RhytidectomyRhytidectomy:: FacialFacial SurgicalSurgical AnatomyAnatomy OverviewOverview

ƒƒ DissectionDissection CourseCourse ƒƒ AnatomyAnatomy DissectionDissection CourseCourse

ƒƒ AprilApril 2929th ƒƒ Unfortunately,Unfortunately, startingstarting withwith sinussinus surgerysurgery ƒƒ FacialFacial plasticsplastics 44--77 PMPM ƒƒ StaffedStaffed byby RawnsleyRawnsley,, KellerKeller andand ReillyReilly ƒƒ BriefBrief lecturelecture toto startstart ƒƒ DissectionsDissections DissectionDissection CourseCourse

ƒƒ Objectives:Objectives: RhinoplastyRhinoplasty –– ClosedClosed rhinorhino incisionsincisions ƒ Intercartilaginous ƒ Transcartilaginous –– OpenOpen RhinoplastyRhinoplasty ƒ Cephalic trim ƒ Lateralize upper lats ƒ Take down the dorsum ƒ Medial and lateral osteotomies DissectionDissection CourseCourse

ƒƒ Facelift:Facelift: SkinSkin andand SMASSMAS dissectiondissection –– SubcutaneousSubcutaneous flapflap elevationelevation –– RaiseRaise SMASSMAS flapflap –– IdentifyIdentify ZygomaticusZygomaticus ƒƒ BrowliftBrowlift –– CoronalCoronal approachapproach –– IdentifyIdentify differentdifferent planesplanes ofof dissectiondissection –– IdentifyIdentify Corrugator,Corrugator, supraorbitalsupraorbital andand supratrochlearsupratrochlear nervesnerves PatternsPatterns ofof AgingAging ProblemsProblems ofof AgingAging

ƒƒ LossLoss ofof facialfacial softsoft tissuetissue volumevolume –– MidfaceMidface hollowinghollowing –– TemporalTemporal atrophyatrophy –– PeriorbitalPeriorbital atrophyatrophy –– MuscularMuscular volumevolume lossloss ƒƒ GravityGravity inducedinduced descentdescent ƒƒ DynamicDynamic facialfacial rhytidrhytid creationcreation –– AgonistsAgonists andand antagonistsantagonists PathophsiologyPathophsiology ofof thethe AgingAging FaceFace ƒƒ FacialFacial agingaging characteristicscharacteristics –– GravitationalGravitational migrationmigration ofof tissuestissues ƒ Skin ƒ Subcutaneous fat ƒ Superficial fascia –– IncreasingIncreasing prominenceprominence ofof NLFsNLFs –– DownwardDownward--droopingdrooping jowlsjowls –– LaxityLaxity ofof submentalsubmental andand anterioranterior neckneck tissuestissues PathophsiologyPathophsiology ofof thethe AgingAging FaceFace ƒ Vectors of tissue migration – Cheek and lower face ƒ PlPlatysmaatysma suspended by the SMAS ƒ Both elongate with aging ƒ PlPlatysmaatysma, SQ fat, and skin descend vertically – Produces jowls and laxity in the submental and anterior neck regions – 5 fat collections (Hoefflin, 1998) ƒ Malar ƒ NasolabNasolabialial ƒ Jowl ƒ BuccaBuccall ƒ Submental PathophsiologyPathophsiology ofof thethe AgingAging FaceFace ƒ Midface – SMAS invests the lip levator muscles – Overlying malar fat pad slides vertically superficial to the SMAS – Causes increased prominence of the NLF PathophsiologyPathophsiology ofof thethe AgingAging FaceFace – 5 Osteofasciodermal or septal (ligaments) (Hoefflin, 1998) ƒ Malar ƒ Parotid ƒ Masseteric ƒ Zygomatic ƒ Mandibular AnatomyAnatomy

ƒ Five planes (Hoefflin, 1998) – Superficial subcutaneous plane ƒ Epidermis, dermis, and thin layer of SQ fat ƒ Dissection divides subdermal plexus of vessels – Mid-subcutaneous plane ƒ Contains bulk of central facial fat ƒ Some fat left on the platysma/SMAS ƒ Divides axial arcuate vessels – Supraplatysmal plane (i.e. supraSMAS plane) ƒ Dissection is immediately superficial to the platysma ƒ Natural anatomic plane ƒ Preserves the arcuate vessels – Subplatysmal plane (i.e. subSMAS plane) – Subperiosteal plane TriviaTrivia

ƒƒ WhatWhat musclesmuscles doesdoes thethe SMASSMAS invest?invest? AnatomyAnatomy

ƒƒ SMASSMAS –– SuperficialSuperficial MusculoMusculo--AponeuroticAponeurotic SystemSystem –– 19741974 Skoog,Skoog, 19761976 Mitz/PeyronieMitz/Peyronie –– deepdeep toto thethe subdermalsubdermal plexusplexus andand superficialsuperficial toto thethe majormajor vesselsvessels andand nervesnerves –– DividesDivides subqsubq fatfat intointo 22 layerslayers ƒ Nonseptate fat between muscles and SMAS ƒ Fibrous septae connect SMAS to dermis –– TransmitsTransmits forcesforces ofof facialfacial expressionexpression ƒ SMAS is stretched superiorly and inferiorly ƒ Relays contractions of facial muscles along the longitudinal network parallel to skin ƒ Also transmits in a perpendicular direction toward the facial skin through the fibrous septa SMAS Ligaments

Ligaments SMASSMAS

ƒ Upper 3rd of face – Thick – Galea – Temporoparietal fascia (i.e. superficial temporal fascia) – Frontalis m. ƒ Middle 3rd of face – Tightly adherent to, – Zygomaticus maj. & min. ƒ Lower 3rd of face – Platysma & lip depressors SMASSMAS

ƒƒ PlatysmaPlatysma – Origin: clavicles and 1st rib – Insertion: blends with the SMAS and lip depressors SMASSMAS

ƒƒ UpperUpper SMASSMAS –– SphincterSphincter collicolli profundusprofundus ƒ Mid and upper face ƒ Firm bony attachments ƒƒ LowerLower SMASSMAS –– PrimitivePrimitive platysmaplatysma ƒ Risorius ƒ Platysma ƒ Depressor anguli oris ƒ Auricular muscles IdealIdeal AestheticAesthetic PositionPosition ofof BrowBrow

ƒƒ BeginsBegins mediallymedially atat verticalvertical lineline drawndrawn perpendicularperpendicular throughthrough alaralar basebase ƒƒ TerminatesTerminates laterallylaterally atat obliqueoblique lineline drawndrawn throughthrough laterallateral canthuscanthus andand alaralar basebase ƒƒ MedialMedial andand laterallateral browbrow atat samesame levellevel ƒƒ MedialMedial browbrow clubclub shaped,shaped, taperstapers laterallylaterally ƒƒ ApexApex onon verticalvertical lineline throughthrough laterallateral limbuslimbus ƒƒ ArchesArches aboveabove orbitalorbital rimrim inin womenwomen andand atat browbrow inin menmen IdealIdeal BrowBrow BrowBrow AnatomyAnatomy

ƒ Frontal hairline to glabella ƒ Two compartments – Central ƒ Above arcus marginalis ƒ Medial to conjoint – Lateral ƒ Lateral to conjoint ƒ Superficial to superficial Layer of deep temporalis fascia SCALPSCALP

ƒƒ LayersLayers--skin,skin, subcutaneoussubcutaneous tissues,tissues, aponeurosisaponeurosis,, looseloose areolarareolar tissue,tissue, periosteumperiosteum TriviaTrivia

ƒƒ BrowBrow Elevators?Elevators?

ƒƒ BrowBrow Depressors?Depressors?

CentralCentral BrowBrow

ƒ Frontalis only elevator, horizontal furrows ƒ Corrugator, procerus, medial orbicularis, depressor supercilii – Corrugator-vertical glabellar lines – Procerus-horizontal glabellar lines – Orbicularis-lateral crows feet CentralCentral browbrow

ƒ Neurovascular supply – Supratrochlear, supraorbital branches of V1 – Emerge orbit pierce periosteum ant orbital rim, deep to orbicularis, over corrugator, superficial to frontalis TempleTemple AnatomyAnatomy

SDTFSDTF insertsinserts laterallateral zygomazygoma

DDTFDDTF insertsinserts medialmedial zygomazygoma TempleTemple AnatomyAnatomy LateralLateral BrowBrow--FacialFacial NerveNerve AnatomyAnatomy

ƒƒ TarsusTarsus – Dense, fibrous tissue – Contour and skeleton – Contain meibomian glands – Length – 25 mm – Thickness – 1 mm – Height ƒ Upper plate – 10 mm ƒ Lower plate – 4 mm AnatomyAnatomy –– MusclesMuscles

ƒƒ ProtractorProtractor –– OrbicularisOrbicularis ƒƒ RetractorsRetractors –– LevatorLevator –– MMüüllerller’’ss OrbicularisOrbicularis OculiOculi MuscleMuscle LevatorLevator palpebralpalpebral superiorissuperioris andand MMüüllerller’’ss musclemuscle EyelidEyelid AnatomyAnatomy LowerLower LidLid AnatomyAnatomy EyelidEyelid AnatomyAnatomy--Septum/TarsusSeptum/Tarsus

ƒ Arcus marginalis-confluence of periosteum and periorbita origin of orbital septum ƒ Tarsus – 8-10 mm upper, 4-5 mm lower AnatomyAnatomy

ƒƒ OrbitalOrbital SeptumSeptum – Fascial barrier – Underlies posterior orbicularis fascia – Defines anterior extent of orbit and posterior extent of eyelid AnatomyAnatomy

ƒƒ CanthalCanthal tendonstendons –– ExtensionsExtensions ofof preseptalpreseptal && pretarsalpretarsal orbicularisorbicularis –– LateralLateral slightlyslightly aboveabove medialmedial –– LateralLateral tendontendon attachesattaches toto WhitnallWhitnall’’ss tubercletubercle 1.51.5 cmcm posteriorposterior toto orbitalorbital rimrim –– MedialMedial tendontendon complex,complex, importantimportant forfor lacrimallacrimal pumppump functionfunction CanthalCanthal TendonsTendons LacrimalLacrimal SystemSystem LacrimalLacrimal ExcretoryExcretory PumpPump AnatomyAnatomy –– BloodBlood SupplySupply

ƒƒ RichRich anastomosesanastomoses fromfrom internalinternal anan externalexternal carotidscarotids ƒƒ MarginalMarginal arcadesarcades –– 22 toto 33 mmmm fromfrom lidlid marginmargin ƒƒ PeripheralPeripheral arcadearcade –– upperupper lidlid betweenbetween levatorlevator aponeurosisaponeurosis andand MMüüllerller’’ss musclemuscle EyelidEyelid AnatomyAnatomy

ƒƒ OrbicularisOrbicularis oculioculi transitiontransition browbrow toto upperupper eyelideyelid –– Orbital,Orbital, palpebralpalpebral,, divideddivided pretarsalpretarsal,, preseptalpreseptal ƒƒ OrbitalOrbital septumseptum anterior/posterioranterior/posterior lamellalamella ƒƒ AnteriorAnterior lamellalamella--skin,skin, orbicularisorbicularis ƒƒ PosteriorPosterior lamellalamella--conjunctiva,conjunctiva, upper/lowerupper/lower elevators/retractorselevators/retractors ƒƒ MiddleMiddle lamellalamella septum/tarsusseptum/tarsus EyelidEyelid AnatomyAnatomy--orbitalorbital FatFat

ƒƒ PreaponeuroticPreaponeurotic fat,fat, deepdeep toto septumseptum –– LandmarkLandmark forfor depressors,depressors, elevatorselevators –– UpperUpper lidlid twotwo compartmentscompartments ƒ Medial, middle (largest) ƒ Lateral occupied by lacrimal gland –– LowerLower lidlid threethree ƒ Medial, central, lateral ƒ Inf. Oblique separates medial/central

AnatomyAnatomy

ƒ Platysma muscle – from the lower cheek to the level of the second rib – Three variations of the anterior boarders of the right and left platysma muscle ƒ Type1: separated in the suprahyoid region and interlacing 1 to 2 cm from the chin ƒ Type2: intermingled at the level of the thyroid cartilage ƒ Type3: remained completely separated along the entire length ƒƒ LaxityLaxity inin thethe platysmaplatysma == BandsBands ƒ Facial nerve – Protected by superficial lobe of the parotid gland – travels beneath the parotidomasseteric fascia – Innervates superficial facial mimetic muscles from deeper surface

TechniquesTechniques

ƒƒ SubcutaneousSubcutaneous liftlift ƒƒ SMASSMAS liftlift ƒƒ DeepDeep--planeplane liftlift ƒƒ CompositeComposite liftlift ƒƒ SubperiostealSubperiosteal liftlift SMASSMAS FaceliftFacelift SMASSMAS liftlift

ƒƒ IncisionIncision SMASSMAS liftlift

ƒ Flap elevation – Start at peri-auricular area – Temple: subfollicular/ subcutaneous – Parotid: subcutaneous to a line from lateral canthus to angle of mandible – Posterior scalp: subfollicular / superficial subcutaneous – Neck: over SCM and superficial to platysma SMASSMAS liftlift

ƒƒ SMASSMAS plicationplication – sutures that fold the SMAS onto itself to shorten it – pulled in posterosuperior direction – The first suture is applied at the jaw line and is anchored at the mastoid periosteum, or deep tissues in the pre- auricular area ƒƒ SMASSMAS imbricationimbrication DeepDeep PlanePlane FaceFace LiftLift

ƒƒ RedRed -- AreaArea ofof suprasupra-- SMASSMAS underminingundermining

ƒƒ YellowYellow –– AreaArea ofof subsub-- SMASSMAS underminingundermining ƒƒ BordersBorders ofof subsub--SMASSMAS dissectiondissection – Superior - orbicularis oculi and zyogomaticus maj. and min. – Medial – ZM&M, NLF, buccal fat pad – Inferior – tail of parotid and masseter – Deep – parotidomasseteric fascia DeepDeep--planeplane liftlift

ƒƒ HamraHamra inin 19901990 ƒƒ improveimprove thethe nasolabialnasolabial foldfold areaarea ƒƒ descentdescent ofof thethe cheekcheek fatfat isis responsibleresponsible forfor thethe increasingincreasing redundancyredundancy ofof thethe nasolabialnasolabial foldfold withwith agingaging ƒƒ cheekcheek fatfat hashas toto bebe liftedlifted fromfrom thethe zygomaticuszygomaticus majormajor andand minorminor musclesmuscles ƒƒ deepdeep--planeplane faceliftfacelift flapflap consistsconsists ofof skin,skin, subcutaneoussubcutaneous tissue,tissue, cheekcheek fatfat andand platysmaplatysma DeepDeep--planeplane liftlift ƒ limited subcutaneous dissecdissectiontion approximately 2- 3 cm in front of the tragus ƒ SMAS is incised and sub- SMAS dissection from malar eminence to jawline ƒ changes to the levlevelel superficial to the zygomaticus musculature when the lateral edge of the zygomaticus major muscle is reached ƒ extends medial to the nasolabial fold LateralLateral BrowBrow--FacialFacial NerveNerve

ƒƒ InferiorInferior toto zygomazygoma facialfacial nervenerve deepdeep toto SMAS,SMAS, deepdeep toto OOOO ƒƒ OverOver zygomazygoma closeclose toto periosteum,periosteum, elevateelevate SDTFSDTF ƒƒ HamraHamra (1990)(1990) – Reported 403 patients who had deep-plane lift in 1990 – 4 patients with post-op hematoma of the neck requiring evacuation in the operating room – 2 patients had pseudoparesis of the lower lip – 2 patients had weakness of the upper lip – All of them recovered within 6 weeks – Advantage: ƒ better address the nasolabial fold ƒ traps the entire subcutaneous vascular system to give the result flap a more vigorous circulation ƒ thicker flap also gives a greater tensile strength CompositeComposite FaceFace LiftLift CompositeComposite liftlift

ƒƒ HamraHamra (1992)(1992) – based on the deep- plane rhytidectomy – intended to improve the inferiolateral descent of the orbicularis oculi – composite face lift flap consists of orbicularis, cheek fat and platysma en bloc CompositeComposite liftlift CompositeComposite liftlift ƒƒ HamraHamra (1992)(1992) –– 167167 patientspatients –– nono nervenerve injuryinjury –– oneone patientpatient hadhad neckneck hematomahematoma –– malarmalar tendernesstenderness andand edemaedema maymay persistpersist forfor severalseveral monthsmonths –– repositioningrepositioning inin thisthis techniquetechnique mustmust bebe donedone withwith extraordinaryextraordinary tensiontension SubperiostealSubperiosteal liftlift

ƒ first published by Psillakis in 1987 ƒ revised by Ramirez in 1990 ƒ superior displacdisplacementement of the muscles ƒ approaches: – bicoronal, transtemporal, transoral, transorbital – open vs. endoscope ƒ Advantage: – Tension remains in deeper tissue and less tension on skin – Better preserved blood supply to the flap – Better correction of mid-face SubperiostealSubperiosteal liftlift

ƒƒ Disadvantage:Disadvantage: –– IncreasedIncreased horizontalhorizontal widthwidth ofof thethe faceface –– greatergreater swellingswelling andand ecchymosisecchymosis –– NerveNerve injuryinjury ƒ Infraorbital nerve ƒ Frontal branch of facial nerve injury – 105 patients by Psillakis – 4 out of their first 20 patients had temporary paralysis of the frontal branch SubperiostealSubperiosteal liftlift

ƒƒ RamirezRamirez (1990)(1990) – 28 patients – bicoronal incision – completely detach soft tissues from the zygomatic arch – no patient with nerve injury – facial edema which can take up to 6 weeks to resolve – mask effect which improves gradually over a 4-month period