RhytidectomyRhytidectomy:: FacialFacial SurgicalSurgical AnatomyAnatomy OverviewOverview DissectionDissection CourseCourse AnatomyAnatomy DissectionDissection CourseCourse AprilApril 2929th Unfortunately,Unfortunately, startingstarting withwith sinussinus surgerysurgery FacialFacial plasticsplastics 44--77 PMPM StaffedStaffed byby RawnsleyRawnsley,, KellerKeller andand ReillyReilly BriefBrief lecturelecture toto startstart DissectionsDissections DissectionDissection CourseCourse Objectives:Objectives: RhinoplastyRhinoplasty –– ClosedClosed rhinorhino incisionsincisions Intercartilaginous Transcartilaginous –– OpenOpen RhinoplastyRhinoplasty Cephalic trim Lateralize upper lats Take down the dorsum Medial and lateral osteotomies DissectionDissection CourseCourse Facelift:Facelift: SkinSkin andand SMASSMAS dissectiondissection –– SubcutaneousSubcutaneous flapflap elevationelevation –– RaiseRaise SMASSMAS flapflap –– IdentifyIdentify ZygomaticusZygomaticus BrowliftBrowlift –– CoronalCoronal approachapproach –– IdentifyIdentify differentdifferent planesplanes ofof dissectiondissection –– IdentifyIdentify Corrugator,Corrugator, supraorbitalsupraorbital andand supratrochlearsupratrochlear nervesnerves PatternsPatterns ofof AgingAging ProblemsProblems ofof AgingAging LossLoss ofof facialfacial softsoft tissuetissue volumevolume –– MidfaceMidface hollowinghollowing –– TemporalTemporal atrophyatrophy –– PeriorbitalPeriorbital atrophyatrophy –– MuscularMuscular volumevolume lossloss GravityGravity inducedinduced descentdescent DynamicDynamic facialfacial rhytidrhytid creationcreation –– AgonistsAgonists andand antagonistsantagonists PathophsiologyPathophsiology ofof thethe AgingAging FaceFace FacialFacial agingaging characteristicscharacteristics –– GravitationalGravitational migrationmigration ofof tissuestissues Skin Subcutaneous fat Superficial fascia –– IncreasingIncreasing prominenceprominence ofof NLFsNLFs –– DownwardDownward--droopingdrooping jowlsjowls –– LaxityLaxity ofof submentalsubmental andand anterioranterior neckneck tissuestissues PathophsiologyPathophsiology ofof thethe AgingAging FaceFace Vectors of tissue migration – Cheek and lower face PlPlatysmaatysma suspended by the SMAS Both elongate with aging PlPlatysmaatysma, SQ fat, and skin descend vertically – Produces jowls and laxity in the submental and anterior neck regions – 5 fat collections (Hoefflin, 1998) Malar NasolabNasolabialial Jowl BuccaBuccall Submental PathophsiologyPathophsiology ofof thethe AgingAging FaceFace 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) Malar Parotid Masseteric Zygomatic Mandibular AnatomyAnatomy Five planes (Hoefflin, 1998) – Superficial subcutaneous plane Epidermis, dermis, and thin layer of SQ fat Dissection divides subdermal plexus of vessels – Mid-subcutaneous plane Contains bulk of central facial fat Some fat left on the platysma/SMAS Divides axial arcuate vessels – Supraplatysmal plane (i.e. supraSMAS plane) Dissection is immediately superficial to the platysma Natural anatomic plane Preserves the arcuate vessels – Subplatysmal plane (i.e. subSMAS plane) – Subperiosteal plane TriviaTrivia WhatWhat musclesmuscles doesdoes thethe SMASSMAS invest?invest? AnatomyAnatomy 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 Nonseptate fat between muscles and SMAS Fibrous septae connect SMAS to dermis –– TransmitsTransmits forcesforces ofof facialfacial expressionexpression SMAS is stretched superiorly and inferiorly Relays contractions of facial muscles along the longitudinal network parallel to skin Also transmits in a perpendicular direction toward the facial skin through the fibrous septa SMAS Ligaments Ligaments SMASSMAS Upper 3rd of face – Thick – Galea – Temporoparietal fascia (i.e. superficial temporal fascia) – Frontalis m. Middle 3rd of face – Tightly adherent to, – Zygomaticus maj. & min. Lower 3rd of face – Platysma & lip depressors SMASSMAS PlatysmaPlatysma – Origin: clavicles and 1st rib – Insertion: blends with the SMAS and lip depressors SMASSMAS UpperUpper SMASSMAS –– SphincterSphincter collicolli profundusprofundus Mid and upper face Firm bony attachments LowerLower SMASSMAS –– PrimitivePrimitive platysmaplatysma Risorius Platysma Depressor anguli oris Auricular muscles IdealIdeal AestheticAesthetic PositionPosition ofof BrowBrow BeginsBegins mediallymedially atat verticalvertical lineline drawndrawn perpendicularperpendicular throughthrough alaralar basebase TerminatesTerminates laterallylaterally atat obliqueoblique lineline drawndrawn throughthrough laterallateral canthuscanthus andand alaralar basebase MedialMedial andand laterallateral browbrow atat samesame levellevel MedialMedial browbrow clubclub shaped,shaped, taperstapers laterallylaterally ApexApex onon verticalvertical lineline throughthrough laterallateral limbuslimbus ArchesArches aboveabove orbitalorbital rimrim inin womenwomen andand atat browbrow inin menmen IdealIdeal BrowBrow BrowBrow AnatomyAnatomy Frontal hairline to glabella Two compartments – Central Above arcus marginalis Medial to conjoint – Lateral Lateral to conjoint Superficial to superficial Layer of deep temporalis fascia SCALPSCALP LayersLayers--skin,skin, subcutaneoussubcutaneous tissues,tissues, aponeurosisaponeurosis,, looseloose areolarareolar tissue,tissue, periosteumperiosteum TriviaTrivia BrowBrow Elevators?Elevators? BrowBrow Depressors?Depressors? CentralCentral BrowBrow Frontalis only elevator, horizontal furrows Corrugator, procerus, medial orbicularis, depressor supercilii – Corrugator-vertical glabellar lines – Procerus-horizontal glabellar lines – Orbicularis-lateral crows feet CentralCentral browbrow 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 TarsusTarsus – Dense, fibrous tissue – Contour and skeleton – Contain meibomian glands – Length – 25 mm – Thickness – 1 mm – Height Upper plate – 10 mm Lower plate – 4 mm AnatomyAnatomy –– MusclesMuscles ProtractorProtractor –– OrbicularisOrbicularis RetractorsRetractors –– LevatorLevator –– MMüüllerller’’ss OrbicularisOrbicularis OculiOculi MuscleMuscle LevatorLevator palpebralpalpebral superiorissuperioris andand MMüüllerller’’ss musclemuscle EyelidEyelid AnatomyAnatomy LowerLower LidLid AnatomyAnatomy EyelidEyelid AnatomyAnatomy--Septum/TarsusSeptum/Tarsus Arcus marginalis-confluence of periosteum and periorbita origin of orbital septum Tarsus – 8-10 mm upper, 4-5 mm lower AnatomyAnatomy OrbitalOrbital SeptumSeptum – Fascial barrier – Underlies posterior orbicularis fascia – Defines anterior extent of orbit and posterior extent of eyelid AnatomyAnatomy 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 RichRich anastomosesanastomoses fromfrom internalinternal anan externalexternal carotidscarotids MarginalMarginal arcadesarcades –– 22 toto 33 mmmm fromfrom lidlid marginmargin PeripheralPeripheral arcadearcade –– upperupper lidlid betweenbetween levatorlevator aponeurosisaponeurosis andand MMüüllerller’’ss musclemuscle EyelidEyelid AnatomyAnatomy OrbicularisOrbicularis oculioculi transitiontransition browbrow toto upperupper eyelideyelid –– Orbital,Orbital, palpebralpalpebral,, divideddivided pretarsalpretarsal,, preseptalpreseptal OrbitalOrbital septumseptum anterior/posterioranterior/posterior lamellalamella AnteriorAnterior lamellalamella--skin,skin, orbicularisorbicularis PosteriorPosterior lamellalamella--conjunctiva,conjunctiva, upper/lowerupper/lower elevators/retractorselevators/retractors MiddleMiddle lamellalamella septum/tarsusseptum/tarsus EyelidEyelid AnatomyAnatomy--orbitalorbital FatFat PreaponeuroticPreaponeurotic fat,fat, deepdeep toto septumseptum –– LandmarkLandmark forfor depressors,depressors, elevatorselevators –– UpperUpper lidlid twotwo compartmentscompartments Medial, middle (largest) Lateral occupied by lacrimal gland –– LowerLower lidlid threethree Medial, central, lateral Inf. Oblique separates medial/central AnatomyAnatomy 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 Type1: separated