Jennifer Elizabeth Woerner and Ghali E. Ghali

Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA

A procedure used to correct changes of the lower face and neck caused by the gravitational forces of physiologic aging.

Indications

1. Moderate to severe cervicofacial skin laxity
2. Jowling
3. Platysmal banding

Contraindications

1. Poorly controlled medical conditions
2. Patients seeking surgery due to psychological motivation or with unrealistic expectations
3. Uncontrolled mental illness or body dysmorphic disorder
4. Cigarette smoking, alcoholism, and illicit drug use are relative contraindications

Anatomy

• Great auricular nerve: With the head turned 45°, the greater auricular nerve can be identified as it crosses the sternocleidomastoid (SCM) muscle 6.5 cm below the bony external auditory meatus (Erb’s point). The greater auricular nerve provides sensation to a portion of the cheek and earlobe. Along with the external jugular vein, this nerve remains deep to the superficial musculoaponeurotic system (SMAS). The greater auricular nerve is the most commonly injured nerve during a facelift procedure.
• Superficial musculoaponeurotic system (SMAS): Fibromuscular layer between the subcutaneous tissue and the parotid-masseteric fascia. The facial nerve runs deep to this layer. The SMAS transfers the forces of the muscles of facial expression to the overlying skin through septal connections. It is continuous with the frontalis and galea superiorly and the platysma inferiorly.
• McGregor’s patch: The area overlying the malar eminence of ligamentous attachments between the periosteum and the dermis. Dissection in this region is difficult, and bleeding may be encountered due to its high vascularity.
• Mesotemporalis: Contains the superficial temporal artery and the frontal branch of the facial nerve. It marks the transition from the sub-SMAS dissection to the subcutaneous dissection.

Superficial (supra-SMAS) Rhytidectomy Technique

1. Proposed incision lines and anticipated areas of undermining are marked while the patient is seated in an upright position prior to anesthesia (Figures 40.3 and 40.4 [all figures cited in this chapter appear in Case Report 40.1]).

2. The procedure may be performed with intravenous sedation or with laryngeal mask airway (LMA) or oral endotracheal general anesthesia.
3. After induction of anesthesia, the patient is placed supine on the operating room table; the hair, face, and neck are treated with surgical prep; and the patient is draped in a sterile fashion.
4. Local anesthetic is administered along the proposed incision lines with 2% lidocaine solution with 1:100,000 epinephrine.

5. A #11 blade is used to create bilateral temporal (Figure 40.5), infralobular (Figure 40.6) and mastoid (Figure 40.7) trochar incisions and a single, midline submental (Figure 40.8) trochar incision. Tumescent solution (a mixture of 20 mL of 2% lidocaine with 1:100,000 epinephrine solution with 180 mL of normal saline, creating a solution of 0.2% lidocaine with a 1:1,000,000 epinephrine concentration) is used to hydrodissect through the trocar sites within the supra-SMAS plane 1 cm beyond the planned area of dissection. 75 mL of tumescent solution should be placed on each side, and 50 mL should be deposited within the submental region. The tumescent solution should be allowed at least 10 minutes to take effect before further dissection is carried out. The contralateral side should not be infiltrated until just prior to closure of the first side.

6. Blunt cannula dissection is performed through the trocar sites without suction to bluntly dissect the cervicofacial supra-SMAS rhytidectomy flap. A 5 mm incision is made just posterior to the submental crease for open liposuction. Open liposuction is performed within the supraplatysmal plane with a 3 mm blunt cannula facing the platysma (Figure 40.9). The liposuction is performed inferiorly to the superior aspect of the thyroid cartilage and laterally to the anterior border of the SCMs. Care is taken to leave a uniform layer of fat against the skin to prevent developing an unnatural atrophic appearance of the neck (cobra deformity).
7. If a neck lift is indicated, a 2 cm long transverse incision (Figure 40.10) is placed within the submental skin 1-2 mm posterior to the dominant (submental) crease. Do not place this incision within the dominant crease, or upon healing it may create a “double-chinned” deformity.
8. The cervical dissection is initiated within the subcutaneous plane. The medial borders of the platysma muscle are identified and released along their deep surface to the level of the thyroid cartilage to allow for sufficient mobilization (Figure 40.11).
9. The medial borders of the platysma muscle are plicated using a 2-0 slowly resorbing suture from the level of the thyroid cartilage as far superiorly as possible. Partial myotomy of the inferior aspect of the muscles may be needed for adequate mobilization and relief of tension at the anterior surface of the neck. A diamond-shaped portion of the midline platysma muscle may be removed and reapproximated with 3-0 Mersilene sutures.
10. The rhytidectomy incision is initiated along the conchal bowl cartilage on the posterior surface of the ear. The incision rises superiorly onto the back of the conchal bowl (Figure 40.12) approximately 3 mm until reaching the level of the postauricular sulcus. The incision courses posteroinferiorly approximately 4 to 5 cm into the scalp of the retromastoid region.

11. In the pre-auricular region, the incision follows the natural curvature of the inferior ear lobule and is curved inferiorly 2 mm below the junction of the lobule with the cheek. The incision courses superiorly just above the base of the incisura intertragica, following the margin of the tragus and staying anterior to the curve of the crus helicis (Figure 40.13). The temporal incisions are placed at least 2 cm posterior to and parallel to the hairline (Figure 40.14).

12. Considerations for incision design in male patients:
    1. Modification of incision design in the temporal area must be considered in those with thinning hair, temporal recession, or significant male pattern baldness.
    2. When assessing the pre-auricular region, the incision should extend in a linear fashion, following a natural skin crease adjacent, parallel, and anterior to the sideburn in order to leave the non-hair-bearing area anterior to the ear intact.
    3. Place the posterior extension of the incision along the postauricular hairline. This will prevent a step deformity or posterior displacement of the hairline.

13. Flap elevation begins by undermining 1 cm along the entire length of the rhytidectomy incision (Figure 40.15) using blunt-tipped scissors (face-lift scissors) in a push-cutting motion (Figure 40.16). The appropriate level of dissection is within the subdermal plane, leaving approximately 4 mm of subcutaneous fat on the underside of the flap. Rees T-clamps are placed along the flap edges for countertraction. In the temporal region, the dissection is carried through the temporoparietal fascia (subgaleal) down to the loose areolar tissue overlying the deep temporal fascia. Dissection within this plane creates a thicker flap, preserving hair follicles and therefore preventing alopecia. The dissection is continued across the cheek within the subcutaneous plane. This transition from the sub-SMAS to the subcutaneous plane marks the mesotemporalis. The dissection is carried superiorly to the level of the lateral canthus and within 1 cm of the oral commissure. When a neck lift is also planned, the dissection is carried inferiorly to the level of the thyroid cartilage bilaterally. Below the earlobe, it is important to stay within the subcutaneous plane in order to protect the great auricular nerve and external jugular vein.

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