浅表肌腱膜系统多重悬吊的全颜面除皱术

目的探索一种操作简单、安全、效果持久的全颜面除皱术式，以利于推广应用。方法采用浅表肌腱膜系统(superficial musclo-aponeurotic system，SMAS)多重悬吊法进行全颜面除皱术，首先进行广泛皮下组织分离；接着应用1号丝线折叠缝合切口前1～2cm的SMAS，缝合间距1cm，折叠量约1～2cm，将颈阔肌后缘略做分离，向后上与胸锁乳突肌筋膜缝合；再用4-0可吸收线将眼轮匝肌及口角、鼻翼附近的SMAS分区向外上悬吊缝合。结果两年来临床应用此法为48例进行手术，术后随访6～16个月，无面神经损伤、血肿等严重并发症，受术者对手术效果均满意。并发症包括：颞部秃发3例，暂时性不对称2例，耳后瘢痕增生2例。结论本法克服了单纯皮下分离除皱时疗效不持久的缺点，避免分离SMAS造成的面神经损伤。实践证明，SMAS多重悬吊的全颜面除皱术是一种操作简单、安全、效果持久的除皱术式。     

传统面部除皱术结合QUILL悬吊SMAS中面部年轻化

目的探讨传统的面部除皱术结合可吸收双向倒刺线(QUILL)悬吊SMAS,实现中面部年轻化的效果。方法在传统面部除皱术基础上显露SMAS,并在SMAS上置入QUILL,利用QUILL对脂肪垫、韧带及SMAS进行悬吊并固定于颧弓韧带,实现面部松弛下垂组织整体复位;无张力切除多余皮肤,美容线缝合切口。结果本组共27例患者,切口均一期愈合。其中,2例患者早期有轻度淤青,无面瘫和血肿等并发症。术后获随访6个月,患者的面部皮肤紧致,鼻唇沟无加深,除皱效果较满意。结论在传统除皱术的基础上使用QUILL进行面部SMAS悬吊,可达到脂肪垫的复位与固定,术后面部年轻化效果较满意。     

改良中面部除皱术在临床中的应用

目的探讨改良中面部除皱手术的方法，以及手术要点与优势。方法对43例面中部皮肤及软组织松弛的女性，采用颞部“w”形＋耳前倒“L”形切口，在皮下和SMAS筋膜之间分离组织间隙达到设计范围，并在耳前纵向解剖分离一“舌形”SMAS筋膜瓣，大小约2．5em×1．5cm；将筋膜瓣掀开，在SMAS筋膜前侧断缘，斜向上45。对位拉紧缝合，使口角上提，鼻唇沟变浅；再将预制的SMAS筋膜瓣向上提紧，缝合固定于颧弓处；下颌缘及部分颈部皮肤上提，去除颞部及耳前多余皮肤并缝合固定。结果本组共43例患者，术后随访3～18个月，鼻唇沟明显变浅，下颌缘及颈部形态清晰，效果满意。结论采用改良中面部除皱术能有效改善口角、鼻唇沟、下颊部及部分颈部的皮肤松弛，同时手术切口张力小，瘢痕不明显，位置隐蔽，且术后皮肤紧致、弹性好，表情自然，值得临床推广应用。     

双层面两阶梯递进式接力提升面中部除皱术

目的:探讨颞部双层面分离、固定除皱术递进式接力于中面部,双层面分离后提升固定,两阶梯复合术式在面中部年轻化中的应用疗效.方法:应用颞部皮下和颞中筋膜下双层面分离颞部除皱术接力于下睑皮下和眼轮匝肌下,直到眶下部骨膜浅层的双层面分离,眶肌筋膜韧带(王韧带)松解、切断,提升,并将王韧带固定于眶外侧骨膜或外眦韧带上,解决中老年人面中部皮肤和眼轮匝肌松弛、皱纹.眶隔脂肪突出等老化问题.9例患者因泪槽畸形而同时行眶隔脂肪弓状缘释放.结果:本组69例患者均施行了双层面两阶梯递进式接力提升面中部除皱术.术后随访3～18个月,均取得满意效果.结论:双层面两阶梯递进式接力提升除皱术治疗面中部老化疗效可靠.     

分段SMAS提紧法面部年轻化手术

目的 探询一种有效、持久、简便的面部年轻化手术方法.方法 在面部除皱术中紧贴皮下进行广泛分离,注意保持SMAS层的完整性,并对其进行远近端两段折叠悬吊.然后提紧皮肤,去除松弛多余的皮肤组织.结果 自2003年10月至2006年2月对38例患者实行此种手术,随访1个月～27个月,近、远期均取得良好的年轻化效果,未发现面神经瘫痪等严重并发症.结论 对SMAS层进行分段悬吊提紧可取得有效持久的年轻化效果,且简便易学,值得推广.     

SMAS筋膜瓣双重悬吊在面中部除皱术中的应用

目的探讨面中部除皱术中的SMAS筋膜瓣悬吊方法及效果。方法2002年1月-2008年12月期间,共有10例面中部皮肤及软组织松弛就医者在面中部除皱术中采用SMAS筋膜瓣双重悬吊方法即在耳轮脚、耳屏做切口及颞部作“W”型切口,将预制的SMAS筋膜瓣边折叠后,向上、向外缝合数针固定于颧弓表面软组织及耳前SMAS筋膜瓣;以4#丝线行面中部双环荷包缝合SMAS筋膜,固定于耳前颧弓上方的颞深筋膜上,形成向上、向外的上提力量;去除颞部及耳前多余皮肤并缝合固定。结果本组10例就医者均取得较好效果。具有创口小而隐蔽、出血少等优点,可使面部变得年轻,随访1～5年,面中部皮肤仍收紧且富于弹性,颧脂肪垫下垂、加深的颧颊沟、下颌脂肪堆积、加深的鼻唇沟以及皮肤松垂等均得到改善,就医者较为满意。结论SMAS筋膜瓣双重悬吊术对面中部皮肤松弛有较好的提紧效果,方法简便,效果确实持久,易于推广。     

颧脂肪垫悬吊技术辅以SMAS折叠的中面部除皱术

目的：出于中面部提升简单化的趋势,介绍一种颧脂肪垫提升和SMAS移位的除皱技术。以期改善颧下区域空虚、鼻唇沟加深等中面部老化的问题。方法：采用一种中面部年轻化方法,行颊部耳前SMAS折叠,同时将下垂的颧脂垫缝线悬吊于耳前筋膜,使老化中面部维持长期的提升效果。结果：2006～2010年,在52例面部除皱术中运用该技术,中面部提升效果维持时间长,恢复期短,无面神经损伤等严重并发症出现。结论：皮下层的安全剥离避免了面神经分支的损伤。颧脂肪垫悬吊技术辅以SMAS折叠术,避免了较长的恢复期和深层剥离可能导致的损伤。这种方法可作为独立的中面部手术在局麻下实施,操作简单、安全、效果持久。     

上提折叠面中部软组织的面部三维除皱术

目的：在面部除皱中为了使患者恢复年轻时的面部轮廓，达到三维除皱效果，延长有效时间，从理论及实际观察中探讨面中份老年化及面部轮廓改变形成的原因，并通过相应手术方法进行矫正。方法：全麻下进行全面部除皱术，术中在皮下、SMAS筋膜及骨膜下广泛分离，在面颊部，颧弓下定一关键点，并在此上提折叠面颊部皮下软组织及移位折叠SMASA筋膜，下垂脂肪上提复位。结果：从2002年2月至2003年5月，完成手术12例，术后患者面部轮廓改善明显，除皱效果满意。结论：本手术方法旨在通过折叠上提面颊部皮下软组织及移位折叠SMAS筋膜，使面部松弛软组织向上和外侧方向牵拉同时使软组织向前方隆起，从而重塑年轻时的面部轮廓达到三维除皱效果。     

两级递进式提紧浅表肌腱膜系统除皱术

目的探讨两级递进式提紧面部浅表肌腱膜系统（superficial muscular aponeurotic system，SMAS）-颈阔肌除皱术效果。方法颞面颈部皮下小范围分离，颞区颞深筋膜浅面大范围分离，面颈部SMAS-颈阔肌下大范围分离，离断SMAS-颧颊部韧带。分SMAS-颈阔肌瓣为前、后两叶。先提紧前叶：在其前下方最远处以3-0涤纶线横褥式缝1针向后上提紧固定在SMAS的后上切缘处；再在其后上方以褥式缝合固定在颧弓根部骨膜上。后提紧后叶：在其前下方最远处以3-0涤纶线横褥式缝合，向后提紧固定在SMAS瓣的后切缘处；再在其后方横褥式缝合固定在胸锁乳突肌腱膜上。颞支蒂瓣也以两级递进式提紧固定，重建颈阔肌-耳韧带。额部除皱术的操作要点是确切地切除皱眉肌、降眉肌和额肌。结果共施术284例，绝大部分结果令医者与受术者双方满意。仅有9例发生中度（15～20ml）血肿，8例耳后乳突区皮瓣早期血运不良，经及时处理无不良后果产生。结论两级递进式提紧固定SMAS-颈阔肌瓣和颞支蒂瓣，对于提紧表情区，特别是鼻唇沟附近、颌缘前段的软组织松垂，具有比较明显的效果，但是对于静态脸型或（和）动态脸型比较宽大者，上述方法的效果不明显。     

全面部复合除皱术30例分析

目的 探讨一种可以整体上提面中、上部,并解决睑袋、颧部皮肤软组织松弛、鱼尾纹、额纹、鼻唇沟过深的复合除皱术.方法 自2008年2月至2011年5月,共对30例患者施行全面部复合除皱术.额颞部选择发际缘切口与额部切口入路,颞部在颞深筋膜浅层剥离至颞肌前缘及眶外缘,额部在帽状腱膜下剥离至眶上缘及鼻根部,并在眉上1.0cm处及两侧眉峰间离断额肌、皱眉肌和降眉肌.联合应用耳前、耳后切口,行面中、下部超过鼻唇沟的广泛皮下及SMAS下剥离,分别向上、后、乳突3个方向悬吊,对松弛的眼轮匝肌进行悬吊,并将颧脂肪垫向外上方悬吊、固定于颧骨体表面.对于睑袋及颧部松弛严重者,辅以睑袋切口,在面中部骨膜下分离颧骨上分离至鼻唇沟外上1.5cm并悬吊.结果 本组30例患者,术后随访6～24个月,额纹、眉间纹、鱼尾纹、鼻唇沟过深、面中部组织松弛等问题均得以改善,无血肿、面瘫等并发症发生,效果满意.结论 全面部复合除皱术可从根本上改善老年患者面部组织松垂问题,效果持久,只要严格手术操作,避开重要血管、神经及其分支,可作为一种安全、可靠的面部年轻化手术的选择.     

鼻唇沟区域解剖学研究

目的 对颌面整形美容外科提供形态学依据。方法 对20例成人新鲜尸头行10％福尔马林血管灌注固定后，在手术放大镜下进行形态学观测。结果 ①首次对少数国人与鼻唇沟区域相关的各表情肌逐块进行长、宽、厚的显微解剖测量。②测得鼻唇沟内侧脂肪厚度为1．3mm，外侧为4．5mm。③鼻唇沟内侧真皮层有肌纤维附着，外侧也有稀少肌束附着。④面部有浅肌肉宰不但存在腱膜，还由筋膜、肌肉、腱膜共同构成一个立体网状结构。结论 进一步证实了有关SMAS中央腱的理论假说。     

鼻唇沟区域解剖学研究

目的对颌面整形美容外科提供形态学依据。方法对２０侧成人新鲜尸头行１０％福尔马林血管灌注固定后,在手术放大镜下进行形态学观测。结果①首次对少数国人与鼻唇沟区域相关的各表情肌逐块进行长、宽、厚的显微解剖测量。②测得鼻唇沟内侧脂肪厚度为１３ｍｍ,外侧为４５ｍｍ。③鼻唇沟内侧真皮层有肌纤维附着,外侧也有稀少肌束附着。④面部表浅肌肉之间不但存在腱膜,还由筋膜、肌肉、腱膜共同构成一个立体网状结构。结论进一步证实了有关ＳＭＡＳ中央腱的理论假说。     

Treatment of the Aging Face Using the “Round-lifting” Technique

Background: Characteristics of the aging face include not only senescence and flaccidity of the skin, but also sagging of deeper tissues, especially in the fascial and fatty layers. Objective: This study was undertaken to evaluate the different surgical approaches to the aging face, specifically the techniques available for correction of the prominent nasolabial fold, which is a significant sign of facial aging. Methods: Through a total of 7446 cases in more than 40 years of experience in the surgical correction of the aging face, the senior author has emphasized the importance of the repositioning of the skin and the facial soft tissues. After appropriate treatment of the superficial musculoaponeurotic system (SMAS) and the malar fat pad has been completed, adequate placement of the skin flaps is done by rotation, as described in the round-lifting technique, rather than by direct traction. The anatomic basis of this correction is discussed. Results: Traction of the SMAS was found to soften the appearance of the nasolabial fold to varying degrees, but other complementary procedures such as collagen injection or fat grafting often were necessary to achieve a more satisfactory correction. Durability of nasolabial fold correction with simple SMAS traction varied with each individual and his or her unique aging process. Simple traction of the SMAS did not include treatment of the fascial fatty layer. The senior author has included the treatment of the fascial fatty layer in his standard rhytidectomy over the last 2 years, with improved aesthetic results. Again, long-term correction by this technique is related to the aging process, and the final result was deemed superior to treatment of the SMAS alone. Direct excision of the nasolabial fold was performed in patients ranging from 35 to 60 years of age who had extremely prominent folds. In these very select cases, the results were considered satisfactory to both the surgeon and patient, with correction of the fold and acceptable scars. Conclusions: There is as yet no ideal solution for the surgical correction of the naso-labial fold component of the aging face. However, all of the techniques described are considered safe and have precise indications. It should be stressed to the patient that the nasolabial fold is part of the anatomy of the face and that the goal of treatment is to soften the appearance of the fold, not to eliminate it completely.     

Autologous superficial musculoaponeurotic system graft as implantable filler in nasolabial fold correction

OBJECTIVE: To determine whether superficial musculoaponeurotic system (SMAS) graft implantation can improve the appearance of the nasolabial fold. METHODS: Single-blinded cohort study in a private facial plastic surgery practice. Treatment and control patients were selected from those presenting for aesthetic surgery. All patients underwent rhytidectomy with SMAS imbrication by a single surgeon. In addition, treatment patients underwent subcutaneous implantation of excised SMAS strips to the nasolabial fold. Treatment and control patients were matched for any other simultaneous procedures known to affect appearance of the nasolabial folds. Preoperative and postoperative photographs were graded by 3 blinded observers using the Wrinkle Severity Rating Scale to evaluate the nasolabial fold. Postoperative photographs were evaluated approximately 3 months and again 1 year after the procedure. RESULTS: Compared with controls, there was a significant difference in the nasolabial folds of patients undergoing SMAS implantation at the 3-month postoperative evaluation (P = .03; chi(2) = 4.696). This benefit was lost when the results were evaluated 1 year after the procedure (P = .88; chi(2) = 0.0212). CONCLUSION: Superficial musculoaponeurotic system implantation to the nasolabial folds offers modest temporary improvement to this area in patients undergoing rhytidectomy with SMAS imbrication.     

广泛多层次剥离复合除皱术

目的　矫正鼻唇沟过深、颌下线中断等面中下部老化表现。方法　行面中下部超过鼻唇沟的广泛皮下及SMAS下剥离 ,将掀起的SMAS瓣 ,依耳轮脚及耳垂下极水平分成三份 ,分别向上、后、乳突方向悬吊 ,对松弛的眼轮匝肌进行紧缩和悬吊 ,将颧脂肪垫向外上方向牵拉固定于颧骨体表面筋膜 ,去除部分过度增厚的颧脂肪垫。结果　12例面中部老化明显者 ,手术后随访 5个月至 3年 ,效果良好 ,无面瘫、血肿等并发症。结论　该术式对鼻唇沟面中下部老化表现矫正十分安全有效     

Anatomy of the SMAS Revisited

Despite the relevance of the superficial musculoaponeurotic system (SMAS) in facial rejuvenation a clear anatomic definition of the SMAS is still lacking. Therefore, the morphology of the SMAS in 18 cadavers was investigated using different macroscopic and microscopic techniques. The region-specific anatomy of the SMAS is described in the forehead, parotid, zygomatic, and infraorbital regions, the nasolabial fold, and the lower lip. The SMAS is one continuous, organized fibrous network connecting the facial muscles with the dermis. It consists of a three-dimensional scaffold of collagen fibers, elastic fibers, and fat cells. Two different types of SMAS morphology were demonstrated: type 1 SMAS architecture is located lateral to the nasolabial fold with relatively small fibrous septa enclosing lobules of fat cells, whereas type 2 architecture is located medial to the nasolabial fold, where the SMAS consists of a dense collagen–muscle fiber meshwork. Overall, it was demonstrated that different facial regions show specific morphological characteristics, and thus region-specific surgical interventions may be necessary in facial rejuvenation.     

Superextended facelift: our experience with 3,580 patients

Our experience using the "Superextended" facelifting technique in 3580 female patients is presented herein. The technique is based on extended subcutaneous facial and neck skin undermining, extensive superficial musculoaponeurotic system (SMAS) dissection with low lateral freeing of the edges of the platysma muscle. The trimmed SMAS is fixed to the adjacent tissues, enabling the upward and lateral pulling effect of the facial structures. The neck contour is rebuilt by lateral pulling and fixing of the dissected lateral platysmal edges, along the entire neck, and meticulous supraplatysmal fat sculpturing. The skin is redraped over the newly built SMAS and platysmal skeleton, trimmed, and sutured without any tension. The concept of beauty in the eyes of the surgeon is expressed by adding other ancillary procedures during or shortly after the main procedure. Subcutaneous forehead lift using the hairline incision was performed in 70% of the female patients, concomitantly with the face-lifting procedure. Upper and lower blepharoplasties, chin implant, perioral dermabrasion, rhinoplasty, and fat grafting have been performed according to the surgeon's judgment and the patient's request. The objectives of an ideal facial surgery, which are youthful, natural, dynamic, attractive, feminine, and long-lasting results, can be achieved using this technique. Lack of major complications and an overall minor complications rate of only 4.4% makes this technique safe, reproducible, and reliable. This is one of the largest presented series of this procedure, performed by 1 surgeon. The presented cases demonstrate the results obtained using this technique.     

The RSVP Facelift: A Highly Vascular Flap Permitting Safe, Simultaneous, Comprehensive Facial Rejuvenation in One Operative Setting

This study describes our effort to develop a reliably safe method for combining currently available treatment modalities in an effort to obtain comprehensive facial rejuvenation in one operative setting. Detailed evaluation of 101 available consecutive patients, their per- and postoperative photos and charts was undertaken. Five groups of patients were studied: (1) traditional facelift with wide subcutaneous undermining and SMAS plication. (2) Similar traditional facelift with regional laser resurfacing. (3) RSVP (rejuvenation with sparing of vascular perforators) facelift. Subcutaneous undermining stops 3 cm lateral to the nasolabial fold to preserve the rich angular/facial arterial supply and venous drainage, still permitting lateral SMASectomy or SMAS plication. Subcutaneous neck undermining is discontinuous, the posterior dissection being limited to that which is necessary for identification of the posterior edge of the platysma and its plication to the mastoid and SCM muscle. The anterior dissection is limited to that necessary for anterior platysmal repair leaving intact a vertical subcutaneous non-undermined zone 4–6 cm in width, preserving the submental perforating artery. If indicated, gentle liposuction with a fine cannula is performed through this area. (4) RSVP facelift and regional laser resurfacing. (5) RSVP facelift with total facial laser resurfacing. Mean follow-up was 13.6 months, minimum 6 months. There were no additional major complications associated with the addition of laser resurfacing or fat grafting to the RSVP group. The patients with laser resurfacing were pleased with their result, and estimated that their apparent age had been reduced by a mean of 10.4 years, compared with 6.6 years for the non-lased group. We conclude that the RSVP flap is a hardy, vascular flap permitting simultaneous laser resurfacing, fat grafting, and other adjunctive procedures without significant fear of flap loss.     

容量提升理论指导下的鼻唇沟填充技术

目的探讨一种能够同时解决皮肤松垂和容量流失问题的鼻唇沟填充技术，力求恢复年轻时中面部软组织的分布特征，达到自然流畅的年轻化效果。方法采用点状注射法进行深内侧脂肪室的填充，形成深部支撑提升；以扇状注射法进行白唇真皮深层的填充，补充鼻唇沟内下方的缺失。在美学颧突点到鼻唇沟的垂线上进行多层次的连续线状注射，补充中面部的容量流失，重塑中面部年轻化曲线，拉升鼻唇沟外上方的皮肤松垂。结果本组共418例患者，其中412例患者的老化鼻唇沟得到明显改善，使面部呈现年轻化效果；6例患者的老化鼻唇沟得到一定程度改善，效果基本满意。37例患者在治疗后出现局部皮下淤血、青紫，于10d内消失。最佳效果维持时间6—12个月。结论恢复年轻时面部软组织分布特征的填充术，是一种针对面部老化后解剖学改变特点的注射填充技术，能够有效地恢复自然年轻态的鼻唇沟，并在一定程度上可达到面中部提升的效果。