Rhinoplasty Dr Bashar Bizrah Article on: Related Facial Surgery Part 4: Facelifting

Facelifting procedures will be discussed purely from a practical angle, including the particular techniques which the author finds more straight forward, sharp, less complicated and invasive.

The features and signs of an aging face result mainly from the following major factors:

1. Atrophy of the cutaneous fat.
2. Loss of elasticity of the skin.
3. Facial skeleton bone absorption including periodental.
4. Overactive facial and neck muscles.

Common features of an aging face are:

• Skin wrinkles, rhytids, creases, furrows, fissures, folds and deep lines of facial
  expressions.
• Eyes sagging, eye bags, bulging, fullness, redundant eyelid skin and fat herniation and prolapse.
• Fat deposits in submandibular and submentum.
• Redundant skin and ptosis of the lateral neck, anterior neck, cheek, submandibular, submentum and postcervical neck.
• Ptosis of the nose and chin.
• Vertical platisma muscle folds and binding submentum.
• “Gaunt” appearance due to fat atrophy.
• Acquired pigmentation and skin lesions.
• Loss of hair pigmentation, sparse and coarse hair.

The goals of lower facelifting are to achieve the following:

• Natural, satisfactory and safe results.
• Avoiding unwanted postoperative problems.
• Short hospital stay and early mobilization (day case).
• Early return to work.

The technique of lower facelifting that the author has been using for the last seven years is based on a combination of:

• Suspension rhytidectomy (superficial musculoaponeurotic system plication).
• Superficial musculoaponeurotic system management: limited superficial musculoaponeurotic system flap, elevation and advancement, trimming, rotation and suture imbrication.

The main advantages of combined suspension rhytidectomy and superficial musculoaponeurotic system flap techniques are:

• Limited dissection that reduces bruises, echymosis, tension cones and dog ear formation.
• Reduction of subcutaneous dead space that limits and reduces the haematoma, infection, abscess formation and leads for rapid wound healing.
• The branches of the facial nerves are usually safe.
• Procedure is easily performed under local anaesthesia and sedation as a day case.
• Preserve the hair pattern.
• Good healing resulting in invisible scars.
• Return to work usually in five days time.

Fig. 18 - 9. A 65-year-old patient was presented w ith redundant skin of the lateral neck, anterior neck and submandibular regions with skin wrinkles, rhytids, creases and eyes sagging.
Postoperative photos showed the results of facelilting, forehead lilting w ith upper and lower blepharoplasty

Fig 18 - IO. Earty postoperative phocographs rollowing or suspension rhytideccomy with faceli'fting. This shoM the aavantage echymosis and the patrent m.:iy return limited to SMAS work llap technique. There are very Jinle bruises and after one week.

The following steps for lower facelifting are recommended:

• Patient man upright position. The planned skin incision is marked, the anterior, infenor and posterior limits of the dissection are noted. The regions of fat deposition or atrophy are pointed out. (Fig. 18 – 24)
• Local anaesthesia Xylocaine 1 %, 1:200,000 adrenaline is infiltrated.
• Skin incision: the following incision is the author’s preference, because it preserves the normal anatomy and avoid changes in hair pattern or hair loss. A double taft of hair in the temporal and preauricular area should be preserved. The incision starts on the anterior hairline of the sideburns at the level of the eyebrow, then follows the hairline of the sideburns down, then around, then up along the posterior hairline of the sideburns to the junction of the antihelix with temporal skin, then, the skin incision runs inferiorly in a preauricular crease two mm anterior to the tragus in the males to prevent beard growth in the ear, but in females the incision passes just within the ear behind the tragus. Next the incision runs around the ear lobule one mm below its Grease, after that, it is angled up and runs superiorly on the medial surface of the concha five mm above the postauricular sulcus and continues up the level of junction of the inferior crus with the helix rim. Then the incision is angled at 900 and extends horizontally in the occipital skin just anterior to the posterior proturberance, finally angled at 45° downwards for about two cm. (Fig. 18 – 24)
• Dissection and undermining of skin is carried out forwards, downwards, backwards in all directions up to the noted dissection limits. The dissection is carried out by a straight blunt scissors just deeper than the hair follicles between skin and platisma.
• Undermining should be superficial to the platisma muscle to avoid injury to the mandibular branch of facial nerve. As well as the cheek flap, the temple flap should be undennined superficially and stopped halfway between the ear and lateral canthus, in order to protect the frontal branch of the facial nerve at the transition between the temple and cheek flap. Dissection below the ear should be done with care superficially to avoid injury to the greater auricular nerve. (Fig. 18 – 25)
• Superficial musculoaponeurotic system management:
  The preparotid fat is removed and superficial musculoaponeurotic system fascia identified. A vertical incision 1.5cm anterior to the preauricular incision is made through the SMAS, it extends from xygomatic arch and inferiorly three cm below the mandibular. border. The vertical incisions made in continuity with three cm horizontal incision just below the xygomatic arch. The superficial musculoaponeurotic system plane is entered with a blunt scissors superficial to the parotid capsule. The SMAS flap is elevated anteriorly for only two to three cm along the vertical incision, then advanced and rotated superiorly, the excessive overlapped tissue is trimmed, then edge to edge suture repair is completed with appropriate advancement and rotation using 2/0 Ethibol)d. The superficial musculoaponeurotic system flap is split horizontally at the mandible border with the lower segment sutured to the mastoid fascia. (Fig. 18 – 25)
• Suspension rhytidectomy:
  SMAS plication in addition to the above SMAS management is recommended. We add six to eight sutures 2/0 Ethibond which are positioned anteroposteriorly, from the anterior limit of the dissection at the junction between the skin and platisma then posteriorly just one cm anterior to the skin incision. (Fig. 18 – 25)
• The above manoeuvre will definitely achieve excellent SMAS lifting, resulting in skin closure with no tension and significant reduction of subcutaneous tissue space leading for rapid healing and decreases the risk of haematoma and infection.

Fig. 18 - 11. (A) Standard incisions for male. (B) Incisions for a male with thinning hair

• Skin flap redistribution:
  Flap redistribution and skin closure should be under no tension, whatsoever. The redistribution of the flap made perpendicular to facial folds by drapping a right angle to prevent tension cones or dog ear formation. The face is observed for smoothness. The flap is secured initially by a stapler at two key points: first, postauricular at the junction between scalp hairline and non hair bearing of
  postauricular skin. The second, just above the helix. The excess skin is tailored and trimmed in an appropriate way without any tension to avoid skin necrosis, later wound dehesance, and unwanted scars. A stapler is used in hair bearing skin. Subcutaneous 4/ 0 Dexon or interrupted 4/ 0 nylon is used on non hair bearing skin in the preauricular area. Small drains are applied. (Fig. 18 – 25)
• Steri-strips, Sofratulle and gentle pressure dressings are applied. Appropriate medication for nausea, vomiting and coughing are given. Pain may indicate haematoma. Drains removed and dressing are changed next morning. Patient discharged home on antibiotics and mild pressure dressing and reviewed in five days. Sutures are removed in eight days, and staples in twelve days. Antibiotics and steroid ointment on the wound are recommended for two weeks. Gentle hair shampooing from day five postoperative. (Fig. 18 – 10)

Summary of complications

1. Early haematoma, bruises, echymosis, wound dehesance, infection and abscess formation.
2. Facial nerve weakness which may be transcient due to the local anaesthesia injection which usually recover in a few hours. Permanent weakness is due to iatrogenic nerve injury.
3. Late unwanted scar, tension cones, dog ears, change in pattern of the hair.
4. Patient dissatisfaction due to undercorrection or overcorrection.