper eyelid in Caucasians and Asians. line and the margin of the lid at primary gaze is pretarsal Thin asian eyelid exposure (Fig. 10.4). After blepharoplasty, the pretarsal expo- sure is determined by several factors, such as the height of Fig. 10.3 The cross-sectional anatomy of the Asians with thin eyelid. incision, the amount of pretarsal skin excision, the height of

Orbicularis oculi Orbicularis oculi

Orbital fat Orbital fat

Orbital septum Orbital septum

Müller muscle Retromuscular fat

Müller muscle

Levator aponeurosis Levator aponeurosis

Tarsal plate Tarsal plate a c b

A Caucasian B Puffy asian eyelid without double fold d Fig. 10.2 (A) The cross-sectional anatomy of the Caucasian upper eyelid. (B) The cross-sectional anatomy of the Asians with puffy eyelid.

caruncle and lacrimal lake and increases the intercanthal dis- operation. This medial epicanthoplasty will decrease the wide tance. In East Asians, at least 50% of adults have epicanthal intercanthal distance and increase the horizontal width of fold. If slight traces are included, almost all East Asians retain the palpebral apertures. However, surgeons should be very epicanthal folds, and a mild epicanthus is not an unusual cautious about total elimination of epicanthal folds, because feature for them.1 There has been a recent trend to eliminate this can leave a noticeable scar and result in loss of ethnic Fig. 10.4 The mechanism of double eyelidplasty in North-East Asians. a, Double eyelid line, lower border of fold; b, upper lid margin; c. pretarsal exposure; d, lower lid or loosen the epicanthal fold as part of the double eyelid identity. margin. Asian blepharoplasty 167 168 SECTION I • 10 • Asian facial cosmetic surgery

fixation, and levator function.18 Currently, the preference for are uncomfortable with this configuration, since it appears most Asians is a pretarsal exposure <3 mm, and as little as unnatural to them. They prefer a fold that for most part is 1 mm.7 These desires have geographical variation (Fig. 10.4). parallel to the lid margin. Laterally, the crease may have a Another preoperative consideration is the shape of the slight flare, in that the crease lies farther from the lash line desired crease. Caucasians typically have a semilunar shaped than the central third. Medially, the crease may taper toward Skin crease where the central third of the crease lies farther from the medial canthus (“inside fold”) or run outside the epican- 19 20 the lash line than the medial and lateral thirds. Most Asians thus (“outside fold”) (Fig. 10.5). Orbicularis muscle

Connective tissue Treatment/surgical technique Tarsal plate Conjunctiva Although procedures for blepharoplasty in Asians have a Fig. 10.7 Nonincisional double eyelidplasty (multiple stitch method). number of similarities to those in Caucasians, it is important to recognize that upper blepharoplasty in Asians is not a west- ernization procedure. Thus, surgical techniques should differ in some respects from a Caucasian blepharoplasty. Incisional versus nonincisional methods In the partial incision method, one or more small stab inci- Generally, surgical techniques for double fold formation sions can be made in the planned upper eyelid crease, and can be categorized as incisional and nonincisional methods, after going through orbicularis, the preaponeurotic fat is although some authors have advocated partial incisional removed. A permanent suture material is then placed between methods. the skin edges and the underlying aponeurosis or superior edge of the tarsal plate. The lid should be inverted to confirm that the suture has been placed to catch the upper border of Inside fold Nonincisional methods 21–26 the tarsal plate, and to ensure that the suture has not pierced Numerous nonincisional methods have been described. These methods are used primarily for young people who do the conjunctiva. Video not require skin excision and for patients with thin upper 1 Incisional methods eyelid tissue who do not have an excess of fat. The advantages of these minimally invasive techniques must be balanced For double fold formation in the upper lid, traditional tarso- against the knowledge that the fixation may not be as durable dermal fixation through incisional methods (Fig. 10.9A,B) Fig. 10.8 Partial incisional double eyelidplasty with fat removal. 30 over time when compared with the incisional methods. Non- has been an effective standard method. In patients with incisional methods can be categorized as single stitch and redundant eyelid skin, the incisional approach is unavoidable. multiple stitch methods, both of which have advantages and There are as yet no definite standards for incisional blepharo- disadvantages. plasty, but the common procedures will be described. The In these techniques, stitches are simply inserted through placement of the double fold on the upper lid should be the skin at the level of the preferred lid crease, traversing the postoperative edema, but relapse can sometimes occur. decided preoperatively according to each patient’s appear- full thickness of the lid tissues down to and including either Fixation through the upper portion of the tarsal plate can ance and preference utilizing forceps or a probe. the levator aponeurosis or the tarsal plate. The stitches are tied result in a more definite eyelid crease with minimal The skin incision marking tapers closer to the lash line as in such a way that the knots are buried. relapse, but postoperative edema can occur more it progresses medially towards the epicanthal fold. Some patients may prefer that the medial portion of the crease lies • Single stitch nonincisional methods have many frequently than in levator fixation methods. Outside fold outside the epicanthus. The superior incision is marked such modifications.21 Figure 10.6 shows a nonincisional single • Multiple stitch nonincisional methods can be that the skin to be excised will also taper, usually measuring stitch method. Fixation through the levator aponeurosis performed, usually with 3–5 stitches on each side 1 mm medially, 2 mm centrally, and 3 mm laterally. The skin Fig. 10.5 “Inside” vs “outside” fold in Asian blepharoplasty. can result in a more natural appearance and minimal (Fig. 10.7).27 incision is then made and the strip of skin excised. A strip of Several factors should be considered when performing orbicularis oculi wider than the skin strip is then removed in nonincisional double fold formation. First, the conjunctival order to create a sharp lid crease. Leaving excess orbicularis side of the stitches should not be exposed, since this exposure can result in a puffy appearance. The septum is then entered, can result in corneal damage postoperatively and second, the and a variable amount of retroseptal fat may be either excised possibility of relapse should be considered and mentioned or released, allowing it to ride up superiorly. The levator preoperatively to all patients. aponeurosis is exposed as it approaches the tarsal plate. The Asian tarsal plate typically measures 6–7 mm in height. Partial incisional methods Fixation of the new upper lid crease is then done. Various Video Partial incisional methods (Fig. 10.8) are being used more methods of suture fixation involving internal buried sutures Skin 2 frequently.28,29 These procedures have evolved to overcome have been described. One method is to use 3–7 sutures passing disadvantages of the above two methods. Partial incisional through the aponeurosis and the dermis-muscle of the inferior Orbicularis muscle methods can result in moderate tissue adhesions, preventing skin edge. The skin is thus anchored to the levator mecha- Connective tissue the early relapse observed using nonincisional methods. nism, creating the new lid crease, which will be hidden by the Moreover, partial incision can result in a more natural appear- overhanging tissue of the palpebral fold. Alternatively, fixa- Tarsal plate ance, minimizing scarring of the upper lid. Using the partial tion can be done to the superior edge of the tarsal plate, a Conjunctiva incisional approach, preaponeurotic fat can be easily removed procedure which is thought to create a more static and defined Fig. 10.6 Nonincisional double eyelidplasty (single stitch method). to correct puffy eyelids. upper lid crease (Fig. 10.9B–D). Asian blepharoplasty 169 170 SECTION I • 10 • Asian facial cosmetic surgery

E E

D B C D C A A A C B B D Levator C D D C A A

B B Upper tarsus Skin

Park Z epicanthoplastySkin redraping method Root Z epicanthoplasty A B Fig. 10.10 Various methods of medial epicanthoplasty.

B

A D B A B C A C C D D A B

C D

Fig. 10.9 (A) Incisional method: skin–aponeurosis. (B) Incisional method: skin–tarsus. (C) Double eyelidplasty: preoperative view. (D) Double eyelidplasty: postoperative view. B B

A C A C D D

A B C D

Subclinical ptosis repair have been used for the correction of average Asian medial C D epicanthal folds. Although traditional methods, including Many Asian people who want more attractive looking eyelids 37,38 the Mustarde technique, have been used, these proced- Fig. 10.11 Medial epicanthoplasty with skin redraping method: planning. are not satisfied with the creation of a simple double crease.31 ures may result in bad scars on the medial canthal area. They may have a low resting level of their eyelids, which if These problems may be overcome by the half Z-plasty tech- corrected will give them a more open and attractive palpebral nique.37,39,40 Nevertheless, the amount of release is limited and 32 fissure. These patients have a tendency for upper eyelid a moderate scar remains. Many Asian patients have com- Lateral canthoplasty height than is desired. Postoperative instructions are as ptosis, and are defined as having “subclinical ptosis”. They plained about these scars. New methods, including skin follows: may be candidates for the same procedures utilized in cases redraping methods, have therefore been developed to elimi- Lateral canthoplasty (Figs 10.13, 10.14) may increase the hori- 1. Cold compresses, as tolerated, for 24 h of mild ptosis, including Müllerectomy, or levator aponeuro- nate the possibility of scarring of the medial canthal area.36,41 zontal length of the palpebral fissure and result in a more 33–35 2. sis plication or advancement. These skin redraping methods, which have become very natural appearance around the lateral canthus.42 Although Antibiotic ointment for the suture lines popular in Asia, include a medial subciliary incision on the currently controversial, these procedures are being used for 3. Cleanse the wound with clean water lower eyelid which makes a nonvisible scar and resection/ these purposes. 4. The external sutures may be removed in 4–5 days. Medial epicanthoplasty releaser of medial epicanthal adhesions, procedures that can minimize medial epicanthal scars and correct medial epican- Postoperative care Medial epicanthoplasty (Figs 10.10–10.12) is a very important thus quite well (Figs 10.11 and 10.12). Outcomes, prognosis, and complications component of Asian eyelid surgery.36 Various methods were These methods, however, can also have side-effects, includ- Postoperative care for Asian blepharoplasty patients is similar originally introduced for the correction of blepharophimosis ing unnatural dimpling at the releasing points of medial epi- to that for Caucasians. Scarring is generally not a problem, Complications are similar to those observed during routine in Western countries. In Asia, however, these procedures canthal adhesions. although excessive swelling can result in a higher crease blepharoplasty procedures. These complications include Asian blepharoplasty 171 172 SECTION I • 10 • Asian facial cosmetic surgery

B 1 1 A C D B C D A A A B B C 1 C D D A B d b a Conjunctiva 2 2 c

2

C D 3 3 Fig. 10.12 Medial epicanthoplasty with skin redraping method: completion.

B Blair method

Fig. 10.14 Lateral canthoplasty: other A Von ammon method C Blaskovics method techniques.

asymmetry, prolonged swelling, multiple folds, infection and Differences in nasal soft tissue and skeletons hematoma. Asymmetry is the most common problem after Asian between Asian and Caucasian noses blepharoplasty, especially when combined with levator plica- The nasal profile of Asians is quite different from that of tion or advancement. Revision surgery may be required for Caucasians. The Asian nose has a shorter height, less tip patients with major and persistent asymmetry. Patients should Palpebral conjunctiva projection, and a wider nasal base when compared to the be informed of this preoperatively. Caucasian nose. The Asian nose has a similar height and nar- rower width than the African nose.44 The overlying soft tissue enveloping Asian noses consists of a dense fibromuscular Asian rhinoplasty layer along with a fatty layer, especially over the alar lobule. The linear dimensions of the nose are smaller in Asians than Introduction in Caucasians, but their noses are wider, although their nostril floor widths are quite similar. These findings can be attributed A Augmentation rhinoplasty is one of the most common aes- to the thicker, flaring alar lobule in Asians.45 A comparison of thetic plastic surgery procedures in Asian countries. Whereas the aesthetic proportions of Asian and Caucasian noses found most Western literature addresses issues related to rhino- that Asian noses projected less from the face and were broader plasty in Caucasians, such as reduction and corrective rhino- at the intercanthal level and alar base, but not at the bony plasty procedures, augmentation of the nasal dorsum and tip base. Moreover, Asian noses projected less at all levels, includ- remain key issues for Asian plastic surgeons.43 In the past, ing the nasion projection and tip projection.46 most of these operations consisted of simple augmentation Although there are racial variations among Asians, nasal 2mm * rhinoplasty. More recently, however, the needs of patients skeletons are generally smaller and weaker in Asians than in * have become more complex, requiring more meticulous pre- Caucasians.47 The shape of the nasal bone in Germans has Cornea 3mm operative diagnosis and more involved surgical techniques. been classified into eight types, whereas the width of the nasal * Ideally, rhinoplasty should enhance the harmony between the bones was shorter and the width of the pyriform aperture 5mm nose and face, thus requiring general evaluation of the entire was wider in Asians than in Germans. The nasal base width face. For this purpose, the entire face must be evaluated. The in Asians is greater than in Caucasians but less than in general principles for rhinoplasty in Asians are quite similar Africans. Asian noses have been found to be wider at the nasal B C D to those in Caucasians. However, rhinoplasties in Asians and base, but similar or shorter in the height of the nasal base Caucasians have different characteristics. This section will (tip projection), than in Caucasians.48 Contrary to popular describe various aspects of rhinoplasty in Asians, as well as thought, the alar cartilage in Asians is not markedly smaller Fig. 10.13 Lateral canthoplasty technique. commonly encountered problems and solutions. than in Caucasians, although there are differences in the Asian rhinoplasty 173 174 SECTION I • 10 • Asian facial cosmetic surgery configuration and thickness of the cartilage and the length of also be considered, especially if an alloplastic augmentation the foot plate of the medial crus. Moreover, nostril shape was is planned. Although the thick skin of Asians is better able to found to be affected mainly by the volume of the dilator naris endure dorsal implants, a tight skin envelope may limit the anterior/posterior muscular components, the depressor septi possibility of a thick dorsal implant. nasi muscle, the shape of the lateral crus and the footplate segment ratio.49 In Asians, there is also a loose connection Underprojection of the nasal tip between the domes of the middle crura and the absence of attachment of the medial crura to the caudal septum. This The cartilaginous framework in most Asians is relatively might explain, at least in part, why the nasal tip is broad, and weak, resulting in an underprojected nasal tip. Asians seeking underprojected, while its base is wide. Moreover, the lateral rhinoplasty desire more nasal tip projection along augmenta- crus is usually concave in Asians, but convex in Caucasians.50 tion of the dorsum. Findings such as these have led to significant advancements Various methods exist for determining nasal tip projec- 57 in Asian rhinoplasty. tion. The ideal tip projection will be different for each patient and must be balanced with the remainder of the face. Many Asians have varying degrees of dentoalveolar protrusion. If A B C D History this is minimal, increased nasal tip projection may be desira- ble, but when it is severe, rhinoplasty alone will not solve the Rhinoplasty in Asians was first reported in 1964 by Khoo Boo- patient’s problem. Fig. 10.15 (A,B) Preoperative view. Flat forehead and nose profile. (C,D) Postoperative view. After augmentation of forehead and nose. Chai.51 He demonstrated augmentation rhinoplasty in Asians using autogenous materials and silicone implants. He pro- Blunt nasal tip posed the “golden point”, midway between the orbital ridge Korea, the use of synthetic nasal implants is well- established, and the intercanthal line, which is the optimal starting point The nasal skin envelope is thicker in Asians than in Caucasians. especially in the dorsum (Fig. 10.15). for the end of a silicone implant on the nasal dorsum. He also This thickness can obscure the underlying nasal cartilaginous The need for an implant material that is readily available, proposed the importance of both dorsal and nasal tip aug- framework which is often flimsy. To overcome these issues, not associated with donor site morbidity, offering ease of mentation in Asian rhinoplasty. In 1974, Furukawa summa- two problems must be addressed: (1) Can the thick skin be sculpting, and with smooth contours, has led to the intro- 16 rized the important aspects of Asian rhinoplasty. He reported altered? (2) How much can the cartilaginous framework be duction of alloplastic materials such as: silicone; nylon anthropometric data of Japanese, identified the ideal Asian manipulated? (Supramid mesh); PTFE (Teflon®, Gore-Tex®, Proplast®); poly- profile and described unique techniques for the Asian nose. ester (Mersilene®); polyethylene (Medpor®), and hydroxyapa- Alloplastic material for Moreover, diverse-shaped silicone dorsal implants were intro- Short or contracted nose tite. Silicone remains the most widely used material in Asia, duced. In 1986, McCurdy showed the aesthetic goals of rhi- dorsal augmentation although its use can be associated with problems such as (mainly with silicone implant) noplasty in the non-Caucasian nose are similar to those in the Surgery in Asians to augment their dorsum and increase tip extrusion, translucency, displacement, and infection. Caucasian nose.52 He also noted that technical modifications projection can result in cephalic tip rotation with exposure are needed when performing a non-Caucasian rhinoplasty. In of the nostrils. This is distressing to most people including One-piece augmentation rhinoplasty 1990, Parsa’s report showed nasal augmentation with split Asians. Lengthening an over-shortened nose is one of the L-shaped silicone implants were originally used for augmen- 53 calvarial grafts in Orientals. Shin and Lee reported, in 1993, most challenging of rhinoplasty procedures. Therefore, it tation rhinoplasty in Asian patients. However, these implants 54 columella lengthening in nasal tip plasty of Orientals. is important to prevent shortening of the nose during aug- were associated with many complications.60,61 Over the long Watanabe analyzed the alar structure of the Oriental nose in mentation rhinoplasty. It is also important to have the means term, placement of a single L-shaped piece of alloplastic mate- 55 1994. In 1996, Han and Kang reported a custom-made nasal to correct the short Asian nose which presents either as rial can result in problems at the nasal tip, such as skin thin- Shield graft implant prefabricated from the curing of silicone adhesive, a primary condition or secondary to previous surgery. The ning, redness, transparency, tip deformation, implant 56 demonstrating satisfactory results in Asian noses. Since short nose can be defined as congenital, postoperative or extrusion, and compression of the cartilaginous framework.62 Columella strut then, different rhinoplasty techniques, depending on anatomy, posttraumatic, with procedures individualized according to An alternative to the L-shaped implant is a straight silicone have been investigated in Asian patients. This was followed etiology. Frequent problems include paucity of the nasal implant designed to only augment the dorsum; this technique by aesthetic modifications and techniques to minimize com- lining, contracture of the skin envelope and limitation in is much less problematic than the L-shaped implant. This plications. Finally, advanced techniques have been developed expansion of the osteocartilaginous framework of the nose. Fig. 10.16 Two piece augmentation rhinoplasty: alloplastic material for dorsal 58 “one piece augmentation” implies a prosthetic implant which augmentation; cartilage graft and suturing method for tip augmentation. for complicated cases and difficult situations. These three components should be corrected simultaneously. extends to the nasal tip. For this classification, the one piece Recently, the release of five fibrous connections has been augmentation implies a prosthetic implant which extends to emphasized. The most effective length was reported to be the nasal tip. A variation of this technique is to attach a carti- Diagnosis gained by severing the lateral crus from the upper lateral 63 lage graft at the distal end of the straight silicone implant. a no-touch technique is used as much as possible, decreasing cartilages, with moderate gain from release at the pyriform Despite the use of such cartilage grafts on implants, similar Nasal analysis in Asians is similar to that in Caucasians. The aperture and the mucoperichondrium of the upper lateral the chance for contamination. For ideal positioning of the universal standards for rhinoplasty do not differ greatly. The long-term complications can occur in the nasal tip area. nasal implant, the uppermost level is determined by the mid- cartilage. Release of other tip-defining structures was not sta- Because of these problems, many Asian plastic surgeons following is a discussion of the most frequent findings and tistically effective.59 pupillary level or by the midpoint between the eyebrow and strategies when dealing with Asian noses. prefer a two-piece augmentation rhinoplasty. medial canthus. The underside of the implant is contoured into a concave shape to fit the contour of the nasal dorsum. Two-piece augmentation rhinoplasty Low profile and broad nasal dorsum Surgical techniques and treatment The implant is scored or perforated to allow tissue ingrowth In the two-piece technique (Fig. 10.16), an alloplastic implant and thereby minimize movement of the implant.65 Interdomal Video Most Asian people have a relatively low nasal dorsum com- Low profile nasal dorsum augmentation 3 is used to augment the dorsum as far down as the supratip and transdomal sutures are often added to improve nasal tip pared with Caucasians. In recent years, many Asian patients break. The tip is augmented using the cartilage techniques projection. have requested augmentation of their dorsal nasal contour, as Although autogenous cartilage remains the material of choice described below. There is no connection between the silicone well as increased projection of their nasal tip. It has therefore for rhinoplastic grafts, an alternative grafting material is often implant and the cartilage used to augment the nasal tip; Underprojected nasal tip become important to diagnose the height of the nasal dorsum required. For cosmetic surgery, most patients desire simple unlike the one-piece method, this may lead to a discontinuity in the context of the entire lateral profile involving the fore- procedures that avoid the additional scarring associated with between the tip and the new dorsum, necessitating additional Many Asian people have a relatively underprojected nasal tip head, lip, and chin point. The thickness of the nasal skin must autogenous graft harvesting. In Asians, and especially in cartilage grafting.64 In placing the dorsal alloplastic implant, compared with Caucasians, making projection of the nasal tip Asian rhinoplasty 175 176 SECTION I • 10 • Asian facial cosmetic surgery a key factor in Asian rhinoplasty. As mentioned earlier, one potential side-effect of increasing projection of the nasal tip is cephalic rotation and nasal shortening. This should be avoided, especially because visibility of the nostrils on the frontal view is considered a sign of bad luck in many Asian countries. Alloplastic materials around the nasal tip Although AlloDerm or polytetrafluoroethylene is sometimes used for nasal tip projection, these materials are associated with many potential problems. Furthermore, while, porous polyethylene (Medpor) can be used for columellar strut or septal extension, it has been associated with long-term com- plications, including infection and tissue contracture, perhaps A B C D due to exposure of the porous polyethylene through the thin 66 membranous septum. Due to long-term complications of Fig. 10.18 Bulbous nose in Asians. (A,B) preoperative view; (C,D) postoperative view. alloplastic materials around the nasal tip, few Asian plastic surgeons use these materials. Over the past 20–30 years in Korea, nasal tip plasty has been performed mainly using autologous materials, including conchal and septal cartilage. concha is used for columellar struts and derotation grafts, whereas cavum concha is used for onlay grafts.71 Derotation Cartilaginous work for nasal tip projection grafting with conchal cartilage is relatively easy to perform Septal extension graft and can yield stable results with nasal tip lowering. However, Although various suture methods based on tripod concepts supratip bulging can occur after this procedure. can be applied to Asian patients, most Asian noses are rela- tively short. Thus, creating tip projection using a suture Rib cartilage or dermal-fat graft method can result in an up-turned nose. To prevent this side- Fig. 10.17 Septal extension graft in oriental nose for preventing or correcting the effect, derotation of the nasal tip is frequently required during short nose. Rib osteochondral grafts were originally designed for the the procedure to increase tip projection. One method to reconstruction of saddle nose deformities. This procedure accomplish this involves placement of cartilage grafts on the has been used primarily for the secondary correction of con- 72 caudal surface of the nasal tip cartilages. These grafts slightly with very thick skin, but the risk of necrosis of the skin enve- tracted noses, for which there were no other options. lengthen the cartilage framework in the tip, causing the lope is relatively high. Thus, many Asian plastic surgeons Although some authors advocate the primary usage of rib appearance of tip derotation. choose to augment the skeletal framework to camouflage cartilage graft on short noses, this is considered controversial. The other effective way to do this is to release the fibrous bulbous skin. Dermal-fat grafts can be very helpful in secondary revision of Upper lateral contracted nose. attachments between the upper and lower lateral cartilages. cartilage After this procedure, the nasal tip could be projected effec- Short or contracted nose tively with various nasal tip suture techniques including Lower lateral cartilage Septal extension grafts are commonly utilized in Korea for Outcomes, prognosis, and complications transdomal, interdomal sutures without fearing the cephalic correction of short noses. Septal extension grafts were first rotation of the nasal tip. Fig. 10.19 Substantial lengthening with septal or conchal cartilage graft for introduced in 1997 and categorized into three types: direct prevention of contracted nose. Implant deviation extension, paired spreader, and paired batten grafts.69 Because Onlay graft This is the most common complication after augmentation most Asians have smaller septal cartilages, the efficient usage bone grafts and diced cartilage may provide better results. rhinoplasty in the Asian nose. It typically occurs with alloplas- Onlay cartilaginous grafting in the nasal tip can result in an of this graft material is very important. Along with septal The cartilage framework may be lengthened using a septal tic materials, which have been placed through a unilateral additional projection. Such onlay grafts may be visible in thin extension, the lower lateral cartilage must be released from extension graft, a derotation graft with conchal cartilage or a vestibular incision into a deviated pocket. This may be pre- skinned patients. However, such grafts are successful in most the upper lateral cartilage in order to allow inferior displace- rib osteochondral graft. vented by bilateral incisions, even when using the closed Asian patients due to the thickness of their skin in this area. ment of the tip. Without this procedure, a septal extension approach. In the open approach, implant fixation on the graft can result in a hanging columella. Occasionally, spacer Septal extension graft midline portion of the cartilaginous framework may prevent Septal extension graft grafts are necessary between the separated upper and lower deviation of the implant. Septal extension grafts (Fig. 10.17) were originally devel- cartilages in order to prevent alar retraction. The procedure is quite similar to that used for correction of short noses. However, mucosal release may be difficult in oped for correction of contracted noses. In Asian patients, Due to the prevalent use of alloplastic material in the nose Implant exposure indications for such grafts have been expanded to improve and/or illegal administration of liquid alloplastic materials by contracted noses complicated by infection or severe scar con- tractures. Complete meticulous release of soft tissue including nasal tip projection without cephalic rotation of the nasal tip nonmedical personnel, a contracted nose is an iatrogenic Visibility, redness, infection, and skin thinning may indicate and derotation of short noses.67,68 Since many Asians have a deformity common throughout Asia. Chronic inflammation the mucosa may be needed. Moreover, since excessive caudal extension can result in soft tissue thinning on the nasal tip future implant exposure. Because this may be aggravated by thin septal cartilage, additional support with batten type car- along the implant after rhinoplasty can result in a contracted implantation of another alloplastic material, autogenous tilage may be required. Long-term stability of septal extension nose.70 This may be corrected by complete removal of the scar area, the soft tissue envelope around the nasal tip should be considered during lengthening procedures. tissue should be considered. In Korea, dermal-fat grafts are grafts requires secure fixation and complete release of soft tissue around the implant and followed by the complete most frequently used. Other types of autogenous grafts tissue constraints release of the soft tissue envelope from the nasal skeleton. include rib cartilage, bone and diced cartilage. Without the latter, the contracted soft tissue envelope cannot Derotation graft Bulbous nose be lengthened, despite lengthening of the cartilaginous frame- Derotation (Fig. 10.19) of the nasal tip requires wide dissection Implant infection work. After removal of the implant from the nose, other allo- of the skin envelope, with release of the fibrous tissue Although there have been many attempts to correct the plastic materials can be used for dorsal augmentation, but between the caudal portion of the upper lateral cartilage and Alloplastic materials should be removed from patients with bulbous nose (Fig. 10.18), complete correction is usually not their use may result in other complications. Therefore, autolo- the cephalic portion of the lower lateral cartilage. During this implant infections, with revision rhinoplasty performed after achieved. Skin thinning procedures are possible in patients gous tissue such as dermal-fat grafts, rib cartilage, calvarial procedure, the nasal mucosa must be preserved. Cymba a minimum delay of 3 months. Asian facial bone surgery 177 178 SECTION I • 10 • Asian facial cosmetic surgery

Capsular contracture around implants mathematically. The golden ratio, which was originally used Baek et al. reported 94 cases using a technique involving the as the mandibular angles. Sometimes, these procedures are in architecture, geometry and other areas is defined by a line coronal approach followed by either an in situ transposition performed simultaneously with narrowing genioplasty, Capsular contractures may occur around any alloplastic divided into two unequal segments, where the ratio of the osteoplasty or the removal of the malar complex and contour- resulting in a smaller lower face. implant and cause deformity and possible implant extrusion. entire line to the longer segment is identical to the ratio of the ing of the bone with replacement as a free bone graft.83 In 1991, Treatment of this complication is similar to that advocated for longer to the shorter segment, or 1.618.76 The golden ratio has Uhm and Lew classified zygoma prominence into three cat- Orthognathic surgery and anterior implant exposure. been used in planning correctional surgery for a facial deform- egories, including true zygoma protrusion, pseudozygomatic ity, creating a line drawing of a mask outlining ideal facial protrusion and combination.84 Yang and Park reported, in segmental ostectomy 77 Secondary procedures proportions. Although others have claimed that this mask 1992, an infracture technique for the zygomatic body and arch Profiloplasty of the lower face by maxillary and mandibular does not describe an ideal facial shape, the facial golden mask reduction, which he postulated could minimize the age- anterior segmental osteotomies (ASO) was first described in has been used as an objective index for facial analysis, with related ptosis of soft tissues of the cheek. Surgical procedures 97 Forehead augmentation (Fig. 10.15) 78 1993. Taiwanese plastic surgeons YuRay Chen, Philip Chen, some correlation to the degree of facial attractiveness. In for zygomatic reduction in Orientals have also been described, and LunJou Lo have played important roles in developing Augmentation rhinoplasty can make the lateral profile more view of artistic standards, the Asian is known to have a rela- as has an “infracture technique for zygomatic osteotomy and 85 orthognathic surgery suitable for Asians. Recently in Korea, attractive. However, patients with a flat forehead profile tively wider mid and lower face, based on the golden ratio. arch reduction.” In 1993, Satoh and Watanabe showed the orthognathic surgery is being performed for purely aesthetic may benefit from a simultaneous forehead augmentation. These findings may explain why many Asians request facial results using the tripod osteotomy via the coronal approach reasons. Although maxillo-mandibular complex clockwise ® 86 Traditionally, custom-made silicone or Gore-Tex implants reduction procedures, including the malar reduction, mandi- and simultaneous frontoperiorbital lifting in oriental patients. rotation has been found quite helpful for skeletal class III have been used for forehead augmentation despite the pos- ble angle reduction and maxillomandibular setback proce- Cho compared the results of the intraoral and bicoronal patients, the true indications for these procedures have not 73 87 sibility of seroma or infection of the implant. This may be dures. In addition, Asian people have smaller noses and approaches. Baek and Lee showed that intraoral malar yet been clarified. due to the ease of the technique and the more natural contour greater bizygomatic and bigonial widths, according to the reduction could result in cheek drooping. Thus, the combina- of the forehead resulting from the use of these implants. golden ratio.79 Reduction of the mandible angle and/or tion of reposition malarplasty and facelift proved to be a sat- Microfat grafting with the Coleman technique or augmenta- zygoma reduction is regarded by many Asian women as a isfactory method.88 Many reports for simultaneous mandibular Diagnosis and indications tion with various cements may also be used to improve the means of becoming more attractive. contouring and zygoma reduction have been reported for forehead profile. The second tool for measuring the facial profile is cephalo- balanced facial contours. Mandible angle metric analysis.75 This method, along with other analytic Paranasal augmentation methods, has been the standard until now for facial analysis. Mandible angle reduction Many Asian people want to improve their square face appear- However, these analytic methods have their shortcomings. ance by reducing the size of their prominent mandible angles. In Asia, augmentation rhinoplasty combined with paranasal Thus, it has been concluded that clinical aesthetic evaluations The presence of prominent mandibular angles in Asians sug- Therefore, mandibular angle reduction is a popular procedure augmentation has become quite popular. Paranasal augmen- are more valuable than cephalometric standards, and that gests a harsh and masculine appearance. This led to the design in Asia. An acute gonial angle can be corrected by mandible tation is performed using PTFE (Gore-Tex®), silicone or poly- strict adherence to cephalometric standards does not lead to of procedures for aesthetic contouring of the mandible. The angle ostectomy (bone removal). Mandible angle reduction ethylene (Medpor) implants. Since this procedure can result either harmonious or more beautiful faces. Despite these con- square facial appearance in Asians is not only due to masse- results in a narrower bigonial distance. Moreover, the lateral in inflammation or chronic infection, patients should be troversies, cephalometric analysis has been the standard tool teric hypertrophy but also to a posterior projection and lateral flaring in frontal view can be corrected with external corti- informed preoperatively. Microfat grafts with the Coleman for analysis of facial growth and orthognathic surgery. flaring of the mandibular angle. In 1989, Baek et al. reported cotomy and angle reduction. If, in addition, a patient has technique may also be used for paranasal augmentation. McNamara et al. reported a study of the lateral profile of 60 the mandible angle ostectomy in 42 Asian patients.89 In 1994, masseteric hypertrophy, it can be corrected with Botox injec- Koreans and 42 European–American adults with normal technical refinements were reported,5 which classified the tion, but only with temporary effects. Thus, an alternative in Alar base surgery occlusion.80 Their study showed that the Koreans had a lower prominent mandible angle according to the anatomic type of such patients is to combine an osseous mandibular angle angle of nasal inclination and a higher degree of lip protru- mandibular angle: lateral bulging in frontal view and poster- reduction and resection of the masseter muscle. These com- Many Asians are also concerned about the width of their nasal sion, whereas the slope of the forehead did not differ signifi- oinferior projection in lateral view, or a combination of these bined procedures are still controversial. base. The very real risk of visible scarring must be carefully cantly. Dentoalveolar protrusion is another characteristic of types. Curved and/or tangential osteotomy of the lateral discussed with the patient before proceeding with any modi- Asian people. Thus, many of orthognathic procedures in Asia flaring was performed based on the category. Mandible con- Zygoma fication of the alar base. are done to setback of dentoalveolar complex and maxillo- touring surgery could be performed with an oscillating saw, mandibular complex.81 and multiple mandible angle ostectomy was found to result Most Asian people have prominent cheekbones. Prominent Genioplasty Anthropometry, a method by which direct measurements in a smoother contour of the mandible angle postoperatively. cheekbones are considered attractive in Western women. This are taken on live subjects, offers numerous advantages: these In 1994, Kyutoku et al. invented the gonial angle stripper for is not true in eastern societies, where prominent cheekbones As in Caucasian patients, chin projection should always be 90 considered in relation to nasal tip projection and the overall measurements are easy to take, noninvasive, and inexpensive, treatment of prominent gonial angle. Satoh reported man- are indicative of strength and considered undesirable in as well as being suitable for a wide variety of purposes. In dibular contouring surgery by angular contouring combined Asian women. Thus, most Asian women want less prominent profile of the face. Osseous genioplasty or augmentation gen- 91 ioplasty with alloplastic materials are both successful in Asian order to be meaningful, there must be an adequate number with genioplasty in orientals. In 1997, Deguchi et al. reported zygomas. However, in performing zygoma reduction surgery, patients. of subjects representing all ethnic groups and different social angle-splitting ostectomy for reducing the width of the lower the bitemporal widths should be considered. Overcorrected backgrounds. In addition, well-trained examiners should face.92 In 2005, Gui and colleagues reported intraoral one- zygoma widths can result in an unnatural appearance, remov- use sophisticated measurement tools. Honn and Goz used this stage curved osteotomy in 407 cases.93 Among the methods ing the soft contour of the face. Moreover, the anterior part of method to investigate differences between female Korean- described to reduce the bigonial width were external corti- the zygoma should be preserved in most patients. Without Asian facial bone surgery Americans and Caucasian–Americans.75 cotomy with a sagittal split which involved removal of the this protrusion, patients tend to look older. Therefore, to pre- The above discussion suggests that there is no perfect way external cortex of the mandibular ramus, thus reducing the serve a youthful appearance, only the anterolateral and lateral Introduction to define beauty. Therefore, it would be wise to use the both bigonial angle. Han and Kim reported reduction mandibulo- parts of the zygoma should be reduced. subjective and objective tools for analysis of facial profiles plasty, which he described as ostectomy of the lateral cortex Although the standards of facial beauty have changed according to the ethnic standards. around mandibular angle.94 Lo et al. showed the high satisfac- Chin over time, certain features remain constant. Many studies have tion rates after zygoma and mandible reduction surgery in shown that symmetry and averageness could be the overall History outcome assessments. He also showed the significant volume Genioplasty in Asian people, either for setback or advance- standards for beauty profiles.74 Throughout history, humans change in osseous mandible and masseter muscle after the ment, is a similar procedure to that in Caucasians. Recently, a have attempted to define beauty objectively. Beauty can be Malar reduction mandibular contouring surgery.95 Hong and colleagues three- narrowing genioplasty has been introduced in Korea. This is measured by various methods, including artistic standards, dimensionally analyzed the relationship among lower facial often done in conjunction with mandible angle reduction. cephalometric standards and anthropometric analysis.75 Reduction malarplasty, first reported at 1983 by Onizuka width, bony width, and masseter muscle volume in promi- Park reported the narrowing genioplasty, either as a single By using the golden ratio, Leonardo Da Vinci employed and colleagues, was based on underpositioning of the osteo- nent mandible angles.96 Long curved osteotomy was recently procedure or in combination with mandible reduction, making artistic standards to try and explain facial beauty tomized zygoma through an intraoral approach.82 In 1988, introduced in Korea to reduce the mandibular body as well the lower face appear slender and produces a more feminine Asian facial bone surgery 179 180 SECTION I • 10 • Asian facial cosmetic surgery chin contour. Trapezoid or broad chins can be reduced by narrowing genioplasty. Dentoalveolar protrusion Anterior segmental setback ostectomy (ASO) is indicated in Asians with bimaxillary protrusions. Many Asian people have a tendency towards dentoalveolar protrusion, which may require orthodontic treatment or ASO. The latter procedure, External corticotomy however, should be limited to patients with large protrusions. Mild dentoalveolar protrusion might be better treated with orthodontic treatment alone. Excessive dentoalveolar setback with ASO can result in an unnatural appearance in Asians. A Facial profiles Orthognathic surgery was originally designed to correct den- tofacial deformities in patients with angle classification II or III. In Asia, the indications for orthognathic surgery have recently been extended to patients with almost normal occlu- Long-curved ostectomy and narrowing genioplasty sion and mild skeletal dentofacial disharmony. Although standard protocols have not yet been defined, orthognathic A B surgery has been found to change the facial proportions more ideally and reduce the size of the face. Since many Asian Fig. 10.21 (A,B) Prominent mandible angle: mandible angle ostectomy and external corticotomy with microfat graft in older ages. people have a mild skeletal class III pattern, many orthog- B nathic surgery procedures in Asia involve class III corrections. Moreover, recent trends in facial bone surgery in Asia include the reduction of the facial contour, making it smaller than Asian average. In 2006, Jin et al. showed that orthognathic surgery for correction of occlusal class I in skeletal class III cases is effective in some patients. This report showed that it is possible to enhance the aesthetic outcome in this subset Multiple ostectomy of Asians by changing skeletal characteristics so that the facial measurements more closely approach normal values.98 However, the indications for orthognathic surgery in this C group of patients remain controversial.

Fig. 10.20 (A–C) Various methods for mandibular reduction. Surgical techniques and treatments L-shape Infracture Superior ostectomy technique repositioning Facial contouring surgery Mandible angle ostectomy (Figs 10.20, 10.21) on the mandible body area. If not, patients may complain of A B C Traditionally, mandible angle ostectomy has been performed irregular mandibular contours postoperatively. Three differ- ent ostectomy patterns may be performed: Fig. 10.22 (A–C) Various methods for malar reduction. (A) Typical L-shape ostectomy. (B) Green stick fracture. (C) Superior repositioning of malar complex via the with an oscillating saw. An external approach was previously bicoronal approach. used because it allowed direct access to the mandibular angle. • Curved ostectomy with an oscillating saw: This procedure However, this procedure is now usually performed using an is indicated in most patients with prominent mandible intraoral approach. In the latter, meticulous subperiosteal dis- angles. It especially helps in reducing posteroinferior first of which is soft tissue ptosis. Wide periosteal dissection section is important to minimize bleeding and postoperative flaring in the lateral view. Malar reduction surgery involves detachment of the zygomatico-cutaneous ligaments. edema. Mandible angle ostectomy with an oscillating saw • Tangential ostectomy with a reciprocating saw: With this Malar reduction (Fig. 10.22) was first performed in the early Postoperatively, soft tissue tends to displace downwards. requires the somewhat blind removal of the mandible angle procedure, the external cortex of the mandibular ramus 1980s to reduce the bizygomatic width. While the malar The implication is that minimal dissection over the maxilla is area. In patients with inwardly curved angles, ostectomy may is removed. Tangential ostectomy is performed to narrow complex can be approached through intraoral, bicoronal, or preferred. The second pitfall is nonunion. With the intraoral be facilitated by burring on the ramus area or by the use of the bigonial distance in mandibles with lateral flaring in preauricular incisions, the intraoral approach is often pre- approach, high fixation of the zygomatic segments is not easy. indirect mirrors. Important anatomical structures must be the frontal view. This procedure alone, however, may not ferred. This approach to malar reduction begins with an oral The masseteric power is quite great so postoperative down- respected. In women, the average distances of the inferior make the lateral contour smooth.100 incision and subperiosteal dissection. The osteotomy line is ward displacement of the zygomatic bone may occur. Without alveolar nerve from the mandibular angle are 23.69 mm for • Long-curved ostectomy: This procedure is indicated in usually between the most concave line to the maxillary but- bone union, the masseter muscle tends to displace the zygo- square faces versus 20.66 mm for normal faces. In men, these patients with a prominent mandible angle and wide tress, but may vary according to the preference of the surgeon. matic complex. These problems may be overcome by using a distances are 27.30 mm and 23.28 mm, respectively.99 During mandibular body. Simultaneous reduction of the A higher position on the upper osteotomy site can result bicoronal approach, an infracture technique with incomplete this procedure, the facial artery and the retromandibular vein mandibular angle and body can result in a much in greater malar reduction. Exposure of the maxillary sinus osteotomy, or by minimizing dissection during malar reduc- are the most vulnerable vessels and should therefore be smaller lower facial contour. Recently in Korea, this does not usually lead to infection, but avoiding an excessive tion. For osteotomy of the zygomatic arch, a small incision avoided. Following ostectomy, the secondary angle should procedure is often performed along with narrowing anterior osteotomy is important in order to achieve good around the hairline is usually made, allowing for use of a also be manipulated by burring or doing multiple ostectomies genioplasty. bony contact. Intraoral malar reduction has some pitfalls, the reciprocating saw or a small osteotome. Use of the former may Asian facial bone surgery 181 182 SECTION I • 10 • Asian facial cosmetic surgery sometimes involve a temporal approach with a small incision. and postoperative orthodontic treatment is mandatory to Some surgeons perform intraoral osteotomy on the zygomatic obtain predictable results. arch area without making any incision on the preauricular area. The optimal procedure for malar reduction in Asians Outcomes, prognosis, and complications has not been determined, but may depend primarily on each patient’s condition and the surgeon’s preferences Zygoma reduction (Fig. 10.22). Possible approaches to malar reduction include PP the following. Intraoperative complications are rare. However, long-term PP complications include drooping of cheek tissues and malar Intraoral L-shaped ostectomy bone nonunion. Excessive wide dissection can release the This is the traditional method of malar reduction (Fig. zygomatico-cutaneous ligaments leading to soft tissue ptosis. 10.22A). Segmental resection of the malar bone decreases Poor fixation of the osteotomy can lead to nonunion. the bizygomatic width and often results in an unnatural Unfortunately, intraoral fixation of the malar complex in the appearance. superior-medial direction is not easy. The bicoronal approach can solve this problem by providing access for secure fixation. Intraoral infracture technique with incomplete osteotomy PP Alternatively, an infracture technique with a green stick frac- To overcome the limits of intraoral malar reduction, this pro- ture can be done. Finally, in order to minimize complications, cedure may be useful (Figs 10.22B). Infracture with green stick less invasive approaches with minimal dissection are being fracture of the malar bone can minimize the incidence of post- introduced. operative soft tissue ptosis and malar nonunion. Additional burring is often needed to decrease the bony step in the malar Mandible angle reduction area. Also, secure zygomatic arch fixation may be needed. Many complications from mandible angle reduction have been Bicoronal approach reported.101 The most critical complications include the condyle Narrowing genioplasty For purely aesthetic reasons, this procedure is not well- fracture caused by a wayward osteotomy, massive bleeding accepted. However, in complicated cases, malar reduction via Fig. 10.23 Narrowing genioplasty for the correction of the chin width. from the retromandibular vein or facial vessels and damage to bicoronal approach can give the best results in fixation and the mental nerve. During angle reduction, precise ostectomy precise correction of the malar complex. This approach may around the mandible posterior border is important in order to be advantageous in middle age or older patients because a Fig. 10.24 Two jaw rotational setback. avoid a condylar fracture. When using the oscillating saw, forehead lift can be done simultaneously without additional mandibular prognathism in class III dentofacial deformities. adequate periosteal dissection is needed to allow visualization incisions. However, many Asian patients have a varying degree of den- of the posterior mandibular border. If the retromandibular toalveolar protrusion which makes the Asian face look differ- vein is torn during the procedure, direct coagulation or other Narrowing genioplasty ent from their Caucasian counterparts. In Asians, the maxillary means of hemostasis is not easy. Therefore, manual compres- advancement procedures may sometimes cause the aggrava- sion for at least for 30 min can help. The facial artery is some- Narrowing genioplasty (Fig. 10.23), either as a single proce- tion of dentoalveolar protrusion or widening of alar base, times injured during periosteal dissections. This problem can dure or in combination with mandible reduction, makes the both of which would be detrimental to their facial appearance. be addressed by manual compression or direct ligation of lower face appear slender and produces a more feminine chin Moreover, Asian females tend to have a flat occlusal plane and vessel. Fortunately, damage to the facial nerve is rare. contour. Soft tissue attachment of the chin is maintained to a prominent mandibular angle which results in a square produce a maximum narrowing effect and maintain the blood appearance. For these reasons, a posterior maxillary impac- flow to bony segments. Horizontal osteotomy and two verti- tion without any maxillary advan cement would be the pre- cal osteotomies are designed as shown in figure. The amount ferable in some Asian class III patients (Figs 10.24–10.27). of resection in the central segment is determined preopera- However, caution must be exercised because excessive poste- tively, depending on the width of chin and the patient’s desire. rior impaction of maxilla along with the mandibular set back The two segments are approximated centrally and fixed with may impair the airway or change the shape of the smile. microplates and screws. Advancement of the two segments is In some cases, total maxillary setback is needed for simul- also possible if correction of the profile is required. The resec- taneous correction of a dentoalveolar protrusion. The vascular tion of the central strip has ranged from 6 to 12 mm. plexus should be avoided during this procedure and the total amount of total maxillary setback is limited compared to that Orthognathic surgery and anterior with ASO (Fig. 10.27). segmental ostectomy Lip and chin profiles differ considerably between Asian and Bimaxillary protrusion: anterior segmental Western populations. Asians tend to have bimaxillary protru- setback ostectomy sion and a class III skeletal pattern, which have made ASO This procedure is designed to osteotomize the anterior por- setback and class III correction with orthognathic surgery tions of the Lefort I segment and mandible and move them quite popular in Asian countries. posteriorly. Preoperatively or intraoperatively, the first or second premolar is extracted for ASO setback. For anterior A B Orthognathic surgery: jaw rotation segmental ostectomy of the maxilla, two different pedicles can The standard approach in management of class III dentofacial be used, with the palatal pedicle commonly used with the Fig. 10.25 (A,B) Preoperative and postoperative lateral cephalometry. The lateral cephalometry shows the rotational movements of maxilla and mandibular complex (MMC). deformity in Caucasian patients is simultaneous maxillary buccal approach. This approach provides improved exposure In these cases, the maxillary advancement procedures may cause aggravation of dentoalveolar protrusion or widening of alar base and these changes are harmful to the advancement and mandibular setback. This procedure is and easier performance of surgery. During these procedures, aesthetics of Asian face. Moreover, Asian females tend to have a flat occlusal plane and a prominent mandibular angle which causes their faces to look square. For these indicated when maxillary hypoplasia exists relative to care must be taken to preserve the palatal mucosa. Preoperative reasons, a large amount of posterior maxillary impaction without any maxillary advancement would be the preferable in Asian class III patients. Asian facial bone surgery 183 References 183.e1

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Yang DB, Park CG. Infracture technique for the 98. Jin H, Kim BH, Woo YJ. Three-dimensional mandible 48. Lee SH, Yang TY, Han GS, et al. Analysis of the nasal Surg. 2008;60(6):600–603. zygomatic body and arch reduction. Aesthetic Plast reduction: correction of occlusal class I in skeletal class bone and nasal pyramid by three-dimensional 67. Han K, Jin HS, Choi TH, et al. A biomechanical Surg. 1992;16(4):355–363. III cases. Aesthetic Plast Surg. 2006;30(5):553–559. computed tomography. Eur Arch Otorhinolaryngol. comparison of vertical figure-of-eight locking suture 86. Satoh K, Watanabe K. Correction of prominent 99. Lo LJ, Wong FH, Chen YR. The position of the inferior 2008;265(4):421–424. for septal extension grafts. J Plast Reconstr Aesthet Surg. zygomata by tripod osteotomy of the malar bone. Ann alveolar nerve at the mandibular angle: an anatomic 49. Dhong ES, Han SK, Lee CH, et al. Anthropometric 2010;63(2):265–269. Plast Surg. 1993;31(5):462–466. consideration for aesthetic mandibular angle reduction. Ann Plast Surg. 2004;53(1):50–55. study of alar cartilage in Asians. Ann Plast Surg. 68. Kim JS, Han KH, Choi TH, et al. Correction of the 87. Cho BC. Reduction malarplasty using osteotomy and 2002;48(4):386–391. nasal tip and columella in Koreans by a complete repositioning of the malar complex: clinical review 100. Jin H, Park SH, Kim BH. Sagittal split ramus 50. Han SK, Lee DG, Kim JB, et al. An anatomic study septal extension graft using an extensive harvesting and comparison of two techniques. J Craniofac Surg. osteotomy with mandible reduction. Plast Reconstr of nasal tip supporting structures. Ann Plast Surg. technique. J Plast Reconstr Aesthet Surg. 2007;60(2): 2003;14(3):383–392. Surg. 2007;119(2):662–669. 163–170. 2004;52(2):134–139. 88. Baek RM, Lee SW. Face lift with reposition malarplasty. New concept of mandible angle ostectomy. 51. Khoo BC. Augmentation rhinoplasty in the Orientals. 69. Byrd HS, Salomon J, Flood J. Correction of the Plast Reconstr Surg. 2009;123(2):701–708. 101. Hwang K, Han JY, Kil MS, et al. Treatment of condyle Plast Reconstr Surg. 1964;34:81–88. crooked nose. Plast Reconstr Surg. 1998;102(6): fracture caused by mandibular angle ostectomy. 2148–2157. 89. Baek SM, Kim SS, Bindiger A. The prominent 52. McCurdy JA Jr. Aesthetic rhinoplasty in the non- mandibular angle: preoperative management, J Craniofac Surg. 2002;13(5):709–712. Caucasian. J Dermatol Surg Oncol. 1986;12(1):38–44. 70. Jung DH, Moon HJ, Choi SH, et al. Secondary operative technique, and results in 42 patients. Plast rhinoplasty of the Asian nose: correction of the Reconstr Surg. 1989;83(2):272–280. 53. Parsa FD. Nasal augmentation with split calvarial contracted nose. Aesthetic Plast Surg. 2004;28(1):1–7. grafts in Orientals. Plast Reconstr Surg. 1991;87(2): The pioneer article for Asian mandible angle ostectomy. 245–253. 71. Paik M. Correction of short nose. J Korean Soc Aesthet Plast Surg. 2005;11(1):22. 54. Shin KS, Lee CH. Columella lengthening in nasal tip plasty of Orientals. Plast Reconstr Surg. 1994;94(3): 72. Lee Y, Kim J, Lee E. Lengthening of the postoperative 446–453. short nose: combined use of a gull-wing concha composite graft and a rib costochondral dorsal onlay 55. Watanabe K. New ideas to improve the shape of graft. Plast Reconstr Surg. 2000;105(6):2190–2201. the ala of the Oriental nose. Aesthetic Plast Surg. 1994;18(4):337–344. 73. Wong JK. Forehead Augmentation with Alloplastic Implants. Facial Plast Surg Clin North Am. 56. Han K, Kang J. A custom-made nasal implant: 2010;18(1):71–77. prefabrication from curing of silicone adhesive. Plast Reconstr Surg. 1996;97(2):436–444. 74. Rhodes G, Yoshikawa S, Clark A, et al. Attractiveness of facial averageness and symmetry in non-western SECTION I Aesthetic Surgery of the Face History 184.e1

preauricular, postauricular, and mastoid area incision. With History modifications, his incision is essentially that used for facial- plasty today. Hunt25 published a book, Plastic Surgery of the Facelift surgery dates from the early part of the 20th century. Head, Face and Neck, that included facelifting and forehead/ Its colorful history has been thoroughly reviewed by Stuzin,1 browlifting operations. whose summary is reproduced here. All the early facialplasty procedures were limited to skin In the past, the history of aesthetic facial surgery has been excision and wound closure without subcutaneous under- 11.1 reported by a number of authors, including: Rogers,2,3 Rees mining. Bames26 described subcutaneous face and neck under- and Wood-Smith,4 Gonzalez-Ulloa,5 Rees6 and Barton.7,8 mining, skin redraping, and excision of excess skin. The There is still doubt as to who performed the first facelift, continuous incision described by Bettman24 and subcutaneous but most sources date it to the first decade of the 20th undermining recommended by Bames26 essentially estab- Facelift: Principles century.3,9,10 According to Rogers,3 Hollander11 reported in a lished the basic facelift procedure for the next 40 years. As chapter entitled “Cosmetic Surgery” in Handbuch der Kosmetik discussed by Rees,6 a great deal of secrecy surrounded early that “as a victim of the art of feminine persuasion,” he removed facelift procedures. Surgeons were reluctant to share their pieces of skin at the margins of the hairline and in the natural techniques because of professional jealousy and greed. The Richard J. Warren aging skinfolds of a woman to freshen up “her wrinkles and disdain for “vanity” surgery by both the medical profession drooping cheeks”. In this chapter, Hollander did not date the and the public restricted most facelift procedures to private procedure, but in 1932 he stated that his original procedure offices and small clinics. The extent of surgery in such settings had been performed in 1901 for a Polish aristocrat.12 Lexer,10 was necessarily limited. Many prominent plastic surgeons in however, reported in 1931 that he had performed a facelift for major medical centers were forced to perform their facelifts in an actress in 1906 and that he was unaware of any such opera- small clinics or to hide their cases by misnaming the proce- tion before that date. Joseph9 reported in 1921 that he had dures on the operating schedule. Renowned plastic surgeons facialplasty, although in this text, the more common term, SYNOPSIS performed an operation in 1912 for correction of aging cheek after the First and Second World Wars, such as Gillies, Blair, “facelift” will be used. tissues in a 48-year-old woman. By the time Hollander, Lexer, Davis, Pierce, McIndoe, Mowlem, Conway, and others, did a ᭿ Age-related changes occur in all layers of the face, including skin, Facelift surgery was originally conceived as a method of and Joseph reported their first procedures, a number of other great deal of cosmetic surgery but were reluctant to publish superficial fat, SMAS, deep fat, and bone. placing traction on the aging face by excising skin in the prominent surgeons in Europe, such as Noel, Passot, Morestin, on the subject.6 The conventional facelift operation (skin dis- ᭿ Patients presenting for facial rejuvenation surgery are usually periphery of the face and closing the resulting defect under Bourguet, and Lagarde, were busy performing cosmetic surgi- section only) failed to address the effect of aging and the force middle aged or older, thus increasing the chance of underlying tension. Since that simple beginning over 100 years ago, the cal procedures. In the United States, Miller and Kolle had of gravity on the structures (e.g. muscle, fat, and superficial medical problems. Risk factors such as hypertension and smoking procedure has evolved to encompass a wide range of tech- large cosmetic surgery practices. Passot13 in 1919 published an fascia) deep to the skin. Likewise, the classic skin dissection should be dealt with prior to facelift surgery. niques which lift, augment, and rearrange facial tissues in an illustrated article showing sites of elliptic skin excision of the facialplasty failed to account for the wide variation in facial, attempt to rejuvenate the aging face. ᭿ A careful preoperative assessment will provide the surgeon with an hairline, the forehead, and the temporal and preauricular jaw line, and cervical deformities; in the location of fat depos- Despite the development of many less invasive technolo- aesthetic diagnosis regarding the underlying facial shape, the age areas to tighten the skin and an elliptic excision of skin and its; in the asymmetry of anatomic structures; and in the geneti- gies, nothing can match a facelift in its ability to globally treat 14 related issues which predominate and the appropriate surgical fat to reduce submental fat deposits. Bourguet reported cally determined deformities, such as microgenia and the the face, returning its basic architecture to a more youthful procedures for every individual patient. elliptic skin excisions similar to those of Passot. He was the obtuse cervicomental angle. configuration. 27 ᭿ Almost all facelift techniques begin with a subcutaneous facelift first to report fat excisions to correct herniated periorbital fat Aufricht discussed the limitations of the subcutaneous 15 flap. Careful incision placement, tissue handling, and flap pads (1924) and to publish preoperative and postoperative facelift, particularly its failure to correct submental fat depos- 16 28 repositioning are important in order to avoid the obvious stigmata photographs of fat pad excision (1925). Noel published a its and platysma bands. Adamson and colleagues discussed 17 of facelift surgery. Anatomy and patient presentation book in 1926, La Chirurgie Esthetique: Son Role Social, describ- correction of the platysma bands in the submental area, and 29 ᭿ ing facialplasty, blepharoplasty, forehead lifting, and correc- Millard and co-workers recommended extensive submental Volume augmentation, and in some locations volume reduction, 30 31 should be considered in all cases of facelift surgery. The classic stigmata of the aging face include: tion of loose skin of the neck, burns, scars, protruding ears, defatting. Pennisi and Capozzi and Baker and Gordon ᭿ • Visible changes in skin, including folds, wrinkles, and laxity of the upper arms. Although her procedures were described suture plication of the deep tissues of the cheek and Facial aging is usually a pan-facial phenomenon. Therefore, in 32 order to obtain a harmonious result, patients will often benefit from dyschromias, dryness and thinning not aggressive by modern standards, Noel was a true master lateral neck. Tipton challenged the deep suture techniques surgery to other components of their face. • Folds in the skin and subcutaneous tissue created of that era. in a study of 33 patients in whom he performed unilateral Miller18 published the first book in medical history devoted plication. Two years postoperatively, there was no obvious ᭿ The most common complication of facelift surgery is hematoma. by chronic muscle contraction: glabellar frown lines, 33,34 entirely to the subject of cosmetic surgery. Miller was described difference in the two sides of the face. Skoog described a This problem should be dealt with promptly. transverse forehead lines, and crow’s feet over the lateral 3 orbital rim. by Rogers as a “quack” on one hand and at the same time, technique of dissection of the superficial fascial layer in the “a surgical visionary years ahead of his academic colleagues face, in continuity with the platysma muscle in the neck and • Deepening folds between adjoining anatomic units: … medicine’s first truly cosmetic surgeon.” Miller was a pro- advancement of the myofascial unit in a cephaloposterior Access the Historical Perspective section online at the nasojugular fold (tear trough), nasolabial folds, lific writer. In 1906, he wrote the first article in the medical direction. This was the beginning of the modern era in facelift- http://www.expertconsult.com marionette lines and submental crease literature describing an attempt to remove excess skin from ing. Mitz and Peyronie35 used cadaver dissections to define • Ptosis of soft tissue, particularly in the lower cheek, jowls the eyelids.19 In 1907, he published the first article with a the limits of the superficial musculoaponeurotic system and neck photograph illustrating lower eyelid incisions,20 and he also (SMAS) in the face and noted that tightening of this layer • Loss of volume in the upper two-thirds of the face which published three cosmetic surgery textbooks.18,21,22 Kolle was would be beneficial in facialplasty. SMAS-platysma facelift- Introduction creates hollowing of the temple, the lateral cheek and the born in Germany and practiced in New York. His book Plastic ing, wide skin undermining, and extensive fat removal soon central cheek. The result is a more skeletal appearance in and Cosmetic Surgery23 represented the second description of gained worldwide popularity. Surgery of the tissue layers A complete discussion of facial rejuvenation would involve the temple, the periorbita and the malar region cosmetic surgery in medical history. The book was more than deep to the skin of the face and neck is now established as an the periorbital region, forehead, cheek, neck, and perioral • Expansion of volume in the neck and lateral jaw line 500 pages in length and contained hundreds of illustrations, essential part of cervical and facialplasty operations. Many region. (The periorbital zone is reviewed in Chapter 8 and which leads to the formation of jowls and fullness of the including preoperative and postoperative photographs of surgeons have described different SMAS-platysma techniques the forehead in Chapter 7.) In this chapter, we will be dealing neck (Fig. 11.1.1). protruding ears; it took a rather aggressive surgical approach to improve the cervicofacial area and to remedy problems not with the middle and lower thirds of the face – the cheek The driving force behind our ability to explain these many to the correction of excess skin of the eyelids. Bettman24 was corrected by conventional facialplasty.36–44 Furnas,45 in 1989, and neck. Terminology for procedures which address these changes has been an improved understanding of facial the first to publish preoperative and postoperative facelift described the retaining ligaments of the midface, which led to areas include rhytidectomy, rhytidoplasty, meloplasty and anatomy and the way this anatomy changes over time. Aging photographs and to describe a continuous temporal scalp, a better understanding of anatomic areas where facial soft ©2013, Elsevier Inc. All rights reserved. 184.e2 SECTION I •11.1• Facelift: Principles Anatomy and patient presentation 185 tissue is supported and the involvement of these ligaments in release in sub-SMAS dissection,47–56 the primary goal of these leading to the anatomic changes that occur with aging. These procedures being to reposition descended facial fat to the ligaments were further defined by others46,47 who thought that anatomic location of youth. Other surgeons, preferring sub- loss of the support from the retaining ligament system allowed periosteal rather than sub-SMAS dissection to reposition facial fat to descend inferiorly in the face, deepening the fat, developed procedures whose similar goal is to resuspend nasolabial fold and forming facial jowls with aging. The descended malar fat to the malar eminences using the sub- importance and location of the retaining ligaments led to periosteal plane.57–59 A combination of subperiosteal and 60 modifications in procedures involving retaining ligament subcutaneous lifting has also been described. Transverse forehead creases Frontalis contraction Temporal wasting Temporal fat pad atrophy

Upper lid sulcus hollowing Lateral brow ptosis Crow’s feet Obicularis contracture Lower lid laxity Obicularis oculi laxity Tear trough Loss of midface fat Midface flattening Cheek descent Malar fat descent Nasolabial folds Elongating upper lip Thinning lips Peri oral wrinkles Marionette lines Buccal fat pad ptosis Expansion and ptosis of jowl fat Jowls

Excess preplatysmal and subplatysmal fat Transverse neck folds Platysma bands Platysma muscle laxity Vertical neck pleats

Figure 11.1.1 The aging face exhibits changes in the skin, superficial wrinkles, deeper folds, soft tissue ptosis, loss of volume in the upper third and middle third and increased volume in the lower third.

of the face occurs in all its layers, from skin down to bone; no branch of the transverse facial artery. Changes in the skin tissue is spared. For the purposes of this discussion, the face of the face are some of the most obvious signs of aging. will be viewed as a five-layer structure as described in Chapter Skin aging over time is both intrinsic and extrinsic. Intrinsic 6: skin, subcutaneous fat, the superficial musculoaponeurotic aging is the result of genetically determined apoptosis. The system (SMAS) and muscles of facial expression, fascial skin becomes thinner; there is a decrease in melanocytes, a spaces, and deep fascia. Underlying everything is bone, except reduced number of fibroblasts and a loss of skin appendages. over the oral cavity. The surgical significance of this concentric In the dermal matrix, there is fragmentation of the dermal layer arrangement is that dissection can be done in the planes collagen and impairment of fibroblast function.61,62 As the skin between the layers. Also, anatomical changes in each of the weakens and thins, the underlying contraction of facial layers can be addressed independently, as required to treat muscles creates permanent skin folds in predictable locations the presenting problem. (see Fig 11.1.5). Extrinsic forces include sun exposure, cigarette smoke, extreme temperatures and weight fluctuations. The net result Skin is that facial skin loses its ability to recoil, a condition called elastosis. This has surgical implications, because firm tight Normal skin is directly adherent to underlying fat via the skin is youthful, and to varying degrees, the tightening of retinacular cutis system. In certain predictable areas the skin loose facial skin is part of a good surgical result. However, a is tethered to bone or underlying muscle by condensed areas facelift does not appreciably improve the quality or texture of of connective tissue. In some places, these are string-like cuta- the skin. Therefore, patients with good quality skin are likely neous ligaments, and in other areas, these are ribbon-like to enjoy a better result from facelift surgery than the patient septae. Because nerves and vessels often reach the skin adja- with poor quality skin. Alternatively, when skin quality is cent to these vertically running fibrous structures, dissection poor, other options such as injectable fillers and skin resurfac- of skin is more difficult and bloody where the skin is tethered; ing may be more important for rejuvenation than facelift McGregor’s patch is such an area because of its association surgery. In most cases of facial rejuvenation, medical and sur- with the zygomatic cutaneous ligaments and a perforating gical therapies can work in concert for a more complete result. 186 SECTION I •11.1• Facelift: Principles Anatomy and patient presentation 187

(These complementary therapies are reviewed in Chapters 4 and 5.)

Facial fat: ptosis, volume loss and volume gain

The face is carpeted in a layer of superficial fat which lies immediately deep to the dermis. Between individuals, there is much variability in the thickness of the superficial fat layer. This has surgical implications, because a heavier patient will have thicker, heavier tissues to reposition, but the dissection of the facelift skin flap will be easier. Conversely in a thin patient, facial layers are packed closely together, like an onion, necessitating greater care if the surgeon wishes to separate skin from SMAS and SMAS from underlying structures. Superficial facial fat also varies in thickness depending on the area of the face. The most important area of thickened subcu- Medial taneous fat is the malar fat pad.54 This is a triangular shaped Middle mass of fat bordered by the nasolabial fold, the infraorbital Orbicularis oculi arch and a diagonal line across the mid-cheek. Its apex is over the malar eminence. The malar fat pad is present throughout life (Fig. 11.1.2). Zygomaticus major One study looked at fat volume in the cheek area and Nasolabial found 56% of the fat superficial to the SMAS and 44% was 63 deep to the SMAS and the muscles of facial expression. The Malar fat pad superficial fat is separated by vertical septae into five distinct compartments: nasolabial, medial cheek, middle cheek, lateral Lateral temporoparietal, and the inferior orbital fat (Fig. 11.1.3A).64 The two central fat compartments (medial and middle) are A the primary components of the Malar Fat Pad. The deep fat is also divided into compartments (Fig. 11.1.3B). The most significant is the deep medial fat compart- ment, which lies directly against bone and is bordered above by the orbicularis retaining ligament, laterally by the zygo- maticus major and buccal fat pad and medially by the pyri- form aperture65 (Fig. 11.1.3C). The authors who identified this compartment propose that Figure 11.1.2 The malar fat pad is a triangular area of thickened superficial fat age related deflation of deep medial fat compartment leads with its base along the nasolabial fold, and its apex over the superolateral malar to “pseudoptosis” of the overlying superficial fat and skin – prominence. ptosis which is real, but which is caused by lack of underlying support.65 This in turn is thought to cause deepening of the nasolabial fold and development of the “inverted V deformity” inferior to the infraorbital rim.66 Adjacent and lateral to the deep zygoma. Simultaneously there is an apparent ptosis of the medial fat is the suborbicularis oculi fat (SOOF), which itself malar fat pad which causes bunching of fat and deepening is divided into a medial and lateral component. of the nasolabial fold. Surgeons have traditionally viewed Generally in youth, facial fat is tightly packed, creating superficial fat in the cheeks as a ptotic layer which requires surface contours which undulate smoothly from convexity to correction for facial rejuvenation to occur. In support of this concavity. Cosmetic highlights rise above areas of depression. theory, it has been demonstrated that the primary muscles of ORL SCS The malar fat pad which extends over the body of the zygoma facial expression in the mid-cheek (zygomaticus major and ORL creates the principle cosmetic highlight zone in the youthful minor) do not change in length, while the overlying fat SOOF face, immediately above the normal depression overlying the appears to migrate inferiorly.68 Another study, using CT scans, buccal recess. Make-up artists accentuate this zone by high- confirmed the presence of facial fat compartments and identi- lighting the apex and simulating a depression immediately fied age related inferior migration of the midfacial fat com- ZM below. In the aging face, fat is less tightly packed, and facial partments as well as inferior volume shift within the individual Figure 11.1.3 (A) Superficial contours become more abrupt. In areas of tight ligamentous compartments.68a facial fat is compartmentalized by attachment, such as the preparotid area, the anterior jowl At the time of writing, it is unclear whether the cause of vertically running septae. In the border and the zygomatic ligament insertions, there appears superficial fat ptosis is gravitational due to relaxed fixation, mid-cheek, from medial to lateral, these compartments are the to be an acceleration of volume loss with indenting of the or if it relates to pseudoptosis caused by the loss of volume nasolabial, medial, middle, and 67 surface contour. With more advanced aging, there is malar in the deep fat compartments. Also, it is uncertain whether Nasolabial Medial Middle Lateral lateral compartments. fat atrophy, leading to a more skeletal appearance of the volume of facial fat is lost equally from the deep and 188 SECTION I •11.1• Facelift: Principles Anatomy and patient presentation 189

Gradually, there is a reversal of facial shape as the cheek because it is used as a landmark in certain facelift techniques prominence of youth gives way to the jowl prominence of age. (Fig. 11.1.5). Effectively, in youth, the cheeks are full, but with age, the Most muscles of facial expression take their origins from jowls and neck become full. The face changes from a heart bone and insert into the dermis thus allowing for voluntary shape to a more rectangular shape, or from an egg sitting on and involuntary movement of facial soft tissues. The platysma its narrow end to an egg resting on its broad end. This change is a purely subcutaneous muscle which takes its origin from has been called losing the “inverted cone of youth”, and has the fascia of the pectoralis, and inserts into soft tissue of the been likened to a reversal of the “Ogee” curve, a natural face, with a small bony insertion on the anterior mandible. S-shaped curve seen in architecture.60,72 The platysma interdigitates with the depressor labii inferioris which in some individuals, gives it some effect on the depres- sion of the lower lip. In the neck the platysma is thicker, Superficial musculoaponeurotic system forming visible bands; superiorly the platysma thins dramati- cally as it crosses the mandibular border, but continues supe- Immediately deep to the subcutaneous fat is the superficial riorly, often visible during surgical dissection well into the musculoaponeurotic system (SMAS), described by Mitz and mid-cheek, at times approaching the lower fibers of the orbic- B C Peyronie in 1976.73 The SMAS, or its analogues can be thought ularis oculi. of as a continuous fascial sheath which encompasses the While most muscles of facial expression do not change entire face and neck. Superiorly, it continues into the temple Fig. 11.1.3, cont’d The nasolabial and medial compartments make up the malar fat pad. (B) The deep facial fat is also compartmentalized by septae. The deep medial fat appreciably with age, the orbicularis oculi and the platysma pad (here stained blue) is bounded above by the orbicularis retaining ligament, medially by the pyriform aperture, and laterally by the zygomaticus major (labeled ZM) as the superficial temporal fascia (temporoparietal fascia) and are thought to undergo age-related changes. Both of these muscle and the buccal fat pad (labeled B). (C) Over the body of the zygoma, the sub orbicularis oculi fat (SOOF) is deep fat. It is seen here with a medial portion (yellow) then into the scalp as the galea aponeurotica.74 Inferiorly, into muscles have a large surface area but are relatively thin – a and a lateral portion (stained blue). It is bounded medially by deep medial fat pad (stained red). (A, Courtesy of Rohrich RJ, Pessa JE. The fat compartments of the face: the neck, the SMAS becomes the superficial cervical fascia configuration which lends them to potential redundancy if anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227; B,C Courtesy of Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and which envelopes the platysma muscle. Clinically, the thick- the deep medial fat compartment. Plast Reconstr Surg. 2008;121(6):2107–2112). they lose tone or if there is attenuation of their deep tissue ness and strength of the SMAS varies between patients, and attachment. For example, in some individuals redundancy also varies in every individual face, being thicker and adher- develops in the lower half of the orbicularis, a condition ent over the parotid, and thinner anteriorly. The SMAS is most which has been speculated to cause lower eyelid festoons.77 tenuous under the malar fat pad where it splits to encompass Some have suggested that it is the loss of support of the the zygomaticus major and the orbicularis oculi.53,75 The SMAS orbicularis through attenuation of the orbicularis retaining has important surgical implications because its fibrous attach- ligament (orbitomalar ligament), which contributes to deform- ments to skin allow it to act as a carrier for overlying subcu- ities of the lower eyelid/cheek junction.66 Similarly, the paired taneous fat; also it has been shown to be much more resistant platysma muscles, which are encased by SMAS, appear to to stretch than skin.76 Furthermore, below the zygomatic arch, gradually fall away from their deep cervical attachment car- all branches of the facial nerve are deep to the SMAS. rying the overlying fat and skin. The net result is a more The relationship of the SMAS (superficial fascia of the obtuse cervico-mental angle and the development of visible face) to the deep fascial structures of the face, involves areas platysma bands at the anterior platysmal border. Another of mobility interspersed between areas of attachment. The issue common to orbicularis oculi and platysma is that these superficial fascia is tethered to the deep fascia by retaining are the only facial muscles which are undermined during ligaments in the following locations: over the parotid gland, certain surgical procedures, thus imperiling some of their at the inferior border of the zygomatic body, and along the motor innervation. Fortunately, the orbicularis has multiple anterior edge of the masseter. (These ligaments are described motor nerve branches which provide a level of collateral in Chapter 6 and are reviewed later in this chapter.) Between innervation.78 There is a less elaborate innervation to the areas of fixation the SMAS is free to move over the underly- platysma; two or three cervical branches can be identified just ing deep fascia. These are the suprazygomatic zone where inferior and anterior to the angle of the mandible in the plane superficial temporal fascia slides over the deep temporal between the deep cervical fascia and the undersurface of the fascia, the mid-cheek, where SMAS rides over the parotid platysma. Preservation of these branches is potentially impor- masseteric fascia (premasseteric space), and the neck where tant because the platysma acts as a support structure and also A B the platysma overlies the underlying strap muscles. influences lower lip depression, especially in those individu- als with a “full dentition” smile.79 Figure 11.1.4 This healthy 72-year-old woman has never undergone facial surgery, has gained 10 pounds, but has aged 50 years. She appears to have lost fat in the Facial muscles periorbital region and middle third of her face, revealing underlying bone. The orbit seems to have enlarged. Overall volume has been lost in the middle third of the face. The soft tissues which remain appear to be ptotic, flattening her cheeks, and widening her jaw line. The heart-shaped face of youth has become more rectangular. The muscles of facial expression are found in a superficial Retaining ligaments layer and a deep layer. The superficial muscles are orbicularis superficial fat layers, or if it lost equally or differentially from Change in facial shape oculi, orbicularis oris, zygomaticus major, zygomaticus minor, Facial soft tissue and skin is held in place by retaining liga- the various fat compartments which have been identified.65 levator labii superioris, risorius, and depressor anguli oris. All ments which run from underlying fixed structures through In the lower face, the area of the jowl just posterior to the The loss of facial volume is an important phenomenon which of these muscles are innervated on their deep surface by facial fat, inserting into the dermis.45,48,80 Effectively, these liga- marionette lines appears to become thicker with age, making surgeons recognized much later than the more obvious ptosis branches of the facial nerve (VII). Consequently, surgical dis- ments attach the superficial fascia (SMAS) and the overlying the mandible appear wider. This phenomenon has been called of soft tissue. To arrive at this conclusion, astute observations section on the superficial surface of these muscles will not skin to the underlying deep fascia and bone (Fig. 11.1.6). “radial expansion” (Lambros, pers. comm. 1999).69 This may were made about changes in surface contours which lead to endanger their innervation. The only facial muscles inner- There are two ligament systems. The first group is true be due to fat accumulation, or it may be caused by soft tissue inferences about internal volume loss.65,67,70,71 vated on their superficial surface are the muscles in the deep osteocutaneous ligaments, which tether skin to bone: the ptosis within the premasseteric space, a natural glide plane.69a The combination of volume loss in some areas, volume layer: levator anguli oris, mentalis and buccinator. The three orbital, zygomatic and the mandibular ligaments. The orbital Below the mandible, a similar expansion occurs in the neck gain in others, and soft tissue ptosis creates a cascade facial muscles which are most important to surgeons are ligament is found at the junction of the superior and lateral as soft tissue falls away from deep tissue attachments and fat effect which results in the loss of natural youthful curves orbicularis oculi and platysma, because they are often orbital rims and constitutes the inferior thickening of the tem- tends to accumulate. (Fig. 11.1.4). manipulated during facelift surgery, and zygomaticus major poral crest line zone of fixation (zone of adhesion). (This area 190 SECTION I •11.1• Facelift: Principles Anatomy and patient presentation 191

Galea aponeurotica

Frontalis Procerus Frontalis Superficial layer of deep Corrugator supercilii temporal fascia Temporal crest

Orbicularis oculi, orbital portion Upper edge of temporal fat Temporalis Orbicularis oculi, preseptal portion Orbicularis oculi, pretarsal portion Orbital ligament Obicularis oculi Nasalis Occipitalis Temporal fat pad Levator labii superioris alaeque nasi Levator labii superioris Nasalis Auricularis anterior Zygomatic ligaments Zygomaticus minor Tympanoparotid Zygomaticus major Zygomaticus major (Lore’s) fascia Zygomaticus minor Levator anguli oris Masseteric ligaments Masseter Platysma auricular fascia Buccinator Buccinator Depressor septi nasi Risorius Risorius Obicularis oris Sternocleidomastoid Depressor anguli oris Orbicularis oris Mentalis Depressor anguli oris Depressor labii inferioris Platysma Mentalis Mandibular ligament Platysma Figure 11.1.5 Muscles of facial expression. The solid lines demonstrate overlying skin creases caused by repeated contraction of the underlying muscles. (Netter illustration from www.netterimages.com. © Elsevier Inc. All rights reserved.) Figure 11.1.6 Facial soft tissue is tethered to underlying bone by the orbital, zygomatic and mandibular ligaments. Soft tissue is tethered to underlying deep fascia by the masseteric cutaneous ligaments and by an area of attachment anterior and inferior to the earlobe, known by a number of different terms: platysma auricular ligament (Furnas), platysma auricular ligament (Mendelson), parotid cutaneous ligament (Stuzin), and a distinct area anterior to the earlobe known as Lore’s fascia. is reviewed in Chapter 7.) The zygomatic ligament is actually the posterior border of the platysma, the superficial fascia is a group of ligaments which originate from the lower half of firmly attached to the deep fascia. A number of authors have the zygomatic body where it joins the zygomatic arch. The identified the importance of this area, and with some subtle zygomaticus major inserts into bone at this location. These differences, a number of different names have been applied volume which leads to ptosis, but the ligaments tether the ligaments stabilize the overlying malar fat pad, going through to the same soft tissue attachment: platysma-auricular fasica,81 skin, leading to depressions and grooves in the surface contour this structure to the overlying skin. In this area, a perforating platysma-auricular ligament,45 parotid cutaneous ligament,80 of the face. Examples of tethering include: the mid-cheek branch of the transverse facial artery courses from deep to and a localized area called Lore’s fascia.82,83 In this zone, the groove, caused by the zygomatic ligaments, the nasojugular superficial, contributing to the clinical bleeding seen when the SMAS and the overlying skin are tethered to such a degree groove, partly caused by the orbicularis retaining ligament zygomatic ligaments are released in this area during superfi- that soft tissue in this area does not become ptotic with age. (orbitomalar ligament) and the jowl/marionette line caused cial skin flap dissection (McGregor’s patch). A branch of the A prime surgical significance is that the “fixed SMAS” of the by the mandibular ligament.81–83,85 zygomaticofacial nerve also accompanies the ligaments in this posterior cheek can be used to support the surgically mobi- It is likely that both of these theories are in play – ptosis area, coursing directly from bone to skin providing sensation lized portion of the more anterior “mobile SMAS”. A number and deflation, although conclusive proof of how face age is to the skin of the malar cheek prominence. As described of facelift techniques depend on this concept (Fig. 11.1.7). not available at the time of this writing. Either way, the tether- in Chapter 6, the zygomatic ligaments constitute the lower The importance of retaining ligaments in the aging process ing structures play an important role in determining the way border of the prezygomatic space and must be released if the is potentially two-fold. One theory holds that with age, liga- a face will age. Furthermore, these same tethering structures malar fat pad is to be fully mobilized and elevated. The man- ments relax, leading to a gravitational shift of overlying can be manipulated during facelift surgery, depending on the dibular ligament is a short but strong structure originating superficial fat and skin. In youth, the superficial fat and skin specific indication. from the parasymphysial mandible, which tethers the overly- appear to be firmly adherent to underlying bone and deep ing skin and contributes to formation of the marionette lines. fascia, while with age the same soft tissue appears to become The second ligament system involves tethering structures ptotic. One area where this has been proposed is along the Deep fascia which do not originate from bone, but rather, tether the infraorbital rim, where the orbicularis retaining ligament may superficial fascia (SMAS) to the deep fascia. Along the ante- relax, leading to the V-deformity at the lid cheek junction.66,84–86 Figure 11.1.7 Mendelson’s interpretation of soft tissue attachments (Ch. 6). The The deepest layer of the face is the deep fascia, which covers rior border of the masseter, the masseteric ligaments extend Over the malar highlight area, the ligament relaxation theory fixed posterior soft tissue is held in place by the platysma auricular fascia (large deep muscles and overlies the oral cavity (Ch. 6). In the face, in a line from the zygoma down to the lower cheek.80 These suggests that the zygomatic ligaments become attenuated and red area). The anterior face is fixed by a vertical column of attachments: orbital this fascia is a continuation of the deep cervical fascia in the ligaments support the anterior cheek and are more clinically the malar fad pad becomes ptotic, causing a migration of fat ligament, lateral orbital thickening (superficial canthal tendon), zygomatic neck which covers the superficial surface of the strap muscles ligaments, masseteric ligaments, mandibular ligament). In the mid-cheek, there is significant superiorly, where they intermingle with the zygo- medially and inferiorly, deepening the nasolabial fold. some mobility of these ligaments, while there is limited mobility over the platysma and the sternocleidomastoid. The equivalent layer in the matic ligaments. The most superior fibers of the platysma can The second way that retaining ligaments become an issue auricular fascia. The so-called “fixed SMAS” is that portion attached to the parotid temple is the deep temporal fascia covering the temporalis. In also be seen terminating in the most superior masseteric liga- with aging is through their tethering effects. The concept of and the posterior border of the platysma. Anterior to this, is the “mobile SMAS”. the cheek, this fascia is found covering the masseter muscle, ments. Over the parotid gland with an extension down along “pseudoptosis” holds that it is primarily the loss of facial fat (Courtesy of Dr Levent Efe, CMI.) where it is called masseteric fascia, and covering the parotid 192 SECTION I •11.1• Facelift: Principles Patient selection 193

gland, where it is called the parotid fascia or capsule; the more superiorly. In Chapter 6, facial spaces are described, combined complex is called the parotid masseteric fascia with the mandibular branches coursing at the lower border of (parotidomasseteric fascia). When the SMAS is raised surgi- the premasseteric space, which displaces inferiorly with age. cally, just anterior to the parotid gland in the premasseteric Consequently, in elderly patients in the supine position, they space, the parotid masseteric fascia can be seen as a thin shiny have been found coursing well inferior to the mandibular membrane – an important landmark, because in the cheek border.102 (unlike the neck and temple), all branches of the facial nerve The cervical branches are the most inferior, exiting the are deep to this deep fascial layer. Superficial to this layer, but parotid at its inferior border and always coursing below deep to the SMAS, there is often an additional thin layer of the mandibular border. The cervical branches innervate the

fat, the sub – SMAS fat, which adds further protection to the platysma. There are usually two or three branches with Video underlying nerves when the SMAS is raised. In the neck along considerable variation in branching patterns. A contribution 1 the posterior border of the platysma, the SMAS becomes from the sensory transverse cervical nerve has also been fused with the deep cervical fascia where the deep fascia described.79 covers the sternocleidomastoid muscle. This is important, Because the buccal and zygomatic branches are multiple because a surgeon planning to mobilize a platysma flap to A and interconnected, there is a reserve capacity in the event of address the neck, will have to release the platysma’s attach- a single branch injury; therefore, permanent injury is uncom- ment to the deep cervical fascia in this area.87 mon. However, the temporal and marginal mandibular branches enjoy less collateral innervation making permanent loss much more likely if these branches are injured. Damage Bone to the cervical branches can lead to a “pseudo paralysis” of the lower lip because in some patients the platysma The bony skeleton of the face was once thought to be quite contributes to depression of the corner of the mouth stable in volume and shape as the body aged. However, there (Fig. 11.1.10).103 is ample evidence that atrophy in certain portions of the facial skeleton is a significant factor in facial aging.88–93 Computed tomography of young and old skulls has shown Sensory nerves a retrusion of the infraorbital rim as well as recession of the The great auricular nerve, a branch of the cervical plexus, is maxillary face below the infraorbital rim (Fig. 11.1.8).90 sensory to the earlobe and lateral portion of the pinna. This This has been confirmed by others who have demonstrated nerve wraps around the posterior border of the sternocleido- an enlarging orbital aperture (Fig. 11.1.9).94 mastoid, and courses obliquely across the muscle in a superior The loss of bone has surgical implications because it con- direction. The classic landmark for this nerve is at the mid tributes to an overall loss of volume, and more specifically, to B portion of the sternocleidomastoid, 6.5 cm. below the external loss of soft tissue support in critical areas such as the infraor- auditory canal (Fig. 11.1.11). bital rim. This contributes to development of the tear trough Figure 11.1.9 Computed tomography scan of (A) a male patient in the young It runs parallel and about 1 cm posterior to the external deformity and age related flattening of the anterior midface. age group and (B) a male patient in the older age group. The image from the jugular vein which also crosses the sternocleidomastoid Following the principle of replacing like with like, bone loss older age groups shows significant bony remodeling (arrows) both superomedially roughly along the same vector. The nerve is deep to the super- can be replaced with solid objects such as facial implants (Ch. Figure 11.1.8 Computed tomography of young and old skulls has demonstrated a and inferolaterally. (Courtesy of Kahn DM, Shaw RB. Aging of the bony orbit: a ficial cervical fascia, but the platysma is usually absent over 15), or with soft tissue volume enhancement such as with fat three-dimensional computed tomographic study. Aesthetic Surg J. 2008;28:258.) retrusion of the infraorbital rim. (Courtesy of Pessa JE. An algorithm of facial aging: the posterior sternocleidomastoid. Hence, the nerve is at risk grafting (Ch. 14). verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral of injury during surgical dissection along the posterior border suborbital trough deformity. Plast Reconstr Surg. 2000;106:479.) of the sternocleidomastoid, because with lack of fascial cover, Nerve anatomy consistently found anterior and inferior to the anterior branch it is technically subcutaneous.104,105 of the temporal artery, a palpable landmark in the temple.100 The auriculotemporal nerve, a branch of the trigeminal is Facial nerve a point 1.5–3.0 cm superior to the zygomatic arch, the tempo- The zygomatic and buccal branches, all exit the parotid sensory to the preauricular skin and the lesser occipital nerve ral branches transition from deep to superficial, travelling at gland deep to the parotid masseteric fascia. As they travel is sensory to the retroauricular scalp. The zygomaticofacial The facial nerve exits the stylomastoid foramen, and separates first on the undersurface and then within the superficial tem- anteriorly, they often arborize with each other. Zygomatic nerve exits through its foramen in the body of the zygoma, into an upper and lower division within the parotid glad. poral fascia (temporoparietal fascia), staying there until they branches course parallel to the transverse facial artery. When piercing the malar fat pad to provide sensation to the skin of Classically, there are five branches which arise and exit the terminate in the frontalis muscle, upper orbicularis and frown they reach the area of the zygomatic retaining ligament, the malar prominence; this nerve is often transected when the cover of the superficial lobe of the parotid: temporal, zygo- musculature. The surgical implication is that a SMAS flap can they travel to the undersurface of the muscles which they malar fat pad is surgically mobilized (Fig. 11.1.12). matic, buccal, marginal mandibular, and cervical. There are be safely raised from a point just superior to the zygomatic innervate: zygomaticus major, zygomaticus minor, and typically 2–3 temporal branches; 4–5 zygomatic branches; arch providing that surgical dissection does not extend supe- orbicularis oculi. Deep to the parotid masseteric fascia, within 3 buccal branches; 2–3 mandibular branches, and 2–3 cervical riorly to the level where the temporal branch transitions the premasseteric space, the parotid duct courses anteriorly branches. superficially.98 along an imaginary line from the tragus to the corner of the Patient selection In fact, there is considerable variation in the anatomy A classic external landmark for the course of the temporal mouth. Accompanying the duct is normally a buccal branch. of facial nerve branches. One study identified up to eight branch has been along a line drawn from a point 0.5 cm below Beyond the anterior border of the masseter, a buccal branch Like any elective surgical procedure, a prerequisite is to branches exiting the parotid, with multiple connections the tragus to a point 1.5 cm lateral to the lateral eyebrow.99 can normally be seen crossing the buccal fat pad (fat pad of confirm that a patient’s physical status and mental status between these branches.95–97 More recent studies have found that the temporal branch Bichat). At this level, the portion of buccal fat seen is the are appropriate to withstand the rigors of surgery, the recov- The temporal branches exit the parotid superiorly, coursing actually consists of 2–5 individual branches which do not buccal extension, which is the most inferior portion of the ery phase and any potential complications. The patient’s obliquely and superiorly across the middle-third of the adhere completely to this landmark. One study found that buccal fat pad.101 expectations must be explored to determine if they are realis- zygomatic arch. Like all other facial nerve branches, the tem- these branches cross the middle-third of the zygomatic arch, The mandibular branches exit the parotid approximately tic, and if they are technically achievable. The quality of surgi- poral branches start out deep to the deep fascia of the mid- with a posterior safe zone 1 cm anterior to the acoustic meatus, near the angle of the mandible. They then travel anteriorly cal result will be affected by many patient related factors cheek (parotid masseteric fascia), but unlike all other facial and an anterior safe zone 2 cm posterior to the lateral orbital near the border of the mandible, until they encounter the including the facial skeleton, the weight of facial soft tissue, nerve branches in the cheek, they become more superficial. At rim. Once above the zygomatic arch, these branches were facial artery and vein, crossing those vessels and then turning the depth and location of folds, and the quality of the skin. 194 SECTION I •11.1• Facelift: Principles Patient selection 195

additional volume. Any asymmetry should be pointed out to the patient because facelift surgery will make some asym- metries more obvious. Surgeons should develop an organized way to examine all the zones of the face: forehead, eyelids, cheeks, the perioral Temporal branches area, and the neck. In certain individuals, the appropriate procedure will be a correction of only one of these areas, but more commonly, all or most or the zones should be addressed in order to achieve a harmonious result. Assessment of the Zygomatic branches forehead and orbital area are discussed in Chapters 7 and 8. In the cheeks, the surgeon should assess the shape and promi- Posterior nence of the underlying skeleton, the volume and distribution auricular nerve of facial fat, the degree of soft tissue atrophy and ptosis and the relative mobility of the subcutaneous (superficial) fat. Temporofacial divison Any significant hollowing or flattening should be noted, and Cervicofacial division conversely, any radial expansion in the jowl and neck should be noted. With the diversity of surgical techniques available, Parotid gland 6.5cm a surgeon should think like a sculptor – considering the face in three dimensions with a view to adding tissue in some Buccal branches areas, removing tissue in other areas, and repositioning tissue McKinney’s point where indicated. In the perioral area, the plumpness of the Marginal mandibular Great auricular nerve lips should be assessed, and any elongation of the upper lip branch External jugular vein should be noted. On smiling, the amount of dental show is observed. The skin should be assessed, with its quality noted, Cervical branch along with the depth of wrinkles and folds, including the B nasolabial fold and the marionette lines. A Assessment of the neck is discussed in Chapter 13, but in general, the neck should be examined in various positions: Figure 11.1.11 The great auricular nerve crosses the midportion of the Figure 11.1.10 (A) A cadaveric dissection of the facial nerve. Note three temporal branches crossing the middle third of the zygoma, the arborization between zygomatic sternocleidomastoid at McKinney’s point, which is 6.5 cm inferior to the external neutral, flexion, and turning side-to-side. The patient is asked and buccal branches, the marginal mandibular branch running along the mandibular border, and two cervical branches innervating the platysma. (Courtesy of Dr Julia Terzis). auditory canal. It usually travels about 1 cm posterior to the external jugular vein. to contract the platysma by clenching the teeth and grimacing. (B) Diagram of the facial nerve. The facial nerve exits the stylomastoid foramen and normally divides within the parotid gland into a superior and inferior division. Classically, Anterior to McKinney’s point, the nerve is covered by the superficial cervical fascia This will help identify the degree of platysma laxity, the five groups of branches are seen: temporal, zygomatic, buccal, mandibular, and cervical. There is arborization between branches, particularly between the zygomatic and and the platysma (SMAS), but at the posterior border of the sternocleidomastoid, strength of platysma bands and the amount of subcutaneous buccal branches. the nerve is effectively subcutaneous. The most common point of injury is at the fat superficial to the platysma. The amount of subplatysma posterior border of the sternocleidomastoid muscle. fat is also estimated. Ptosis of the submandibular gland should be noted and pointed out to the patient preoperatively; this condition, if untreated, will be more obvious after facelift surgery than before. Some issues can be reversed, others attenuated, and some arteriole function, which may never return to normal. The ear should be examined with a thought to the potential may not be correctable at all. Nevertheless, there are significant short-term effects which placement of incisions. Important factors include the size and The patient presenting for facial rejuvenation will usually can be reversed by abstaining from tobacco use for 2–3 weeks it is important to recognize what the patient can see is the orientation of the earlobe, the angle of attachment of the be middle age or older, thus increasing the chances of under- prior to surgery. Tests for the metabolites of nicotine in the patient’s primary concern. To help focus the discussion, old tragus, the difference in character of the cheek skin and tragal lying medical problems. In an otherwise apparently healthy blood are available to confirm abstinence from smoking. photographs are very useful in determining which aging skin, and the size of the tragus. Also influencing the choice of individual, specific issues which must be addressed are blood Commonly used non-steroidal anti-inflammatory medica- changes predominated and what features the patient would incisions are the density of the hair surrounding the ear and pressure, smoking history and the use of medications or sup- tions (NSAIDs) and the consumption of certain dietary sup- most like corrected. This will help improve patients’ under- the location of the hairline in the temple, the sideburn, and plements which can promote surgical bleeding. plements may promote intraoperative and postoperative standing of exactly how they have aged, and what, if any, posterior to the ear. Incipient hypertension is common in the general popu- bleeding based on platelet function inhibition. Patients should rejuvenation they would like to undergo. They will also gain A careful assessment of the overlying skin is also important lation and can promote postoperative hematomas if it is avoid these medications for 3 weeks prior to surgery. a better understand of the magnitude of surgery which may to determine if anything of a non-surgical nature is indicated not identified prior to surgery. Hematoma is by far the com- Female patients in the facelift age group may be on hormone be required to accomplish what they desire. either before, during or after facelift surgery. Assessment will monest complication in facelift surgery. Uncontrolled hyper- replacement and are therefore at increased risk for developing Prior to surgery, the entire face should be properly assessed. include skin type, skin quality, skin excess, the depth of folds, tension is a contraindication for surgery, while controlled postoperative deep vein thrombosis (DVT) and a potentially This examination is conducted in a well lit room with the the degree of fine wrinkling and the amount of photo-aging. hypertension is not a contraindication. The labile hyperten- lethal pulmonary embolism. For these patients, in addition to patient sitting vertically in a comfortable position. Examination In particular, perioral rhytides should be examined as they are sive can be the most insidious situation; if possible it should all recognized preventative measures, consideration should should proceed in an orderly fashion so that nothing is missed. often a significant concern for the patient. Issues with the skin be identified preoperatively and controlled. If patients have be given to stopping hormonal replacement 3 weeks prior to The face is examined with the patient in repose as well as should be pointed out to the patient, and options discussed intermittent hypertension (the white coat syndrome), or they surgery. in animation. In doing so, facial nerve function is clinically because facelift surgery itself will not improve the texture and are simply type A individuals who are easily excitable, peri- With respect to the surgical objectives in facelift surgery, assessed. The face should be assessed as a whole – looking for quality of the skin – a common misconception. operative treatment with medications such as Clonidine aging causes fundamental anatomical changes in all parts the equality of facial thirds, the degree of symmetry, and the Excellent photographic documentation of the preoperative should be considered and in all tissues of the face. However, patients will typically overall shape (round, thin, wide). Underlying skeletal form face is very important, and should include frontal, oblique, Smokers have been shown to exhibit delayed wound present with specific concerns about specific areas – often will potentially influence the choice of surgical procedure; for and profile views. Other optional views include the smile and healing due to microvasoconstriction and abnormal cell func- the ptosis of soft tissue in the neck or jowls, or the visible example, a wide full face will not be as amenable to malar fat close up views of the neck in repose and with platysma con- tion.106 One study reported a 12.5 times greater chance of wrinkles and folds in the cheek and neck. Patients are usually pad repositioning as a narrow, long face. Conversely, a thin tracture. Changes in the face from facelift surgery may be having skin flap necrosis in a smoking patient compared with unaware of the underlying anatomic changes which are face will require the preservation of all soft tissue, overlap- more subtle than other aesthetic procedures, so a reliable a non-smoker.107 Long-term smokers have a reduction in causing the problems they can see in the mirror. Nevertheless, ping it rather than excising it, and potentially adding record of the surgical starting point is imperative. 196 SECTION I •11.1• Facelift: Principles Technique 197

the fundamental issues which pertain to all facelift techniques informed that the alternative incision along their temporal will be reviewed. (The various methods specifically designed hairline may result in a more visible scar. Because of this to manipulate the deep tissues of the face will be described problem a number of solutions have been devised along the later, in Chapters 11.2–11.8.) temple hairline including beveling the incision to encourage growth of hair through the scar and the use of zig-zag incisions.112,113 In any circumstance, the anterior hairline inci- Subcutaneous facelift sion should be meticulously sutured under minimal tension. Also, the patient’s wishes should be taken into consideration The first facelift, which dates from the early 20th century, was prior to surgery, because the location of the incision in the Supratrochlear nerve a simple skin incision at the temporal hairline and anterior to temple is inevitably a compromise and the patient may have Ophthalmic nerve V1 Supra-orbital nerve the ear; several authors lay claim to this innovation.9–11 This preferences which will influence the surgeon’s choice. method soon evolved into a subcutaneous dissection of a Anterior to the ear, the incision can be pre-tragal, or along Lacrimal nerve large random pattern skin flap which was shifted in a superior- the tragal edge (Fig. 11.1.13D,E). The advantage of the tragal Zygomaticotemporal nerve lateral direction.24,26 Still used today, this classic procedure edge incision is that it is hidden, but care must be taken to tightens excess skin, and relies completely on skin tension to Infratrochlear nerve thin the flap covering the tragus in order to simulate a normal shift underlying facial soft tissue against the force of gravity. External nasal nerve tragal appearance. Furthermore, as pointed out by Connell,111,114 Maxillary nerve V2 The advantages of the subcutaneous facelift are that it is rela- Zygomaticofacial nerve the tragus looks like a rectangle, with a top and a bottom, and tively safe, it is easy to do, and patient recovery is rapid. For Auriculotemporal nerve to preserve a distinct lower border, a short transverse cut at the thin patient with excess skin, and minimal ptosis of deep Infra-orbital nerve the inferior end of the tragus (the incisura) should be done. soft tissue, this procedure is effective. However, the reverse, Before committing to a tragal edge incision, the quality of namely a heavier patient with significant ptosis of deep tissue, Buccal nerve tragal skin and that of facial skin must be compared; if is a poor candidate. The inherent disadvantage of the “skin- Mandibular nerve V the difference is too great, drawing thick cheek skin onto the 3 only” facelift is that skin placed under tension to support tragus may be problematic because the skin covering the heavy underlying soft tissue will stretch, leading to a loss of tragus will not be anatomically appropriate. Therefore, in Mental nerve surgical effect. An attempt to overcome this problem with certain cases, a pretragal incision is preferred. For example, in excess skin tension may lead to distortion of facial shape, men, the pretragal approach may be beneficial if it appears abnormal re-orientation of wrinkles, and local problems at that thick-bearded skin will be drawn up onto the tragus the incision line including stretched scars and distorted and the surgeon is concerned that removing hair follicles and earlobes. thinning the flap will not ameliorate the appearance of cheek skin on the tragus. Elsewhere in front of the ear, the superior portion of the incision should follow a curved line along the Facelift incisions helix, and a slightly straighter curve along the anterior attach- The purpose of a facelift incision is two-fold. First, the incision ment of the earlobe; a long, straight line incision in front of Video Figure 11.1.12 Major sensory nerves of the face. allows elevation of a flap which provides access for surgical the ear should be avoided. 2 manipulation of the deep tissues of the face. Second, the Around the earlobe, the incision can be place either in resulting skin flap can be repositioned with excess skin being the cleft of earlobe attachment or 1–2 mm distal to the cleft, removed along the incision line; this is the primary goal of leaving a cuff of skin along the earlobe. This cuff will ease the a skin-only subcutaneous facelift. Generally, the incision is process of insetting the earlobe on skin closure. hidden by the hair and by contours of the ear. In the retroauricular sulcus, the incision can be placed In the temple area, the incision can be placed in the hair, at directly in the conchal groove as it courses superiorly. Various cheek is shifted into the middle and upper cheek. Patients see the anterior hairline, or a hybrid of the two, with an incision landmarks have been described to determine how high to Surgery the same thing in a mirror when they manually lift their cheek in the hair plus a transverse extension at the base of the side- carry this incision. These include the level of the external audi- or if they lie on their back. Effectively, by shifting lower facial burn (Fig. 11.1.13A,B). tory canal, or slightly higher, at the level of the antihelix. fat superiorly, volume is restored to the midface while simul- The advantage of the incision in the hair is that it is hidden, A significant surgical decision is whether to extend the A facelift is a significant operation. It should be done under taneously, ptotic tissue is lifted. As we have seen, changes in but when the flap is drawn up, the anterior hairline and side- postauricular incision across the non hair baring skin into excellent conditions with appropriate medical staff, appropri- volume are a significant part of facial aging. Surgeons have burn will shift, the degree of this depending on skin laxity. the occipital region. Generally speaking, the occipital incision ate equipment and adequate back up. Anesthesia can be safely been able to improve the lower third of the face and neck by If the incision is placed at the anterior hairline, the scar is should be made when there is a need to remove excess redun- done with many different approaches, including local anes- removing excess volume, and in recent years, surgeons have potentially more visible, but there will be no shift of the hair- dant neck skin. A “short scar” facelift is one which avoids thetic with different levels of intravenous sedation and with demonstrated that people may look younger with volume line. A transverse incision at the base of the sideburn is a the occipital incision, and will suffice for many patients.115 If varying levels in the spectrum of general anesthesia. An augmentation alone.108,109 By combining these approaches – compromise solution, which ameliorates much of the hairline the incision is kept short, the lateral neck is accessed from the anesthesiologist, if involved, can decide in consultation with adding volume in some areas, subtracting volume in others, shift, while preserving a largely hidden scar. Other compro- earlobe and retroauricular incision, and any bunching of skin the surgeon what form of anesthesia is preferred for an and by repositioning ptotic tissue, the surgeon has the ability mises have been described.110 Several factors should be is redistributed within the retroauricular sulcus. Disadvantages individual patient. There should be proper intraoperative to sculpt facial shape and more accurately restore the contours assessed before committing to an incision within the temple of the short scar technique are that access to deep tissues is patient positioning, intraoperative monitoring, intraoperative of youth. hair. First, a preoperative estimate of skin redundancy will somewhat limited, there is a tendency to draw the skin flap warming, and intraoperative DVT prophylaxis. The repositioning of ptotic tissue is the principle objective give the surgeon some sense of how far the skin flap will in a more superior direction possibly requiring a pre-hairline which has interested surgeons since facelift surgery began. move. The distance between the lateral orbital rim and the incision in the temple, and the fact that excess neck skin, if Many methods have been described. The choice of technique temporal hairline should be assessed. In youth, this distance there is any, must be gathered up in the retroauricular sulcus, will depend on the individual patient’s aesthetic diagnosis, is generally <4–5 cm, while in older patients, the distance often creating pleats. Technique the patient’s desires, and the surgeon’s comfort level with a increases.111 If the distance is already excessive, or if the If the decision has been made to extend the incision beyond certain procedure. While differences between surgical tech- expected movement of the temporal hairline will create a the retroauricular sulcus, many variations are described, Historically, surgeons have been guided by the empirical niques can be significant, many commonalities exist. In this distance over 5 cm, then an incision in the hair should be ranging from an incision which goes vertically into the scalp116 finding that people look younger when soft tissue of the lower section, the classic subcutaneous facelift will be described and avoided (Fig. 11.1.13C). On the other hand, patients must be to an incision which courses inferiorly along the hairline of 198 SECTION I •11.1• Facelift: Principles Technique 199

A B

Figure 11.1.14 When there is minimal skin shift expected, the incision is limited to the retro-auricular sulcus only (“short scar” technique). When more skin shift is expected, especially from the neck, the incision is extended across nonhair-baring skin into the occipital hair. A wide range of patterns for this extension have been described, ranging from a vertical incision down to an incision that follows the hairline. Most surgeons follow a course somewhere in between, as in this photo Figure 11.1.15 The traditional incision for a facelift flap curves vertically or where a “lazy S” follows the occipital hairline for 1 or 2 cm before entering the slightly anteriorly in the temple, follows the contours of the ear, both anteriorly and occipital hair. posteriorly, and then angles into the posterior scalp.

rough guide is to use the lazy S approach if 2 cm or more of anterior hairline, the dissection plane must transition into the neck skin is to be removed at the incision line.117 This approach subcutaneous facelift plane. This change of plane results in a allows an adequate excision of skin without a stair-step narrow ribbon of superficial temporal fascia which will deformity, while hiding the lower, potentially most visible contain the superficial temporal artery and vein and branches Video part of the scar in the wispy hair of the lower occipital scalp of the auriculotemporal nerve. This is known as the “meso- 3 (Figs 11.1.14, 11.1.15). temporalis”, and must be divided, often requiring ligation of Either the temple dissection or the post-auricular dissection the superficial temporal vessels. The argument in favor of the can be done first, depending on surgeon preference. The dis- deeper dissection is to protect temporal hair follicles, although D E section is usually begun with a scalpel, for the first 1–2 cm, at vessels and a nerve must be sacrificed (Fig. 11.1.16A). The which point many surgeons switch to scissors. In the post- superficial plane has the reverse attributes: vessels and nerves auricular area, the flap is firmly attached to the deep cervical within the superficial temporal fascia are preserved, but the fascia of the sternocleidomastoid and the mastoid. Also, this hair follicles can be injured during the dissection unless care is the most common location to see skin flap necrosis, so the is taken (Fig. 11.1.16B). flap should be raised sharply under direct vision, keeping the Anterior to the anterior hairline, the subcutaneous plane is dissection against the underlying deep fascia in order to main- then developed. Commonly referred to as the “facelift plane”, tain flap thickness. As the dissection continues inferior to the the level of dissection normally leaves about 2 mm of fat on earlobe level, the surgeon must be cognizant of the great auric- the dermis. This results in a large random pattern skin flap C ular nerve, where it is most at risk over the posterior border of the survival of which will entirely depend on the subdermal Figure 11.1.13 (A) The traditional hidden incision in the temple hair is appropriate when the temporal hairline will not be shifted adversely. (B) A temple incision along the the sternocleidomastoid. By keeping the dissection in the sub- plexus. In the upper face, this dissection continues anteriorly hairline is used if a hidden incision will adversely shift the hairline. (C) The distance from the lateral orbital rim to the temporal hairline should not exceed 5 cm (D) The cutaneous plane, the great auricular nerve will be protected. until the orbicularis oculi is encountered where it encircles the retrotragal incision follows the edge of the tragus. (E) The pretragal incision is placed in the pretragal sulcus. In the temple, if the incision has been made along the ante- lateral orbital rim. Depending on the type of deep plane rior hairline, dissection is begun directly in the subcutaneous surgery planned, the mid-cheek dissection may stop short of plane. If the incision has been made in the hair baring scalp the malar fat pad (see Ch. 11.7), or alternatively, carry on over the neck. Most commonly, surgeons use an incision which the retroauricular incision can curve posteriorly into the of the temple, dissection can be carried out in one of two the fat pad, freeing it from the overlying skin in the temple is between these two extremes. The principle objectives for occipital hair from the retroauricular sulcus. If more skin from planes: superficial to the superficial temporal (temporopari- and cheek (see Ch. 11.6). Lower in the cheek, immediately the occipital incision are to gain access to the neck in order the neck is going to be removed, this approach could create a etal fascia) which will continue directly into the subcutaneous anterior to the ear and the earlobe, the skin is tethered to to take up redundant neck skin, while making the incision notch in the posterior hairline, so a called “lazy S” pattern can facelift plane, or between the superficial temporal fascia underlying structures by secure fascial attachments (variously as invisible as possible with little or no distortion of the occipi- be used, where the incision follows the occipital hairline for and the deep temporal fascia. If the deeper approach is used, named: platysma auricular fascia, parotid cutaneous liga- tal hairline. If a small amount of skin is going to be removed, 1–2 cm, before angling more posteriorly into the scalp. A the dissection proceeds quickly against deep fascia, but at the ment, and Lore’s fascia). Beyond this area, the subcutaneous 200 SECTION I •11.1• Facelift: Principles Technique 201

Figure 11.1.16 (A) Facelift flap has been raised in two different planes, initially deep to the superficial temporal fascia, against the deep temporal fascia (seen as an oval window), with a change of planes near the anterior temporal hairline into the subcutaneous plane. The “mesotemporalis” is a bridge of tissue which develops between these two planes. In order to unify the planes, it has been divided with ligation of the superficial temporal artery. (B) Facelift flap has been raised in a single subcutaneous plane, with dissection directly A B on the superficial temporal fascia and deep to the hair follicles of the scalp. The purple A B line outlines the course of the anterior branch of the superficial temporal artery.

dissection proceeds relatively easily. Once the skin flaps ante- rior and posterior to the ear have been raised, the two dissec- tions are joined. The extent of the facelift flap dissection into the cheek and neck will depend on the type of deep tissue technique being employed (see Ch. 11.2). When a submental incision is done with midline platysma muscle plication (Ch. 13), there will be traction on the cervical skin toward the midline of the neck. In that circumstance it is important to widely mobilize the cervical skin from the underlying platysma in order to allow the cervical skin to be redraped along a vector opposite to that in which the platysma is being moved. If, on the other hand, there is no submental incision, the neck dissection can be more limited (Figs 11.1.17, 11.1.18).

D Deep tissue surgery C

The subcutaneous facelift flap does two things – it allows for Figure 11.1.18 (A) Traditional subcutaneous flap dissection with no submental incision. (B) Traditional subcutaneous flap dissection with submental incision. reposition and removal of excess facial skin, and it provides access to the deep tissues of the face. Techniques to address the deep tissues of the face will be reviewed in Chapters the skin flap along an oblique vector which is slightly less first of two anchor points; it can be held in place with a half 11.2–11.8. These will include: SMAS plication, loop sutures vertical than the vector for repositioning deep tissues. In buried mattress suture in order to minimize the chance of a (MACS lift), SMASectomy, subSMAS with skin attached, sub certain techniques, surgeons employ a nearly vertical vector visible suture mark (Fig. 11.1.19). SMAS with separate skin flap, and subperiosteal. to the skin flap (Ch. 11.4). One concept is to place the skin flap Posteriorly, the skin flap should be drawn along a vector “where it lies”, using the vector which facial skin naturally which roughly parallels the body of the mandible. The second Skin flap mobilization and closure assumes when the patient is lying in the supine position. This anchor point will be at the superior most extent of the postau- Video is based on the theory that we all look better lying on our back ricular sulcus at the point where the incision starts to transi- 4 Once the deep tissues have been managed, skin flap mobiliza- with facial skin redraping itself in a natural direction (Fogli, tion posteriorly. Once again, a half buried mattress suture can tion and closure must be done accurately and with care. pers. comm.). A common guide is to advance the skin flap be used. At this point, trimming of the overlapping flap and Despite masterful deep tissue surgery, errors made on skin toward the temple along a vector which is perpendicular to suturing can be done in the temple and in the occipital region; closure can create some of the most obvious of facelift deform- the nasolabial fold. This is also approximately along the line the order is based on surgeon’s preference. During this ities. At all times, the skin should be considered a covering Figure 11.1.17 Subcutaneous facelift flap has been raised. of the zygomaticus major muscle. A skin flap marker can be process, the facelift flap is redraped in the desired direction layer, not a structural one. Therefore, skin flap repositioning very useful in determining where the skin should be incised. with gentle tension. Attention is then turned to trimming should be seen as a removal of redundancy rather than a The anterior anchor point is immediately adjacent to helix of excess skin around the ear, with absolutely no tension on the method to hold up ptotic soft tissue. Most techniques advance the ear at the junction of the hair baring scalp. This will be the closure. If a tragal edge incision is used, the tragal flap is 202 SECTION I •11.1• Facelift: Principles Technique 203

Proper insetting of the ear lobe

Mandibular symphysis

Thyroid cartilage

A B Limited platysma interdigitation Extensive platysma interdigitation No platysma interdigitation Figure 11.1.20 The earlobe should be inset with the long axis of the earlobe (dotted line) about 15° posterior to the long axis of the ear itself. If the earlobe is Figure 11.1.21 Three types of platysma anatomy. pulled forward, an unnatural appearance results.

accumulates in the anterior neck, although this is highly vari- centrally and to do a partial transaction of the muscle inferi- Ancillary techniques able; in some thin individuals, there may be little or no sub- orly. Some surgeons advocate multiple rows of sutures to cutaneous fat in the neck. If subcutaneous fat is the only aggressively advance the platysma muscles medially: the Browlift surgery and blepharoplasty problem, and the skin is firm, or will be surgically tightened, corset platysmaplasty.124 Deep to the platysma, excess sub- the fat can be simply removed with closed liposuction.120 platysmal fat may be removed, hypertrophic digastric muscles Facial aging rarely occurs in a regional fashion, and is typi- Deep to the fat, the paired platysma muscles have well can be thinned and ptotic submandibular glands can be cor- cally a pan-facial phenomenon. Therefore, a comprehensive Figure 11.1.19 Diagram shows typical skin flap redraping along an oblique recognized variations in their anatomy. The majority (roughly rected by repositioning or by partial excision.125,126 approach to facial rejuvenation is normally required to achieve direction which is slightly less vertical than the vector along which deep tissues are 75%) of necks exhibit interdigitation of the platysma muscles In some facelift cases, only minimal correction of the neck a harmonious result. For many patients, surgery for the brow moved. There is considerable variation in this however; some techniques involve a in the submental region for the first 1–2 cm behind the is required and a facelift with deep tissue advancement will (Ch. 7) and the eyelids (Ch. 8) are critical components of a more horizontal vector (dual plane extended SMAS, see Ch. 11.6), while other 121,122 techniques utilize a nearly vertical vector (MACS, see Ch. 11.4). chin. The remaining 25% either overlap extensively, or do supply adequate correction. Conversely, in patients concerned global approach for which a facelift would be only part of the not overlap at all (Fig. 11.1.21). only with the neck, this can be treated as an isolated proce- solution. With age, there appears to be a loss of tethering of the dure utilizing a number of different techniques: isolated lipo- platysma muscles to the deep cervical fascia, analogous to the suction, liposuction plus platysma plication and transection, Volume removal thinned and hair follicles are removed. In the retroauricular loss of tethering of the orbicularis oculi along the infraorbital or a retroauricular approach to tighten the platysma posteri- sulcus, there is normally little or no skin to be trimmed if the rim. As a result, the platysma seems to fall away from the orly.127 If after submental surgery, there is skin laxity, it can be With radial expansion of the lower third of the face, many posterior flap has been correctly positioned. Earlobe inset is cervical mandibular angle and the sharp angle of youth gives tightened with an isolated retroauricular incision, or with a patients require fat removal. Subcutaneous fat can be removed done last and is designed to angle 15° posterior to the long way to the obtuse angle of age. The visible bands, which full subcutaneous facelift. either by direct excision or with liposuction. In the cheek, this 114,117 access of the ear (Fig. 11.1.20). develop with age, are normally the leading edge of the paired In some older males, the preferred procedure may be a is often done on a limited basis for the jowls, especially in Skin trimming around the ear should be guided by having platysma muscles, but clinical experience has demonstrated direct neck excision of excess skin, leaving a scar in the cases where jowls cannot be corrected by soft tissue elevation no tension on the sutures when the wound is closed. Tension these visible bands may also represent pleats in the redundant midline. This can be done with a zig-zag pattern or with a alone. Removal of deep fat can be done by partially removing on the earlobe can lead to distortions such as the pixy ear muscle just posterior to their leading edge. Bands are consid- vertical ellipse broken up with two or more Z-plasties.128 the buccal fat pad, which can be approached through a facelift deformity and the malpositioned earlobe, both of which are ered either static (present at rest), or active (only present on In the typical case of the aging neck, there is usually a dissection or through an incision in the upper buccal sulcus. difficult to correct (see Ch. 12). animation). There are two different surgical options to deal combination of factors (skin laxity, excess fat, and lax platysma In the neck, superficial fat can be removed using liposuction with platysma bands in the anterior neck. One approach muscle). In such a scenario, there is controversy as to how or by direct excision through a submental or a facelift incision. Neck surgery involves mobilizing the posterior borders of the paired aggressive to be with surgical treatment. While most surgeons Fat deep to the platysma can be removed using direct excision platysma muscles, drawing them in a superior oblique direc- agree that a youthful neck contour is one of the principle through the submental approach. In all cases of fat removal, The basic principles of neck surgery will be covered here. tion and fixating the muscle to firm fascia (platysma auricular objectives of facelift surgery, many fear the possibility of creat- caution is advised because of the potential defects which can (Surgical rejuvenation of the neck is reviewed in Chapter 13.) fascia, or the Lore’s fascia component).83,118 ing the “overdone” neck. And while some surgeons feel that be produced when too much fat is removed. Like the face, the layers of the aging neck must be assessed Alternatively, the paired platysma muscle can be drawn any platysma banding warrants open surgery, others virtually independently in order to devise an appropriate surgical plan. medially, and approximated in the midline of the neck.28,123 never do an open neck procedure, relying instead on liposuc- Volume augmentation Superficially, the skin of the neck is typically thinner and Access for this is through a 2–3 cm incision placed adjacent to tion and posterior-superior platysma traction. Some surgeons less elastic than facial skin. With age, further skin laxity devel- or in the submental fold. Through this submental incision, feel that ptotic submandibular glands should always be Long-term experience with elevating deep facial tissues has ops, causing vertical wrinkles and pleats. These can be cor- several anatomical structures can be addressed directly: addressed while others feel it need never be done. The impli- shown this approach to add some fullness to the middle third rected by tightening the skin in a posterior oblique direction. subcutaneous fat, subplatysma fat, the platysma muscles, cation of these opposing opinions is that a perfect, universal of the face (see Chs 11.2–11.8). However, a more complete Some surgeons believe that such a correction should be digastric muscles, and the submandibular glands. A common procedure for the neck probably does not exist, and surgeons result can be obtained if specific volume augmentation is accompanied by superior oblique repositioning of the under- approach is to remove excess subcutaneous and subplatysma must individualize their approach to variations in anatomy done. The addition of volume can be accomplished with a lying platysma.118,119 With age, subcutaneous fat usually fat, to approximate the anterior platysma muscle edges and patient expectations. number of different methods including: synthetic implants 204 SECTION I •11.1• Facelift: Principles Surgical complications 205

(cheek implants, submalar implants, orbital rim implants), with resurfacing procedures. Options include chemical peel, injectable synthetic fillers, hydroxy appetite granules or surgical dermabrasion or laser treatment. (These techniques injected fat (all of which are reviewed in Chs, 4, 14, and 15). are discussed in Chapter 5.) The most common problem is In particular, the harvesting, processing and injection of permanent depigmentation when the resurfacing has been micro-droplet fat grafts (lipofilling) have undergone great overly aggressive. technical improvements.70,129 This technology is now reproducible, and for many sur- Dressings geons is a major component of their facelift technique.130,131 There is a high rate of fat graft take after fat injection in the Some surgeons feel that dressings after facelift surgery are middle third and upper third of the face; in fact significant not necessary, but most surgeons use light dressings to protect over-grafting should be avoided in the periorbital area because the incisions and to act as an absorbent for wound drainage. of the propensity for visible ridges and lumps if excess fat Dressings should not be tight or constrictive, but rather soft grafting has been done. Fat grafting is less reliable around the and comfortable. The initial dressing is normally removed on vascular, mobile lips. Specific areas which are commonly the first postoperative day. grafted in conjunction with facelift surgery fat are the perior- bita (orbital rim, upper lid sulcus, and the tear trough), the A Postoperative care mid-facial groove, and the malar prominence. The depth of injection can be in the superficial fat layer (superficial to In the initial postoperative period, the patient is kept still and Figure 11.1.23 Postoperative hematoma in a hypertensive male. Note the SMAS), or in the deep fat layer. As mentioned above, it has blood pressure is monitored closely. Any signs of blood pres- ineffective suction drain. been proposed that the deep medial fat compartment may sure increase should be taken very seriously; the patient is play a unique role in support of soft tissue in the mid face, examined for possible causes (pain, anxiety, urinary retention) 64 suggesting the benefits of fat grafting this zone. Fat injection and appropriate measures taken. If the increase in blood pres- have been explored, including dressings, drains, fibrin glue, can be done independently, or in combination with facelift sure is endogenous, it should be treated pharmacologically. If > and platelet gel. A positive association has been found when Video surgery. When done in conjunction with facelifting, it is the surgical procedure has been long ( 3 h), sequential com- simultaneous open neck surgery is done, with patients taking 5 usually done first, before the facelift flap has been raised. pression devices are kept on the legs in recovery room until platelet inhibitors such as Aspirin and anti-inflammatories, the patient can ambulate normally. The patient is then encour- with hypertension in the postoperative period, and with the Midfacelift (blepharoplasty approach) aged to get out of the bed with assistance, in order to walk to rebound effect when the epinephrine wears off postopera- the bathroom. The patient’s positioning involves keeping the tively.140,141 Hematoma prevention involves avoiding these In an attempt to lift the tissue immediately inferior to the head of the bed elevated, but avoiding flexion of the neck. variables as much as possible. Hematomas typically develop infraorbital rim (the midface), an approach through the lower Avoiding the use of a pillow for 10–14 days will help keep the 132 in the first 12 h after surgery. If an expanding hematoma is lid was developed. This involves a subciliary or a transcon- patient’s head in a neutral, non-flexed position. Cool packs to identified it should be promptly drained. If skin flap compro- junctival blepharoplasty type incision followed by a dissec- the face will increase comfort and help decrease swelling. B mise is suspected and there is a delay in returning to the tion down over the face of the maxilla. This procedure can be Analgesics and antinauseants are used as necessary. In some operating, a temporary solution can be the removal of sutures done in the subperiosteal plane, which requires an inferior jurisdictions, patients are discharged home, but in other set- in order to relieve pressure (Fig. 11.1.23). periosteal release, or it can be done in a supraperiosteal Figure 11.1.22 Pre- and postoperative photographs of a lip-shortening procedure tings, patients are kept under the care of a medically trained plane.133 After mobilization of the cheek mass the soft tissue using a bullhorn-shaped incision along the nostril sill. individual for the first night after surgery. On the first post- is fixated superiorly, either laterally along the lateral orbital operative day, the patient is reviewed, paying particular atten- Sensory nerve injury rim,132 or more vertically with anchoring to the bone of the tion to the possibility of a hematoma, the dressings are infraorbital rim.134 Disadvantages have included the learning potentially visible scar and a certain degree of relapse making changed or removed, and drains are removed. After the first The terminal branches of sensory nerves to a facelift flap are curve necessary for surgeons to feel comfortable with this revisions common (Fig. 11.1.22). day, options include another light dressing, a commercially routinely divided when the flap is raised. The consequence is approach and a significant incidence of revisions for malposi- Alternatively, a strip of skin can be removed along the available “chin strap”, or no dressing at all. Patients are a self-limiting paresthesia which usually recovers completely tion of the lower eyelid.135 An alternative approach to the vermillion border, advancing the vermillion superiorly. This usually permitted to have a shower and wash their hair when in 6–12 months. The great auricular nerve is the major sensory midface is endoscopically through the temple. This procedure has the advantage of immediately increasing the apparent the incisions are sealed from the environment – usually 2–4 nerve at greatest risk for damage during facelift surgery. is described in detail in Ch. 11.2. width of the vermillion lip, but the disadvantages that the days postoperatively. Subsequently, patients are seen for Transection will lead to numbness of the lateral portion of the white roll is eliminated and a permanent scar will be left along dressing changes, suture remove and wound inspection, at external ear as well as skin anterior and posterior to the ear. Lip procedures the vermilion border. Women can deal with this by using intervals up to 7–9 days when the final sutures are removed. A painful neuroma can also develop. If knowingly transected lipstick, but this is usually a life-long commitment when the Typically, there is a return visit at 2–3 weeks and then again during facelift surgery, either partial or complete, it should be The aging face often develops changes in the perioral region, scar is visible. between 6 and 8 weeks. Photographic documentation of the repaired intraoperatively. A portion of the zygomaticofacial but a facelift will not affect the perioral region to any appreci- Lip augmentation can be done with many different tech- surgical result should be deferred for at least 6 months to nerve is often transected when the malar fat pad is lifted; this able degree. Common changes include elongation of the niques. Commonly used methods include: injectable fillers allow for all postoperative swelling to settle completely. will lead to numbness of the lateral cheek, which will continue upper lip as measured from Cupid’s bow to the base of the (Ch. 4), injected fat, dermal fat graft, acellular dermis and to improve for over a year. In this area, some permanent columella, a thinning of the vermillion, and the development SMAS grafts. Many different human tissues, and many syn- numbness is possible. of perioral rhytides. thetic materials have been used to thicken lips. Depending on Elongation of the upper lip is highly variable, but if present, the technique used, problems have included resorption and Surgical complications Motor nerve injury tends to hide the upper teeth, in some cases almost eliminat- loss of effect, permanently over filled lips, distorted shaped ing the normal upper dental show on smiling. It has been lips, immobile lips, and in some cases tissue necrosis from Hematoma Damage to a facial nerve branch can easily go unnoticed by estimated that the ideal distance from Cupid’s bow to the base vascular compromise. Attempts to augment the lip along the the surgeon until muscle paralysis is identified postopera- of the columella is 15 mm.136,137 vermillion border lead to a duck like appearance, while aug- Postoperative hematoma is the most common facelift compli- tively. Immediately after surgery, in the recovery room setting, The upper lip can be shortened by performing a skin mentation along the wet dry junction is more likely to achieve cation, and has a reported incidence of 2–3% in women. The facial nerve paresthesias are extremely common and are excision along the contours of the base of the nose (bull horn a normal appearing lip. incidence in men has been reported up to 8%, although this usually caused by the lingering effects of local anesthetic. pattern). Skin is excised, with the direct approximation of Perioral rhytides are a common finding in the facelift age can be decreased to 4% through meticulous surgery and post- Once the temporary anesthetic effects are gone (approx. 12 h skin acting as a subcutaneous lift. Disadvantages include a group. They can be effectively treated at the time of surgery operative blood pressure control.138,139 Numerous variables for bupivacaine), persisting dysfunction may be due to 206 SECTION I •11.1• Facelift: Principles Conclusion 207 surgical traction or the effect of cautery near a nerve branch; Anatomic dissections of deep facial fat are presented (fat Anatomic dissections confirm the presence of retaining these issues can be expected to resolve spontaneously over which is deep to the muscles of facial expression). The deep ligaments previously described by other authors as well as days or weeks. If a facial nerve branch has been transected or fat is compartmentalized by septae, creating the deep medial newly described masseteric ligaments. The authors discuss wrapped in a suture, complete functional recovery may still fat pad, and the suborbicularis oculi fat. the support these structures supply between fixed bone and be possible if the target muscle receives collateral innervation. 68. Gosain AK, Amarante MTJ, Hyde JS, et al. A dynamic deep fascia and the superficial fascia. The anatomic issues were discussed earlier. The most com- analysis of changes in the nasolabial fold using 95. Tzafetta K, Terzis J. Essays on the facial nerve: Part I. monly injured branches are thought to be the buccal branches, magnetic resonance imaging: Implications for facial Microanatomy. Plast Reconstr Surg. 2010;125(3): although long-term sequelae are rare due to multiple inter- rejuvenation and facial animation surgery. Plast 879–889. connections between nerve branches. Damaged temporal Reconstr Surg. 1996;98:622. The authors review facial nerve anatomy and present or marginal mandibular branches are less likely to recover A comparative MRI study demonstrates the changes in anatomic findings which confirm extensive arborization because they are terminal branches with less collateral 96 subcutaneous fat which develop with age. The authors between facial nerve branches. The discussion by Stuzin support. Fortunately, permanent paralysis of any degree is a conclude that superficial fat in the cheek becomes ptotic highlights clinically important issues. rare event, and has been reported as being less than 1%.142 while the underlying elevators of the lip do not elongate 96. Stuzin JM. Discussion: essays on the facial nerve: Part with age. I. Microanatomy. Plast Reconstr Surg. 2010;125(3): Unsatisfactory scars 69. Stuzin J. Restoring facial shape in facelifting: the role 890–892. of skeletal support in facial analysis and midface 111. Marten TJ. Facelift planning and technique. Clin Plast Depending on the incision chosen, scars can potentially be soft-tissue repositioning (Baker Gordon Symposium Surg. 1997;24(2):269–308. obvious and deforming. Improper placement of incisions can Cosmetic Series). Plast Reconstr Surg. 2007;119:362. This review article covers the planning, surgical lead to distortion of the ear and unnatural shifting of the This review discusses the changes in facial shape which marking and technical details of two layer facelift hairline. Excessive tension can lead to loss of hair, depigmen- occur with aging, the surgical means we have to correct surgery. Details regarding the skin incisions are tation and widened scars. Some scars can be improved with these changes, and alterations which should be made with emphasized. scar revision at a later date. Hypertrophic scars can be dealt different degrees of underlying skeletal support. with by steroid injection, and scar revision if necessary. (These 129. Coleman SR. Structural fat grafting. St Louis: Quality issues are discussed in Chapter 12.) Figure 11.1.24 Abscess under cervical portion of facelift flap, 1 week after a 70. Coleman SR. Facial recontouring with lipostructure. Medical; 2004. facelift. This was treated with drainage and antibiotics. Clin Plast Surg. 1997;24(2):347. This text is a comprehensive review of the history, basic Alopecia A pioneer of facial fat grafting presents early experience science and technical details of fat harvest and fat injection. Infection with lipoinjection of the face. 141. Jones BM, Grover R. Avoiding hematoma in Loss of hair can occur along the incision line or within the hair 73. Mitz V, Peyronie M. The superficial cervicofacial rhytidectomy: a personal 8-year quest. Reviewing 910 patients. Plast Reconstr Surg. baring scalp which has been raised as a flap. The usual cause Infection is reported to be rare in facelift surgery, with various musculoaponeurotic system (SMAS) in the parotid 2004;113:381. is excess tension at the incision line. However, if a flap of hair series indicating an incidence of less than 1%.143–145 and cheek area. Plast Reconstr Surg. 1976;58:80. baring skin is raised, follicles can also be damaged by the dis- However, most authors with published series have only This paper is the first description of the superficial The authors review a large facelift series where the most section itself, by cautery, or by traction on the flap. Permanent counted cases requiring surgical drainage or hospitaliza- musculoaponeurotic system. common complication of facelift surgery, hematoma, is hair loss can be treated in some cases by mobilization of an tion. Minor cases of cellulitis and stitch abscesses are likely 80. Stuzin JM, Baker TJ, Gordon HL. The relationship addressed. Variables thought to influence the formation of adjacent flap of hair baring scalp. However, for significant more common. Should an infection occur, treatment is with of the superficial and deep facial fascias: relevance hematoma were reviewed, including the use of dressings, alopecia, achieving adequate coverage with hair growth in the surgical drainage, antibiotics and appropriate wound care to rhytidectomy and aging. Plast Reconstr Surg. drains, soft tissue adhesives and epinephrine. proper direction is best achieved with micro-hair-grafting (Fig. 11.1.24). 1992;89:441. (Ch. 23).

Skin loss Conclusion

Facelift dissection creates a large relatively thin random Facelift surgery has evolved in parallel with our more advanced pattern skin flap which is then placed under tension; it has a understanding of the anatomy of facial aging. For over a remarkable ability to survive. Factors which can contribute to century, innovative surgeons have developed a wide variety the avascular loss of skin include excessive tension, an overly of approaches to treat age related changes. In this chapter we thin flap, hematoma, constrictive dressings, and perhaps the have reviewed surgical anatomy as it relates to facial aging. most damaging of all – smoking. Established skin necrosis We have introduced the classic skin-only facelift along with should be dealt with conservatively; the majority of such cases the issues which pertain to preoperative and postoperative will eventually heal spontaneously. Scar revision can be done patient care. In the coming chapters, various methods of hand- at a later date. ling the deep facial tissues will be discussed.

Access the complete references list online at http://www.expertconsult.com

64. Rohrich RJ, Pessa JE. The fat compartments of the face: In some locations, the septae dividing the fat anatomy and clinical implications for cosmetic surgery. compartments are aligned with retaining Plast Reconstr Surg. 2007;119:2219–2227. ligaments. Anatomic dissections are presented which demonstrate 65. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and how the subcutaneous fat of the face is partitioned the deep medial fat compartment. Plast Reconstr Surg. into multiple, independent anatomical compartments. 2008;121(6):2107–2112. References 207.e1 207.e2 SECTION I •11.1• Facelift: Principles

25. Hunt HL. Plastic surgery of the head, face and neck. 47. Mendelson BC. Correction of the nasolabial fold: 65. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and References Philadelphia: Lea & Febiger; 1926. extended SMAS dissection with periosteal fixation. the deep medial fat compartment. Plast Reconstr Surg. 26. Bames H. Truth and fallacies of face peeling and Plast Reconstr Surg. 1992;89:822. 2008;121(6):2107–2112. 1. Stuzin J. Aging face and neck. In: Mathes SJ, ed. Plastic facelifting. Plast Reconstr Surg 1927;126:86. 48. Bosse JP, Papillon J. Surgical anatomy of the SMAS at the Anatomic dissections of deep facial fat are presented (fat surgery. Philadelphia: Saunders Elsevier; 2006. 27. Aufricht G. Surgery for excess skin of the face and malar region. Transactions of the 9th International Congress which is deep to the muscles of facial expression). The deep 2. Rogers BO. A brief history of cosmetic surgery. Surg neck. 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Transactions of the Seventh International Congress occur with aging, the surgical means we have to correct 14. Bourguet II J. La disparition chirurgicale des rides et 1974;54:127. of Plastic and Reconstructive Surgery, Rio de Janeiro; these changes, and alterations which should be made with plis du visage. Bull Acad Med (Paris) 1919;82:183. 37. Peterson R. Cervical rhytidoplasty – a personal 1980:393. different degrees of underlying skeletal support. 15. Bourguet JV. Les hernies graisseuses de l’orbite. approach. Presented at the Annual Symposium on 58. Psillakis JM, Rumley TO, Camargos A. Subperiosteal 69a. Mendelson BC, Freeman ME, Wu W, Huggins RJ. Notre traitement chirurgical. Bull Acad Med (Paris) Aesthetic Plastic Surgery, Guadalajara, Mexico, approach as an improved concept for correction of the Surgical anatomy of the lower face: The premasseter 1924;92:1270. October; 1974. aging face. Plast Reconstr Surg. 1988;82:383. space, the jowl, and the labiomandibular fold. Aesthetic 16. Bourguet J. Chirurgie esthetique de la face. Les nez 38. Connell BF. Cervical lifts: the value of platysma muscle 59. Ramirez OM, Maillard GF, Musolas A. The extended Plast Surg. 2008;32:185. subperiosteal facelift: a definitive soft tissue concaves, les rides et les “poches” sous les yeux. Arch flaps. Ann Plast Surg. 1978;1:34. 70. Coleman SR. Facial recontouring with lipostructure. remodeling for facial rejuvenation. Plast Reconstr Surg. Prov Chir 1925;28:293. 39. Guerrero-Santos J. The role of the platysma muscle in Clin Plast Surg. 1997;24(2):347. 1991;88:227. 17. Noel A. La chirurgie esthetique: son role social. Paris: rhytidoplasty. Clin Plast Surg. 1978;5:29. A pioneer of facial fat grafting presents early experience 60. Little JW. Three-dimensional rejuvenation of the Masson et Cie; 1926. 40. Guerrero-Santos J. Surgical correction of the fatty fallen with lipoinjection of the face. midface: volumetric resculpture by malar imbrication. 18. Miller CC. The correction of featural imperfections. neck. Ann Plast Surg. 1979;2:389. Plast Reconstr Surg. 2000;105:267. 71. Lambros V. Observations on periorbital and midface Chicago: Oak Printing Company; 1907. 41. Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast Plast Reconstr Surg 61. Fitzgerald R, Graivier MH, Kane M, et al. Update on aging. . 2007;120:1367. Surg. 1979;3:529. 19. Miller CC. The excision of bag-like folds of skin from facial aging. Aesthetic Surg J. 2010;30(Suppl 1):11S–23S. 72. Little JW. Volumetric perceptions in midfacial aging the region about the eyes. Med Brief 1906;34:648. 42. Lemmon ML, Hamra ST. Skoog rhytidectomy: a 62. Kligman LH. Photoaging. Manifestations, prevention, with altered priorities for rejuvenation. Plast Reconstr five-year experience with 577 patients. Plast Reconstr 20. Miller CC. Semilunar excision of the skin at the outer and treatment. Dermatol Clin. 1986;4(4):517. Surg. 2000;105:252. canthus for the eradication of crow’s feet. Am J Surg. 1980;65:283. 63. Raskin E, LaTrenta GS. Why do we age in our cheeks? 73. Mitz V, Peyronie M. The superficial Dermatol. 1907;11:483. 43. Kaye BL. The extended neck lift: the “bottom line”. Aesthetic Surg J. 2007;27(1):19. musculoaponeurotic system (SMAS) in the parotid Plast Reconstr Surg. 1980;65:429. and cheek area. Plast Reconstr Surg. 1976;58:80. 21. Miller CC. Cosmetic surgery: the correction of featural 64. Rohrich RJ, Pessa JE. The fat compartments of the face: imperfections. Chicago: Oak Printing Company; 1908. 44. Kaye BL. The extended face-lift with ancillary anatomy and clinical implications for cosmetic surgery. This paper is the first description of the superficial 22. Miller CC. Cosmetic surgery: the correction of featural procedures. Ann Plast Surg. 1981;6:335. Plast Reconstr Surg. 2007;119:2219–2227. musculoaponeurotic system. imperfections, 2nd ed. Philadelphia: FA Davis; 1925. 45. Furnas D. The retaining ligaments of the cheek. Plast Anatomic dissections are presented which demonstrate how 74. Gosain AK, Yousif NJ, Madiedo G, et al. Surgical 23. Kolle FS. Plastic and cosmetic surgery. New York: Reconstr Surg. 1989;83:11. the subcutaneous fat of the face is partitioned into multiple, anatomy of the SMAS: a reinvestigation. Plast Reconstr Appleton; 1911. 46. Stuzin JM, Baker TJ, Gordon HL. The relationship of independent anatomical compartments. In some locations, Surg. 1993;92:1254. 24. Bettman AG. Plastic and cosmetic surgery of the face. the superficial and deep facial fascias: relevance to the septae dividing the fat compartments are aligned with 75. Barton Jr FE. The SMAS and the nasolabial fold. Plast Northwest Med 1920;19:205. rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441. retaining ligaments. Reconstr Surg. 1992;89:1054. References 207.e3 207.e4 SECTION I •11.1• Facelift: Principles

76. Saulis AS, Lautenschlager EP, Mustoe TA. suborbital trough deformity. Plast Reconstr Surg. 108. Coleman SR. Long-term survival of fat transplants: This text is a comprehensive review of the history, basic Biomechanical and viscoelastic properties of skin, 2000;106:479. controlled demonstrations. Aesthetic Plast Cur. science and technical details of fat harvest and fat injection. SMAS, and composite flaps as they pertain to 92. Bartlett SP, Grossman R, Whitaker LA. Age-related 1995;19:421. 130. Trepsat F. Volumetric facelifting. Plast Reconstr Surg. rhytidectomy. Plast Reconstr Surg 2002;110:590. changes of the craniofacial skeleton: an anthropometric 109. Lambros V. Fat injection for aesthetic facial 2001;108(5):1358. 77. Furnas DW. Festoons, mounds, and bags of the eyelids and histologic analysis. Plast Reconstr Surg. 1992;90:592. rejuvenation. Aesthetic Surg J. 1997;17(3):190–191. 131. Roberts TL, Pozner JN, Ritter E. The RSVP facelift: A and cheek. Clin Plast Sur. 1993;20:367–385. 93. Shaw RB, Katzel E, Koltz P, et al. Aging of the 110. Guyuron B, Watkins F, Totonchi A. Modified temporal highly vascular flap permitting safe, simultaneous, 78. Lowe JB, Cohen M, Hunter RT, Mackinnon SE. mandible and its aesthetic implications: a three incision for facial rhytidectomy: an 18 year experience. comprehensive facial rejuvenation in one operative Analysis of the nerve branches to the orbicularis oculi dimensional CT study. Plat Reconstr Surg. Plast Reconstr Surg. 2005;115(2):609–616. setting. Aesthetic Plast Surg. 2000;24:313. muscle of the lower eyelid in fresh cadavers. Plast 2010;125:332–342. 111. Marten TJ. Facelift planning and technique. Clin Plast 132. Hester TR, Codner MA, McCord CD. Subperiosteal Reconstr Surg. 2005;116(6):1743. 94. Kahn DM, Shaw RB. Aging of the bony orbit: a Surg. 1997;24(2):269–308. malar cheeklift with lower lid blepharoplasty. In: Eyelid 79. Salinas NL, Jackson O, Dunham B, Bartlett SP. three-dimensional computed tomographic study. This review article covers the planning, surgical marking surgery: principles and techniques. New York: Lippincott- Anatomical dissection and modified Sihler stain of the Aesthetic Surg J. 2008;28(3):258–264. and technical details of two layer facelift surgery. Details Raven; 1995. lower branches of the facial nerve. Plast Reconstr Surg. 95. Tzafetta K, Terzis J. Essays on the facial nerve: Part I. regarding the skin incisions are emphasized. 133. Moelleken B. The superficial subciliary cheeklift, a 2009;124(6):1905–1915. Microanatomy. Plast Reconstr Surg. 2010;125(3): 112. Camirand A, Doucet J. A comparison between parallel technique for rejuvenating the infraorbital region and 80. Stuzin JM, Baker TJ, Gordon HL. The relationship 879–889. hairline incisions and perpendicular incisions when nasojugal groove: a clinical series of 71 patients. Plast of the superficial and deep facial fascias: relevance The authors review facial nerve anatomy and present performing a facelift. Plast Reconstr Surg. 1997;99(1): Reconstr Surg. 1999;104:1863. to rhytidectomy and aging. Plast Reconstr Surg. anatomic findings which confirm extensive arborization 10–15. 134. Le Louarn C. The concentric malar lift: malar and 96 1992;89:441. between facial nerve branches. The discussion by Stuzin 113. Tonnard PL, Verpaele AM. The MACS-lift short scar lower eyelid rejuvenation. Aesthetic Plast Surg. Anatomic dissections confirm the presence of retaining highlights clinically important issues. rhytidectomy. St Louis: Quality Medical; 2004. 2004;28(6):359–372. ligaments previously described by other authors as well as 96. Stuzin JM. Discussion: essays on the facial nerve: Part 114. Connell BF, Marten TJ. Deep layer techniques in 135. Hester Jr TR, Codner MA, McCord CD, et al. Evolution newly described masseteric ligaments. The authors discuss I. Microanatomy. Plast Reconstr Surg. cervicofacial rejuvenation. In: Psillakis J, ed. Deep of technique of the direct transblepharoplasty the support these structures supply between fixed bone and 2010;125(3):890–892. face-lifting techniques. New York: Thieme; 1994. approach for the correction of lower lid and midfacial deep fascia and the superficial fascia. aging: maximizing results and minimizing 97. Davis RA, Anson BJ, Budinger JM, et al. Surgical 115. Baker DC. Minimal incision rhytidectomy (short scar complications in a 5-year experience. Plast Reconstr 81. Mendelson BC, Jacobson SR. Surgical anatomy of the anatomy of the facial nerve and parotid gland based facelift) with lateral SMASectomy. Aesthet Surg J. Surg. 2000;105:393. midcheek; facial layers, spaces, and midcheek upon a study of 350 cervicofacial halves. Surg Gynecol 2001;21(1):68–79. segments. Clin Plast Surg. 2008;35:395–404. 136. Austin HW. The lip lift. Plast Reconstr Surg. 1986;77:990. Obstet. 1956;102:385–412. 116. Marchac D, Brady J, Chiou P. Facelifts with hidden 82. Lore JM. An atlas of head and neck surgery, Vol. 2, 2nd 98. Agarwal CA, Mendenhall 3rd SD, Foreman KB, et al. scars: the vertical U incision. Plast Reconstr Surg. 137. Austin HW, Weston GW. Rejuvenation of the aging ed. Philadelphia: Saunders; 1973:596–597. The course of the frontal branch of the facial nerve in 2002;109(7):2539–2551. mouth. Clin in Plast Surg. 1992;19:511. 83. Labbe, D, Franco, RG, Nicolas J. Platysma suspension relation to fascial planes: an anatomic study. Plast and 117. Marten TJ. Facelift. Planning and technique. Clin Plast 138. Baker DC, Aston SJ, Guy CL, et al. The male during neck lift. Plast Reconstr Surg. Reconstr Surg. 2010;125:532–537. Surg. 1997;24(2):269–308. rhytidectomy. Plast Reconstr Surg. 1977;60:514. 2001;117(6):2001–2010. 99. Pitanguy I, Ramos AS. The frontal branch of the facial 118. Fogli A. Skin and platysma muscle anchoring. Aesthetic 139. Baker DC, Stafani W, Dhiu ES. Reducing the incidence 84. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of nerve: the importance of its variations in facelifting. Plast Surg. 2008;32(3):531–541. of hematoma requiring surgical evacuation following the superficial musculoaponeurotic system and Plast Reconstr Surg. 1966;38:352–256. male rhytidectomy: a 30 year review of 985 cases. Plast 119. Tonnard P, Verpaele A, Monstrey S, et al. Minimal characterization of the orbitomalar ligament. Ophthal 100. Gosain AK, Sewall SR, Yousif NJ. The temporal branch Reconstr Surg. 2005;116(7):1973–1985. Plast Reconstr Surg. 1996;12:77. access cranial suspension lift: a modified S-lift. Plast of the facial nerve: how reliably can we predict its Reconstr Surg 2002;109:2074–2086. 140. Grover R, Jones BM, Waterhouse N. The prevention of 85. Mendelson BC, Muzaffar AR. Surgical anatomy of the path? Plast Reconstr Surg 1997;99:1224. haematoma following rhytidectomy: a review of 1078 120. Courtiss EH. Suction lipectomy of the neck. Plast midcheek and malar mounds. Plast Reconstr Surg. facelifts. Br J Plast Surg. 2004;54:481. 101. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The Reconstr Surg. 1985;76:882. 2002;119:885. anatomy and clinical applications of the buccal fat pad. 141. Jones BM, Grover R. Avoiding hematoma in 121. Vistnes AM, Souther SG. The anatomical basis for 86. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy Plast Reconstr Sur. 1990;85:29. cervicofacial rhytidectomy: a personal 8-year quest. common cosmetic anterior neck deformities. Ann Plast of the ligamentous attachments in the temple and Reviewing 910 patients. Plast Reconstr Surg. 102. Nelson DW, Gingrass RP. Anatomy of the mandibular Surg. 1979;2:381. periorbital regions. Plast Reconstr Surg 2000;105:1475. branches of the facial nerve. Plast Reconstr Surg 2004;113:381. 122. DeCastro CC. The anatomy of the platysma muscle. 87. Mustoe, TA, Rawlani V, Zimmerman H. Modified deep 1979;64:479. The authors review a large facelift series where the most Plast Reconstr Surg. 1980;66(5):680. plane rhytidectomy with a lateral approach to the 103. Ellenbogen R. Pseudo-paralysis of the mandibular common complication of facelift surgery, hematoma, is neck: an alternative to submental incision and branch of the facial nerve after platysmal face-lift 123. Knize DM. Limited incision submental lipectomy and addressed. Variables thought to influence the formation of dissection. Plast Reconstr Surg. 2011;127(1):357–370. operation. Plast Reconstr Surg. 1997;63:364–368. platysmaplasty. Plast Reconstr Surg. 1998;101:473. hematoma were reviewed, including the use of dressings, 88. Jelks GW, Jelks EB. The influence of orbital and eyelid 104. Rohrich R, Taylor NS, Ahmad J, et al. Great auricular 124. Feldman JJ. Neck lift. St Louis: Quality Medical; 2007. drains, soft tissue adhesives and epinephrine. anatomy on the palpebral aperture. 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Reconstr Surg. 1980;66:675. submandibular gland resection for facial rejuvenation. in face-lift surgery. Arch Facial Plast Surg. 90. Pessa JE, Chen Y. Curve analysis of the aging orbital 106. Kruger JK, Rohrich RJ. Clearing the smoke: the Plast Reconstr Surg 2003;112:1150–1154. 2008;10(2):116–123. aperture. Plast Reconstr Surg. 2002;109(2):751–755. scientific rationale for tobacco abstention with plastic 127. Zins J, Fardo D. The “anterior-only” approach to neck 144. Ullman Y, Levy Y. Superextended facelift: our 91. Pessa JE. An algorithm of facial aging: verification of surgery. Plast Reconstr Surg. 2001;108:1063–1073. rejuvenation: an alternative to facelift surgery. Plast experience with 3,580 patients. Ann Plast Surg. Lambros’s theory by three-dimensional 107. Rees TD, Liverett DM, Guy CL. The effect of cigarette Reconstr Surg. 2005;115(6):1761–1768. 2003;52:8. stereolithography, with reference to the pathogenesis smoking on skin flap survival in the facelift patient. 128. Gradinger GP. Anterior cervicoplasty in the male 145. Matarasso A, Elkwood A, Rankin M, Elkowitz M. of midfacial aging, scleral show, and the lateral Plast Reconstr Surg. 1984;73:911. patient. Plast Reconstr Surg 2000;106:1146. National Plastic Surgery Survey: face lift techniques 129. Coleman SR. Structural fat grafting. St Louis: Quality and complications. Plast Reconstr Surg. Medical; 2004. 2000;106(5):1185–1195. SECTION I Aesthetic Surgery of the Face Subcutaneous facelift 209

11.2 Facelift: Introduction to deep tissue techniques

Richard J. Warren

described. In this chapter the standard methods available to SYNOPSIS elevate and rearrange the deep soft tissues of the face are ᭿ In its pure form, the subcutaneous, skin-only facelift has a limited outlined; in the coming chapters, they will be described in effect on the position of heavier deep tissue. detail by authors who developed these techniques, or by ᭿ In SMAS plication, a skin flap is created with suture manipulation authors who use them routinely. The subcutaneous facelift of the superficial fat and the underlying SMAS/platysma. is included here for comparison purposes, although in its ᭿ In loop suture techniques (MACS lift), a skin flap is created with classic form, there is no attempt to address the deeper tissues of the face. long suture loops taking multiple bites of superficial fat and Fig. 11.2.1 Subcutaneous facelift. platysma – fixed to a single point on the deep temporal fascia. ᭿ The supraplatysma plane creates a single flap of skin and superficial fat mobilized and advanced along the same vector. Subcutaneous facelift line can cause malposition of the hairline, alopecia, distorted ligaments which in this technique are not released. When the earlobes, widened scars, and the potential for skin flap subcutaneous fat is fragile, suture fixation may fail, and plica- ᭿ SMASectomy involves a skin flap plus excision of superficial fat necrosis. tion may have a limited effect in patients with heavy jowls and SMAS from the angle of the mandible to the malar The “skin-only” facelift (Fig. 11.2.1) is used to tighten loose and ptotic tissues in the neck. prominence, with direct suture closure of the resulting defect. facial skin by advancing a random pattern skin flap and ᭿ A SMAS flap raised with skin attached (deep plane) creates a flap removing the excess. By definition, there is nothing done to SMAS plication of SMAS/platysma, superficial fat and skin, all mobilized and the deep facial tissues. A tried and true technique, this method Loop sutures (MACS lift) advanced along the same vector. can be effective when the only significant problem is loose After surgeons learned to raise a large random pattern skin skin. For example, some patients with very thin faces and little flap, it became apparent that facial shape could be changed A variation of suture plication is the loop suture method ᭿ A separate SMAS flap (dual plane) creates two flaps, the skin flap or no subcutaneous fat may present with loose skin only. It is by using sutures to manipulate the underlying soft tissue.1 (Fig. 11.2.3), for which the main variant is the MACS and the superficial fat/SMAS/platysma, which are advanced along also useful in secondary or tertiary situations where deep Suture plication creates an infolding of the superficial fat, lift (minimal access cranial suspension). This procedure, two different vectors. tissues have previously been repositioned and the presenting drawing fat from the lower in the face up to the point which itself was derived from the “S-lift”, relies on long ᭿ The subperiosteal lift involves dissection against bone, with problem is a recurrence of skin laxity. In that setting, a short where the sutures are placed. Areas of fixed tissue, such as the suture loops which take multiple small bites of soft tissue.4,5 mobilization and advancement of all soft tissue elements. scar approach will often suffice. Advantages of the skin-only fixed SMAS (Fig. 11.2.2) over the parotid gland are less Some of these bites are strategically placed into the SMAS facelift include its simplicity, a rapid postoperative recovery, movable, and can act as an anchoring point; anterior to the and platysma. The loop sutures are fixated to the deep and the use of a dissection plane which does not risk damage parotid, mobile tissues can be easily manipulated.2 Multiple temporal fascia at a point just superior to the zygomatic Introduction to the facial nerve or other deep structures. Disadvantages sutures with customized vectors can be used allowing reshap- arch and anterior to the ear. The theoretical explanation include: a minimal effect on underlying facial shape and the ing of the superficial facial fat. The technique is relatively easy for the efficacy of this technique relates to the use of multiple In the previous chapter, the generic subcutaneous “skin-only” inherent disadvantage that skin is an elastic structure which to master; it can be customized for the individual case, and bites of tissue which the developers of the technique facelift was described. However, as reviewed in Chapter 6, the will stretch when tension is applied. Therefore, the longevity can be modified intraoperatively by removing and replacing feel creates “microimbrications” of the superficial fat and anatomy of facial aging is a complex process involving all of effect is in question, especially when the skin is used to sutures as necessary. The superficial fat can be shifted in a SMAS.5 Anteriorly, a third suture can be placed to advance layers of the face from the skin through to the bone. Logically, reposition heavy facial tissues. Unfortunately, if the surgeon different direction than the skin. When plication sutures are the malar fat pad, although the fat pad is not surgically surgical rejuvenation of the aging face should address all or increases skin tension in a misguided attempt to reposition placed properly, there is little or no risk to branches of the released and its repositioning depends on its own intrinsic most of these tissue layers. To this end, rejuvenation of the ptotic deep tissue, the shape of the face can be distorted. Skin facial nerve. Proponents of plication claim long-lasting results mobility. Treatment of the neck usually involves closed skin is reviewed in Chapter 5. Within the soft tissue of the tension will flatten facial shape, negating the rounded con- without the need for invasive and potentially dangerous dis- liposuction. Proponents of this technique recommend a nearly face, the two principle age-related changes are loss of midface tours of youth. Also patients in the facelift age group have sections.3 The primary concern with plication is the potential vertical vector for the skin flap, with a short scar incision. volume and soft tissue descent. (Surgical methods to add usually lost elasticity in their skin and therefore, with tension, loss of effect if sutures cut through the soft tissue (the “cheese The advantages with this technique are similar to those of volume are described in Chapters 14 and 15.) With regard to are prone to a stretched look with wrinkles re-oriented in wire” effect). Another concern is that the degree of improve- plication, although proponents point to the added benefit of soft tissue descent, a host of surgical approaches have been abnormal directions. Lastly, excess skin tension at the incision ment may be limited by the tethering effect of the retaining using a more firm point of fixation (deep fascia) and the ©2013, Elsevier Inc. All rights reserved. 210 SECTION I •11.2• Facelift: Introduction to deep tissue techniques Supra-platysmal plane facelift 211

SMAS/platysma Superficial fat

ESP dissection

SMAS/platysma

B

Area of skin and subcutaneous fat A elevation in extended supraplatysmal plane (ESP) Fig. 11.2.4 Supra-platysmal plane (ESP lift).

Fig. 11.2.2 Subcutaneous flap with SMAS plication. Fig. 11.2.3 Subcutaneous flap with loop sutures (MACS lift).

Compared with a SMAS flap, the procedure is more rapid, incised, and the rest of the dissection is done deep to the with less theoretical risk to the facial nerve because there is SMAS as far as the zygomaticus major muscle from which the improved effect of micro-imbrications. Disadvantages are the released, and it produces a thick very robust flap. Also, with no deep plane dissection. Proponents feel that fixation is effec- SMAS is released. The skin and subcutaneous fat are left same as SMAS plication: potential loss of effect if the sutures no surgical penetration of the underlying SMAS, there is theo- tive because the location of the SMASectomy resection is attached to the SMAS and the entire flap is then advanced and pull through, the lack of ligamentous release and concerns retically no risk to branches of the facial nerve. Concerns roughly at the junction of the mobile SMAS, which allows fixated as the surgeon desires. Advantages of this technique about the effectiveness of sutures holding heavy jowls and about this method are that the flap is unidirectional (the skin mobile tissue to be sutured to the fixed SMAS. Disadvantages are the robustness and physical strength of the flap, and the ptotic neck tissues against gravity. Lastly, surgeons must and fat move en bloc), and the fact that repositioning the include the possibility of injuring a facial nerve branch (if the requirement for only one plane of dissection. Ligaments are address the tendency for loop sutures to cause fat to bunch weight of this flap depends primarily on skin tension at the SMAS removal is done too deeply) and the lack of any liga- also thoroughly released. Certain variations of the technique up, potentially leaving bulges which can be visible through suture line. mentous release, which may limit the movement of certain also allow for repositioning of the malar fat pad.10,13 the skin. tissues such as the malar fat pad. Disadvantages include the inherent risk of dissecting under Subcutaneous facelift with SMAS the SMAS with the potential for damage to the facial nerve. Also, these procedures are “monobloc” techniques where the removal (SMASectomy) SMAS flap with skin attached skin, subcutaneous fat and SMAS are generally moved in one Supra-platysmal plane facelift direction. In the SMASectomy procedure (Fig. 11.2.5), a strip of SMAS (deep plane facelift) The supra-platysmal plane facelift (Fig. 11.2.4) involves a deep and overlying fat is removed with direct suture closure of the subcutaneous dissection carried out immediately superficial resulting defect.7 The excised strip angles obliquely across the Tord Skoog, in 1974, published his method of raising skin, to the SMAS and platysma. Originally described as the cheek from the angle of the mandible to the lateral malar subcutaneous fat, and the SMAS as a single layer which Subcutaneous facelift with separate SMAS extended supra-platysmal (ESP) dissection plane, this proce- eminence at the edge of the malar fat pad. The procedure has created a thick robust flap with excellent blood supply. It also flap (dual plane facelift) dure raises the superficial fat and skin as a single layer, leaving been described after using either a conventional facelift inci- contained a stretch-resistant structure (the SMAS), with the the SMAS layer untouched. The zygomatic ligaments are sion or a short scar approach. Advantages include the fact that promise of a long-lasting result.8 Originally, there was limited Surgeons wishing to move the SMAS and subcutaneous fat in released as dissection of the superficial facial fat extends over the location of traction is close to the ptotic lower facial tissues, improvement in the anterior face with little or no change to a different direction than the skin arrived at the concept of the malar prominence as far forward as the nasolabial folds. and therefore potentially more effective than a SMAS flap the nasolabial fold. This lack of anterior movement was two separate flaps: the random pattern facelift skin flap and The theory behind this technique is the belief that the super- raised at a higher level. The technique allows for skin and later found to be due to tethering of the SMAS to the lip eleva- an SMAS flap carrying the superficial fat (Fig. 11.2.7). Multiple ficial fat is a ptotic structure, but the underlying SMAS and SMAS to be moved along different vectors. By suturing two tors: zygomaticus major and minor, and levator labii superi- variations of this popular concept have been developed with platysma are not.6 After the flap has been raised, the fat on opposing freshly cut edges, fixation is potentially more secure oris.9 In order to overcome some of these shortcomings, terminology introduced by different authors (extended SMAS: the underside of the flap can by contoured and sutures can than plication alone. The cut edges being sutured have not multiple variations have been developed (Barton: high SMAS; Stuzin; high SMAS: Connell and Marten; FAME: Aston).14–22 also be placed from this fat to underlying fixation points. This been undermined, potentially making them more viable, and Hamra: deep plane) (Fig. 11.2.6).10–13 The skin is normally As in plication, MACS and SMASectomy, proponents of this technique provides good mobilization because ligaments are the resulting fixation more secure than undermined flaps. raised for only 2–3 cm anterior to the tragus, the SMAS is then method feel that that moving the skin and subcutaneous soft 212 SECTION I •11.2• Facelift: Introduction to deep tissue techniques Summary 213

Subperiosteal facelift

Paul Tessier, in 1979, first presented his concept for a subpe- riosteal approach using craniofacial principles to elevate facial tissue.23,24 Variations were developed,25,26 but it was not until the introduction of the endoscope that surgeons widely adopted this concept (Fig. 11.2.8). Approaching from the temple, the midface can be dissected 27,28 29,30 Subgaleal in either the subperiosteal or supra-periosteal plane. dissection Added exposure can be achieved with a lower eyelid or an Subcutaneous tunnel intra-oral incision. The advantages are a dissection which is superior to arch Lateral SMASectomy deep to all vital structures, a relatively short incision, and Subcutaneous extends from tail of dissection 4cm parotid to lateral harmonious lifting of the midface and lateral brow. There is Only skin expected canthus little or no tension on the skin thus eliminating problems from to be removed is undermined excess tension on the skin. Some surgeons feel this technique Resection is at interface of fixed and mobile SMAS. is uniquely advantageous for the patient requiring improve- Width of resection ment in the infraorbital midface in conjunction with lateral determined by SMAS laxity and desired de-bulking browlifting. The younger patient who requires midface improvement without skin tightening has been proposed as a Undermining posterior border good candidate for this technique. Disadvantages of subperio- of platysma for advancement steal lifting include the additional technology and equipment to mastoid involved, a limited effect in the lower face/neck region and limited effect on superficial structures, particularly loose skin. Furthermore, the early aging midface which seems suited to this technique may in fact be due to volume loss, a problem Subcutaneous dissection of neck from which can be correctable with less invasive procedures such mastoid to midline superficial to platysma as fat grafting. Fig. 11.2.5 Subcutaneous flap with SMAS excision (SMASectomy). Summary

Multiple techniques have been devised to elevate and reposi- tion tissues in the aging face. In the following chapters, leading surgeons will address two issues: first, they describe how they handle the deep tissues of the face, and second, they explain tissues along different vectors will result in a more accurate the logic behind their own particular technique. This is a field reversal of the aging process. Typically, the deep tissue flap is where personal opinions are strong, and at the time of this shifted more vertically than the skin flap. A second advantage writing, the greatest difference of opinion among facelift sur- Upper lateral Temporal branch, corner of SMAS facial nerve is the ability to reposition deep facial tissues by mobilizing geons relates to the various methods used to manipulate deep remains attached and fixating the SMAS flap internally without the need to rely facial tissue. All surgeons have been striving for the same to skin on skin tension for support. Theoretically, the disadvantages objective: a procedure which will be effective, have a rela- of excess skin tension are therefore avoided. Also, as in the tively a long-lasting result, and a high margin of safety. Over SMAS incision deep plane technique, ligaments are surgically released, the years, a number of studies have been done to compare resulting in excellent mobilization and advancement for the different facelift techniques.31–40 In order to assess the available Dissection from SMAS and overlying fat. Disadvantages relate to a more time- data, a systematic review of the world literature over a 60-year beneath SMAS over zygomaticus consuming procedure because two different surgical planes period was made in an attempt to locate reliable studies which major thus releasing are developed. In addition, these two planes introduce the could attest to the efficacy and safety of one method over restraint of investing inherent problems of each: potential damage to deep structure another.41 Despite this exhaustive review, no clear indication fascia when doing the SMAS flap dissection, and potential problems could be found that any one facelift technique was superior with the skin flap if it is too thinly dissected or if it is placed to the others. Therefore, surgeons must continue to use their on too much tension. In a thin patient, both layers can be quite own judgment for technique selection based on their patient’s Marginal mandibular thin, which increases the technical demands placed on the needs, balanced against their personal convictions about branch of facial nerve surgeon. quality, longevity and safety.

Fig. 11.2.6 SMAS flap with skin attached (deep plane facelift). 214 SECTION I •11.2• Facelift: Introduction to deep tissue techniques Summary 215

Access the complete references list online at http://www.expertconsult.com

3. Berry MG, Davies D. Platysma-SMAS plication Facelift. records were reviewed using the nasolabial fold as an J Plast Reconstr Aesthetic Surg. 2010;63(5):793–800. indicator of surgical result 6 months after surgery. Using this The authors describe their logic for using soft tissue plication hard endpoint, improvement was almost universally achieved and describe their particular method, called the PSP lift with a low complication rate. Recommendations are made as (platysma SMAS plication). A series of 117 consecutive to the extent of dissection required based on depth of the patients is reported, all of whom were followed objectively nasolabial fold. with a 5-point scale. There was excellent improvement with a 17. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS low complication rate: 3.4% hematoma and 3.4% transient dissection as an approach to midface rejuvenation. Clin facial nerve palsies. Plast Surg. 1995;22(2):295. 5. Tonnard P, Verpaele A, Monstrey S, et al. Minimal This review article outlines the authors’ understanding access cranial suspension lift: a modified S-Lift. Plast of facial anatomy as it pertains to facelift surgery, their Reconstr Surg. 2002;109:2074. understanding of facial aging, and it describes their surgical procedure in detail. The procedure is called the extended The authors report that in 1999, they modified the previously SMAS dissection because it involves raising the malar fat described S-lift to include improved suture fixation and soft pad in conjunction with the SMAS flap. The authors tissue elevation, which they named the MACS lift, an emphasize the importance of flap fixation in order to create acronym for minimal access cranial suspension. Two long a long lasting result. loop sutures are used to elevate facial soft tissue with fixation to the deep temporal fascia above the zygomatic arch and a 18. Marten TJ. High SMAS facelift: combined single flap third suture is used for the malar fat pad in the extended lifting of the jawline, cheek, and midface. Clin Plast version of the procedure. A total of 88 patients over 20 Surg. 2008;35(4):569–603. months were presented with a low complication rate. The The review article outlines the author’s logic in utilizing operative technique is described in detail. a two layer facelift, emphasizing that skin has a covering function, and that deep tissue manipulation is necessary for 6. Hoefflin SM. The extended supraplatysmal plane (ESP) facial reshaping. The high SMAS facelift is described in face lift. Plast Reconstr Surg. 1998;101:494. detail, with emphasis on skin incisions, and the proper The author presents his logic behind using a facelift flap, selection of vectors. Fig. 11.2.7 Subcutaneous facelift with separate SMAS flap (dual plane facelift). which contains skin and all the subcutaneous fat down to, 28. Ramirez OM, Maillard GF, Musolas A. The extended but not including the SMAS. The technique is described subperiosteal face lift: A definitive soft-tissue in detail and the results with a series of 300 patients are remodeling for facial rejuvenation. Plast Reconstr Surg. presented. There was high patient satisfaction reported, no 1991;88:227. nerve injuries and relatively rapid recovery. 7. Baker D. Lateral SMASectomy. Plast Reconstr Surg. The authors’ experience with subperiosteal facelift techniques 1997;100(2):509. is reviewed. Pertinent points include: (1) using an interconnected subperiosteal approach which involve the The author presents his personal evolution in arriving at the entire zygomatic arch; (2) utilizing upward pull of the SMASectomy technique, describing his logic in doing so, muscles of facial expression to elevate the mouth; (3) keeping and reports a series of 1500 cases over 5-year period. One the dissection deep in the temple to protect the temporal transient buccal branch injury was encountered. The author branch, and (4) utilizing the temporal fascia as a lifter and feels this technique affords a safe, effective technique, but anchoring point. acknowledges that other techniques also produce excellent results. 41. Chang S, Pusic A, Rohrich RJ. A systematic review of comparison of efficacy and complications rates among 8. Skoog T. Plastic surgery. Philadelphia: WB Saunders; face-lift techniques. Plast Reconstr Surg. 2011;127(1): 1974. 423–433. SOOF In this classic text, the author describes the first technique to This paper presents the results of a systematic review utilize the sub-SMAS plane to elevate ptotic facial tissue. that assessed all studies in the English language literature Illustrations effectively convey the basics of this new from 1950 until 2009 in which there was a comparison Fronto-temporal approach Intraoral technique. incision of facelift techniques. There were 57 studies identified; 13. Barton FE Jr, Hunt J. The high-superficial aponeurotic only 10 of these directly compared the efficacy of different Intraoral approach Subcutaneous system technique in facial rejuvenation: an update. Plast facelift techniques. The study found there to be a lack of dissection Reconstr Surg. 2003;112:1910. quality data regarding the efficacy and safety of facelift BF Submental approach This is a follow-up of a previous publication by Barton, which techniques and concluded that there was no evidence described his variation for a SMAS-based facelift technique to support the use of any one facelift technique over called the high SMAS technique. In this paper, 267 patient another.

Fig. 11.2.8 Subperiosteal facelift. References 215.e1 215.e2 SECTION II •11.2• Facelift: Introduction to deep tissue techniques

9. Barton FE Jr. The SMAS and the nasolabial fold. Plast 22. Warren RJ. The oblique SMAS with malar fat pad fixation in face lifts. Plast Reconstr Surg. 1977;60: References Reconstr Surg. 1992;89:1054. elevation. Presented at the Canadian Society for 851–859. 10. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. Aesthetic Plastic Surgery 29th Annual Meeting, Toronto, 33. Webster RC, Smith RC, Papsidero MJ, et al. Comparison 1. Aufricht G. Surgery for excess skin of the face. In: 1992;90:1. Ontario, 2002. of SMAS plication with SMAS imbrication in face Transactions of the Second International Congress of Plastic 11. Hamra ST. The zygorbicular dissection in composite 23. Tessier P. Facial lifting and frontal rhytidectomy. In: lifting. Laryngoscope. 1982;92:901–912. and Reconstructive Surgery. Edinburgh: E& S Livingstone; rhytidectomy: an ideal midface plane. Plast Reconstr Fonseca J, ed. Transactions of the VII International 34. Ivy EJ, Lorenc ZP, Aston SJ. Is there a difference? 1960. Surg. 1998;102:1646. Congress of Plastic and Reconstructive Surgery. Rio de A prospective study comparing lateral and standard 2. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS 12. Barton FE Jr. Rhytidectomy and the nasolabial fold. Janeiro: Cartgraf; 1979:393–396. SMAS face lifts with extended SMAS and composite plication for the treatment of prominent Plast Reconstr Surg. 1992;90:601. 24. Tessier P. The subperiosteal facelift. Ann Chir Plast rhytidectomies. Plast Reconstr Surg. 1996;98:1135–1147. nasomandibular folds and restoration of normal cheek 13. Barton FE Jr, Hunt J. The high-superficial aponeurotic Esthet. 1989;34:193. 35. Kamer FM, Frankel AS. SMAS rhytidectomy versus contour. Plast Reconstr Surg. 1995;96(6):1279–1287. system technique in facial rejuvenation: an update. 25. Psillakis JM, Rumley TO, Camargos A. Subperiosteal deep plane rhytidectomy: An objective comparison. 3. Berry MG, Davies D. Platysma-SMAS plication Facelift. Plast Reconstr Surg. 2003;112:1910. approach as an improved concept for correction of the Plast Reconstr Surg. 1998;102:878–881. J Plast Reconstr Aesthetic Surg. 2010;63(5):793–800. This is a follow-up of a previous publication by Barton, which aging face. Plast Reconstr Surg. 1988;82:383. 36. Becker FF, Bassichis BA. Deep-plane face-lift vs The authors describe their logic for using soft tissue plication described his variation for a SMAS-based facelift technique 26. De la Plaza R, Valiente E, Arroyo JM. Supraperiosteal superficial musculoaponeurotic system plication and describe their particular method, called the PSP lift called the high SMAS technique. In this paper, 267 patient lifting of the upper two-thirds of the face. Br J Plast face-lift: A comparative study. Arch Facial Plast Surg. (platysma SMAS plication). A series of 117 consecutive records were reviewed using the nasolabial fold as an Surg. 1991;44:325. 2004;6:8–13. patients is reported, all of whom were followed objectively indicator of surgical result 6 months after surgery. Using this 27. Hinderer UT. The sub-SMAS and subperiosteal 37. Zager WH, Dyer WK. Minimal incision facelift. with a 5-point scale. There was excellent improvement with hard endpoint, improvement was almost universally achieved rhytidectomy of the forehead and middle third of the Facial Plast Surg. 2005;21:21–27. a low complication rate: 3.4% hematoma and 3.4% transient with a low complication rate. Recommendations are made face: a new approach to the aging face. Facial Plast Surg. 38. Prado A, Andrades P, Danilla S, et al. A clinical facial nerve palsies. as to the extent of dissection required based on depth of the 1992;8:18. retrospective study comparing two short-scar face 4. Saylan Z. The S-lift: less is more. Aesthetic Surg J. nasolabial fold. 28. Ramirez OM, Maillard GF, Musolas A. The extended lifts: Minimal access cranial suspension versus 1999;19:406. 14. Owsley JQ. Platysma-fascial rhytidectomy. Plast Reconstr subperiosteal face lift: A definitive soft-tissue lateral SMASectomy. Plast Reconstr Surg. 2006;117: 5. Tonnard P, Verpaele A, Monstrey S, et al. Minimal Surg. 1977;60:843. remodeling for facial rejuvenation. Plast Reconstr Surg. 1413–1427. access cranial suspension lift: a modified S-Lift. Plast 15. Connell BF. Eyebrow, face, and neck lifts for males. 1991;88:227. 39. Antell DE, Orseck MJ. A comparison of face lift Reconstr Surg. 2002;109:2074. Clin Plast Surg. 1978;5(1):15–28. The authors’ experience with subperiosteal facelift techniques techniques in eight consecutive sets of identical twins. The authors report that in 1999, they modified the previously 16. Connell BF, Marten TJ. The trifurcated SMAS flap: is reviewed. Pertinent points include: (1) using an Plast Reconstr Surg. 2007;120:1667–1673. described S-lift to include improved suture fixation and soft three-part segmentation of the conventional flap for interconnected subperiosteal approach which involve the 40. Alpert BS, Baker DC, Hamra ST, et al. Identical twin tissue elevation, which they named the MACS lift, an improved results in the midface, cheek, and neck. entire zygomatic arch; (2) utilizing upward pull of the face lifts with differing techniques: A 10-year follow-up. acronym for minimal access cranial suspension. Two long Aesthetic Plast Surg. 1995;19(5):415–420. muscles of facial expression to elevate the mouth; (3) keeping Plast Reconstr Surg. 2009;123:1025–1036. loop sutures are used to elevate facial soft tissue with fixation 17. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS the dissection deep in the temple to protect the temporal 41. Chang S, Pusic A, Rohrich RJ. A systematic review of to the deep temporal fascia above the zygomatic arch and a dissection as an approach to midface rejuvenation. Clin branch, and (4) utilizing the temporal fascia as a lifter and comparison of efficacy and complications rates among third suture is used for the malar fat pad in the extended Plast Surg. 1995;22(2):295. anchoring point. face-lift techniques. Plast Reconstr Surg. 2011;127(1): version of the procedure. A total of 88 patients over 20 This review article outlines the authors’ understanding 29. Byrd HS, Andochick SE. The deep temporal lift: a 423–433. months were presented with a low complication rate. The multiplanar, lateral brow, temporal, and upper face lift. operative technique is described in detail. of facial anatomy as it pertains to facelift surgery, their This paper presents the results of a systematic review that understanding of facial aging, and it describes their surgical Plast Reconstr Surg. 1996;97:928. assessed all studies in the English language literature from 6. Hoefflin SM. The extended supraplatysmal plane (ESP) procedure in detail. The procedure is called the extended 30. Hunt JA, Byrd HS. The deep temporal lift: a multiplanar 1950 until 2009 in which there was a comparison of facelift face lift. Plast Reconstr Surg. 1998;101:494. SMAS dissection because it involves raising the malar lateral brow, temporal, and upper face lift. Plast Reconstr techniques. There were 57 studies identified; only 10 of these The author presents his logic behind using a facelift flap, fat pad in conjunction with the SMAS flap. The authors Surg. 2002;110(7):1793. directly compared the efficacy of different facelift techniques. which contains skin and all the subcutaneous fat down to, emphasize the importance of flap fixation in order to create 31. Tipton JB. Should the subcutaneous tissue be plicated in The study found there to be a lack of quality data regarding but not including the SMAS. The technique is described a long lasting result. a face lift? Plast Reconstr Surg. 1974;54:1–5. the efficacy and safety of facelift techniques and concluded in detail and the results with a series of 300 patients are 18. Marten TJ. High SMAS facelift: combined single flap 32. Rees TD, Aston SJ. A clinical evaluation of the that there was no evidence to support the use of any one presented. There was high patient satisfaction reported, no lifting of the jawline, cheek, and midface. Clin Plast results of submusculoaponeurotic dissection and facelift technique over another. nerve injuries and relatively rapid recovery. Surg. 2008;35(4):569–603. 7. Baker D. Lateral SMASectomy. Plast Reconstr Surg. The review article outlines the author’s logic in utilizing 1997;100(2):509. a two layer facelift, emphasizing that skin has a covering The author presents his personal evolution in arriving at the function, and that deep tissue manipulation is necessary for SMASectomy technique, describing his logic in doing so, facial reshaping. The high SMAS facelift is described in and reports a series of 1500 cases over 5-year period. One detail, with emphasis on skin incisions, and the proper transient buccal branch injury was encountered. The author selection of vectors. feels this technique affords a safe, effective technique, but 19. Mendelson BC. Correction of the nasolabial fold acknowledges that other techniques also produce excellent extended SMAS dissection with periosteal fixation. Plast results. Reconstr Surg. 1992;89:822. 8. Skoog T. Plastic surgery. Philadelphia: WB Saunders; 20. Aston SJ. The FAME Technique. Presented at the Aging 1974. Face Symposium. Waldorf Astoria Hotel, New York, NY, In this classic text, the author describes the first technique 1993. to utilize the sub-SMAS plane to elevate ptotic facial tissue. 21. Aston SJ, Walden J. Facelift with SMAS technique and Illustrations effectively convey the basics of this new FAME. In: Aston SJ, Steinbrech DS, Walden JL, eds. technique. Philadelphia: Saunders Elsevier; 2009. SECTION I Aesthetic Surgery of the Face Evaluation 217

Table 11.3.1 Comparison of chief features for the PSP and MACS facelifts

PSP MACS

Incision Vertical temporal Inverted L (anterior (± post-auricular only) 11.3 extension) Skin flap As required Limited to 5 cm oval Dissection into neck Yes No Facelift: Platysma-SMAS plication Platysmaplasty Direct (infralobular Indirect excision) SMAS fixation SMAS-SMAS SMAS-DTF Dai M. Davies and Miles G. Berry Malar augmentation Yes No Vector Cephaloposterior Predominantly vertical Skin excision Tailored, no tension Tailored, high tension Neck Multiple procedures Liposuction in >95% Ancillary procedures Yes No

less-than-impressive effect on the nasolabial folds and jowls Experience with these limitations led the authors to the SYNOPSIS and long operating times, requiring extended periods of use of sutures to plicate the SMAS; a procedure termed the ‘platysma-SMAS plication’ (PSP) lift. Its advantages ᭿ Allows multi-vector traction to individualise the facelift. careful surgery, particularly with anterior SMAS dissection. 12 (Table 11.3.1) include the application of a postero-superior, as ᭿ Furthermore, the SMAS is relatively avascular, behaving Sutures placed closer to the point of lift have the best effect. opposed to purely vertical, vector, which allows a lift tailored ᭿ Delivers a good malar auto-augmentation. more as a graft in certain circumstances, and may be thin and attenuated, thus holding sutures poorly. During revision or to each individual. The vertically-extended skin incision ᭿ Reduced downtime. secondary surgery, the poverty of vascular supply to the permits synchronous temporal lift and reduces sideburn ele- ᭿ 16,17 Fig. 11.3.1 Incision and area of subcutaneous dissection employed with the Safe and ideal for thin, attenuated SMAS layers or repeat facelifts. undermined SMAS may present the surgeon with a mass of vation and a visible scar. While concealing the scar within temporal hair risks alopecia, it allows greater flexibility with PSP-lift. Note that the posterior extension is not always required, but is useful where scar tissue. excess skin remains in the neck after SMAS plication. Given the recent paradigm shift towards minimally- no risk of highly visible alopecia between the helical root and invasive techniques, to limit facial nerve complications and hairline. A post-auricular extension, not employed in all cases, sulcus (Fig. 11.3.1). A post-auricular extension is used where reduce recovery time, the minimal access cranial suspension is important to ameliorate the post-auricular skin dog-ear, required and subcutaneous dissection tailored to each patient. (MACS) lift was initially popularly accepted.13 Since its which adds to down-time and has been reported as a problem 9 The anterior SMAS is grasped in a postero-superior direction Introduction description in 2002, the MACS has proven effective, particu- with the MACS. to provide a satisfactory effect on the jowl (Fig. 11.3.2). The larly for younger patients concerned with early jowling, With no sub-SMAS dissection, PSP is safer, particularly key suture, using 2-0 PDS (Johnson & Johnson Medical Ltd), As summarized in Chapter 11.2, facelifting has evolved appre- minimal neck ptosis and the desire for minimal downtime. with respect to the facial nerve, and quicker. It is also benefi- is then inserted to attach this SMAS to the relatively immobile ciably from the simple, skin-only procedures of the early 20th Itself a derivation of Saylan’s ‘S-lift’,14 the MACS lift focussed cial where SMAS vascularity is poor. Large bites of SMAS pre-auricular parotid-masseteric fascia. Further sutures com- century. Today, we have an almost bewildering array of tech- on the anatomical basis, suture anchoring position and skin allow greater security, and therefore potential longevity. A plete plication of the cervical platysma, below the mandibular niques and tissue planes from which to choose. While each excision, but certain limitations have been shown by experi- second layer of finer imbrication sutures is used, producing angle, to the mastoid fascia (Fig. 11.3.3) and any surface irreg- proponent may provide convincing support for their particu- ence. One of these, the relative lack of malar augmentation both a smooth finish and perhaps additional strength. It is, of ularities are addressed by suture imbrication with 3-0 Vicryl lar technique, most are in agreement about the central role of was addressed by the addition of a third suture and quickly course, not without sequelae and does produce two dog-ears (Johnson & Johnson). Excess SMAS in the infra-lobular region the superficial musculoaponeurotic system (SMAS), origi- became commonly applied.15 However, precise purse-string in the subcutaneous layer. Fortunately, the first, overlying the is excised, following hydrodissection, and closed with 3-0 nally highlighted by Skoog in the 1970s1 and detailed in Mitz suture placement is not always easy and subcutaneous irregu- malar prominence, has the effect of auto-augmentation and Vicryl. Following meticulous haemostasis, excess skin, with and Peyronie’s now classic treatise.2 The question remains larities may not settle as well as described. Whilst good for assists with the overall rejuvenation by reversion of the aged low tension only, is trimmed and the wound closed over a precisely what to do with the SMAS in order to balance younger patients, the authors feel it does not always have a “square” to a youthful “triangular” face. The second, in the small suction drain with 4-0 and 6-0 nylon. A light, compres- invasiveness, and thus tissue trauma from which the patient sufficiently strong effect on the lateral neck of older patients, sub-lobule region is not so beneficial, but is simply excised; a 7 sive facelift dressing remains overnight and is removed with must recover, in addition to potential complications, and its and is painful in the initial postoperative period, with a limita- manoeuvre common to both Baker’s and Waterhouse’s modi- 18 the drain the following morning. These can be similarly longevity. tion of mouth-opening, acknowledged by the originators.13 fied SMASectomy procedures. removed immediately prior to discharge in day-case patients. The SMAS may be simply elevated and advanced,3 dis- Finally, there are two areas of tissue excess, or dog-ears, in Sutures are removed at 4–6 days. sected at various planes,4,5 rolled upon itself with mesh to pure vertical-vector lifts, which may fail to settle satisfactorily. augment malar projection,6 excised,7 or plicated.8 The multi- The first is infero-posterior to the lobule. The second, cutane- Technique plicity of techniques bears testament to the fact that a univer- ous bunching at the lateral canthus, is particularly pronounced Video sal and standard procedure eludes us still. There is also some with the powerful suture of the extended MACS15 and may 1 The surgical procedure is as follows: patients are prepared as Evaluation evidence that there may be little actual difference, in either be addressed through a lower lid blepharoplasty incision, for a standard facelift with tumescent infiltration (20 mL 0.5% the short9 or the long term, between techniques of varying however, not all patients require this additional procedure. It bupivacaine and 1 mL 1 : 1000 adrenaline in 200 mL normal Patients and methods aggressiveness10,11; therefore, procedures with less inherent has been demonstrated that by utilizing tension in the SMAS saline) into the subcutaneous plane. The incision extends ver- risk to important structures, such as the facial nerve may rather than the skin, both cutaneous dog-ears and scar stretch3 tically in the temporal scalp, along the anterior helical sulcus In the authors’ practice, the PSP-lift was initiated in 2004 and be safer. Problems noted include inconsistent results, a are minimized. then passes post-tragal, and on occasion into the post-auricular an initial evaluation was performed on a consecutive cohort ©2013, Elsevier Inc. All rights reserved. 218 SECTION I •11.3• Facelift: Platysma-SMAS plication Discussion 219

Table 11.3.3 Number of procedures synchronous with the visible socially, in the temporal incision that improved spon- PSP-lift taneously. A single patient underwent corrective fat transfer for a persistent surface irregularity. There was no statistically n Procedure significant relationship between any complication and hyper- tension, smoking or secondary surgery. Face alone 13 Face + 1 additional 40 Face + 2 additional 41 Discussion Face + 3 additional 12 Face + 4 additional 5 Facial rejuvenation is increasingly viewed by patients as a Face + non-face additional 6 suitable recourse in a more ageist society that lives both longer and more healthily. Interestingly, studies directly comparing Total 117 highly invasive with less aggressive procedures have shown no significant differences between the two10,11 and more afflu- ent, younger patients are requesting procedures with as little Table 11.3.4 Type and number of options employed in “down-time” as possible. The PSP facelift was designed to management of the neck address these issues. Management of the neck n It must be remembered that SMAS advancement, whether composite or independent, exerts uniform traction, much Liposuction alone 54 like braces on trousers. Studies by Rohrich have elegantly demonstrated discrete facial partitions that go a long way to Band division + platysmaplasty 11 explaining why simple SMAS elevation-advancements often Liposuction + band division + platysmaplasty 9 provide only partial correction.21 PSP exploits the fact that Lipectomy + band division + platysmaplasty 6 the optimal effect from a suture derives from its proximity to the point of lift, and plication sutures can be placed wherever + Liposuction platysmaplasty 3 they are required. This answers one of the drawbacks of Liposuction + lipectomy + band division + platysmaplasty 2 SMASectomies and conventional SMAS flaps where the exci- Lipectomy + platysmaplasty 2 sion is remote from both the jowl and nasolabial fold (NLF). With plication, the SMAS is sutured directly, rather than in Band division alone 2 a purse-string fashion used with the MACS lift, and has the Fig. 11.3.2 Placement of the first and key suture, which takes a generous bite of Fig. 11.3.3 Tying the key suture produces a ‘dog-ear’ of SMAS that produces a + anterior SMAS and tractions it postero-superiorly onto the parotido-masseteric convenient malar autoaugmentation. A second suture passes between the posterior Liposuction lipectomy 1 potential for an infinite multiplicity of vectors, to obtain the precise effect tailored to the individual. This differs from fascia. It can be trialled and its effect easily measured externally by observing platysma and the mastoid fascia to complete the effect on the jowl and commence Liposuction + lipectomy + platysmaplasty 1 reduction of the jowl and effacement of the nasolabial fold as the SMAS is the necklift. Robbins’ anterior plication, which employs a vertical row of tractioned and the suture tied. Liposuction + lipectomy + band division 1 SMAS sutures lateral to the NLF.8 While addressing the NLF, Platysmaplasty alone 1 this anterior only approach obliges antero-inferior traction on both lateral SMAS and malar fat thus counterbalancing malar between August 2004 and May 2007. During this time, 122 Total 92 Table 11.3.2 Example of assessment proforma (blank) augmentation. patients were followed prospectively and specific assessment Many have reported that the SMAS progressively thins of outcome was performed. While specific, validated evalua- Right Left 3,7,10 17 19 anteriorly, particularly in secondary surgery. Saulis et al. tion systems are available for surgical correction of the breast (range 2–5) and 4.49 (3–5) were obtained for patients and demonstrated both the weakness and reduced suture-retention 20 Nerve damage and upper limb, there is little available for evaluation of surgeon, respectively initially and 4.43 (2–5) and 4.45 (3–5), of the SMAS when raised alone,22 as compared to an SMAS cosmetic facial surgery. Thus, a simple proforma (Table 11.3.2) Asymmetry finally. The same score was given at both stages in 42.9%, flap raised in continuity with the skin, a feature which has was established allowing both patient and surgeon to contrib- improved with time in 39.3%, and deteriorated in 17.8%. Unevenness been cited by supporters of composite flaps. However, they ute to the assessment employing a linear analogue scale also demonstrated less tissue creep and stress relaxation in the (LAS), whereby poor and excellent results scored 1–5, respec- Scars Complications SMAS flap as compared to skin flaps, lending credence to tively. Statistical analysis was performed with Kappa’s Eye closure SMAS tightening procedures such as plication, in the pursuit correlation. The commonest complication was hematoma requiring a of surgical longevity. The degree of skin flap undermining is Subconjunctival return to theatre which was required in four patients (3.4%); also much greater in the PSP than with procedures such as the Results Corneal symptoms one following drain removal. All underwent evacuation MACS in observance of Baker’s philosophy that SMAS vec- under local anesthesia without apparent adverse effect on toring to give maximal anatomic improvement is not adversely Surgeon assessment Of the original cohort, five were lost to follow-up or had insuf- outcome (mean score 4.75). Some degree of nerve dysfunction affected by employing a separate vector for skin redraping.23 ficient data for analysis. Of the remaining 117, all but eight 54321 was noted in five patients. Of the four with motor symptoms, Minimal access supporters stress the importance of vertical were women (two male-female transgender patients were only one lasted more than 6 weeks and was associated with vectors in contemporary facelifts,13 however, in our view, Very happy Happy OK Unhappy Very unhappy analyzed as biologically male). Mean age was 55 (range ipsilateral infection. One with unilateral dysesthesia was facial ageing occurs in multiple directions, according to 29–79). General anesthesia was employed in the majority Patient assessment followed-up at the chronic pain clinic after 3 months. The rate gravity, the locations of retention ligaments, and local muscu- 16 with three undergoing local anesthesia-sedation. Additional 54321 of temporary nerve injury overall was therefore 4.3%, motor lar forces, and senescence is characterized by antero-inferior aesthetic procedures were performed in 104 patients 3.4%, and sensory 0.85%. Five patients experienced delayed descent.7 It seems counter-intuitive to disregard some vectors (Table 11.3.3). The neck was addressed with a variety of pro- Very happy Happy OK Unhappy Very unhappy wound healing, but all settled conservatively; oral antibiotics at the expense of others.10 cedures in 92 (78.6%) patients (Table 11.3.4). being required in one case, and the longest healed by 8 weeks. Additionally, traditional SMAS techniques in which the Overall, there was a high correlation (r = 0.76) between the Two received intralesional steroid therapy for mild scar malar fat is not specifically dissected, have a limited effect on assessments of patient and surgeon. Mean scores of 4.45 hypertrophy. One complained of a small area of alopecia, not both malar ptosis and the NLF.3 As shown in Figure 11.3.4, 220 SECTION I •11.3• Facelift: Platysma-SMAS plication Conclusion 221

such that supero-lateral traction exerts a powerful effect on both lateral and anterior platysma.25 Waterhouse emphasized Conclusion a similar concept18 for optimal results in the neck, which we fully endorse. It is worth reiterating the advantage of infra- The use of suture plication of the SMAS has been encour- lobular dissection, with or without a posterior incision, which aging both for aesthetic outcome (Figs 11.3.6–11.3.8) and allows SMAS anchoring to the mastoid fascia for a strong complication rate. The PSP-facelift seeks to combine the lateral platysmaplasty. A little over three-quarters of our advantages of SMAS advancement with those of plication patient cohort underwent some additional management of the whilst minimizing complications and maximizing outcome. neck, the majority (54 of 92) receiving liposuction alone. It has a sound anatomical basis, allowing individual, and dif- Following our assessment, nine (7.7%) were felt to have sub- ferential, SMAS and skin vectoring that provides specific optimal neck outcomes. Distribution was equal in the first and anatomical correction and ameliorates asymmetry. Moreover, second halves of the study with no obvious features to assist the technique is safe to perform and easily acquired by train- in the preoperative selection of such patients. ees and less experienced aesthetic surgeons. The skin incision Patient satisfaction was high with scores of 4.45. Inter- is standard and allows optimal access to the relevant anatomy. A observer correlation was also high, lending some credence to It is suitable for day-case surgery as a single procedure or what is effectively a subjective assessment. With respect to with multiple concomitant aesthetic facial procedures and is those who downgraded their scores, 75% had experienced a particularly good for autologous malar augmentation. It problem of some kind, including persistent dysesthesia, post- works particularly well where the facial ptosis is concen- operative hematoma and skin flap telangiectasia; all were trated primarily in the midface and at the jowl and has been considered by the surgeon to have achieved at least a grade 4 noted by our patients to settle rapidly and thereby minimize surgical outcome. “downtime”.

Fig. 11.3.4 Completion of the face and necklift, leaving the beneficial malar dog-ear and the undesirable infero-posterior lobule dog-ear. B

Fig. 11.3.5 Following the platysma-mastoid suture tying, the infero-posterior PSP can exert a powerful effect on the malar prominence and lobule excess is (A) marked and (B) excised. The cut SMAS edges are then NLF due to individualized plication. Another advantage of sutured. the PSP lift is that after initial plication any residual SMAS irregularities are addressed with secondary imbrication to leave a smooth surface, this second layer further contributing The neck A B C D to the integrity of the SMAS fixation. Personal experience has shown that the purse-string technique may lead to irregulari- The neck continues to be a problem area for several reasons: Fig. 11.3.6 A 67-year-old female shown 12 months following PSP-lift demonstrating its effect, particularly on jowl and cervical skin excess reduction. She also underwent ties, which do not always resolve as claimed and can lead to swelling and scarring always seem to mature slowly and cor- synchronous bilateral upper and lower blepharoplasties and peri-oral CO2 laser treatment. (A,C) preoperative; (B,D) postoperative. patient dissatisfaction. Debate continues as to where the rection of platysmal bands is often incomplete. In addition, advanced SMAS should be fixed.24 Deep fixation can also aggressive submental lipectomy may leave irregularities and leave the patient with “marked pain and restricted mouth exacerbates the appearance of any residual jowling. Finally, opening.”13 The success of SMASectomy procedures attests to seroma and excess skin are a frequent source of complaint the strength of SMAS-SMAS fixation.7,18 Furthermore, there is and secondary surgery. The neck is a defining feature as small the added benefit of autologous malar augmentation as pro- remnant anomalies can spoil an otherwise excellent result in posed by Baker.7 The infra-lobular platysma-SMAS excess is the face. Management of the neck, therefore, remains contro- excised (Fig. 11.3.5), and the defect closed, to remove the versial with supporters at both minimal and aggressive ends lateral swelling beneath the ear lobe, a feature typical of more of the spectrum. That such a range and difference of opinion minimal techniques. exists indicates the universal procedure remains elusive, Nerve dysfunction, particularly motor, remains the most although the pendulum appears to be swinging towards mini- feared complication of any facelift and in our series, none malism due to the limited margin for technical error and were permanently affected. Of note, half underwent synchro- healing irregularities.11,13 The viscoelastic properties of cervi- nous endoscopic browlifts that more likely caused the frontal cal flaps have been demonstrated to be inherently different branch palsies. Interestingly, all nerve complications occurred from facial flaps with greater creep and stress-relaxation in the first third of the study indicating a learning curve. That thereby allowing increased relapse, although the reason all motor function in this series recovered fully and rapidly for this remains unclear.22 The importance of the postero- A B C D indicates the inherent safety of PSP and assuages critics’ fears superior region of the neck’s anterior triangle has been high- that blind needle insertion into the pre-masseteric SMAS is lighted in a recent publication, which demonstrated a gliding Fig. 11.3.7 Preoperative views (A,C) in a woman who underwent PSP-lift. Postoperative images (B,D) underline the malar autoaugmentation in addition to jowl dangerous. plane between the platysma and the sternocleidomastoid diminishment and a good result in the cervical region. 222 SECTION I •11.3• Facelift: Platysma-SMAS plication References 222.e1

12. Whetzel TP, Stevenson TR. The contribution of the References SMAS to the blood supply in the lateral face lift flap. Plast Reconstr Surg. 1997;100:1011–1018. 1. Skoog T. Plastic surgery. Philadelphia: WB Saunders; 13. Tonnard P, Verpaele A, Monstrey S, et al. Minimal 1974:300–330. access cranial suspension lift: a modified S-lift. 2. Mitz V, Peyronie M. The superficial musculo- Plast Reconstr Surg. 2002;109:2074–2086. aponeurotic system (SMAS) in the parotid and cheek 14. Saylan Z. Purse string-formed plication of the SMAS area. Plast Reconstr Surg. 1976;58:80–88. with fixation to the zygomatic bone. Plast Reconstr Surg. A classic facelift paper in which the SMAS was described. 2002;110:667–671. It opened up a new field for surgery and study in addition 15. Verpaele A, Tonnard P, Guerao FP, et al. The third to the benefits of much improved longevity over skin-only suture in MACS-lifting: making midface-lifting simple lifts. and safe. J Plast Reconstr Aesthet Surg. 2007;60: 3. Owsley JQ. Platysma-fascial rhytidectomy: 1287–1295. a preliminary report. Plast Reconstr Surg. 1977;59: 16. Mendelson BC. Surgery of the superficial A B C D 843–850. musculoaponeurotic system: principles of release, 4. Hamra ST. The deep plane rhytidectomy. Plast Reconstr vectors, and fixation. Plast Reconstr Surg. 2001;107: Surg. 1990;86:53–61. 1545–1552. Fig. 11.3.8 This figure demonstrates both the acceptability of PSP in the male and its ability to ameliorate deep-set nasolabial folds. 5. Hamra ST. The zygorbicular dissection in composite The scholarly treatise of anatomy and vectors now accepted as rhytidectomy: An ideal midface plane. Plast Reconstr a benchmark of the principles underpinning facelifting. Surg. 1998;102:1646–1657. 17. Guyuron B. Secondary rhytidectomy. Plast Reconstr Access the complete references list online at http://www.expertconsult.com 6. Stuzin JM, Baker TJ, Baker TM. Refinements in face Surg. 2004;114:797–800. lifting: enhanced facial contour using Vicryl mesh 18. Waterhouse N, Vesely M, Bulstrode NW. Modified incorporated into SMAS fixation. Plast Reconstr Surg. lateral SMASectomy. Plast Reconstr Surg. 2007;119: 2. Mitz V, Peyronie M. The superficial musculo- 11. Alpert BS, Baker DC, Hamra ST, et al. Identical twin 2000;105:290–301. 1021–1026. aponeurotic system (SMAS) in the parotid and cheek face lifts with differing techniques: a 10-year follow-up. The use of Vicryl mesh to both improve the fixation and area. Plast Reconstr Surg. 1976;58:80–88. Plast Reconstr Surg. 2009;123:1025–1033. 19. Pusic AL, Klassen AF, Scott AM, et al. Development enhance overall contour. This technique excises no SMAS, of a new patient-reported outcome measure for breast A classic facelift paper in which the SMAS was described. It 13. Tonnard P, Verpaele A, Monstrey S, et al. Minimal but utilizes the excess to augment the malar area. surgery: the BREAST-Q. Plast Reconstr Surg. 2009;124: opened up a new field for surgery and study in addition to access cranial suspension lift: a modified S-lift. Plast 7. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 345–353. the benefits of much improved longevity over skin-only lifts. Reconstr Surg. 2002;109:2074–2086. 1997;100:509–513. 20. The Institute for Work & Health. The disabilities of the 5. Hamra ST. The zygorbicular dissection in composite 16. Mendelson BC. Surgery of the superficial 8. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS arm, shoulder and hand (DASH) outcome measure. Toronto: rhytidectomy: An ideal midface plane. Plast Reconstr musculoaponeurotic system: principles of release, plication for the treatment of prominent The Institute for Work & Health; 2005. Surg. 1998;102:1646–1657. vectors, and fixation. Plast Reconstr Surg. 2001;107: nasomandibular folds and restoration of normal cheek 21. Rohrich RJ, Pesa JE. The fat compartments of the face: 6. Stuzin JM, Baker TJ, Baker TM. Refinements in face 1545–1552. contour. Plast Reconstr Surg. 1995;96:1279–1287. anatomy and clinical implications for cosmetic surgery. lifting: enhanced facial contour using Vicryl mesh The scholarly treatise of anatomy and vectors now 9. Prado A, Andrades P, Danilla S, et al. A clinical Plast Reconstr Surg. 2007;119:2219–2227. incorporated into SMAS fixation. Plast Reconstr Surg. accepted as a benchmark of the principles underpinning retrospective study comparing two short-scar face lifts: 2000;105:290–301. facelifting. 22. Saulis AS, Lautenschlanger EP, Mustoe TA. minimal access cranial suspension versus lateral Biomechanical and viscoelastic properties of skin, SMAS The use of Vicryl mesh to both improve the fixation and 20. The Institute for Work & Health. The disabilities of the SMASectomy. Plast Reconstr Surg. 2006;117: and composite flaps as they pertain to rhytidectomy. enhance overall contour. This technique excises no SMAS, arm, shoulder and hand (DASH) outcome measure. Toronto: 1413–1425. Plast Reconstr Surg. 2002;110:590–598. but utilizes the excess to augment the malar area. The Institute for Work & Health; 2005. 10. Ivy EJ, Lorenc PZ, Aston SJ. Is there a difference? 23. Baker TJ. Rhytidectomy: a look back and a look 8. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS 22. Saulis AS, Lautenschlanger EP, Mustoe TA. A prospective study comparing lateral and standard forward. Ann Plast Surg. 2005;55:565–570. plication for the treatment of prominent Biomechanical and viscoelastic properties of skin, SMAS SMAS facelifts with extended SMAS and composite nasomandibular folds and restoration of normal cheek and composite flaps as they pertain to rhytidectomy. 24. Baker TJ, Stuzin JM. Personal technique of face lifting. rhytidectomies. Plast Reconstr Surg. 1996;98: Plast Reconstr Surg. 1997;100:502–508. contour. Plast Reconstr Surg. 1995;96:1279–1287. Plast Reconstr Surg. 2002;110:590–598. 1135–1143. 25. Labbé D, Franco RG, Nicolas J. Platysma suspension 10. Ivy EJ, Lorenc PZ, Aston SJ. Is there a difference? A 25. Labbé D, Franco RG, Nicolas J. Platysma suspension A study with the dual interest of both being able to undertake prospective study comparing lateral and standard and platysmaplasty during neck lift: anatomical study and platysmaplasty during neck lift: anatomical study different procedures on opposite sides, in addition to the and analysis of 30 cases. Plast Reconstr Surg. 2006;117: SMAS facelifts with extended SMAS and composite and analysis of 30 cases. Plast Reconstr Surg. 2006;117: finding that significant differences were hard to detect. rhytidectomies. Plast Reconstr Surg. 1996;98:1135–1143. 2001–2007. 2001–2007. 11. Alpert BS, Baker DC, Hamra ST, et al. Identical twin A study with the dual interest of both being able to undertake A beautifully conducted and illustrated paper that goes a long A beautifully conducted and illustrated paper that goes a long face lifts with differing techniques: a 10-year follow-up. way to explaining why the neck is frequently the most different procedures on opposite sides, in addition to the way to explaining why the neck is frequently the most Plast Reconstr Surg. 2009;123:1025–1033. finding that significant differences were hard to detect. disappointing part of a facelift. disappointing part of a facelift. • SECTION I Aesthetic Surgery of the Face 224 SECTION I 11.4 • Facelift: Facial rejuvenation with loop sutures, the MACS lift and its derivatives

Surgical foundation for the MACS-lift

The surgical foundation for facial rejuvenation should address the biomechanical effects of facial aging and volume loss for each patient, depending on their particular needs. Surgeons must be faulted in the past for not having a fundamental 11.4 understanding of facial aging, volume loss, laminar anatomy, and biomechanical engineering. Our current understanding of the anatomy of facial aging is thoroughly reviewed in Chapter 10, giving insight into the complex biomechanics of Facelift: Facial rejuvenation with loop sutures, facial aging. Aging involves the gravimetric effects on skin and SMAS, loss of elastic property of tissue, volume loss and descent within in fat compartments, and extrinsic effect of the MACS lift and its derivatives sun, genetics, weight loss/gain, and smoking.11–13 Fat within the face does not exist as a confluent mass, but in discreet compartments separated by septae, formerly known as liga- Mark Laurence Jewell ments. Facial anatomy involves a laminar concept in which, movement between layers is possible without surgical dela- mination. Proponents of ligament release feel that such move- ment is inadequate for facial rejuvenation, but experience with the MACS-lift provides evidence that sufficient inter- layer movement is, indeed possible and surgically effective. From the perspective of biomechanics, surgical approaches rejuvenation has evolved beyond surgical technique to now that rely on sheet tightening of attenuated facial structures SYNOPSIS encompass facial aesthetics, ancillary treatments, biomechan- (SMAS) may not produce a long-term effect due to the loosen- ᭿ Limit undermining of skin to planned areas for suture loops or for ics of facial rejuvenation, and consumer preferences for lesser- ing of this layer over time (shear-yield). Suture line repairs redraping of skin. The indiscriminate delamination of skin of neck invasive procedures with rapid recovery. such as linear plication or excision techniques (plication or structures or in the post-auricular region can unduly influence In retrospect, we have moved back and forth between a SMASectomy) remain vulnerable to disruption (shear failure outcomes. Undermine only as necessary to accomplish the lift, variety of technical solutions versus a more holistic process and “cheese wiring”) by down-pulling the platysma whose not more. of how to optimally deliver operational excellence in facial fascia is contiguous with the SMAS facial rejuvenation, is ᭿ Ensure that the neck loop suture has a good bite of platysma rejuvenation for a diverse patient population. As a surgeon, therefore an exercise in biomechanical engineering in terms of Fig. 11.4.1 The basic MACS-lift involves two suture loops placed into the SMAS fascia. This is important to prevent failure of the neck-lifting it is sometimes easier to fall in love with a single technique of how much force is required to vertically lift facial and neck in a purse-string fashion. The vertical loop captures the platysma muscle below the component. facial rejuvenation and not engage in critical thinking about structures and suspend them in place with approaches that angle of the mandible, elevating soft tissues of the neck. The cheek loop captures and elevates soft tissue of the mid cheek and jowl. ᭿ Do not make the cheek loop too small. This can result in a wad of the shortcomings and tradeoffs of that particular technique. are less prone to failure. Surgery is part of the solution for tissue that cannot be made smooth. At the same time, when confronted with newer techniques facial rejuvenation, but ancillary procedures found in cos- and concepts for facial rejuvenation, many surgeons adopt a metic medicine such as medical skin care, fillers, neurotoxins, ᭿ Understand the ability that you have to innovate with the MACS-lift, defensive reasoning mindset that prevents adoption of these and light-based treatments work synergistically to produce a based on your patient’s individual needs. Too often, we become approaches. “wow effect” when used masterfully. tightening of the neck skin when the platysma is tightened.7 wedded to a sequence of techniques and ancillary procedures MACS-lift is an acronym for “minimal access cranial sus- The MACS-lift concept involves the use of suture loops The zone of adherence just anterior to the earlobe, called that limits our ability to individualize and adapt for each of your pension”.1 The first time that I (the author) read the MACS placed in a purse-string fashion in order to elevate deep facial Lore’s fascia, can be used as a fixed structure to pull against patients. short-scar rhytidectomy paper by Tonnard et al.,2–5 it seemed tissue by anchoring to a fixed point. In the basic MACS-lift, in order to achieve vertical tightening of the platysma as ᭿ The MACS suture loop suspension approach works nicely in a puzzling principle which relied on suture loop suspension there is one anchoring point on the deep temporal fascia, just described by Labbé.5 secondary or revisionary situations, where there has been earlier to a cranial anchoring point, far different that the sheet tight- above the lateral zygoma, and posterior to the passage of the The traditional skin incision for the MACS-lift utilizes a deep layer work and repeat deep layer dissections could be both ening approach of the classic SMAS-lift that I was performing temporal branch of the facial nerve. This is a very robust “short scar” anterior hairline approach with no retroauricular challenging and risky. MACS loop sutures hold well in scar from at the time. It took a trip to the anatomy lab and a visit with anchor point that will hold a 0-0 or 2-0 suture without a pull- dissection. After deep tissue reposition, skin redraping is previous surgery. Tonnard and Verpaele in Belgium to convince me that there out failure The “CS” part of the MACS-lift is “cranial suspen- designed in a purely vertical direction (Fig. 11.4.4). ᭿ Critical evaluation of outcomes is part of the learning process was something different (and possibly better) about the sion”, which refers to the deep temporal fascia’s attachment The amount of skin excision with the vertical approach of in terms of determining what went right and areas that require MACS-lift. Once this approach for facial rejuvenation was to the cranium along the temporal crest line. The MACS-lift the MACS-lift is much less than seen with the classic SMAS- improvement. Refinement of technique comes with an honest examined in light of other publications by Labbé,6 Mendelson,7 does not utilize sheet tightening of the SMAS, SMAS plication, lift. Attention must be paid to a tension-free skin closure in analysis of the outcome. Besins,8 Pessa/Rohrich,9 and Gardetto,10 there actually appears or SMASectomy, but relies purely on specialized suture sus- order to promote excellent healing and avoid earlobe distor- to be a unifying concept that has scientific and biomechanical pension. The basic MACS-lift involves two suture loops, one tion. In a divergence of philosophy and practice from Tonnard validity as a mainstay technique for facial rejuvenation. vertical and one oblique, while the “extended MACS-lift” and Verpaele, patients with greater facial and neck laxity will First, we should ask ourselves, “Why do we think that it is involves an additional suture to elevate the malar fat to a more require extending the incision into the retroauricular area in Introduction necessary to delaminate the face in order to rejuvenate? Can anterior anchoring point (Figs 11.4.1, 11.4.2). Suture loops order to manage lax skin (Fig. 11.4.5). we accomplish volume redistribution/repositioning without placed within facial tissues results in a gathering and suspen- Therefore, the “MA” (minimal access) portion of the MACS Facial rejuvenation surgery has had an interesting evolution having to engage in complex, deep anatomic dissections? sion of tissue. Tonnard and Verpaele describe this as “micro- terminology must be expanded to address situations where over the last 75 years. It is an interesting exercise to examine What is the validity of using a cranial suspension platform imbrication” (Fig. 11.4.3). there is more tissue laxness necessitating a retroauricular inci- the chronicle of progress of facial rejuvenation surgery and at to re-suspend facial structures over traditional ways?” And How the loops are designed and sequenced is crucial, as sion. In optimal situations, with younger patients, the short the same time, critically ask ourselves: “What were they finally: “Can we innovate a less-invasive procedure for facial once the platysma is pulled upward, it is possible to rotate the scar approach is preferable, yet can be modified when the thinking when they came up with that particular procedure rejuvenation that gives a durable outcome and allows for layers of the face without a downward traction component of amount of loose tissues cannot be managed with a short scar for facial rejuvenation?” Our concept regarding facial future revisions?” the platysma. By not dissecting skin off the platysma, there is approach. Extending the incisions into the post-auricular ©2013, Elsevier Inc. All rights reserved. Patient evaluation 225 226 SECTION I •11.4 • Facelift: Facial rejuvenation with loop sutures, the MACS lift and its derivatives

Ocular region

Dermatochalasis, brow position, brow ptosis, fat bags, lower eyelid looseness requiring lateral canthal work, lower eyelid skin, and malar bags should all be assessed. Given the sub- stantive lift of the MACS-lift, a lower eyelid blepharoplasty is often an integral part of this approach. Neck 2.0 Neck laxness and platysmal banding will influence the need to consider extended incisions and possibly a submental approach for direct work on platysma banding. The presence 1.8 2.0 of submental fat may be addressed either through lipoplasty if superficial or direct excision if submuscular. Fig. 11.4.4 The short scar incision used in the standard MACS-lift. Jowls

The squareness of the jaw line is largely influenced by the downward descent of facial structures. Depending on the severity, dissection into the pre-masseteric space may be required.

Previous surgery

Patients seeking additional refinements or “maintenance” of facial rejuvenation from previous surgical procedure may present with distorted changes due to conflicting traction vectors or ineffectual outcomes. This type of patient requires Fig. 11.4.2 The extended MACS-lift adds a third suture to elevate the malar fat Fig. 11.4.6 The temporal branches of the facial nerve course over the middle third thoughtful consideration of what can be safely addressed pad. of the zygomatic arch. The MACS suture anchor points are designed to avoid with reoperative surgery. damage to these nerve branches. Fig. 11.4.5 Vertical skin advancement in the standard short scar approach for a MACS-lift. Facial skeletal structure and asymmetry Medical history Structural needs such as cheek or chin deficiency must be facial tightening without deep layer work. This technique Patients seeking facial rejuvenation may have medical condi- addressed. Evaluate for facial nerve function, muscular func- appears very adaptable to most patients seeking primary and tions that can influence their safety during facial rejuvenation. tion, any asymmetry. secondary facial rejuvenation. It also has the advantage of Not everyone seeking facial rejuvenation surgery is a candi- being reversible during surgery, as suture loops can be date for surgery, based on chronic medical disorders. Attention changed or the entire technique be abandoned for a more Skin quality, character, and looseness should be paid to a thorough review of systems with empha- traditional approach. The learning curve for successful adop- sis on cardiac and circulatory issues. Unique subsets of tion of the MACS-lift is something that can be mastered by Photodamage and photoaging must be addressed and consid- patients with surgical weight loss procedures may present most surgeons who are willing to invest the time required to eration given for medical skin care or light-based treatments. with additional factors such as facial lipoatrophy, tissue learn a new approach to surgical facial rejuvenation. Rhytides and looseness in the perioral area cannot be resolved wasting, and obstructive sleep apnea. DVT risk must be Fig. 11.4.3 MACS sutures result in a bunching up of soft tissue. This has been with rhytidectomy. assessed and managed. termed microimbrication. Patient evaluation Forehead and glabellar rhytides region resolves bunching of loose skin at the level of the Patient expectations earlobe. Each patient is unique with respect to their particular needs Forehead rejuvenation may involve the use of neurotoxins, or There are numerous advantages of the MACS-lift. Deep for facial rejuvenation. It then is incumbent on the surgeon to rejuvenation surgery through the endoscopic, or transpalpe- The management of patient expectations becomes a major tissues are readily repositioned without deep plane dissec- formulate a strategy that will provide solutions for each bral approach. part of facial rejuvenation, whether surgical or medical. It tion, which risks injury to the facial nerve. Less dissection is patient. In the author’s experience, a more holistic approach is essential that patients see themselves for who they are also likely to result in faster recovery. The short scar approach works best in his own patient population. This involves both Facial volume before treatment and that realistic portrayal of outcomes be avoids dissection over the sternocleidomastoid muscle and cosmetic medicine and aesthetic plastic surgery, allowing for communicated. Occasionally, there is the need for revisionary therefore removes the potential for injury to the great auricu- care to be ongoing and to advantage each patient with adjunc- Assessment of the loss of facial volume is done. Volume surgery/procedures that must be addressed prior to treat- lar nerve. MACS sutures are anchored at fixed points which tive services of medical skin care, fillers, neurotoxins, and enhancement in the submalar sulcus may be done with ment versus afterwards. Revision surgery may not be avoid the temporal branches of the facial nerve (Fig. 11.4.6). light-based treatments. surgery, autologous fat grafts, or synthetic fillers. The recogni- successful. It has outcomes that are acceptable over time, and favora- The following components of a patient’s face require evalu- tion of volume loss that occurs due to attritional lipoatrophy The better informed that patients are regarding their par- ble biomechanics that address volume redistribution and ation and strategy. is underestimated. ticular needs and your recommendations, both surgical and Surgical strategy 227 228 SECTION I •11.4 • Facelift: Facial rejuvenation with loop sutures, the MACS lift and its derivatives

nonsurgical, they will be able to obtain the best outcome. author harvests and processes fat at the beginning, followed If a patient does not appear to be capable of obtaining an by injection prior to the incisions for the MACS-lift. It is pre- outcome from treatments/procedures, it is better to commu- ferred not to store AFT graft tissue at ambient temperature for nicate this up front and avoid the vexing problem of a dissatis- long periods during the procedure. Any anterior neck surgery, fied patient who had unrealistic expectations. such as lipoplasty is performed first. The cheek flap is then dissected and the loop sutures are placed. If a temporal lift or endobrowlift is contemplated, it is done next. A blepharo- Surgical strategy plasty, if planned, is done last. Video 1 The use of worksheets and templates has proven useful in Skin incision and undermining many areas of aesthetic surgery and cosmetic medicine. A simple form based on your practice helps you develop your Local anesthetic containing epinephrine is injected along the surgical strategy for each patient’s care. It allows you to make incision line. In the area of flap undermining, the author notes, show specific details, and more importantly determine prefers lipoplasty wetting solution that contains epinephrine A the tradeoffs involved. Such a form is a nice fit with your 1 : 500 000. The short scar incision extends from the earlobe informed consent(s) for the surgical procedure or cosmetic below to the anterior hairline above. It follows the attachment treatments (fillers, neurotoxins, etc.). of the earlobe from the retroauricular crease, around to the How you choose to communicate your strategy with the anterior attachment of the earlobe, following the tragal edge, × patient is also important. Simple aids such as a 10 15 cm the anterior helical attachment to the root of the helix, then print from a digital camera on which you can draw, can be across the lower portion of the sideburn and up the anterior useful. Other approaches involve drawing on the patient with hairline. Anteriorly, the incision is made in a zigzag pattern Fig. 11.4.7 The short scar incision has been made, and the skin flap raised. The an eyeliner marker (easily removed) and taking a photograph. 1–2 mm within the hairline. The zigzag incision effectively zygomatic arch is marked in purple. Note the marks on the skin designating the Both of these are good communication tools to make certain increases the length of the temporal incision to better receive location of the suture loops. The scissors are dissecting a window down to the deep that your plans are in alignment with the patient’s expecta- temporal fascia which will be used as the anchor point for the vertical and cheek the elevated cheek flap. In the standard MACS-lift, the inci- suture loops. tions and needs. Even something as simple as displaying a sion is carried up to the level of the lateral canthus, while in digital photograph on a large-screen LCD television works far the extended MACS-lift, the incision extends up to a point better than using a hand mirror. opposite the tail of the eyebrow. Flap elevation is accom- Anesthesia for the MACS-lift can be minimalistic: local plished with scissor dissection. If an extended incision in the anesthetic with conscious sedation; more complex with moni- retroauricular zone is required, this is done early in the pro- and breakage. In my (the author) first few cases, I found that tored anesthesia care – deep sedation (MAC) or general cedure as it generally facilitates suture loop placement and I did not have an adequate grip on the platysma fascia and anesthesia (GA). If general anesthesia is contemplated, the skin redraping when the neck is tightened vertically. that neck tightening was not optimal; for neck tightening to B author prefers an endotracheal tube (ET) over the laryngeal occur, adequate suture purchase of the platysma below the mask (LMA) device because of less neck distortion with the angle of the mandible is imperative. When performing the Fig. 11.4.8 (A,B) Cadaveric example demonstrating placement and the effect of ET. Other important considerations would be DVT prophy- Anchor point short scar variation, a fiberoptic retractor is helpful to visual- the vertical neck suture. The orientation is vertical, and neck traction depends on laxis and a warming blanket for prevention of hypothermia. ize correct suture placement in the depth of the dissection. achieving excellent suture purchase of the platysma muscle below the angle of the Although some surgeons consider chemoprophylaxis with The deep temporal fascia anchor point is chosen to avoid Should additional reinforcement of the neck be desired, 2-0 mandible. fractionated heparin on long cases, there are reasonable con- the superficial temporal vessels and the temporal branch of polydioxanone sutures can be placed from the platysma into cerns of increased risk of hematoma incidence. Some anesthe- the facial nerve. Small scissors are used to create a window the fascial zone of adherence just below the tragus (Lore’s siologists prefer GA over MAC because of better airway in the subcutaneous tissue approximately 1 cm above the fascia) or from the platysma to the mastoid fascia. Suture management and the ability of a gas analyzer to measure end zygomatic arch and 1 cm in front of the helical rim in order knots in this area should be inverted to avoid knot palpability tidal CO2 as an index of ventilation. to expose the deep temporal fascia (Fig. 11.4.7). through the skin (Fig. 11.4.8). Care should be given during the procedure to installing When placing the suture into the temporalis fascia, the The malar suture protective eye ointment in order to prevent corneal exposure author sews away from the temporal vessel location. A single Once the cheek loop is tied, it is possible to add a third loop problems. Sterile tape strips may also be used to prevent anchor point is used for both the neck loop and the cheek loop for elevation of the malar fat; this constitutes the “extended eyelid opening. Individuals with a history of LASIK proce- in order to diminish the amount of suture used and the pal- The cheek suture MACS-lift” variant. A different anchor point is used anterior dures are especially at risk for corneal problems due to dimin- pability of knots. Absorbable monofilament sutures such as The cheek loop is placed next. It originates at the same anchor to the temporal branch of the facial nerve. This point can ished corneal sensory innervations that triggers tearing. When 0-polydiaxonone are preferred over nonabsorbable polypro- point from the deep temporal fascia. Taking bites of the SMAS, either be the deep temporal fascia just lateral to the lateral operating on a post-LASIK patient, consider an evaluation by pylene or braided polyester suture. suturing progresses inferiorly just anterior to the first loop orbital rim, or the periosteum of the zygoma, approximately an ophthalmologist for adequacy of tear production and tear and then curves more anteriorly, creating a wider loop above 1.5 cm lateral to the lateral canthal area. Access to either of film quality. The neck suture the jowl extending anteriorly as far as the skin flap has been these anchor points requires a small window in the orbicularis raised. The author has found that the loop works best when muscle where the fibers run vertically. This purse-string Surgical sequence The suture loop for the neck is placed first. Going inferiorly it is in the configuration of a logarithmic spiral, like a Nautilus suture travels obliquely toward the malar fat pad where at a in the natural sulcus that is anterior to the tragus, firm bites shell. This allows for upward rotation of facial structures and point 2 cm below the lateral canthus, the direction is reversed, The patient is marked before the start of the procedure; key between 1 cm and 1.5 cm long are taken into the SMAS. volume repositioning. The overall angle of the cheek loop is creating a narrow U-shaped loop that is tight under tension. points are the planned incision, the degree of undermining, Progressing inferiorly past the angle of the mandible, two approximately 30° across the cheek, as compared to the verti- In my experience, the direction of pull will be oblique, but and the location of suture loops The degree of skin flap under- or three suture bites are taken into the platysma before the cal neck loop. The suture is then tied under tension. Novice ideally should be as vertical as possible. If the surgeon is dis- mining typically extends inferiorly just past the mandibular suturing is directed upward and back to the anchor point. MACS-lift surgeons tend to make too small of a cheek loop satisfied with the placement of the loops, it is easy to cut and angle and anteriorly 5–6 cm in front of the ear. If an extended A U-shape loop about 1 cm wide is created and the knot is and are then faced with a situation of a peculiar wad of tissue replace the loops until satisfied with their placement and MACS-lift is planned, undermining is marked over the malar then tied at the anchor point under tension. The suture loop when the loop is tied. Experience teaches that if a suture loop tissue gathering. prominence. The sequence of performing a MACS-lift is is tied without any instrument that might be used to hold the appears unsatisfactory, the best strategy is to take it out and Tissue bunching is an integral problem with the MACS straightforward. If autologous fat grafting is considered, the first knot. This diminishes the possibility of suture damage replace it. suture loops. It is resolved with imbrications with 4-0 Surgical strategy 229 230 SECTION I •11.4 • Facelift: Facial rejuvenation with loop sutures, the MACS lift and its derivatives polyglactin braided suture. The author prefers the version of Skin advancement and resection excision is to have a tension free closure with wound margins Wound closure is also straightforward with absorbable this suture that contains triclosan, an antibacterial agent in coapted against each other. 5-0 monofilament in the deeper layers and 5-0 and 6-0 order to diminish risk of stitch abscess. Before leaving the The skin flap is then redraped along a vertical axis and the The author’s personal technique uses approximately 1 cc polypropylene skin sutures places as interrupted and continu- deep tissue, it is necessary to place the skin flap over the tissue excess skin is resected. If there is excess skin at the level of the of fibrin glue (5 units/mL dilution) that is sprayed on the flaps ous (horizontal mattress). and observe for unresolved bunching and tissue tethering at ear lobe, it must be resolved by incisions in the posterior ear and held for 3 min. I find that this diminishes ecchymosis Dressings involve customary facelift dressings. The author the margins of the undermined area. Scissor removal of pro- region. My philosophy is to resolve this skin by extending my formation and eliminates the requirement for drains. Care personally prefers some silicone-backed foam for the anterior truding fat may be needed in order to produce a smooth tissue incisions in the posterior sulcus of the ear, instead of dealing must be given to not apply excessive fibrin glue as it can neck if lipoplasty has been performed. Otherwise, aftercare is surface inside the loops. Imbrication of tissue in the region with skin bunching post surgery. If necessary, the author uses interfere with revascularization of the flaps. similar to standard facelift procedures. just anterior to the tragus is important in order to preserve a classic rhytidectomy incision in the post-auricular region, this normal sulcus. depending on the patient’s neck laxity. The goal for skin

A B C A B C

D E F D E F

Fig. 11.4.9 (A–F) A 61-year-old woman who underwent a 3-loop extended MACS-lift, submental liposuction, autologous fat graft to submalar region, and hyaluronic acid Fig. 11.4.10 (A–I) This 56-year-old woman developed a relapse of neck soft tissue laxity after a MACS-lift. She underwent a secondary procedure with the placement of fillers to the perioral area. The result shown is at 12 months. both neck and cheek sutures. The result shown is at 12 months after the revision surgery.

tahir99 - UnitedVRG tahir99 - UnitedVRG vip.persianss.ir vip.persianss.ir References 231 SECTION I Aesthetic Surgery of the Face

11.5 Facelift: Lateral SMASectomy

Daniel C. Baker

G H I

Fig. 11.4.10, cont’d less invasive and that involve less downtime is becoming SYNOPSIS increasingly important.3 SMASectomy advantages When SMAS dissection first became popularized after Three representative cases utilizing the MACS-lift concept 5. Aston S, Steinbrech, D, Walden J. MACS facelift. the work of Mitz and Peyronie in 1976, many surgeons ᭿ Minimal SMAS dissection are shown in Figures 11.4.9 and 11.4.10. In: Tonnard P, ed. Aesthetic plastic surgery. Philadelphia: dissected the SMAS directly overlying the parotid gland ᭿ Saunders-Elsevier; 2009:137–149. Greater tension can be put on SMAS re-approximation developing a SMAS flap which was rotated to elevate the 6. Labbé D, Franco R, Nicolas J. Platysma suspension and ᭿ Malar fat pad can be elevated deeper tissue. I (the author) initially utilized this form of Summary platysmaplasty during neck lift: anatomical study and ᭿ Reduces skin undermining SMAS dissection beginning in the late 1970s and continued analysis of 30 cases. Plast Reconstr Surg. 2006;117(6): ᭿ Reduces tension of skin flap with it into the mid-1980s but overall, was disappointed with The MACS-lift is a facelift technique which is ideally suited 2001–2007. ᭿ Simple and direct. the effects of a simple elevation and tightening of the lateral for the lower and middle third of the face. By using strategi- 7. Mendelson B, Muzaffar AR, Adams WP Jr. Surgical Avoiding SMASectomy pitfalls superficial fascia. Specifically, there was little difference in cally placed sutures, deep tissues are repositioned without the anatomy of the midcheek and malar mounds. Plast overall facial contour whether I had performed a SMAS flap ᭿ dangers of deeper dissection. The vertical vector ensures that Reconstr Surg. 2002;110(3):885–896. Keep parotid fascia intact or plication. ᭿ many patients benefit from a short scar approach with a faster 8. Besins T. The ‘R.A.R.E.’ technique (reverse and Maintain correct plane from parotid edge to malar eminence As greater experience was gained with SMAS dissection, it recovery. The technique is adaptable to a wide cross section repositioning effect): the renaissance of the aging ᭿ Suture at proper level became obvious that for the superficial fascia to produce any of patients, and it can be mastered by most surgeons who are face and neck. Aesthetic Plast Surg. 2004;28(3): ᭿ Feather all irregularities. effective contour change in facelifting, it was necessary to willing to learn a new technique. 127–142. elevate the SMAS anterior to the parotid gland. The problem of more extensive SMAS dissection is that facial nerve branches 9. Rohrich RJ, Pessa, J E. The fat compartments of the face. 4,5 Plast Reconstr Surg. 2007;119:2219–2227. are placed in greater jeopardy. It was also noted that the superficial fascia tends to thin out as it is dissected more References 10. Gardetto A, Dabernig J, Rainer C, et al. Does a Introduction anteriorly, making the SMAS easy to tear. A SMAS dissection superficial musculoaponeurotic system exist in the that is not raised as a continuous fascial sheet but rather is 1. Tonnard P, Verpaele A, Monstrey S, et al. Minimal face and neck? An anatomical study by the tissue Rhytidectomy is a procedure that continues to evolve as sur- raised with several tears in it is a poor substrate for holding access cranial suspension lift: a modified S-lift. Plast plastination technique. Plast Reconstr Surg. 2003;111(2): geons seek to offer patients natural rejuvenation with reduced the tension of contouring the face. For these reasons, the Reconstr Surg. 2002;109(6):2074–2086. 673–675 morbidity. Over the years, we have witnessed an evolution of author felt that an extensive SMAS dissection was often not 2. Tonnard P, Verpaele A. The MACS-lift short-scar 11. Mazza E, Papes O, Rubin MB, et al. Simulation of the techniques ranging from basic skin lifts to superficial mus- warranted in most patients and offered little long-term benefit rhytidectomy. St Louis: Quality Medical; 2004. aging face. J Biomech Eng. 2007;129(4):619–623. culoaponeurotic system (SMAS) procedures to even more when compared with SMAS plication. 3. Tonnard P, Verpaele A, Gaia S. Optimising results from 12. Barbarino G, Jabareen M, Trzewik J, et al. Biomedical complex, deep-plane operations in search of an operation that In 1992, the author realized that an alternative to formal minimal access cranial suspension lifting (MACS-lift). Simulation: Physically based finite element model of the face. reliably restores facial form with minimal morbidity.1 More elevation of the SMAS was to perform a “lateral SMASectomy”, Aesthetic Plast Surg. 2005;29:213. Berlin: Springer-Verlag; 2008:1–10. recently, the need for extensive incisions for rhytidectomy has removing a portion of the SMAS in the region directly overly- 4. Tonnard P, Verpaele A. Short scar face lift, operative 13. Barbarino G, Jabareen M, Trzewik J, et al. Development also been questioned. It has become increasingly clear that not ing the anterior edge of the parotid gland at the interface of strategies and techniques. St Louis: Quality Medical and validation of a three-dimensional finite element all patients require the full classic temporal preauricular and the fixed and mobile SMAS.6 Excision of the superficial fascia Publishing, 2007. model of the face. J Biomech Eng. 2009;131:1–10. retroauricular incisions.2 The incision, as well as the planes or in this region secures mobile anterior SMAS to the fixed levels of facial dissection, should be individualized for each portion of the superficial fascia overlying the parotid. The patient, in-keeping with the physical changes related to aging direction in which the SMASectomy is performed is oriented and the desired result. As more patients seek facial rejuvena- so that vectors of elevation following SMAS closure are per- tion at an earlier age, the need for surgical solutions that are pendicular to the nasolabial fold or even more vertical, thereby ©2013, Elsevier Inc. All rights reserved. tahir99 - UnitedVRG tahir99 - UnitedVRG vip.persianss.ir vip.persianss.ir Operative technique 233 234 SECTION I •11.5 • Facelift: Lateral SMASectomy producing improvement not only of the nasolabial fold but Incisions also of the jowl, jaw line, and midface. The advantages of lateral SMASectomy are several when When the temporal hairline shift is assessed as minimal, the compared with formal SMAS elevation.7 First, since the pro- preferred incision is well within the temporal hair. With cedure does not require a formal SMAS flap elevation, there this incision, it is often necessary to excise a triangle of skin are fewer concerns about tearing of the superficial fascia. below the temporal sideburn at the level of the superior Second, the potential for facial nerve injury is less because the root of the helix in order to prevent over elevation of the majority of the dissection is carried over the parotid gland. If sideburn. Preferred incision Optional temporal the SMASectomy is performed anterior to the parotid, the When a larger skin shift is anticipated or the distance incision for deep fascia (parotid masseteric fascia) similarly will provide between the lateral canthus and temporal hairline is >5 cm, recessed hairlines protection for the facial nerve branches as long as the resec- the author prefers an incision a few millimeters within the tion of the superficial fascia is done precisely and the deep temporal hairline. Although this is a compromise, the alterna- facial fascia is not violated. Third, because SMAS flaps have tive of a receding temporal hairline is rarely acceptable to a Usual extent of not been elevated, they tend to be more substantial in terms female patient. When the incisions are executed properly, Optional preauricular subcutaneous of holding suture fixation, and the problems of developing these scars heal well and are easy to revise or camouflage. The or intratragal incision undermining to postoperative dehiscence and relapse contour are reduced. only exception might be in a patient who has deeply pig- lateral canthus Because of the design of the lateral SMASectomy along the and release of mented skin in whom the scar will contrast and appear as a malar ligaments anterior border of the parotid, the SMASectomy is performed white line. The temporal hairline incision should be made Subcutaneous undermining at the interface of the superficial fascia fixed by the retaining parallel to the hair follicles and no higher than the frontotem- into neck allows for ligaments and the more mobile anterior superficial facial poral hairline. exposure of platysma fascia. On closure, this brings the mobile SMAS up to the The temporal hairline incision allows for more vertical and skin redraping junction of the fixed SMAS, producing a durable elevation of elevation of the facial flap without changing the hairline. Submental incision Usual lower border of both superficial fascia and facial fat. In contrast, simple plica- Other indications for this incision are a receding hairline from in normal skin crease. undermining tion pulls on unreleased facial fascia (still bound by the retain- previous facelifts and a fine, fragile hairline. Undermining ing ligaments) such that proper vectors of elevation and The choice of preauricular incision is up to the surgeon. connects laterally obtaining long-lasting fixation can be problematic. When executed properly, all of these incisions heal well In the author’s practice, utilizing the lateral SMASectomy and are imperceptible. I (the author) usually prefer a curved technique, we are confident that we can obtain consistently incision anterior to the helix and continue inferiorly anterior Fig. 11.5.1 Incisions and extent of skin undermining. good results with minimal risk, complications, and morbidity, to the tragus in a natural skin fold. This practice preserves and a speedy postoperative recovery. This method represents the thin, pale, hairless tragal skin and its demarcation from a rapid, safe, and reproducible operation, allowing the surgeon the usual coarser, thicker, darker cheek skin with its lanugo masseteric-cutaneous ligaments and, if necessary, the man- provides another vector to enhance the cervicomental recon- the versatility obtained with formal SMAS flap undermining hairs. I perform intratragal incisions in patients in whom dibular ligaments. touring (Fig. 11.5.2). while producing both the safety and rapidity of SMAS plica- the cheek and tragal skin are similar and the tragal cartilage Subcutaneous dissection continues over the angle of the The submental incision is made either in the submental tion. However, we not apply this technique in every patient, is not sharp or prominent. Closure must be without tension mandible and sternocleidomastoid for 5–6 cm into the neck, crease or just anterior to it. The subcutaneous dissection is and patients with a thin face, where fat needs to be preserved, and the flap overlying the tragus should be defatted to which exposes the posterior half of the platysma muscle. If a performed with the neck hyperextended, and undermining is get an excellent result with just a skin undermining, SMAS dermis. submental incision has been made, the facial and lateral neck usually to the level of the thyroid cartilage and angle of the plication and redraping. In short scar facelifting, efforts are made to end the incision dissection is connected through and through to the submental mandible. Suction-assisted lipoplasty is then performed with There are certainly other rhytidectomy techniques that at the base of the earlobe, but sometimes a short retroauricular dissection. a large, single-hole cannula under direct vision. Direct fat produce excellent results.8 Each surgeon must adopt a tech- incision is often necessary to correct a dog-ear after the facial excision is performed if necessary, but to avoid depressions, nique that serves his or her patients best. Ideally, the tech- flap rotation (Fig. 11.5.1). Defatting the neck and jowls subplatysmal fat is rarely removed. nique should be safe, consistent, easily reproducible, and The medial borders of the platysma muscle are identified applicable to a variety of anatomic problems. The surgeon Skin flap elevation Whenever possible, I prefer closed suction assisted Lipoplasty and elevated for several centimeters. To break the continuity must also have the versatility to adapt and modify his or in the neck and jowls. I use a 2.4 mm Mercedes tip cannula, of the bands, a wedge of muscle is removed at the level of the her technique to the needs and desires of each patient. At All skin flap undermining is performed under direct keeping it under constant, steady motion in the subcutaneous hyoid. The medial borders of the muscle are then sutured present, the lateral SMASectomy provides this for many of vision (with scissors dissection) to minimize trauma to the space. I attempt to leave a layer of fat subcutaneous fat on the together with interrupted buried 4-0 PDS (Ethicon Inc., my patients. subdermal plexus and preserve a significant layer of subcuta- undersurface of the cervical skin. If I suction the jowls, this is Somerville, NJ). neous fat on the undersurface of the flap. Subcutaneous always done conservatively. I rarely suction or remove sub- The submental incision is left open to allow for final hemo- dissection in the temporal region is preferable, because platysmal fat because: (1) the facial nerves run just beneath stasis and recontouring after communication with the facial the skin seems to redrape better. (I believe that hair loss the platysma, and (2) any patient who has significant sub- dissection and completion of the lateral SMASectomy. Operative technique results primarily from tension rather than superficial under- platysmal fat probably has a fat, round face, so removing mining.) Therefore, dissection in this area is done directly subplatysmal fat could create an over-operated look. Lateral SMASectomy including against superficial temporal fascia (temporoparietal fascia.) I usually perform lipoplasty before elevating the skin flaps. Anesthesia Subcutaneous dissection in the temporal region must be per- In doing so, I am careful not to over-suction the portion of the platysma resection formed carefully to avoid penetrating the superficial temporal SMAS platysma that will be elevated over the mandible with Virtually all of the author’s procedural facelifts are performed fascia that protects the frontal branch of the facial nerve. All the lateral SMASectomy. The outline of SMASectomy is marked on a tangent from with the patient under monitored intravenous propofol seda- dermal attachments between the orbicularis oculi muscle and the lateral malar eminence to the angle of the mandible, essen- tion. Patients are given oral clonidine, 0.1–0.2 mg, 30 min the skin are separated up to the lateral canthus. tially in the region along the anterior edge of the parotid before surgery to control their blood pressure. The face Dissection extends across the zygoma to release the zygo- Open submental incision with medial gland. In most patients, this involves a line of resection and neck are infiltrated with local anesthesia, 0.5% lidocaine matic ligaments but stops several centimeters short of the platysma approximation extending from the lateral aspect of the malar eminence with 1:200 000 epinephrine, through use of a 22-gauge spinal nasolabial fold. I have never believed that further dissection toward the tail of the parotid gland. Usually, a 2–4 cm segment needle. The author injects the face before scrubbing to provide provides significant benefits; on the contrary, the only result The author opens the neck in patients who had active platysma of superficial fascia is excised, depending on the degree of the requisite 10 min for vasoconstriction. is increased bleeding. In the cheek, dissection releases the bands on animation, and therefore, the medial approximation SMAS-platysma laxity (Fig. 11.5.3).

tahir99 - UnitedVRG tahir99 - UnitedVRG vip.persianss.ir vip.persianss.ir Operative technique 235 236 SECTION I •11.5 • Facelift: Lateral SMASectomy

SMAS and platysma Malar fat pad vector approximation suspension. Suture is just beneath SMAS Facial vectors

Suture from submandibular platysma SMAS to anterior Submandibular tympano-parotid fascia vertical vector Temporalis fascia Last suture lifts (vertical vector) malar fat pad Zygomatic arch

Platysma flap Medial and lateral sutured to mastoid platysma vectors create Plication of periosteum (lateral a muscular hammock mobile to fixed SMAS oblique vector) support and define the jawline

Wedge resection of 4-5cm medial platysma border to interrupt bands Fig. 11.5.2 Platysmaplasty and SMASectomy advancement vectors.

Fig. 11.5.4 Optional plication of SMAS, for thin In SMAS resection, the author likes to pick up the superfi- faces when debulking is not indicated. cial fascia region of the tail of the parotid, extending the resec- tion from inferior to superior in a controlled fashion. When SMAS resection is being performed, it is important to keep the dissection superficial to the deep fascia and avoid dissec- tion into the parotid parenchyma. Note that the size of the parotid gland varies from patient to patient; consequently, the amount of protection for the underlying facial nerve branches also varies. Despite this, as long as one carries the dissection superficial to the deep facial fascia, ensuring that only the superficial fascia is resected, facial nerve injury and parotid injury will be prevented. In essence, this is a resection of the Lateral SMASectomy superficial fascia in the same plane of dissection in which one extends from tail of parotid to lateral would normally raise a SMAS flap. canthus

Resection is at interface of Vectors fixed and mobile SMAS. A B C D Width of resection The various vectors accomplish corrections of the anterior determined by SMAS laxity neck, the cervicomental angle, the jowls, and the nasolabial Fig. 11.5.5 (A–D) A 79-year-old: face and neck, platysmaplasty, chin implant. and desired de-bulking fold. The first key suture grasps the platysma at the angle of Undermining posterior border the mandible and advances it in a posterosuperior direction; of platysma for advancement it is secured with 2-0 Maxon (United States Surgical Corp., If firm monofilament sutures are used, such as PDA or to mastoid Norwalk, CT) to the fixed lateral SMAS overlying the parotid Maxon, the sutures should be buried and sharp ends on the Skin closure, temporal and (see Fig. 11.5.2). This action lifts the cervical platysma and knot trimmed. Final contouring of any SMAS or fat irregulari- earlobe dog-ears cer vical skin. ties along the suture line is completed with scissors. Fat can After SMAS resection, interrupted 3-0 PDS buried sutures also be trimmed at the sternomandibular trough, final con- After SMAS and platysma approximation, some tethering are used to close the SMASectomy, fixed lateral SMAS being touring being accomplished with lipoplasty. of the skin might appear at the anterior and submandibular evenly sutured to more mobile anterior superficial fascia In the thin face where facial soft tissue should be preserved, skin. Suture fixation is at the level of the insertion of the supe- Fig. 11.5.3 Lateral SMASectomy. (see Fig. 11.5.2). Vectors are usually perpendicular to the SMAS plication is a viable alternative. Instead of an incision rior helix. The author prefers to use a buried 3-0 PDS through nasolabial fold. The last suture lifts the malar fat pad, securing line into the SMAS, a row of plication sutures is placed, utiliz- the temporal fascia with a generous bite of dermis on the it to the malar fascia. It is important to obtain a secure fixation ing the same vectors, the same suture tension and the same skin flap. Closure is under minimal to moderate tension. to prevent postoperative dehiscence and relapse of facial suture material as with the SMASectomy. Skin redraping com- Staples are used to close any incisions in the hair. A wedge contour. pletes the procedure (Fig. 11.5.4). is usually removed at the level of the sideburn to preserve

tahir99 - UnitedVRG tahir99 - UnitedVRG vip.persianss.ir vip.persianss.ir References 237 SECTION I Aesthetic Surgery of the Face

11.6 Facelift: The extended SMAS technique in facial rejuvenation

A B C D James M. Stuzin

Fig. 11.5.6 (A–D) A 62-year-old: face and necklift-platysma, peel face.

aesthetic concepts of improving facial shape and bringing out Introduction the beauty in the face which existed during youth. To these goals, the surgeon attempting facial rejuvenation must have Surgical rejuvenation of the aging face has evolved into one a thorough understanding of facial soft tissue anatomy, com- of the most frequently performed surgical procedures in the prehend the anatomic changes which occur in aging which United States. Facelifting, initially performed as a skin tight- produce a change in facial shape, and understand the ideal ening procedure since the early 1900s, has technically matured facial shape which can be obtained for a particular patient. during the last quarter of a century. This evolution is directly Artistic design of surgical access incisions to minimize scar related to the scientific investigation of facial soft tissue perceptibility, as well as prevent hairline distortion, is also key A B C D anatomy, resulting in a better understanding of the facial ana- in preventing surgical stigmata. tomic changes which occur with aging. Over the last 30 years, The evolution of aging in the human face is complex Fig. 11.5.7 (A–D) A 68-year-old: face and neck, platysmaplasty, chin implant, excise buccal fat. a plethora of procedures have evolved which utilize a variety and multifactorial. Problems that the plastic surgeon con- of technical approaches, having as a common goal the recon- fronts in midface rejuvenation include: (1) the dermal com- struction of aging-related anatomic changes. ponent of aging related to intrinsic and extrinsic skin changes the hairline. If an anterior hairline incision has been made, 2. Baker DC. Lateral SMASectomy, placation and short scar Both the public’s perception as well as the aesthetic con- (dermal elastosis); (2) facial fat descent; (3) facial deflation, I like to close it with buried 5-0 Monocryl sutures (Ethicon, facelifts: indications and techniques. Clin Plast Surg. cepts in facelifting have similarly evolved over time. Initially, which tends to be regionally specific; (4) radial expansion Inc.) and 5-0 nylon sutures. Extra time and attention must be 2008;35:533–550. both patients and surgeons focused solely on the laxity which as facial fat becomes situated centrifugally away from the sent on this closure to eliminate any dog-ears and obtain the 3. Baker DC. Short scar facelift. In: Aston SJ, Steinbrech D, occurs with facial aging, attempting to tighten what was facial skeleton; and (5) the degree of skeletal support of the finest scar. Walden J, eds. Advances in Aesthetic Surgery London: loose rather than shape the face. Hence the term “facelift” (as soft tissue which influences both loss of volumetric highlights, Excess skin is then trimmed from the facial flap so that Elsevier; 2009. opposed to “facialplasty”), a mechanical term implying a pro- as well as the descent of facial fat.1–4 All of these factors there is no tension on the preauricular closure. Wound edges 4. Baker DC, Conley J. Avoiding facial nerve injuries in cedure, the goal of which is to lift what has fallen. Unfortunately, influence facial shape changes with aging. Individual patients should be “kissing” without sutures. Trimming at the earlobe rhytidectomy. Anatomical variations and pitfalls. Plast this mechanical approach to facial rejuvenation often pro- will exhibit various degrees of these problems at the time must also be without tension, and the skin flap is tucked Reconstr Surg. 1979;64:781. duced a tight-appearing, operated look, the stigma of the they request surgery, and each component of the aging under the lobe with 4-0 PDS sutures, taking a bite of the 5. Baker DC. Complications of cervical rhytidectomy. Clin “wind-tunnel appearance” so often associated with surgical face should be addressed according to individual patient earlobe dermis, cheek flap dermis, and conchal perichon- Plast Surg. 1983;10:543–562. rejuvenation of the aging face. Nonetheless, based on a better needs. drium to minimize any tension (if a short scar facelift is per- understanding of facial soft tissue anatomy and the anatomic Evaluation of patient photographs taken during youth and formed a small dog-ear might be present behind the earlobe; 6. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:509–513. changes which occur in aging, facelifting has developed into middle age are helpful in determining how a specific patient this is easily trimmed and tailored into a short incision in the both a reconstructive procedure (whose goal is to reconstruct has aged. Young photographs will usually demonstrate the 7. Baker DC. Lateral SMASectomy. Semin Plast Surg. 2002;16: retroauricular sulcus). A closed suction drain is usually the anatomic changes which occur in aging) as well as a more location of the volumetric highlights present in youth, or 417–422. brought out through a separate stab in the retroauricular artistically defined technique, which attempts to enhance serve to document areas which have deflated over time, delin- sulcus (Figs 11.5.5–11.5.7). 8. Alpert BS, Baker DC, Hamra ST, et al. Identical twin face facial appearance while minimizing signs that a surgical pro- eating both the position and vector of facial fat descent. These lifts with differing techniques: a 10-year follow-up. Plast cedure, has been performed. factors illustrate patient-specific changes in facial shape from Reconstr Surg. 2009;123:1025–1036. There are many treatment goals in facelifting besides youth to middle age, as well as clarifying the possibilities of References simply correcting the hallmarks of the aging face, including methods which facial fat repositioning can improve and improvement of the nasolabial folds, facial jowling and cor- restore shape. From my perspective, the restoration of facial 1. Baker DC. Deep dissection rhytidectomy: A plea for rection of obliquity of cervical contour. As important as the shape is a more worthy aesthetic goal than attempting to caution. Plast Reconstr Surg. 1994;93:1498–1499. mechanical aspects of tightening a loose, aged face, are the tighten a loose face. ©2013, Elsevier Inc. All rights reserved. tahir99 - UnitedVRG vip.persianss.ir vip.persianss.ir Aesthetic analysis and treatment planning 239 240 SECTION I •11.6 • Facelift: The extended SMAS technique in facial rejuvenation

attenuated, facial shape changes. The position of the retaining Anatomic considerations ligaments also dictates the degree of dissection required in a facelift. To adequately mobilize the skin flap, the dissection The anatomic basis that allows rhytidectomy to be performed needs to be carried at least to the peripheral extent of the safely is that the facial soft tissue is arranged as a series of retaining ligament system, specifically dissecting the skin flap concentric layers. This concentric arrangement allows dissec- into the malar region, as well as past the anterior border of tion within one anatomic plane to proceed completely sepa- the masseter. Similarly, the location and restrictiveness of the rate from structures lying within another anatomic plane. retaining ligaments dictates the degree of SMAS elevation The layers of the face are the: (1) skin; (2) subcutaneous required to adequately release the superficial fascia. In general, fat; (3) SMAS (superficial facial fascia); (4) mimetic muscles; this requires the surgeon to extend the SMAS dissection into (5) parotidomasseteric fascia (deep facial fascia); and (6) plane the malar region, releasing the superficial fascia from the Rights were not granted to include this figure Rights were not granted to include this figure of the facial nerve, parotid duct, buccal fat pad, and facial restraint of the zygomatic ligaments, the upper masseteric in electronic media. in electronic media. artery and vein. (This information is thoroughly reviewed in ligaments, as well as medial to the anterior border of the Please refer to the printed publication. Please refer to the printed publication. Chapter 6.) parotid. In an overview of the architectural arrangement of the facial soft tissue, the essential point is that there is a superficial component of the facial soft tissue which is defined by the superficial facial fascia and includes the SMAS and those ana- Aesthetic analysis and tomic components which move facial skin (including super- treatment planning ficially situated mimetic muscle invested by SMAS, the subcutaneous fat, and skin). This is in contrast to the deeper As the human face ages, facial shape changes, morphologic component of the facial soft tissue, which is defined by the facial changes are multifactorial. Some of these changes are deep facial fascia and those structures related to the deep straightforward to address, while others remain difficult fascia (including the relatively fixed structures of the face, technical challenges. A paradox has always been that facial such as the parotid gland, masseter muscle, periosteum of the anatomy (in terms of basic soft tissue architecture) is essen- Fig. 11.6.1 (A) Preoperative appearance of a 42-year-old patient with early facial aging resulting primarily from deflation. Note the hollowing effect within the lateral cheek and preparotid region. Deflation in this young patient has occurred in the fat compartments lateral to the zygomaticus major muscle. (B) Postoperative result following face facial bones, and facial nerve branches). As the human face tially unchanged from youth to middle-age, but facial appear- ages, many of the stigmata which are typically seen in aging and necklift. Note, as anteriorly situated fat is brought into the upper lateral midface, it fills the areas of deflation, thereby blunting the lines of demarcation between aesthetic ance changes greatly over time and is patient specific. subunits which develop with age. Notice also the change in facial shape, which now appears more structured and supported following facial fat repositioning. relate to a change in the anatomic relationship which occurs Although each face ages differently, there are common themes between the superficial and deep facial fascia. With aging, noted in all aging faces. facial fat descends in the plane between superficial and deep facial fascia, and the radial expansion of the superficial soft tissue away from the facial skeleton occurs within this plane. Descent of facial fat In the author’s opinion, these anatomic changes justify repo- sitioning facial fat through subSMAS dissection to restore As the human face ages, facial fat descends and with it facial youth (malar, preparotid, lateral and infraorbital rim, lateral At the risk of over-simplification, one key to understanding facial shape.5,6 shape changes. Typically, the youthful face is full of well- chin) become volumetrically deflated over time. With defla- facial deflation is the recognition of the location of zygomati- supported fat. Volumetric highlights are located within facial tion, soft tissue becomes less supported and therefore appears cus major muscle, which traverses from the malar eminence Retaining ligaments aesthetic subunits, which have a high density of retaining lax. Youthful faces have a smooth blending of contour between to the oral commissure. Deflation of the cheek lateral to the ligaments (zygomatic eminence and zygomatic arch, prepa- the aesthetic subunits of the face. Middle-aged faces, second- zygomaticus major muscle tends to occur independently from The communication between the superficial and deep facial rotid, orbital rim) and serve to fixate this volume of fat to ary to both deflation and facial fat descent, develop lines of deflation in the malar region, medial to the zygomaticus fascia occurs at the level of the retaining ligaments which are underlying structures. Juxtaposed to the volumetric fullness demarcation between one region of the face and another, major. For many patients, lateral cheek deflation develops at discussed in Chapter 11.1. These structures fixate facial soft (or convexity) of the malar and preparotid region is com- which is intuitively identified as old. An accurate aesthetic an earlier age than malar pad deflation, and is often noted in tissue in normal anatomic position, resisting gravitational monly a concavity within the submalar region, overlying treatment plan to improve facial shape requires repositioning patients in their forties. Medial cheek and malar pad deflation forces.1,7 In the evolution of midface aging, the zygomatic the buccinator muscle and buccal recess. The combination descended soft tissue into areas of facial deflation to improve tend to occur later in life and is responsible not only for the and masseteric cutaneous ligaments bear particular attention. of fullness in the malar region and lateral cheek, associated shape, not only by restoring volume to the position noted in loss of volumetric support within the anterior cheek, but also The zygomatic ligaments originate from the periosteum of the with submalar concavity and a well-defined mandibular youth, but also serving to blunt the lines of demarcation leads to the development of what has been termed the infraor- malar region. Their function is to fixate the malar pad to the border, accounts for the angular, tapered appearance of the between aesthetic subunits. Volumetric augmentation through bital V-deformity. Deflation in this region results in an appar- underlying zygomatic eminence in the youthful face. youthful face. autologous fat injection or other injectable soft tissue fillers ent increase in the vertical length of the lower lid, as the Support of the soft tissues of the medial cheek is provided With aging, facial fat can descend and produce significant are ancillary agents, which can be useful in augmenting areas lid–cheek junction visually descends inferiorly into the poorly from a series of fibrous bands that extend along the entire changes in facial shape. In middle-age, as ligamentous support of deflation. supported anterior cheek (Fig. 11.6.2). anterior border of the masseter muscle. These are the “mas- becomes attenuated, facial fat volumetrically becomes situ- Deflation in the aging face is a complex process which tends An interesting region of deflation develops in some patients seteric cutaneous ligaments”, and are identified superiorly in ated anteriorly and inferiorly in the cheek, producing a to be regional and age-specific. Key elements in understand- in the submalar region lateral to the oral commissure. In these the malar area where they mingle with the zygomatic liga- contour that is square and bottom heavy with little differential ing how deflation occurs have been enlightened following an patients, deflation can result in accentuation of the submalar ments and extend along the anterior border of the masseter between malar highlights and submalar fat. As facial fat is elucidation of the compartmentalization of subcutaneous fat concavity, which can become more obvious following the ver- situated more inferiorly in the face, middle-aged faces appear 8 as far inferiorly as the mandibular border. These fibers repre- 3,4 within the cheek as defined by Rohrich and Pessa. What these tical soft tissue shifts associated with facelifting procedures. sent a coalescence between the superficial and deep fascia, vertically longer than young faces (Fig. 11.1.4). investigators realized was that the cheek subcutaneous fat, An accentuation of submalar depression lateral to the oral extending from the masseter muscle vertically to insert into rather than being homogeneous, is compartmentalized, with commissure can result in the development of what has been the overlying dermis. These masseteric ligaments support the Volume loss and facial deflation each facial fat compartment surrounded by specific septal termed “joker lines” or cross-cheek depressions, which are soft tissues of the medial cheek superiorly above the man- membranes and with each compartment having an independ- a typical stigmata that a patient has undergone a facelift. dibular border in youth. Youthful faces are full of well supported facial fat. Over time, ent perforator blood supply. Aesthetically, the significance of Avoidance of vertical soft tissue repositioning in conjunction The surgical significance of the retaining ligaments is that deflation occurs, and tends to be most apparent in regions of compartmentalization of facial fat is that deflation tends to with volume addition in the submalar recess lateral to the oral they represent the anatomic communication between superfi- the face with a high density of retaining ligaments. For this occur within a specific region of the cheek, explaining why commissure is useful in preventing the accentuation of post- cial and deep facial fascia. As this support system becomes reason, the areas which are noted to be volumetrically full in the entire cheek does not deflate homogeneously (Fig. 11.6.1). operative cross-cheek depressions (Fig. 11.6.3).9

tahir99 - UnitedVRG vip.persianss.ir Radial expansion 241 242 SECTION I •11.6 • Facelift: The extended SMAS technique in facial rejuvenation

be noted postoperatively despite heroic efforts at reposition- ing descended facial fat.

Role of skeletal support in formulating a surgical treatment plan

Rights were not granted to include this figure Facial shape and contour is intuitively evaluated when ana- in electronic media. lyzing a patient for facial rejuvenation. Often the two- Please refer to the printed publication. dimensional considerations seen in photographs are the easiest aspects of aging to identify, and such factors as naso- labial fold depth, jowl prominence, and cervical contour Rights were not granted to include this figure become the primary objectives to improve appearance in the in electronic media. middle-aged face. While these factors are certainly important Please refer to the printed publication. considerations in treatment planning, the more subtle three- dimensional qualities of facial shape are equally important to evaluate, and are greatly influenced by underlying skeletal Fig. 11.6.2 (A,B) Preoperative appearance of a 59-year-old male following a 90 pound weight loss from a gastric bypass procedure. Notice the significant areas of facial support. deflation along the infraorbital rim, lateral orbital rim and malar region. Also note the apparent length of the lower lid as the infraorbital V-deformity develops in association In evaluating facial shape during preoperative analysis, with malar pad deflation. Note also the radial expansion of skin and fat lateral to the nasolabial fold, most marked on the right side. Not only does malar fat deflate and there follow some of the major factors which are helpful to descend, but attenuation of the retinacular connections between skin, fat and deep facial fascia lateral to the nasolabial line allows centrifugal prolapse of soft tissue which consider.4 accentuates nasolabial prominence. (C,D) Postoperative result. The areas of deflation along the infraorbital rim, lateral orbital rim, and malar region are improved as facial fat has been repositioned into these regions. The nasolabial folds are somewhat improved following malar pad repositioning, but correction is incomplete, especially on the right. Malar pad elevation helps to flatten the prominent nasolabial fold, and improve the infraorbital V-deformity, but does little to correct radial expansion, with the skin Facial width, bizygomatic diameter, lateral to the nasolabial line remaining prolapsed from its attachments to the facial skeleton. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal and malar volume support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.) The emphasis in facelifting over the last 30 years has focused on malar pad elevation.2,11–19 While malar pad elevation and Fig. 11.6.4 Facial width and bizygomatic diameter reflect the underlying degree of restoration of malar highlights is an important factor in skeletal support. Patients who exhibit strong malar eminences and wide bizygomatic improving facial shape, it needs to be patient-specific. Many diameter often benefit from having malar highlights restored, but usually do not require significantly enhancing malar volume (which will cause a wide face to Radial expansion patients present preoperatively with wide faces, strong malar appear wider postoperatively). Shaping considerations in these types of faces eminences and large malar volume, with little evidence of usually focus on improving the appearance of the lower two-thirds of the cheek, Not all facial aging is vertical and a major challenge in facial malar fat descent. In these individuals it is necessary to evalu- specifically addressing jowl fat repositioning, as well as creating submalar rejuvenation is the radial expansion of facial soft tissue which ate preoperatively the degree of malar pad elevation required hollowing which improves the aesthetic relationship between malar and submalar occurs along specific areas of the midface. In youth, the skin to improve facial shape. While limited degrees of malar pad regions. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal and underlying subcutaneous fat are densely attached to the elevation can be helpful in patients who present with wide support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.) deep facial fascia by retinacular fibers which transverse bizygomatic diameters, in general, if the malar volume is sig- between skin, subcutaneous fat, superficial fascia and insert nificantly enhanced in these types of individuals, the aesthetic into the deep fascia and facial musculature. Over time, with effect is to make a wide face appear even wider on the front prolonged animation such as smiling, the skin along the view postoperatively. In patients with adequate facial width, nasolabial line is forced deep to the subcutaneous fat, posi- the author tends to limit both SMAS release and malar pad tioned lateral to the nasolabial fold, attenuating these reti- elevation to the lateral aspect of the zygomatic eminence such nacular attachments. Prolonged animation therefore forces that bizygomatic diameter is not increased postoperatively within the submalar region overlying the buccinator. As the skin and fat lateral to the nasolabial fold to expand radi- (Fig. 11.6.4). patients age, the relationship between the malar and submalar ally and prolapse outward from the facial skeleton, account- regions changes and with it, facial shape changes. As facial fat ing for much of the nasolabial fold prominence in the aging Facial length and the relative vertical heights of descends and facial deflation occurs, there is less volume face. Radial expansion lateral to the oral commissure and the lower and middle-third of the face overlying the malar eminence and an associated increase in marionette line similarly accounts for the prominence of the fullness resulting from radial expansion within the submalar jowl in many middle-aged patients, making the older face Compared with wide faces, patients who present with vertical region. As the aesthetic relationship between the malar and appear square in shape and bottom heavy.4,10 maxillary excess often have long, thin faces on front view. As submalar region becomes modified with time, there is a loss Radial expansion is technically difficult to correct, as there facial fat descends in middle age, it becomes situated anteri- of the angular, tapered configuration in shape noted in youth, are few surgical solutions to re-establish the retinacular attach- orly and inferiorly in the face, and the face appears even and middle-aged faces often appear oval. With greater facial ments between skin, subcutaneous fat and deep fascia. longer with age. Malar pad elevation and enhancing malar fat descent, and an increase in submalar fullness, older faces Nonetheless, repositioning of facial fat through some form of volume in these types of patients is usually beneficial. As appear square. Fig. 11.6.3 A cadaver dissection illustrates the muscular insertions into the oral support to the superficial fascia will not only reposition fat malar volume is enhanced and bizygomatic diameter is Preoperatively, an evaluation of the relationship between commissure and modiolus. The small arrow overlies the facial portion of the vertically, but will also provide some degree of internal repo- increased, the face appears wider on the front view, detracting the malar and submalar region on front view is an essen- platysma, and points to the risorius muscle. The large arrow points to the depressor sitioning such that the superficial facial soft tissues lie closer from relatively excessive facial length (Fig. 11.6.5). tial component of aesthetic treatment planning. For many anguli oris in the region where it merges with the platysma. Superiorly, note the to the facial skeleton. As the soft tissues become situated patients, a restoration in this relationship by increasing insertion of the zygomaticus major into the lateral commissure with a slip of closer to the underlying deeper structures of the face, facial Convexity of the malar region juxtaposed to malar highlights and malar volume, in association with a muscle inserting inferiorly into the modiolus. Following deflation in this area, the medial component of the cross cheek depression develops in the watershed morphology tends to be restored to a more youthful configu- the concavity of the submalar region restoration of concavity in the submalar region through between the elevator and the depressors of the lip. (From Lambros V, Stuzin JM. ration. Because of the technical difficulty to completely treat repositioning fat internally overlying the buccinator muscle The cross-cheek depression: surgical cause and effect in the development of the radial expansion in many faces, incomplete correction of both In youth, facial fat is situated overlying the malar and prepa- becomes a central component in improving facial shape “Joker Line” and its treatment. Plast Reconstr Surg 2008;122:1543.) the jowl and nasolabial fold resulting in under-correction can rotid region. This malar fullness is juxtaposed to a concavity (Figs 11.6.6, 11.6.7). Radial expansion 243 244 SECTION I •11.6 • Facelift: The extended SMAS technique in facial rejuvenation

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Fig. 11.6.5 Long, thin faces often benefit from an enhancement of malar volume. SMAS dissection and facial fat repositioning carried anteriorly over the zygomatic eminence allows the surgeon to restore malar volume, thereby increasing bizygomatic diameter. When malar volume is enhanced, the face appears wider, detracting from the relatively excessive facial length. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.)

Fig. 11.6.7 (A) Preoperatively, the patient shows a similar blunting of the relationship between the malar and submalar regions. (B) Postoperative appearance. Enhancing malar volume (and bizygomatic diameter) and restoring the concavity within the submalar region make the face appear more angular, as well as vertically shorter. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.)

The aesthetic advantages of formal aesthetic effects of vertical skin vectoring unfortunately have been poorly delineated. Specifically, when skin is shifted in a SMAS elevation in a two-layer dual cephalad direction, the effect of skin tension commonly pro- plane SMAS facelift duces an accentuation of flatness in the preparotid region, an Rights were not granted to include this figure Rights were not granted to include this figure area that typically deflates with aging. In my opinion, vertical in electronic media. in electronic media. All modern techniques share a commonality in that postop- skin shifting can produce an unnatural tightness to facial Please refer to the printed publication. Please refer to the printed publication. erative contour is largely dependent on facial fat repositioning shape, producing some of the typical stigmata associated with Fig. 11.6.6 (A) Preoperative appearance. through some form of SMAS manipulation. The advantage Note that facial shape is oval, secondary to rhytidectomy. If the surgeon has been successful in reposition- malar deflation associated with an increase of formal SMAS flap elevation lies in its aesthetic versatil- ing descended facial fat, the use of strong vertical skin tension in submalar fullness. (B) Postoperatively, ity. Once the superficial fascia has been freed from the is neither desirable nor required to enhance the postoperative following malar pad elevation, malar volume restraint of the retaining ligaments, it offers the surgeon result (Fig. 11.6.9). is enhanced in association with a restoration several advantages, including: (1) vector versatility; (2) greater of submalar concavity, producing a more control in terms of long-term vertical facial fat repositioning; angular appearance to facial shape. (From and (3) greater control in terms of long-term internal facial fat Stuzin JM. Restoring facial shape in repositioning. facelifting: The role of skeletal support in Surgical technique: extended facial analysis and midface soft-tissue Regarding vector versatility, dermal elastosis and skin Video repositioning. Plast Reconstr Surg laxity in the aging face often does not occur in the same direc- SMAS dissection 1 2007;119:362.) tion nor at the same rate as aging related to the descent of fat. The main advantages of performing skin dissection separate Restoration of support to the underlying deeper facial soft from SMAS dissection is that it allows these two layers to be tissues has become the key ingredient to the approach to draped along vectors which are independent of one another improve facial aging. If the SMAS is thin, plication is an alter- The vertical height of the mandibular (Fig. 11.6.8).2,19–21 Another advantage of a two-layer SMAS native method. Nonetheless, better contouring and longer excellent skeletal support for soft tissue repositioning and are, facelift is that the tension of contouring is placed on the super- lasting results are obtained following a formal dissection ramus and the horizontal length of therefore, less of a surgical challenge. In contradistinction, ficial fascia, thereby allowing the surgeon to use less tension of the superficial fascia. In the author’s experience, after the the mandibular body patients with a short mandibular ramus, an open mandibular for skin closure. This improves control regarding scar percep- superficial fascia is freed from the restraint of the retaining plane angle and a short length of the mandibular body typi- tibility.20,21 In terms of vectors, in the author’s experience, ligament, it slides freely, allowing greater control in vertically The vertical height of the mandibular ramus and the horizon- cally have poor skeletal support for midface and perioral soft facial fat is commonly repositioned in a more vertical vector repositioning of facial fat. Full release of the SMAS also allows tal length of the mandibular body provide skeletal support tissue repositioning. These patients are a greater surgical chal- than skin flap redraping. Strong vertical shifting of the cervi- the superficial fascia to better conform internally to the under- for the lower two-thirds of the face. Patients who present lenge in restoring facial shape, and often benefit from volu- cofacial flap is a maneuver that has traditionally been utilized lying deeper facial soft tissue and facial skeleton. Greater with a normal mandibular ramus height, as well as adequate metric augmentation, either alloplastic or autogenous, to in many facelift techniques. While skin tightening can produce control of internal fat repositioning provides for more com- horizontal length of the mandibular body, usually have enhance skeletal support. a dramatic effect in terms of improvement of facial laxity, the plete correction of radial expansion. Surgical technique: extended SMAS dissection 245 246 SECTION I •11.6 • Facelift: The extended SMAS technique in facial rejuvenation

limit the skin undermining several centimeters lateral to the nasolabial fold rather than undermining the skin to this facial landmark. The reason is that if one limits the dissection of the skin flap in the medial aspect of the cheek, this will preserve some of the attachments that go from the deep fascia through the SMAS to facial skin. The preservation of these attach- ments, followed by adequate undermining of the superficial facial fascia (SMAS), will allow the surgeon to re-elevate ante- riorly displaced fat and skin through SMAS rotation rather than to redrape the superficial fascia completely independent of skin flap redraping. The ability to re-elevate and resuspend facial soft tissue through SMAS rotation produces a more Rights were not granted to include this figure Rights were not granted to include this figure pleasing aesthetic result and a greater degree of correction of in electronic media. in electronic media. radial expansion within the cheek, as the facial fat is brought Please refer to the printed publication. Please refer to the printed publication. internally to conform to the underlying buccinator muscle (Fig. 11.6.10).

SMAS elevation

The dissection of the superficial fascia allows the surgeon to re-elevate jowl and descended malar fat back upwards into the face toward their previous, normal anatomic location.2,5 In patients with prominent nasolabial folds and significant infraorbital hollowing, it is my feeling that the SMAS dissec- tion should extend into the malar region in an effort to re-elevate the malar fat pad back upward overlying the zygo- Fig. 11.6.9 These two patients show the effect of vertical rotation of the cervicofacial flap associated with hairline distortion. A skin flap that is overly rotated in a cephalad direction not only can compromise the temporal hairline, but also tends to produce flatness in the lateral midface overlying the masseter and parotid. This imparts a tight, matic eminence. An added benefit of performing a more unnatural appearance to the face. Also notice the effect of scar perceptibility when strong skin tension is used in an attempt to contour the aging face. (From Baker TJ, extensive anterior dissection of the SMAS is that it frees this Gordon HL, Stuzin JM. Surgical rejuvenation of the aging face, 2nd edn. St Louis: CV Mosby; 1995.) layer from the restraint of both the zygomatic and masseteric ligaments, and this anterior release provides for a more com- plete elevation of the facial fat below the oral commissure and along the anterior portion of the jowl. an important technical point in obtaining the mobility neces- retaining ligaments. Once these structures are divided, The incisions (Fig. 11.6.11) for extended SMAS dissection sary to reposition the malar soft tissue superiorly. To obtain one notes greater mobility when traction is applied to the begin approximately 1 cm inferior to the zygomatic arch to this mobility usually also requires a division of the upper malar portion of the SMAS flap, translating into greater move- ensure frontal branch preservation. This horizontal incision fibers of the masseteric cutaneous ligaments, which will ment along the uppermost portion of the nasolabial fold Fig. 11.6.8 The direction of SMAS redraping in the face tends to be cephalad in is continued several centimeters forward to the region where expose the underlying body of the buccal fat pad. The cheek (Fig. 11.6.12). its orientation as opposed to skin flap redraping, which is oriented along a more the zygomatic arch joins the body of the zygoma. At this portion of the SMAS dissection is performed beginning horizontal vector. The aesthetic versatility of vectoring the SMAS in a direction point, the malar extension of the SMAS dissection begins directly overlying the parotid gland and then extending this independent of skin flap redraping is a major advantage of a two-layer SMAS-type with the incision angling superiorly over the malar eminence dissection anterior to the parotid utilizing a combination facelift. SMAS fixation toward the lateral canthus for a distance of 3–4 cm. On reach- of sharp and blunt dissection toward the anterior border of ing the edge of the subcutaneous skin flap in the region the masseter. Repositioning and closure of the SMAS is then performed. The key to performing successful dissection of an extended of the lateral orbit, the incision is carried inferiorly at a 90° In most patients, following extended SMAS dissection The malar SMAS flap is advanced superio-laterally over the SMAS flap is precise dissection of the skin flaps during sub- angle toward the superior aspect of the nasolabial fold. A of the cheek and malar regions, mobility of the soft tissues zygomatic prominence in a direction perpendicular to the cutaneous undermining, with care to leave a moderate amount vertical incision is designed along the preauricular region, lying lateral to the nasolabial fold remain restricted unless nasolabial fold, and usually paralleling the zygomaticus of fat intact on the superficial surface of the SMAS, especially extending along the posterior border of the platysma to a the dissection is carried more medially. This restriction in major muscle. After superior and lateral advancement, if a in the regions where the SMAS is to be dissected. If the skin point 5–6 cm below the mandibular border. In essence, the movement results from the undivided retaining ligaments malar augmentation is not planned, the excess tissue can be flaps are dissected so that little fat is left along the superficial malar extension of the SMAS dissection simply represents which originate medial to the zygomaticus minor. To improve excised and the flap securely fixated to the zygomatic perio- surface of the SMAS, the SMAS becomes more difficult to an extension of a standard SMAS dissection into the malar mobility, I commonly continue malar pad elevation medi- steum with interrupted sutures (Fig. 11.6.13). raise, appearing thin, tenuous and prone to tearing. In a region in an attempt to obtain a more complete form of deep ally in an area where I have not subcutaneously undermined Once the malar flap is secure, the cheek-SMAS flap is SMAS-type facelift, much of the contouring that is obtained layer support. the skin. This dissection is carried directly in the plane bet- rotated superiorly perpendicular to the mandibular border. is due to elevation and fixation of the SMAS layer. The more The SMAS in the malar region is then elevated in continu- ween the malar fat and the superficial surface of the elevators This portion of the SMAS flap is used to contour jawline and substantial the SMAS flap, often the better long-term results ity with the SMAS of the cheek. When elevating this flap, of the upper lip. It is usually quite easy to delineate this jowl. The SMAS overlying the preauricular region and ear is that can be obtained in terms of facial contouring. The use of the fibers of the orbicularis oculi, as well as the zygomati- level of dissection after the malar SMAS elevation is complete, then treated as a transposition flap and carried posteriorly contralateral transillumination is helpful in providing a cus major and minor, are usually evident and the flap is ele- and the superficial surface of the elevators of the upper behind the ear, helping to restore tone to the submental region clearer definition of the interface between subcutaneous fat vated directly along the superficial surface of these muscles. lip visualized. The scissors are then inserted directly super- and neck. Following trimming, the SMAS flap is carefully and superficial fascia, allowing for greater precision in skin It is important to carry the dissection directly external to ficial to the elevators of the upper lip and blunt dissection secured with multiple interrupted sutures. Occasionally, skin flap elevation. these muscle fibers, where a natural plane exists, remember- is quickly performed by pushing the scissors in a series dimpling is noted after securing the SMAS flap and this Preoperatively, I (the author) decide the extent of subcuta- ing that the facial nerve branches lie deep to these muscular of passes bluntly toward the nasolabial fold. I find that when results from the forces of SMAS rotation on resuspended neous skin flap undermining based on the most medial aspect bellies. The malar SMAS is then elevated until the flap is we insert the scissors in the proper plane, the dissection facial skin. Skin dimpling is treated by simply performing of where I want to end the SMAS dissection, which typically freed from the underlying zygomatic prominence. Freeing quickly glides through the malar soft tissues and I usually a bit more subcutaneous undermining prior to skin flap is situated just medial to the retaining ligaments. I prefer to of the SMAS completely from the zygomatic attachments is will feel a “snap” as we dissect through the remaining redraping. Surgical technique: extended SMAS dissection 247 248 SECTION I •11.6 • Facelift: The extended SMAS technique in facial rejuvenation

B

A

Fig. 11.6.10 (A) If an extended SMAS dissection is to be performed, it is important not to widely undermine the skin all the way to the nasolabial fold, but rather to preserve some of the attachments that exist between the skin and the SMAS (the limit of subcutaneous undermining is the shaded area). If these attachments are left intact, this allows the surgeon to simultaneously re-suspend undissected anterior facial skin at the time of SMAS rotation and fixation. (B) It is important to understand which A B portion of the SMAS flap will affect facial contouring. In this diagram, the most superomedial aspect of the SMAS dissection affects contour along the nasolabial fold, whereas the more lateral portion of the SMAS dissection is used to re-elevate jowl fat upward into the cheek. A portion of the SMAS flap is rotated into the postauricular region with the vector of rotation of this portion of the SMAS dissection affecting submental and cervical contouring. Fig. 11.6.11 (A) In patients with malar deflation or malar pad descent, the author typically performs what is termed an extended SMAS dissection. By this, I mean I extend the SMAS dissection into the malar region in an attempt to re-elevate ptotic malar fat back upward over the zygomatic prominence. The incisions begin at the junction where the zygomatic arch joins the body of the zygoma. From this point, the incision in the SMAS is angled superiorly toward the lateral canthus and along the lateral orbital rim. The incision in the SMAS is then carried medially and inferiorly toward the peripheral extent of skin flap undermining, angling toward the uppermost portion of the nasolabial fold (the amount of subcutaneous undermining is shaded in pink, whereas the amount of SMAS undermining is shaded in yellow.) (B) The malar-SMAS dissection is then performed in continuity with the cheek-SMAS dissection. Dissecting in the malar region carries the dissection directly along the superficial surface of Following proper contouring of the SMAS dissection, the elevators of the upper lip. Dissecting the skin flap the zygomaticus major and usually exposes the lateral aspects of the zygomaticus minor as well. To obtain adequate mobility in terms of SMAS dissection, it is necessary facial skin flaps are rotated and closed in the direction decided thinly in this region leaves a substantial amount of to elevate the malar portion of the dissection completely from the zygomatic eminence and free it from the zygomatic ligaments. To obtain mobility in terms of SMAS movement affecting the jowl contour, the uppermost portions of the masseteric cutaneous ligament commonly are divided, especially where they merge with the zygomatic upon, based on preoperative evaluation. In general, these skin subcutaneous fat intact along the surface of the ligaments of the malar area. If these fibers are not divided, they will restrict the upward redraping of jowl fat. On division of the upper portion of the masseteric cutaneous flaps are inset with a minimum degree of tension placed along superficial fascia, providing greater ease in SMAS ligaments, the buccal fat pad becomes evident, and commonly the zygomatic nerve branches traversing toward the undersurface of the zygomaticus major muscle are the key sutures and then the skin flaps are trimmed with a dissection and minimizing the possibility of tearing visualized. This diagram illustrates the typical degree of mobilization performed in our extended SMAS dissection. degree of redundancy between the key sutures to minimize this layer. tension along the incision sites. 3. The most difficult portion of an extended SMAS To summarize, the key points in mobilizing the superficial dissection is freeing the superficial fascia from the fascia from the restraint of the retaining ligaments of the cheek restraint of the superior masseteric ligaments, which are as follows: vectors in which facial fat is repositioned, and the location and are lateral to the zygomaticus major muscle. If these Variations in extended SMAS technique method for SMAS fixation. 1. The SMAS overlying the parotid gland and malar ligaments are not mobilized, restricted movement is eminence tends to be substantial and easy to dissect, noted in the portion of superficial fascia that affects to affect a restoration in facial shape with both the parotid and zygomaticus major and contouring along the lower nasolabial fold, oral Release minor muscles protecting the underlying facial nerve commissure and anterior jowl. The zygomatic branches The biomechanics of SMAS repositioning have been previ- branches. These areas are very safe regions to begin of the facial nerve are in close proximity to the upper ously described and are influenced by the degree of release, The incision design of an extended SMAS dissection allows SMAS elevation and delineate the subSMAS plane. masseteric ligament. At times it can prove difficult vector of fat repositioning and how the superficial fascia is for complete release of the SMAS from its underlying retain- 2. The thinnest fascial component of an extended SMAS to differentiate between ligaments and facial nerve fixated.22 As postoperative contour is dependent on each of ing ligamentous attachment in the lateral midface. As sur- dissection is in the region just lateral to the zygomaticus branches. Caution is stressed in this region of these factors, preoperative planning needs to be patient- geons, there is a tendency to believe that a greater degree major muscle, where the SMAS splits to invest the dissection. specific in terms of the degree of SMAS release required, the of SMAS dissection equates with a better result, but this Vectors of fat elevation: facial asymmetry 249 250 SECTION I •11.6 • Facelift: The extended SMAS technique in facial rejuvenation

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Fig. 11.6.14 Patients with wide bizygomatic diameters and good underlying skeletal support typically do not require a significant anterior malar dissection to improve facial shape. Most commonly, the SMAS dissection in these patients (while kept high), is extended only as medial as the lateral orbital rim, so that malar volume restoration is limited to the lateral aspect of the zygomatic eminence. The shaping considerations for these types of faces usually emphasize reducing fullness within the submalar area, as well as jowl fat elevation. Notice that postoperatively the patient’s face appears more tapered and thinner in morphology through facial fat repositioning without removal of facial fat. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.)

Fig. 11.6.13 The vectors of redraping of the extended SMAS flap are determined according to the preoperative evaluation of the patient and are generally more cephalad than skin flap redraping.

Fig. 11.6.12 It is commonly necessary to extend the malar SMAS dissection more peripherally than the subcutaneous dissection to obtain adequate flap mobility of infraorbital and lateral orbital rims). Most commonly, these the soft tissues lateral to the nasolabial fold. This portion of the dissection is easily performed by simply inserting the scissors in the plane between the superficial types of patients require only a restoration of malar highlight surface of the elevators of the upper lip and the overlying subcutaneous fat. Once and not significant anterior malar volume enhancement. the scissors are inserted in the proper plane, the surgeon bluntly dissects in a Limiting the SMAS dissection to the lateral aspect of the malar Rights were not granted to include this figure Rights were not granted to include this figure series of passes past the nasolabial fold (area marked in green). As long as the eminence will not increase facial width on the front view.4 in electronic media. in electronic media. scissors remain superficial to the elevators of the upper lip, motor nerve injury will Typically, the shaping considerations for these patients is Please refer to the printed publication. Please refer to the printed publication. be prevented. Usually three or four passes are required to obtain adequate flap focused on reducing fullness in the submalar region (Fig. mobility. 11.6.14). Vertically long faces often benefit from carrying the malar portion of the extended SMAS dissection anteriorly, medial to the lateral orbital rim so that malar volume restoration is has not been my experience. Rather, precision in the degree performed along the anterior aspect of the zygomatic emi- of SMAS dissection and its release from the retaining liga- nence. Carrying the SMAS dissection more medially allows ments as dictated by the aesthetic needs of a patient increases the surgeon to enhance malar volume and restore malar surgical control and consistency in while minimizing highlights anteriorly over the zygomatic eminence, thereby morbidity.3 increasing facial width on the front view (Fig. 11.6.15). How much to release the SMAS, and how high and anterior to carry the SMAS dissection, needs to be decided preoper- Fig. 11.6.15 Faces which are more dominated by their facial length (especially the lower third of the face) usually benefit from malar volume restoration. To enhance malar atively. As discussed previously, in patients who present with Vectors of fat elevation: volume requires the SMAS dissection be carried toward the anterior aspect of the zygomatic eminence, such that malar volume is increased in this region. (From Stuzin JM. adequate malar volume, wide bizygomatic diameter and little Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.) evidence of malar pad descent, it is usually unnecessary to facial asymmetry carry the SMAS dissection medial to the lateral orbital rim (although the author usually carries the dissection high within All patients exhibit some degree of facial asymmetry. the malar eminence to allow fat repositioning along the Commonly, one side of the face is vertically longer and the SMAS fixation 251 252 SECTION I •11.6 • Facelift: The extended SMAS technique in facial rejuvenation

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Fig. 11.6.16 Vectors of SMAS elevation have a significant impact on facial shape. Vertical repositioning of the SMAS allows the surgeon to enhance malar volume and reduce fullness within the submalar region, as fat is forced up along the concavity of the buccinator. Restoration of submalar hollowing through SMAS vectoring is useful Fig. 11.6.17 This patient exhibits asymmetry in the submalar region preoperatively. Notice that she appears hollow and concave on the right, while she is fuller on the left in contouring full faces, making them appear thinner postoperatively. In this patient, a small amount of jowl defatting through needle aspiration was also performed. (From side. For this reason, the SMAS was vectored obliquely on the right to volumetrically enhance the submalar region, while it was vertically vectored on the left side to restore Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.) submalar hollowing and balance the two sides of her face. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.)

repositioned internally, forcing the soft tissue to conform to underlying subplatysmal fat, the anterior belly of the digastric short side of the face is usually wider than the long side. Malar the underlying deep facial structures. This gives the surgeon muscle, and the strap muscles overlying the thyroid cartilage. highlights are typically more superiorly located on the long SMAS fixation greater control in improving radial expansion (Fig. 11.6.18). At times, numerous small venules are encountered within the side of the face and, with age, facial fat tends to descend in a subplatysmal fat and careful hemostasis must be obtained. more vertical direction on the long side. As facial asymmetry In a two-layer SMAS-type facelift, the tension of contouring Following mobilization of the medial edges of the platysma, and facial skeletal configuration are asymmetric in most indi- is placed on the superficial fascia rather than the skin enve- the subplatysmal fat is conservatively contoured according to viduals, it follows that the vectors of fat elevation (SMAS lope. For this reason, the fascial quality and tensile strength Correction of platysma bands and preoperative planning. repositioning) should be specific for the right and the left side of the superficial fascia has an influence on both the longevity Following mobilization, the medial edge of the platysma of the face. of result, as well as the volume of fat which can be reposi- cervical obliquity muscle is grasped on either side and overlapped in the midline The vector in which the SMAS is repositioned has a signifi- tioned intraoperatively and maintained postoperatively. In in order to estimate the amount of excess muscle present. cant impact on the location and volume of elevated facial fat, other words, soft tissue quality influences long term contour, Correction of the neck is thoroughly reviewed in Chapter 13. Muscle excess will vary from patient to patient. A portion of thereby influencing facial shape. Decisions regarding the and is the primary reason why facelifts in young patients are In the author’s hands, the best approach to the anterior the medial edge can be excised to remove redundancy within direction of SMAS vectoring for the right and left side of the more predictable. platysma is via a submental incision, placed just caudal to the the platysma. A conservative resection is performed so that face are best determined preoperatively, as it is very difficult In an effort to improve fascial quality in a SMAS facelift, submental skin crease.5,23–26 If this crease is very deep, the skin undue tension is not present at the time of suture plication. to make aesthetic vector judgments intraoperatively with the for over a decade I incorporated Vicryl mesh into the SMAS cephalad is elevated toward the base of the chin pad and Muscular plication consists of edge-to-edge approximation patient recumbent. fixation.3 It was my initial observation that incorporating along the caudal mandibular border to free any retaining using multiple interrupted sutures at the mentum and extend- SMAS vectors influence postoperative facial shape. Vertical Vicryl mesh into fixation improved not only longevity of mandibular ligaments, which tend to accentuate the crease. ing at least to the level of the hyoid. Suture placement back SMAS repositioning typically provides a larger amount of fat result, but greater aesthetic control. Nonetheless, I have Following this, the cervical skin is carefully elevated. The from the leading edge of the muscle, in areas of intact mus- for malar eminence enhancement, as well as allowing for a stopped using Vicryl mesh, as I have come to realize that cervical skin is usually undermined at least to the level of cular fascia, is an important technical point in preventing reduction in fullness within the sub-malar region as fat is what was the predominant factor in improving fixation is the the cricoid. suture pull-through postoperatively. forced internally along the concavity of the buccinator. For method in which the superficial fascia was secured. Obtaining Upon exposing the platysma muscle anteriorly, most In most patients, the edge-to-edge suturing below the this reason, vertical SMAS vectors are often indicated to a secure fixation utilizing multiple sutures placed deeply patients exhibit a decussation of platysmal fibers across the hyoid is continued inferiorly toward the cricoid cartilage. The reshape round, full faces, allowing them to appear more within the superficial fascia allows the surgeon greater control midline, at least for a few centimeters below the mentum. goal of muscular plication is to produce an even, smooth tapered and thinner postoperatively (Fig. 11.6.16). If the in postoperative shape. Suturing the SMAS securely under When platysma band surgery is contemplated, these decus- contouring of the platysma that is tightly adherent to the SMAS is vectored more obliquely, there is less volume of fat moderate tension affects facial shape in two ways: (1) adding sating fibers must be sharply divided with scissor dissection underlying floor of the mouth and thyroid cartilage, provid- brought into the malar region and a greater volume of fat more sutures allows the surgeon to stack volume in specific directly in the midline. Following this, the medial edge of the ing a flat framework for redraping of cervical skin. A low repositioned into the submalar region. Oblique SMAS reposi- areas of the midface, which is useful in augmenting areas platysma is mobilized from the mentum inferiorly at least to plication joining a widely separated platysma over a pro- tioning is therefore helpful in elderly patients who appear of deflation, as well as augmenting volume along the the hyoid and commonly as caudal as the cricoid cartilage. minent thyroid cartilage also tends to blunt a prominent gaunt over the buccal recess, as it allows the surgeon to volu- malar eminence; (2) as the superficial fascia is sutured under Mobilization, usually performed using a combination of sharp larynx and produce a rounder, more feminine appearance to metrically enhance the submalar region (Fig. 11.6.17). tension, facial fat is not only repositioned vertically, but also and blunt dissection, separates the platysma from the the neck. Correction of platysma bands and cervical obliquity 253 254 SECTION I •11.6 • Facelift: The extended SMAS technique in facial rejuvenation

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Fig. 11.6.20 (A) Preoperative appearance. Note the hollowed contour in the lateral cheek, which represents the region from which the facial fat has descended and deflated, as well as the marked cervical obliquity. (B) Postoperative result following extended SMAS dissection. If the surgeon can re-elevate descended facial fat back to its previous anatomic location and secure it there postoperatively, this will help to enhance the mandibular border, providing for predictable cervical contouring through platysmaplasty. This lessens the need for preplatysmal fat removal. In general, necks look softer if cervical fat is preserved. (From Stuzin JM, Baker TJ, Baker TM. Refinements in facelifting: Enhanced facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg 2000;105:290.) Fig. 11.6.18 This diagram illustrates how the excess SMAS, rather than being excised, is rolled onto itself to form a double layer of SMAS thickness. Once the Fig. 11.6.19 After edge-edge approximation of the platysma from the mentum to SMAS has been rolled, it is fixated to the periosteum of the zygomatic eminence. the cricoid cartilage, some form of muscular release is performed. This usually An added benefit of preserving the excess SMAS rather than excising it is that, as consists of a horizontal cut extending from the midline to the anterior border of the the thickened SMAS layer is secured to the zygomatic eminence, it highlights the sternocleidomastoid muscle. malar region, serving as an autogenous malar augmentation. Highlighting the malar area tends to enhance angularity in facial contour. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface In most patients in whom I perform a platysmaplasty, small fixation, the surgeon will notice less redundancy along the soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.) drains are placed and left in place until drainage is minimal medial borders of the platysma; there is also less need to resect and the skin flaps are adherent. In my experience, the use of muscle at the time of platysmaplasty. The enhanced contour drains has lessened postoperative edema, ecchymosis and effects of extended SMAS dissection, associated with precise seroma formation (Fig. 11.6.20). platysmaplasty, tend to diminish the need to remove cervical Following edge-to-edge approximation of the platysma, where the transection is performed. Preservation of preplatys- fat. In general, the neck and jaw lines appear softer if pre- some form of muscular release is performed. This muscular mal fat lower in the neck where the transection is to be per- platysmal fat is preserved when contouring the neck (Fig. release commonly involves a partial transection of the formed is obviously an important factor in preventing this Sequence of SMAS fixation 11.6.21). platysma muscle with the myotomy performed inferiorly problem. versus platysmaplasty within the neck. In most patients, only partial division is required. The Incisions Platysma transection is an effective technique in the treat- myotomy is performed from the midline laterally until the Because the SMAS and the platysma represent the same ana- ment of platysma bands and in obtaining the desired cervical tension is completely released from the platysmaplasty closure tomic layer, if platysmaplasty is performed before the SMAS Incisions have been reviewed in Chapter 11.1. The importance contour. This procedure must be performed meticulously (approximately the anterior border of the sternocleidomastoid dissection, it can adversely affect facial contour.3,20,21 Contouring of incision quality cannot be over-emphasized in diminishing because the early experience with transection was fraught muscle in most patients). the neck before the midface can also be problematic. When signs that the patient has undergone a surgical procedure. with complications. Specifically, if the transection is per- The muscular release seen following platysma transection the platysmaplasty is performed first, the descended jowl fat One of the major advantages of a two-layer facelift is that the formed at a high level, it can be associated with unveiling of serves many purposes: is locked down into the neck, and movement of the superficial tension of contouring is along the superficial fascia and thus the submaxillary glands and denervation of the platysma fascia diminishes following elevation of the SMAS. This there is less need to redrape the skin flap with great force. 1. It alleviates tension along the medial portion of the associated with lower lip dysfunction. Also, obvious contour diminished movement tends to lessen surgical ability to Decreased tension on the key sutures in both the preauricular platysma transection following plication. depressions associated with divided muscular edges can be modify facial shape; it also produces a loss of aesthetic contour. and postauricular region provides greater control for scar per- noted in the overly thin neck (Fig. 11.6.19). 2. It allows the platysma to shift superiorly, producing a If the SMAS dissection is performed before platysmaplasty, ceptibility. If the incisions are artistically designed, patients The key to platysma transection is that the transection of deeper cervicomental angle. descended jowl fat is brought cephalad to the mandibular can typically wear their hair up off their ears without obvious the muscle be performed lower in the neck, often as inferior 3. It prevents the conversion of two platysmal border and easily repositioned. After the SMAS has been stigma that a facelift has been performed.21 as the level of the cricoid cartilage. The disadvantage of hori- bands to a single band following edge-to-edge securely sutured bilaterally, the mandibular border appears Whereas many authors have described the salient factors zontal transection at this level is that a depression in the neck approximation, which can be visible when the more distinct, making cervical contouring less demanding. regarding incision design, we would delineate the main can develop if preplatysmal fat has been removed at the level neck is extended. When performing platysmaplasty subsequent to SMAS points: Summary 255 256 SECTION I •11.6 • Facelift: The extended SMAS technique in facial rejuvenation

Access the complete references list online at http://www.expertconsult.com

1. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS 8. Rohrich RJ, Pessa JE. The fat compartments of the face: dissection as an approach to midface rejuvenation. Clin Anatomy and clinical implications for cosmetic surgery. Plast Surg. 1995;22:295. Plast Reconstr Surg. 2007;119:2219. 2. Stuzin JM, Baker TJ, Gordon HL. The relationship of Cadaveric dissection demonstrated multiple discrete the superficial and deep facial fascias: Relevance to compartments of subcutaneous fat in the human face. rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441. The clinical significance of this finding is addressed. Facial anatomy is characterized as a series of concentric 10. Lambros V. Fat contouring in the face and neck. Clin Rights were not granted to include this figure Rights were not granted to include this figure layers based on cadaveric and intraoperative dissection. These Plast Surg. 1992;19:401. in electronic media. in electronic media. findings inform a discussion of the anatomic basis of facial 11. Lemmon ML, Hamra ST. Skoog rhytidectomy: a five- Please refer to the printed publication. Please refer to the printed publication. aging. year experience with 577 patients. Plast Reconstr Surg. 4. Stuzin JM. Restoring facial shape in facelifting: The 1980;65:283. role of skeletal support in facial analysis and midface 14. Barton Jr FE. Rhytidectomy and the nasolabial fold. soft-tissue repositioning. Plast Reconstr Surg. 2007;119: Plast Reconstr Surg. 1992;90:601. 362. The Skoog facelift was modified to free the SMAS from the The authors emphasize the importance of establishing underlying mimetic muscles of the face. A sizeable clinical patient-specific aesthetic goals in planning a facelift. series demonstrated improvement in nasolabial fold aesthetics. Skeletal anatomy is a key component of this analysis. 15. Owsley Jr JQ. Lifting the malar fat pad for correction 7. Furnas DW. The retaining ligaments of the cheek. Plast of prominent nasolabial folds. Plast Reconstr Surg. Reconstr Surg. 1989;83:11. 1993;91:463. The anatomy of the facial retaining ligaments is reviewed. 22. Mendelson BC. Surgery of the superficial The importance of addressing these structures in facelift musculoaponeurotic system: Principles of release, Fig. 11.6.21 (A) Preoperative appearance. (B) Postoperative appearance. Another example of how facial fat re-elevation influences cervical appearance. Sequencing errors procedures is addressed. vectors, and fixation. Plast Reconstr Surg. 2001;107:1545. can lead to loss in contour; it is my preference to perform SMAS elevation and fixation before performing platysmaplasty. As the facial fat and skin is re-elevated back into the midface through SMAS rotation, the mandibular border becomes more distinct, making cervical contouring more predictable.

1. The author prefers tragal incisions, performed at the margin of the tragus, rather than preauricular incisions, Summary because the color difference between the pale skin of the ear and the blush skin of the cheek is usually better From a personal perspective, after two decades of striving to camouflaged when the incision is brought internally into improve techniques in facial rejuvenation, it is my firm con- the ear. viction that improving technical control when contouring the 2. Tragal incisions are more demanding than preauricular superficial facial fascia and platysma provides for a more incisions, requiring precise design and insert so that the consistent, aesthetically pleasing result, which is non-surgical tragus is not distorted. The aesthetic unit of the tragus in appearance. The difficulty in performing a two-layer is rectangular as opposed to semilunar. If the surgeon SMAS-type facelift is that it requires a commitment on the designs the tragal incision properly, respecting the part of the surgeon, not only to understand facial soft tissue incisura of the tragus, the tragus will appear normal anatomy, but also to perform a procedure which demands in its shape postoperatively, exhibiting both a visual technical precision. A two-layer SMAS-type facelift is a time beginning at its junction with the helix and a visual consuming operation, with both the skin flap elevation, as ending along the preserved incisura. well as the dissection of the SMAS, requiring meticulous and accurate dissection. Obtaining consistency with this proce- 3. Detached earlobes tend to appear more natural than dure is challenging because of the variability in thickness of attached earlobes. If a small cuff of cheek skin is left subcutaneous fat and the SMAS which exists among indi- attached to the earlobe, it will allow surgical rotation of vidual patients. Following precise dissection, secure fixation the skin up under the earlobe during skin flap redraping, of both SMAS and platysma is mandated to maintain the suturing the earlobe distinctly from the cheek flap. The shaping desired in postoperative contour. Meticulous hemo- earlobe should be inset in an axis posterior to the axis of stasis followed by careful skin flap inset are required to the pinna, thereby avoiding a pixie deformity. minimize postoperative scar perceptibility and ensure a rapid There is increasing public demand for natural appearing postoperative recovery. results in facial rejuvenation. This places the onus on the Despite these demands, this author has found the extended surgeon to create incisions that are imperceptible if these pro- SMAS technique to be personally rewarding, with a high cedures are to be justified. No matter how well deep-layer degree of patient satisfaction. All techniques have advantages support is obtained, and facial contour improved by SMAS and disadvantages. For me, the biggest advantage of the elevation and platysmaplasty, if the incision is obvious, scar extended SMAS technique remains its aesthetic versatility, quality poor, the hairline disturbed, or the earlobe deformed, allowing the surgeon to vary the contouring aspects of the the overall result remains disappointing procedure according to the aesthetic needs of the patient. References 256.e1 SECTION I Aesthetic Surgery of the Face

11. Lemmon ML, Hamra ST. Skoog rhytidectomy: a five- References year experience with 577 patients. Plast Reconstr Surg. 1980;65:283. 1. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS 12. Mendelson BC. Correction of the nasolabial fold: dissection as an approach to midface rejuvenation. Clin Extended SMAS dissection with periosteal fixation. Plast Plast Surg. 1995;22:295. Reconstr Surg. 1992;89:822. 2. Stuzin JM, Baker TJ, Gordon HL. The relationship of 13. Hamra S. The deep plane rhytidectomy. Plast Reconstr 11.7 the superficial and deep facial fascias: Relevance to Surg. 1990;86:53. rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441. 14. Barton FE Jr. Rhytidectomy and the nasolabial fold. Facial anatomy is characterized as a series of concentric Plast Reconstr Surg. 1992;90:601. layers based on cadaveric and intraoperative dissection. These The Skoog facelift was modified to free the SMAS from the Facelift: SMAS with skin attached – findings inform a discussion of the anatomic basis of facial underlying mimetic muscles of the face. A sizeable clinical aging. series demonstrated improvement in nasolabial fold 3. Stuzin JM, Baker TJ, Baker TM. Refinements in aesthetics. the “high SMAS” technique facelifting: Enhanced facial contour using Vicryl mesh 15. Owsley JQ Jr. Lifting the malar fat pad for correction incorporated into SMAS fixation. Plast Reconstr Surg. of prominent nasolabial folds. Plast Reconstr Surg. 2000;105:290. 1993;91:463. Fritz E. Barton Jr. 4. Stuzin JM. Restoring facial shape in facelifting: The 16. Connell BF, Marten TJ. The trifurcated SMAS flap: role of skeletal support in facial analysis and midface Three-part segmentation of the conventional flap for soft-tissue repositioning. Plast Reconstr Surg. 2007;119: improved results in the midface, cheek and neck. 362. Aesthet Plast Surg. 1995;19:415. The authors emphasize the importance of establishing 17. Aston SJ. Facelift with FAME technique. Paper patient-specific aesthetic goals in planning a facelift. Skeletal lower face and neck. If the only disharmony is brow ptosis, a presented at the 32nd Annual Baker Gordon SYNOPSIS forehead procedure alone may suffice. The same may be true anatomy is a key component of this analysis. Symposium on Cosmetic Surgery, Mercy Hospital, ᭿ regarding the eyelids in young patients. In such a situation, 5. Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of Miami, FL, February, 1998. The patient consultation considers both the potential for anatomic improvement as well as the patient’s expectations. correcting a single aged feature, so as to match the remaining the aging face. 2nd ed. St Louis: CV Mosby; 1995. 18. Little JW. Three-dimensional rejuvenation of the ᭿ youthful features, actually restores facial harmony. 6. Freilinger G, Gruber H, Happak W, et al. Surgical Maintenance of facial “harmony” is paramount. midface: Volumetric resculpture by malar imbrication. However after the age of 40, most patients have aging anatomy of the mimic muscle system and the facial ᭿ A “high SMAS” facelift vertically repositions the skin and the Plast Reconstr Surg. 2000;105:267. changes throughout multiple areas. They may look slightly nerve: Importance for reconstructive and aesthetic subcutaneous tissues as a single unit. 19. Owsley Jr JQ. SMAS-platysma facelift: A bidirectional aged, but they look natural, since all areas match. If natural surgery. Plast Reconstr Surg. 1987;80:686. cervicofacial rhytidectomy. Clin Plast Surg. 1983;10:429. facial harmony is to be maintained, all aged areas need simul- 7. Furnas DW. The retaining ligaments of the cheek. Plast 20. Connell BF. Neck contour deformities: The art, Access the Historical Perspective section online at taneous correction. Reconstr Surg. 1989;83:11. engineering, anatomic diagnosis, architectural planning, http://www.expertconsult.com Such an approach is often met with resistance by patients, The anatomy of the facial retaining ligaments is reviewed. and aesthetics of surgical correction. Clin Plast Surg. particularly young patients. They are used to the traditional The importance of addressing these structures in facelift 1987;14:683. approach of sequential segmental surgery – an approach that procedures is addressed. 21. Marten TJ. Facelift planning and technique. Clin Plast most of us were trained to do. Adding to the confusion is the 8. Rohrich RJ, Pessa JE. The fat compartments of the face: Surg. 1997;24:269. patient’s faulty logic that, by doing less at a single stage, they Patient consultation are less likely to look operated. Anatomy and clinical implications for cosmetic surgery. 22. Mendelson BC. Surgery of the superficial While debate remains regarding the relative roles of defla- Plast Reconstr Surg. 2007;119:2219. musculoaponeurotic system: Principles of release, The patient consultation is divided into three portions: tion (loss of fat) and descent, there are several inescapable Cadaveric dissection demonstrated multiple discrete vectors, and fixation. Plast Reconstr Surg. 2001;107:1545. (1) evaluation of the patient’s health; (2) evaluation of the truths. compartments of subcutaneous fat in the human face. 23. Connell BF. Cervical lifts: the value of platysma muscle The clinical significance of this finding is addressed. facial anatomic features; and (3) evaluation of the patient’s The practical fact is that aging patients have lax facial flaps. Ann Plast Surg. 1978;1:34. appropriateness. tissues. And when standing erect (as most people judge their 9. Lambros V, Stuzin JM. The cross-cheek depression: 24. Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast First and foremost, cosmetic surgery is only appropriate for appearance), gravity causes the facial tissues to descend. The surgical cause and effect in the development of the Surg. 1979;3:529. healthy patients. As physicians, our overriding responsibility second fact is that aged people have excess facial skin. “Joker Line” and its treatment. Plast Reconstr Surg. is to do no harm. A patient’s life should never be placed at Re-inflating the skin envelope to the point of eliminating 2008;122:1543. 25. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg. 1990;85:333. significant risk for improvement of appearance. Intercurrent laxity would create an unattractively puffy face. Third, the 10. Lambros V. Fat contouring in the face and neck. Clin 26. Feldman JJ. Neck lift. St Louis: Quality Medical; 2006. illnesses such as cardiac disease, cerebrovascular disease, descended tissues look better when repositioned superiorly. Plast Surg. 1992;19:401. major organ dysfunction, and potential healing impairment Finally, a method of maintaining the tissues in their may preclude safe surgery. upward position has to be found, even if the repair is Assuming the patient is healthy, the evaluation turns to the non-anatomic. anatomic analysis. From my perspective, maintaining facial While the “high SMAS” approach to the cheek is the harmony is paramount. The worst of all outcomes is to look assigned focus of this chapter, the need to maintain facial “operated”. The are a number of causes of an “operated” look, harmony necessitates a brief description of pan-facial and these will be addressed in more detail later in the chapter. analysis. But surgical disharmony – that is, correcting one aging feature Starting at the top, forehead analysis begins at the hairline. while leaving other aged areas uncorrected – is disharmony The determination of hairline height is assessed from mid- by design. Regardless of the effectiveness of the surgical tech- pupil to hairline – not brow to hairline. While forehead reju- nique, segmental disharmony compromises the result. venation is colloquially referred to as a “browlift”, the brow Young patients may have only segmental aging. Most com- is actually only one element of forehead improvement. Lateral monly, early aging involves the forehead and orbit before the brow hooding, corrugator lines, and procerus creases also ©2013, Elsevier Inc. All rights reserved. History 257.e1 258 SECTION I •11.7 • Facelift: SMAS with skin attached – the “high SMAS” technique

suspension loops from the preauricular fascial to the anterior must be addressed. Perhaps most important, the upper lid History nasolabial fat in an effort to better efface anterior jowling. But cannot be correctly assessed without restoring the brow to the importance of specific suspension of the subcutaneous proper position. The upper eyelid and brow thus form a com- Triggered by the appearance of surface laxity, early attempts mass, in addition to skin redraping was best described by bined unit. A similar combination occurs with the lower 12 at facial rejuvenation focused on skin excision. Since the Aufricht in 1960 : “In order to understand the mechanics of eyelid and cheek. Finally, the neck serves as a relatively inde- surface skin was sufficiently mobile to efface anterior redun- the sagging cheek, one must consider the behaviour of the pendent unit, though its best correction often involves dancy, undermining and release seemed unnecessary. Limited skin and the areolar fatty layer separately. Both layers are addressing the lower face. We will focus here in detail on the peripheral skin excisions dominated the gestation period of subject to histo-morphological changes of their own. This lower eyelid and cheek. facelifts,1–3 in the first quarter of the 20th century. While these fact is important. It indicates that the surgical correction for The lower eyelid and upper cheek overlap, and as a procedures yielded improvement, they were limited in ante- sagging cheeks generally requires a two phase procedure: (1) result, they should be addressed together in the patient over rior effect and temporary in duration. subcutaneous suspension (or lift), i.e., suspension of the fatty the age of 40. The delicate lower eyelid is separated from Seeking greater effect, Lexer4 lengthened and combined the areolar layer; and (2) cutaneous suspension after the removal the heavier cheek by two fascial partitions. The orbicularis 13 14 separate temporal, preauricular and mastoid incisions. Bames5 of excess skin.” retaining ligament (orbitomalar membrane ) extends from later added skin undermining to further enhance the result. The concepts of removal and/or repositioning of both the the junction between the pre-septal and periorbital portions This concept of wide skin undermining dominated the think- skin as well as the subcutaneous fatty mass remain the cardi- of the orbicularis muscle to attach to the bony skeleton. Malar fat pad ing of the mid-20th century,6–8 and remains popular today.9,10 nal points of modern surgical facial rejuvenation. What to The orbicularis retaining ligament (ORL) inserts into the do is generally agreed upon. How best to do it remains orbital rim medially, then courses down and lateral onto the The presence of the subcutaneous facial mass may have Nasolabial fold been recognized as early as the 1930s by Pires.11 Pires placed controversial. body of the zygoma. A second fascial partition, the malar membrane15,16 (zygomaticocutaneous ligament17) extends from the lower border of the periorbital orbicularis to insert in the malar bone below. Medially, the malar membrane origins Jowl align with the orbicularis retaining ligament at the medial tear trough. Laterally, however, it courses obliquely across the cheek, inserting into bone in the bare area above the deep origins of the upper lip levators. Together, these two partitions protect the eyelid suspensory apparatus from the weight of the cheek. There are six essential elements of the lower eyelid which require assessment. Beginning from deep: (1) the prominence of the orbital bony rim – a positive, negative, or neutral vector Fig. 11.7.1 The superficial subcutaneous fatty mass. orbit; (2) the prominence of the arcus marginalis insertion; (3) the competence of the orbital septum and fat herniation; (4) presence of orbicularis ptosis; (5) skin laxity and wrinkling; and (6) competence of the lateral canthal tendon. Essentially, anterior fat accumulates along the jowl at the mandibular all aging patients develop ptosis of the orbicularis muscle. border. The analysis of the individual patient, involves iden- They may or may not have abnormalities of any or all of the tifying the extent of each of these changes. other elements. Consideration of the degree of facial laxity introduces the Likewise, evaluation of the cheek involves six elements: (1) discussion of the ideal age and stage for facial rejuvenation Skin surface abnormalities (dyschromia, actinic damage, etc.); surgery. The traditional timing for facial rejuvenation was (2) dermal quality; (3) degree of skin laxity; (4) facial skeletal mid-50s to mid-60s. Timing was based upon the experience shape; (5) overall facial volume; and (6) contour of the subcu- with skin-based facelifts in which significant relapse of skin taneous mass. laxity from dermal stress relaxation was inevitable. Therefore, For the purposes of this chapter, we will focus on the if half of the benefit was to be lost quickly, there needed to be degree of facial laxity and the variations of contour of the sub- a great deal of laxity present for a net gain. With more power- cutaneous fatty mass. ful fascial (SMAS) based procedures available, the strategy Variations in the volume, shape and position of the subcu- changes. The author has come to recognize that actually, the taneous fatty mass influence the ultimate surgical plan. The ideal time for facial rejuvenation is when aging changes are superficial layer of the subcutaneous fatty mass – that portion present, but early. The best strategy is to try to maintain external to the superficial layer of the mimetic muscles – is the youthful appearance, rather than losing it, then trying to portion which influences facial shape and which is most mal- recapture it. Specifically, the ideal time for facial rejuvenation leable in facial rejuvenation surgery. The upper border of the in most women is in her early 40s. fatty mass is at the lower orbital rim and zygomatic arch; the Finally, before formulating a surgical plan, the surgeon lateral border is the auricle, the lower boundary is the man- must decide whether the patient’s goals are both achievable dibular border, and the medial border is the fusion plane at and realistic. the nasolabial fold. Sometimes, the patient’s analysis of the problem is accu- The specific sub-areas to be addressed are the malar pro- rate, but there may not be a predictable correction. Making a minence, the nasolabial fold, and the jowl (Fig. 11.7.1). The full face thin or permanently removing every wrinkle are typical aging face shows descent of the malar portion of the examples. Conversely, the patient may grossly exaggerate a subcutaneous mass, so that the maximal cheek prominence is minor problem and seek an unrealistic result. Surgery should sub-malar, rather than over the body of the zygoma. Anteriorly, be avoided in both situations. Often, the accurate evaluation the upper anterior portion of the cheek fat shelves over the of the patient’s mind is more difficult than the evaluation of fixed fusion plane at the nasolabial fold. And finally, the lower their anatomy. Evolution of the “high SMAS” technique 259 260 SECTION I •11.7 • Facelift: SMAS with skin attached – the “high SMAS” technique

endoscopic approach or no forehead surgery is planned, then Evolution of the “high SMAS” technique only a horizontal sideburn incision is done. With use of the sideburn incision, it is critical to limit the upward extent. The The modern “high SMAS” technique evolved from my (the fine, posterior-directed upper temple hair will not hide an author) failed experiences with other methods. Early in my incision. clinical practice, I performed a moderately wide skin under- Orbicuarlis A post-tragal auricular incision is used routinely in both mining with redraping. It yielded good results in younger moves alone males and females. The only exception is dark skinned males patients who had excellent quality skin, thin faces, and good with very dark, heavy beards. In most males, skin displaced lower orbits. I believe the procedure can still yield good to the tragus can have the hair follicles excised from beneath results in that sub-group of patients. the dermis. Any remaining hair can be controlled with an But not all of my patients were of that type. As I encoun- Alexandrite laser. The location and extent of the mastoid inci- tered older patients, those with more jowls and deeper nasola- sion depends upon the amount of neck skin laxity. bial folds, my results with skin-only facelifts were often Sequencing of the facial units is the next consideration. The disappointing and brief in duration. Worst of all, as I became Malar and author usually starts at the midline of the neck and works in more aggressive with the procedure to overcome these defi- bucccal/mandibular an upward sequence. This moves the redundancy upward areas move together ciencies, some patients developed a “stretched” look. It was through the cheek and eyelid, then out the top. One criticism then that I became acutely aware of the viscoelastic relaxation of this sequence is that the anterior platysmal closure in the (“stress relaxation”) of skin placed under tension. neck might restrict the upward motion of the platysma Aufricht12 and others18 had pointed out the need to directly (SMAS) in the cheek. This restriction can be avoided by merely address suspension of the subcutaneous facial fat as an essen- connecting the medial platysmal borders loosely to each tial component of facelifting. I, therefore, went through a other in the midline, so as to allow later upward motion in phase of skin dissection followed by suture plication, as the cheek. described by Aufricht. My experience was that the initial The cheek dissection is begun by elevating the skin in the facial contours of the nasolabial fold and jowl were improved. pre-auricular area sharply. Above the level of the tragus, a But in follow-up, only about one-half of the patients achieved subcutaneous tunnel is formed to the lateral border of the a lasting correction. Moreover, using the dermis to secure orbicularis oculi muscle. This tunnel will facilitate later hori- the skin advancement still caused many patients to look SMAS zontal division of the upper SMAS. From the tragus down, “stretched”. My overall results improved, and some patients the skin flap is thinly dissected only to the extent of estimated maintained a natural improvement, but the results were too Fig. 11.7.3 “High SMAS” elevation of the subcutaneous fatty mass with skin excision (Fig. 11.7.4). Care is taken not to overly separate orbicularis suspension separately. inconsistent for my satisfaction. the skin from the SMAS, especially at the upper corner where In 1974, Tord Skoog published his classic text,19 in which the previous tunnel was made. The lower extent of the sub- he described a revolutionary facelift procedure. Undermining added. Otherwise, I have remained consistent with the “high cutaneous cheek dissection extends below the mandibular the skin and superficial subcutaneous mass together as a com- SMAS” technique for over 25 years (Fig. 11.7.3).24,33,34 border. If no previous neck skin dissection has been done, the posite, the cheek mass was then re-suspended using the submandibular skin dissection is carried approximately one- superficial subcutaneous fascia (later termed the superficial half way down the neck and one-half way to the midline. This musculoaponeurotic system or SMAS20). This approach Surgical planning release is necessary to allow partial division of the lateral Fig. 11.7.2 Release of the SMAS investment of the zygomaticus major muscle. offered repositioning of the skin along with the superficial platysma, and its investing fascia, to facilitate upward dis- subcutaneous mass as a single unit, without placing tension on Surgical planning involves both the surgical sequence as well placement of the cheek composite tissues. the skin. Unfortunately, Skoog died before he was able to work beneath a second fascial layer over the zygomatic arch. This as patient preparation. As previously mentioned, in the With the skin dissection complete, attention is turned to the out the nuances to develop his concept into maximally effec- finding allowed us to safely divide the SMAS horizontally patient who has not had previous surgery, I believe a pan- SMAS. The safest place to penetrate the SMAS is between tive procedure. But the concept of cheek repositioning while above the zygomatic arch to facilitate upward mobilization of facial approach is usually necessary. The actual components the top of the tragus and the bottom of the ear lobule. Here, avoiding skin stretching was very appealing. the upper (malar) portion of the fatty mass along with the of the procedures of the forehead, orbit and neck vary with the SMAS is the thickest, and the facial nerve lies deep Other surgeons21,22 adopted Skoog’s basic idea, and set out lower buccal-mandibular portion. the patient’s anatomy and aging deformity. (Those planning within the parotid gland. In this location, the SMAS is a mul- to modify it. Their early attempts focused on the buccal and Anterior release of the SMAS from the zygomatic retaining details are beyond the scope of this chapter, however.) tilayer fibro-fatty structure laminated to the parotid capsule. mandibular area, where the SMAS was more defined and ligaments as well as from the investment of the anterior Preoperative patient preparation means stabilizing any The proper dissection plane leaves a thin translucent fibrous more mobile. The upper cheek, or malar area, was left only mimetic muscles, combined with horizontal SMAS division intercurrent medical problems or medications not serious layer over the visible parotid acini. As this dissection plane is dermal support.23 It seemed clear to me that such differential above the zygomatic arch, provided complete cheek mobiliza- enough to preclude surgery. The most common intercurrent extended anteriorly and inferiorly an areolar plane on the suspension – fascia in the lower face, and only dermal suspen- tion. This dissection became known as the “high SMAS” illness to stabilize is hypertension. underside of identifiable platysma fibers can be visualized. sion of the malar portion of the subcutaneous fatty mass – technique. Preparation of the healthy facelift patient involves mainly Once in this areolar plane, dissection is carried to the anterior would give incomplete repositioning of the malar prominence. As my experience with the “high SMAS” technique grew, avoidance of any interference with wound healing. It has border of the parotid gland, and down the anterior border of And worse, over time, the weak dermal support would relax I began to make technique variations to match patient varia- been my observation that the body will heal well if not the sternocleidomastoid muscle. faster than would the lower fascial portion. tions. Compiling the data of my first clinical series,26 it became interfered with. Avoidance focusses on nicotine products At the anterior border of the parotid gland, the dissection It was that dilemma that fostered our anatomic dissections clear that dissection completely across the nasolabial fold was and medications that interfere with clotting (e.g., Aspirin, method changes from sharp to blunt spreading in the anterior in the late 1970s and early 1980s.24,25 We first demonstrated not necessary in every patient. I subsequently developed NSAIDs, etc.). areolar plane. Over the parotid gland, the SMAS is fixed to that the dissected subSMAS cheek flap was supplied as an three variations, which I will delineate below, in the surgical the gland capsule – the so-called “fixed SMAS”. Anterior to axial myocutaneous flap from the anterior facial artery planning portion of this chapter. The direct vertical relocation the parotid gland, in the buccal area, there is an areolar gliding branches. Second, we found that anteriorly, the SMAS became vector of the technique caused accentuation of the orbicularis Surgical technique plane which can be separated bluntly, to avoid any risk to the the investing layer of the superficial layer of the mimetic oculi ptosis. Influenced by the work of others,27–29 I routinely underlying facial nerve branches. It is imperative to maintain muscles (Fig. 11.7.2). Third, we found that the upper SMAS added correction of the lower eyelid to the cheek procedure. The initial incision location in the temporal area depends the filmy, near-transparent deep fascia over the masseter did not insert into the zygomatic arch, but rather, continued And finally, being made aware of the tendency to a rounded upon what is to be done with the forehead. If a bicoronal muscle, since the facial nerve branches lie just beneath. over the arch to fuse with the temporoparietal fascia. And eye in lower blepharoplasty from laxity of the lateral canthal or hairline incision is to be utilized for the forehead, then Inferiorly, the dissection continues down the fascial fusion most importantly, the frontal branch of the facial nerve lay tendon with aging,30–32 added lateral canthal tightening was that extension is used for the cheek dissection. If only an plane at the anterior border of the sternocleidomastoid muscle. Surgical technique 261 262 SECTION I •11.7 • Facelift: SMAS with skin attached – the “high SMAS” technique

Subgaleal dissection Subcutaneous tunnel Temporal branch, superior to arch facial nerve Subcutaneous Upper lateral corner of SMAS dissection 4cm remains attached to skin Only skin expected to be removed is undermined SMAS incision

Dissection from beneath SMAS over zygomaticus major thus releasing restraint of investing fascia

Marginal mandibular branch of facial nerve Subcutaneous dissection of neck from mastoid to midline superficial to platysma Fig. 11.7.4 The skin flap is thinly dissected only to the extent of estimated skin excision.

Here the cervical investing fascia of the platysma continues dissection also minimized swelling by preserving the anterior Fig. 11.7.5 Complete release of the SMAS. to invest the sternocleidomastoid muscle. Without a “back facial venous and lymphatic supply. cut” in this fascia, upward motion of the platysma (SMAS) In patients with moderately deep nasolabial folds, the same can be restricted. Thus, a short 2–3 cm “back cut” in the limited cheek dissection is done, but a fibro-fatty SMAS investing fascia and platysma is made about 4 cm below the graft,35,36 trimmed from the lateral dissection, is tunneled in order to avoid denervation. But by leaving the ptotic orbic- mandibular border. The “back cut” is made at this level to beneath the nasolabial fold (Fig. 11.7.7). I find this graft to ularis in place, upward cheek movement accentuates the avoid any aberrant branches of the marginal mandibular survive most of the time, such that, accurate placement is shelving of the lower orbicularis. It is therefore necessary to facial nerve. critical. add orbicularis suspension, with or without correction of At this point in the dissection, the buccal-mandibular In patients with deep nasolabial folds, usually associated other lower lid malformations, to the routine “high SMAS” portion of the cheek will mobilize well, but the upper (malar) with a thin face, complete dissection across the nasolabial fold cheek lift. portion of the cheek mass is little affected. into the lip is done (Fig. 11.7.8). While the cheek mass, including anterior cheek skin, moves Completion of cheek mobilization is achieved by release of In the rare patient, the upper one-third of the nasolabial in a vertical direction, correction of neck redundancy neces- the anterior ligament and fascial restrictions. The SMAS is fold may be quite deep. In such a case, more anterior cheek sitates posterior (horizontal) redraping. This is accomplished divided horizontally above the zygomatic arch over to the elevation is needed. In this situation, the author combines the by lateral suspension of the SMAS to the mastoid fascia, lateral orbicularis. Using the visible edge of the orbicularis as “high SMAS” cheek lift with a subperiosteal “malar lift”.38,39 accompanied by lateral skin redraping and excision. As a depth marker, the dissection is carried over the malar area With the cheek supporting its own weight, rather than being opposed to the cheek, where the skin and subcutaneous fat to release the zygomatic retaining ligaments. Again, using the suspended from the lid, the risk of secondary ectropion is are mobilized as a composite, the neck dissection separates inferior-lateral border of the orbicularis oculi muscle as a greatly reduced. the skin from the underlying platysma. Thus, the redundant depth gauge, the dissection is carried over the lateral border With completion of this release, the entire subcutaneous cervical skin can be mobilized horizontally, while the cheek of the zygomaticus major muscle into the subcutaneous plane. cheek mass, from mandible to orbit, will freely move superi- mass moves vertically. Since the anterior SMAS is attached to the zygomaticus major orly. It is paramount to mobilize the cheek in a pure vertical – not as its investing fascia, the muscle attachment will restrict horizontal or oblique – direction. The primary vector is vertical upward cheek mass mobilization unless released. By making along the lateral orbital rim (Fig. 11.7.9). Stops before anterior Ancillary procedures Video a transition in the cheek dissection plane from a subSMAS Key sutures are placed in the deep temporal fascia and in facial vascular and lymphatic territory 1 plane to over the surface of the zygomaticus major muscle, the mastoid fascia. The periauricular SMAS is then completely Defatting the face presents a different challenge when using the investing fascia is released. Dissection is then carried closed with a continuous suture to disperse the tension from the “high SMAS” facelift. The dissection plane is deep to the down the lateral border of the zygomaticus major muscle to the key sutures. platysma at the jowl, while the jowl fat lies superficial to the the level of the modiolus (Fig. 11.7.5). The extent of anterior Redundant skin is trimmed in place – with no additional platysma. The author finds liposuction, through a nasal ves- subcutaneous dissection depends upon the characteristics of tension. It is paramount to the “high SMAS” concept that all tibule incision, to be most expeditious. A 2.4 mm cannula the nasolabial fold. suspension load is placed on the fascia (SMAS) – the skin is never works quite well. It should be cautioned, however, that In patients with minimal nasolabial fold depth, dissection placed under greater than normal tension. liposuction the buccal area should be avoided. Secondary stops short of the fold to preserve attachment of the fat to the This upward cheek mobilization, however, does not elevate grooving is too likely. cheek flap (Fig. 11.7.6). This allows elevation of the cheek or redrape the ptotic orbicularis oculi. Care is taken not to Two areas respond well to fat grafting. There is often a to spread the medial fat away from the fold. The limited undermine the lower orbicularis with the cheek dissection, Fig. 11.7.6 Cheek dissection I stops short of the nasolabial fold. small redundant strip of excess in the SMAS mobilized to the Postoperative care 263 264 SECTION I •11.7 • Facelift: SMAS with skin attached – the “high SMAS” technique

SMAS fat graft

A B C Limited dissection

Fig. 11.7.7 Cheek dissection II stops short of nasolabial fold with tunneled SMAS graft. Fig. 11.7.9 The cheek mass is suspended vertically (shown with key sutures), and the entire SMAS flap is closed with a continuous suture to disperse the tension from the key sutures. An orbicularis flap is then done to suspend the orbicularis.

mastoid. This fibrofatty strip can be used to tunnel beneath the nasolabial fold or to provide lip fullness.35–37 As previously mentioned, the graft takes reliably in the nasolabial area, but survives only about 50% of the time in the lips. Vertical upper lip lengthening is present in some patients. In the properly selected individual, a “gull wing” excision at the nostril sill40,41 will provide subtle improvement. Perioral lines, either from actinic damage or recurrent D E F orbicularis contraction, are very common in aging patients. While a number of corrective methods exist, all have limited Fig. 11.7.10 (A–C) This 53-year-old woman underwent hairline browlift, upper and lower blepharoplasty, “high SMAS” rhytidectomy with dissection short of the nasolabial benefit. The dilemma is that in order to completely remove fold, submental plication and SMAS grafts to the lips. (D–F) The result is shown at 6 months postoperatively. deep wrinkles, you often remove pigment and skin app- endages. This can leave the patient with a smooth, but white, waxy appearance. Lighter peels and fractionated Intraoperatively, a 0.2 mg clonidine dermal patch is placed. The other major element to control in the postopera- lasers have fewer side-effects, but less complete correction The maximal onset of action coincides nicely with maximum tive period, is swelling. Any facial dissection, whether (Fig. 11.7.10). absorption peak of the adrenalin in the local anesthetic solu- subcutaneous or sub-SMAS, temporarily interrupts part of Dissection across tion, 4–6 h postoperatively. The patch is usually left in place the lymphatic drainage. While the lymphatics reconstitute nasolabial fold onto lip until the first postoperative morning, unless the patient dem- over 3–6 months,42 during that interval, swelling can compro- Postoperative care onstrates hypotension. mise the result. Even young skin, maintained under stretch, Xylocaine 0.5% with 1:400 000 adrenalin is used for local undergoes stress relaxation. But young patients’ skin can Immediate postoperative care consists of basic post-anesthesia anesthesia and hemostasis. The 1:400 000 adrenalin strength recoil back to normal dimension. Older patients, however, recovery and avoidance of hematoma. Due to the depth seems to provide adequate tissue hemostasis, and results in do not have skin recoil. If skin is held under stretch from and precision of dissection, most patients are under general less postoperative rebound hypertension than the stronger prolonged edema, the initial surgical improvement can be Fig. 11.7.8 Cheek dissection III across the nasolabial fold into the lip. anesthesia. dilutions. compromised. Complications 265 References 265.e1

Three things are helpful to control postoperative swelling. Skin necrosis is quite rare, since the cheek flap is thick and 20. Mitz V, Peyronie M. The superficial musculoaponeurotic First, dexamethasone 8–10 mg is given intravenously prior to well vascularized. On rare occasions in previous smokers, a References system (SMAS) in the parotid and cheek area. Plast dissection and a Dosepak of dexamethasone or methylpred- small patch of skin necrosis can occur in the thin mastoid skin. Reconstr Surg. 1976;58:80. nisolone is continued orally for 4 days to minimize initial While patients can discontinue the immediate exposure to 1. Miller CC. Cosmetic surgery. The correction of featural This seminal study details SMAS anatomy and its clinical surgical edema. Second, strict control of fluid intake is very smoke products, some degree of permanent obliterative imperfections. Chicago: Oak Printing; 1908. implications. beneficial. Patients are instructed to minimize fluid volume endarteritis always remains. 2. Bourguet J. Notre traitement chirurgical de “poches” < 21. Owsley JQ. Platysma-fascial rhytidectomy. Plast Reconstr intake. They can drink when thirsty, but they are cautioned Incisional infection is also very rare ( 2%). Infection is sous les yeux sans cicatrice. Arch Fr Belg Chir. Surg. 1977;60:843. not to force excess fluids in an attempt to improve health. usually caused by one of two organisms. Many patients, par- 1928;31:133. Third, strict attention to sodium intake is crucial. A low ticularly health care workers, may carry Staph. aureus in their 22. Lemmon ML, Hamra ST. Skoog rhytidectomy: A 3. Noel A. La chirurgie esthetique. Clermont (Oise): Theron sodium diet is very difficult to achieve. All preserved foods, nostrils. If a carrier status is suspected, topical mupirocin five-year experience with 577 patients. Plast Reconstr et Cie; 1928. fast foods, and food sauces are loaded with sodium. Patients ointment will usually eradicate it. The second problematic Surg. 1980;65:283. are instructed to calculate sodium intake for 3–6 months. organism is pseudomonas aeruginosa. This organism is most 4. Lexer E. Zur Geischtsplastik. Arch klin Chir. 1910;92:749. 23. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Ideally, they should restrict sodium intake to <2000 mg/day. commonly harbored in the external auditory canal. 5. Bames OH. Truth and fallacies of face peeling and face Surg. 1990;86:53. The closer to 1000 mg/day, the better. The greatest concern of surgeons performing more exten- lifting. Med J Rec. 1927;126:86. The subSMAS facelift is discussed as a means to address the sive dissections, is facial nerve injury. In the publication of the 6. Conway H. The surgical face lift-rhytidectomy. Plast prominent nasolabial fold. Outcomes are reported in over 400 initial clinical series, the author reported a 15% temporary Reconstr Surg. 1970;45:124. patients. neurapraxia. All were of the marginal mandibular branch, 7. Rees TD, Wood-Smith D. Cosmetic facial surgery. 24. Barton Jr FE. Facial rejuvenation. St Louis: Quality Complications and all promptly recovered. In re-examining the cause, it was Philadelphia: WB Saunders; 1973. Medical; 2008. realized that the neurapraxias were due to spreading dissec- 8. Stark RB. A rhytidectomy series. Plast Reconstr Surg. 25. Barton FE Jr. Rhytidectomy: The anatomical basis for As mentioned above, the most common postoperative com- tion of the platysma over the anterior mandible. It was also 1977;59:373. complete dissection. Presented at the Annual Meeting plication is hematoma. In non-hypertensive patients, the fre- realized that that degree of anterior dissection under the 9. Hoefflin SM. The extended supraplatysmal plane (ESP) of the American Society for Aesthetic Plastic Surgery, quency is 3%; in hypertensive patients, the frequency may “mobile SMAS” was unnecessary. Subsequent elimination of Los Angeles; 1989. approach 8%. Very small collections restricted to the mastoid the dissection over the mandible eliminated the temporary face lift. Plast Reconstr Surg. 1998;101:494. may be treated by closed aspiration. But larger collections, neurapraxias in subsequent patients. The author has never 10. Duffy MJ, Friedland JA. The superficial-plane 26. Barton Jr FE. The SMAS and the nasolabial fold. Plast particularly located low in the neck, are best surgically had a permanent facial nerve injury in his approximately 1000 rhytidectomy revisited. Plast Reconstr Surg. 1994;93: Reconstr Surg. 1992;89:1054. evacuated. “high SMAS” dissections. 1392. 27. Furnas DW. Festoons of orbicularis as a cause of baggy 11. Pires D. Kosmetische chirurgie der gesichtsrunzein. eyelids. Plast Reconstr Surg. 1978;61:540. Fortschr Med. 1934;52:576. 28. Hamra ST. Repositioning the orbicularis oculi muscle 12. Aufricht G. Surgery for excess skin of the face. In: in composite rhytidectomy. Plast Reconstr Surg. Access the complete references list online at http://www.expertconsult.com Transactions of the Second International Congress of 1992;90:14. Plastic and Reconstructive Surgery. Edinburgh: E & S 29. Fogli AL. Orbicularis myoplasty and face lift: a better orbital contour. Plast Reconstr Surg. 1995;96:1560. 7. Rees TD, Wood-Smith D. Cosmetic facial surgery. 20. Mitz V, Peyronie M. The superficial musculoaponeurotic Livingstone; 1960. Philadelphia: WB Saunders; 1973. system (SMAS) in the parotid and cheek area. Plast 13. Muzaffar AR, Mendelson BC, Adams WP. Surgical 30. Ousterhout DK, Weil RB. The role of the lateral canthal Reconstr Surg. 1976;58:80. anatomy of the ligamentous attachments of the lower tendon in lower eyelid laxity. Plast Reconstr Surg. 12. Aufricht G. Surgery for excess skin of the face. In: 1982;9:620. Transactions of the Second International Congress of This seminal study details SMAS anatomy and its clinical lid and lateral canthus. Plast Reconstr Surg. 2002;110(3): Plastic and Reconstructive Surgery. Edinburgh: E & S implications. 873. 31. Flowers RS. Canthopexy as a routine blepharoplasty component. Clin Plast Surg. 1993;20:351. Livingstone; 1960. 22. Lemmon ML, Hamra ST. Skoog rhytidectomy: A Cadaveric dissections and histological analyses were performed to characterize the deep attachments of the lower 13. Muzaffar AR, Mendelson BC, Adams WP. Surgical five-year experience with 577 patients. Plast Reconstr 32. Heinrichs HL, Kaidi AA. Subperiosteal face lift: a eyelid region. Surgical considerations are discussed. anatomy of the ligamentous attachments of the lower Surg. 1980;65:283. 200-case, 4-year review. Plast Reconstr Surg. 1998;102: 843. lid and lateral canthus. Plast Reconstr Surg. 2002;110(3): 23. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr 14. Kikkawa DO, Lemke BN, Dortzback RK. Relations of 873. Surg. 1990;86:53. the superficial musculoaponeurotic system to the orbit 33. Barton Jr FE. Rhytidectomy and the nasolabial fold. and characterization of the orbitomalar ligament. Plast Reconstr Surg. 90:601, 1992. Cadaveric dissections and histological analyses were The subSMAS facelift is discussed as a means to address the Ophthal Plast Reconstr Surg. 1996;12:77. performed to characterize the deep attachments of prominent nasolabial fold. Outcomes are reported in over 400 34. Barton Jr FE, Hunt J. The high-superficial aponeurotic the lower eyelid region. Surgical considerations are patients. 15. Pessa JE, Garza JR. The malar septum: the anatomical system technique in facial rejuvenation: an update. Plast basis of malar mounds and malar edema. Aesthetic Surg Reconstr Surg. 2003;112:1910. discussed. 26. Barton FE Jr. The SMAS and the nasolabial fold. Plast J. 1997;17:11. 17. Muzaffar AR, Mendelson BC, Adams WP. Surgical Reconstr Surg. 1992;89:1054. 35. Guyuron B, Michelow B. The nasolabial fold: a 16. Pessa JE, Zadoo VP, Adrian EK, et al. Anatomy of a challenge, a solution. Plast Reconstr Surg. 1994;93:522. anatomy of the midcheek and malar mounds. Plast 37. Hester TR, Codner MA, McCord CD. The “centrofacial” “black eye”: a newly described fascial system of the Reconstr Surg. 2002;110(3):885. approach for correction of facial aging using the 36. Lassus CA. A surgical solution to the deep nasolabial lower eyelid. Clin Anat. 1998:11(3):157. The surgical anatomy of the malar region is defined through transblepharoplasty subperiosteal cheek lift. Aesthetic fold. Plast Reconstr Surg. 1996;97:1473. cadaveric and clinical dissections. The anatomical basis for Surg Quart. 1996;Spring:51. 17. Muzaffar AR, Mendelson BC, Adams WP. Surgical 37. Leaf N, Firouz JS. Lip augmentation with superficial anatomy of the midcheek and malar mounds. Plast midfacial aging is discussed. The anatomical basis for midface aging is described. musculoaponeurotic system grafts: report of 103 cases. Reconstr Surg. 2002;110(3):885. 19. Skoog T. Plastic surgery – new methods. Philadelphia: Outcomes in over 750 patients are assessed after direct Plast Reconstr Surg. 2002;109:319–326. WB Saunders; 1974. transblepharoplasty midface rejuvenation. The surgical anatomy of the malar region is defined through 38. Hester TR, Codner MA, McCord CD. The “centrofacial” cadaveric and clinical dissections. The anatomical basis for approach for correction of facial aging using the midfacial aging is discussed. transblepharoplasty subperiosteal cheek lift. Aesthetic 18. Pangman II WJ, Wallace RM. Cosmetic surgery of the Surg Quart. 1996;Spring:51. face and neck. Plast Reconstr Surg. 1961;27:544. The anatomical basis for midface aging is described. 19. Skoog T. Plastic surgery – new methods. Philadelphia: WB Outcomes in over 750 patients are assessed after direct Saunders; 1974. transblepharoplasty midface rejuvenation. • 265.e2 SECTION I 11.7 • Facelift: SMAS with skin attached – the “high SMAS” technique SECTION I Aesthetic Surgery of the Face

39. Hester Jr TR, Codner MA, McCord CD, et al. Evolution 40. Austin HW. The lip lift. Plast Reconstr Surg. 1986;77:990. of technique of the direct transblepharoplasty approach 41. Austin HW, Weston GW. Rejuvenation of the aging for the correction of lower lid and midfacial aging: mouth. Clin Plast Surg. 1992;19:511. maximizing results and minimizing complications 42. Meade R, Griffiths L, Barton FE. Presented at the Annual in a 5-year experience. Plast Reconstr Surg. 2000;105: Meeting of the American Society for Aesthetic Surgery, 393. New York; 2006. 11.8 Facelift: Subperiosteal facelift

Oscar M. Ramirez

views, the advantages of the subperiosteal dissection will be SYNOPSIS outlined in this chapter. Another area of controversy and ᭿ Subperiosteal dissection is used for preferential rejuvenation of the poorly understood strategy is the combination of the subpe- central oval of the face: forehead, periorbita, midface, and chin. riosteal facelift of the central oval of the face, with the stand- ᭿ The subperiosteal and subcutaneous are the safest plane of ard maneuvers of the lower face and neck. The rationality and dissection. Both are combined in my biplanar technique. advantages of such maneuvers will also be described. The subperiosteal facelift has evolved from the open tech- ᭿ The biplanar technique maximizes the positive features of the niques of the upper face described initially by Paul Tessier to subperiosteal and subcutaneous plane of dissection to prevent the 1,2 windswept appearance and to give a more natural look. the endoscopic techniques described in the early 1990s. In this chapter you will learn the relevant surgical anatomy ᭿ The forehead-upper eyelid, midface-lower eyelid and the lower of the midface and eyelid to understand the safest plane of face-neck are areas that should be approached as aesthetic units dissection. I (the author) will describe the zygomaxillary during facial rejuvenation. anthropometric point as a key anthropometric structure to ᭿ The combination endomidface and lower blepharoplasty makes create an esthetically pleasing cheek mound. I will also surgery on the lower eyelid a lesser procedure with maximal describe the methods to efface the tear-trough deformity. I will improvement and minimal complications emphasize the role of the Bichat’s fat pad and other structures ᭿ The Bichat’s fat pad mobilization as a pedicle flap is the maneuver in creating the “OGEE line” of the midface.3 Finally, you will that has its maximal effect in the creation of the Ogee of the learn the anatomical basis and surgical maneuvers to prevent midface. complications and obtain the best aesthetic and durable ᭿ Subperiosteal dissection is the most suitable plane for placement results. of facial implants or other skeletal support manipulation at the same time as the facial rejuvenation is done. The advantages of the subperiosteal facelift Introduction I have been performing subperiosteal facelifts since my years as a senior Resident of the University of Pittsburgh in 1983– Although the midface seems to be the area which demon- 1984. My preference for this approach has not changed over strates the maximum benefit of the subperiosteal facelift, the years. I will enumerate the reasons for this: impressive results can also be obtained in the forehead and jaw regions. The reason why the subperiosteal dissection has 1. The subperiosteal dissection allows en bloc mobilization more recognition in the midface is because no other technique of the soft tissues. Once dissection is done either in the in my view can offer the advantages of subperiosteal under- forehead, the midface or the entire jaw line, the tissues mining. Those advantages will be outlined later in the chapter. can be lifted in a vertical or superolateral direction Detractors of the subperiosteal approach point out the “tre- (Fig. 11.8.1). To maintain soft tissue position, key mendous invasiveness” of this surgical approach. They claim suspension sutures are used to maintain the desired that the periosteum does not age and therefore question the elevation. Some surgeons prefer to use prefabricated need of the dissection in this plane. As opposed to those suspension systems (Endotines® by Coapt) or to use ©2013, Elsevier Inc. All rights reserved. Technique 267 268 SECTION I •11.8 • Facelift: Subperiosteal facelift

4. The subperiosteal plane has better visibility and Temporal suspension Frontalis-pericranium suspension orientation than the more superficial planes, particularly when using endoscopic techniques. The bony surface is a better reflector of light, some bone areas are good landmarks for orientation. As opposed to these, the Canthoplasty/ supraperiosteal or more superficial planes of dissection canthopexy ROOF tend to absorb the light and orientation can be more suspension difficult. 5. The subperiosteal plane is a safer plane for the facial nerves. Despite the unfounded claims that the subperiosteal plane of dissection has a high incidence of nerve injury, I strongly believe that this plane is as safe as the subcutaneous plane of dissection and safer than the intermediate plane of dissection. This assumption is based on my experience over many years. My rate of nerve injury is about 2%, and the great majority is only temporary. For this reason, in my biplanar techniques, I combine the safest planes of dissection: subperiosteal Fronto-temporal approach and subcutaneous (Fig. 11.8.3). 6. It is probably more durable than other more superficial Intraoral approach techniques. Once the block of soft tissues has been Intermediate repositioned, and healing has occurred in the elevated temporal fascia Submental approach position, it will stay there for a very long time. In over 25 years of performing subperiosteal facelifts (open and endoscopic), I have seen that the operation on the central Fig. 11.8.1 During subperiosteal surgery the approach and direction of dissection oval of the face (forehead and midface) lasts for over 10 Superomedial SOOF SOOF suspension are similar for the open or endoscopic methods. The upper face is worked from the years. The area that tends to relapse earlier is the lower frontal and temporal approaches. The midface is worked via upper sulcus intraoral Modiolus suspension Mentopexy face and the neck, in which a more superficial dissection suspension incision. The chin and mandible is worked via a submental incision. has been done. This usually last 5–7 years. Mandibular periosteum suspension 7. Allows more balanced and natural rejuvenation. The A B more superficial planes of dissection usually pull the soft Fig. 11.8.2 There are many suspension points for the upper, mid and lower face. These are located in the deep planes of dissection: at the periosteal and or deep fat tissues in a horizontal or oblique direction. Furthermore, barbed sutures for fixation. Over the years, I have tried compartments (midface), cortical tunnel (mentopexy) or at the muscle layer (frontalis/galea/periosteum) during the biplanar forehead rejuvenation. ROOF, retro-orbicularis the central midface soft tissues are pulled indirectly by these and other methods of suspension. They work oculi fat; SOOF suborbicularis oculi fat. the tension applied to the peripherally dissected flaps. very well but they do not offer significant advantages These two characteristics create tension bands and more over the simplest methods of fixation: percutaneous pull on the periphery than in the centrally located screw fixation for the forehead and suture suspension tissues, giving the typical “windswept” or “motorcyclist” for the midface. Although suture fixation can be used appearance to the face. for the mandible, I reserve this for the most difficult Forehead and upper eyelid cases (Fig. 11.8.2). The mandibular soft tissues can be The frontalis muscle and the more superficial periorbital remodeled without specific traction sutures by the muscles are functionally and anatomically interrelated. The insertion of chin and jaw implants, by the indirect Technique frontalis muscle is a brow and forehead elevator, while the traction of the midfacelift in a vertical direction or procerus, corrugator, depressor orbicularis and orbicularis by the traction exerted by the cervicofacial flaps in an When a patient consults for facial rejuvenation, my own per- oculi muscles are brow depressors. Gravity and the depressor oblique superolateral direction during the biplanar sonal approach is to perform surgical correction for all the muscles will pull down the brow while the frontalis will be approach. To allow this type of en bloc mobilization, areas affected by the aging process. I will rarely agree to do the only muscle to counteract this function. One way to dimin- it is critical to release periosteal attachments in key partial rejuvenation unless the patient requires it or refuses ish the hyperactivity of the frontalis muscle is to decrease the anatomical areas along the lowermost boundaries of the more extensive approach. At the very least, I will advise counteracting function of the brow depressors, particularly the area of dissection. the patient about my philosophy. The consultation therefore the more “functionally negative muscles” such as the procerus 2. The subperiosteal dissection facilitates soft tissue becomes a teaching process for the patient and a sound deci- and corrugator muscles. This is done with botulinum toxin or remodeling. This can be accomplished by imbricating the sion can be made. If any shortcomings or unbalanced looks surgery. The endoscopic forehead approach is in my view the entire mass of the dissected tissues, by transposition of occur after the surgery, the patient will be aware of the reasons best option to do this. This method obtains a more complete vascularized fat flaps and by injection of fat grafting to for these. ablation of the corrugator and the only way to ablate the the entire thickness of the elevated soft tissues. The aging process should be corrected by functional and procerus is via the approach from the frontal area. The trans- 3. The subperiosteal dissection leaves exposed the anatomical units. From my point of view, the forehead and palpebral route does not treat the procerus unless the tech- underlying bony skeleton. This allows skeletal upper eyelid is one unit. The lower eyelid and midface is nique described by the author is used.4 Even in those another unit. The lower face and neck is another unit. Surgery contouring by bone reduction or by augmentation with Fig. 11.8.3 The safest planes of dissection are the subcutaneous and the circumstances, the dissection is bloody and there is not good the use of implants. There is no need to open a different in one unit usually facilitates and enhances the correction of subperiosteal planes. When both approaches are used simultaneously, it is called control of the resection. plane of dissection, which is the case with subcutaneous, the adjacent unit. This will become obvious as we describe the biplanar approach. The intermediate lamella of the face is the area where the When a patient has brow ptosis and excess eyelid skin that subSMAS (sub-Superficial Musculo-Aponeurotic System) the techniques. I will focus more on the midface which is the facial mimetic muscles and motor nerves of the face are located. The author prefers patient should be assessed preoperatively with the patient in or inter-muscular dissections. topic of this chapter. not to work in those planes. a sitting position. The amount of excess eyelid skin can be Technique 269 270 SECTION I •11.8 • Facelift: Subperiosteal facelift judged by digitally elevating the brow to an aesthetically preserving its function. Additional improvements will be seen pleasing position. This will give an estimate of the needed with better lower eyelid position, improvement of laxity and skin excision. If there is any doubt it is better to postpone correction of the V deformity of the lower orbit/upper cheek. the blepharoplasty for a second stage when the brow and The midfacelift begins with Xylocaine 0.5% mixed with forehead has settled. The combination browlift and blepharo- epinephrine at 1/200 000 dilution, which is infiltrated in the plasty allows the surgeon to be conservative for both pro- temporal and midface areas. cedures: brow positioning and the extent of upper eyelid The midface is approached from above through a temporal excision. The combined procedure prevents over-resection incision, and from below through an intraoral buccal mucosal of eyelid skin that may occur by trying to correct upper incision. The length of the incision in the temporal area eyelid fullness and excess skin with a blepharoplasty only. will depend on the technique used. In the open approach the Consequently, the combined procedure will make the upper incision is either a coronal incision if the forehead lift is also blepharoplasty resultant scar shorter and more confined to the done concomitantly or a limited temporal-frontal incision. inner orbit. Conversely, if an attempt is made to correct full- Dissection in the temporal area separates the superficial tem- ness and excess skin with a browlift only, a surprised look by poral fascia from the temporal fascia proper in the upper hyper-elevation of the brow position may be the result. temporal area and the superficial temporal fascia from the Dissection in the frontal area is done entirely in the sub- intermediate temporal fascia in the lower temporal area. In periosteal plane and in the temporal area between the super- the endoscopic technique, dissection continues in this plane ficial temporal fascia and the temporal fascia proper in the Fig. 11.8.5 During lower eyelid blepharoplasty, the author avoids transecting the until the superior border of the zygomaticus arch is reached. upper temporal area and over the intermediate temporal orbicularis oculi muscle when entering the preseptal-suborbicular plane, because With upward traction of the temporal flap, the periosteum of this will denervate its pretarsal portion. The motor nerves travel perpendicular to the fascia in the lower temporal area. Both areas of dissection orientation of the muscle incision. the zygomaticus arch is elevated with a sharp periosteum (temporal and frontal) are connected across the temporal line elevator. In the open approach the intermediate temporal of fusion with the undermining coming from temporal to fascia with its attached intermediate fat pad is elevated 2–3 cm Fig. 11.8.4 The forehead and the upper eyelids are treated as one cosmetic unit. simultaneously becomes a guessing game in determining the frontal orientation (four incision technique, see below). The The forehead is usually approached through four small endoscopic ports. Fixation is above the zygomaticus arch and the periosteum is dissected most appropriate brow position. 1 lower limit of the temporal dissection is about 1 cm above the obtained via a suspension of the superficial temporal fascia to the temporal fascia in continuity. This fascial flap will be used as an anchor sus- zygomatic arch. proper and by percutaneous screws in the frontal area. Direction of traction is pension of the midface. Alternatively, in the open technique My endoforehead can be done with 2, 3, or 4 incisions, superomedially. Midface and lower eyelid this fascial flap elevation can be avoided and rely on the depending on the complexity of the surgery and the difficulty Video suspension points of the midface used in the endoscopic imposed by the patient’s anatomy. If two incisions are used, when eyes are being closed, the frontalis muscle will usually 1 The lower eyelid is a structure in which the functional and approach. In either of the alternatives the temporal nerve these are located about 3 cm from the midline. If three inci- relax. In patients with congenital unilateral or bilateral weak- aesthetic effect of aging is more critical than in any other branch of the facial nerve is protected in the elevated flap. It sions are used, one is made centrally and the other two are ness of the levator system, the individual will use the frontalis structure in the face. This makes its surgical approach equally is important although not critical to save the temporal vein #2 paramedian, 4 cm from the midline. If four incisions are used, muscle to compensate for this function. This will create fore- critical. (sentinel vein) and the zygomaticus-temporal nerve(s). This two are paramedian at 2.5 cm from the midline and the other head lines and creases. This is more frankly seen in the severe Although some controversies have arisen in relation to its will minimize ecchymosis, swelling, and hypoesthesias. two, one on each temporal area, are located 2 cm inside the eyelid ptosis. The same situation is seen in cases of acquired innervations, I stand by the original conclusions of my origi- Next, the intraoral buccal incision is made. This is located temporal scalp in a line tangential to a line extending from the eyelid ptosis. However, there is a condition of gradual devel- nal research in which we showed that the innervations of the at the level of the first premolar and done either vertically or nasal alae and external canthus. opment with aging that at an early stage may not be quite lower orbicularis muscle fibers comes in a perpendicular slightly obliquely. The initial incision is done through the The more lateral incisions (paramedian or temporal) are apparent. In this scenario, there is a gradual weakening of the direction to its fibers (Fig. 11.8.5).6 If these fibers come from mucosa only, then the buccinator muscle is spread with the used to do the periosteal release of the lateral brow in cases aponeurosis insertion into the tarsal plate. This may eventu- the zygomaticus branch or the buccal branch or from both, it periosteal elevator and a subperiosteal dissection is carried of hooding of the brow. The paramedian incisions in general ally progress to a frank disinsertion of the levator aponeuro- is irrelevant as far as the planned incision is made. If the out on the maxilla and malar bones. Medially, this extends are used to do corrugator and procerus ablation. The multiple sis. To compensate for this weakness, the patient will contract classic skin-muscle flap is used (the original McIndoe opera- to the pyriformis area and laterally underneath the fascia incisions are utilized for the introduction of two separated the frontalis muscle. At an early stage, this will produce a tion), the pretarsal portion of the lower orbicularis oculi of the masseter muscle. This lateral extension goes about instruments for the standard triangulation technique used in tonic contraction of the frontalis without the development of muscle will at its best be temporarily denervated and at worst 2.5 cm over the masseter tendon. Dissection superiorly is endoscopic surgery. After the muscle manipulation and perio- significant lines and creases. As the process continues, the will be totally denervated. The degree of denervation will done to separate the orbicularis muscle attachments to the steal release are done, one “butterfly” drain of 2 mm diameter collagen composition of the skin deteriorates and the additive depend of the extent of the original muscle transection. The inferior orbital rim, thus releasing the arcus marginalis. The is introduced to the glabellar area. The drain is introduced effect of the brow ptosis occurs, the patient will develop recovery process will also depend of the degree of neurotiza- attachments around the infraorbital nerve are freed after through a separate mini stab wound incision in the scalp severe lines and creases in the forehead. During this stage, the tion of the pretarsal orbicularis. A better chance of neurotiza- the fixation points on the midface are applied and just before posterior to the entrance ports for dissection. Fixation in the patient will develop a condition that I have coined “spastic tion will occur when more contact between the preseptal and their fixation in the temporal fascia proper. That will avoid majority of cases is done with two percutaneous self-retaining frontalis syndrome”.5 This is characterized by the severe con- pretarsal segments of the muscle exist at the end of the opera- traction neuropathy by excessive manipulation. The zygoma- self-stabilizing screws (Synthes®). These are applied at the traction of the frontalis muscle, elevated brows, severe fore- tion. This is accomplished by preseptal orbicularis suspension ticofacial nerve is also preserved to avoid the occasional superior projection of the tails of the brows in the frontal scalp head wrinkles and inability of the patient to relax the forehead, methods, such as the orbicularis “hitch”. Canthopexy methods painful neuropathy and/or localized anesthesia. Subperiosteal with the vector of traction in the superomedial direction Even when the brow is pushed down digitally this immedi- will also prevent the flabby tarsal orbicularis to heal in a dissection of the midface is connected with the temporal (Fig. 11.8.4). Upper blepharoplasty, if indicated, is done at the ately moves upwards like a rubber band. When the patient is relaxed position and will make innervations functionally optical cavity over the anterior two-thirds of the zygomatic end of the endoforehead procedure. In the majority of cases asked to relax the forehead they are unable to do it voluntarily. more effective. Some of the secondary effects of incomplete arch (Fig. 11.8.6). Dissection includes elevation of the soft the lateral extent of the blepharoplasty excision does not Even when they are asked to close the eyes the frontalis innervations in order of severity are: tilting of the ciliary tissues from the external lateral orbital rim. extend beyond the lateral orbit. remains spastic. In the early stages however, the diagnosis can border with anterior exposure of the white line of the lower The sutures applied to the midface have the following Another important functional interrelation is the function be difficult and ptosis surgery may be a proposition to the eyelid, sclera show, bowing of the lateral third of the lower effects: suspension, volumetric remodeling and lifting. I rou- of the frontalis muscle and the levator muscle. It is important patient that he/she did not expected. The treatment for this eyelid and frank ectropion. Lesser degrees of the problem still tinely use four sutures per side, although in some particular to understand this critical connection because this will affect is usually carried out in two stages. Ptosis repair is done first will affect how the tear film is distributed across the cornea cases it may be three or two depending on the aesthetic objec- not only function of the eyelid and brow but also will have under local anesthesia. The frontalis muscle is allowed to relax and from the aesthetic point of view will show an eye that tives (Fig. 11.8.7). The first one to be applied is to the anterior very important aesthetic consequences. The basic functional and the brow will subsequently drop. This may take weeks looks “funny” even if the patient or the surgeon can not pin- central SOOF (suborbicularis oculi fat), which is anchored to fact is that the frontalis and levator muscles are agonist or months. After the final position of the brow is determined, point the exact cosmetic defect. the most anterior portion of the temporal fascia proper near muscles. The frontalis will usually contract forcefully every a decision can be made about how much brow elevation is The midfacelift combined with my functional blepharo- the lateral orbital rim. This is a 4-0 polydioxanone (PDS) time an individual wants to look up or at a distance. Similarly, required. In this situation, performing both operations plasty is an excellent tool to rejuvenate the lower eyelid while suture that prior to its passing to the temporal area can be Technique 271 272 SECTION I •11.8 • Facelift: Subperiosteal facelift

anterior SOOF area and the localization of this deformity. If the deformity is mostly in the area medial to the location of the infraorbital nerve then the improvement will be minimal. This technique improves mostly the laterally and centrally located defect. A different procedure such as fat grafting or orbital rim implant will be required to obtain a significant improvement of the centrally located defect. Another effect is the volumetric augmentation of the midface. This is created by the combination of the lateral SOOF lift and Bichat’s fat Masseter pad repositioning. During aging or in chubby faces, Bichat’s fat pad will usually migrate towards the lower anterior cheek area just above the area of the jowl. In the oblique view, this contributes to the flat, linear configuration of the upper cheek and convex shape in the lower cheek. Changing the anatomi- cal position of the buccal fat pad will simultaneously, with one SOOF with Zygomatic branch suspension maneuver, augment the upper cheek and change the lower suture cheek from a convexity to either a flat surface or to a concavity. MS with Buccal branch This helps create the “Ogee line”, which is a feature of beauty suspension and youth. Bichat’s fat pad, the imbrication by the lateral suture SOOF suspension and the direction of traction of the modio- Facial vein Buccinator lus suture all will converge at the so-called “zygomaxillary point”.9 This is the point that will get the maximal augmenta- Facial artery BF with tion. This is also the point that has the maximal convexity in suspension suture the outline of the Ogee in the young and beautiful individual. Therefore, this technique allows creating or recovering this line of beauty. • The midface cavity is irrigated with antibiotic solution and closure of the intraoral incision is done with interrupted 4-0 chromic catgut sutures. • After the blepharoplasty is done, the forehead and Fig. 11.8.7 An endoscopic browlift is shown in conjunction with an endoscopic midface are tapped with brown colored micropore tape midfacelift. For the midfacelift, four sutures are used to obtain the maximal for additional support and temporary splinting effect. Fig. 11.8.8 The Bichat’s (buccal) fat pad has its own facial covering and its own remodeling and beneficial effect of the subperiosteal dissection. The anterior SOOF • The lower blepharoplasty is then done in a totally (suborbicularis oculi fat) effaces the infraorbital V deformity. The lateral SOOF lifts blood supply. It is located inside the buccal space. This space has a gliding surface the midface. The MS (modiolus suspension) lifts the corner of the mouth. These that allows the buccal fat pad to work as a syssarcosis but also makes it prone to different fashion to the traditional technique. Fig. 11.8.6 The “endo-midface” is approached by a single temporal and an three sutures also produce imbrication, thus increasing the anterior projection of the pseudo-herniation towards the para commissural/jowl area. This fat pad can be There are two fundamental differences here, compared intraoral incision. For this reason, it is better called an endotemporo-midface mobilized towards the malar area after opening the periosteum/buccinator layer. cheek. The last suture suspension is the buccal (Bichat’s) fat pad (BF). This is the with traditional methods. First, I usually do not remove any procedure. The midface and temporal cavities are connected across the zygomatic structure that helps more than any other to create the Ogee line of the midface. arch. The subperiosteal dissection here is critical to avoid injuring the frontal fat from the lower eyelids/orbits. In the few cases that I have branch of the facial nerve. The midface dissection extends under the masseteric suture. The objective is to limit the upward mobilization of done, it was done in an extremely conservative manner and fascia for 2–3 cm. the so-called buccal space (Fig. 11.8.8). To enter here, you need the buccal fat pad and its potential accidental tearing off of using muscular or transconjunctival tunnels. Second, I do not to open the periosteum/buccinator that forms its antero- this structure. The next maneuver is to anchor the modiolus detach the pretarsal muscle from the preseptal portion. The medial wall. This is just medial to the masseter tendon. This stitch to the anterior part of the temporal fascia proper just continuity of the orbicularis oculi is maintained. The preser- anchored to the immediately superior arcus marginalis which is best done with a blunt and long scissor. The blades of the behind the anchor point of the anterior SOOF. Last is the fixa- vation of fat prevents the sunken eye appearance with post- will act as a pulley to direct the anterior SOOF towards the scissors are opened and the fat pad will extrude from its tion of the lateral SOOF to the most posterior portion of the surgical enophthalmos that eventually leads to small beady orbital rim area helping to efface the tear trough area. This is encased buccal space. The fat pad is then gently pulled with temporal fascia proper. All the sutures anchored to the tem- eye look, seen in many post-blepharoplasty patients. The anchored before passing the rest of the sutures to the temporal two blunt scissors. Simultaneously, the surgical assistant will poral area are done using the endoscopic sliding Peruvian preservation of muscle integrity will maintain its innervation area because this does not restrict with the placement of the push with his finger from the external lower cheek/jowl area fisherman’s knot.8 This suture technique allows control of the and its function. The eye after this type of blepharoplasty will rest of the sutures and it may become entangled with the rest encouraging the most inferior portion of the fat pad to migrate tension applied to each structure. It is also reversible up to look healthy, vibrant, and fuller, with a slight pretarsal roll of the other sutures if left for later. The next suture is the toward the oral cavity. During this process, the fascia that some point, therefore it can be made a bit looser if needed. A typical of a youthful eye. The ciliary margin will be in an lateral SOOF that is applied to the compound periosteum/ forms the wall of the buccal space is gently teased. The buccal 2 mm “butterfly” drain is introduced via a mini stab incision. excellent position, facilitating good lacrimal tear film distribu- SOOF tissue 3 cm inferior and vertical to the lateral canthal fat pad has a very thin fascial layer that protects the fat pad The last suspension suture is applied to the superficial tem- tion and normal pumping of tears by the good muscle tendon insertion. This is done with a 3-0 PDS suture. The next and carries the nourishing vessels. This has to be maintained poral fascia at the inferior lip of the temporal entrance port function. suture is the modiolus suspension. This is applied to the fibro- to maintain the integrity of the pad. Separating the buccal wall and anchored to the temporal fascia proper above and ante- Lower eyelid blepharoplasty is done after the midfacelift adipose tissue just inferior to the most anterior portion of the fascia from the fat pad itself is similar to the maneuver used rior to it. During this process, the temporal scalp is pulled in is completed. A skin incision 2 mm below the ciliary border intraoral incision. This is done with 4-0 PDS suture. These two to reduce an inguinal hernia. Once the fat pad has been deliv- a superomedial direction. This prevents posterior shifting of is extended directly into the crow’s foot area without making sutures are tunneled to the temporal area end exited through ered, it is still attached to buccal fat remaining inside the the sideburn and encourages a more vertical lift of the upper any sharp curves as traditionally we were taught. The full the temporal port. The last suture is applied to the Bichat’s buccal space and to the deeper structures of the modiolus. A cheek temple areas. The scalp is closed with staples. thickness lower eyelid skin is “peeled” off the orbicularis fat pad. This is perhaps the most difficult and the one that 4-0 PDS suture with an RB1 needle is weaved into the fat pad One effect of this multiple and independent suture suspen- muscle layer for an average of 1.5–2 cm inferiorly, creating a has the steepest learning curve among the different sutures utilizing two or three passes. The next step is to anchor these sion is that the lower eyelid will be elevated in relation to the pure skin flap. The exposed lateral extension of the preseptal applied to the midface. Once this technique is mastered, there sutures. The first one to be anchored is the Bichat’s fat pad orbital rim, and the V deformity of the lower orbit will be portion is anchored to the most anterior portion of the tem- is nothing to replace it in the finesse and beautifying effect of suture, which is done to the loop of SOOF suture applied totally or partially effaced (Fig. 11.8.9). The degree of this poral fascia proper with a 5-0 or 6-0 Prolene suture. For this its mobilization.7 The Bichat’s or buccal fat pad is located in beforehand. We call this technique “piggy backing” the SOOF effacement will depend on the amount of soft tissue in the maneuver, a window in the lateral orbital portion of the Technique 273 274 SECTION I •11.8 • Facelift: Subperiosteal facelift

laterally, affecting those muscles. Consequently, on muscle contraction during facial animation tension bands become evident. I include the cervicofacial lift during facial rejuvenation of patients with significant laxity or excessive fat accumulation of those areas. This is usually in patients above the age of 50 years (Fig. 11.8.10). After the midface rejuvenation has been done, the lower face is approached at the same surgical stage or as a second stage through a periauricular incision extend- ing posteriorly into the occipital scalp. The anterior auricular incision extends up to the sideburn. No temporal scalp inci- sion is done. I prefer the marginal tragal incision as opposed to the pretragal one in both female and male patients. In males, I trim the root of the hair follicles on the periauricular flaps. SOOF My retroauricular incision in done at the crease itself and Orbital septum not against the conchae, as is sometimes taught. I make the Intraorbital fat incision high in the anterior mastoid area at the level of the Orbicularis oculi Intraoral superior insertion of the ear. From here, the incision angles incision sharply (about 45° angle), initially for 1–2 cm at the hairline SOOF Subcutaneous and gradually into the occipital scalp in an oblique direction. dissection That way, I avoid a visible scar and a sharp contrast of skin A B C BF color and texture in the mastoid area. It also avoids distortion of the ear due to pull in the conchae. The dissection is done at the subcutaneous plane. I make a thick subcutaneous dis- Fig. 11.8.9 The medial suborbicularis oculi fat (SOOF) located below the inferior orbital rim can be elevated to efface the V deformity. This can be sutured to the arcus section initially with the scissors and after the very adherent marginalis or to the post-septal fat pads which are advanced over the infraorbital rim. OOM, orbicularis oculi muscle. areas are separated using a sharp periosteal elevator. This separates the subcutaneous plane from the SMAS in an ana- tomical plane and does not make perforations of the subcuta- orbicularis muscle is created with a blunt dissection. This However, I do not rely on fat grafting for the volumetric aug- neous plane that often occur with the scissors. Dissection is maneuver will lift the entire lower orbicularis and apply mentation of the cheek unless the patient is too thin and usually extended as far as an oblique line from the sideburn tension on the post-septal fat pushing the fat inside the eye emaciated and does not have enough soft tissues to create Fig. 11.8.10 An endoscopic browlift is shown in conjunction with a midfacelift to the jowl area. The neck dissection is through-and-through orbit. The skin will also be brought up by the orbicularis volume with the imbrications techniques and advancement of and a subcutaneous facelift. This creates a biplanar facelift in which the central oval across the midline. If needed, a submental incision is done to elevation and thick soft tissue will be positioned over the Bichat’s fat pad. of the face (forehead, midface, and chin) is addressed at the subperiosteal level and defat the area, do a platysmaplasty or do a subplatysmal dis- inferior orbital rim giving additional support to the intraor- Facial implants to the paranasal areas, to the lower the peripheral hemicircle is dissected at the subcutaneous plane. The vectors of section. After the appropriate amount of skin is removed, the bital fat and improving the infraorbital V deformity. The periorbita and to the cheek are used as a way to enhance traction are different in both regions. There is some overlap between both planes of dissection but the intermediate lamella of the face is preserved. flaps are inset and closed in two layers using 5-0 and 4-0 upward lifting of the orbicularis will also roll up muscle fibers the aesthetic results but in cases of atrophy of those areas by Prolene. To create a natural parotid area-ear interface, a from preseptal to pretarsal areas, providing to this area the the aging process as a way to restore the facial skeleton natural fullness seen in younger individuals. volume and provide long term support to the tissues that has been lifted. Since the dissection has been done at the Methods to enhance midface rejuvenation subperiosteal plane, the field is ready for the use of this implant. Those implants are customized to the facial contour The methods described above will work in the majority of with the use of physical facial skeletal model obtained from patients, particularly in the younger group (up to age 50), a reformatted facial CT scan. This is an advanced methodol- However those patients with thin faces, those with poor skel- ogy to obtain the most precise fitting of those implants to the etal support and the much older individuals will require other facial skeleton. Implants are fixed in place with titanium ancillary procedures to improve the results of the midface miniscrews. rejuvenation and provide three-dimensional rejuvenation. As indicated in one of my previous articles, there are several Lower face and neck methods to enhance the tri-dimensional or volumetric rejuve- nation of the entire face.10 In relation to the midface these The lower face and neck is another facial aesthetic unit that include implants (cheek, periorbital, paranasal) and fat traditionally has been treated with various methods of cervi- grafting. cofacial lift that are covered elsewhere in this text. I rarely do Fat grafting techniques can be easily incorporated into isolated cervicofacial lifts because that will create a dishar- A B C D the operation because fat can be injected anywhere from the mony with rest of the face. Furthermore, the horizontal/ dermis down to the periosteum. Fat is usually obtained from oblique pull that is done with these techniques will create the periumbilical area and after it is spun in a centrifuge the tension bands in a horizontal or oblique direction. These Fig. 11.8.11 (A) Preoperative front view of a 55-year-old woman without history of previous facial surgery requesting total facial rejuvenation. Observe the heavy face and fluid elements are separated. Using a 1 cc Luer Lock type of tension bands may not be visible on photographs taken in neck and the poor chin bone support. (B) Postoperative front view 2 years after. She underwent endo-forehead, endo-midface, functional lower blepharoplasty, cervicofacial component with short preauricular incision, deep neck defatting, 5 mm Medpor RZ geniomandibular custom carved chin implant and liplift, with the bull’s horn incision. No syringe with mini-cannulas the fat is injected to correct any neutral expression but are much more evident during facial upper blepharoplasty was done. (C) Preoperative three-quarters view. More evident is the heaviness of her face, particularly around the jaw line and neck. Also, observe the residual asymmetries, to improve the nasolabial folds and animation. These are, in my observation, more prevalent in “witch’s chin”. (D) Postoperative three-quarters view. Observe the brow elevation, improvement of the lower orbital V deformity, and the creation of the “double Ogee line” into the brow and glabellar areas as needed. I use an average those patients who have had SMAS facelifts because the on the oblique outline. Also, observe the improvement of the perioral aesthetics and dynamics due to the combined effect of the midfacelift, liplift and chin implant. Make of 30 cc of fat for the entire face as an adjunctive technique. SMAS is attached to the facial mimetic muscles and is pulled particular note of the reversal of the suprajowl convexity to a slight concavity and the increase of the zygomaxillary point. Results 275 276 SECTION I •11.8 • Facelift: Subperiosteal facelift

Cadaveric dissections were performed to detail the course of References the facial nerve as it supplies the lower portion of orbicularis oculi. Implications for blepharoplasty and midface access are 1. Ramirez OM, Maillard GF, Musolas A. The extended addressed. subperiosteal facelift: a definitive soft tissue remodeling 7. Ramirez OM. Three-dimensional endoscopic midface for facial rejuvenation. Plast Reconstr Surg. 1991;88: enhancement. A personal quest for the ideal cheek 237–238. rejuvenation. Plast Reconstr Surg. 2002;109:329–340. The authors report favorable results with their technique Midface rejuvenation is achieved by a combined open/ for deep plane rhytidectomy. Salient operative details are endoscopic approach through a temporal slit and upper oral discussed. sulcus incisions. Complications were minimized and results 2. Ramirez OM. Endoscopic full facelift. Aesthetic Plast compared favorably with those achieved by the author with Surg. 1994;18:363–371. other midface rejuvenation techniques. 3. Ramirez OM, Volpe CR. Double ogee facial 8. Ramirez OM, Tezel E, Ersoy B. The Peruvian rejuvenation. In: Panfilov DE, ed. Aesthetic surgery of the fisherman’s knot: a new, simple, and versatile self- A B C D facial mosaic. New York: Springer Verlag; 2007:288–299. locking sliding knot. Ann Plast Surg. 2009;62:114–117. 4. Ramirez OM. Transblepharoplasty forehead and upper 9. Nahai F. The art of aesthetic surgery: principles and Fig. 11.8.12 (A) Preoperative front view of a 48-year-old woman with generalized aging of the face. Observe the periocular aging with a lower orbital V deformity, brow face rejuvenation. Ann Plast Surg. 1996;37:577–584. techniques. St Louis: Quality Medical; 2005. ptosis, nasolabial fold, jowls. (B) Postoperative front view 18 months after. She had the author’s biplanar version of facial rejuvenation: endo-forehead, endo-midface, lower A technique for facelifting through blepharoplasty incisions 10. Ramirez OM, Heller L. The anchor tragal flap: A blepharoplasty, cervicofacial lift and a small amount of fat grafting. There was no upper blepharoplasty done. Observe the generalized rejuvenation without the typical is detailed. Indications, procedural details, and outcomes are method of preserving the natural pretragal depression stigmata of a “facelift”. (C) Preoperative three-quarters view. Observe corrugator hyperactivity, sagging of brows, V deformity on the lower orbits, sagging cheeks, jowls and reviewed. during rhytidectomy. Plast Reconstr Surg. 2005;116: laxity of neck. (D) Postoperative three-quarters view. Patient has not changed her features but looks significantly younger and more beautiful. Observe the double Ogee line of 1115–1121. the oblique outline, her beautiful cheeks and excellent jawline. There is no windswept appearance. 5. Ramirez OM. Spastic frontalis: a description of a new syndrome. Presented at the Annual Meeting of the The tragus and pre-tragus depression are facial landmarks American Society of Aesthetic Plastic Surgery, Dallas, often sacrificed during rhytidectomy. A technique to preserve Texas; 1994:April. these structures is described. 6. Ramirez OM, Santamarina R. Spatial orientation of 11. Ramirez OM. Full face rejuvenation in three dimensions: motor innervation to the lower orbicularis oculi muscle. a “face-lifting” for the new millennium. Aesthetic Plast Aesthetic Surg J. 2000;20:107–113. Surg. 2001;25:152–164.

A B C D

Fig. 11.8.13 (A) Preoperative front view. Observe the depressed and tired look typical of the aging face. Notice the hooding of the upper eyelids and the V deformity of the lower orbit. The woman’s corrugator hyperactivity gives her a tense and angry look. Her cheeks are sagging and the lower face presents jowls and jaw line laxity. Her neck is loose and presents platysma bands and horizontal creases. She had previous neck surgery via a submental incision, performed somewhere else. (B) Postoperative front view at 36 month’s follow-up. She underwent endo-forehead, endo-midface, lower blepharoplasty, cervicofacial lift and small amount of fat grafting. (C) Preoperative three- quarters view. Hyperactivity of the frontalis is more evident in this view. (D) Postoperative three-quarters view. Observe the more sophisticated outline of the Ogee line and a natural and beautiful look. There is no windswept appearance. pretragal depression is created with the technique previously soft tissues of the jaw line area. Also, once subperiosteal published.11 detachment of the soft tissues is done, the flaps of the cervi- cofacial lift helps to remodel these areas. The role of subperiosteal dissection

Subperiosteal dissection of the chin and anterior mandible Results is done to insert the different shapes of implant designed to enhance the rejuvenation of the lower face. Subperiosteal Well over 800 patients have had subperiosteal facial rejuvena- mentopexy is another procedure used to lift the ptotic chin. tion of the midface. The complication rate has been minimal Dissection of the gonial area and lateral mandible is done to and of no long-term duration or significance. It is a safe opera- insert mandibular ramus or gonial angle implants. These tion and the surgical results speak for themselves, as is shown implants give support and enhance the lower face. The in the random sample of patients included in this chapter upward lifting of the midface also helps to lift the detached (Figs 11.8.11–11.8.13). Bibliography 276.e1 SECTION I Aesthetic Surgery of the Face

Vasconez LO, Core GB, Gamboa-Bobadilla M, et al. Bibliography Endoscopic techniques in coronal brow lifting. Plast Reconstr Surg. 1994;94:788–793. Ramirez OM. The central oval of the face: three-dimensional Isse NG. Endoscopic facial rejuvenation: endoforehead, endoscopic rejuvenation. Facial Plast Surg. 2000;16: the functional lift. Aesthetic Plast Surg. 1994;18:21–29. 283–298. Ramirez OM. Endoscopic techniques and facial Ramirez OM. Aesthetic craniofacial surgery. Clin Plast Surg. rejuvenation: I. An overview. Aesthetic Plast Surg. 12 1994;21:649–659. 1994;18:141–147. Ramirez OM, Heller L. Facial rejuvenation. In: Peled IJ, Hamas RS. Endoscopic management of glabellar frown Manders EK, eds. Aesthetic surgery of the face. London: lines. Clin Plast Surg. 1995;22:675–681. Taylor & Francis; 2004:73–90. Ramirez OM. Fourth generation subperiosteal approach to Secondary deformities and the secondary facelift Ramirez OM, Volpe CR. Three-dimensional endoscopic the midface: The tridimensional functional cheek lift. facelift. In: Azizzadeh B, Murphy MR, Johnson CM, eds. Aesthetic Surg J. 1998;8:133–135. Master techniques in facial rejuvenation. Philadelphia: Ramirez OM. The central oval of the face: Tridimensional Saunders Elsevier; 2007:173–196. endoscopic rejuvenation. Facial Plast Surg. 2000;16: Timothy J. Marten and Dino Elyassnia Ramirez OM. Advanced considerations determining 280–298. procedure selection in cervicoplasty: Part one: Little JW. Three-dimensional rejuvenation of the midface: anatomy and aesthetics. Clin Plast Surg. 2008;35(4): volumetric resculpture by malar imbrication. Plast 679–690. Reconstr Surg. 2000;105:267–285. Ramirez OM. Cervicoplasty: Non excisional anterior Ramirez OM. Buccal fat pad pedicle flap for midface approach. Plast Reconstr Surg. 1997;99:1576. augmentation. Ann Plast Surg. 1999;43:109–118. Ramirez OM. Cervicoplasty non-excisional anterior Ramirez OM. Endoscopically assisted biplanar forehead-lift. approach: ten year follow up. Plast Reconstr Surg. Plast Reconstr Surg. 1995;96:323–333. SYNOPSIS 2003;111:1342. Ramirez OM, Pozner JN. Subperiosteal endoscopic ᭿ Although many aspects of planning and performing secondary and suspended under differential tension. This allows each layer Fuente del Campo A. Facelift without preauricular scars. techniques in secondary rhytidectomy. Aesthetic Surg J. facelift surgery are similar to those of the primary procedure, one to be addressed individually as indicated and, in turn, results in a Plast Reconstr Surg. 1993;92:642. 1997;17:22–26. must identify and treat not only new problems that are the product more comprehensive and natural appearing improvement. Ramirez OM, Roberston KM. Comprehensive approach Aiche AE, Ramirez OM. The suborbicularis oculi fat (SOOF): of age, but those that have resulted from any prior procedure as ᭿ It is not enough in most secondary facelift procedures to limit to rejuvenation of the neck. Facial Plast Surg. 2001; An anatomical and clinical study. Plast Reconstr Surg. well. Often it is these secondary deformities that present the treatment of the neck to pre-platysmal lipectomy and post-auricular 17:129. 1995;95:37–42. biggest challenge in terms of creativity, planning, preparation, skin excision in secondary facelift patients. For many patients, and technique. subplatysmal fat accumulation, submandibular salivary gland ᭿ Recognizing the problems in the secondary facelift patient and “ptosis”, and digastric muscle hypertrophy will contribute appreciating their underlying anatomical abnormalities is significantly to their neck deformity and necessitate additional fundamental to planning and performance of any repair. Although treatment. not all problems can always be completely corrected, any surgeon ᭿ As experience is gained in evaluation of patients presenting able to recognize their anatomic basis can, through the application for secondary surgery, prominent submandibular glands will of logic and careful planning, select techniques that are safe, increasingly be recognized as a frequent part of the secondary effective, and rational. neck deformity and the underlying cause of objectionable residual ᭿ Secondary deformities are worth every surgeon’s consideration, bulges in the lateral triangle of the lateral submental region. In most even if he or she performs only the occasional secondary instances, the secondary facelift will provide an opportunity for procedure, as they exist as compelling reminders of mistakes to proper diagnosis and appropriate treatment, when present. avoid in the planning and performance of any primary procedure. ᭿ The secondary facelift will generally require a comparatively small ᭿ Hairline displacement and disruption remain predictable outcomes resection of skin and an increased focus on correcting deep layer of many currently used facelift plans and are a source of problems and secondary deformities, depending upon the skill of disappointment and frustration for patients and surgeons alike. the surgeon performing the primary procedure and the type of These problems are the result of poor analysis and planning and technique used. failure to use an incision along the hairline when indicated. ᭿ Secondary facelifts are often time consuming and technically ᭿ The placement of an incision and thus of the resultant scar along demanding when compared to primary procedures and are likely a hairline at secondary surgery represents a choice between two to test the patience and composure of most surgeons. imperfect alternatives but the best overall artistic and aesthetic ᭿ Many patients requesting secondary facelifts are chronologically compromise in many patients. elderly, but deceptively young in appearance. A careful medical ᭿ Using the SMAS to lift sagging facial tissues and restore facial history must be taken because they often have medical problems contour circumvents the problems associated with skin-only consistent for their age group. facelifts, as it is an inelastic structural layer capable of providing ᭿ The opportunity to perform a facelift is a unique artistic privilege meaningful and sustained support. Although skin must be excised granted to us by our patients that carries a significant in SMAS procedures, only redundant tissue is sacrificed and responsibility. It deserves nothing less than our best effort, and a closure can be made under normal skin tension. few extra hours of our time in the operating room benefits them for ᭿ “Lamellar” dissections, in which the skin and SMAS are dissected the rest of their lives. as two separate layers, offer the important advantage that skin and ᭿ Performing a secondary facelift if frequently a considerable SMAS can be advanced different amounts, along separate vectors, undertaking and its difficulty should not be underestimated. ©2013, Elsevier Inc. All rights reserved. 278 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 279

The procedure must be carefully planned, meticulously carried out, and the patient’s safety and wellbeing unfailingly insured. ᭿ Performance of the procedure itself only fulfills part of our obligation to the patient and the care they receive perioperatively is arguably as important as the surgery itself. Diligent perioperative care will ensure the best result and reduce the likelihood that problems and complications will occur.

Introduction

The increased number of patients seeking facelifts at a younger age, coupled with the continued good health of an older group of patients who have already undergone one or more procedures, has resulted in a significant increase in requests for secondary and tertiary procedures. Although many aspects of planning and performing secondary surgery are similar to those of the primary procedure, additional considerations must be taken into account in the evaluation and treatment of the patient presenting for secondary facelift, as one must iden- tify and treat not only new problems that are the product of age, but those that have resulted from any prior procedure as well. Often, it is these secondary deformities that present the A B biggest challenge to the surgeon in terms of creativity, plan- Fig. 12.1 Identification of secondary aging deformities. Surgery does not arrest the Fig. 12.2 (A,B) Displacement of the sideburn and temple hair due to poor incision planning. The temporal portion of the facelift incision was made in the temporal scalp in ning, preparation, and technique. aging process, and patients requesting secondary facelifts usually present with a well-intended effort to hide the resulting scar. Because cheek flap redundancy was large and skin elasticity poor, advancement of the cheek skin flap has resulted in Consideration must also be given to possible underlying many of the same problems seen when they presented for their primary procedures. objectionable hairline displacement. An incision along the hairline would have prevented this deformity. (Procedures performed by an unknown surgeon.) anatomical damage that may have resulted from previous This is particularly true if the primary facelift was limited and consisted of skin procedures but is not evident as a visible deformity. This excision and skin tightening only, as with this patient. Problems typically seen includes possible damage to skin, fat, SMAS and deeper layer include nasolabial folds, labiomental folds, cheek ptosis, infraorbital hollowing, structures. Injury to these tissues at the time of the primary malar flattening, jowl laxity, submental fat accumulation, and platysma band performs only the occasional secondary procedure, as they Placing the incision along a hairline, however, usually procedure can preclude certain maneuvers and limit the formation. Note that although some wrinkling and atrophy are present, the patient’s exist as compelling reminders of mistakes to avoid in the results in a fine scar only visible on close inspection when predominant problem is deep layer tissue ptosis. Additional skin excision and overall amount of improvement possible at the time second- tightening under these circumstances will be of little benefit to the patient. planning and performance of any primary procedure. correctly planned and proper technique is used. And unlike ary surgery is performed. “Red flag” procedures in this regard (Previous procedure performed by an unknown surgeon.) displaced hair, a scar along the hairline can usually be easily include radiofrequency and ultrasonic “skin tightening” treat- Hairline displacement and disruption concealed with make-up or tattooed if necessary, but gener- ally go unnoticed in most social situations and casual encoun- ments, prior “suture lifts”, and prolonged large volume use subplatysmal fat accumulation, submandibular gland hyper- Hairline displacement and disruption remain predictable out- ters. Often, they are difficult to detect even on close inspection of facial fillers (“filler fibrosis”). trophy, and cervical band formation (Fig. 12.1). comes of many currently used facelift plans and are a source (see Fig. 12.5). Attempts to disguise displaced hair by combing As in primary procedures, recognizing the problems in the Regrettably, many surgeons have been traditionally taught of disappointment and frustration for patients and surgeons adjacent hair over these areas is no more effective than the secondary facelift patient and appreciating their underlying to perform a limited “tuck” or “touch-up” in secondary pro- alike. These problems are the result of poor analysis and plan- “comb-over” hairstyles worn by many balding men. Although anatomical abnormalities is fundamental to planning and per- cedures consisting of additional skin excision and skin tight- ning at the time of the primary procedure and failure to use this is perhaps preferable to the patient to having bald spots formance of any repair. Although not all problems can always ening. This does not address the true underlying problems an incision along the hairline when indicated. Although hair- and missing hair showing, it is immediately evident that the be completely corrected, any surgeon able to recognize their however, and compounds the secondary deformities present line displacement may be acceptable after some primary problem is still present in most cases. anatomic basis can, through the application of logic and in many patients. careful planning, select techniques that are safe, effective and facelifts in which incisions were made in the traditional loca- The temporal portion of the facelift incision traditionally rational. tion within hair bearing scalp, it will almost always be intoler- placed within the temporal scalp will frequently result in a Identification and analysis of able after a secondary facelift if such an incision plan is used tell-tale and unnatural-appearing superior elevation and pos- again. For this reason, thoughtful planning of secondary and terior displacement of the temporal hairline. Secondary or Identification and analysis of secondary surgical deformities tertiary facelifts frequently requires the use of incisions placed tertiary facelifts using the same incision plan will compound along hairlines, rather than behind them. this problem and often result in a bizarre appearing and objec- secondary aging deformity The number and degree of secondary deformities present will The placement of an incision and thus of resultant scar tionable absence of temple hair (Fig. 12.3). determine the difficulty of any additional surgery and the along a hairline at secondary surgery represents a choice This can best be minimized or avoided at secondary facelift Surgery does not halt the aging process and patients request- overall potential for improvement possible. Typical problems between two imperfect alternatives but the best overall artistic by the use of an incision along the hairline (Fig. 12.4). ing secondary or tertiary facelifts usually present with many seen in the patient presenting for secondary facelift include and aesthetic compromise in many patients. Although inci- If it is appropriately planned and carefully executed, an of the same problems seen when they presented for their hairline displacement, hair loss, poorly situated scars, thick sions upon the scalp produce concealed scars within the hair, acceptable scar will result that is artistically and aesthetically primary procedures. This is particularly true if the primary scars, wide scars, scleral show, eyelid dysfunction, tragal dis- they will result in tell-tale and objectionable hairline displace- superior to additional hairline displacement (Fig. 12.5). facelift was limited and consisted of skin excision and skin tortion, earlobe distortion, over-excision of cervicofacial fat, ment in many patients that is usually readily apparent upon In choosing the location of the temporal portion of the tightening only. In such instances, a tight or pulled appear- distortion and abnormal appearances due to inappropriate casual glance and at some distance. These deformities are facelift incision, it is important to note the degree of existing ance will typically be present, but problems of deep layer tissue shifts, and abnormal appearance when emoting. Less often not subtle and frequently result in an unnatural or even temple “skin show” (Fig. 12.6) and consider it in conjunction origin will still be evident and will likely have worsened over commonly, problems related to nerve injury, skin slough, or grotesque appearance (Fig. 12.2). In addition, they are uni- with skin redundancy present over the cheek (Fig. 12.7). time. These include nasolabial folds, labiomental folds, cheek other surgical complications may be present. These problems formly difficult for the patient to disguise and a challenge for This allows an estimate to be made of the degree of eleva- ptosis, infraorbital hollowing, malar flattening, jowl laxity, are worth every surgeon’s consideration, even if he or she the surgeon to correct. tion and/or displacement of the sideburn and temporal hair 280 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 281

superiorly and that the majority of skin redundancy is present superiorly over the upper lateral neck and sometimes onto over the lateral neck. Both careful consideration and direct the pre-lobular and post auricular area. It must also be kept observation will reveal the proper direction of post auricular in mind that neck contour should be the result of deep layer flap shift to be in a mostly posterior, slightly superior direction repair, and not skin tightening. Thus, neck skin should be that roughly parallels the mandibular border if an optimal shifted and excised along a vector that allows maximum elim- result is to be achieved in the cervicosubmental area. This is ination of redundancy, and not one that appears to produce because it is along this vector that the majority of neck skin the most neck tightness. redundancy is present. As the flap is shifted along a more Although occipital hairline displacement may sometimes superiorly directed vector, as it must be with any high trans- be acceptable to patients after their primary procedure, sec- verse occipital incision plan, tension will rise across the cer- ondary or tertiary facelifts using the same incision will com- vicomental angle, but a diminished effect will be seen over pound this problem and usually result in an unnatural and the anterior neck and submental regions. In addition, trans- intolerable absence of occipital hair and notching of the occip- verse cervical rhytides, if present, will be unnaturally shifted ital hairline (Fig. 12.9). If an attempt is made to reconstitute the hairline by supe- rior shifting of the post- auricular flap, a wide scar will usually result as the tissue discarded in any such maneuver is neces- sary for side-to-side head tilt and shoulder drop when the patient is in an upright position. These problems can best be Fig. 12.3 Sideburn elevation and displacement of the temporal scalp after multiple facelifts. A secondary facelift using the same incision plan as at the primary minimized at the time of secondary facelift by the use of an procedure has resulted in the telltale displacement of temple hair and elevation of incision along the occipital hairline (Fig. 12.10). the sideburn (procedure performed by an unknown surgeon). If the incision is appropriately planned and carefully exe- Fig. 12.4 Plan for incision along the temporal hairline. An incision along the cuted, an acceptable scar will result that is artistically and temporal hairline should be considered whenever objectionable displacement of the aesthetically superior to additional hairline displacement. In sideburn and temple hair is predicted. Although a fine scar is present in these patients, it is not evident upon casual inspection. Note the preservation of lush addition, this plan will sometimes allow scalp displaced at the temple hair and a full, youthful appearing sideburn. primary procedure to be partially advanced back towards its proper position (Fig. 12.11). When and incision is used along the occipital hairline it should be planned in such a way that the inferior portion of the incision and thus the resulting scar is turned back into the scalp and at the junction of thick and fine hair on the nape of the neck (see Figs 12.10, 12.11). It should not be carried more inferiorly because it will be incompletely concealed and is likely to be visible to others (Fig. 12.12). Fundamental to obtaining an inconspicuous, well-healed scar when incisions are placed along the temporal or occipital hairline is the diversion of tension to deeper tissue layers and Fig. 12.6 Temporal skin show. The distance between the lateral orbit and the precise flap trimming so that wound edges abut each another temple hairline and how it will change with flap shift must be considered when under little if any tension before sutures are placed. The inci- planning the temple portion of the facelift incision. sion is then closed using a combination of half buried vertical

A B

Fig. 12.5 (A,B) Healed incisions along the temporal hairline. The use of an incision along the hairline, when indicated, can prevent hairline and sideburn displacement without compromising the end result. Although a fine scar is present in these patients, it is not evident upon casual inspection. Note the preservation of lush temple hair and a full, youthful appearing sideburn (compare with Figs 12.2 and 12.3). (Procedures performed by Timothy J Marten, MD, FACS.) that will occur when facelift flaps are shifted, and thus facili- The occipital portion of the facelift incision is traditionally tates rational planning of incision placement. In certain placed high upon the occipital scalp, in a well intended, but instances, a sub-sideburn incision used in conjunction with a almost always counter-productive effort to hide the resulting traditional incision on the temporal scalp will be adequate in scar. Unfortunately, any such a plan embodies an inherent preventing objectionable sideburn elevation and/or hairline defect in design that will preclude optimal improvement in displacement. In other situations, however, the incision must the neck and frequently result in a tell-tale and unnatural A B extend more superiorly along the temple hairline. Such an appearing displacement of the occipital hairline (Fig. 12.8). incision will accommodate large posterior-superior skin shifts A high transverse post-auricular incision plan presumes Fig. 12.7 (A,B) Estimating skin redundancy over the upper cheek. Gauging the skin redundancy over the cheek assists in predicting the degree of temporal hairline and prevents tell-tale hairline displacement. that the resultant vector of skin redundancy is directed mostly displacement that will occur when the facelift flap is shifted. 282 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 283

Fig. 12.8 Displacement of occipital scalp due to poor incision planning. The Fig. 12.9 Elevation and displacement of the occipital scalp after multiple facelifts. A B occipital portion of the facelift incision was made high within the occipital scalp in A secondary facelift using the same incision plan as at the primary procedure has a well-intended effort to hide the resulting scar. Because cervical redundancy was resulted in the objectionable displacement of the hairline (procedure performed by large and skin elasticity poor, advancement of the neck skin flap has resulted in an unknown surgeon). Fig. 12.11 Healed incision along the occipital hairline. The use of an incision along the occipital hairline will prevent hairline displacement without compromising the end objectionable hairline displacement. An incision along the hairline would have result. Although a fine scar is present in these patients, it is not evident upon casual inspection and they are free to wear their hair up off their neck in any manner they prevented this deformity (procedure performed by an unknown surgeon). choose. (Procedures performed by Timothy J Marten, MD, FACS.)

displacement at a secondary procedure, they do not provide for correction of large and severe problems sometime seen (see Figs 12.2, 12.3, 12.8, 12.9). In these situations, considera- tion must be given to the use of hair flaps, hair transplanta- tion, and scalp expansion. Hair loss

Hair loss is an all too common and avoidable stigmata of facelift surgery seen in many patients presenting for second- ary procedures. Hair loss is generally the result of technical errors, including improperly made incisions that damage hair follicles, placement of overly tight sutures, or the closure of inadequately mobilized scalp flaps under too much tension. It may occur, however, in smokers, certain individuals with scalp disease (alopecia areata), eating disorders, or patients with a variety of systemic illness in the absence of any wrong doing on the part of the surgeon. Consideration should be Fig. 12.10 Plan for incision along the occipital hairline. An incision along the given to an origin of this sort before hair loss experienced by occipital hairline should be considered whenever objectionable displacement of the the patient at the primary procedure is attributed to technical occipital hairline is predicted. This incision plan protects the hairline and prevents error. Hair loss is also frequently the result of the ill-conceived hairline displacement. shifting of scalp flaps along the wrong vector. This is com- monly seen on the temporal scalp after erroneous attempts to smooth the forehead and glabella by applying lateral traction mattress sutures of 4-0 nylon with the knots tied on the scalp on the forehead flap (Fig. 12.13). side and multiple simple interrupted sutures of 6-0 nylon. The The use of cautery near or within the plane of hair follicles 6-0 sutures provide precise wound alignment and are removed can also result in hair loss, as can rough flap handling in 5 days. The half buried vertical mattress sutures of 4-0 and pinching or prolonged folding of scalp flaps beneath nylon provide wound support, while simultaneously avoid- retractors. Fig. 12.12 Improper design of an incision along the occipital hairline. The incision Fig. 12.13 Temporal hair loss. Hair loss is frequently the result of improper ing cross-hatched marks. These sutures are removed 7–10 Small areas of hair loss resulting from tight suture place- has been made too low and carried too far inferiorly in front of the fine hair on the shifting of scalp flaps along the wrong vector. This is commonly seen on the days after surgery. ment or attempts at spot suspension of the scalp can often be nape of the neck. It would have been better concealed if it had been made more temporal scalp after well intended but misguided attempts to smooth the forehead Although incisions placed along the frontal, temporal, corrected at the time of secondary facelift by direct excision superiorly and turned posteriorly into scalp hair more superiorly. (Procedure and glabella by excising temporal scalp and applying lateral traction on the and occipital hairlines will prevent additional hairline after adequate mobilization of surrounding tissue or by incor- performed by an unknown surgeon.) forehead flap (procedure performed by an unknown surgeon). 284 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 285

Fig. 12.14 Hair loss resulting from tight suture placement or attempts at spot suspension of the scalp. These problems can often be corrected at the time of secondary facelift by direct excision after adequate mobilization of surrounding A B C tissue or by incorporation of the hairless area into a more comprehensive incision plan (procedure performed by an unknown surgeon). Fig. 12.15 Large areas of hair loss. Large areas of hair loss are usually difficult to Fig. 12.16 Retrotragal scar. (A) The scar resulting from a properly situated retrotragal incision will usually be inconspicuous, even if it is suboptimally healed, as the eye correct, especially if scalp excision was aggressive at the primary procedure and will mistake it for a reflected highlight. Note the well-concealed scar on this darkly complexioned patient. A scar of the same type would be more obvious if the incision had little residual redundancy is present. In such cases, complete correction may not be been placed in a pretragal position. (B) A healed retrotragal face lift incision in another patient with fair skin. Transitions of color and texture are hidden along natural poration of the hairless area into a more comprehensive inci- possible at the time of secondary facelift and that hair transplantation, scalp flaps interfaces. (C) A healed retrotragal incision in another patient. If the incision is closed carefully, a natural appearance without anatomic distortion should result. sion plan (Fig. 12.14). and scalp expansion may be required (procedure performed by an unknown surgeon). Larger areas of hair loss resulting from excessive flap tension, an overly tight closure or ill-conceived scalp flap shifting are usually much more difficult to correct, especially if scalp excision was aggressive at the primary procedure and part of the face, or is mistaken to be a reflected highlight little residual redundancy is present (Fig. 12.15). In such (Fig. 12.16). instances, the patient and surgeon must accept that complete The pre-auricular region is a common point of reference for correction may not be possible at the time of secondary facelift those seeking to identify the facelift patient, and, as such, it is and that hair transplantation, scalp flaps and even scalp of concern to patients and worthy of careful consideration by expansion may be necessary at a later date. The goal at any the surgeon. The pre-helical portion of the pre-auricular scar secondary procedures in these patients is to select a surgical is often situated too far anteriorly in the patient presenting for plan that does not further compound the problem. secondary surgery and the illusion of the scar as an anatomi- cal feature is lost. Moving this scar so that it rests in the Poorly situated scars helical-facial sulcus will result in a less conspicuous scar and a more natural appearance. This is generally possible in most Poorly situated scars are a common problem after primary secondary and tertiary cases if skin resection has not been facelift and the result of artistic insensitivity, poor planning, overly excessive at prior procedures (Fig. 12.17). and tension-based surgical techniques. In many patients, sec- Although it is not possible to move a pre-tragal scar to a ondary facelift will provide the opportunity to relocate these “retro-tragal” position along the margin of the tragus in every to a more appropriate, less conspicuous location, but in others patient presenting for secondary surgery, this is preferred A B C it must be recognized and accepted that complete correction when possible, for the reasons outlined above (Fig. 12.18). The is not possible if additional problems are to be avoided. feasibility of relocating a pre-tragal scar to a retrotragal posi- Poorly situated scars are typically seen in the pre-auricular, tion will depend on the amount of cheek skin redundancy that Fig. 12.17 Improper and proper placement of pre-helical scar. The pre-helical portion of the pre-auricular scar is often poorly situated (A,B) and the illusion of it as an peri-lobular, and post-auricular areas. They can also be found remains after the primary procedure. Because preoperative anatomical feature is lost. (A) The pre-helical incision has been made too far anteriorly and the illusion of the scar as an anatomical feature is lost. (Procedure performed by unknown surgeon.) (B) The pre-helical incision has been made too far posteriorly and has obliterated the helical facial sulcus and part of the helix itself. The illusion of the in the submental region in many patients. Proper placement assessment of residual cheek skin redundancy can be difficult scar as an anatomical feature is lost. (Procedure performed by unknown surgeon.) (C) A patient with a properly placed pre-helical incision. The scar has been placed directly of incisions is important, particularly in the pre-auricular area, and exceedingly deceptive at the tragus, it is sometimes best in the helical facial sulcus. In this location a transition of color and texture is expected and the scar appears to be a natural anatomical feature. (Procedure performed by because even a thin, well-healed scar will ultimately be visible to make the initial incision along the existing pre-tragal scar, Timothy J. Marten, MD, FACS.) and noticed by others in most cases as a result of the gradient when present. The decision to sacrifice the remaining skin of skin color and texture typically present on each side of it. over the tragus and move the scar to the tragal margin can Although differences in skin color can sometimes be con- then be delayed until after cheek flaps have been mobilized, must be accepted. If the secondary facelift incision is initially The peri-lobular area is a common location for poorly situ- cealed with make-up, differences in texture usually cannot. SMAS advanced, and the actual amount of cheek skin recruited made along the margin of the tragus when a pre-tragal scar ated facelift scar in secondary and tertiary facelift patients. Scars placed along natural anatomic interfaces tend to be through these maneuvers, if any, determined. Often, skin is present but before intraoperative assessment of skin redun- Typically, it is low lying due to poor planning and the skin overlooked by the eye however, where a gradient of color recruited is needed to recreate an absent pre-tragal sulcus and dancy can be made, needed skin may be erroneously excised. settling that occurs after “skin only”, non-SMAS facelift tech- and texture is expected to be seen and where the scar appears to correct a “buried tragus” deformity. In such instances, relo- This will force an inappropriately tight closure and result in niques (Fig. 12.19). to be a natural crease on the face. Make-up becomes less nec- cation of a pre-tragal scar to the margin of the tragus will not tragal distortion, tragal retraction, and obliteration of the pre- Unlike the pre-helical and post-auricular portions of the essary as the scar is lost in shadow, appears to be a natural be possible and the existing pre-tragal location of the scar tragal sulcus. facelift scar, however, which should be placed directly in their 286 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 287

A B A B

Fig. 12.18 Pre-tragal and retrotragal incisions compared. (A) Pre-tragal incision in a patient presenting for secondary facelift. The scar has healed satisfactorily but attention Fig. 12.20 Improper and proper placement of the post-auricular incision. (A) The post-auricular incision has been made too far posteriorly. The scar lies outside the is drawn to it due to differences in color and texture on each side of it. (Procedure performed by an unknown surgeon.) (B) Same patient after secondary facelift in which auriculomastoid sulcus and is evident if hair is worn short or up off the neck (Procedure performed by an unknown surgeon.) (B) A different patient seen after facelift. incision was moved to a retrotragal position. Color and texture differences, and the scar itself, are hidden along natural anatomic interfaces. (Procedure performed by Timothy The post-auricular scar has been placed in the auriculomastoid sulcus. In this location it mimics a natural anatomic feature and is overlooked on even close inspection. J. Marten, MD, FACS.) (Procedure performed by Timothy J Marten, MD, FACS.)

of secondary or tertiary facelift will depend on the amount of redundant skin is available along the needed superior vector cheek skin that remains after the primary procedure. If cheek of shift. skin excision has been excessive at the primary procedure, or The submental incision will frequently be seen to have been if a “pixy” earlobe is present, relocation may not be possible. erroneously placed directly along the submental crease in a For these patients, it must be accepted that only partial cor- well-intended effort to hide the resulting scar (Fig. 12.21). rection can be accomplished. Regrettably, this serves only to reinforce the submental retain- A poorly situated post-auricular scar, although not as ing ligaments and accentuate a “double chin” or “witch’s readily apparent and easier to disguise in most social situa- chin” appearance. In such situations, consideration should be tions than a poorly situated scar in the pre-auricular region, given to moving the submental incision 1–2 cm posterior to is nonetheless an objectionable deformity that should be cor- the crease so that the existing scar car be undermined and rected when possible. Typically, the poorly situated post- released. Although this results in a new scar, it will be incon- auricular scar will be seen to lie outside the auriculo-mastoid spicuously hidden in the shadow of the mandible in all but sulcus, and too low over the mastoid to be concealed by the the unusual case (Fig. 12.22). This is preferable and a worth- pinna. Such a deformity is the result of poor planning and while trade-off for correction of the more obvious and objec- inferior–posterior migration of the post-auricular flap due to tionable contour deformity that would result if the incision excessive tension placed upon it at the primary procedure were made again in the same place upon the existing scar. If (Fig. 12.20). limited work in the neck only is needed and minimal or no Moving the post-auricular scar so that it rests directly in double chin deformity is present, it may be possible and the auriculo-mastoid sulcus is sometimes possible in second- appropriate to use an existing scar in the submental crease as ary and tertiary patients, if tissue sacrifice has not been exces- the site for secondary incision. If more extensive maneuvers sive or along an improper vector at the primary procedure. are required and a marked double chin deformity is present A B Moving the scar more superiorly, although seemingly straight however, a new more posteriorly situated submental incision forward, is often not possible because of the common practice is indicated (Fig. 12.23). Fig. 12.19 Improper and proper placement of the peri-lobular incision. (A) The peri-lobular incision has been made too far inferiorly and is evident even on casual of inappropriately excising tissue from the superior tip of the If skin excision has been aggressive and excessive at the inspection. (Procedure performed by an unknown surgeon.) (B) A different patient seen after facelift. The peri-lobular scar has been placed more superiorly and in such a post-auricular flap at the primary procedure. Attempts to do primary procedure, relocation of poorly situated scars may manner that it is hidden by the lobule itself. In this location it cannot be seen. (Procedure performed by Timothy J. Marten, MD, FACS.) so will often result in a forced closure under excessive tension not be possible at the time of request for secondary facelift, and eventual inferior migration and widening of the scar due regardless of how much the patient and surgeon would wish respective anatomic creases the peri-lobular scar should not obtained if the scar is situated a few millimeters inferior to to inferior traction on the post-auricular flap. Although an otherwise. These patients have typically undergone aggres- lie directly in the lobular-facial crease because the crease itself this junction and an attempt is not made to join thin, soft apparent redundancy will be present in the supine patient on sive skin-only, non-SMAS procedures and have overly tight constitutes a delicate, aesthetically significant anatomical earlobe skin directly with course, thick cheek skin. As is the the operating table due to a high lying position of the shoul- faces with wide and/or hypertrophic scars (Fig. 12.24). Often subunit that cannot be reconstructed and should not be dis- situation with the relocation of other scars about the ear, relo- ders, this will be seen to vanish in the upright position when earlobes have been pulled or placed too far inferiorly into the rupted. Other factors being equal, a superior result will be cation of the peri-lobular portion of the facelift scar at the time the shoulders fall to a normal position. As a result, little if any cheek as well, compounding the problem. In such cases, it is 288 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 289

A B

Fig. 12.23 Correction of the double chin and witch’s chin deformities. If the submental incision is placed posterior to the submental crease, the submental retaining ligaments can be released and the fat of the chin and the neck blended. (A) Patient with double chin before secondary facelift. (Procedure performed by an unknown A B surgeon.) (B) Patient after secondary facelift. The submental incision was made 1 cm posterior to the submental crease, the submental restraining ligaments released, and the subcutaneous fat of the chin and the submental areas sculpted and blended to achieve optimal contour. Platysmaplasty, transverse platysma myotomy, and submandibular gland reduction were also performed. (Procedure performed by Timothy J Marten, MD, FACS.) Fig. 12.21 Incorrect and correct plan for the submental incision. (A) Incorrect position for the submental incision. The incision should not be placed directly along the submental crease because this will accentuate it and reinforce the double chin appearance. Note that the traditional plan of skin undermining (shaded area) also promotes a double chin. (B) Correct position for the submental incision. Placement of the submental incision posterior to the submental crease prevents accentuation of the double chin and witch’s chin deformities and provides for easier dissection and suturing in the anterior neck. Note that this incision plan allows the submental crease to be undermined (shaded area) and released and the fat of the chin pad and neck to be blended.

Wide scars

Wide, thick, hypertrophic, and keloid scars, often attributed to be the result of the patient’s own poor healing, are more often due to the over excision of skin along improper vectors in procedures in which the surgeon has employed skin tension as a vehicle to lift sagging deeper layer tissue, rather than the SMAS and platysma. In fact, it is noteworthy that scar widen- ing and hypertrophic healing have rarely seen after a primary facelift in patients of all skin types, providing a technique of no skin tension has been employed. Because the factors underlying suboptimal healing leading Fig. 12.25 Wide scars. Wide, thick, hypertrophic and keloid scars, often attributed to wide or hypertrophic scars are still present to some extent to be the result of the patient’s own poor healing, are usually due to the over in the patient requesting secondary surgery, each must excision of skin along improper superiorly directed vector in procedures in which be approached with caution. Like the patient with a skin the surgeon has employed skin tension as a vehicle to lift sagging deeper layer shortage and poorly situated scars, the patient with wide or tissue. As is the case in the patient with poorly situated scars, the patient with wide hypertrophic scars may be impossible to effectively treat if or hypertrophic scars may be impossible to effectively treat if skin excision has skin excision has been excessive at the primary procedure been excessive at the primary procedure. (Procedure performed by unknown surgeon.) (Fig. 12.25). This is true, regardless of how much the patient Fig. 12.22 Placement of the submental incision. Close-up view of the submental and surgeon wish otherwise. Re-operation in the absence of region of a patient after secondary face lift. A previous incision had been made adequate skin to make proper repair will be a frustrating act directly in the submental crease (small arrow). The incision used at the secondary Fig. 12.24 Poorly situated, hypertrophic scars. If skin excision has been aggressive including hairline displacement, hypertrophy, and wide scars procedure was made posterior to the prior incision (large arrow), and the scar and of futility in which little, if any, benefit will be gained. at the primary procedure, relocation of poorly situated incisions may not be (Fig. 12.26). crease were released. Smooth submental contours are present, and both scars are possible at the time of request for secondary facelift. In these situations, it is Cross-hatched scars can simply and easily be avoided by inconspicuous. usually best to defer surgery until scars have matured, skin has relaxed, and Cross-hatched scars adequate tissue is available to make proper repair. This may mean waiting until employing a facelift technique that does not rely on skin 2 cm or more of skin can be pinched up along each jaw line. (Procedure performed tension. Diverting tension to the SMAS allows skin incisions Cross-hatched scars are a completely avoidable deformity by unknown surgeon.) to be closed under little if any tension with loosely tied, fine usually best to defer surgery until scars are mature, skin has commonly seen in patients presenting for secondary facelift. sutures that can safely be removed in 4–5 days after surgery. relaxed, and adequate tissue is available to make proper Like most secondary facelift deformities, they are the product Diverting tension to the SMAS and platysma will not, in repair. In most cases, this will mean waiting until 2–3 cm or of errors in both planning and technique. The underlying spots go on to heal as scars. As skin relaxation occurs and of itself, prevent cross-hatched scars. If skin is closed more of skin can be pinched up along each jaw line along a cause of most cross-hatched scars can be traced directly to over time the hatch marks and suture hole scars stretch and under tension, or shifted along an improper vector after line extending from the chin to the lobule. Re-operation in the skin tension and tension-based facelift techniques. When inci- migrate away from the incision scar, giving the appearance SMAS and platysma fixation, the opportunity to avoid absence of adequate skin to make proper repair will be a sions are closed under tension, larger sutures must be used, that the wound was closed in a crude fashion with large, tension-based secondary deformities will be lost and one of frustrating act of futility in which little if any benefit will be and these must be tied tighter and left in longer. Inevitably, widely placed sutures. Almost always cross-hatched scars are the major benefits of the utilization of the SMAS and other gained. varying degrees of necrosis occur beneath each, and these accompanied by other signs of over reliance on skin tension deep layer tissue will be subverted. 290 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 291

correction may not be possible if additional problems are to be avoided. Common types of tragal distortion seen after primary facelift include changes in tragal shape, changes in tragal contour, tragal retraction, and obliteration of the pre-tragal sulcus. Less commonly, more severe degrees of distortion can also be present. In rare cases, the tragal cartilage has been excised and the tragus is absent. The most commonly observed forms of tragal distortion seen in patients presenting for secondary facelift are loss of tragal contour and obliteration of the pre-tragal sulcus. These are frequently seen concurrently, although they have some- what different underlying causes. Loss of tragal contour is usually the result of improper incision planning, superior Fig. 12.26 Cross-hatched scars. The underlying cause of most cross-hatched overshifting of cheek skin, and imprecise trimming of the scars can be traced directly to skin tension and tension based facelift techniques. tragal skin flap. The tragus is seen to have no distinct begin- When incisions are closed under tension, necrosis occurs beneath sutures and ning or end and no posterior projection. A tell-tale “chopped- these spots go on to heal as scars. As skin relaxation occurs over time the hatch marks and suture hole scars stretch and migrate away from the incision scar, giving off” appearance results (Fig. 12.27A). This is generally the appearance that the wound was closed with large, widely placed sutures. correctable if tension is diverted to the SMAS, skin can (Procedure performed by unknown surgeon.) recruited from secondary advancement of the cheek skin flap, and the skin flap is properly trimmed and fit over the tragal A B C cartilage. Accepting that skin need not be tight is difficult for most Loss of the pre-tragal sulcus results from failure to leave Fig. 12.27 “Chopped-off”, “buried” and “retracted” tragal deformities. (A) In the “chopped-off” tragus deformity the tragus is seen to have no distinct beginning or end surgeons trained in classical facelift technique. For many, it enough skin to fill the pre-tragal depression when the tragal and no posterior projection. It is usually the result of improper incision planning, superiorly overshifting of the cheek skin and imprecise trimming of the tragal flap. (B) In seems not only counter-intuitive, but also at cross-purposes flap is trimmed and is almost unavoidable in any technique the “buried” tragus deformity the tragus appears indistinct from the cheek anterior to it and the pre-tragal depression is absent. This deformity results from failure to leave with traditional goals and objectives. Dismissing this idea, in which tension is placed on the cheek skin flap. The over- enough skin to fill the pre-tragal sulcus and is commonly seen when tension is placed on the cheek skin flap. (C) The “retracted tragus” represents an extreme case of the and failing to accept related concepts, however, are major trimmed skin flap bridges the pre-tragal sulcus which in turn “buried tragus” deformity and is the result of an over trimmed cheek skin flap. The retracted tragus deformity differs from the buried tragus deformity, however, in that not stumbling blocks to achieving high quality scars and a “non- is gradually filled with fibrotic tissue and scar over time. The only is the pre-tragal sulcus obliterated, but the tragal cartilage itself is pulled anteriorly. This results in an open auditory canal and a tell-tale and unnatural appearance. (All procedures performed by unknown surgeons.) surgical” and natural postoperative appearance. tragus appears “buried” and indistinct from the cheek ante- The correction of cross-hatched scars is often difficult rior to it. It can also be seen to have a flat, two-dimensional because the factors leading to the problem are still present to contour (Fig. 12.27B). “Pixy ear” is a pejorative term used by some to describe some extent in the patient requesting secondary surgery, and Correction of the buried tragus deformity requires recruit- the unnatural, impish, or elf-like appearance the ear assumes each must be approached with caution. As is the situation in ment of sufficient skin from the cheek at the secondary pro- when the lobule is attached directly to the cheek and pulled the patient with hairline displacement and wide or poorly cedure to fill the three dimensional contours of the pre-tragal anteriorly and inferiorly (Fig. 12.29A). situated scars, for the patient with cross-hatched scars, it area. Pre-tragal subcutaneous scar filling the pre-tragal sulcus It is often the result of inartistic, improper, or careless may be impossible to effectively treat the patient with must also be excised, and the tragal skin flap must be redraped resetting of the earlobe into the cheek after the cheek flap has cross-hatched scars if skin excision has been excessive at the under no tension. Skin must then be trimmed to a precise fit been suspended. It can also result as a delayed effect after primary procedure or if enough residual skin redundancy is while the flap is depressed and held in the pre-tragal sulcus. artistically appropriate resetting of the lobule at the time of not present to allow simultaneous excision of scars, skin No deep suture is necessary to hold the skin flap in the pre- surgery in a skin only – non-SMAS facelift. The lack of deep flap advancement along an appropriate vector, and closure tragal hollow if the above steps are properly carried out. layer support in such cases will inevitably lead to some without tension. The “retracted tragus” represents an extreme case of the inferior migration and settling of the cheek skin flap and It is a common error to think that scars can simply be “buried tragus” deformity. It too, is the result of technical eventual traction on the lobule. “Loving cup” ear is used excised and the skin needed for closure can be recruited by error and has its origin in an overly tight and excessively to describe the situation in which the ear resembles the wide undermining of overly tight adjacent areas. Experience trimmed cheek skin flap. The retracted tragus deformity handles commonly seen on vase-like trophy cups. In this will show that re-operation in the absence of adequate skin to differs from the buried tragus deformity, however, in that not deformity, the earlobes are joined to the cheek in a less extreme allow excision along a proper vector along with a tension free only is the pre-tragal sulcus obliterated by subcutaneous scar, fashion, but also have been inset or pulled too far inferiorly closure will result in a recurrence of the problem and other but the tragal cartilage itself is pulled anteriorly by the over- (Fig. 12.29B). associated tension-based deformities. In most patients, it is trimmed skin flap. This results in an open auditory canal and This problem is often made worse by inferior migration of best to accept partial correction of the problem, rather than a tell-tale and unnatural appearance (Fig. 12.27C). Simple Fig. 12.28 Correction of the “retracted tragus” deformity. To correct the retracted the cheek skin flap over time when a skin-only, traction-based create new or worse problems by attempting complete elimi- recruitment of skin from the cheek and excision of pre-tragal tragus deformity cheek skin is undermined and subcutaneous scar in the pretragal facelift technique is used. nation. Make-up, tattooing or restyling of hair may be neces- subcutaneous scar is not sufficient to correct the retracted sulcus be excised. The anterior surface of the tragal cartilage then incised to allow A full understanding of the origin of lobular deformity it to bend posteriorly to its proper anatomical position. The cartilage is secured in sary to conceal the residual scars. tragus deformity because the retracted tragal cartilage is this configuration with a mattress suture of 4-0 nylon. Skin is then recruited by requires that the surgeon understands and appreciates normal usually stiff, fibrotic, and unable to return to its natural posi- facelift flap advancement and the tragal flap is carefully trimmed to ensure that lobular anatomy. This sets the stage for appropriate and tion and configuration on its own. Correction usually requires adequate skin is preserved to fill the pre-tragal sulcus. (Procedure performed by natural resetting of the lobule into the cheek at the time of the Distortion of tragal anatomy that the cartilage be scored on its anterior surface and then Timothy J. Marten, MD, FACS.) primary procedure and the avoidance of unnatural secondary secured with a mattress suture once in its proper anatomic deformities. Young patients presenting for other procedures Distortion of tragal anatomy is a common problem in patients position (Fig. 12.28). and friends and family members who have not undergone presenting for secondary facelifts. Like many other problems mal-position of the earlobe. Like most other problems associ- plastic surgery serve as useful subjects for study in this regard. associated with secondary surgery, it is the result of artistic Distortion of earlobe anatomy ated with secondary surgery, it is the result of artistic insen- Photographs of actors, models, and celebrities are less valu- insensitivity, poor planning, and errors in technique. In many sitivity, poor planning and errors in technique. Common able however, as many have secondary lobular deformities patients, the secondary facelift will provide an opportunity to There is perhaps nothing as tell-tale and objectionable in the types of earlobe distortion seen after primary facelift include that may not be immediately recognized due to concealment improve or correct tragal distortion, but in others complete patient who has undergone a prior facelift as distortion or the “pixy ear” and the “loving cup” ear. of scars by photo-retouching or make-up. 292 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 293

A B

Fig. 12.29 The “pixy ear” and “loving cup ear” deformities. (A) “Pixy ear” describes the unnatural, impish or elf-like appearance the ear assumes when the lobule is attached directly to the cheek. It is the result of inartistic resetting of the earlobe into the cheek after the cheek flap has been suspended. It can also result as a delayed effect A B after artistically appropriate resetting of the lobule at the time of surgery in a “skin only” facelift. (B) “Loving cup ear” describes the state in which the ear resembles the handles commonly seen on vase like trophy cups. In this deformity, the earlobes are not only attached to the cheek, but have been inset or pulled too far inferiorly. Fig. 12.31 Over-excision of subcutaneous fat. (A) The patient has undergone a “weekend” facelift in which aggressive liposuction was performed and too much fat was (Procedures performed by unknown surgeons.) removed. The neck and submental region are irregular and unattractive. (B) A different patient who has had a previous facelift. Submental “microliposculpture” was performed as part of the procedure. Inappropriate over-resection of fat has resulted in harsh and unnatural contours. Note the contrast with the soft contours of the cheek and neck. (Procedures performed by unknown surgeons.)

make proper repair will be a frustrating act of futility in which Over-excision of subcutaneous fat little, if any, benefit will be gained. Redundant skin available over the jaw line and in the The introduction of liposuction, along with ill-conceived upper neck can be assessed by pinching it up and measuring procedures in which subcutaneous fat of the face and neck it. In general, if <2–3 cm is present, it is best to advise the is aggressively curetted, excised or even subjected to laser patient that complete correction will most likely not be pos- and ultrasound treatment, has resulted in a group of patients sible. The extent to which correction can be made will depend, with excessively defatted necks and concomitant deformities Fig. 12.30 Earlobe aesthetics. (A) In the youthful of course, on the degree of deformity present. Although com- (Fig. 12.31). appearing attractive ear, the long axis of the lobule (dotted line) will be seen to rest 15° posterior to the long axis of monly practiced, anchoring the lobule to auricular cartilage These patients with “cadaver necks” have little fat between the pinna (solid line). (B) As the long axis of the lobule is or adjacent deep tissue with buried sutures will not be effec- their cervical skin and the underlying platysma and present shifted anterior to the long axis of the pinna a less natural tive if enough skin is not present to allow closure to be made a difficult problem when they request secondary procedures. “surgical” appearance is produced. (C) If the long axis of under minimal skin tension. Over time, the lobule will migrate Often, they require platysma surgery, although they have little A B C the lobule is shifted further anteriorly and/or inferiorly an inferiorly. superficial fat to disguise any irregularities that may arise objectionable deformity will result. In all but the unusual case, there will not be enough skin from these procedures. In addition, if isolated surgery on the present to correct loving cup earlobes by undermining and neck was performed as the primary procedure, pseudoptotic A careful examination of the youthful lobule will show that the patient has had a facelift, but also will make appropriate elevating the cheek skin. It will also be an artistic error to jowl fat and fat lying along the mandibular border has usually it is distinct from the cheek and that its long axis lies approxi- positioning of the lobular difficult at a secondary procedure. simply place the lobule back in an inappropriate position. In been erroneously excised. This can result in harsh or irregular mately 15° posterior to the long axis of the pinna (Fig. 12.30A). Correction of the pixy and loving cup ear deformities such instances, it may be best to move the lobule into a normal contours when the SMAS is subsequently elevated and defat- As the axis of the lobule is moved anteriorly to rest anterior requires that sufficient skin can be recruited along the jaw line position and carefully close the defect into which it was origi- ted areas are unavoidably advanced superiorly onto the face to the long axis of the pinna, a tell-tale “surgical” appearance at the secondary procedure to allow the lobule and cheek flap nally inset using meticulous technique. The resulting scar will (Fig. 12.32). is produced (Fig. 12.30B). If the long axis of the lobule is to be elevated to a natural position under no tension. As is the go unnoticed because the eye will not be drawn to the area as In these situations, care must be taken in any secondary shifted well anterior to the long axis of the pinna and/or is case in the patient with a skin shortage and poorly situated, it once was by the abnormal appearing lobule. In addition, procedure to preserve as much fat as possible and to carefully drawn inferiorly, an objectionable and grotesque appearance cross-hatched, or wide scars, the patient with a pixy or loving the scar itself will often heal well following this maneuver, as contour fat at the interface between face and neck. can result (Fig. 12.30C). cup earlobe may be impossible to effectively treat if skin exci- the incision can be closed under minimal tension under these It should be the aim of every surgeon who endeavors to On occasion a patient presenting for primary facelift will sion has been aggressive and excessive at the primary proce- circumstances. A small amount of make-up or a cosmetic rejuvenate the face to create an attractive neck and not one be encountered, in whom the lobule naturally sits in an dure or if the ear lobe has been reset too far inferiorly into the tattoo is often usually sufficient to conceal it. If the healed scar simply devoid of fat. Excessive fat excision does not produce anterior–inferior position. In these patients, it is best to reset cheek. In addition, if deep layer support is not provided, it is is raised or irregular and is incompletely concealed with attractive or youthful contours, and often exposes and accen- the lobule in an attractive, artistically appropriate, more pos- likely that skin elevated at a secondary procedure will migrate make-up dermabrasion can be performed as a subsequent tuates other neck problems. These problems include platysma terior position, rather than where it was originally found. If inferiorly over time and the deformity will recur. This is true, step. For most patients, a scar on the cheek will be less notice- bands, prominent submandibular glands and large digastric the lobule is reset in its original position, a “surgical” appear- regardless of how much the patient and surgeon wish other- able than a displaced lobule, and an acceptable trade-off for muscles. Each of these neck problems generally requires that ance is likely to result. This will not only raise suspicion that wise, and re-operation in the absence of adequate skin to obtaining proper lobular position. wide cervical skin undermining be performed if appropriate 294 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 295

Fig. 12.32 Erroneous excision of submental and pseudoptotic jowl fat. Aggressive liposuction is performed as a primary procedure over the neck and jowl (shaded area) in a misguided attempt to Fig. 12.33 (A,B) The “dug out neck” rejuvenate the face. When the patient returns for formal deformity. The “dug out neck” deformity is facelift and ptotic deep layer tissues are properly a term used to describe situations in which repositioned, denuded areas are advanced up onto subplatysmal and/or deep cervical fat has visible areas of the face. This can result in harsh and been erroneously over excised resulting in irregular contours. an objectionable depression in the A B submental region. (Procedures performed by unknown surgeons.) correction is to be made. This is often difficult when little present, reducing these as part of the procedure may be suf- fat is present. Any such dissection must be carried out with ficient to hide the deformity. If secondary surgery is planned great care to avoid any injury to residual subdermal fat, the and adequate platysma is present, an anterior invagination platysma, and regional motor nerves. Excessive fat excision (rather than excision) of the redundant portion of the medial can also result in troublesome dermomuscular adhesions. platysma borders can also produce some improvement. These frequently result in tethering and abnormal appear- ances in animation and generally require careful division if Over-excision of buccal fat an open dissection of the neck is planned. If no modification of the platysma or other deep layer structures is needed, Although the judicious excision of buccal fat will occasionally dermomuscular adhesions can be treated transcutaneously benefit certain patients seeking primary or secondary facelift, with a “V” tipped needle dissector and carefully placed fat it will usually result in an ill or haggard look inconsistent injections. with the intended goal of producing an improved appearance Although judicious excision of cervical fat is often neces- (Fig. 12.34A). This is evident in many patients presenting for sary as part of rejuvenation of the aging neck, the excision of secondary surgery who have undergone “minilifts”, “week- A B C facial fat will usually produce an aged and haggard look, end facelifts”, and limited incision procedures in which buccal inconsistent with the intended goal of producing an improved fat excision is often performed. In these patients, SMAS Fig. 12.34 (A) Inappropriate excision of buccal fat. Excision of buccal fat as part of a “mini” face lift has resulted in an ill or haggard look. This problem is most easily appearance. This haggard appearance is evident in many advancement or midfacelifts can exacerbate this situation by corrected by fat injections, and these can generally be performed as part of the secondary face lift procedure. (Procedure performed by unknown surgeon.) (B,C) Correction patients presenting for secondary surgery who have under- elevating the over-reduced buccal pad. These patients will of the overresected buccal fat pad. (B) Secondary face lift patient who had buccal fat removed as part of her primary procedure. An unattractive, ill appearance has resulted. gone “minilifts”, “weekend” facelifts, “microliposculpture”, often benefit from less aggressive SMAS surgery and avoid- (Procedure performed by unknown surgeon.) (C) Same patient after secondary face lift that included fat injections. The lower face has been filled and lost buccal volume and other procedures in which facial liposuction is often ance of midfacelifting. restored. A healthy, youthful, and attractive appearance results. (Procedure performed by Timothy J. Marten, MD, FACS.) performed. In these cases, remaining fat must be carefully Correction of the over-resection of buccal fat is most easily tailored to produce the best contours possible. These patients made using fat injections and these can generally be per- will also often benefit from facial fat injections. formed as part of the secondary facelift procedure (Fig. residual bulges in the lateral triangle of the lateral submental be separated from its capsule and adjacent tissue using a 12.34B). Injections should be made meticulously in small region (Fig. 12.35). Often, these bulges go unnoticed at the combination of gentle blunt and sharp scissors technique. Over-excision of subplatysmal fat amounts and in multiple passes in multiple planes with a time of the primary procedure owing to the fact that they are Care should be taken when mobilizing the superior-lateral small blunt infiltration cannula. In general, 3–7 cc of centri- obscured by neck fat and lax platysma muscle. In most portion of the gland as both the retromandibular vein and the Although not all surgeons routinely explore the subplatysmal fuged fat is needed for each cheek. Alternatively, free fat instances, the secondary facelift will provide an opportunity marginal mandibular branch of the facial nerve are in proxim- space and excise subplatysmal fat, patients with an unappeal- grafts, or dermis fat grafts can be used. Facial fat injections for proper diagnosis and appropriate treatment, when present. ity in this area. ing “dug out neck” deformity are increasingly presenting for can also be performed as a separate procedure after secondary If a large or ptotic sub-mandibular gland is present, it can An examination of the dissected submandibular gland will secondary procedures. The dug out neck deformity is a term facelift is performed. This allows the patient and surgeon to usually be seen and/or palpated lateral to the ipsilateral ante- show it to be large, and not “ptotic”, and careful consideration used by some to describe situations in which subplatysmal examine what was accomplished during the secondary pro- rior belly of the digastric muscle within its respective sub- of this fact will reveal that attempts to reposition it more and/or deep cervical fat has been erroneously over-excised cedure, and adjust the fat injection procedure accordingly. mandibular triangle. superiorly with sutures or by tightening the platysma are resulting in an objectionable depression in the submental Large glands can be incrementally resected through the misguided and will ultimately be fruitless. This observation region (Fig. 12.33). Typically, this depression is more evident Prominent submandibular glands sub-mental incision after raising the ipsilateral platysma but forms the basis of the recommendation that partial resection when the neck is flexed somewhat or when the patient before submental platysmaplasty is performed, if indicated. be performed in these patients. swallows. As experience is gained in evaluation of patients presenting Submandibular glands are usually firm and have a distinctive After the protruding portion of the gland has been exposed Correction of the dug out neck deformity is best made for secondary surgery, prominent submandibular glands will lobulated appearance. Reduction is begun by incising the and freed from adjacent tissue, the redundant portion of the using fat injections if it is the only problem present. If large increasingly be recognized as a frequent part of the secondary glandular capsule inferomedially and grasping the inferior submandibular gland is excised using a long tipped cautery digastric muscles and/or large submandibular glands are neck deformity and the underlying cause of objectionable most portion of the gland. The gland can then easily and a long pair of shielded forceps. Adequate exposure is 296 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 297

A B

Fig. 12.38 Isolation of the protruding portion of the anterior digastric muscle. The Fig. 12.35 (A,B) Prominent submandibular glands. Prominent submandibular glands are commonly seen in patients presenting for secondary facelifts. They are typically Fig. 12.37 Prominent anterior belly of the digastric muscle. The patient has had prior face and necklift. The anterior belly of the digastric muscle can be seen as tips of curved hemostatic forceps are bluntly pushed through the midbody of the evident as objectionable residual bulges in the lateral triangle of the lateral submental region. Prominent glands often go unnoticed at the primary procedure because they are muscle belly. (View from patient’s right of right digastric muscle through submental obscured by neck fat and lax platysma muscle. (Procedures performed by unknown surgeons.) objectionable linear paramedian fullness in the submental region that spoils and otherwise good result. Prominent digastric muscles often go unnoticed at the time incision. Patient’s chin is on the left and neck on right.) of the primary procedure due to the fact that they are frequently hidden by cervical fat and lax platysma muscle. (Procedure performed by unknown surgeon.) This corresponds to a plane tangent with the ipsilateral inferior mandibular border and anterior belly of the digastric platysma muscle borders mobilized. Partial digastric myec- muscle. Intraglandular vessels are often encountered and tomy is usually best performed after subplatysmal fat excision these must be carefully divided and immediately cauterized and submandibular gland reduction have been performed, if in a controlled fashion. Any bleeding points on the raw surface indicated, as it is easiest to assess the muscles at that time. of the gland are then further cauterized once the redundant Two basic techniques can be used: incremental tangential portion has been excised. Platysmaplasty (suturing the medial shave excision and muscle splitting myectomy. In the former borders of the right and left platysma muscles together in the the protruding portion of the muscle is shaved tangentially in midline) and platysmamyotomy (transverse division of the an incremental fashion using a DeBakey forceps and medium platysma at the level of the cricoid cartilage) are then per- Metzenbaum scissors until appropriate contour is obtained. formed as indicated. A 10F closed suction drain is placed in The neck is re-examined and the maneuver repeated until an both the pre-platysmal and subplatysmal spaces when sub- improved contour is obtained. Usually this entails the exci- mandibular gland reduction is performed. It is not necessary sion of 25–50% of the superficial most part of the anterior to remove the entire gland to create an attractive cervical muscle belly, but occasionally 50–90% of the muscle must be contour. Complete submandibular gland excision risks injury removed. In the muscle-splitting partial myectomy technique to the marginal mandibular branch of the facial nerve and is the protruding portion of the muscle is isolated on a tonsil likely result in a depression or other contour abnormality. forceps, or similar instrument, by pushing the instruments Subtotal submandibular gland excision to date has resulted in tips transversely through the muscle belly (Fig. 12.38). The no cases of nerve injury, hematoma, seroma formation, sali- isolated segment is then excised with scissors or electrocau- vary fistula, or gustatory sweating. Fig. 12.39 Excision of protruding portion of anterior digastric muscle. The muscle Fig. 12.36 Overview of the technique for reduction of prominent submandibular tery by dividing the muscle near the mandible and the hyoid has been isolated on a hemostat. The isolated muscle segment is then divided near gland. A submental incision has been made approximately 1 cm posterior to the (Fig. 12.39). Contours are checked and the maneuver repeated the hyoid and mandible using electrocautery. (Courtesy of Timothy J Marten, MD, submental crease and the neck subcutaneously undermined. The right platysma Large digastric muscles as indicated. Platysmaplasty (suturing the medial borders of FACS.) muscle has been elevated and is retracted with a double pronged skin hook and a the right and left platysma muscles together in the midline) malleable retractor. The gland will be seen as a distinct bulge just lateral to the ipsilateral anterior belly of the digastric (scissors tips rest on digastric). The As experience is gained in evaluation of patients presenting and platysmamyotomy (transverse division of the platysma capsule has been incised inferiorly and medially and the submandibular gland for secondary surgery, large, low lying anterior bellies of the at the level of the cricoid cartilage) are then performed as of suction excision of preplatysmal fat with and without post- isolated using blunt dissection. The gland, once isolated, is gently pulled inferiorly digastric muscles will increasingly be recognized as a frequent indicated. auricular skin excision. Although this occasionally yields a (forceps). The protruding portion is then excised incrementally with electrocautery. part of the secondary neck deformity and the underlying A 10F closed suction drain is usually placed in the good result in a younger patient with modest deep layer prob- (Courtesy of Timothy J. Marten, MD, FACS.) cause of objectionable linear paramedian fullness in the sub- subplatysmal space when digastric myectomy is performed, lems, more often it accomplishes little more than exposing mental region. These bulges often go unnoticed at the primary and almost always if subplatysmal fat excision or sub- underlying platysma bands, resulting in an objectionable and procedure because they are often obscured by neck fat and lax mandibular gland reduction is concomitantly carried out. elderly appearance. necessary, as is good light, an attentive assistant, and a good platysma muscle. In most cases, the secondary facelift will Digastric myotomy has not resulted in dysphagia, dysphonia, Primary and secondary platysma bands are best treated source of suction. It should be noted that all vital structures provide an opportunity for proper diagnosis and appropriate or other functional problem. by transverse platysma myotomy (transverse division of the are situated lateral to the dissection and lie outside the glan- treatment (Fig. 12.37). platysma at the level of the cricoid cartilage), as the underly- dular capsule. Excision is begun by grasping the inferior Prominent anterior bellies of the digastric muscles can ing problem is one of platysma hyperfunction, not horizontal portion of the gland and gently pulling it inferiorly and medi- be treated by superficial subtotal myectomy. Superficial, Residual platysma bands platysmal laxity. Dividing the muscle defunctionalizes the ally out of its fossa and away from adjacent structures. The subtotal anterior digastric myectomy is performed under muscle similar to the way in which the gastrocnemius muscle redundant portion is subsequently incised incrementally direct vision, working through the submental incision after The introduction of liposuction has resulted in many surgeons is defunctionalized when the Achilles tendon is ruptured. along the planned line of resection (Fig. 12.36). the subplatysmal space has been opened and the medial adopting a closed plan of treatment for the neck, consisting Platysmaplasty alone (suturing the right and left platysma 298 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 299

better tolerated and may be helpful for minor muscular irreg- It is common at the time of secondary facelift surgery to ularities. Neither, however, addresses directly the anatomical find that the SMAS has been dissected timidly at the primary basis of the problem. procedure and that the high, extended dissection described Excision of platysma bands, although recommended and above can easily be performed in a virgin plane. Fortunately, practiced for some time, can result in nerve injury and muscle a secondary SMAS dissection is also still possible after a more dysfunction, and typically results in visible irregularity, and extensive primary SMAS procedure, and the subSMAS plane recurrent deformity. Excision does not address the anatomic usually offers little in terms of scar, adhesions, or other basis of the problem and often results in new bands on each encumbrances. side of the excised muscle. Advancing the cheek SMAS flap superiorly and suspend- ing it without excising its superior margin or folding it supe- rior edge upon itself at the primary procedure, provides the Uncorrected and under-corrected ideal setting for secondary SMAS surgery. The overlapping midface deformities tissue segments are easily dissected at some future date and minimal subSMAS cicatrix is produced. A high SMAS plan A careful examination of the typical patient presenting for also precludes dimpling and irregular contours over the secondary surgery is commonly remarkable for an uncor- upper cheek when the patient smiles (“smile block”) due to rected or under corrected midface evident as infraorbital hol- impingement of the cheek pad at suture sites and tethering of Fig. 12.40 Treatment of residual anterior platysma lowing, malar flattening, and nasolabial fold formation. These tissue there. This can occur, however, if attempts are made to bands. Schematic showing anterior band and plan for changes often appear more obvious and more objectionable suspend midface or malar pad over the superior aspect of the platysma myotomy. After myotomy and SMAS flap after the patient’s primary procedure as they typically stand zygoma or to the periosteum along the infraorbital rim. advancement. in contrast to an overly tight jaw line and against a back- It should be recognized that the nasolabial fold and crease ground of aggressive rejuvenation of other adjacent areas. are a product of the patient’s individual anatomical make-up Treatment of midface problems remains controversial and and in many cases a specific familial trait. In such cases, eleva- a consensus of opinion as to the best way to correct them has tion of the midface as described should not be expected to yet to arise. A major short-coming of “skin lifts” and the eliminate or obliterate these features. Indeed, in such cases typical “low” SMAS flap elevated below the zygomatic arch, there is little artistic imperative to do so. is that neither is able to produce significant improvement in Most midfacelifts are generally conceptually flawed and the midface area. Skin lifts fail because skin provides little in of limited utility in the secondary facelift patient in that they the way of support of the malar fat pad. “Low” SMAS flaps erroneously assume the problem seen in the anterior upper are ineffective, as they are unable by design to exert a signifi- cheek to be solely one of tissue sagging. Failure to acknowl- cant vector of pull over the midface and infraorbital region. edge the fact that atrophy is present to a significant degree in Incising and elevating the SMAS flap “higher”, along the mid- most cases has led to general disappointment following many body of the zygomatic arch, and extending the dissection procedures for both patients and surgeons, and has resulted medially to release and mobilize midface tissue, however, in the addition of dermis fat grafts, orbital fat transposition enables problems in these areas to be addressed (Figs 12.42, and “septal resets” to “midfacelift” procedures. It is question- 12.43). This high SMAS plan, as such, provides a means for able and remains to be answered however, whether these both elevating ptotic infraorbital and malar tissue, and increas- procedures can produce a restoration of lost volume as simply, ing lower lid support. naturally, and effectively as can be obtained with fat

Fig. 12.41 Treatment of residual anterior and lateral platysma bands. Schematic showing anterior and lateral bands and plan for platysma myotomy. After myotomy and SMAS flap advancement.

muscles together in the midline) is usually insufficient as it taught, muscle and low lip dysfunction is common and does not address the underlying cause of the problem. an unattractive overly sharp cervicomental angle is likely Transverse platysma myotomy generally requires complete to result. subcutaneous undermining of the neck because myotomy Anterior bands require transection of the platysma to must be preformed at or near the level of the cricoid cartilage a point lateral to the band to the midpoint of the muscle where the platysma muscle is thin if visible irregularities are (Fig. 12.40). If lateral bands are present, transection is extended to be avoided. Bleeding will also be minimal when myotomy further laterally to a more lateral point in the muscle to include is performed at this location, and there is minimal chance that them as well (Fig. 12.41). lower lip dysfunction will be produced. If platysma transec- Platysma bands are the result of platysma muscle hyper- tion is performed higher where the muscle is thicker, bleeding function they are not logically or effectively treated in most Fig. 12.42 “Low” SMAS flap. The traditional “low” from cut muscle edges is more common, and contour irregu- cases by suspension sutures or direct excision. Suspension plan for the cheek SMAS flap is by design only able to apply a vector to the lower cheek and jowl, but not the larities are likely to be evident once swelling is gone and sutures and straps, especially those extending from mastoid midface. Plan for low SMAS flap. Low SMAS flap after healing is complete. A high division of the platysma can also to mastoid, often result in an overly rigid noose that is dis- advancement and fixation. Arrow indicates that flap precipitate lower lip dysfunction. If wedge resection of the turbing and uncomfortable to patients, especially when they elevation results in improvement in the lower cheek platysma is made near the hyoid as is often traditionally look down. Sutures extending partially across the neck are and jowl only. 300 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 301

shifted posteriorly and partially excised, and kept off the face. This minimizes cervical wrinkle shift onto the face and other secondary irregularities resulting from improper skin shifts. This treatment of the skin and SMAS as separate layers is referred to as a “lamellar” or “bi-directional” facelift. Neck to face wrinkle shift is difficult to correct, especially in the patient with little residual skin redundancy. Although skin flap elevation and re-advancement along a more poste- riorly directed vector can produce some improvement, the degree to which the flap can be shifted back into a normal position will be limited by the severity of the previous skin over-shifting, the previous cut-out made for the lobule at the primary procedure, and the amount of recurrent redundant Fig. 12.43 “High” SMAS flap. The “high” plan for the skin present at the time that secondary surgery is requested cheek SMAS flap allows a vector to be applied to not only the lower cheek and jowl, but not the midface (Fig. 12.46). and infraorbital region as well. Plan for High SMAS flap. High SMAS flap after advancement and fixation. Arrow indicates that flap elevation results in not only Compression of the temporal face improvement in the lower cheek and jowl, but in the midface and infraorbital region as well (compare with Although advancement of the SMAS along a mostly superi- Fig. 12.42A,B). orly directed vector will produce the most comprehensive improvement in the midface, cheek, jowl, and infraorbital areas, it will also inevitably produce compression of the temporal face and lateral orbital region if tissue shifts have In most patients, the secondary facelift will provide an oppor- been meaningful and temple lift or foreheadplasty is not per- tunity to reposition sagging jowl tissues and to restore attrac- formed. This compression and wrinkling not only contribute tive mandibular contour. Although liposuction and direct Fig. 12.45 Abnormal appearance due to inappropriate skin shifts. Wrinkles to a “young face–old forehead” deformity, but also will be excision of jowl fat can be used to improve mandibular con- originally present on the neck have been moved up over the jaw line and in front of worse after a secondary facelift if temple and lateral upper tours in some instances, this fat more appropriately belongs the lobule. This occurs in “skin lift” procedures when the skin is advanced along a facial tissue are not correspondingly repositioned. higher on the face and should not be arbitrarily sacrificed (see superiorly directed vector in a mistaken attempt to improve neck contour. It can Patients are often aware that a problem exists in the temple Fig. 12.33 also occur in Skoog and “composite” procedures as skin and SMAS must ). In addition, in most instances liposuction and/or obligatorily be advanced in the same direction. (Procedure performed by unknown area after their primary facelift but often mistakenly assume direct jowl fat excision was performed aggressively at the surgeon.) it to be a problem of skin wrinkling and residual “crow’s feet”. primary procedure, and little residual superficial fat is typi- Many rightly observe that tissue compression is worse upon cally present in secondary cases. Almost all patients with smiling. These patients will benefit from repositioning of tem- residual jowls presenting for secondary surgery will be better poral tissues or formal foreheadplasty if not performed as part served by formal SMAS dissection and suspension, than by of the primary procedure. fat excision. Occasionally, patients with very heavy jowls will superiorly directed vector. This deformity is commonly require the combination of repositioning of jowl fat via SMAS accompanied by temporal hairline displacement, unless an elevation and conservative jowl fat removal via direct excision incision along the temporal hairline has been used. The fun- Skin deficiencies and “tight look” or liposuction. In a minority of instances however, residual damental problem with these procedures is that they fail to large jowls present after a primary facelift represent a combi- address the fact that skin and SMAS age at different rates and Whenever prospective patients and the lay public discuss nation of residual excess fat, jowl tissue ptosis, and atrophy along different vectors. In general, skin needs to be advanced facelift surgery they inevitably express the most concern and at the geniomandibular groove, and a combination of SMAS along a vector perpendicular to the nasolabial fold whereas the dismay over the tight faces of various celebrities and their SMAS and deep layer tissue needs to be advanced along a more friends and acquaintances who have undergone the proce- Fig. 12.44 Residual jowl and jaw line laxity. Incomplete elevation of the jowl is elevation, judicious fat excision, and geniomandibular groove fat grafting may be indicated. superiorly directed vector roughly parallel to the long axis of the dure. Many unhesitatingly demonstrate what they see to be commonly seen in patients presenting for secondary facelifts and represents zygomaticus major muscle. In skin-only lifts, skin is typically the problem by pulling forcefully on their cheeks, eyes, and incomplete or under utilization of the cheek SMAS. Although liposuction and direct excision of jowl fat may straighten mandibular contours, this fat more appropriately over-shifted along a superiorly directed vector in a misguided eyebrows asking either not to look that way after their surgery, belongs higher on the face and should not be arbitrarily sacrificed. (Procedure Distortion and abnormal appearances attempt to correct problems of deep layer origin seen in the or stating they will never undergo surgery for fear of ending performed by unknown surgeon.) due to inappropriate skin shifts lower face and along the jowl. In deep plane and composite up with a similar appearance. This concern is reinforced by procedures, skin is obligatorily advanced as a composite with the numerous jokes and references in the popular press to Many patients presenting for secondary facelift will have underlying SMAS and skin must be over-shifted superiorly to “masks”, “wind tunnels”, and “faces so tight they will crack” abnormal appearances due to inappropriate shifts of skin obtain the best SMAS effect. The “wrinkle shift deformity” is if their wearer smiles. Despite these expressed concerns and injections. The current trend seems to strongly favor a “filling” flaps. This problem is particularly common in the older patient most problematic in MACS lifts and short scar procedures, the frequent popular ridicule of the typical outcome of mul- rather than a “lifting” approach. with deep rhytides and poor skin elasticity and will typically and any similar procedure in which an attempt is made to tiple skin-only facelifts, procedures based predominantly on be evident as superiorly over-shifted cervicofacial rhytides in shorten or eliminate the post-auricular scar. These procedures, skin excision that produce a tight look continue to be widely the lower lateral cheek, perilobular area, and upper lateral by design, require that cervicofacial skin flaps be shifted performed. Residual jowl neck sometimes referred to as a “wrinkle shift deformity” along a purely vertical vector, and do not provide a means for The fundamental problem with a “skin-only” facelift, espe- (Fig. 12.45). wrinkled cervical skin to be partially excised, shifted more cially if multiple such procedures are performed, is that skin Incomplete elevation of the jowl, or recurrent jowl ptosis, is a Superior over-shifting of cervicofacial rhytides is com- posteriorly, and kept on the cervical area. is meant to serve a covering function and not a supporting common problem seen in patients presenting for secondary monly seen in skin-only facelifts and “composite” type pro- Separating the skin and SMAS from one another into sepa- one. Most of the changes seen in the aging face, however, are facelifts that in all but the unusual case, represents incomplete cedures, and in MACS (minimal access cranial suspension) rate lamella and advancing each along independent vectors the result of an attenuation of support and subsequent descent mobilization, improper shift, inadequate fixation or other lifts, and other “short-scar” procedures in which a short post- allows each layer to be treated most appropriately and as of deep layer facial tissues, and not sagging of skin. Any improper or under utilization of the cheek SMAS (Fig. 12.44). auricular incision is used and skin is obligatorily shifted along indicated. When this is done, wrinkled cervical skin can be attempt to lift significant sagging of deep facial tissue with 302 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 303

recruited by wide undermining of adjacent cheek or neck tissue. Even the surgeon who knows better will often set good judgment aside when subjected to the persistent pleading of a patient desperate for some kind of improvement. Experience has shown however, that simple scar excision and adjacent tissue undermining in these patients will result in inadequate skin for a tension free repair and a forced, excessively tight closure. This tight closure, in turn, will inevitably result in wound dehiscence, scar widening, and associated tension- related deformities including scar hypertrophy, cross hatched suture marks, facial distortion, tragal irregularities, and lobular malposition. In these patients it is best to accept partial correction of the problem, rather than creating a new one, or injuring remaining normal tissue. Make-up, camouflage tat- tooing, or restyling of hair are better alternatives to conceal the residual scars in these circumstances. If make-up is ineffective in concealing scars due to ridges and step-offs where they abut normal tissue, dermabrasion may be helpful in reducing the discrepancy in tissue height and smoothing the transition between the two areas. Even if Fig. 12.48 “Drapery lines” and “lateral sweep”. “Drapery lines” and “lateral discrepancies in tissue height can be reduced in this manner, sweep” are common problems following a “skin-only” facelift. In these procedures A B skin tightness is most pronounced in the pre-auricular region where it is least there is usually a marked difference in tissue texture that needed. More inferiorly, in the jowl and peri-oral region, skin will be under less prevents the scar from being completely concealed. Patients tension where it is needed most. “Drapery lines” develop because skin is fixed and wishing further improvement may benefit from scar excision Fig. 12.46 Improvement of inappropriate skin shifts. (A) Wrinkles originally present on the neck have been moved up over the jaw line and in front of the lobule at the tethered in the pre-auricular and peri-stomal regions, but has little no support in and full thickness skin grafting as this technique can provide patient’s primary procedure. (Procedure performed by unknown surgeon.) (B) After secondary facelift. Contour has been created using the SMAS and platysma and cheek between where deep layer tissue sagging is greatest. (Procedure performed by skin has been shifted inferiorly to the extent possible. (Procedure performed by Timothy J. Marten, MD, FACS.) cover with more natural appearing skin texture. Several unknown surgeon.) follow-up dermabrasion procedures may be necessary to smooth the interface between the skin and skin grafts and these patients are likely to benefit from the use of a silastic gel sheet and/or facial compression garments during the healing excision will result in an accentuation of their deformities, and process. In some circumstances, it may be better to excise skin will be short-lived, destined to produce an overly tight little improvement in facial contour. some normal skin along with scarred areas and graft a large appearance, and doomed to result in secondary deformities. anatomical sub-unit, rather than creating a patch quilt of As the elastic limits of skin are exceeded in a skin-only smaller grafts. In extreme situations, consideration may have facelift, a tight or pulled appearance develops and facial Skin slough to be given to cheek or neck skin expansion. contour is flattened. Tightness and flattening will be most Skin slough can be minimized or avoided by exercising pronounced in the pre-auricular region where tension is The continued popularity of procedures in which the skin caution, using common sense, and adhering to basic plastic highest and the threshold of elasticity exceeded the most. of the face and neck is extensively undermined and then surgery principles. All patients who smoke or have a history More inferiorly, in the jowl and peri-oral region, skin will be suspended under abnormal tension in an attempt to create of smoking should be identified and their surgery planned in under less tension and below its threshold of inelasticity. Less youthful contour has resulted in the continued occurrence of a way that recognizes their increased risk for compromised tightness will thus be present in these areas, where it is needed potentially avoidable secondary deformities resulting from healing skin necrosis. Consideration should be given to not most. Further tightening of the skin usually results in more skin slough. Skin slough is also frequently the result of inap- performing a facelift on heavy smokers with a long history of pre-auricular flattening but little improvement in jowl and propriately aggressive surgery on smokers and arguably risky tobacco use, or employing a facelift technique that does not peri-oral contour. Over time, “tight lines” (Fig. 12.47) will procedures in which a facelift is performed concomitantly involve wide skin flap undermining and skin flap tension. appear across the lower cheek and upper lateral neck upon with aggressive laser resurfacing of undermined skin. Many of these patients will be satisfied with a combination of neck flexion and “drapery lines” (Fig. 12.48), or “lateral Small areas of scarring resulting from skin slough in limited lower risk procedures including closed forehead- sweep” will develop over the lower cheek and jowl. Drapery patients presenting for secondary surgery can sometimes be plasty, eyelid surgery, conservative submental liposuction, fat lines and lateral sweep develop because skin is fixed and corrected at the time of the secondary procedure by direct injections, and laser resurfacing. Smokers should always be tethered in the pre-auricular and peri-stomal regions, but has excision after adequate mobilization of surrounding tissue approached with caution however, and every surgeon should no support in between where deep layer tissue sagging is or by incorporation of the scarred area into a more compre- recognize these patients have a higher risk of experiencing greatest. Wrinkling and tightness extending from the lobule hensive incision plan. Larger areas of skin loss resulting from healing problems after surgery. to the jowl and submental area when the patient looks down excessive flap undermining, excessive flap tension, rough Flap necrosis is dependent upon a variety of factors under (“tight lines”) also occurs after well-intended attempts to tissue handling, or overly tight facial bandages are usually the surgeon’s control and can be minimized by procedure contour the face by skin excision because the elastic limits Fig. 12.47 “Tight lines”. Wrinkling and tightness extending from the lobule to the much more difficult to correct, especially if skin excision design. These factors include tissue trauma, the extent of skin of cheek skin is exceeded when the neck is flexed and its jowl and submental area when the patient looks down (“tight lines”) occurs after was aggressive at the primary procedure and little residual undermining, and skin tension. Because deep layer techniques well-intended attempts to contour the face by skin excision because the elastic normal covering function is corrupted (Fig. 12.47). This tell- limits of cheek skin is exceeded and its normal covering function is corrupted. redundancy is present. Regrettably, this is all too frequently limit skin undermining, preserve important cheek perfora- tale deformity is typically evident when the patient is looking (Note other tension artifacts including retracted lobule and wide, cross-hatched the case. In such situations, the patient and surgeon must tors, and avoid excessive tension on cervicofacial skin flaps, down and the neck is markedly flexed (e.g., when looking at peri-lobular scar.) (Procedure performed by unknown surgeon.) accept that complete correction is not possible at the time of a careful surgeon employing a gentle, atraumatic, technique a menu, book, or theater program). the secondary procedure no matter how much they wish it in carefully selected patients should infrequently encounter The patient presenting for secondary facelift who had skin were so. skin slough. And when the procedure is performed in this excision only at their primary procedure is the quintessential It is a common error to assume that scarred areas can manner, skin slough, should it occur, should be limited and patient in need of deep layer support. Additional skin simply be excised and that the skin needed for closure can be easily managed. 304 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 305

This is usually best accomplished by high suspension of often result in troublesome and difficult to correct secondary the cheek and midface using a high SMAS flap (Fig. 12.43), deformities. It is often best to encourage the patient to return or by employing a subperiosteal midfacelift technique. to the surgeon who originally placed these implants before Techniques that require suture fixation of more superficially secondary surgery is performed if he or she wishes them to situated tissue, or “low” fixation on the face, should be be removed. This allows problems associated with implant avoided. Smile block can also often be corrected percutane- removal to be clearly defined prior to the secondary surgery, ously by release of tethered areas with a small “V” tipped and an appropriate plan for correction to be made. If implant lipo-infiltration needle and concomitant fat injection. removal is made as part of the secondary facelift, problems may be erroneously attributed to that procedure or the tech- nique used. Unaesthetic facial implants The un-rejuvenated forehead It is not uncommon to find patients presenting for secondary facelift who have inappropriate or unaesthetic facial implants Rarely does isolated aging occur in the cheek and neck. that detract from their appearance and limit the potential for Nonetheless, most attempts to rejuvenate the face are tar- improvement at any secondary procedure. Frequently, these geted at these areas and many patients presenting for implants were placed in an attempt to offset the deficiencies secondary facelift will have a distinct and tell-tale “young and shortcomings of a “minilift”, “laser facelift”, “infomercial face–old forehead” deformity. This results from a failure to lift”, “franchise facelift”, or “weekend” procedure, or placed recognize and treat forehead aging at the primary procedure in an isolated procedure in a patient who would have argu- (Fig. 12.51). Fig. 12.50 “Smile block”. If the SMAS is suspended too low, too far medially over ably been better served by formal facelift surgery. These A careful consideration of the typical patient presenting for the zygoma, or too rigidly directly to the periosteum, tissue tethering can result in can include under and over-sized malar implants, submalar secondary facelift frequently reveals that isolated tightening dimpling and other irregularities when the patient smiles (arrow). This problem can implants, chin implants, and mandibular angle implants. of the neck and cheeks is often an artistically inappropriate also be seen when attempts are made to directly suspend the malar pad or when Often even more troublesome are PTFE (Gore-Tex®) strips and undertaking. This is due, at least in part, to the fact that the malar midface or other mobile area of the face is suspended to the infraorbital similar implants placed in the lips and nasolabial folds. These changes in the forehead are more likely to be mistakenly Fig. 12.49 Contour irregularity (arrow) due to prior SMAS injury. A common rim or other part of the bony skeleton. (Procedure performed by unknown surgeon.) can be seen to result in visible surface irregularities and buckle assigned emotional significance than those in the lower face type of SMAS injury resulting in secondary deformity occurs when the SMAS is and fold upon facial animation. and neck, and as such, play a greater role in how we interact knowingly or unknowingly “button-holed” at the primary procedure. This can result in bulges or contour irregularities when the patient animates or clenches her teeth. Although facial implants collectively comprise a significant with and are regarded by others. In addition, rejuvenating (Note the bulge in the lower cheek in this patient when clenching her teeth.) advance in aesthetic surgery and have helped many patients, the lower face and neck only will typically result in facial (Procedure performed by unknown surgeon.) individualized according to the specific problems present. they were devised primarily to be used in individuals with disharmony and an unnatural, unbalanced, and “surgical” Some correction is usually possible if tissues are carefully skeletal deficiencies. Patients troubled by age-associated soft appearance. examined and the origins of the problem can be ascertained. tissue ptosis are more logically, appropriately, and effectively Recognizing the “young face–old forehead” deformity is SMAS advancement along an improper vector can result in treated by procedures that reposition and redistribute ptotic necessary for it to be corrected and a pre-requisite to com- Distortion and abnormal appearances due to distortions in animation and at rest. These typically occur tissue, rather than those designed to augment the facial skel- municating the need for forehead surgery to the patient. To inappropriate SMAS shifts or SMAS injury when the cheek SMAS flap has been erroneously advanced eton. Patients troubled predominantly by soft tissue atrophy appreciate the “problem”, the surgeon must examine the and suspended under tension along a predominantly poste- are likewise more appropriately treated by fat injections than patient’s face in its entirety and consider the way in which his Many patients presenting for secondary facelift will have had rior, rather than mostly superior vector and are typically with facial implants. or her appearance might make others feel. This is often best skin only, non-SMAS procedures and as such, will be poten- evident as a “clown mouth” or “pulled mouth” appearance Many patients with unaesthetic facial implants are aware accomplished by viewing the patient’s face at a distance and tially free from deformities related to inappropriate SMAS and bizarre and unusual facial movements in animation. that all is not right with their appearance and are more than momentarily deferring to one’s intuition. maneuvers. SMAS injury during non-SMAS surgery can, The proper vector of advancement of the SMAS is along a vector willing to consent to implant exchange or removal. These Because a patient’s hairstyle can conceal important signs of however, result in distortion and irregularities of SMAS parallel to the long axis of the zygomaticus major muscle. If the patients are typically seen to have small button-like chin forehead aging, and compensatory frontalis spasm can give origin, even though no actual SMAS surgery was performed. SMAS is advanced along another vector, the zygomaticus or cheek implants, oversized malar implants, or submalar the false impression that the eyebrows are in an appropriate The typical SMAS injury resulting in secondary deformity major muscle will be bowed off its axis of normal function implants placed in a failed attempt to improve their nasolabial position, it is imperative that the face of the patient presenting for occurs when the SMAS is knowingly or unknowingly “button- and its action corrupted. Posterior traction also exaggerates folds. secondary facelift be examined with the patient’s hair pushed well holed”. This will result in asymmetries and contour irregulari- risorius action and results in an objectionable change in the A more difficult situation exists when the patient does not back off their forehead. In addition, because patients who wear ties, especially when the patient is in animation or clenches resting posture of peri-oral tissues. Secondary deformities see the problem and is unwilling to consider implant exchange forehead concealing hairstyles often do not see the full extent their teeth (Fig. 12.49). Identification and repair of these SMAS related to an improper advancement of the SMAS flap are or removal. In these patients, one must decide whether it is of these problems, it is helpful, as it is during the rest of their defects at secondary surgery will eliminate many of these often markedly improved during secondary surgery when the possible to work around this, or if it is preferable to let the evaluation, for the patient to hold a hand mirror during this types of problems. Larger rents or defects in the SMAS, result- SMAS is re-elevated and re-advanced along a proper vector. patient enlist the services of another surgeon. part of the examination. They can then be shown these impor- ing from larger areas of SMAS injury, SMAS excisions, and In general, the removal or exchange of facial implants at tant findings and counseled as to how they are actually the failed plications present a bigger challenge and can be diffi- “Smile block” the time of secondary facelift is not difficult and results in a product of forehead ptosis. cult to fully correct. few untoward occurrences. If implants were originally placed The erroneous assumption that forehead ptosis is not present Patients who have had prior SMAS lifts may have other Attempts to directly suspend the midface or malar fat pad subcutaneously, a more natural appearance can usually be because the eyebrow appears to be in a normal position is the single secondary SMAS deformities that must be recognized and with sutures, or low rigid suspension of the SMAS to the facial obtained when they are moved to a subperiosteal position. biggest stumbling block in evaluating the forehead for patients and addressed as well. These deformities include ridges from skeleton, will prevent natural gliding of cheek and midface Submalar implants often can be removed at secondary proce- surgeons alike. Patients are accustomed to optimizing the SMAS plication or SMAS excision, irregularities from an tissue during animation. This will be clinically apparent post- dures, as cheek and midface repositioning will often result in appearance of their face when looking at their reflection by uneven or overly tight SMAS suspension, and distortion and operatively, when the patient emotes as dimpling and contour abnormal appearances if these are left in place. Alternatively, unconsciously raising their eyebrows. This is often further unnatural appearances from advancement of the SMAS along irregularities often referred to as “smile block” (Fig. 12.50). they can be left in place and removed in a subsequent proce- compounded by the fact that many women aggressively an improper vector. Smile block can usually be improved at a secondary pro- dure, if necessary, if the patient desires. pluck the inferior-lateral portion of their eyebrow to give the Ridges and irregularities from prior plication or SMAS cedure by a thorough release of the tethered area and PTFE (“Gore-Tex”) implants placed in the lips and nasola- allusion that it is higher and more arched. In many cases, the excision may limit the potential for improvement in second- re-suspension of ptotic tissues using a technique that allows bial folds present a particular problem in that they can be entire outer third of the eyebrow will be seen to be missing ary procedures, and secondary correction techniques must be unrestrained and natural gliding of malar pad and midface. exceedingly difficult to remove. In addition, removal can and has been drawn on in a higher position with an eyebrow 306 SECTION I • 12 • Secondary deformities and the secondary facelift Identification and analysis of secondary surgical deformities 307

A B C A B

Fig. 12.51 The “young face–old forehead” deformity. (A) Patient seen after face lift, neck lift, genioplasty, and eyelid surgery performed elsewhere. Her forehead appears older than the rest of her face, and her overall appearance is disharmonious and unnatural. (Procedure performed by unknown surgeon.) (B) Same patient seen after hairline lowering foreheadplasty. No eyelid surgery or other procedures have been performed. Her face appears more natural, harmonious, and balanced, and all areas appear to be the same age. (Procedure performed by Timothy J. Marten, MD, FACS.) pencil. The all too commonly observed circumstance is one in Facial atrophy which the patient with a marked frontalis spasm and marked transverse forehead wrinkling holds a hand mirror during his Traditionally, the aging face has been thought of and defined or her consultation and sees only that his or her eyebrows in terms of tissue relaxation and surface wrinkling, but appear in a normal position. more recently surgeons have come to appreciate atrophy Because many patients presenting for secondary facelift and lipodystrophy as integral parts of the aging process. will have un-rejuvenated foreheads, foreheadplasty will usu- A careful examination of patients presenting for secondary ally be an important component of the planned facelift proce- facelift will reinforce this assertion and reveal that simply dure. (Forehead rejuvenation is discussed in Chapter 7.) smoothing wrinkles and lifting sagging tissues will fall short of truly rejuvenating the face in most cases. This is particularly Un-rejuvenated peri-oral region true if the patient is thin, buccal fat was removed as part of the primary procedure, or facial liposuction was per- Although advanced peri-oral aging is usually appreciated at formed (Fig. 12.52). the time of primary facelift, more subtle deformities often go Atrophy is usually most profound and most easily observed unnoticed, especially when viewed against a background of around the orbits, upper midface, and infraorbital and peri- advanced aging elsewhere on the face. As a result, peri-oral oral areas but can be seen on close inspection of many patients deformities often go untreated at the primary procedure and in the forehead, brow, temple, cheek, jaw line, chin and neck. D E F usually appear more apparent after rejuvenation of adjacent Atrophy is not corrected by traditional “facelift” procedures, areas is done. This can result in a tell-tale “young face–old and is usually incompletely or poorly corrected by tradition- Fig. 12.52 Facelift and fat injection example. (A–C) Before surgery view of a woman, aged 75, who has had multiple prior facelifts and related procedures, including laser mouth” deformity. ally used facial implants. These procedures may even exacer- resurfacing, performed by unknown plastic surgeons. Note marked, uncorrected panfacial atrophy and, despite her multiple traditional lifts, a frail, ill, and elderly appearance. Recognizing the “young face–old mouth” deformity is nec- bate the problem, and result in an arguably more unnatural, (D–F) Same patient, 1 year 4 months after secondary facelift, necklift, foreheadlift, upper and lower blepharoplasties, canthopexy, and aggressive fat transfer to the forehead, essary if improvement is to be made and a pre-requisite to hard and objectionable appearance. temples, cheeks, upper and lower orbits, lips, peri-oral area, buccal recess, chin, and jaw line. A total of 90 cc of fat was injected. No skin resurfacing, facial implants, or communicating the need for the procedure to the patient. Correction of facial atrophy requires the addition of volume to the ancillary procedures were performed. Note that the patient has soft, natural facial contours and absence of a tight or pulled appearance. Atrophy in all treated areas has been Because many patients presenting for secondary facelift will face, not a subtraction, lifting, or tightening, and a rethinking of the markedly improved with fat injections to create a softer, more youthful, fit, healthy, athletic, and energetic appearance. Such an improvement cannot be obtained with traditional lifting and tightening. It can only be achieved by volume replacement. As was the case in this patient, for many secondary facelift patients, volume replacement is have an un-rejuvenated peri-oral area, peri-oral rejuvenation traditionally taught approach to rejuvenation of the face. Unlike more important than the facelift itself. will often be an important component of the planned second- problems corrected by a “lift” of the face, correction of atrophy ary “facelift” procedure. This will usually require some form requires the surgeon to employ techniques that “fill” and of skin resurfacing to improve skin quality and reduce skin “sculpt” the face, and to think in three, instead of just two, wrinkling, and fat or filler injections to counteract peri-oral dimensions (Fig. 12.52). atrophy. Other treatments such as upper liplifts and corner Currently, the most effective and natural correction of facial lifts of the mouth are also very useful in secondary facelift atrophy is best achieved through the use of fat injections. Fat patients. injections, when properly performed produce soft and natural 308 SECTION I • 12 • Secondary deformities and the secondary facelift References 308.e1 contours and afford one the opportunity to correct problems “surgical” appearance, often easily recognized by even the traditional surgery cannot (Fig. 12.53). FIG 12.53 APPEARS ONLINE untrained eye at a considerable distance. ONLY In all but the unusual instance, facial contour takes artistic As a practical matter, fat injections are most effectively precedent over smooth skin. Indeed, a few surface wrinkles performed in areas where tissue planes have not been opened. will be overlooked by the eye if youthful facial contour is As a result, they are less applicable and less commonly per- successfully re-established. A more balanced, harmonious and formed concurrently with a facelift in some areas. These areas natural appearance will result, and a less “surgical look” will include the pre-auricular cheek and the neck. Other areas, be present. however, including the temples, forehead, brows, glabella, If the patient presenting for secondary facelift has had radix, orbits, cheeks, midface, “tear troughs”, buccal recess, good repositioning of ptotic tissue at the primary procedure, lips, nasolabial folds, nasal base, stomal angles, genioman- and little recurrent ptosis is present, skin resurfacing may be dibular grooves, chin, and jaw line lend themselves to concur- worthwhile and appropriate if residual surface textural wrin- rent treatment, when indicated. kling is present. It must be kept in mind, however, that skin resurfacing will do little to permanently reduce wrinkles that are the product of muscle hyperactivity. These include glabel- Eyelid skin deficiencies and lar frown lines, transverse forehead wrinkles, and lateral eyelid malposition periorbital lines. Correction of these “expression lines” will require reduction or resection of hyperactive muscles, reposi- Many patients presenting for secondary facelift have under- tioning of ptotic tissue, or removal of excess tissue stimulating gone aggressive excision of eyelid skin at their primary muscle contraction. Although skin resurfacing will temporar- procedure and are secondarily troubled functionally by noc- ily disguise forehead wrinkles by inciting swelling, it is no turnal lagophthalmos, lid retraction, canthal laxity, scleral substitute for formal foreheadplasty. show, and dry eye problems, and aesthetically by orbital hol- Patients who have undergone prior skin resurfacing can lowing, change in eye shape, and unnatural ocular appear- present a number of technical problems at the time of second- ance. (These problems and deformities and their treatment are ary facelift as well. The most vexing of these is the inevitable A B discussed in Chapter 9.) shift of the line of demarcation between resurfaced and un-resurfaced areas below the jaw line onto the lower face. This “demarcation line shift” usually requires that a second Over reliance on laser resurfacing resurfacing procedure be performed to lower this line back into the shadow of the submental area. Motivated by largely unscientific claims of laser manufactur- Although many surgeons now assert concomitant facelift ers and enticing, but deceptive, early postoperative photo- and laser skin resurfacing to be safe (and cheek skin has argu- graphs of patients shown at meetings and included in ably been “delayed” at the primary procedure) this combina- commercial advertisements, many plastic surgeons and phy- tion of procedures still carries significant risk in any case in sicians in other specialties embraced laser resurfacing as a which skin has been undermined. For this reason it is prefer- substitute for traditional surgical maneuvers in which ptotic able to defer resurfacing until three months or more after the deep layer tissue was repositioned and redundant tissue facelift procedure, at which time the face can be safely, com- excised. Indeed, laser resurfacing was often referred to as a prehensively, and aggressively treated, if necessary. “laser facelift” and numerous claims were made regarding the The patient who has had a previous combined facelift and lasers ability to incite skin contraction and “tighten” the facial skin resurfacing procedure is often an excellent candidate for skin. Although laser resurfacing has proven to have clinical secondary facelift. This is because the previous surgeon, utility, experience has shown that it does not produce the skin fearing complications might result from aggressive surgical tightening once hoped for. In addition, “wrinkle relapse” is undermining or relying heavily on resurfacing to make up for common once patients are fully healed and all traces of swell- shortcomings of the chosen surgical procedure, has been con- ing are gone. servative in his or her surgical approach and timid during Many patients who have undergone laser resurfacing are dissection. Indeed, examination usually shows that these now presenting for formal facelifts, disappointed in the lack patients have residual uncorrected or under corrected deep of “lift” gained from their “laser facelift” and concerned over layer ptosis and residual forehead deformities. associated secondary deformities including hypopigmen- A new generation of “skin shrinking” technologies has now C D tation, skin sensitivity, abnormal skin texture, lower lid been introduced that have been widely embraced and said by malposition, and an unnatural “smooth face-wrinkled neck” some to eventually supplant the traditional facelift. In its Fig. 12.53 Case study 1. Multiple views of a 57-year-old woman before and 12 months after secondary cervicofacial rejuvenation. The primary facelift was performed by an appearance. Radiofrequency and ultrasound-based technolo- current form this certainly is not the case, and for the time unknown surgeon using conventional techniques and included aggressive upper and lower blepharoplasty but no forehead surgery. The secondary procedure consisted of a gies suffer the additional drawback that they often result in a being at least, facelifts and secondary facelifts offer improve- high cheek SMAS advancement with post-auricular transposition flaps, preplatysmal and subplatysmal cervical lipectomy, anterior platysmaplasty, and platysma myotomy. loss of subcutaneous facial fat. ments unobtainable by other means. Incisions along the hairline were used in the temporal and occipital areas and the preauricular incision was moved from a pretragal position to the margin of the tragus. Artistically, the fundamental problem with laser resurfac- Foreheadplasty, lower blepharocanthoplasty, bilateral ptosis correction, and perioral dermabrasion were also performed. Full thickness skin grafts taken from the postauricular ing is that its primary effect is to smooth skin, and that it does areas were applied to the upper lids to allow foreheadplasty to be performed and the eyebrows elevated to an appropriate position. No resurfacing or other ancillary procedures were performed. (A) Patient, aged 57, several years after primary conventional facelift, necklift and upper and lower blepharoplasty were performed elsewhere. little, if anything, to reposition ptotic tissue, to reduce skin Note residual and secondary deformities including unrejuvenated forehead, bilateral senile ptosis, midface ptosis, and residual jowl laxity. (B) Same patient, 12 months redundancy, or to correct facial atrophy. Its misapplication to Patient considerations after secondary facial rejuvenation. Note improvement in forehead, cheeks, periorbital area, and along jaw line that has been achieved without a tight or pulled appearance. the patient with ptotic deep layer tissue and redundant skin (C) Aged 57, several years after conventional facelift was performed elsewhere. Note residual and secondary deformities including obvious preauricular scar. (D) Same typically produces an unnatural, incongruent and “smooth Many patients requesting secondary or tertiary facelifts are patient, 12 months after a secondary facial rejuvenation. (Secondary facelift and related procedures performed by Timothy J. Marten, MD, FACS.) skin-sagging face” appearance. Because this combination chronologically elderly, but deceptively young in appearance. appears rarely in nature, the patient is left with a tell-tale A careful medical history must be taken because they often Technical considerations in secondary facelift 309

have concomitant medical problems consistent for their age stripped of fat and these areas must be carefully dissected group that were not present at the time of their primary pro- when skin flaps are elevated. Not uncommonly, dermomus- cedure. It is also wise to obtain independent medical clearance cular adhesions are present in the upper lateral neck over the prior to surgery as this group of patients will commonly mini- superficial most portion of the great auricular nerve. Similar mize existing problems and deny important symptoms of age caution must be taken when subcutaneous dissection is made related illness. secondarily in the temple. It is also very common for the A careful documentation of all existing secondary prob- anterior neck and submental regions to have been aggres- lems and deformities must also be made in patients undergo- sively defatted at the primary procedure by aggressive small ing secondary facelift procedures, including, but not limited cannula liposuction, ultrasonic lipectomy, excessive direct to, facial muscle weakness, dyskinesias, numbness, paresthe- excision, or by other means. In such patients, it is very easy sias, eye dryness, visual disturbances, and chronic pain. These to perforate, get under the platysma or damage it while problems do not show up in a photograph and are not always attempting to re-elevate the cervicosubmental skin. Entry recognized or volunteered by the patient. If not documented under the platysma can result in nerve injury and platysma preoperatively, they will inevitably be attributed to be the dysfunction, and can render the SMAS or platysma useless in result of the secondary procedure. the planned repair. For these reasons, all skin flap dissection must be made with great care in secondary procedures and it is not advisable to use aggressively patterned “super-sharp” E F Technical considerations in or serrated scissors for flap elevation. These scissors tend to pick up and cut delicate structures and are more likely to secondary facelift result in the inadvertent fenestration of the platysma, or unin- tended excision of subdermal fat. The secondary or tertiary facelift will present technical prob- Subcutaneous fat is generally precious in the secondary lems and certain risks not seen in primary procedures. In facelift patient and as much of it as possible should be pre- addition, the general approach to secondary procedures is served until the surgeon is certain that its sacrifice is artisti- somewhat different depending upon the type of secondary cally appropriate and of benefit to the patient. Care must be deformities present. taken however, not to injure the SMAS and platysma, while The secondary or tertiary facelift will generally require a com- elevating skin flaps as these will serve as the workhorse paratively small resection of skin and an increased focus on correct- tissue layers in restoring more youthful facial contours. ing deep layer problems and secondary deformities, depending The margin for error is thus very small, and often critically upon the skill of the surgeon performing the primary proce- so. The careful infiltration of dilute local anesthetic solutions dure and the type of technique used. This is because the focus is often helpful in these situations in pre-establishing of most primary procedures is usually on skin resection and the proper plane by hydrodissection. This beneficial effect this is more easily and quickly performed than deep layer will be lost if infiltration is made carelessly or in the maneuvers. In addition, skin resection and skin tightening are wrong plane. the underlying cause of many secondary problems. Very A satisfactory and uncomplicated SMAS dissection can often, the skin elevated and recruited by deep layer maneu- usually be performed in most secondary procedures particu- vers at the secondary or tertiary procedure is needed to correct larly if the primary surgeon previously elevated the SMAS in these problems and will not be excised. a skilled manner. Occasionally, the SMAS will be found to It should also be recognized that secondary facelifts are have been damaged or thinned however, or compromised by often time consuming and technically demanding when com- previous plication or suture lifts, making elevation difficult pared with primary procedures and are likely to test the and putting facial nerve branches at risk. Use of a nerve stim- patience and composure of most surgeons. It is highly recom- ulator or raising the flap with cautery on a low setting can be mended that additional operating room time be allotted for helpful in such instances to differentiate retaining ligaments G H the procedure and that the services of an anesthesiologist or from nerve branches. Ultimately, however, no amount of competent nurse anesthetist be enlisted. This is particularly aesthetic improvement is worth a facial nerve injury and dis- true if the procedure is being performed on a patient who is section should not be continued if overly difficult and motor overly apprehensive or has a history of anesthetic difficulties, nerve branches are put at unacceptable risk. In such cases, a hypertension or other medical problems. formal SMAS elevation may have to be abandoned and Although less bleeding is often encountered in elevation of replaced by an arguably safer alternative treatment such as the skin flap in secondary surgery, skin flap undermining is SMAS plication. often more taxing because of subcutaneous scar and adhe- Not all deformities resulting from the primary procedure sions resulting from the previous dissection. Scissors pushing can necessarily be corrected and the patient needs to have techniques should not be used and it is wise that dissection their expectations set in this regard. In addition, the secondary be made carefully, under direct vision, in good light, with an facelift patient will often need ancillary procedures in addi- experienced assistant. tion to secondary facelift surgery if maximum improve- I J Patients undergoing secondary procedures have at least ment is to be obtained (Figs 12.53–12.55). FIGS 12.54, 12.55 APPEAR some areas of their face or neck that have been aggressively ONLINE ONLY Fig. 12.53, cont’d (E) Aged 57, several years after conventional facelift was performed by an unknown surgeon. Note residual and secondary deformities midface ptosis, malar flattening, residual jowl, residual cervical obliquity and “witch’s chin” deformity. (F) Same patient, 12 months after a secondary facial rejuvenation. Cheek and midface tissue has been elevated, the pretragal scar has been moved to the margin of the tragus, and cervical contour improved. The witch’s chin deformity has also been corrected. (G) Aged 57, several years after conventional facelift and upper and lower blepharoplasty was performed elsewhere. Note severe, untreated residual brow ptosis. When the patient’s eyebrows were held up in an appropriate position, she was unable to close her eyelids. (H) Same patient, 12 months after a secondary facial rejuvenation. Full thickness postauricular skin grafts were applied to the upper eyelids so that foreheadplasty could be performed without compromising lid function. Canthopexy and bilateral ptosis correction was also performed. (I,J) Improved periorbital appearance is evident. References 309.e1 309.e2 SECTION I • 12 • Secondary deformities and the secondary facelift

E F

A B

G H

Fig. 12.54, cont’d (E) Patient aged 64, 8 years after conventional facelift was performed by an unknown surgeon. Note residual and secondary deformities. (F) 13 months C D after a secondary facial rejuvenation. Note improvement in jowl contour has achieved made without the creation of skin tightness or flattening of facial contour. (G) Patient aged 64, 8 years after conventional facelift was performed elsewhere. Note residual and secondary deformities midface ptosis, malar flattening, shift of cervical wrinkles onto lower face, loving-cup ear, residual jowl and residual cervical obliquity. (H) 13 months after a secondary facial rejuvenation. Cheek and midface tissue has been elevated, the Fig. 12.54 Case study 2. Multiple views of a 64-year-old woman before and 13 months after tertiary cervicofacial rejuvenation. The primary facelift and secondary necklift pretragal scar has been moved to the margin of the tragus, the lobular-facial junction has been improved, overshifted wrinkles have been partially moved back onto neck, and were performed by an unknown surgeon using conventional techniques. The secondary procedure consisted of trifurcated cheek SMAS advancement with temporal and cervical contour improved. postauricular transposition flaps, preplatysmal and subplatysmal cervical lipectomy, anterior platysmaplasty, platysma myotomy and correction of “loving cup” ear. Incisions along the hairline were used in the temporal and occipital areas and the preauricular incision was moved from a pretragal position to the margin of the tragus. Foreheadplasty, lower blepharoplasty, bilateral ptosis correction and crow’s feet reduction were also performed. No resurfacing or other ancillary procedures were performed. (A) Patient, aged 64, 8 years after primary conventional facelift was performed by an unknown surgeon. A secondary necklift had also been performed by the same surgeon at a later date. Note residual and secondary deformities including unrejuvenated forehead, bilateral senile ptosis, midface ptosis, and residual jowl laxity. (B) Same patient aged 65, 13 months after tertiary facial rejuvenation. Note improvement in forehead, cheeks, periorbital area, and along jaw line that has been achieved without a tight or pulled appearance. Note also residual aging in perioral area (“young face–old mouth” deformity). Regrettably, the patient declined recommended perioral rejuvenation. (C) Patient age 64, 8 years after primary conventional facelift was performed elsewhere. A secondary necklift had been performed by the same surgeon at a later date as well. (D) 13 months after tertiary facial rejuvenation. Note that SMAS and platysma surgery has not resulted in abnormalities during expression. References 309.e3

A B

I J

K

Fig. 12.54, cont’d (I) Patient aged 64, 8 years after conventional facelift was performed by an unknown surgeon. Note shift of cervical wrinkles onto lower face, loving-cup C D ear, and residual cervical obliquity. (J) 13 months after a secondary facial rejuvenation. The pretragal scar has been moved to the margin of the tragus, the lobular-facial junction has been improved, overshifted wrinkles have been partially moved back onto neck, and cervical contour improved. (K) An incision along the temporal hairline was used to prevent objectionable hairline displacement. Although the scar can be seen on close inspection, it is not evident on casual glance and in social situations. Fig. 12.55 Case study 3. Secondary cervicofacial rejuvenation. Multiple views of a 68-year-old woman seen before, and 1 year and 8 months after secondary facelift and related procedures. The primary procedure was performed by an unknown surgeon. The secondary procedure consisted of a high SMAS facelift, neck lift, small incision closed forehead lift, upper and lower blepharoplasties with reinsertion of the levator aponeurosis and canthopexy, facial fat injections, peri-oral dermabrasion, scalp scar revisions, and nevus excision. The neck procedures included excision of residual subplatysmal fat, submandibular gland reduction, superficial digastric myectomy, anterior platysmaplasty with post-auricular transposition flaps, and full width platysmamyotomy. No subcutaneous cervical fat was removed. Fat injections were performed in the temples, upper and lower orbits, the upper nasal dorsum, the cheeks, midface, piriform, nasolabial, stomal angle, peri-oral, lips, chin, GMG (geniomandibular groove), and jaw line areas. No resurfacing or other ancillary procedures were performed. (A) Preoperative AP view. The patient can be seen to have suboptimal eyebrow position and configuration with over-elevation of the medial brow, residual cheek and jowl ptosis, and poor posture of the peri-oral tissues. The peri-ocular appearance suggests aggressive upper and lower blepharoplasty had been previously performed. Marked atrophy can be seen in the temples, orbits, cheeks, oral and peri-oral, and peri-mental areas. Marked facial asymmetry, mild peri-oral wrinkling, and bilateral senile ptosis, worse on the left, are also present. Overall, the face has an ill, tired, and aged appearance. (B) Postoperative AP view. The patient has a soft, natural nonsurgical appearance. The lateral portion of each eyebrow has been raised and eyebrow position and configuration have been improved creating a more alert and engaged appearance. The cheek mass and jowls have been raised and the posture of tissues around the mouth improved. The temples and the upper and lower orbits have been filled using fat injections. A slight under correction of upper orbital atrophy on the left can be seen. Atrophy present in the oral, peri-oral, chin, geniomandibular groove and upper nasal dorsum areas has been nicely improved using fat injections as well. The lips have been subtly filled with fat and the lip border enhanced without a “stung by a bee” or “filler lip” appearance. The combination of fat injections and peri-oral dermabrasion has produced natural appearing correction of peri-oral wrinkling. Overall improved facial symmetry can also be seen. The patient’s ptosis has been improved. (C) Preoperative smiling view. Smiling reveals mandibular asymmetry and a poor transition from the lower eyelid to the cheek. (D) Postoperative smiling view. The patient appears natural when smiling. The transition from the lower eyelid to the cheek is improved. The chin is integrated with the jaw line and the two together form one continuous and desirable aesthetic line. The lips are fuller but the shape of the mouth is unchanged. 309.e6 SECTION I • 12 • Secondary deformities and the secondary facelift

E F

I J

Fig. 12.55, cont’d (I) Preoperative lateral flexed view. The patient can be seen to have a poor transition from the lower eyelid to the cheek, cheek and jowl ptosis, residual cervicosubmental fullness, an indistinct jaw line, and a “double chin”. Residual poor neck contour results an overweight, indecisive, and unattractive appearance. The lips are flat and the peri-oral area is retruded resulting in an elderly appearance. (J) Postoperative lateral flexed view. The patient now has a fit, athletic look and an attractive, photogenic appearance. A strong mandibular contour is present with the chin and the jowl integrated into a distinct, aesthetically desirable, continuous line. Residual subplatysmal fat and protruding portions of the submandibular glands have been removed, and platysma laxity corrected. The posterior jaw line has also been strengthened with fat injections adding to the effect. The double chin deformity has been eliminated by dissecting subcutaneously in a retrograde fashion onto the chin to release the submental retaining ligaments, and blending the fat of the chin and submental regions. The orbits have been filled using fat injections, and the lips and peri-oral are project to produce a more aesthetic and youthful appearance.

G H

Fig. 12.55, cont’d (E) Preoperative oblique view. The patient has a sad, forlorn appearance and the orbital area looks sunken and hollow. The lower face lacks strength and aesthetic appeal and appears elderly. Suboptimal eyebrow position and configuration is evident and residual cheek and jowl ptosis can be seen. Atrophy can be seen in the temples, orbits, upper cheek, oral and peri-oral, and peri-mental areas. The chin is frail and narrow appearing and is poorly integrated with the jaw line. The posterior jaw line is weak and the mandible has a diminutive appearance. The lips are thin and have an elderly retruded appearance. (F) Postoperative oblique view. Overall, the patient has a soft, natural, nonsurgical look and a youthful, athletic, aesthetic, and healthy appearance. The lateral eyebrow has been raised and the eyebrow position and configuration have been improved. The cheek mass and jowls have been re-positioned and the temples and the upper and lower orbits have been filled. An improved transition from the lower eyelids to the cheeks is present. Atrophy present in the oral, peri-oral, chin, and geniomandibular groove areas has been nicely improved and the posterior jaw line has been strengthened with fat injections. This has resulted in a broader more aesthetic and youthful appearing chin that is integrated with a stronger, more photogenic jaw line. The lips have been subtly filled and the lip border enhanced, and the entire peri-oral area can be seen to have been filled and strengthened. Fat injections to the upper nasal dorsum have also resulted in a more aesthetic and attractive nasal line. A better overall aesthetic balance between facial features is present and the patient has a more attractive and feminine appearance. (G) Preoperative lateral view. The patient can be seen to have a poor transition from the lower eyelid to the cheek, cheek and jowl ptosis, residual cervicosubmental fullness and platysmal bands, a large submandibular gland, suboptimal jaw line contour, a retracted tragus, and a mild “loving-cup” earlobe. Marked atrophy can also be seen in the upper and lower orbits, cheeks, oral and peri-oral, and peri-mental (geniomandibular) areas. (H) Postoperative lateral view. Overall, the patient has a soft, natural, nonsurgical look. Improved balance between facial features can be seen and the patient has an attractive, photogenic appearance. Scars are well concealed and the retracted tragus and loving cup earlobe have been corrected. The cheek mass and jowl have been raised resulting in improvement in “drool lines” and nasolabial folds. Atrophy present in the oral and peri-oral areas has been improved with fat injections and the lips have been subtly filled and the lip border enhanced creating a more youthful and attractive mouth. The geniomandibular groove (“pre-jowl sulcus”) has been filled integrating the chin and the jowl into a strong, aesthetically desirable, continuous line. The posterior jaw line has also been strengthened with fat injections adding to the effect. The protruding portion of the enlarged submandibular gland has been reduced, the cervicomental angle improved, and platysma bands corrected. The improved cervicosubmental configuration provides a youthful, fit, decisive, and attractive appearance. 310 SECTION I • 12 • Secondary deformities and the secondary facelift References 311

Bonus images for this chapter can be found online at http://www.expertconsult.com peri-oral wrinkling. Overall improved facial nicely improved and the posterior jaw line has integrating the chin and the jowl into a strong, symmetry can also be seen. The patient’s been strengthened with fat injections. This has aesthetically desirable, continuous line. The Fig. 12.53 Case study 1. Multiple views of a Fig. 12.54 Case study 2. Multiple views of a margin of the tragus, the lobular-facial junction ptosis has been improved. (C) Preoperative resulted in a broader more aesthetic and posterior jaw line has also been strengthened 57-year-old woman before and 12 months 64-year-old woman before and 13 months has been improved, overshifted wrinkles have smiling view. Smiling reveals mandibular youthful appearing chin that is integrated with with fat injections adding to the effect. The after secondary cervicofacial rejuvenation. The after tertiary cervicofacial rejuvenation. The been partially moved back onto neck, and asymmetry and a poor transition from the a stronger, more photogenic jaw line. The lips protruding portion of the enlarged primary facelift was performed by an unknown primary facelift and secondary necklift were cervical contour improved. (K) An incision lower eyelid to the cheek. (D) Postoperative have been subtly filled and the lip border submandibular gland has been reduced, the surgeon using conventional techniques and performed by an unknown surgeon using along the temporal hairline was used to smiling view. The patient appears natural enhanced, and the entire peri-oral area can cervicomental angle improved, and platysma included aggressive upper and lower conventional techniques. The secondary prevent objectionable hairline displacement. when smiling. The transition from the lower be seen to have been filled and strengthened. bands corrected. The improved blepharoplasty but no forehead surgery. The procedure consisted of trifurcated cheek Although the scar can be seen on close eyelid to the cheek is improved. The chin is Fat injections to the upper nasal dorsum have cervicosubmental configuration provides a secondary procedure consisted of a high SMAS advancement with temporal and inspection, it is not evident on casual glance integrated with the jaw line and the two also resulted in a more aesthetic and youthful, fit, decisive, and attractive cheek SMAS advancement with post-auricular postauricular transposition flaps, preplatysmal and in social situations. together form one continuous and desirable attractive nasal line. A better overall aesthetic appearance. (I) Preoperative lateral flexed transposition flaps, preplatysmal and and subplatysmal cervical lipectomy, anterior Fig. 12.55 Case study 3. Secondary cervicofacial aesthetic line. The lips are fuller but the shape balance between facial features is present view. The patient can be seen to have a poor subplatysmal cervical lipectomy, anterior platysmaplasty, platysma myotomy and rejuvenation. Multiple views of a 68-year-old of the mouth is unchanged. (E) Preoperative and the patient has a more attractive and transition from the lower eyelid to the cheek, platysmaplasty, and platysma myotomy. correction of “loving cup” ear. Incisions along woman seen before, and 1 year and 8 months oblique view. The patient has a sad, forlorn feminine appearance. (G) Preoperative lateral cheek and jowl ptosis, residual Incisions along the hairline were used in the the hairline were used in the temporal and after secondary facelift and related appearance and the orbital area looks sunken view. The patient can be seen to have a poor cervicosubmental fullness, an indistinct jaw temporal and occipital areas and the occipital areas and the preauricular incision procedures. The primary procedure was and hollow. The lower face lacks strength and transition from the lower eyelid to the cheek, line, and a “double chin”. Residual poor neck preauricular incision was moved from a was moved from a pretragal position to the performed by an unknown surgeon. The aesthetic appeal and appears elderly. cheek and jowl ptosis, residual contour results an overweight, indecisive, and pretragal position to the margin of the tragus. margin of the tragus. Foreheadplasty, lower secondary procedure consisted of a high Suboptimal eyebrow position and cervicosubmental fullness and platysmal unattractive appearance. The lips are flat and Foreheadplasty, lower blepharocanthoplasty, blepharoplasty, bilateral ptosis correction and SMAS facelift, neck lift, small incision closed configuration is evident and residual cheek bands, a large submandibular gland, the peri-oral area is retruded resulting in an bilateral ptosis correction, and perioral crow’s feet reduction were also performed. No forehead lift, upper and lower blepharoplasties and jowl ptosis can be seen. Atrophy can be suboptimal jaw line contour, a retracted elderly appearance. (J) Postoperative lateral dermabrasion were also performed. Full resurfacing or other ancillary procedures were with reinsertion of the levator aponeurosis and seen in the temples, orbits, upper cheek, oral tragus, and a mild “loving-cup” earlobe. flexed view. The patient now has a fit, athletic thickness skin grafts taken from the performed. (A) Patient, aged 64, 8 years after canthopexy, facial fat injections, peri-oral and peri-oral, and peri-mental areas. The chin Marked atrophy can also be seen in the upper look and an attractive, photogenic postauricular areas were applied to the upper primary conventional facelift was performed dermabrasion, scalp scar revisions, and nevus is frail and narrow appearing and is poorly and lower orbits, cheeks, oral and peri-oral, appearance. A strong mandibular contour is lids to allow foreheadplasty to be performed by an unknown surgeon. A secondary necklift excision. The neck procedures included integrated with the jaw line. The posterior jaw and peri-mental (geniomandibular) areas. (H) present with the chin and the jowl integrated and the eyebrows elevated to an appropriate had also been performed by the same excision of residual subplatysmal fat, line is weak and the mandible has a Postoperative lateral view. Overall, the patient into a distinct, aesthetically desirable, position. No resurfacing or other ancillary surgeon at a later date. Note residual and submandibular gland reduction, superficial diminutive appearance. The lips are thin and has a soft, natural, nonsurgical look. Improved continuous line. Residual subplatysmal fat and procedures were performed. (A) Patient, aged secondary deformities including unrejuvenated digastric myectomy, anterior platysmaplasty have an elderly retruded appearance. (F) balance between facial features can be seen protruding portions of the submandibular 57, several years after primary conventional forehead, bilateral senile ptosis, midface with post-auricular transposition flaps, and full Postoperative oblique view. Overall, the patient and the patient has an attractive, photogenic glands have been removed, and platysma facelift, necklift and upper and lower ptosis, and residual jowl laxity. (B) Same width platysmamyotomy. No subcutaneous has a soft, natural, nonsurgical look and a appearance. Scars are well concealed and laxity corrected. The posterior jaw line has blepharoplasty were performed elsewhere. patient aged 65, 13 months after tertiary facial cervical fat was removed. Fat injections were youthful, athletic, aesthetic, and healthy the retracted tragus and loving cup earlobe also been strengthened with fat injections Note residual and secondary deformities rejuvenation. Note improvement in forehead, performed in the temples, upper and lower appearance. The lateral eyebrow has been have been corrected. The cheek mass and adding to the effect. The double chin including unrejuvenated forehead, bilateral cheeks, periorbital area, and along jaw line orbits, the upper nasal dorsum, the cheeks, raised and the eyebrow position and jowl have been raised resulting in deformity has been eliminated by dissecting senile ptosis, midface ptosis, and residual that has been achieved without a tight or midface, piriform, nasolabial, stomal angle, configuration have been improved. The cheek improvement in “drool lines” and nasolabial subcutaneously in a retrograde fashion onto jowl laxity. (B) Same patient, 12 months pulled appearance. Note also residual aging peri-oral, lips, chin, GMG (geniomandibular mass and jowls have been re-positioned and folds. Atrophy present in the oral and peri-oral the chin to release the submental retaining after secondary facial rejuvenation. Note in perioral area (“young face–old mouth” groove), and jaw line areas. No resurfacing or the temples and the upper and lower orbits areas has been improved with fat injections ligaments, and blending the fat of the chin improvement in forehead, cheeks, periorbital deformity). Regrettably, the patient declined other ancillary procedures were performed. (A) have been filled. An improved transition from and the lips have been subtly filled and the lip and submental regions. The orbits have been area, and along jaw line that has been recommended perioral rejuvenation. (C) Preoperative AP view. The patient can be seen the lower eyelids to the cheeks is present. border enhanced creating a more youthful filled using fat injections, and the lips and achieved without a tight or pulled appearance. Patient age 64, 8 years after primary to have suboptimal eyebrow position and Atrophy present in the oral, peri-oral, chin, and and attractive mouth. The geniomandibular peri-oral are project to produce a more (C) Aged 57, several years after conventional conventional facelift was performed configuration with over-elevation of the medial geniomandibular groove areas has been groove (“pre-jowl sulcus”) has been filled aesthetic and youthful appearance. facelift was performed elsewhere. Note elsewhere. A secondary necklift had been brow, residual cheek and jowl ptosis, and residual and secondary deformities including performed by the same surgeon at a later poor posture of the peri-oral tissues. The obvious preauricular scar. (D) Same patient, date as well. (D) 13 months after tertiary facial peri-ocular appearance suggests aggressive 12 months after a secondary facial rejuvenation. Note that SMAS and platysma upper and lower blepharoplasty had been rejuvenation. (Secondary facelift and related surgery has not resulted in abnormalities previously performed. Marked atrophy can be procedures performed by Timothy J. Marten, during expression. (E) Patient aged 64, 8 seen in the temples, orbits, cheeks, oral and MD, FACS.) (E) Aged 57, several years after years after conventional facelift was performed peri-oral, and peri-mental areas. Marked facial conventional facelift was performed by an by an unknown surgeon. Note residual and asymmetry, mild peri-oral wrinkling, and patient are worth careful consideration, even for the surgeon unknown surgeon. Note residual and secondary deformities. (F) 13 months after a bilateral senile ptosis, worse on the left, are Conclusion who performs only the occasional secondary procedure, as secondary deformities midface ptosis, malar secondary facial rejuvenation. Note also present. Overall, the face has an ill, tired, they exist as compelling reminders of mistakes to avoid in the flattening, residual jowl, residual cervical improvement in jowl contour has achieved and aged appearance. (B) Postoperative AP The increased number of patients seeking early facelifts at a planning and performance of any primary procedure. obliquity and “witch’s chin” deformity. (F) made without the creation of skin tightness or view. The patient has a soft, natural Same patient, 12 months after a secondary flattening of facial contour. (G) Patient aged nonsurgical appearance. The lateral portion of younger age, coupled with the continued good health of an facial rejuvenation. Cheek and midface tissue 64, 8 years after conventional facelift was each eyebrow has been raised and eyebrow older group of patients who have already undergone one or has been elevated, the pretragal scar has performed elsewhere. Note residual and position and configuration have been more procedures, has resulted in an increase in requests for References been moved to the margin of the tragus, and secondary deformities midface ptosis, malar improved creating a more alert and engaged secondary facelift procedures. Although many aspects of cervical contour improved. The witch’s chin flattening, shift of cervical wrinkles onto lower appearance. The cheek mass and jowls have planning and performing secondary surgery are similar to deformity has also been corrected. (G) Aged face, loving-cup ear, residual jowl and residual 1. Guyuron B, Eriksson E, Persing JA, et al., eds. Facelift been raised and the posture of tissues around those of the primary procedure, additional considerations 57, several years after conventional facelift cervical obliquity. (H) 13 months after a the mouth improved. The temples and the in plastic surgery: indications and practice. Philadelphia: and upper and lower blepharoplasty was secondary facial rejuvenation. Cheek and upper and lower orbits have been filled using must be taken into account in the evaluation and treatment Saunders; 2009. of the patient presenting for secondary facelift as one must performed elsewhere. Note severe, untreated midface tissue has been elevated, the fat injections. A slight under correction of 2. Marten TJ. High SMAS facelift: combined single flap residual brow ptosis. When the patient’s pretragal scar has been moved to the margin identify and treat not only new problems that are the product upper orbital atrophy on the left can be seen. lifting of the jaw line, cheek, and midface. Clin Plast Surg. eyebrows were held up in an appropriate of the tragus, the lobular-facial junction has Atrophy present in the oral, peri-oral, chin, of age, but those that have resulted from the prior procedure 2008;35(4):569–603. position, she was unable to close her eyelids. been improved, overshifted wrinkles have geniomandibular groove and upper nasal as well. Often, it is these secondary deformities that present been partially moved back onto neck, and (H) Same patient, 12 months after a dorsum areas has been nicely improved using the biggest challenge to the surgeon in terms of creativity, 3. Marten TJ. Lamellar high SMAS face and midfacelift: secondary facial rejuvenation. Full thickness cervical contour improved. (I) Patient aged 64, fat injections as well. The lips have been planning, preparation and technique. The secondary facelift a comprehensive technique for natural-appearing postauricular skin grafts were applied to the 8 years after conventional facelift was subtly filled with fat and the lip border rejuvenation of the face. In: Nahai F, ed. The art of upper eyelids so that foreheadplasty could be performed by an unknown surgeon. Note shift patient is also usually short on skin and will typically present enhanced without a “stung by a bee” or “filler aesthetic surgery: principles and techniques performed without compromising lid function. of cervical wrinkles onto lower face, loving-cup lip” appearance. The combination of fat with problems of deep layer origin. Additional excision of . 2nd ed. Canthopexy and bilateral ptosis correction ear, and residual cervical obliquity. (J) 13 injections and peri-oral dermabrasion has large amounts of skin is likely to be counterproductive, result St Louis: Quality Medical; 2010:1525. was also performed. (I,J) Improved periorbital months after a secondary facial rejuvenation. produced natural appearing correction of in unnatural appearances and compound existing deformi- 4. Marten TJ, ed. Facelift – state of the art. Seminars in appearance is evident.. The pretragal scar has been moved to the ties. Many of the problems seen in the secondary facelift plastic surgery. New York: Thieme Medical; 2002. 312 SECTION I • 12 • Secondary deformities and the secondary facelift

5. Marten TJ, ed. Maintenance facelift: early facelift for 8. Connell BF, Marten TJ. Facelift. In: Cohen M, ed. Mastery younger patients. In: Facelift: state of the art. Seminars in of plastic and reconstructive surgery. Boston: Little Brown; plastic surgery. New York: Thieme Medical; 2002. 1994:1873–1902. 6. Marten TJ. Facelift: planning and technique. Clin Plast 9. Connell BF, Marten TJ. Orbicularis oculi myoplasty: Surg. 1997;24:269. surgical treatment of the crow’s feet deformity. In: 7. Connell BF, Marten TJ. Deep layer techniques in cervico- Jurkiewicz MJ, Culbertson JH, eds. Operative techniques facial rejuvenation. In: Psillakis J, ed. Deep face-lifting in plastic and reconstructive surgery. Philadelphia: WB techniques. New York: Thieme Medical; 1994. Saunders; 1995.