john m hilinski and dean m toriumi search strategy …€¦ · history of ageing face surgery the...

222The ageing face

JOHN M HILINSKI AND DEAN M TORIUMI

Introduction 3068

History of ageing face surgery 3068

Biology of ageing 3069

Clinical evaluation 3070

Surgical technique 3071

Submental liposuction and platysmaplasty 3073

Complications 3074

Key points 3075

Best clinical practice 3075

Deficiencies in current knowledge and areas for future

research 3075

References 3076

SEARCH STRATEGY AND EVIDENCE-BASE

The data is this chapter are supported by a Medline search using the key words rhytidectomy, facelift and facialrejuvenation. All evidence is based at levels 3/4.

INTRODUCTION

As populations expand and life expectancy increases,growing numbers of people are seeking methods tocounteract the ageing process. Over the past threedecades, refinements in surgical techniques have en-hanced our ability to manage the ageing face patient. Thegoal of ageing face surgery is to achieve a natural,rejuvenated, youthful appearance. Higher patient expec-tations and increasing demand for comprehensiverejuvenation have led to today’s multi-faceted approachto the ageing face. This chapter focuses on rhytidectomy,or facelift surgery, which is a central component in ageingface surgery. Other important considerations, such aslaser skin resurfacing and blepharoplasty are covered inChapter 58, Laser principles in Otolaryngology, head andneck surgery; and Chapter 221, Blepharoplasty.

HISTORY OF AGEING FACE SURGERY

The history of ageing face surgery dates back to thebeginning of the twentieth century. Average life spans

increased sufficiently around this time, such thatindividuals began manifesting signs of ageing for the firsttime. Issues of senescence became commonplace through-out society. Surgeons were soon honouring patientrequests for procedures that would help counter theageing process. Early pioneers of plastic surgery werecommonly referred to as ‘featural surgeons’, reflecting theprevailing negative attitude toward ‘unnecessary’ surgery.Although most respected members of the medicalcommunity shunned this type of surgery, others recog-nized its benefits and secretly practised on growingnumbers of hopeful patients. Unfortunately, publicdisdain curbed widespread acceptance of plastic surgeryand limited attempts at documenting these early efforts.

The German surgeon Erich Lexer (1867–1937) is widelycredited as the first individual to describe a rhytidectomy,doing so in 1906. Using S-shaped incisions, Lexer excisedskin paddles in strategic temporal and preauricularlocations to rid patients of lateral rhytids or wrinkling,hence the term rhytidectomy. Skin excision was fairlyconservative and was performed only to facilitate closure.Not surprisingly, Lexer’s technique resulted in only a subtleimprovement. In the ensuing years, other European

surgeons, including Eugen Hollander (1912), Suzanne Noel(1920) and Jacques Joseph (1921), reported their experi-ence with minor variations of the same technique.American participation in the evolution of rhytidectomywas virtually independent of European contributions. Thefirst American to publish on the technique was CharlesConrad Miller (1907), also one of the first surgeons toprovide anatomical drawings guiding incision placement.Another American, Adalbert Bettman (1920), introducedthe continuous pre- and post-auricular incision that laterbecame known as the contemporary rhytidectomy incision.

Subsequent advances in anaesthesia safely permittedmore extensive undermining beyond the preauricularmargin. Eventually, the elevation of long skin flaps overthe entire lower face and upper neck became routinepractice. This so-called ‘long flap’ technique combinedwith Bettman’s continuous incision to usher in the era ofthe subcutaneous rhytidectomy. The subcutaneous tech-nique quickly gained popularity because it was technicallystraightforward and relatively safe. Unfortunately, tensionwas placed exclusively on the skin flap, often leading to an‘operated look’. Results were also short-lived due to whatwe now recognize as skin creep and rebound stretching.Despite these drawbacks, no other significant contribu-tions were made during this period. Thus, subcutaneousrhytidectomy remained as the standard in ageing facesurgery for nearly 50 years.

The 1970s witnessed two major advancements inageing face surgery. The first was introduced by TordSkoog1 in 1974. Until that time, fear of injuring neuro-vascular structures precluded attempts at dissecting deepto the subcutaneous layer. Skoog pointed out theexistence of a safe dissection plane below a tough fasciallayer spanning the face. He also highlighted the fact thatthis plane is continuous with the subplatysmal plane inthe neck. By developing a ‘short flap’ along this plane, thefascial layer could be used as a ‘girdle’ to lift the skin andsubcutaneous fat together. Skoog reasoned that suspen-sion of this composite unit, as opposed to a skin only flap,would generate less tension on the skin. This translatedinto less visible scarring and longer-lasting results. For thefirst time, Skoog demonstrated how the lower face andupper neck could be safely rejuvenated as one anatomicunit without detaching the skin.

The second major advancement was the description ofthe superficial musculoaponeurotic system (SMAS), byMitz and Peyronie2 in 1976. This landmark publicationvalidated the fascial layer referred to by Skoog anddetailed its anatomic relationship with other facialstructures. It demonstrated the SMAS to be a condensedfibrous mesh layer situated below the subcutaneous fatand over the facial muscles. A series of transverse fibrousseptations between the SMAS and skin helped intransmitting facial expression. Because the ageing processweakened elasticity of these fibrous septations, Mitz andPeyronie contended that suspension of the SMAS couldaid in reestablishing a youthful facial appearance.

Description of the SMAS has served as a catalyst forevolution of a variety of rhytidectomy techniques over thepast 25 years. Most variations involve some form of SMASmanipulation as part of the surgical technique. Much ofthe debate today focuses on the extent of dissection belowthe SMAS. For instance, some surgeons argue thatdissecting further medially (such as in extended SMASand deep plane techniques) provides additional benefit.Thus far, convincing evidence does not exist to supportthis claim. Most facial plastic surgeons would agree thatthe traditional SMAS technique provides excellent reliableresults and remains the standard in ageing face surgery.

BIOLOGY OF AGEING

Facial ageing involves an array of biological changesinfluenced by intrinsic and extrinsic mechanisms. Intrinsicageing is primarily characterized by atrophy of the facialskin and subcutaneous fat, as well as volume changes in thefacial skeleton. Numerous histological transformations oc-cur within the epidermal and dermal layers of skin. Ageingresults in a significant decline in the density of keratinocytesand melanocytes within the epidermis.3 This contributes tothinning and abnormal pigmentation of the skin. Withinthe dermis, elastic fibres begin to disappear resulting indeficient tissue recoil and manifesting as excess wrinkling.Retraction of dermal papillae and rete ridges causesflattening of the dermal–epidermal junction. In combina-tion, these changes result in the decreased capacity to retainmoisture and lead to dryness that typifies aged skin.

Atrophy of subcutaneous fat is a hallmark of facialageing. The supporting fascial attachments around the fatpads also begin to weaken with age. Gravitational forcesgradually redistribute these tissues in a more inferior andlateral direction. Consequently, entire subunits, such asthe malar fat pad and jowl, become ptotic and contributeto a tired facial appearance.

As we age, volume changes occur in the facial skeletondue to continuous remodelling. Relative changes can beseen in terms of both volume reduction and expansion. Anappreciable reduction in height occurs with modestincreases in width and depth.4 For example, over time,the vertical height of the maxilla decreases while the widthof the orbital bones increases. Such changes lead to adisproportionate balance between the available bony sur-face area and soft tissue coverage. This results in inferiordisplacement of the cheek pad and skin. This same processaccounts for jowl formation and sagging along the neckline.

Extrinsic mechanisms of ageing most commonlyinvolve skin damage sustained from solar exposure,known as photoageing. The process of photoageing iswidely known to amplify the changes resulting fromintrinsic mechanisms noted above. In addition, photoa-ging causes disorganization of dermal elastic tissue fibres,termed elastosis, which contributes to further develop-ment of fine skin wrinkles.

Chapter 222 The ageing face ] 3069

CLINICAL EVALUATION

Achieving success in ageing face surgery begins withproper patient selection. One of the most critical factorsto consider is the patient’s psychological motivation forsurgery. Numerous studies5, 6 demonstrate that patientpsychology is a significant determinant of postoperativesatisfaction in ageing face surgery. The patient who has astable self-image and internal desire for a more youthfulappearance is more likely to be satisfied with thepostoperative result. In contrast, the patient seekingsurgery to remedy a situational or social dilemma mayhave unrealistic expectations and heralds unhappy resultsfor themselves and the surgeon.

It is imperative that patient and surgeon are incomplete agreement on the indications for surgery andthe resulting anticipated changes. Rhytidectomy is anexcellent technique to correct visible signs of ageing in thelower two-thirds of the face and upper neck. This includesredundant facial skin and deep rhytids, jowling or loss ofa well-defined mandibular contour, and modest improve-ment of prominent nasolabial folds. Patients should becounselled that rhytidectomy is not effective for super-ficial rhytids resulting from solar damage or minordepressions secondary to acne scarring. These abnormal-ities are more appropriately treated with adjunctivetechniques, such as laser resurfacing or dermabrasion.

As with any elective procedure, overall good health is aprerequisite in ageing face surgery. Preoperative evalua-tion includes a thorough history and review of systems toscreen for potential complicating factors. Many patientsconsider rhytidectomy following significant weight loss. Iffurther weight loss is planned or a history of repeatedweight loss and gain is suspected, surgery should bedelayed until a plateau has been reached. Patients with ahistory of coronary artery disease, hypertension, pulmon-ary compromise and hepatic or renal insufficiency shouldbe cleared by the appropriate medical specialist inadvance. Relative contraindications to rhytidectomyinclude predisposition to poor wound healing, as seenin diabetes mellitus, chronic steroid use, connective tissuedisorders (such as Ehlers–Danlos syndrome) and pastradiation therapy. An absolute contraindication tosurgery is a history of a bleeding diathesis.

All medications containing aspirin and nonsteroidalantiinflammatory agents are discontinued at least threeweeks prior to surgery to minimize bleeding. It isimportant to enquire about use of supplemental vitamins(particularly vitamin E) and homeopathic preparations(including gingko biloba and garlic). These medicationsare in widespread use but rarely disclosed voluntarily bypatients and can contribute to unexpected bleeding.

A history of tobacco use is particularly relevant in theassessment of the ageing face patient. It has beenestimated by Rees and Aston7 that smokers have a 12times increased risk of skin slough following rhytidect-omy compared with nonsmokers. This is attributed to a

higher incidence of haematoma formation and vasocon-striction. Although long-term effects of smoking on skincannot be negated by perioperative cessation, surgicalcomplications can be reduced by smoking cessationwithin two months of surgery.

There is no ideal age when considering timing forageing face surgery. In general, individuals in their middleto late ages are considered excellent candidates. Chrono-logic age alone should not be used as the qualifyingcriteria. More importantly, consideration is given to thevisible degree of ageing in a particular individual. Patientsdemonstrating mild to moderate degrees of ageing aremore likely to achieve a natural, rejuvenated appearance.Signs of advanced ageing, such as extreme skin sagging,are more difficult to correct and will limit expectedimprovement. Rhytidectomy is often an operation ofcompromise. Dramatic improvement can be made in oneregion, however, this may occur at the expense ofsuboptimal change in another. In patients with advancedsigns of ageing, it is beneficial to strive for less dramaticbut more natural change initially, with further refinementat a later date if necessary.

Physical examination begins with assessment of thepatient’s skin type. An ideal candidate for rhytidectomy isan individual with fair, medium-thickness skin. Darkpatients usually have thicker skin and enjoy less dramaticimprovement. The increased weight of their skin alsoresults in more postoperative skin relaxation. Thepresence of a moderate amount of skin elasticity isbeneficial. Less elastic skin can be tightened by rhyti-dectomy, but the duration of improvement may be lessthan satisfactory. A modest degree of subcutaneousfullness is also desirable, particularly in the midface. Thisreflects a healthy adipose tissue layer and contributes to amore youthful look.

.Facial skeletal structure can help predict a more or lessfavourable surgical outcome. Patients with a strong facialskeleton usually demonstrate more obvious improvement.Well-defined bony contours provide excellent support forskin redraping and accentuate desirable facial features.Patients with mid-facial hypoplasia are poor candidatesfor rhytidectomy alone and typically require adjunctiveprocedures. Similarly, patients with microgenia and poorchin definition require chin augmentation in conjunctionwith rhytidectomy to achieve enhanced results.

Many rhytidectomy patients express concern regardingskin laxity and fullness in the submental region. This isbest appreciated on a profile view by assessing the cervico-mental angle. The submentum should be palpated todetermine relative contributions from redundant skin,fatty tissue and platysmal banding. Redundant skin alonecan usually be addressed with standard rhytidectomytechnique by suspension of the cervical skin. Excess fattytissue is most effectively treated by submental liposuction.Patients with prominent platysmal banding require muscletailoring, or platysmaplasty, to attain a more favourablecervico-mental angle. In patients with extreme fatty

3070 ] PART 18 PLASTIC SURGERY OF THE HEAD AND NECK

deposition, platysmal banding may not be appreciateduntil after liposuction has been performed. Thus, patientsshould be counselled that platysmaplasty may be indicatedin addition to submental liposuction. It is worth notingthat a subgroup of patients have an inherent anatomiclimitation to the degree of improvement that can berealized in the submental region. These patients have anabnormally low positioned hyoid bone and are consideredless than ideal candidates for surgery. Such patients shouldbe thoroughly counselled that rhytidectomy, even inconjunction with liposuction and platysmaplasty, willnot significantly affect their submental profile view.

Preoperative photographs are taken with standardized1:8 full-face frontal, lateral and oblique views. Digitalimaging is often useful in demonstrating to the patientrealistic changes that can be expected following surgery.

SURGICAL TECHNIQUE

This section outlines general steps in surgical techniquefor SMAS rhytidectomy and submental liposuction orplatysmaplasty.

The patient is marked preoperatively in the sittingupright position. Areas of special concern are highlighted,as well as anatomic landmarks such as the geniomandib-ular groove, mandibular border and submental triangle.A preoperative intravenous dose of an appropriateanti-staphylococcus antibiotic is then administered.

We prefer to perform rhytidectomy under localanaesthesia with intravenous sedation. This anaesthesiais well tolerated by the patient and the facelift operation iseasily performed after performing appropriate anaestheticinjections and nerve blocks. Anaesthetic solution contain-ing 1:100,000 epinephrine is infiltrated along the pre- andpost-auricular borders and in a fan-like fashion beneaththe facial and upper cervical skin flaps. If liposuction orplatysmaplasty is planned, additional solution is infil-trated throughout the submental region. In multipleprocedure cases that may run for an extended period oftime, a general anaesthetic may be more appropriate. Theendotracheal tube is prepped into the surgical field andpositioned to allow side to side movement during theoperation. The entire face, neck and scalp are preppedand draped in the usual sterile manner.

Careful incision design and placement are vital toachieving natural appearing results in rhytidectomy. Theideal incision camouflages scar formation, minimizeschanges in the temporal and post-auricular hairline, andavoids distortion of the earlobe. An oblique incision beginsin the temporal hair tuft region and varies for theindividual patient. If a low temporal hairline is present,the incision is placed within the hair tuft to raise thehairline to a normal position postoperatively. If a normal orelevated temporal hairline exists, the incision is designed torun directly on the hairline to avoid raising it any further.The incision extends posteriorly 2–3 cm, gently curving into

the temporal hair. It is then redirected inferiorly toward theroot of the helix and into the preauricular crease.

A post-tragal incision is used in most female patients(Figure 222.1). The incision is positioned 2–3 mm ontothe posterior tragal surface and not deep toward its base.It exits at the inferior margin of the tragus and transitionstoward the lobule. Alternatively, a pretragal incision canbe used that courses within the preauricular skin crease.In male patients this incision is positioned approximately1 cm anterior to the preauricular crease to avoid havinghair-bearing skin placed adjacent to the auricle.

The lobule incision can be variably positioned. Inpatients with a ‘hanging’ lobule, the incision can be placed1–2 mm below the lobule attachment and readily camou-flaged. If a dependent lobule is not present, the incision ismade at the junction of the lobule and infra-auricularskin. The lobule incision extends onto the posteriorsurface of the auricle coursing over the conchal bowl.Approximately 3–5 mm should remain between theincision and the post-auricular sulcus. In the male patient,the incision rests within the sulcus to avoid displacinghair-bearing skin onto the ear. The incision extends to thelevel of the fossa triangularis before turning posteriorly. Aless dependent skin flap can be created in patients with asmoking history by limiting the superior extent of thisincision. A V-shaped dart is created as the incision

Figure 222.1 The post-tragal incision is placed just behind the

tragal cartilage. Note how the outline of the tragus is defined

by the incision.


traverses the sulcus and minimizes postoperative webbing(Figure 222.2). The incision extends into the hair-bearingskin before coursing parallel to the occipital hairline.

Elevation of the skin flap begins in the post-auricularregion. The flap is elevated in an avascular plane whilepreserving the subdermal plexus and a thin fatty layer onthe undersurface of the skin. Elevation continues into theneck in a supra-platysmal plane. The preauricular skinflap is elevated in a similar manner. Near the zygomaticarch, dissection is limited to the posterior one-third of thearch to avoid potential frontal nerve injury. A full-thickness skin flap is elevated off the tragal cartilage. Thisfacilitates redraping of the skin and helps maintain thenatural tragal contour. The preauricular skin flap iselevated approximately 9 cm anteriorly and can beextended over the jawline into the neck. Dissection inthe neck is most commonly performed in the subcuta-neous plane. In many patients, liposuction of the neck canbe performed without connecting the preauricular withthe neck dissection.

Once the skin flap is elevated, the SMAS is identified.A horizontal incision is made in the SMAS just below andparallel to the zygomatic arch but limited to the posterior

one-third segment (Figure 222.3). This connects to avertical limb coursing 2 cm anterior to the tragus. TheSMAS incision should not extend beyond the angle of themandible because the marginal mandibular nerve is inclose proximity. The SMAS flap is elevated approximately3–5 cm. In many cases the platysma is incorporated as anextension of the SMAS. The SMAS flap is then advancedand primarily pulled in a superior vector with a slightposterior vector. Maximal pull should be avoided whensuspending the first side as this may restrict mobility ofthe contralateral side and result in facial asymmetry. Atriangular segment of SMAS is excised and the edges ofthe SMAS flap are then sutured to the dense fibrous tissueat the inferior margin of the zygomatic arch and thepreauricular SMAS. Multiple 4-0 PDS and 5-0 nylonsutures can be used for this SMAS imbrication. In somepatients, a post-auricular SMAS flap can be dissected andsuture plicated to the mastoid periosteum.

After tightening the SMAS, the skin flap advanceseasily over the face. The post-auricular skin is pulledsuperiorly and slightly anteriorly, whereas the preauri-cular skin is pulled superiorly and slightly posteriorly. Thepost-auricular skin is temporarily anchored at its superiormargin with staples. Similarly, the superior margin of thepreauricular skin is anchored to the temporal hair line.After careful measurement, the excess skin is sharplytrimmed. The tragal skin flap should be thinnedsufficiently to allow natural redraping over the cartilage(Figure 222.4). It is imperative to avoid excess skintension as displacement of the tragus can easily result.Meticulous care should be taken to realign the occipitaland temporal hairline.

Attention is then focused on the portion of the skinflap hammocking the lobule. The skin is sharply dividedto ‘release’ the lobule leaving a significant hammock effecton the lobule. This support on the lobule will helpprevent a satyr ear deformity due to postoperative settlingof the earlobe. The excess skin is trimmed to recreate anatural lobule contour. It is important to minimizetension placed on this closure.

Figure 222.2 The post-auricular incision runs along the

posterior surface of the conchal cartilage with a V-shaped dart

in the posterior limb of the incision as it moves toward the

hairline. This dart acts to break up the scar and prevent scar

contracture.

Figure 222.3 The SMAS flap is elevated just below the

zygomatic arch and elevated anteriorly and inferiorly.


The entire incision is closed in a layered fashion over a1/4 inch penrose or suction drain. The subcutaneous layeris closed with 5-0 polydioxanone sutures. The temporal,preauricular and lobule skin segments are closed with 6-0nylon vertical-mattress sutures. The post-auricular skin isclosed with 5-0 fast-absorbing plain gut suture. Anti-bacterial ointment is applied to all incision lines followedby a dry gauze pressure dressing.

All rhytidectomy patients are observed overnight. Thefollowing morning, the drain is removed and a pressuredressing is reapplied. Antibiotics are prescribed for a totalof ten days postoperatively. Sutures are removed seven to

ten days after surgery. Oedema resolves over several weeksand facial contour stabilizes at approximately four to sixweeks after surgery (Figure 222.5). Erythema of the tragalincision should fade over several months.

SUBMENTAL LIPOSUCTION ANDPLATYSMAPLASTY

When indicated, submental liposuction and platysma-plasty are performed prior to the rhytidectomy. A midlineincision is made within the first well-developed sub-mental skin crease posterior to the mandible. If liposuc-tion alone is planned, this is limited to a 5 mm stabincision. If a wider incision is later needed forplatysmaplasty, the stab incision should be made initiallyto maintain vacuum pressure during liposuction.

A wide variety of liposuction cannulas exists, rangingfrom flat to round-tipped with an array of suction portdesigns. Surface irregularities appear to be minimizedwith the use of smaller cannulas. We prefer pre-tunnellingwith a 2 mm cannula followed by applied low suction.The cannula is inserted into the subcutaneous spacebetween the dermis and platysma. The dominant handcontrols movement of the cannula while the contralateralhand guides tip position. Pre-tunnelling involves limiteddissection to facilitate passage of the larger cannula.Liposuction is performed by dissecting with the cannulain radial fashion away from the incision. One atmosphere(760 mmHg) of negative pressure is usually sufficient. Thesuction port should always be directed away from the skinto minimize dermal trauma and dimpling. Uniformsuctioning is performed across the submental triangledown to the hyoid bone. Liposuction should be limitednear the inferior border of the mandible to avoid injuringthe marginal mandibular nerve. Periodic inspection ofskin using the ‘pinch and roll’ technique helps determinethe degree and extent of liposuction required. A sufficientamount of fat should remain to maintain natural skincushioning.

Figure 222.4 The post-tragal closure requires that the skin

flap over the tragus is tension free. Removal of subcutaneous

fat on the tragal flap will ensure good tragal definition.

(a) (b) (c) (d) (e) (f)

Figure 222.5 This patient underwent rhytidectomy with SMAS imbrication. Chin augmentation was also performed to provide better

skeletal support. (a) Preoperative frontal view; (b) postoperative frontal view; (c) preoperative lateral view; (d) postoperative lateral

view; (e) preoperative oblique view; (f) postoperative oblique view.


Platysmaplasty requires creation of a slightly widersubmental incision. Blunt scissor dissection is used toexpose the medial border of the platysma muscles.Residual fat surrounding the incision and in betweenthe muscles is removed under direct vision. If minorplatysmal banding is present, plication of the exposedmuscle borders across a short distance is sufficient toimprove the submental contour. In patients with severeplatysmal banding, both muscles are horizontally incisedat the level of the hyoid bone. The muscles are thenplicated anterior to this incision, thereby recreating awell-defined cervico-mental angle (Figure 222.6). Thesubmental incision is closed in a layered fashion.

COMPLICATIONS

Haematoma

Haematoma formation is the most common complicationof rhytidectomy. In most modern series, the incidence ofhaematoma is reportedly less than 4 percent.8 A majorityoccur within 48 hours postoperatively and often withinthe initial six to eight hours. Poor hemostasis, extendedskin flaps and severe hypertension9 have all beenpurported to be influential factors. Some haematomasare so small they are considered clinically insignificantand can be observed expectantly. Others result in discretepooling that should be addressed in a timely manner withaspiration using a large-bore needle. Alternatively, a smallstab incision made within a well-developed skin creasewill allow adequate drainage. Application of a pressuredressing may help in preventing recurrent formation.

An expanding haematoma is a surgical emergencyrequiring immediate attention. This is heralded by acuteswelling, pain and discolouration along the buccalsurface. All surgical dressings must be removed and the

skin flaps inspected closely. If flap viability is in question,the immediate removal of consecutive sutures maytemporarily restore adequate circulation. Exploration ofthe wound and evacuation of all visible clot, preferably inthe operating room, is mandatory. In a majority of cases,the specific source of bleeding is never identified.10

Nonetheless, failure to recognize and treat hematoma canresult in abnormal pigmentation, alopecia, skin puckeringand flap necrosis.

Nerve damage

Nerve damage resulting from rhytidectomy is a rareoccurrence. Baker and Conley reported a 0.1 percentincidence of permanent nerve damage in a series of 6500rhytidectomies.11 The most commonly injured branch isthe great auricular nerve. Mechanisms of injury includeinadvertent dissection deep to the sternocleidomastoidfascia, plication of the post-auricular SMAS and trans-mission of thermal electrocautery. In most cases, theintegrity of the nerve has not been disrupted and fullreturn of sensation can be expected.

Branches of the facial nerve are the most commonlyinjured motor nerves in rhytidectomy. Proximity to theplane of dissection, especially during elevation of theSMAS, makes them particularly vulnerable to mechanicalinjury. The frontal nerve is most often injured duringSMAS elevation near the zygomatic arch. Within thisregion, the frontal nerve becomes increasingly superficialas it courses over the middle segment of the arch. Ifsurgical dissection is limited to the posterior one-third ofthe arch, risk to the frontal nerve branch is virtuallynegated. Injury to the marginal mandibular nerve typicallyresults from transection of the platysma or excess SMASretraction near the angle of the mandible. Fortunately,nearly 85 percent of paralyzed motor branches will recoverspontaneously with minimal residual deficits.

Figure 222.6 This patient underwent rhytidectomy with submental liposuction. The platysma muscle was plicated in the midline to

correct the platysmal banding. (a) Preoperative frontal view; (b) postoperative frontal view; (c) preoperative lateral view;

(d) postoperative lateral view.


Skin slough

Skin slough most commonly arises as a consequence ofunrecognized and untreated haematoma. Excess skintension and disruption of the subdermal plexus are alsofrequent causes. The toxic effects of smoking have longbeen recognized as another predisposing factor in skinsloughing.12 The post-auricular flap is at greatest riskbecause skin tension is typically highest in this region.Dependent flap length is also maximal and the skin isrelatively thin along this surface. In general, expectantmanagement with meticulous wound care is the rule forskin sloughing. However, frequent visits and repeatedpatient reassurance are necessary. Superficial epidermalsloughing typically results in an acceptable appearanceafter healing. In cases of full-thickness sloughing, escharformation is seen and serial debridement is required topromote healing by secondary intention. Invariably,patients with full-thickness loss can expect some degreeof hypertrophic scarring and abnormal pigmentation.

Alopecia

Alopecia in the temporal region is a common complica-tion of rhytidectomy and one that is easily avoided withcareful incision design and placement. In some casesalopecia is a transient phenomenon, termed telogeneffluvim, attributed to temporary follicular shock. Inother instances alopecia is more permanent, for example,when the hair follicles have been injured by thermalelectrocautery. If no evidence of regrowth is noted after awaiting period of four to six months, hair restoration canbe attempted using either micrografts or local skin flaps.

Satyr ear deformity

Satyr ear, or ‘devil’s ear’ deformity, results from improperincision placement around the lobule and/or overzealousexcision of the skin flap. Tension caused by postoperativerelaxation of skin leads to an inferior displacement of thelobule and abnormal banding. This complication can beavoided by preserving a tight supporting margin of skinbelow the lobule attachment that actually pulls up on thelobule.

KEY POINTS

� Sun damage to the skin, atrophy of tissuesand the effects of gravity bring on thechanges seen in the ageing face patient.

� Preoperative analysis is critical to determinethe specific needs of the patient.

� Incision placement is critical to help hideincisions and avoid deformity of thehairline.

� Patients must stop smoking cigarettes weeksbefore surgery to avoid vascular compromiseand necrosis of skin flaps.

� Dissection of the skin flaps should be justbelow the level of the subdermal plexus.

� Dissection of the SMAS allows correction ofjowling over the body of the mandible andneck deformity. Placement of tension on theSMAS plication takes tension off the skinclosure.

� The most commonly injured nerve in faceliftsurgery is the greater auricular nerve.

� The incidence of haematoma formation isless than 4 percent.

� Facelift surgery does not provide a long-lasting result as tissues tend to loosen overtime.

Best clinical practice

[ A post-tragal rhytidectomy incision is used in most

female patients, while a pre-tragal incision is used

most commonly in male patients.

[ Elevation of the skin flap and SMAS layer should be

limited to the posterior one-third of the zygomatic

arch to avoid injuring the frontal nerve branch.

[ The post-auricular skin flap is suspended superiorly

and anteriorly, while the pre-auricular skin flap is

suspended superiorly and posteriorly. It is imperative

to avoid tension on any portion of the skin flap.

[ Submental liposuction and/or platysmaplasty should

be considered in patients with neck fullness not

attributed to excess skin alone.

[ Postoperative haematoma formation requires timely

assessment and intervention to minimize chances of

a suboptimal aesthetic outcome.

Deficiencies in current knowledge andareas for future research

$ Advances in facelift surgery should make use of other

methods of suspension to help provide a longer

lasting result.

$ In the future, nonsurgical intervention should be able

to slow the process of ageing and decrease the need

for invasive facelift surgery.


REFERENCES

1. Skoog T. Plastic surgery: new methods and refinements.

Philadelphia, PA: WB Saunders Co, 1974.

2. Mitz V, Peyronie M. The superficial musculo-aponeurotic

system (SMAS) in the parotid and cheek area. Plastic andReconstructive Surgery. 1976; 58: 80–8.

3. Yaar M, Gilchrest BA. Cellular and molecular mechanisms

of cutaneous ageing. Journal of Dermatologic Surgery andOncology. 1990; 16: 915.

4. Zimbler MS, Kokaska MS, Thomas JR. Anatomy and

pathophysiology of facial aging. Facial Plastic SurgeryClinics of North America. 2001; 9: 1–9.

5. Edgerton MT et al. Surgical results and psychological

changes following rhytidectomy. Plastic andReconstructive Surgery. 1964; 33: 503–21.

6. Goin MK, Burgoyne RW, Goin JM. Face-lift operation: the

patient’s secret motivations and reactions to ‘informed

consent’. Plastic and Reconstructive Surgery. 1976; 58:

273–9.

7. Rees TD, Aston SJ. Complications of rhytidectomy. Clinicsin Plastic Surgery. 1978; 5: 109.

8. Larrabee WF, Ridenour BD. Rhytidectomy: technique and

complications. American Journal of Otolaryngology. 1992;

13: 1–5.

9. Straith RE, Raju D, Hipps C. The study of hematomas in

500 consecutive facelifts. Plastic and ReconstructiveSurgery. 1977; 59: 694–8.

10. Pitanguy I, Ceravolo MP. Hematoma postrhytidectomy:

how we treat it. Plastic and Reconstructive Surgery. 1981;

4: 526–8.

11. Baker DC, Conley J. Avoiding facial nerve injury in

rhytidectomy. Plastic and Reconstructive Surgery. 1979;

64: 781–95.

12. Rees TD, Liverett DM, Guy CL. The effect of cigarette

smoking on skin survival in the face lift patient.

Plastic and Reconstructive Surgery. 1984; 73:

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