CB AA TT Arch Otolaryngol Head Neck Surg Plast Reconstr ...

Rhytidectomy (updated 06/06)

1. TT Give us a table of facelift complications. How would you treat each?

2. CB Discuss the anatomy of the SMAS, platysma and the facial nerve. Please
help us understand the temporal fascia. Do the nerves travel in the superficial
layer of the deep temporal fascia, or the deep layer of the superficial temporal
fascia? I am so confused!

3. AA A middle aged woman inquires about a facelift. She wants a dramatic
result. Her friend recently underwent a subperiosteal facelift with a well-known
plastic surgeon. How is this procedure performed? What are its shortcomings?
How does this differ from the deep plane facelift? What is a composite facelift?

4. TT A patient seeks your expert opinion on the management of her deep
nasolabial folds. What are her options? Arch Otolaryngol Head Neck Surg
1999;125:456 and Plast Reconstr Surg 1999;104:1502.

5. HH Is it safe to lift and peel at the same time? Plast Reconstr Surg
1998;102:2480 and Plast Reconstr Surg 1994;93:86.

Yes. Originally, there was fear of skin slough with combined lift and peel;
however, with the advent of deep –plane face lift, this was reexamined.

Simultaneous Deep-Plane Face Lift and Trichloroacetic Acid Peel:
- University of Utah
- dual study:

- 47 porcine flaps (Yucatan minipig) treated with variety of chemoabrasion
agents, determined that 35% trichloroacetic acid was safe (all phenol
peels showed significant shrinkage and thick dermal scar)
- 35 patients underwent modified deep-plane facelift (deep to
subcutaneous fat: subgaleal in forehead, sub-SMAS in midface, on
surface of platysma in neck) along with immediate trichloroacetic acid peel
with 35% the maximum concentration on undermined areas. They had
good results with no complications.

Simultaneous Face Lifting and Skin Resurfacing
- private practice in Newport Beach, CA
- 25 patients who underwent skin resurfacing with tricholoracetic acid peel (20-
30%) or “short pulse” CO2 laser then were lifted after liposuction and SMAS
tightening. 2 patients with partial flap necrosis – one area behind the ear that
was not resurfaced and one area just anterior to the tragus in a patient who was
a “closet” smoker.

- skin preconditioned with vit A/glycolic acid for 6-8 weeks before surgery
- Jessner-trichloroacetic acid peel is used alone on the chest, neck and
face or on chest and neck in combination with the laser resurfacing. (3-4

coats of Jessner then trichloroacetic acid until development of light “foggy”
white frost on skin.
- skin resurfacing –

- ultrapulse CO2 laser using computer pattern generator to 1cm
below jawline; produces 5-10mm of browlift that remains during 2
year follow up
- tru pulse method – more superficial with less persistent erythema
- liposuction and platysmaplasty – neck, jowls, and nasolabial folds are
liposuctioned, superior 1/3 of platysmal bands are plicated with running,
locking 4-0 suture, 3-4cm of muscle bands distal to plication are excised.
- lift – flap elevation performed with liposuction then iconoclast elevator

6. TT What are the retaining ligaments of the face and why are they important?
Plast Reconstr Surg 1192;89: 441-449.

7. CB Discuss the anatomy of the SMAS, platysma and the facial nerve.

8. CB Discuss the blood supply of a face lift flap.

9. CB Describe the anatomy of nasolabial folds.

10. HH Correct an aging neck. Arch Otolarygol Head Neck Surg 1991;117:40.
(UCLA)

Four submental parameters must be assessed:
1. skin – widely undermined skin-subcutaneous musculoaponeurotic system
rhytidectomy
2. fat – excess submental and submandibular fat removed with liposuction
3. muscle – anterior platysmal banding treated with sectioning through lateral
approach if minimal, if more severe, then midline submental incision is used
4. chin – micrognathia may require augmentation

class skin fat Anterior bands micrognathia procedure
1 +- - +/- Rhytidectomy
2 ++ - +/- Rhytidectomy, submental
suction
3 + +/- + +/- Rhytidectomy, submental
suction, APB section lateral
4 + +/- ++ +/- approach
Rhytidectomy, submental
suction, APB section and
plication

11. HH Discuss cervical suspension. Arch Otolarygol Head Neck Surg
1993;119:694.

University of Toronto, 7 pts, first 3 required repositioning and tightening

Particularly problematic anatomic features:
- an abundance of submental superficial and deep-to-the-platysma fatty tissue
- ptotic submandibular glands
- vertical platysma muscle bands
- short and stocky neck
- low positioned hyoid

Technique: incisions made as for standard rhytidectomy with preauricular and
postauricular incisions as well as a 2cm long submental liposuction incision.
Undermining is accomplished with liposuction cannula. A 1mm gortex patch is
cut in the shape of the Mercedes logo and impregnated with bacitracin solution.
It is introduced into the submental area via the lateral incisions. The gortex
membrane was initially attached to the mandible at three points (the mentum and
two angles). However, this was time-consuming and hindered tightening of the
lateral limbs. Instead, they began to use 2-0 nonabsorbable ethibond suture
attaching the goretex to the mandibular periosteum in the midline and just behind
the posterior margin of the masseter at both angles. The membrane is tightened
during the attachment to give a flattened submandibular plane. Laterally, the
SMAS-platysma is plicated to the fascia of the SCM and the periosteum of the
mastoid. A facelift is then completed in the routine fashion.

Advantages:
- Better support to ptotic submandibular glands
- eliminates the contour irregularities caused by bunching of cut and retracted
muscle or of the lumps of subplatysmal fat
- avoids formation of submental depression that follows subplatysma lipectomy or
excessive subcutaneous fat removal
- creates an improved cervicomental angle by producing a better-positioned new
hyoid point

12. AA How do deep-plane and composite rhytidectomies compare to the
traditional SMAS procedures? Fac Plast Surg 1996;12:231.

13. Discuss wrinkle fillers-such as gortex, collagen, fat, etc.

14. AA Should you treat the male face lifts patients differently?

15. AA What is Thermage? Does it really work or is it a gimmick?