Volumetric short scar rhytidectomy--indications, technique and outcomes.

BACKGROUND: Procedures combining a short scar with superficial musculoaponeurotic system (SMAS) manipulation are increasingly popular for patients with early signs of mid- and lower-facial laxity seeking rhytidectomy. We present the senior author's experience with a short scar volumetric malar imbrication rhytidectomy, which avoids post-auricular incisions and sub-SMAS dissection. PATIENTS AND METHODS: Between January 2004 and April 2007, 54 patients underwent a short scar volumetric rhytidectomy (9.6% of all facelifts). These procedures were primary in 38 and secondary in 16 patients, at a mean age of 49 years (range 35-77 years). Average operating time was 90 min. Resultant vertical and horizontal skin movement at the helical root was recorded. Concurrent procedures included blepharoplasty, canthoplasty, endoscopic forehead rejuvenation and fat grafting. Minimum follow up was 3 months. Pre- and 3 month postoperative photographs of 25 randomly selected patients were rated by three independent surgeons. A seven-point scale was used to grade the improvement in the malar eminence, melolabial fold, jowls and cervicomental angle. The overall aesthetic result was assessed using the MDACS grading system. Statistical analysis was performed using Student's t-tests and general estimation equations where appropriate. RESULTS: There were no significant complications. Three patients developed minor cheek swellings which all settled with antibiotics. Mean postoperative aesthetic outcomes were rated as 'Good' using the MDACS scale (mean score 0.64), with no 'Poor' results. Vertical skin lifting was significantly greater than the horizontal skin lifting (P<0.001). Mild postoperative improvements were noted in the malar eminence soft tissue volume, nasolabial fold diminishment, jowl diminishment and cervicomental angle. CONCLUSION: In the appropriately selected face, short scar volumetric malar imbrication rhytidectomy is a straightforward, safe and effective procedure for improving the early signs of ageing.     

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     

Minimal-incision endoscopic face-lift

Ptosis of the midfacial tissues with resultant deepening of the melolabial folds, vertical lengthening of the lower eyelid, and depression of the oral commissure are generally only slightly improved with traditional superficial musculoaponeurotic system (SMAS) suspension or rhytidectomy techniques. Subperiosteal, deep plane, and composite rhytidectomies have evolved in an attempt to rejuvenate these areas. This article reviews a series of patients who underwent an endoscopic subperiosteal face-lift either as an isolated procedure or in conjunction with an SMAS rhytidectomy. Although all patients showed good initial improvement, patients with thin faces and well-defined facial bone structure maintained the best long-term result. Complications were minimal, with no permanent facial nerve injuries observed. The endoscopic subperiosteal face-lift is a useful technique as an isolated procedure or in conjunction with facial liposuction or SMAS suspension rhytidectomy. Arch Facial Plast Surg. 2000;2:274-278     

Liposuction and the treatment of nasolabial folds

We investigate whether the application of liposuction to the nasolabial region is a useful adjunct to the rhytidectomy procedure. We have devised a system to grade the severity of the depth and the length of the nasolabial folds pre-and postoperatively. This grading system was used to evaluate the nasolabial region in 60 consecutive patients who underwent rhytidectomy. We compared two subgroups: those who underwent rhytidectomy alone (Group I) and those who underwent rhytidectomy augmented by liposuction in the region of the nasolabial folds (Group II). A change in the length of the fold occurred in 2% of Group I and in 30% of Group II. A change in depth of the fold occurred in 12% of Group I and in 70% of Group II. These results suggest that suction-assisted lipectomy consistently improves the results of rhytidectomy in the region of the nasolabial fold.Presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery, San Francisco, California, March 1988     

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.     

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。     

Hemiface Rhytidectomy

In the current study, skin flaps raised in the subcutaneous plane were applied for 22 patients who underwent reconstruction for unilateral upper facial skin defects after skin tumor surgery. The defect was reconstructed with flaps designed via procedures similar to classic rhytidectomy techniques using periauricular and temporal skin incisions. Objective assessment of the aesthetic result was possible by comparison with the healthy contralateral side of the face. Immediate postoperative evaluation confirmed facial asymmetry due to unilateral skin tension. High patient acceptance of the procedure, uneventful flap healing, and good aesthetic results were achieved, with almost complete restoration of facial symmetry 1 year postoperatively. In conclusion, unilateral rhytidectomy without plication or resection of the subcutaneous musculoaponeurotic system (SMAS) is an ideal application of aesthetic surgical techniques for the reconstruction of unilateral skin defects.     

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。     

Midface effects of the deep-plane vs the superficial musculoaponeurotic system plication face-lift

OBJECTIVE: To determine if there is any observable difference in the midface of patients who have undergone a deep-plane face-lift vs a standard superficial musculoaponeurotic system (SMAS) plication face-lift. DESIGN: Preoperative and postoperative photographs of 25 patients undergoing each type of face-lift were rated by 3 independent and blinded observers. A 7-point scale was used to grade improvement in 5 areas on the face and neck: malar eminence, melolabial fold, jowls, cervicomental angle, and anterior neck banding. RESULTS: All 3 independent observers rated the patients who underwent a deep-plane face-lift as having a significantly better result (P<.01) in 2 of the measured locations; the observed improvements in the deep-plane group were twice those in the SMAS plication group. CONCLUSION: In our study of 50 patients, the deep-plane face-lift proved to have results that were clinically and statistically better than those of the SMASapplication face-lift in both the midface and the neck.     

Subcutaneous superficial musculoaponeurotic system grafting of the aging melolabial furrow

OBJECTIVE: To describe a technique of subcutaneous superficial musculoaponeurotic system grafting during rhytidectomy to treat the aging melolabial furrow. DESIGN: Two hundred seventeen patients received bilateral superficial musculoaponeurotic system grafts from December 1, 1996, through June 30, 2003 (a 78-month period). The patients' charts were reviewed for demographic data, follow-up dates, and complications. Selected preoperative and postoperative photographs were viewed. RESULTS: In the 217 patients, 434 grafts were performed, with a mean follow-up of 23.2 months. Follow-up postoperative photographs showed effective long-term effacement of the melolabial furrow. There was a 0.9% complication rate involving 4 cases of unilateral graft infection that resolved with oral antibiotic therapy. CONCLUSIONS: Subcutaneous superficial musculoaponeurotic system grafting of the melolabial furrow is a safe, effective technique of treating the prominent melolabial furrow. It adds very little time to the rhytidectomy procedure, is well tolerated by patients, and shows durable results.     

Observations on a New Concept for Correction of the Nasolabial Fold in Rhytidectomy

Correction of the nasolabial fold has been the challenge constantly faced by the plastic surgeon since the start of attempts at facial rejuvenation. In this paper we intend to show observations which were made in a quite different method of approach to the correction of this challenging anatomic detail. It consists of taking the subcutaneous tissue which forms the nasolabial fold, underneath the same fold, following the law of gravity, without touching or dissecting the superficial aponeurotic muscular system (SMAS) and without using any other artifice which could make it difficult to observe this different procedure. The technique was used on 15 patients who requested facial rhytidectomy.     

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.     

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     

The extended SMAS facelift: identifying the lateral zygomaticus major muscle border using bony anatomic landmarks

Extended superficial musculoaponeurotic system (SMAS) rhytidectomy has been advocated for improving nasolabial fold prominence. Extended subSMAS dissection requires release of the SMAS typically from the upper lateral border of the zygomaticus major muscle and continued dissection medial to this muscle. This maneuver releases the zygomatic retaining ligaments and achieves more effective mobilization and elevation of the ptotic malar soft tissues, resulting in more dramatic effacement of the nasolabial crease. Despite its presumed advantages, few reports have suggested greater risk of nerve injury with this technique compared with other limited sub-SMAS dissection techniques. Although the caudal extent of the zygomaticus muscle insertion to the modiolus of the mouth has been well delineated, the more cephalad origin has been vaguely defined. We attempted to define anatomic landmarks which could serve to more reliably identify the upper extent of the lateral zygomaticus major muscle border and more safely guide extended sub-SMAS dissections. Bilateral zygomaticus major muscles were identified in 13 cadaver heads with 4.0-power loupe magnification. Bony anatomic landmarks were identified that would predict the location of the lateral border of the zygomaticus major muscle. The upper extent of the lateral border of the zygomaticus major muscle was defined in relation to an oblique line extending from the mental protuberance to the notch defined at the most anterior-inferior aspect of the temporal fossa at the junction of the frontal process and temporal process of the zygomatic bone. The lateral border of the zygomaticus major muscle was observed 4.4 +/- 2.2 mm lateral and parallel to this line. More accurate prediction of the location of the upper extent of the lateral border of the zygomaticus major muscle using the above bony anatomic landmarks may limit nerve injury during SMAS dissections in extended SMAS rhytidectomy.     

Safety of face-lifts in the older patient

OBJECTIVE: To compare the surgical and anesthesia complications after rhytidectomy in patients 75 years and older vs those aged 45 to 61 years. DESIGN: Retrospective review of 107 patients of a single surgeon in private practice. All patients 75 and older who underwent rhytidectomy (using deep-plane and superficial musculoaponeurotic system plication techniques) from 1998 to 2002 were selected. This cohort was compared with a randomly selected group of rhytidectomy patients aged 45 to 61 from the same period. Complications related to the procedure or anesthesia were recorded, as well as American Society of Anesthesiologists (ASA) physical class, method of procedure, and patient age. RESULTS: The mean ages of the 2 groups were 79.0 years (33 patients) and 54.2 years (74 patients). Five patients in the older cohort had minor complications after surgery, compared with 7 in the younger group (P = .52). No major complications were reported. CONCLUSIONS: Patients 75 and older carry risks of postoperative complications from face-lift procedures that are similar to those of middle-aged patients, when matched for ASA class. Preoperative counseling should emphasize patient health status rather than age when considering the risk of postoperative complications. Face-lift surgery can be safely performed in patients 75 years and older with ASA class less than 3.     

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。     

Subperiostal temporomalar lifting

The subperiosteal face-lift is a procedure designed to rejuvenate the middle third of the face. We present in this study the technical procedure we have developed, based on the subperiosteal detachment of the soft tissues of the midface and their attachment to the deep temporal fascia with a vertical vector of suspension. We reviewed 69 patients who undergone superiosteal temporomalar rhytidectomy, between March 2002 and January 2006, ranged in age from 42 to 65 years (mean 46). All of the patients presented preoperatively prominents nasolabial folds, malar fat pad ptosis. None of them presented a cervical soft tissue ptosis. The mean follow-up period was 32 months. The postoperative complication rate was 11.5 percent and included transient temporal branch weakness (N=4), transient infraorbital nerve paresthesia (N=1), asymmetrical result (N=1); scleral show (N=1) and ectropion (N=1) which required a secondary surgery. The overall aesthetic results were good; with attenuation of the prominent nasolabial folds in 100 percent and diminution of the height of the lower eyelid in 80 percent of the patients. In conclusion, the subperiosteal midace lift is a procedure designed to rejuvenate the middle third of the face.     

Modified Superficial Musculoaponeurotic System Face-Lift: A Review of 327 Consecutive Procedures and a Patient Satisfaction Assessment

Background  

A conventional superficial musculoaponeurotic system (SMAS) face-lift is well established because it allows the skin envelope to be rotated in a bit more lateral direction than the cephalad redirection of the SMAS flap. This ensures an individualization of the treatment plan according to the needs of the patient and avoids a postoperative stretched look. However, this technique has some limitations with respect to its long-term effects on the sagging tissue, inadequate lifting of the malar fat pad, and flattening of the nasolabial fold.     

The Mini Rhytidectomy

A technique is described in which superficial musculoaponeurotic system (SMAS) is plicated from the deep temporal fascia above the zygoma to the level of the earlobe. This procedure requires only an extended preauricular incision. The neck is dealt with by liposuction. This technique is ideally suited to the younger patient requesting facelift and is based on a sound understanding of the anatomy of SMAS. The outcome of 35 patients who underwent this procedure during a 3.5-year period are described. There were no cases of facial nerve paresis or hair loss. There were no cases of skin necrosis but two patients developed small hematomas and one patient complained of a stretched preauricular scar. The mini facelift leads to a satisfactory result in the younger patient requesting rhytidectomy. The technique is simple and safe and can easily be performed on an ambulatory basis. Complications are uncommon and of a minor nature.     

Rhytidectomy and Parotidectomy Combined in the Same Patient

Until now, aesthetic goals in parotid surgery have seldom been addressed because oncologic concerns have largely overshadowed aesthetic issues for patients with parotid masses. Fortunately, the majority of parotid masses are benign pleomorphic adenomas that rarely recur, leaving a large group of patients healthy after their parotid surgery, with some desiring aesthetic improvement in their facial appearance. Traditional parotidectomy incisions leave a visible scar on the neck as well as a visible hollow in the retromandibular region, which can extend onto the cheek. A rhytidectomy approach to the parotid gland allows for a more concealed, aesthetically appealing scar while maintaining good visibility and access to the parotid gland. By performing bilateral sub-SMAS (superficial musculoaponeurotic system) rhytidectomy after a parotidectomy, facial symmetry and balance is enhanced, and these aesthetic deformities can be minimized. The SMAS flap can help to fill the hollow and form a tissue barrier over the resected gland to prevent gustatory sweating. Finally, the incision scarring is minimized with a rhytidectomy-type approach. Two cases are reported in which patients underwent both rhytidectomy and parotidectomy. In the one case, the procedures were performed in the same surgical setting. In the other case, they were performed in a delayed fashion. These cases exemplify the possibility of addressing facial aesthetic goals of rejuvenation in a patient requiring parotid resection.