CC
The patient is a 56-year-old White female who presented for facial rejuvenation surgery ( Fig. 88.1 , eFig. 88.2 to Fig. 88.3 ). Her chief complaints include looking tired around the mid face, loose skin around the lower face, and loose skin under her chin.
HPI
The patient has seen another surgeon already and wants a second opinion. The original surgeon recommended liposuction of submental area and thread lift of the face. Recovery time and expenses are not a concern for the patient. The patient points to the submental areas and jaw line as the areas where she believes she has loose skin and the perioral region for looking tired.
The patient has never had any type of facial surgery. She had noninvasive procedures, including injectables (dermal fillers around the mouth) approximately 1 year ago and was pleased with the results. She appears to have appropriate surgical expectations and is motivated. She also states that she has lost about 25 lb over the past few months to reach an ideal weight before surgery.
PMHX/PDHX/medications/allergies/SH/FH
The patient is a healthy, American Society of Anesthesiology (ASA) class I 56-year-old female. She is seen by her primary care physician annually. She has no active or previous medical history and does not make any prescription medications. She takes daily multivitamins, does not smoke, and does not have any allergies to foods or medications. Her only previous surgical procedure included removal of her tonsils as a teenager. She denies having any facial surgical procedures except injection of perioral dermal fillers about 1 year ago. She does not have any history of perioral herpes outbreak.
Examination
The patient is a Fitzpatrick class II and Glogau 2 during her assessment. She is of average height (5 ft, 5 inches) and weight. She is pleasant and appropriate during her evaluation and assessment. Her focused physical examination is as follows:
Forehead and eyebrows. The eyebrows are symmetrical and in good position compared with the supraorbital rims. She has static and dynamic transverse and vertical forehead lines.
Upper and lower eyelids. A slight amount of excess skin associated with the upper eyelids (dermatochalasia); the lower eyelids are in good position with normal eyelid distraction and SNAP tests. Mild amount of excess skin in the lower eyelids with fat prolapse across all three fat pads. She has hollowed nasojugal areas, mild to moderate skin laxity, and crow’s feet.
Midface. Mild midfacial ptosis and hollowing of the eyelid-cheek junctions; mild to moderate depth nasolabial folds; laxity of midfacial skin.
Lower face. Laxity of the skin overlying the jaw bone; mild to moderate jowling; jaw line fairly intact with some obliteration caused by the jowling.
Neck. Platysmal redundancy in the midline; obtuse cervicomental angle; normal chin projection; small amount of submental lipomatosis.
Perioral. Mild to moderate depth nasolabial folds; downturned commissures; mild to moderate depth marionette lines.
Skin. Dry skin; thick biotype; areas of melasma and dyspigmentation; photoaging.
Imaging
Standard full facial photography for facial cosmetic surgery was obtained. This includes a frontal view, three-quarter oblique views, profile views, and a submental view.
Labs
Considering that the patient is quite healthy (ASA class I), no further medical clearance or any laboratory blood work was required.
Assessment
Bilateral lower eyelid dermatochalasia with fat prolapse, bilateral mid and lower face dermatochalasia and laxity, platysmal redundancy and submental lipomatosis, and intrinsic facial aging and photoaging.
Treatment
The patient was given several options for addressing her cosmetic concerns. These included a two-phase approach, including a cervicoplasty, facelift, and lower eyelid blepharoplasty in the first operation followed by a full-face laser resurfacing about 4 to 6 months after the initial procedure. She was counseled on the different available facelift techniques, including thread lift, superficial facelifting, and deep plane facelifting. Advantages of the deep plane facelift were explained, and the patient opted to choose the deep plane as her best option.
The surgery is performed under general anesthesia with an endotracheal tube in place. The sequence of the surgical procedure was as follows:
- 1.
Skin markings
- 2.
Administration of local anesthesia with vasoconstrictor or tumescent anesthesia
- 3.
Elevation of skin flap in anterior neck
- 4.
Open liposuction of submental fat (supraplatysmal fat)
- 5.
Platysmaplasty
- 6.
Pack the neck and keep it open until closure at end
- 7.
Elevation of skin flap, right face
- 8.
Elevation of superficial musculoaponeurotic system (SMAS) flap, right face
- 9.
SMAS resection and reposition
- 10.
Fibrin sealant application
- 11.
Skin flap reposition and closure, right face
- 12.
Elevation of skin flap, left face
- 13.
Elevation of SMAS flap, left face
- 14.
SMAS resection and reposition
- 15.
Fibrin sealant application
- 16.
Skin flap reposition and closure, left face
- 17.
Closure of submental incision after application of fibrin sealant
- 18.
Bilateral transconjunctival lower eyelid blepharoplasty with fat repositioning
- 19.
Application of pressure dressing
Skin markings are performed in the preoperative area with the patient sitting and looking straight ahead ( Fig. 88.4 , eFigs. 88.5–6 to Fig. 88.7 ). The inferior border of the mandible is marked, both edges of the anterior borders of the sternocleidomastoid (SCM) muscles are marked, the extent of jowling is marked, and a 3-cm midline incision is marked just posterior to the submental crease. Facial markings include a preauricular outline connected to a temporal incision around the temporal hair tuft. Posteriorly, the outline is marked just above the postauricular crease on the ear until the widest part of the ear and then gently fades posteriorly into the hairline.
