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Aesthetic facial surgery Rhytidectomy is intended to rejuvenate the cervicofacial contour. Recognizing the elements of an aging face and neck are a prerequisite to planning any procedure. Common stigmata of facial aging include: ptotic malar pads, heavy nasolabial folds, nasojugal creases, marionette lines, jowls, geniomandibular grooving, cheek and neck skin laxity, platysmal banding, lateral orbital wrinkling, submental lipodystrophy
and salivary gland ptosis.
While all of these structures may be affected by the pull of gravity, repetitive contraction of the underlying muscle, and cellular/subcellular aging, each can be improved by facelifting techniques. Other problems such as forehead and glabellar lines, eyelid bulges and excess skin, fine facial wrinkles, lip atrophy, cheek fat
atrophy, senile nasal dysmorphia cannot be corrected with a facelift. Since it is not possible to design a universal technique for all patients, facelifting must be preceded by a sound knowledge of the anatomy and a thorough understanding of the elements to be corrected. Careful planning and good technique are necessary to precisely remove redundant skin, resuspend or resect fat and repairing lax musculature and fascia.
THE FACE ANATOMY
There are five important anatomic levels in the face and neck: skin, subcutaneous fat, the superficial musculoaponeurotic system (SMAS)/muscle layer, fascia and the facial nerve. While these layers are consistent throughout the face and neck, in some area such as over the zygomatic arch, the layers are highly compressed. In addition to these tissue planes, the surgeon must be familiar with the folds, retaining
ligaments, glands , blood supply and fat pads of the face.
As we age, the skin changes in its appearance and characteristics. Skin aging is accelerated by sunlight; this process is known as dermatohelisosis, solar elastosis, or photoageing. Photoageing is accelerated by long and short wavelength ultraviolet radiation (UVA and UVB) injury to the epidermis and dermis. Studies suggest that UV light can activate enzymes that degrade collagen and elastin in skin. Repetitive solar damage can cause fine lines and wrinkles, telangiectasias, solar comedones, dryness and actinic lentigines (diffuse or mottled brown patches). Signs of skin aging are accelerated by smoking. Facelifting cannot directly improve the quality of photoaged skin, but it can improve the appearance.
The subcutaneous plane provides a relatively safe plane for dissection. This layer contains innumerous fine ligaments passing from the subjacent SMAS/muscle layer to the overlying dermis of the skin. These ligaments transmit mimetic movements into facial expressions but also contribute to facial lines and wrinkles.
Below the skin and subcutaneous tissues, is the SMAS/muscle layer. The SMAS/muscle layer is a continuum from neck to scalp. It is composed of fibrous, muscular, or fatty tissues. In the neck, the platysma represents the most inferior portion of the SMAS/muscle layer. In the face, the SMAS is a tough fibrofatty layer over the parotid. Medial to the parotid, the muscles of facial expression (e.g., zygomaticus major/
minor and orbicularis oculi) are contiguous with the SMAS layer. Above the zygoma, the SMAS is contiguous with the frontalis muscle and the superficial temporal fascia (or temporoparietal fascia). The temporoparietal fascia blends into the galea as it reaches the scalp. Collectively, this layer may be thought of as the platysma-SMAS-temporoparietal-galea layer.
Between the SMAS/muscle layer and the facial nerve is a fascial layer. In the neck, the layer is termed the cervical fascia. Over the parotid, it exists as a filmy, areolar layer called the parotideomasseteric fascia. This thin, nearly transparent layer lies immediately superficial to the facial nerve. The fascia continues cephalad
passing over the zygoma. In the upper third of the face, the layer becomes the innominate fascia that blends into the subgaleal fascia over the scalp. The innominate fascia lies between the SMAS/muscle extension (i.e., temporoparietal fascia) and the superficial layer of the deep temporal fascia. The anatomy here is critical because the frontal branch of the facial nerve (see below) pierces the innominate fascia at the level of the zygomatic arch and travels along the undersurface of the temporoparietal fascia. Collectively, this fascia may be thought of as the cervical-parotideomasseteric-innominate-subgaleal layer.
The main facial nerve trunk emerges from the stylomastoid foramen to provide motor innervation to 20 paired muscles of facial expression as well as the posterior belly of the digastric, stylohyoid and stapedius muscles. In addition, the facial nerve provides sensory innervation to the anterior two-thirds of the tongue, external auditory meatus (nerve of Jacobsen), soft palate and pharynx. The motor portion of the facial nerve divides into five major branches. The branches of the facial nerve travel just deep to the cervical-parotideomasseteric fascia to innervate all muscles of facial expression from their deep surface with three exceptions: (1) mentalis, (2) buccinator, and (3) levator anguli oris. These muscles lie deep to the facial nerve branches and are, therefore, innervated on their superficial surfaces.The frontal branch of the facial nerve leaves the parotid gland immediately beneath to the zygomatic arch. As it crosses the superficial surface of the zygomatic arch, the frontal branch pierces the innominate fascia to travel along the undersurface of the temporoparietal fascia (superficial temporal fascia). At this point, the frontal branch is extremely susceptible to inadvertent injury. The path of the frontal branch can be approximated by connecting a line 2 cm lateral to the edge of the eyebrow to the lower edge of the earlobe, termed Pitanguy’s line. The frontal branch innervates the muscles of the upper part of the face including the upper orbicularis oculi, frontalis and corrugator muscles. Transection of the frontal branch leads to brow ptosis.
The zygomatic branch provides motor fibers to the lower orbicularis oculi, procerus, some lip elevator and some nasal muscles. The buccal branch has tremendous overlap with the zygomatic branch and sends fibers to similar muscles, as well as the buccinator, orbicularis oris, depressor anguli oris and risorius muscles. As the zygomatic and buccal branches exit the medial portion of the parotid, they travel along the superficial surface of the buccal fat pad, just below the SMAS. This position makes them susceptible to injury during facelift procedures, particularly at the lateral edge of the zygomaticus major. As discussed below, when dissecting in the sub-SMAS plane, the surgeon must change to a subcutaneous plane at the lateral
border of the zygomaticus major muscle in order to avoid interrupting the zygomatic and buccal branches.
Transection of the zygomatic and buccal branch leads to unpredictable defects because muscular innervation in the mid face is variable. The buccal branch is the most commonly injured branch of the facial nerve. The marginal mandibular nerve emerges from the inferior border of the parotid gland and crosses the inferior border of the mandible deep to the platysma to reach the face. Studies suggest that posterior to the facial artery, the marginal mandibular branch may dip as far as 2 cm below the border of the mandible. Anterior to the facial artery, the marginal mandibular nerve nearly always lies above the mandibular border. The marginal mandibular nerve has little cross-innervation as it enters the orbicularis oris and lip depressors. Transection of this nerve results in paralysis of the muscles that depress the corner of the mouth; therefore, the paralyzed side of the mouth will appear higher than the innervated side!
The cervical branch travels on the undersurface of the platysma. The platysma acts synchronously with other muscles of the lower lip to draw the oral commissure and lower lip downward. Transection of the cervical branch is uncommon, but it does not result in significant functional or cosmetic deficits.
Additional discussion of this anatomy can be found in Chapter 35.
Tear Trough, Nasojugal, Malar, Nasolabial and Labiomental Folds
The tear trough is a depression near the medial palpebral fissure formed by the separation of the orbicularis oculi and levator labii superioris. The nasojugal fold extends inferiorly and laterally from the tear trough onto the cheek. The malar fold runs inferiorly and medially from the lateral palpebral fissure towards the inferior
extent of the nasojugal fold.
The cutaneous insertion of the zygomaticus major/minor and levator labii superioris muscles determines the nasolabial fold. In a sense, the nasolabial fold may be considered a fasciocutaneous ligament necessary for lip elevating muscles to initiate a smile. Laxity of this fasciocutaneous ligament causes the malar fat pad to
travel inferomedially over the crease to deepen the nasolabial fold. The depressor anguli oris superiorly and the mandibular ligaments inferiorly determine the labiomandibular crease, which similarly is converted into a fold as a result of the laxity of the masseteric ligaments that occurs with age.
Parotid and Submandibular Salivary Glands
Invested by the deep fascia, 80% of the parotid gland lies between the mastoid process and the posterior border of the mandible. About 20% of the gland extends convexly forward over the masseter muscle occasionally as far as the zygomaticus major. The parotid duct (Stensen’s duct) and branches of the facial nerve emerge from the anterior border of the parotid, beneath the parotideomasseteric fascia. The parotid duct (4-6 cm in length) travels parallel to the zygomatic arch, 1.5 cm (approximately 1 finger breadth) below its inferior border, passing over the masseter muscle and then turns medially 90˚ to pierce the buccinator muscle at the level of the second maxillary molar where it enters the oral cavity. Using surface landmarks, Stensen’s duct lies midway between the zygomatic arch and corner of the mouth along a line between the upper lip philtrum and the tragus. The buccal branch of the facial nerve parallels the parotid duct.
The submandibular glands, often referred to as the submaxillary glands because of the tendency of British anatomists to refer to the mandible as the submaxilla, lie in the submandibular triangles formed by the anterior and posterior bellies of the digastric muscles and the inferior border of the mandible. The marginal mandibular branch of facial nerve courses superficial to the submandibular gland and deep to the platysma. The submandibular ducts (Wharton’s ducts) exit the medial surface of each gland and run between the mylohyoid (lateral) and hyoglossus muscles along the genioglossus muscle to empty into the oral cavity lateral to the lingual frenulum.
The lingual nerve wraps around Wharton’s duct, starting lateral and ending medial to the duct, while the hypoglossal nerve parallels the submandibular duct, just inferior to it. The identification of the hypoglossal and lingual nerves as well as Wharton’s duct is important prior to resecting portions of the submandibular glands.
The retaining ligaments of the face support soft tissues in their youthful anatomic positions. Furnas described four retaining ligaments that support the soft tissues of the face. The platysma-auricular and the platysma-cutaneous ligaments are aponeurotic condensations attaching platysma to dermis. Of greater significance are the osteocutaneous zygomatic and mandibular retaining ligaments. The zygomatic ligaments
(McGregor’s patch) anchor the skin of the cheek to the inferior border of the zygoma just posterior to the origin of the zygomaticus minor muscle. With age, these ligaments become lax, leading to inferomedial migration of the malar fat pad and
formation of the nasolabial fold. The mandibular retaining ligaments arise from the parasymphysial mandibular body and insert into the skin inferior to the insertion of the depressor anguli oris. The mandibular ligaments define the anterior extent of the jowls. The zygomatic and mandibular ligaments are obstacles to surgical maneuvers intended to lift the skin flap and, therefore, both are usually divided.
Malar and Buccal Fat Pad
In a youthful midface, the superior border of the triangular shaped malar fat pad lies along the orbital rim and extends laterally to the zygoma. The lateral border can be identified by drawing a line from the lateral canthus to the lateral commissure. The malar fat pad is located beneath the skin and subcutaneous fat, but it is superficial to the SMAS. It is fibrous and fatty, and it is readily distinguishable from the overlying
subcutaneous fat. With advancing age, the malar fat pad slides downward and medially, over the SMAS. Ptosis of the malar fat pad also empties the midface, producing a crescent-shaped hollow at the lower lid-cheek junction. The malar fat pad descent also contributes to the nasojugal and nasolabial folds. To a lesser extent, this displacement also results in the formation of labiomandibular folds (marionette lines) and jowls.
The buccal fat pad lies over the masseter and buccinator muscles, deep to the plane of the parotid duct and facial nerve branches. Medially, it may reach into the pterygopalatine space. It can be approached from a sub-SMAS dissection plane by separating the buccal branches of the facial nerve. Alternatively, it can be approached through the mouth by penetrating the mucosa and buccinator muscle. There are few indications to remove this fat pad because it tends to hollow the cheek giving an aged appearance.
FACE LIFT PREOPERATIVE CONSIDERATIONS
All patients should receive a complete medical examination by the appropriate specialist, including complete blood counts, metabolic chemistries, EKG and, if indicated, a chest roentgenogram. Patients with diabetes mellitus, hepatic, cardiovascular, renal, or thyroid disorders must have preoperative medical clearance. Patients should be instructed to stop taking alcohol or tobacco products 3 weeks prior to surgery. Aspirin, nonsteroidal anti-inflammatory agents, anticoagulants, vitamin E, multivitamins, Alka Seltzer® and homeopathic remedies should also be discontinued 3 weeks prior to surgery.
One of the dreaded complications of the facelift is hematoma. Postoperative nausea and vomiting (PONV) and hypertension are believed to be contributing factors. All patients, unless contraindicated, should receive preoperative antiemetic therapy. For example, preoperative odansetron (Zofran®), 4 mg IV, has been shown to significantly decrease the incidence of PONV. Other less expensive antiemetics are also available. In addition, patients with hypertension should take their medications the morning of surgery. Any patient with even mild hypertension the morning of surgery, should be considered for antihypertensive therapy. Oral clonidine (0.1-0.2 mg) is a commonly used medication for this purpose. The night before surgery, a
benzodiazepine can be given (e.g., lorazepam 2 mg) to prevent preoperative anxiety-induced hypertension.
The patient should refrain from using cosmetics, perfumes, aftershave, and moisturizers on the morning of surgery. Hair coloring should not be performed within 10 days of surgery. Make-up should be removed the night before surgery, and the patient should be instructed to wash their face and shampoo their hair with an
antimicrobial soap. It is standard to administer a single intravenous dose of preoperative
antibiotics. Antibiotics are generally not required postoperatively.
TYPES OF SURGICAL TECHNICS
Incisions vary and depend on the technique, patient anatomy and hairline and surgeon preference. The temporal incision is generally marked in a curvilinear fashion, just within the temporal hairline and superior to the ear. This avoids any loss or elevation of the temporal hairline. The preauricular incision lies in the natural crease at the junction of the auricle and the face, following the curve of the helical root.
The incision can then be continued in either the pretragal crease or behind the tragus. The inferior aspect of the incision is located at the junction of the earlobe and cheek. Curving posteriorly and superiorly around the lobe, the incision is placed
in the postauricular crease. The incision then curves tangentially into the occipital hairline at the level of the inferior crus of the antihelix. This incision placement helps prevent a step-off deformity of the posterior hairline.
Flap elevation proceeds in a subcutaneous plane with care taken to avoid hair follicles. Transilluminating the flap can help to maintain the proper dissection plane. Pre- and postauricular flaps are extended into the neck over the sternocleidomastoid muscle. The great auricular nerve emerges from the anterior border of the sternocleidomastoid muscle 6.5 cm inferior to the external auditory meatus. A separate submental incision may be used to elevate the anterior portion of the cervical flap in a preplatysmal plane. The dissection is limited superiorly by the inferior border of the mandible and inferiorly by the hyoid bone. The preplatysmal plane serves to protect the marginal mandibular nerve as it courses below the mandible. Once elevated
the skin is redraped, tailored and inset under limited tension.
The subcutaneous facelift technique is simplest to perform, with the least risk of injury to the facial nerve branches. The skin-only facelift produces good results for thin women with good skin tone and underlying bone structure. It is difficult to obtain a natural look in patients with heavier faces because high skin tension produces a pulled-appearance, wider scars and alopecia. The skin-only facelift has limited application.
The SMAS facelift begins with the incisions and skin flap elevation as described above. Classically, the SMAS is elevated in the preauricular area, from 1 finger breadth below the zygoma to the lower border of the mandible. The parotideomasseteric fascia is left intact just below the dissection plane, protecting the facial nerve branches.
Dissection continues anteriorly to the nasolabial fold, remembering to change the level of dissection at the lateral border of the zygomaticus major muscle. The dissection plane remains superficial to the zygomaticus major muscle and extends inferiorly to the oral commissure. Sharp division of zygomatic and mandibular retaining ligaments allows full mobilization of the skin and soft tissue, facilitating redraping.
In the neck, subplatysmal dissection can be performed to expose the triangular shaped subplatysmal fat pad. After resecting this fat pad under direct vision, the medial edges of the platysma can be trimmed and the diastasis closed. The muscle sling should be securely plicated in order to correct the platysmal banding.
After completing the dissection, the SMAS is lifted in a vector parallel to the zygomaticus major, trimmed and inset. The skin is then redraped in a vector perpendicular to the nasolabial fold. It is critical that the skin is inset tension-free. The advantage of a SMAS/muscle facelift over a skin only lift is the ability to independently control the vectors of the deep tissues and skin. Moreover, since the lift is based on the SMAS, the skin can be trimmed and inset without tension. There are many variations of this technique which include the limited SMAS, extended SMAS and lateral SMASectomy.
Deep Plane Facelift
Deep plane facelift refers to sub-SMAS dissection without significant undermining in the subcutaneous plane. The subcutaneous dissection is carried approximately 2-3 cm in front of the tragus, from zygoma to the jaw line. The sub-SMAS plane is dissected beyond the nasolabial fold, exposing the orbicularis and zygomatic
muscles (the SMAS is transected at the level of the zygomaticus major muscle and the dissection continued in a subcutaneous plane). This maneuver frees the SMAS from the attached mimetic muscles, allowing the pull on the skin to be transmitted to the fold. The cheek fat is dissected free from the underlying mimetic
muscles and is elevated with the skin/SMAS flap. The technique is said to diminish the appearance of the nasolabial fold. The risk of nerve injury may be greater with the more extensive dissection. There is improved vascularity compared to the subcutaneous plane facelift. However, the major drawback to the deep plane operation is the development of persistent infraorbital and midface ecchymosis and edema that greatly prolong the convalescence.
The composite facelift is a modified deep plane facelift designed to additionally address the orbicularis oculi muscle. With the addition of a lower blepharoplasty incision, the orbicularis oculi is elevated off the malar prominence. This frees the muscle of its attachments to the malar eminence, allowing mobilization and repositioning.
As originally described, this dissection plane is then connected to the deep-plane dissection by an incision made between the inferior lateral border of the orbicularis oculi and the zygomaticus minor muscle. A distinct division between these muscles is not always present because they lie in the same plane. This maneuver
prevents inadvertent elevation of the zygomaticus minor muscle into the composite flap. The inferior aspect of the orbicularis oculi muscle is trimmed, and the muscle is repositioned in a superomedial vector.
The subperiosteal lift is another type of deep plane facelift. Through a coronal approach, subperiosteal undermining is carried out around the orbital rims, over the zygomatic arch and body, over the maxilla and down to the piriform aperture. After undermining, the tissue is advanced superiorly and sutured to the temporal fascia. In older patients with skin laxity, the procedure is combined with a preauricular incision. Patients frequently have marked facial edema for several weeks after surgery and a mask effect for several months. Risk of injury to the frontal branch of the facial nerve was high in the initial series but has been minimized with a deep approach to the zygomatic arch. Many surgeons prefer this technique for patients 45
and under who desire facial implants. There is more swelling with the subperiosteal lift than with more SMAS lifts.
FACELIFT (RHYTIDOPLASTY) POST-OPERATIVE CARE
In the recovery room following surgery, the patient should be evaluated for pain, nausea, or vomiting. If present, pain medication and antiemetics should be administered. The blood pressure must be frequently monitored and precisely controlled with antihypertensives. Patients should rest, but need not stay in bed. While in bed, the patient’s head should be elevated. Drains are usually removed the morning after surgery.
For at least 2 weeks after surgery, the patient should refrain from physical exertion, bending or heavy lifting, sexual activity, driving and flying. The patient should continue to abstain from alcohol and tobacco products, aspirin, nonsteroidal anti-inflammatory agents, anticoagulants, vitamin E, multivitamins, Alka Seltzer® and homeopathic remedies for 3 weeks. A shower and hair washing are permitted on the day after surgery, but no hair brushing or make-up applications are permitted for 10 days. The patient should avoid sun exposure until the scars are mature. Preauricular/temporal sutures are generally removed in 5-7 days and postauricular sutures are removed in 2 weeks.
Men generally have twice the incidence of hematoma after facelift surgery as women (8% versus 4%). This may to be due to the hair follicles in a male’s beard. Secondary facelifts have a lower incidence of bleeding.
Skin slough occurs most often in the postauricular region, and it is more common in patients who smoke. Patients should refrain from smoking at least 3 weeks before and 2 weeks after the operation. Another risk factor for skin slough is acne scarring. The subdermal acne scar is hypothesized to compromise blood flow to skin flap. Good judgment is necessary to determine the amount of skin undermining that can be safely performed in higher risk patients. Skin slough is usually treated by allowing the wound to heal by secondary intention.
The most commonly injured nerve during a facelift is the greater auricular nerve.
Patients undergoing a subcutaneous rhytidetomy have a facial nerve injury risk of 0.5-2% (mean of 1%). Patients who undergo a SMAS-based lift have a facial nerve injury risk of 2-9% (mean of 4%).
Hair loss is uncommon during a face lift (1.2%). Suture line alopecia tends to occur in areas of inappropriately high tension. Elevation of the sideburn or notching of the postauricular hairline is more common, particularly during a secondary lift. Both of these complications can be avoided by careful planning.
Scarring is present in every facelift. Well-designed incisions closed without tension produce the best scars. Patients with a family or personal history of hypertrophic scarring or keloid formation or risk factors for excessive scarring after a facelift should be counseled preoperatively.
RISK THE INFECTION
Infections occur very uncommonly (0.18%) during facelifting due to the robust blood supply of the face.
PEARLS AND PITFALL
A thorough understanding of the nerves encountered during rhytidectomy in the face and neck is essential for avoiding the most dreaded complications of this procedure.
The frontal division of the facial nerve lies within the temporoparietal/SMAS fascia. Dissection in the vicinity must be either extratemporoparietal/extra-SMAS or subtemporoparietal/sub-SMAS. In the subperiosteal approach, dissection should proceed deep to the deep layer of the temporal fascia. The zygomatic branch of the facial nerve lies deep to the zygomaticus major muscle. Sub-SMAS dissection at this point causes trauma to the nerve, as does blind incision of the zygomatic ligaments.
The marginal mandibular branch of the facial nerve usually is not visualized during facelifting. In sub-SMAS dissection in the lower face, it is safer to stay above the mandible posterior to the facial vessels. Use appropriate caution with electrocautery hemostasis around vessels in the SMAS since electricity may be transmitted to nerves causing injury.
In the neck the cervical branch of the facial nerve lies deep to the platysma muscle and is in no danger in a supraplatysmal dissection. The great auricular nerve lies deep to the superficial layer of the deep investing fascia on the sternocleidomastoid muscle as it traverses from posteroinferior to anterosuperior to emerge in the vicinity of the infra-aural region, where the skin is firmly attached to the sternocleidomastoid muscle. Caution with the infraorbital nerve must be exercised during dissection in the subperiosteal plane in the region.
HOW MUCH THE PRICES AND COSTS
FACE LIFT COST
The average price of face lift is $5,000 to $20,000. the average cost also depends on the location of the clinic, the surgeon’s experience and the size of the procedure. In addition, prices include much more than just the surgeon’s fee, which typically costs about $ 4000 – $ 5000, even as the cost of installation fees, hospital fees, anesthesiologist fees, and more.
Average face lift prices according to technique are as follows:
Threadlift face lift: USD$1,900-$5000, average $38000
Standard face lift: $5,000-$14,000, average $7,000
Mini (weekend) face lift: $2,900-$5,500, average $4,000
Mid face lift: $3,800-$9,000, average $8,000
Lower face lift: $3,950-$9,600, average $6,000
- anatomy face
- anatomy face muscles