Anatomical basis for a safe and easier approach to composite rhytidectomy

The authors present the anatomical findings that have made an easier approach to composite rhytidectomy possible. The lower lateral border of the orbicularis oculi muscle (OOM) overlies the zygomaticus major muscle (ZMM), the upper third of which tightly adheres to the malar bone. The OOM is innervated throughout over its circumference by a plexus of small facial nerve branches. From its deeper surface, the ZMM is innervated by two to four branches in its upper third and middle third. These branches are jeopardized in an extended sub-SMAS dissection as this tends to go deep into the ZMM. The malar fat pad is superficial to the SMAS layer that invests the zygomaticus and levator labii muscles and, with age, tends to slide downward, medially deepening the nasolabial folds. An extended dissection beyond the OOM tends to remain superficial to the upper part of the ZMM, zygomaticus minor, and levator muscle complex. We have found that extending the suborbicularis dissection inferiorly and laterally offers three major advantages: (1) The correct deep subcutaneous plane just above the ZMM, zygomaticus minor muscle, and levator complex can be found easily, leaving all of the fat attached to the skin. The only structures at risk are some minor motor branches to the OOM that can be divided without any morbidity because of the extensive plexiform innervation. (2) A. change in the plane from a sub-SMAS to a deep subcutaneous dissection over the ZMM can be made easily and safely by means of separate dissections for the lateral and the medial parts of the cheek with the ZMM acting as a watershed area; the two dissections can then be united under direct vision avoiding any trauma to the muscle or motor nerve branches. (3) The correct repositioning and deep fixation of the malar fat pad is easily performed. This approach has been applied successfully in 19 patients without any complications. We believe that the correct performance of this technical modification, which provides the same composite flaps as those described by Hamra, is easier and may be safer than the standard lateral approach.Presented at the XIIth International Congress of the International Society of Aesthetic Plastic Surgery, Paris, France, September 1993     

现代面部除皱术的面神经解剖学研究

目的明确ＳＭＡＳ与面神经的关系。方法对１２具（２４侧）成人尸头行大体解剖观察。结果ＳＭＡＳ分布于面中部,向前逐渐变薄,于口角水平外侧有小范围的“洞区”。面神经出腮腺后,并非在ＳＭＡＳ深面,而是在咬肌筋膜深面走行。面神经额支在颧弓以下０５ｃｍ区域穿出深筋膜,跨过颧弓。在颊脂肪垫区,大部分面神经分支走行在垫内,小部分分支形成面神经丛,分布于其表面。在颧大肌表面上１／３恒定有一颧支跨过,支配眼轮匝肌下外侧９例（占３７５％）;颧大、小肌及眼轮匝肌８例（占３３３％）;颧大、小肌７例（占２９２％）。结论面部多层次剥离除皱术应在颧弓以下０５ｃｍ区域行ＳＭＡＳ下剥离,至面中部时,应注意保护颧大肌表面上１／３段的面神经颧支,只在颧大肌中下２／３段区域进行剥离,向内掀起颧脂肪垫;或通过下睑缘皮肤切口,向下掀起眼轮匝肌（注意保护位于颧大肌上１／３段的面神经颧支）,与经耳前ＳＭＡＳ下剥离腔隙连通,如上操作可避免面神经损伤。     

现代面中除皱术的面神经解剖学研究

目的 明确ＳＭＡＳ与面神经的关系。方法 对１２具（２４例）成人尸头行大体解剖观察。结果 ＳＭＡＳ分布于面中部,向前逐渐变薄,于口角水平外侧水小范围的“洞区”。面神经出腮腺后,并非在ＳＭＡＳ深面。而是在咬肌筋膜深面走行。面神经额支在颧弓以下０．５ｃｍ区域穿出深筋膜,跨过颧弓。在颊脂肪垫区,大部分神经分支走行在垫内,小部分分支形成面神经丛,分布于其表面。在颧大肌表面上１／３恒定有一颧支跨过,支配眼轮匝     

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     

鼻唇沟除皱术局部解剖学与临床应用研究

目的 提高鼻唇沟除皱手术效果。方法 对１０例成人尸体２０侧鼻唇沟局部解剖及组织切片研究,发现鼻唇沟形成机理,改进手术方法。结果 提出表情肌长期反复运动使得皮肤－皮下组织与ＳＭＡＳ－表情肌之间产生剪切就力及向下相对位移,鼻唇沟部位上下两种质地、结构密度相差较大的组织之间产生相对运动,形成了鼻唇沟及鼻唇沟脊。采用新手术方法为１３例患者进行鼻唇沟除皱手术,获得较好的近期及远期效果。结论 鼻唇沟除皱手术须     

颞部发际缘保留毛囊锯齿形切口除皱术

目的 探讨颞部发际缘保留毛囊锯齿形切口除皱术在临床中的应用。方法 采用颞部发际缘保留毛囊锯齿形切口、眼轮匝肌悬吊固定、SMAS折叠缝合的方法,提升下垂的外眦角和颧部,去除鱼尾纹,减轻较深的鼻唇沟。结果 本组66例患者,其中58例患者经6个月至3年的随访,除2例患者左侧、1例患者右侧切口前缘无毛发生长外,余者切口愈合佳且前缘有毛发生长隐蔽性好,鱼尾纹明显减轻,下垂的外眦角和颧部、较深的鼻唇沟有较明显的改善。结论 颞部发际缘保留毛囊锯齿形切口、眼轮匝肌悬吊固定、SMAS折叠缝合的手术方法是一种简便、安全、有效且切口隐蔽的较新的除皱方法。     

Temporoparietal Fascia Plication in Rhytidectomy

Background The temporal region has a complex subcutaneous fascial structure known as the temporoparietal fascia, which is part of the subcutaneous musculoaponeurotic system. The temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) of the face in the inferior border, the frontalis muscle, and the orbicularis oculi muscle in the anterior border. Therefore, a properly planned temporoparietal fascia plication can increase the tightness of the SMAS. In addition, plication of the temporoparietal fascia can provide lifting to decrease lateral canthal wrinkles with elevation of the lateral brows in rhytidectomy. Furthermore, plication of the temporoparietal fascia can yield deep tissue support, which prevents alopecia and visible scar formation in the temporal region by decreasing the tension along the skin incision. Methods Plication of the temporoparietal fascia was performed for 16 patients who had undergone face-lifts over the previous 10 years. Careful subcutaneous dissection, performed immediately under the hair follicles to avoid frontal nerve injury, provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy and protects the auriculotemporal nerve and the superficial temporal vessels. Results There were no complications such as hematoma, facial nerve injury, alopecia, or visible scar formation attributable to the temporoparietal fascia plication. Conclusion Temporoparietal fascia plication can be performed simply during rhytidectomy as an additional procedure. It not only augments the effects of the rhytidectomy, especially in the lateral brows, the lateral canthal, and the temporal regions, but also decreases the risk of possible complications.     

鼻唇沟除皱术的局部解剖学与临床应用研究

目的提高鼻唇沟除皱手术效果。方法对１０例成人尸体２０侧鼻唇沟局部解剖及组织切片研究，发现鼻唇沟形成机理，改进手术方法。结果提出表情肌长期反复运动使得皮肤—皮下组织与ＳＭＡＳ—表情肌之间产生剪切应力及向下相对位移，鼻唇沟部位上下两种质地、结构密度相差较大的组织之间产生相对运动，形成了鼻唇沟及鼻唇沟脊。采用新手术方法为１３例患者进行鼻唇沟除皱手术，获得较好的近期及远期效果。结论鼻唇沟除皱手术须在ＳＭＡＳ表面、皮下组织深面正确层次中进行，切断ＳＭＡＳ与表情肌及上唇的联系，解剖复位颧颊部组织，重建颧弓韧带。     

面神经分支在颞区的显微解剖学研究

目的 明确面神经在颞区的分布层次和范围，指导面部年轻化手术的操作入路。方法 12具(24侧)成人尸头标本，于5倍光学显微镜下行颞区的解剖观察。结果 颞区包含面神经的颞支和颧支：由面神经的上支分出，出腮腺上缘，颞支发出3～8个分支、颧支2～4个分支，行于颞浅筋膜深面。颞支越过颧弓至颞区，分布于额肌、眼轮匝肌、皱眉肌和耳周围肌等组织，主导其运动；颧支由腮腺上缘向前上方越过颧弓至外眦，支配眼轮匝肌和颧肌的运动；两支之间以及与眼神经的眶上神经和泪腺神经之间．都有交通支。结论 面神经的颞支和颧支分布在颞浅筋膜的深面和颞深筋膜的浅层之间的组织内，支配额部、眼周和耳部的表情肌运动；面部年轻化手术在分离颞区时．应避免在此层进行。     

鼻唇沟除皱术的局部解剖学与临床应用研究

目的提高鼻唇沟除皱手术效果。方法对10例成人尸体20侧鼻唇沟局部解剖及组织切片研究,发现鼻唇沟形成机理,改进手术方法。结果提出表情肌长期反复运动使得皮肤—皮下组织与 SMAS—表情肌之间产生剪切应力及向下相对位移,鼻唇沟部位上下两种质地、结构密度相差较大的组织之间产生相对运动,形成了鼻唇沟及鼻唇沟脊。采用新手术方法为13例患者进行鼻唇沟除皱手术,获得较好的近期及远期效果。结论鼻唇沟除皱手术须在 SMAS 表面、皮下组织深面正确层次中进行,切断 SMAS 与表情肌及上唇的联系,解剖复位颧颊部组织,重建颧弓韧带。     

Spatial orientation of motor innervation to the lower orbicularis oculi muscle

Background: Blepharoplasty and midface access incisions that are currently used were designed on the premise that innervation to the lower eyelid orbicularis oculi muscle approaches the muscle from its lateral aspect and that its segmental fascicles run parallel to the muscle's fibers. These incisions yield a high rate of complications that include ectropion and other eyelid malpositions. Objective: The goal of this study was to investigate the innervation of the lower orbicularis oculi muscle and determine how it is affected by lower eyelid surgery. Methods: Macroscopic anatomic dissections were performed on 10 frozen cadavers, and the origin and distribution of innervation was mapped. An additional 12 fresh cadaver specimens were dissected through use of 3.5× loupe magnification. Six ultrafresh cadaver specimens were used for histologic examination. Fixation was done in 10% formaldehyde. Axial incisions perpendicular to the facial plane were made at 5-mm intervals from the lower forehead level to the oral commissure. Hematoxylin and eosin specimens and Masson's trichrome specimens were made from alternating slices taken at 5-mm intervals. Results: The results of this anatomic study suggest that the upper eyelid orbicularis oculi muscle is innervated by fascicles of the temporal branch of the facial (VII) nerve. These nerves travel along the undersurface of the muscle and branch out parallel to the muscle fibers. The lower eyelid orbicularis oculi muscle seems to be innervated by 3 to 5 branches of the zygomatic nerve, which splits into 2 large groups of fascicles as it crosses the zygomaticus major muscle. These nerves continue toward the orbicularis oculi muscle, splitting into a plexus of nerves that approaches the orbicularis oculi muscle fibers at an angle of approximately 90°. No significant branches from the lateral aspect of the lower orbicularis oculi were observed in this study. Conclusions: The results of this anatomic study indicate that techniques that (1) approach the midface through the lower eyelid and (2) change the plane of dissection from deep to the orbicularis oculi muscle to superficial to the zygomaticus major muscle may place the innervation of the orbicularis oculi muscle at much higher risk.     

Facelift: Measurement of Superficial Muscular Aponeurotic System Advancement With and Without Zygomaticus Major Muscle Release

Multiple authors have sought ways to improve nasolabial folds, jowls, and jaw lines with face-lifting procedures. The retaining ligaments of the face support facial soft tissue in the normal anatomic position. However, with age, gravitational changes occur, and fat descends into the plane between the superficial and deep facial fascia. Face-lift procedures are designed to lift these sagging tissues. To date, the authors have not found a study that quantifies the amount of vertical advancement gain when a face-lift operation is performed with elevation of the superficial muscular aponeurotic system (SMAS). The movement was studied in 22 rhytidectomy SMAS flaps, and measurements of the vertical advancement were compared using two different SMAS patterns. Elevation and fixation of the SMAS was accomplished under the same conditions, and by the same surgeon. A high SMAS elevation was performed after skin and retaining ligaments were released. Precise measurements were obtained at the medial and lateral edges of the SMAS and before and after a backcut release from the zygomaticus major muscle. The results demonstrated an average improvement in medial flap shift gain of 14.04 mm after the release. There were no complications from these measurements during a 16-month follow-up period. The authors believe this is a particularly interesting finding because it demonstrates and quantifies an increased medial SMAS advancement shift with this maneuver, and therefore improves the cosmetic appearance of the jowls and the midface. Excellent aesthetic results were obtained with a high level of patient satisfaction.     

Subfascial and submuscular methods of temporal muscle dissection and their relationship to the frontal branch of the facial nerve. Technical note

The microsurgical anatomy of the temporal and zygomatic branches of the facial nerve are presented along with related local vasculature (frontal and parietal branches of the superficial temporal artery [STA]) as encountered when using subfascial and submuscular temporal muscle dissection techniques for anterolateral craniotomies. Twenty sides were studied in 10 cadaveric specimens that had been previously injected with latex. The rami of the temporal and zygomatic branches of the facial nerve and branches of the STA were dissected out through pterional and orbitozygomatic approaches by using a submuscular or subfascial temporal muscle dissection technique. The three rami of the temporal branch of the facial nerve (the auricularis, frontalis, and orbicularis) were found to run within the galeal plane of the scalp. The zygomatic branch of the facial nerve was found to course deeper than the most caudal extension of the galea, known as the superficial musculoaponeurotic layer. The frontal branch of the STA served as an important landmark for the subfascial or submuscular dissections because excessive reflection of the scalp flap inferior to the level of this vessel would inadvertently injure the frontalis branch of the facial nerve. Subfascial and submuscular dissections of the temporal muscle offer an alternative to the interfascial technique during anterolateral craniotomies. Scalp and temporal dissection performed with careful attention to anatomical landmarks (frontal branch of the STA and the suprafascial fat pad) provides a safe and expeditious alternative to the traditional interfascial technique.     

除皱术解剖学研究及临床应用

目的 以解剖学研究为基础寻找一种操作简单、安全、效果持久的除皱术式。方法 对6具新鲜尸体进行头面颈部逐层解剖，观察鼻唇沟旁脂肪分布特点及皮肤限制韧带分布，结合临床观察对其功能进行评价。结果面部老化时皮肤、皮下组织、SMAS均出现松弛，但松弛程度不同，各层组织需分别提升；鼻唇沟旁脂肪组织肥厚，有较大活动度，皮下分离不必超过咬肌前缘；面部老化后皮肤限制韧带变得松弛，只需双重折叠缝合面部SMAS便可矫正其松弛。临床应用局限性皮下分离，结合SMAS双重折叠缝合，进行100例除皱术，效果满意，无严重并发症。结论 局限性皮下分离，结合SMAS双重折叠缝合的除皱术是一种简单、安全、效果持久的除皱术式。     

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.     

面神经在眶周区的解剖研究

目的探讨面神经颠支、颧支的终末分支进入眼轮匝肌位置和体表解剖。方法选择6具新鲜尸体标本。观察解剖面神经颠支、颧支，辨别出进入眼轮匝肌的颠支、颧支与外眦的关系。通过外眦做一垂线和水平线，使之分别与矢状面和冠状面平行。通过外眦的垂线和水平线来确定进入眼轮匝肌的神经分支与外眦的解剖关系。结果颠支进入眼轮匝肌时．位于外眦水平线平均为2．64cm，位于外眦垂线外平均为2．40cm。在眼轮匝肌的侧缘、颞支和颧支的垂直距离平均为1.54cm。结论位于面神经走行的上或下、与其平行的切口，不易损伤面神经分支。     

The relationship of the great auricular nerve to the superficial musculoaponeurotic system

We reported in 1980 the course of the great auricular nerve from the perspective of the surgeon performing rhytidectomy using the platysma flap operation. Since the superficial musculoaponeurotic system (SMAS) operation has become increasingly popular during the interim, we reviewed the course of the nerve with regard to our current operative dissection. We found, in both clinical cases and anatomical specimens, that the great auricular nerve is deep enough to allow safe division of the SMAS along the anterior border of the sternocleidomastoid muscle.     

改良骨膜下综合剥防除皱术100例分析

目的 为了更有效地使面中部老化组织向上提紧复位。方法 采用扩大的面部骨膜下剥离，或加用ＳＭＡＳ下和皮下多层次综合剥离除皱术。尤其在颧弓部骨膜下进行剥离松解，掀起颧弓韧带的起点，以解除面中部老化组织上提复位的屏障。结果 本组１００例术后显示恢复面部各层组织年轻时的解剖关系，获得了年轻时鼻唇沟的形态和颌线轮廓，效果满意。未出现面神经额支受牵拉损伤的征象。结论 本法适用于不同年龄，尤其是４０岁左右的除皱     

改良限制性切口额颞部除皱术

目的　为提高额颞部除皱术的效果 ,延长有效时间 ,从理论与实际观察探讨额颞部老年化改变形成的原因 ,并采用相应的手术术式进行矫正。方法　肿胀麻醉下 ,通过颞部发际缘切口入路 ,在颞深筋膜浅面剥离 ,内达颞肌前缘及眶外缘 ,下达颧弓上缘 ,后达耳屏前线。额部切口入路在帽状腱膜下剥离 ,下达眶上缘外至颞线后至枕外隆突。口腔内上颊龈沟入路在颧骨及颧弓骨膜下剥离。上述各剥离区域相互贯通 ,最后将颞区皮瓣上提 ,并将颞浅筋膜与颞深筋膜缝合固定。结果　本组共 32例 ,术后眉外侧平均上提 8mm ,鼻唇沟变浅 ,获随访的 7例为术后 3～2 4个月 ,除皱效果满意。结论　本术式旨在通过广泛剥离解除了额颞部皮肤筋膜上提的羁绊 ,同时减少上面部降肌的作用 ,相对增强提肌的作用 ,再辅以筋膜及皮肤上提固定达到除皱的目的 ,效果确实、可靠、安全、持久。     

鼻唇沟的解剖学研究

目的 从解剖学角度对鼻唇沟做出准确描述和定义,为解剖学和整形外科学、美容外科学、颌面外科学提供理论基础.方法 对10具（20侧）成人新鲜尸头行福尔马林血管灌注固定后,在10倍手术放大镜下进行形态学观测.结果 （1）鼻唇沟是面中部多脂肪区与无脂肪区的分界.（2）鼻唇沟起于鼻肌横部在鼻翼上缘皮肤的止点,终止于口角降肌在口角外下方皮肤的止点.（3）从解剖学角度可将鼻唇沟分为上、中、下3段,上段（Ⅰ）：为鼻肌横部区,长（20.38±0.74）mm;中段（Ⅱ）：为上唇提肌区,长（17.13±0.57）mm;下段（Ⅲ）：为蜗轴区,长（20.81±0.70）mm.（4）鼻唇沟是7种表情肌在皮肤上止点形成的连线区域,表层肌腱膜系统（SMAS）与组成鼻唇沟的7块表情肌同属同一层次.结论 鼻唇沟是7种表情肌在皮肤上止点形成的连线区域,不分年龄.永恒存在.不同于面部老化形成的鼻唇沟皱褶和面部老化或表情变化形成的鼻唇沟脊.