Key points
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Facial rejuvenation surgery can produce significant results when a combination of procedures are added to rhytidectomy and performed simultaneously.
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Multiple adjunctive procedures can be performed safely.
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Proper surgical training and experience are critically important to outcomes and patient safety.
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Marketing so-called mini procedures as more safe and effective is misleading to patients.
Introduction
Patients seeking facial rejuvenation surgery often report 3 primary concerns: the desire for a natural, more youthful appearance; the hope that they do not lose their identities; and the goal of avoiding the appearance of a particular celebrity with a poor result from cosmetic surgery. They want their transformations to be safe and minimally invasive when possible, and without the traditional stigmata of surgery, including altered hairlines, noticeable scarring, ear lobe deformities, and irregular facial contours. In addition, patients hope that these improvements can be accomplished without significant postoperative downtime and discomfort.
Because of these factors and others, many manufacturers of aesthetic devices, and also some surgeons, have pursued strategies that speak to patients’ concerns but offer suboptimal results. Techniques typically classified as mini facelifts and other noninvasive aesthetic procedures have become popular, but many are primarily marketing strategies to lure patients into treatments that seem less invasive but still provide good results. It is our opinion that facial rejuvenation surgery is being minimized at the expense of results and often by inadequately trained surgeons in an attempt to meet the demands of this patient population, and also to generate revenue. Well-trained facial plastic/cosmetic surgeons can achieve significant results and minimize the stigmata of surgery by performing a traditional superficial musculoaponeurotic system (SMAS) rhytidectomy approach supplemented with adjunctive techniques such as brow lifting, blepharoplasty, autologous fat transfer, chin and cheek implants, submental liposuction, CO 2 or erbium facial resurfacing, chemical peels, dermabrasion, Botox, and other techniques as indicated.
Of primary importance are the required surgical skill sets, along with choosing the proper placement of incisions, volume addition if needed, and skin resurfacing based on skin type and patient goals. Operative time is also important to improve patient safety and decrease the risk of complications associated with prolonged anesthesia. The adjunctive techniques listed earlier help to maximize the aesthetic result in a safe manner when performed by an experienced facial plastic/cosmetic surgeon. Our opinion is that, although less is now being promoted to be more, it is not when speaking of facial rejuvenation surgery. This article reviews the various techniques that can, and often should, be added to rhytidectomy to obtain excellent results.
Introduction
Patients seeking facial rejuvenation surgery often report 3 primary concerns: the desire for a natural, more youthful appearance; the hope that they do not lose their identities; and the goal of avoiding the appearance of a particular celebrity with a poor result from cosmetic surgery. They want their transformations to be safe and minimally invasive when possible, and without the traditional stigmata of surgery, including altered hairlines, noticeable scarring, ear lobe deformities, and irregular facial contours. In addition, patients hope that these improvements can be accomplished without significant postoperative downtime and discomfort.
Because of these factors and others, many manufacturers of aesthetic devices, and also some surgeons, have pursued strategies that speak to patients’ concerns but offer suboptimal results. Techniques typically classified as mini facelifts and other noninvasive aesthetic procedures have become popular, but many are primarily marketing strategies to lure patients into treatments that seem less invasive but still provide good results. It is our opinion that facial rejuvenation surgery is being minimized at the expense of results and often by inadequately trained surgeons in an attempt to meet the demands of this patient population, and also to generate revenue. Well-trained facial plastic/cosmetic surgeons can achieve significant results and minimize the stigmata of surgery by performing a traditional superficial musculoaponeurotic system (SMAS) rhytidectomy approach supplemented with adjunctive techniques such as brow lifting, blepharoplasty, autologous fat transfer, chin and cheek implants, submental liposuction, CO 2 or erbium facial resurfacing, chemical peels, dermabrasion, Botox, and other techniques as indicated.
Of primary importance are the required surgical skill sets, along with choosing the proper placement of incisions, volume addition if needed, and skin resurfacing based on skin type and patient goals. Operative time is also important to improve patient safety and decrease the risk of complications associated with prolonged anesthesia. The adjunctive techniques listed earlier help to maximize the aesthetic result in a safe manner when performed by an experienced facial plastic/cosmetic surgeon. Our opinion is that, although less is now being promoted to be more, it is not when speaking of facial rejuvenation surgery. This article reviews the various techniques that can, and often should, be added to rhytidectomy to obtain excellent results.
History of the facelift
Surgeons in Europe and the Americas first performed contemporary facelifting techniques in the early 1900s. Bourguet and Bettman have been credited with the first presentation of the subcutaneous rhytidectomy involving undermining of facial skin flaps and lipectomy. In 1928, Joseph introduced the post-tragal, preauricular incision. Advances in safety in anesthesia in the 1960s allowed more extensive procedures to be undertaken. In 1968, Skoog achieved a more prolonged lift by developing a cervicofacial flap involving the platysma and superficial fascia of the lower facial third.
In 1976, Mitz and Peyronie, working under Tessier, described their discovery of the SMAS. This landmark article confirmed the existence of a fascial layer investing the muscles of facial expression, distinct from the underlying parotidomasseteric fascia. The SMAS was noted to lie in a tissue plane contiguous with the platysma of the neck and the temporoparietal fascia of the scalp. Fibrous adhesions from this layer to the overlying subcutaneous fat and skin thus allowed the manipulation of the SMAS to effect changes in the skin. The SMAS rhytidectomy soon became, and has remained, the preferred technique by most facial aesthetic surgeons.
Contributions from accomplished facial plastic surgeons Jack Anderson and E. Gaylon McCollough recently shaped the authors’ current understanding and practice of facial rejuvenation surgery. Many of the techniques described here can be attributed to the direct teaching and observation of both of these surgeons.
Surgical anatomy of the face
SMAS
The SMAS is a fibromuscular layer investing the muscles of facial expression.
The SMAS concept was introduced by Tessier but was later defined by Mitz and Peyronie in 1976. The characteristics used by Tessier and his students to describe the SMAS include the following:
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The SMAS divides the subcutaneous fat into 2 layers
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Fibrous septae extend from the dermis to the SMAS
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Fat lies between the deep facial muscles and the SMAS
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Larger vessels and nerves lie deep to the SMAS, smaller branches perforate it, and the subdermal plexus is superficial to it
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The network of the SMAS may act as a distributor of force for the various facial musculature
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The SMAS lies superficial to the parotid fascia ( Fig. 1 )
Fig. 1 SMAS.( From Bernard R. The anterior vertical SMAS lift. Aesthetic Surg Jour 2003;23(6):486–94; with permission.)
The SMAS below the zygoma corresponds with the superficial fascia and is superficial to the parotid fascia. Jost and Levet described cadaver and clinical studies to support their opinion that the SMAS layer in the cheek includes the parotid fascia. They think that the parotid fascia, as a remnant of the primitive platysma, represents the structurally important layer of the SMAS in this area. They describe it as being contiguous with the platysma below and extending to the zygoma above. Wasset published a study based on anatomic dissections that revealed the parotid fascia to be essentially the same as the SMAS, and that the platysma muscle, parotid fascia, and fibromuscular layer in the anterior cheek represent the same layer. Wasset also states that the superficial layer of the orbicularis oris muscle, where the dermis is directly attached to the underlying muscular tissues, represents the SMAS.
In the midface, the fibromuscular SMAS extends from the parotid and envelops the facial muscle. Because of this firm attachment to the zygomatic major muscle, and its bony attachments, posterior tension on the SMAS cannot significantly affect the contour of the cheek anterior to this level.
The SMAS above the zygoma is a more substantial layer than the fragile fibrous network seen in the midface. There is a discontinuity of the SMAS at the level of the zygoma because of attachments of the various fascial layers at the zygomatic arch. In the temporal region, the SMAS, the superficial temporal fascia, and the temporoparietal fascia are synonymous.
There are important regional variations in the relationship of the SMAS to neurovascular structures. In the lower face, the facial nerve branches are always deep to the SMAS and innervate the facial muscles on their undersurface. The vessels and sensory nerves in the lower face similarly arise deep to the SMAS and remain at that level, except for their terminal branches. These structures are protected if dissection is superficial to the SMAS in the lower face. In the midface, the facial nerve branches are protected if the dissection is superficial to the muscles of facial expression.
In the temporal area, the temporal (frontal) branch of the facial nerve emerges from within the parotid gland just inferior to the caudal border of the zygomatic arch. At the arch level, it closely approximates the periosteum and lies deep to the temporalis fascia. Once the nerve has crossed the arch, it emerges from the deeper fascia and lies within the fatty tissue on the deep surface of the temporoparietal fascia until it enters the undersurface of the frontalis muscle.
The SMAS is alternatively described as a separate or single layer with the parotid fascia. Once a skin flap is elevated, the zygomatic cutaneous ligament (McGregor patch) is encountered, as are the weaker midface fascial ligaments at the anterior border of the masseter. The facial nerve branches can be seen traveling over the thin masseteric fascia and then over the buccal fat pad, and, at the zygomatic major muscle, the SMAS becomes attached to the muscle with its bony insertions. The SMAS thus envelops the other muscles of facial expression.
The platysma is contiguous inferiorly with both the midface SMAS and the depressor muscles of the lower lip. Superficial to this SMAS layer in the cheek lies the malar fat pad, and a plane can be developed between the fibromuscular SMAS and this fibrofatty layer or malar cheek pad. In the neck, elevations superficial to the platysma muscle are free of risk to the facial nerve. The cervical and marginal mandibular branches are both at risk if subplatysmal dissection is performed.
Vascular supply
Understanding of the SMAS and its relationships is key to obtaining long-lasting results in facelift surgery. The primary blood flow to the facelift flap is through the subdermal plexus supplied by branches to the external carotid system. The septocutaneous arteries, particularly in the area of the zygomatic cutaneous ligament, provide additional blood flow, but these are usually severed during facelift surgery ( Fig. 2 ).
Facial nerve
Knowledge of the landmarks for the common branching patterns and the depth of the facial nerve in specific regions is essential for safe facelift surgery. The main trunk of the nerve exits the stylomastoid foramen and immediately enters the parotid gland. The 5 commonly listed major branches of the facial nerve are:
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Temporal (or frontal)
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Zygomatic
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Buccal
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Marginal mandibular
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Cervical ( Fig. 3 )
Fig. 3 Facial nerve anatomy.( Courtesy of Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist. http://creativecommons.org/licenses/by/2.5/ .)
The main trunk usually divides within the parotid into superior (temporofacial) and inferior (cervicofacial) divisions, but the branching patterns then become variable. There are frequent anastomoses between the buccal and zygomatic branches.
The cervical branches are at risk with subplatysmal dissection. The temporal and mandibular branches are usually terminal branches without anastomotic connections. The buccal branches are at risk during surgery where they cross over the masseter muscle and the buccal fat pad. The temporal branches of the facial nerve have perhaps the most complex anatomy, both in terms of horizontal branching patterns and in their relationship to fascial and muscular layers. In general, the nerve emerges just beneath the zygomatic arch from the parotid, crosses over the periosteum of the zygomatic arch, and then becomes more superficial and runs on the deep surface of the temporal parietal fascia (SMAS) before entering the undersurface of the frontalis muscle.
If the marginal mandibular nerve is injured during facelift surgery, the resulting paralysis leading to lower lip asymmetry is apparent. Dingman and Grabb noted in a large cadaver study that, posterior to the facial artery, the marginal mandibular nerve passed above the inferior border of the mandible in 81% of dissections. Baker and Conley noted that, in their clinical experience, the mandibular branch of the facial nerve is usually 1 to 2 cm below the lower border of the mandible and can be as much as 3 or 4 cm below it.
The major sensory nerve at risk in the facelift procedure is the greater auricular nerve. This nerve can be identified in the subcutaneous area overlying the sternocleidomastoid muscle fascia running from the Erb point up to the ear lobe.
Adjunctive techniques for facial rejuvenation
Procedures that are often added to rhytidectomy for improved results include:
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Submental and lower facial/jowl liposculpture
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Platysmaplasty
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Brow lift
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Upper and lower blepharoplasty
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Autologous fat transfer to the face
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Chin, cheek, and lip implants
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CO 2 laser (or erbium) facial skin resurfacing
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Chemical peels (phenol primarily)
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Dermabrasion
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Earlobe reduction
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Neurotoxins and facial fillers
Facial prep and local anesthetic infusion
Tumescent fluid for anesthesia and vasoconstriction is typically infused in all tissue planes of dissection in conjunction with either deep intravenous sedation or general anesthesia, based on both surgeon and anesthetist preference. The fluid, which contains a mixture of lidocaine and epinephrine in normal saline, can be placed via manual injection or with an infusion pump. The details of the tumescent formula are not discussed in this article but are readily available elsewhere ( Fig. 4 ).
