facelift surgery

FACELIFT

Dr Subhakanta MohapatraMch Plastic surgery , IPGME&R & SSKM Hospital,kolkata

Introduction

Facial aging is a panfacial phenomenon

Changes in all layers of face including bone

It converts inverted cone (heart shaped) of face in to rectangular shape

Facelift reposition the ptotic tissue

Age for facelift – in 40s

75% 15 % 10%

1- premasseter space 2 – prezygomatic space 3 – upper temporal space

Pre op

Uncontrolled hypertension is a C/I for Surgery

Smoking , NSAIDs , HRT , anticoagulants - to be stopped 3 wks prior to surgery

Photographic documentation of face. Pt’s youth time photograph can be helpful.

Clinical assessment of facial nerve function

Ptosis of sub-mandibular gland to be noted

Patient counselling

Types of facelift

Subcutaneous facelift SMAS plication MACS facelift Supraplatysmal plane facelift Lateral SMASectomy Deep plane facelift Dual plane facelift Subperiosteal facelift

Facelift incisions

Temporal hair incision Anterior hairline incision Incision in the hair + a transverse

extension at the base of sideburn Pretragal Tragal edge incision Short scar technique(limited to retro

auricular sulcus,no occipital incision)

Short scar incision

Incorrect submental Correct submental incision incision

Safe plane of dissection

Subcutaneous facelift

1st facelift Still used today Basis of other facelift techniques Subcutaneous dissection Leaving 2 mm of fat in dermis Large random pattern skin flap Shifted in superolateral direction

(perpendicular to nasolabial fold , along the line of zygomaticus major muscle)

Normal (long axis of lobule is 15 ° Posterior to long axis of ear)

Subcutaneous facelift

Adv

Relatively safe

Easy to do

Rapid recovery

Disadv

Ineffective in heavier patients with significant ptosis of deep tissue

Skin will stretch with time leading to a loss of effect

Distortion of facial shape

PSP(Platysma – SMAS plication)

Incision - vertical temporal +/- post auricular extension

Vector of traction - Postero – superior SMAS – SMAS fixation SMAS is sutured directly (no purse string fashion) Platysmaplasty – direct (infralobular

excision)

Incision & area of subcutaneous dissection in PSP

Anterior SMAS to PM fascia posterior platysma to(key suture) mastoid fascia

PSP (after completion)

PSP

ADV

Easy Safe Autologous

malar augmentation

DISADV

Cheese wire effect

No release of ligaments

Limited effect in heavy jowls

MACS Lift (Minimal access cranial suspension lift) – Loop sutures

Based on specialised suture suspension

Suture loops placed in purse string fashion

Anchoring point – Deep temporal fascia (SMAS – DTF) Vertical vector of traction

No dissection in neck.(Liposuction in >95%) Types – 1. basic 2. extended

Short scar incision for MACS lift

Temporal branch of facial nerve

Basic MACS Lift

Extended MACS Lift

Microimbrication

MACS lift

ADV

No deep plane dissection

Less dissection – faster recovery

No dissection over SCM muscle

Reversible during surgery

Easy to learn

DISADV

Loss of effect if sutures pull through

No ligament release Less effective for

heavy jowls Relative lack of

malar augmentation

Lateral SMASectomy

Resection of a portion of SMAS - at the interface of mobile & fixed SMAS

(directly overlying the anterior edge of parotid gland).

Extends from tail of parotid to lateral canthus

Lateral SMASectomy

ADV

No SMAS flap elevation , so lesser tearing of superficial fascia & better holding of suture fixation

Facial nerve injury is less , as majority of dissection carried over parotid gland

Rapid,safe,durable & with less complications

DISADV

Not applicable for thin face, where fat needs to be preserved

Extended SMAS technique

Also known as dual plane facelift

Subcutaneous facelift with separate SMAS flap

SMAS flap shifted more vertically than the skin flap

Extended SMAS technique

Adv 2 different

vector is more effective

No skin tension Excellent

mobilisation & advancement of SMAS (ligament release)

Disadv More time

consuming

More chance of damage to deep structures

Thin skin flap

Supraplatysmal plane facelift Deep subcutaneous dissection immediately

superficial to SMAS & platysma

Raising skin & superficial fat as a single layer

SMAS layer untouched

Adv Thick robust flap No facial nerve injury

Disadv Flap is unidirectional Skin tension at suture line

Foundation facelift

Formerly known as deep plane facelift

Composite musculo cutaneous flap

Dissection – deep to SMAS platysma plane (avascular plane so less hematoma)

Robust flap (so indicated in secondary facelift, in smokers )

Particularly effective for deep nasolabial fold & midface

Disadv- facial nerve injury, single vector

Subperiosteal facelift

For central oval of the face (forehead , periorbita , midface , chin )

Most suitable plane for implant placement

Biplanar ( subperiosteal + subcutaneous )

Midface gets maximum benefit

Open / endoscopic technique

One cosmetic unit Forehead & upper eye lid Lower eye lid & mid face Lower face & neck

Subperiosteal facelift

Adv en bloc mobilisation(no

tension on skin) Short incision Implant placement Better visibility & orientation Safe plane More durable More balanced & natural

rejuvenation (no windswept/ motorcyclist appearance)

Disadv

Additional equipments needed

Limited effect in lower face & neck

High SMAS technique

Flap along the superior border of zygomatic arch . (unlike traditional low cheek SMAS flap elevated below arch )

Extending the dissection medially to mobilise midface soft tissue

Improves midface , upper anterior cheek

Allows simultaneous lift of jaw line , cheek & mid face

Corset ( Feldman platysmaplasty )

Post op care

Light dressings Rest with head end of bed elevated No neck flexion (no pillow) Control of blood pressure (pain,

anxiety,urinary retention) Cool packs to face Drain removal on 1st post op morning Suture removal in 7-9th day Photographic documentation of result

– after 6 months of surgery.

Complications

Hematoma – most common Localised & worsening pain T/t – evacuation (rather than giving

analgesic ) Nerve injury(facial & great auricular) Skin slough (retro auricular area) Unsatisfactory scars Alopecia Infection(rare)

Secondary facelift

Goals- To relift the face & neck Remove primary facelift scars Preserve maximum temporal & sideburn

Less skin resection Time consuming, technically

demanding Intra op bleeding & postop

hematoma – less Risk of nerve injury is slightly higher

Conclusion

The worst of all outcomes is to look operated

Surgical disharmony compromises the result

Thank U