January 2003 By Paul S. Nassif, MD, FACS, and J. Regan Thomas, MD, FACS Plastic Surgery Products
A balanced approach to rhytidectomy is paramount in order to achieve optimal results with minimal to no complications. For more than 20 years, coauthor Thomas has performed various facelift techniques, such
as the skin, submuscular aponeurotic system (SMAS), and deep plane lifts.
He eventually found that a modified SMAS lift effectively repositions
ptotic jowl and cervical soft tissue with an excellent safety profile.
Thomas names the procedure the “Safety Facelift.” We believe this
technique is based on sound surgical principles and years of experience.
Long-term follow up with our patients has given us the insight to
constantly improve this conservative, yet effective technique.
Expected Outcomes
The goals of this operation include:
To create a superior and lateral vector for
repositioning ptotic jowls and cervical soft tissue by either imbrication (edge-to edge fixation) or placation (overlapping of tissue) of the SMAS flap. Ptotic midfacial tissues are addressed through an endoscopic midface subperiosteal technique, which will not be discussed in this article.
To create a natural, nonoperated appearance with minimally visible scars. As more younger patients seek rhytidectomy, surgeons have the opportunity to help create a smooth transition into aging. Facial changes are more apparent when operating on elderly patients with severe ptotic jowls; however, a natural appearance without the ptotic excess tissue can be achieved. It is important to suture
without applying tension on skin flaps to ensure unnoticeable results.
To create stable, long-lasting results by use of the proper technique and patient selection. Since the patient population for this procedure is becoming younger, this begs the question: Will the
facelift last longer on younger patients since, in general, the
elasticity of their skin is better than that of the typical older
patient in their early to mid fifties?
To avoid complications by not implementing aggressive
surgical techniques. For example, elevate a medium flap rather than a
long flap, and use smaller sissections to lessen the risk of hematomas,
facial nerve injury, or delays in flap healing. Adapting aseptic
surgical techniques also helps prevent complications.
To promote rapid healing by performing conservative flap elevation with the possible use of autologous platelet-rich plasma or fibrin glue.
Avoiding Unnatural Results
The wind-tunnel, pulled or lateral sweep facial
appearance
This is generally caused by a lateral pull on the deep tissues and
excessive tension on the skin flaps. To aid in the prevention of this
unsightly common facial appearance following a bad facelift, cephalic or
superior repositioning of the SMAS when placating or imbricating is
necessary, in addition to avoiding tension on the skin flaps when
suturing. In patients with midface ptosis, addressing the lower third of
the face without addressing the midface can also create a lateral sweep
look. In this situation, a midface or composite lift is needed.
Hollow midcheek appearance
To prevent this, cephalic or superior repositioning of the ptotic
jowls or tissue at the inferior border of the mandible by placation efface
the depression in the submalar region. The initial SMAS placation suture
should reposition the tissue from the lower mandible to just inferior to
the zygomatic arch. Plication will add bulk to the soft tissues.
Pixie ear deformity (inferomedial tethered earlobe
with loss of natural lobe appearance)
This is generally caused by excess skin tension on the earlobe
when tailoring skin flaps at the lobular-facial junction. Recreating the
precise preoperative anatomic site of this junction is crucial. The
earlobe should rest in a hammock of preauricular and postauricular skin
without any tension. Initially, fixate the hammock at the junction of the
mastoid postauricular hairless skin and the auriculomastoid sulcus, and
second, just superior to the helix of the ear in the temple region. If the
hammock created for the earlobe is not released or cramped, the earlobe
will fold over the formed creases. Some earlobes are preoperatively attached
at the lobular-facial junction and are at increased risk for this
deformity. Surgeons must preoperatively evaluate the type of earlobe and
discuss surgical options with the patient, such as reducing the size if
indicated or creating an unattached earlobe from an attached one.
Cobra deformity
Submental hollowness or depression caused by overaggressive
removal of subplatysmal fat or aggressive submental liposuction with
prominent medial platysmal banding may create a cobra look. Conservative
submental liposculpting or lipectomy can prevent this abnormality.
Occipital hairline step-off
Insufficient superomedial rotation when advancing the cervical
flap posteriorly will cause a step-off. Once again, the correct amount of
cephalic rotation and posterior or lateral advancement will prevent this.
After performing SMAS imbrication or placation, recreate the occipital
hairline with the initial skin fixation suture or staple.
Temple hairline distortion
If your technique involves a temple incision superior to the
helix, overaggressive superior and/or lateral pull will elevate or distort
the temporal hairline. Conservative superior advancement and lateral
rotation will create a smooth nondisorted temple hairline.
Visible preauricular scar
This is usually created by undue tension on the preauricular skin
closure and incisions anterior to the preauricular crease. To prevent this
complication, avoid tension on the skin edges when suturing. The skin
edges should kiss. The preauricular incision should follow in the
preauricular crease and be retrotragal in the region of the tragus.
Meticulous suture placement and removal in 5 to 7 days will help prevent
visible scarring.
Bowstring auriculomastoid sulcus scar
From our basic surgical training, we have learned that an
incision traversing a convex (conchal surface) to a concave surface (auriculomastoid
sulcus) will cause a hypertrophic scar in most situations. Irrevgularizing
or performing a Z-plasty in this area will help decrease the incidence of
a bowstring scar.
Loss of tragal definition
This is caused by not defatting the tragal flap. Proper defatting
of the flap and not having skin tension on the closure will prevent this.
Approximately 4-6 months is needed for the tragus to form definition.
Placement of the dermal suture of the SMAS to the dermis of the skin flap
at the pretragal crease may accelerate the formation of tragal definition.
Outlining the Surgical Procedure
Patients undergoing the safety facelift should be
healthy, have realistic expectations, and the proper anatomical and
physiological features.
1.
While the patient is in the upright position, mark the planned
incisions, the sternocleidomastoid and platysmal muscles medial
border, zygomatic arch, hyoid-thyroid complex, submental
dissection, areas of submental lipodystrophy, jowls, and location
of acial nerve branches (frontal and marginal mandibular). The
occipital and temporal hairline incisions are approximately 5 cm
to 7cm and 2 cm to 3 cm, respectively. Following inducement of
anesthesia with the patient in a supine position, delineate the
extent of the flap dissection. The temporal dissection is
generally within the
Preoperative: frontal
Preoperative: oblique
Six month postoperative views of a
69-year-old woman who underwnet the safety facelift, endoscopic
subperiosteal midfacelift, endoscopic browlift, upper blepharoplasty,
and lower blepharoplasty with fat repositioning. Notice the improvement
of the jowl and neck line.
hairline to prevent trauma to the frontal branches of the
facial nerve. The preauricular dissection starts at the inferior
border of the zygomatic arch and then gradually becomes a medium
flap of 5 cm to 6 cm in the infra- and postauricular regions
culminating at the lateral end of the occipital incision.
2.
The submental and right facial incisions are
infiltrated with 1% lidocaine with1:100,000 epinephrine using 1 cc
to 15 cc in each area. The left side is infiltrated after time has
passed to allow for the initial injection to reabsorb. Allow 10 to
15 minutes to lapse for maximum vasoconstriction.
3.
If needed, conservative submental liposuction using
a 2.5-mm spatula cannula is performed. If extensive liposculpturing
is needed, a 4.0 –mm spatula cannuals may be used initially. The
cannular dissection is initially performed without suction, followed
by conservative liposuction. Open submental lipectomy may be
performed if the operating surgeon deems necessary. If jowl
liposuction is performed, do not cantilever off the mandible, since
injury to the marginal mandibular branch of the facial nerve is
likely. Candidates for jowl lipsuction generally have a moderate to
extensive amount of jowl lipodystrophy and rounded facial features
without midcheek hollowness. Patients with midcheek hollowness
benefits from haing the jowl soft tissue repositioned into this
region and, therefore, should only have conservative jowl
liposuction.
4.
If the candidate has moderate to significant medial
platysmal banding, platysmalplasty is performed. The
predetermined submental dissection is performed in the subcutaneous
plane. The medial edges of the platysma are identified and limited
subplatysmal dissection is performed under complete visualization. A
1-cm to 2-cm back cut is made into the platysmal at the level of the
hyoid with care to maintain absolute hemostasis. A thin strip of the
medial border of each platysma is excised to allow for the wound
edges to scar together when imbrication is perormed. Platysmal
imbrication is performed with 3-0 polydioxanone starting at the
inferior extent of the dissection The sutures are buried. The most
superior platysmal suture additionally passes through the periosteum
of the midline under surface of the mandible, helping to create an
acute cervicomental angle.
5.
The hairline incisions are made parallel to the
hair follicles, thus preserving the follicle to allow ingrowth of
hair into the scar. To avoid trauma to the superficial temporal
vessels and auriculotemporal nerve in the temple region, a tonsil
clamp is used to open the incision and elevate the flap. This
maneuver can be used for the occipital hairline incision. The
facelift flap dissection, including the temple dissection, is
performed in the subcutaneous plane. Keep a thin layer of fat on the
flap underfurface to protect the subdermal plexus. Avoid
cauterization in the hairline region since the thermal energy will
damage hair follicles and increase the risk of alopecia. If needed,
local anesthesia may be infiltrated into the edges of the hairline
incisions causing compression of the oozing blood vessels. If
cautery is used for hemostasis, use bipolar cautery. The
retroauricular flap is elevated just superficial to the fascia
overlying the sternocleidomastoid muscle. Blunt dissection with
liposuction cannulas may be used to facilitate cheek flap elevation
prior to sharp dissection. If significant jowls are present and
liposculpture is needed, the jowls may be suctioned via the cheek
flap with care to stay at least 2 cm from the lateral commissure of
the lip. This prevents neuropraxia of the terminal branches of the
marginal mandibular branch of the facial nerve, since the nerves
innervating the undersurface of the orbicularis oris are
superficial.
6.
If the submalar or midcheek region is hollow,
placation of the SMAS will assist in filing in the depression. If
the midface is full and/or has less than ideal tissue mobility, SMAS
imbrication is performed. Starting at the inferior border of the
zygomatic arch approximately 1 cm medial to the edge of the
preauricular incision, a horizontal SMAS incision parallels the
inferior border of the zygomatic arch for approximately 3 cm. For
the vertical SMAS incision, start at the same place as the
horizontal incision and extend caudally to the inferior aspect of
the dissection approximately 4 cm to 5 cm below the earlob. A
surgical marker is used to mark the proposed incision sites followed
by the injection of local anesthesia. Following the incision,
limited SMAS undermining is performed. The remainder of the
procedure remains the same for placation or imbrication, except that
in imbrication, excess SMAS is resected. The SMAS just superior to
the jowl region is grasped and repositioned vertically and slightly
posteriorly. The second key suture is placed at the lateral border
of the platysma and advanced superolaterally over the dense fascia
of the sternocleidomastoid. Plication or imbrication is performed
using 3-0 polydioxanone. The SMAS-platysmal layer is repositioned
under considerable tension. Approximately five to six sutures are
then placed between these two key fixation points. All sutures are
buried and interrupted. The undermined subcutaneaous tissue space is
reduced significantly diminishing the risk of hematoma.
7.
Skin tailoring may be time-consuming, but it is the
most important part of the procedure. Every skin incision or cut and
every suture placed just be absolutely perfect. The right amount of
both lateral advancement and cephalic rotation of the skin flaps are
necessary to achieve the desired results and prevent facial
distortion. Two key positions are used for the foundation of
tailoring the skin flaps. The first position recreates the occipital
hairline. To aid in the recreation of the hairline, preoperatively
mark the occipital hairline superiorly and inferiorly to the
occipital incision. The second position is just superior to the
helix in the temple region. The next two important fixation points
are the auriculomastoid sulcus followed by recreation of the
earlobe. The contralateral face is injected with local anesthesia.
The retrotragal flap is tailored and defatted. The remainder of the
skin flaps is tailored and closed leaving the retrotragal and
postauricular incisions open to allow for placement of fibrin glue
or platelet-rich plasma at the termination of the procedure.
8.
Depending on the surgeon, a small amount of fibrin
glue or platelet-rich plasma may be placed in the anterior flap via
the retrotragal opening and then in the posterior flap via the
postauricular incision. The remainder of the incisions are closed,
and a light facelift dressing is applied.
Paul S. Nassif, MD, FACS, is a facial plastic and
reconstructive surgeon in private practice in Beverly Hills, Calif. He is
an assistant clinical professor in facial plastic and reconstructive surgery
at the University of California, Los Angeles School of Medicine, and at the
University of Southern California School of Medicine. Nassi is also a member
of Plastic Surgery Products' editorial advisory board.
J. Regan Thomas , MD , FACS, is the Francis L. Lederer
professor and chairman of the Department of Otolaryngology-Head & Neck
Surgery at the University of Illinois at Chicago School of Medicine.
References
Tardy Me, Thomas JR Brown RI The facelift operation:
principles and techniques. In Hurley R, ed: Facial Aesthetic Surgery. St.
Louis : Mosby-Year Book, 1995.
Hamra ST > Composite rhytidectomy. Plast Reconstr Surg.
1992,90(1):1-13.
