Facelift, Blepharoplasty, and Facial Rejuvenation Procedures

Facelift, Blepharoplasty,
and Facial Rejuvenation
Procedures

Robin M. Brody

One may combine modalities or plan on using several modalities as a staged approach for facial rejuvenation.
Preoperative photodocumentation is important for accurate comparison of preand postoperative results, as well as for medicolegal reasons.

Anatomical considerations include platysmal banding (“turkey gobbler deformity”), jowls, position of malar fat pad, bone resorption (may indicate the need for concomitant anatomical implants, e.g., chin implant or prejowl chin implant), prominent nasolabial folds, and skin laxity.
Smoking cessation should be encouraged because smoking increases the risk of flap necrosis and hematoma formation.
Hairline and hairstyle are important in the planning of incisions.

In males, the incision continues inferiorly toward the lobule, in a skin crease that is posterior to the sideburn. This prevents advancing the sideburn into the ear. In women, a post-tragal incision is made.
The incision then curves posteriorly and superiorly in the posterior aspect of the conchal bowl, a few millimeters lateral to the postauricular sulcus.
Posterior extension of the incision at the level of the antihelix is performed, onto the scalp toward the region of the mastoid, then toward the occipital scalp, posterior to the hairline.
If a submental liposuction and/or platysmaplasty are performed, the incision is marked in the region of the natural submental crease.
Local anesthesia, vasoconstriction, and hydrodissection are accomplished with subcutaneous infiltration of 2% lidocaine with 1:200,000 epinephrine along the incision sites and 1% lidocaine with 1:200,000 epinephrine along the flap.

Submental liposuction is performed in the preplatysmal plane to the level of the thyroid cartilage inferiorly and to the region of the submandibular glands laterally. Subcutaneous tunnels are connected.
Medial margins of the dehiscent platysmal muscles with a portion of its intervening fat are identified and held with a heavy clamp. A no. 15 blade is used to excise a small portion of the medial bands and fat. The cut edges are then sewn from inferior to superior, using either interrupted or a running locking suture.

Skin Lift
The skin flap is raised in a subcutaneous plane, trimmed, and repositioned.
This approach is rarely used because it does not take into account the underlying muscular laxity and the multiple vectors involved in facial laxity.

SMAS Plication/Imbrication
A skin flap is raised.
The submuscular aponeurotic system (SMAS) is plicated or imbricated with permanent sutures to tighten redundancy and alter the vector of pull.
The skin is redraped in an appropriate vector and sutured without tension. The superior suture is in a posterosuperior direction, and the inferior cheek suture is directed posterior toward the lobule.
Skin in the region of the tragus is defatted to better define the tragus.
Advantage
- Simple and safe, with minimal postoperative edema
Disadvantage
- May not adequately address the malar fat pad and/or nasolabial fold

Deep Plane
An incision is made through the SMAS in the malar region and continued inferiorly toward the posterior border of the platysma, just below the angle of the mandible.
The SMAS is dissected from the deeper parotidomasseteric fascia with vertical spreading motions of the scissors.
In the region of the nasolabial fold, remain in plane superficial to the zygomatic muscles to prevent injury to the branches of the facial nerve.
The jowl area is bluntly undermined in the fibrofatty plane over the masseter. At the anterior border of the masseter, the masseteric-cutaneous ligaments are sharply transected.
In composite rhytidectomy, the deep plane technique is extended deep to the orbicularis oculi muscle such that the flap is elevated in a subperiosteal plane. This allows for superior repositioning of the malar fat pad.
Advantage
- Better addresses regions of the malar fat pad and nasolabial fold
Disadvantages
- Technically more difficult to perform with prolonged operative time and prolonged postoperative edema
- Increased risk of injury to the facial nerve

Drains may or may not be necessary; fibrin glue may be used as tissue sealant to obviate the need for drain.
A pressure dressing is applied, but avoid excessive pressure.
Cold compresses are applied.

Jun 14, 2016 | Posted by admin in OTOLARYNGOLOGY | Comments Off