5 Mixed-Plane Rhytidectomy: The Superior Vertical-Vector Approach to Rejuvenation of the Neck
“Simplicity is the ultimate sophistication.”
—Leonardo Da Vinci
The evolution of procedures for surgical rejuvenation of the face and neck has been progressing since Lexer1 described his technique of undermining and redraping aging facial skin in 1916. Lam2has suggested that Julien Bourguet, several years later, laid the foundation for modern cervical and facial rhytidectomy, noting that Bourguet’s pioneering work in all aspects of facial plastic surgery would reach its fullest expression in his contribution to modern rhytidectomy of October 14, 1919, when Bourguet addressed the Académie de Médecine de Paris to discuss his aesthetic rejuvenation of the neck. In a speech delivered to the same scientific board earlier that year, Dr. Raymond Passot had reported on his more limited technique of rhytidectomy, which extended only from the hairline to the preauricular area. Unlike his contemporary, Bourguet advocated that the incision for the procedure should be carried behind the ear into the hairline, and that extensive undermining should be carried into the neck in combination with a lipectomy—all of which stand as hallmarks of the modern rhytidectomy. Many years passed before 1968, when Tord Skoog3 of Sweden advocated another significant technique, involving elevation of the platysma of the lower face along with the attendant skin flap and advancing that flap posteriorly and laterally when redraping the facial flap. Skoog’s procedure also involved subplatysmal dissection of the cervical platysma. Skoog described the procedure for his rhytidectomy in 1974, before his death in 1975. As reviewed by Lemmon and Hamra,4 who in 1980 reported the first large series of patients treated with Skoog’s technique, the technique provided significant aesthetic improvements in the lower face including the jawline, but the postoperative appearance of the neck and nasolabial fold was not compatible with the improved jawline.
Mitz and Peyronie,5 working with Dr. Paul Tessier, reported their work on facial anatomy in 1976, describing in great detail the superficial musculoaponeurotic system (SMAS), which they named after reviewing Skoog’s work. This led to the development of many techniques involving the SMAS, many of which are still in use today. These techniques, whether using imbrications or plication, differ only in the extent of elevation of the SMAS flap or in their direction of vector pull. The net aesthetic improvement with all of the techniques involving the SMAS is a more defined jawline, possibly accompanied by softening of the nasolabial and melolabial folds. As in the subcutaneous rhytidectomy, significant improvement in the appearance of the neck was not seen concurrently, and in the late 1970s various procedures were being developed for contouring of the “unimproved neck.”
In 1984 Hamra6 published an article on a new technique that he called “tri-plane rhytidectomy.” Hamra’s triplane rhytidectomy incorporated Skoog’s subplatysmal dissection and wide undermining of the skin in the upper and lower face, but did not continue in the subplatysmal plane in the neck, where his dissection was instead preplatysmal. This technique, still used by Hamra, made it possible to improve the contour of the neck by advancing the cervical platysma muscle anteriorly to some degree and moving the skin and fat posteriorly. Both the medial and lateral approaches to platysmaplasty for rejuvenation of the neck, with or without liposculpture, have many advocates, and are today probably the most commonly used approaches to rejuvenation of the neck. Once again in these procedures, the rejuvenation of the face and that of the neck are seen as distinct operations, and utilize surgical approaches that allow the vectors of pull to differ for the respective rejuvenations of the face, medial neck, and lateral neck. Hamra’s technique continued to evolve to include the deep-plane7 and the composite rhytidectomy.8 My personal technique for rhytidectomy evolved in accord with the techniques just described, and although I did perform several composite rhytidectomies, I found that the technique for this at times affected the function of the orbicularis occuli muscle to a degree that led me to abandon these procedures, and I did not perform composite rhytidectomies after the first year in which I had adopted them as my customary procedures. My preferred technique became the deep-plane rhytidectomy with lateral and medial platysmaplasty to correct concurrent irregularities in the contour of the neck.
These techniques indicate that rejuvenation of the aging face and neck has apparently evolved from aesthetic techniques affecting individual compartments and requiring different surgical approaches for optimal surgical correction. For example, several solutions were proposed for improving the appearance of the nasolabial folds through the adaptation of some of the original techniques for this, including the procedures focused on the SMAS and deep-plane and modified deep-plane rhytidectomy. Table 5.1 summarizes the advantages and disadvantages of the various technical variations for rhytidectomy. A different evolution of technique would be needed to achieve optimal rejuvenation of the neck. What if there were a technique that improved the appearance of both the face and neck concurrently and served as the backbone of a procedure for rejuvenating the face and neck? Specifically, is it possible to use a single procedure to address the three most important deformities caused by aging of the face and neck: skin laxity, pronounced nasolabial and melolabial folds, and jowl formation and descent? This definition of the goals of rejuvenation surgery does not fully address periorbital concerns, which usually require some ancillary procedures, but the technique described in this chapter will contribute to softening some aging-related periorbital changes through volume advancement.
The rejuvenation of the face and neck continued to be viewed as separate components of cervicofacial rejuvenation, and for many years it was believed that improvements in the contour of the neck would occur most significantly with lipoplastic techniques as well as with medial and lateral adjustments of the platysma muscle as the primary directions of vector pull or correction after the completion of rhytidectomy.
◆ The Surgical Connection of Rejuvenation of the Face and Neck Through a Superior Vertical Vector Approach
The history of facelift surgery is relatively short, and the techniques advocated for it over the past century have been fairly entrenched and until now not very flexible to change. The reason for conservative change in facelift surgery with respect to existing techniques is that the safety of a new technique must be well established in relation to the improvements it may provide in outcome. Moreover, a lasting result must be demonstrated if a new procedure is to be considered “mainstream.” Recently, modifications in technique have been made to simplify techniques for rhytidectomy and make recovery from the procedure easier and the surgery less risky, particularly with reference to risks of anesthesia. Part of this has been driven by patients seeking simpler solutions to facial rejuvenation. In some cases the introduction of less intensive surgical methods is more culturally acceptable if surgery is not the preferred method for aesthetic rejuvenation, as is the case in Europe. As a result of looking for the “holy grail” of surgery that is easy to perform, requires less-intensive anesthesia, and permits a rapid recovery, we are now seeing a burgeoning of innovative approaches to surgical rejuvenation of the face and neck, including endoscopic approaches, limited surgical access, and short-flap surgery that can produce satisfying results in well-selected patients. Table 5.2 summarizes some of the various options for modifying rhytidectomy, as well as a proposed classification for discussing the results of the various techniques for hastening postoperative recovery.
Public demand for rhytidectomy will continue to influence surgical techniques for this operation in the next century to an even greater degree than in the past, as will also the ingenuity of surgeons, which will differ from that in the early and relatively slow development of the procedure. As Tonnard and colleagues9 note in their description of minimal-access cranial suspension (MACS) for facelifting, “Every generation is tempted to speak of? state of the art surgery,? but realistically… there is still much work to be done to achieve the goal of making face-lift patients really look more youthful (and) not just different.” Current thinking, emphasizing volume rather than traction, and vertical vectors rather than oblique or horizontal ones, has advanced the quest for natural facial rejuvenation.
Before description of the MACS lift, techniques for “vertical-vector rhytidectomy” were rarely advocated as preferred techniques for producing natural and more youthful results. Nor is vertical-vector rhytidectomy compared with the oblique or lateral vector pull that is usually associated with SMAS lifts and to a lesser extent with deep-plane rhytidectomy. The concept of rhytidectomy with a more vertical vector appears to have begun with the S-lift as described by Zaylan.10 We are now seeing greater acceptance of the soundness of the vertical approach with its adaptation by various surgeons. Little11 has also emphasized the importance of vertical-vector techniques, and as those who have utilized a more significant vertical vector in facelift surgery have observed, adequate elevation of the SMAS by plication, imbrication, or suture techniques in the mid- to lower face will also to a large degree correct deformities in the neck. Why is this? This chapter will demonstrate both anatomically and clinically that pulling of the undissected SMAS along a superior vector also pulls the platysma superiorly, through its attachments and tissue integration with the SMAS, and that this has a dramatic effect on the jawline, neck, and chin.
◆ Current Techniques for Facial Rejuvenation via Rhytidectomy
As noted in the discussion of the brief evolutionary history of techniques for rhytidectomy, numerous adaptations of these techniques have been described, with each adaptation carrying risks and benefits, as well as having proponents and detractors. Although nearly all of the conventionally accepted techniques for rhytidectomy achieve the removal of lax or redundant skin, the variations in the approach to the deeper soft tissues distinguish the main differences in these techniques. Recently, limited-incision or short-scar techniques have grown in popularity, but whether a short-scar (incision) or short-flap technique is used, the approach to the deeper soft tissues remains the distinguishing factor in the technical adaptations of rhytidectomy. In most cases the evolutionary flow of technical adaptations in rhytidectomy was driven by the pursuit of more durable, longer lasting, and more aesthetically pleasing results. Recently there has been a more “surgeon-and-consumer driven” de-evolution of technique, and both the quality of the result and the amount of “down time” required to achieve it are now important. Ideally, the best technique for rhytidectomy is the one that produces the best aesthetic result with the least amount of time for patient recovery. The following discussion summarizes most of the conventional techniques for rhytidectomy, with emphasis on the degree of cervical rejuvenation provided by each technique. The techniques discussed are summarized and illustrated in Figure 5.1 .
Subcutaneous Rhytidectomy
As noted previously, the initial approach to facial rejuve-nation was primarily a subcutaneous approach in which a skin flap was raised by incision between the subdermal layer and the SMAS. The skin flap was advanced, excess skin trimmed, and the flap sutured into its new position ( Fig. 5.1A ). The redraping in this procedure is predominantly lateral-oblique, and because of the lack of a superior vector the temporal hair tuft is not advanced superiorly. The length of the subcutaneous flap in rhytidectomy when the procedure was initially performed was usually short (<4 cm), but the modifications of subcutaneous rhytidectomy that involve the SMAS are usually performed with a flap ranging from 3 to 4 cm to 6 cm. A consistent anatomical vascular finding in the procedure is the inframalar, midfacial perforating vessel, which is located in association with both the dermal attachments of the parotid masseteric fascia at 4 cm from the tragus ( Fig. 5.2A ) and the origins of the facial mimetic musculature (zygomaticus major) at ~6 cm from the tragus ( Fig. 5.2B ).
The main advantages of the subcutaneous rhytidectomy are its uncomplicated nature and ease of performance within a short period, and its lack of a need for deeper planes of anesthesia. The disadvantages of the technique are that it does not produce good short- or long-term results in the areas of the jowl and nasolabial fold, and if done with a limited flap elevation will only tighten the skin somewhat, pulling the lateral skin upward but not correcting the major areas of cosmetic concern. Skin that is stretched excessively and brought up along a lateral oblique vector without adequate undermining can also develop a “windswept” appearance that many patients fear.
Subcutaneous Rhytidectomy: Skoog Modification
The Skoog3 modification of the subcutaneous rhytidectomy ( Fig. 5.1B ) was the first attempt to improve its aesthetic outcome of the procedure by entry into the deeper soft tissues of the neck. In this adaptation the SMAS–platysma complex in the lower face and neck are undermined and advanced along a lateral oblique vector with a slightly superior component. The main advantage of this technical adaptation of the subcutaneous rhytidectomy was that it provided additional improvements in the contour of the jawline and neck and could be completed with the elevation of a relatively short flap. The disadvantages of the Skoog modification are its potentially additional surgical risk of injury to the buccal and mandibular branches of the facial nerve, and the possibly more stimulating nature of the procedure as the result of its deeper plane of dissection, which may require deeper planes of anesthesia. The aesthetic disadvantage of the Skoog modification is the lack of access to the jowl fat for contouring, owing to the dissection being done in a plane that runs under the masseter muscle and SMAS–platysma complex. In the quest for the ideal rhytidectomy, the Skoog adaptation was also thought to provide inadequate aesthetic improvement to the nasolabial folds, which would leave patients with only a partly more youthful look from the improved appearance of the jawline and neck.
Subcutaneous Rhytidectomy: SMAS Imbrication, Plication, and Excisional Modification
Most of the techniques for subcutaneous rhytidectomy involving the SMAS were developed to enhance its results by providing additional refinements in the jawline, neck, and nasolabial folds through repositioning of the deeper soft tissues of the face. Plication involves a suture technique whereby the deep soft tissue is folded on itself in a manner resembling a pleat in a curtain. Imbrication involves the incision with varying degrees of undermining and subsequent advancement of the deeper soft tissues, followed by their overlapping in a manner similar to the overlapping of tiles on a roof. Excisional techniques involve the excision of a portion of the SMAS and the advancement of associated tissue by suture techniques in such a way that the SMAS can be approximated or imbricated. Excisional techniques are commonly done in a location that will permit softening of the nasolabial folds and enhancement of the contour of the jawline. Most of these techniques involve advancing the soft tissues along a lateral oblique vector of correction. Taken collectively, the techniques for subcutaneous rhytidectomy involving modification of the SMAS add refinements to the cosmetic outcome of the procedure. Many of these techniques can be done without general anesthesia or deep sedation and are both technically easier to perform and shorter than the more complicated SMAS advancement flap techniques. The disadvantages of the excisional techniques are that they can often incompletely correct the appearance of the nasolabial folds. The jowl may also be undercorrected if the flap length is very short. These techniques will usually also not correct the jawline and neck as much as the Skoog and deep-plane modifications of rhytidectomy. For rejuve-nation of the neck, other procedures, such as lipoplasty and medial or lateral platysmaplasty, are usually performed concurrently with techniques of subcutaneous rhytidectomy involving the SMAS.
Subcutaneous Rhytidectomy: SMAS Flap Modification
The SMAS flap modification of the subcutaneous rhytidectomy ( Fig. 5.1C ) is often called a modified deep-plane technique by those who believe they are performing a deep-plane procedure, but is more a modification of subcutaneous rhytidectomy itself. The significant technical maneuver that differentiates the deep-plane technique from the subcutaneous modifications of rhytidectomy is that in this procedure the deeper soft tissues remain attached to the skin flap in the deep plane, and there is a bridge of SMAS–plastysma complex at the level of the lower facial mandibular border ( Fig. 5.3 ). This differs from modifications of subcutaneous rhytidectomy involving the SMAS in that the latter elevate a flap of skin and subcutaneous tissue before modification of the SMAS and deeper tissues. A fully elevated SMAS flap can be repositioned along slightly different vectors than can a skin flap, but is most often advanced in a lateral oblique direction ( Fig. 5.4 ). Because they are a composite unit, the tissues of the flap will be advanced along the same vector in the deep plane. In some SMAS flap procedures a longer flap may be raised, with sectioning of the osteocutaneous ligaments constituting a “full rhytidectomy.” Flap procedures involving the SMAS are lengthy and can entail injury to motor nerves. They are usually completed under deeper levels of anesthesia and can be complicated by hematoma from the deeper manipulation of soft tissues. If the SMAS flap is advanced in a more superior direction, some correction of the appearance of the neck can accompany these procedures, but concurrent procedures on the neck, such as lipoplasty and medial and lateral platysmaplasty, are usually completed independently.
Disadvantages of subcutaneous rhytidectomy with the SMAS flap include the loss of mechanical advantage through separation of the SMAS from some of the connective tissue confluent with the platsyma. This results in less definition of the jawline than can be achieved by leaving the tissues intact. The excessive tailoring of SMAS flaps can lead to deformities in the contour of the periauricular area, and to volume loss. Suction drains are commonly needed when completing SMAS flap procedures.
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