Cervical Rhytidectomy

Based on anatomical and clinical considerations, a new classification of the six most common neck problems is presented. In general there are three types of necks—lean, fatty, and medium—which can involve three kinds of tissue—skin, muscle, and fat—that develop wrinkles, laxities, and adiposities. Different magnitudes and combinations of these problems are observed in these three kinds of patients. Medial plication of the platysma is emphasized as a natural way to deal with neck bands.     

Cervicofacial Rhytidectomy: The Superficial Plane

During the past 20 years, numerous techniques have been described to improve the results of facelifting as well as the duration of its rejuvenating effect. These increasingly aggressive techniques have increased the operating time, the potential morbidity of the operation, and the duration of convalescence. No one can ensure that this evolution in sophistication of rhytidectomy techniques give longer lasting results. Therefore, a simple technique applied under the appropriate indications gives good and predictable results.     

Transparent Dressing for Rhytidectomy

Several dressings have been proposed for rhytidectomy. At present, the type most frequently used consists of flat cotton strips soaked in mineral oil placed on the incisions and along the mandibular line. Gauze sponges are then placed on the cheeks and an elastic net is wrapped around the head and left open anteriorly to expose the face and eyes. Despite its widespread use, this technique presents problems. It is uncomfortable for the patient, it is tight and confining, it obstructs hearing, complicates hygiene, attracts unnecessary attention, and, most importantly, does not permit visualization of the surgical site or of the complications that might arise, such as hematomas. Thus, we propose a more efficient dressing made of sterilized, transparent PVC film of the type used to protect food in the refrigerator (Saran Wrap?-like). This dressing has proved to be more comfortable for the patient, is not tight or confining, does not cause changes in hearing, facilitates local hygiene, does not attract unnecessary attention on the part of the patient himself or of third parties and, most importantly, it is transparent and adheres to all points of the skin flap, permitting early visualization of complications, such as hematomas.     

A Nondeforming Rhytidectomy Incision

A new incision for facial rhytidectomy is presented that completely avoids deformation of the frame of the hair and allows the hair to be combed back without showing the scar, which becomes almost completely invisible in most patients if the incision is made at exactly the specified level. Several authors have tried to maintain the normal hairline, but some of their incisions deform the frame of the hair on the sides, higher than the level of the outer corner of the eye, and others go even higher than this point outside of the hairline, making the scar quite visible! The indications and contraindications for this operation and its designed incisions are discussed. These incisions encourage plastic surgeons not to remove any scalp in the rhytidectomy, but only the skin, because it is precisely the removal of scalp instead of skin that deforms the face, unless the amount of scalp tissue removed is very small. These same incisions are indicated for men.     

Full-Face Laser Resurfacing and Rhytidectomy

The Ultrapulse CO₂ laser (Coherent Inc., Palo Alto, CA, USA) was used in 239 patients, from March 1996 to July 1998, for full-face laser resurfacing. In 106 (43%) of these patients rhytidectomy was performed in the same procedure. All patients submitted to laser resurfacing were prepared for 1 to 2 months beforehand with retinoic acid and hydroquinone. The procedures were done under local anesthesia controlled by an anesthesiologist. A clear film dressing impregnated with silicone gel (Silon TSR; Bio-Med Sciences, Bethlehem, PA, USA) was used for 6 to 7 days and complete healing was observed in 7 to 10 days. Complications were exclusively dermatologic, without relation to surgery. No necrosis of the cutaneous flap was observed. Skin biopsies of 10 consecutive patients undergoing the combined procedures revealed no vascular impairment to the dermis. The patients were able to resume their activities 2 weeks after the procedure.     

Rhytidectomy Assisted with Ultrasound Techniques: The Ultra-Lipo-Lift Technique

Ultrasound-assisted liposuction has been practiced in Europe and South America for more than 10 years. This method was clinically introduced in 1989 for removal of fat by Dr. Zocchi, who developed the concept of applying ultrasound energy to adipose tissue [13,14]. Since 1992, we have been using ultrasound lipoplasty, first in body remodeling, then in face and neck surgery, after establishing working and safety rules in a study of 300 patients. In the beginning we were only looking to eliminate deposits of fat in oval faces with acne-scars, subdermal fibrosis, and thick skin, as these types of cases are not good candidates for rithidectomy. We found good skin retraction when we adjusted the superficial movements of the canula and had adequate machine power to avoid complications beneath the skin. Afterwards, we can break and release the adhesion zones of scarring and fibrosis, consequences of subdermic infiltrations or thread implants. Now we report our technique of rithidectomy assisted with ultrasound, which we have called ultra-lipo-lift (ULL). During the two last years we used this technique on 67 patients (48 females and 19 males) with good results and very few complications.     

Neck Rhytidectomy: Aesthetic Treatment Variations

The aesthetic treatment of the cervical region had its real importance in neck rhytidectomy, after the publications of, among others, Padgett, Cardoso de Castro, Millard, Illouz. The author makes an analysis of various cervical pathologies, their treatment with lipoaspiration, lipectomy, and the connection of the platysma muscle (isolated and in conjunction). Pre- and postoperative aspects of cases of diverse neck deformities, and surgical procedures are discussed. Surgeries were done under sedation or local anesthesia as the case dictated. The importance of case-specific treatment for each patient is discussed. The author demonstrated one complication in a patient who underwent neck rhytidectomy before the therapeutic possibilities of today were developed.     

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.     

Suprazygomatic SMAS in Rhytidectomy

A personal method for the treatment of the suprazygomatic SMAS and its results are presented. By acting on the suprazygomatic fibromuscular layer in the rhytidectomy, the surgeon can avoid tension on the cutaneous layer, and possible consequences thereof, as well as diminish the probabilities of damaging the facial nerve. At the same time, desired effects as a result of pulling on crow's feet, wrinkles, lateral eyebrows, and wrinkles on the lateral forehead are enhanced.     

Segmental stepwise lift: two years of experience

We conceive the facial skin and its subcutaneous tissue as a mask which envelopes the internal structures. The relaxation of the facial retention ligaments causes these structures to fall. On the basis of these concepts, for more than two years we have been practicing the segmental stepwise lift. Its basic features are: Placement of the incisions and final scars in function of each particular case. Consideration of the face and neck as two totally different aesthetic units. Wide segmental undermining, starting at the neck region, the face next, and the forehead lastly, in cases that it is deemed necessary. Volumetric concept of the different structures. Placement of tension only on the SMAS-platysma. Maintenance of the mandibular edge as a fixed point. Vertical-only traction on all facial structures. The orbital region, which will be necessary influenced by the movement of the face, will be approached with the idea of balancing the different components in a volumetric sense.     

Rhytidectomy: Suprazygomatic and infrazygomatic SMAS treatment

The soft tissues of the face and neck are firmer above the zygomatic arch than below it. The SMAS should be treated differently according to where it is situated with respect to this arch. Above the arch, both the skin and the S-SMAS are firmly attached making it possible to correct both simultaneously by means of a flap that includes both layers. Beneath the zygomatic arch correcting the I-SMAS by stretching and relocating it enhances the contour of the jaw and neck and gives greater support to the skin. This provides for even better conformation when excess subcutaneous tissue is resected. An intermediate region exists between the corrected areas of the S-SMAS and the I-SMAS where the rhytidoplasty is exclusively performed through traction and rotation of the skin, but added resources diminish traction sequels.     

Deep Planed Torso-Abdominoplasty Combined with Buttocks Pexy

This new procedure was created for aesthetic purposes with the intention of creating a longer and more slender waist and at the same time treating neighboring areas. This procedure also is used to raise or change the position of a previous abdominoplasty scar. In addition it is also beneficial for treating gestation sequelae of the torso-abdominal wall, ptosis of the abdomen, vertical and horizontal enlargements of the musculoaponeurotic system, lipodystrophy, stretch marks, rhytidosis of the inguinal region, and ptosis of the external quadrant of the gluteous and the external trochanter area in one surgical procedure. It is not always necessary to apply the entire procedure to each case. The deep planed torso-abdominoplasty offers a broader selection of techniques for creating aesthetic contouring of the torso-abdominal wall, flanks, inguinal region, and outer thighs. It also creates pexy of the external quadrant of the gluteous region.     

H-Shaped, Double-Contour Plication in Abdominoplasty

H-shaped, double-contour plication, by reducing the longitudinal and transverse abdominal diameters, improves the waistline and reinforces the entire anterior abdominal wall, with better accommodation of the cutaneous flap. The decrease in the longitudinal diameter allows lowering and fixation of the cutaneous flap without tension.     

The Waist and Abdominoplasty

Basing our work on ideal aesthetic features of the feminine figure and focusing our attention on the waist, we add several points to the abdominoplasty classification. We have carried out 150 abdominoplasties in the last 5 years: 60% of the patients presented with musculoaponeurosis alterations, for whom plicature of the rectus abdominis and obliques with wide dissection was accomplished, and 40% with mainly fat excess at the flanks, on whom limited dissection and liposuction were performed. Our objective was to achieve an ideal waist for each patient.     

The effect of laparoscopy on the movement of tumor cells and metastasis to surgical wounds

Background: A variety of mechanisms have been proposed to explain tumor growth in port sites following laparoscopic cancer surgery. We devised two experimental models to determine whether carbon dioxide (CO₂) insufflation during laparoscopic surgery influences the movement of tumor cells and leads to tumor implantation and growth in surgical wounds. Methods: Model 1: Viable adenocarcinoma cells were introduced into the upper abdomen of six syngeneic immune-competent rats during laparoscopy with CO₂ insufflation; the same procedure was followed for a further six rats during gasless laparoscopy. A length of plastic tubing introduced through the anterolateral aspect of the rats' left lower abdominal wall was used to vent the insufflation gas through the abdomen of a recipient rat for 30 min. After 21 days, the peritoneal cavity and surgical wounds of the recipient rat were examined for implanted tumor. Model 2: A suspension of radiolabeled adenocarcinoma cells was introduced into the upper abdomen of five rats during laparoscopy with CO₂ insufflation and an additional five rats during gasless laparoscopy. A length of plastic tubing introduced through the anterolateral aspect of the left lower abdominal flank was used to vent the insufflation gas through phosphate-buffered saline solution. After 30 min, the solution was counted for radioactivity. Results: Tumor growth occurred at the site of both the insufflation and venting ports in the second rat in five of the six rats from the group undergoing insufflation, but it was found in none of the gasless laparoscopy group (p= 0.015). In the second model, significant transfer of tumor cells to the vented gas occurred only in the rats undergoing laparoscopy with insufflation (median, 2.71% versus 0% of the introduced labeled cells; p= 0.008). Conclusions: Carbon dioxide insufflation results in tumor dissemination during laparoscopy, leading to port site metastasis. Gasless laparoscopy may prevent this problem. Received: 17 March 1997/Accepted: 6 June 1997     

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.