Rhytidectomy Approach

Rhytidectomy Approach
The rhytidectomy or facelift approach to the mandibular ramus is a variant of the retromandibular approach. The only difference is that the cutaneous incision is placed in a more hidden location as in a facelift. The procedure for the deeper dissection is the same as that described for the retromandibular approach.
The main advantage of the rhytidectomy approach to the ramus is the less conspicuous facial scar. The disadvantage is the additional time required for closure.
SURGICAL ANATOMY
Great Auricular Nerve
The only significant structure specific to this approach, not mentioned for the retromandibular approach, is the great auricular nerve. This sensory nerve begins deep in the neck as spinal roots C2 and C3, which fuse on the scalene muscles to form the great auricular nerve. As the nerve becomes more superficial, it emerges through the deep fascia of the neck at the middle of the posterior border of the sternocleidomastoid muscle. It crosses the sternocleidomastoid muscle at a 45-degree angle to the mandible, covered only by the superficial musculoaponeurotic system (SMAS) and the skin, and lies behind the external jugular vein. The nerve then may split into two branches as it courses superiorly toward the earlobe (see Fig. 11.1). Some branches pass through the parotid gland and supply the skin of a part of the outer ear and a variably wide area in the mandibular angle region.
TECHNIQUE
▶ Step 1. Preparation and Draping
Pertinent landmarks on the face useful during dissection should be exposed throughout the surgical procedure. When using the rhytidectomy approach to the mandibular ramus/angle, the structures that should be visible in the field include the corner of the eye, the corner of the mouth, and the lower lip anteriorly, and the entire ear and descending hairline, and 2 to 3 cm of hair superior to the posterior hairline, posteriorly. The temporal area must also be completely exposed. Inferiorly, several centimeters of skin below the inferior border of the mandible are exposed to provide access for undermining the skin. Shaving the sideburns and temporal hair is unnecessary, except from a convenience standpoint.
▶ Step 2. Marking the Incision and Vasoconstriction
The skin is marked before injecting a vasoconstrictor. The incision begins approximately 1.5 to 2 cm superior to the zygomatic arch just posterior to the anterior extent of the
hairline (see Fig. 11.2). The incision then curves posteriorly and inferiorly, blending into a preauricular incision in the natural crease anterior to the pinna (the same position as in the preauricular approach to the temporomandibular joint). The incision continues under the earlobe and approximately 3 mm onto the posterior surface of the auricle instead of continuing in the mastoid-ear skin crease. This modification prevents a noticeable scar that occurs during contractive healing of the flap, pulling the scar into the neck; instead, the scar ends in the crease between the auricle and the mastoid skin. At a point where the incision is well hidden by the ear, it curves posteriorly toward the hairline and then runs along the hairline, or just inside it, for a few centimeters.

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Sep 23, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Rhytidectomy Approach
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