29 Short-Incision Facelift and Necklift
A short-incision face-/necklift may result in a more rapid recovery than classic approaches. However, the extent of undermining must extend to the posterior edge of the ptotic superficial muscular aponeurotic system (SMAS) and platysma for adequate suspension.
The multivector SMAS and platysmal suspension technique employs a customized, anatomical method of suspension that restores the ptotic tissue to a more youthful position.
The use of a permanent, monofilament suture permits a means of permanent resuspension. However, to avoid sutures pulling through, the suspension must be reinforced with multiple interrupted or continuous sutures.
The short-incision face-/necklift may be combined with a traditional submentoplasty for patients with significant anterior platysmal banding or liposis.
A horizontal limb extension may be used if there is dimpling of the postauricular skin flap. This extension will not compromise the healing and will allow patients to wear their hair pulled back much more quickly than if there is a visible skin crease.
There has been a great deal of evolution with regard to surgical techniques to address the aging face and neck. The first facelift techniques involved subcutaneous elevation and removal of excess skin in the pretragal area. Unfortunately, there was limited long-term improvement in the cervicomental angle, and laxity due to ptosis of the deeper tissues was not addressed. In 1976, Mitz and Peyronie1 introduced the superficial musculoaponeurotic system (SMAS). SMAS re-suspension, either through imbrications or plication, led to improvement in subcutaneous and cutaneous aging and also increased the longevity of that improvement. The next development was by Hamra, who pioneered both the deep plane lift and then the composite lift.2,3 These innovations were designed to add additional rejuvenation to the melolabial fold and periocular areas. Following the trend of more invasive procedures came the subperiosteal lift.4 Although the more aggressive procedures may have theoretical advantages, in terms of efficacy, over more conservative procedures, this has been an often debated subject, with proponents of the deeper-level lifts arguing better postoperative rejuvenation despite a longer recovery and greater risk of complications. Unfortunately, there have been very few meaningful studies to offer objective evidence to support either argument.5 As with many areas of medicine, market forces and patient demand have led to a reversing trend back to more conservative procedures.
The lateral SMASectomy6 and S-lift7 both use a short incision with a predominantly vertical vector of SMAS suspension. The S-lift utilizes a preauricular incision to gain access to the SMAS and involves making a double purse-string suture to suspend the SMAS to the periosteum of the zygomatic arch. The principal limitation of this technique is the inability to adequately address platysma laxity and cervicomental angle.
The minimal access cranial suspension (MACS) lift was developed in 2001 by Tonnard and Verpaele and was an advance on the purse-string lifts.8 It incorporates additional undermining of the lateral face and jowl and uses larger purse-string sutures to grasp the cranial border of the platysma. Submental liposuction is also used, where indicated, leading to improved results, especially in the heavier-volume face and neck. A further modification has been made through the addition of a third purse-string suture to attempt effacement of the malar fat pad and melolabial fold.9
In 2004, Brandy added another modification to the S-lift by incorporating postauricular and lateral neck undermining to achieve greater correction of the platysma–SMAS complex.10,11 This lift became branded as the Quicklift. The Quicklift and the LifestyleLift, a limited-dissection SMAS/platysma plication, are among two of the more widely advertised face and neck lifts. Their brands imply a minimal degree of invasiveness, risk, and recovery, and through clever marketing, they are influencing the way the American population views facial rejuvenation.
Consequently, there is a greater awareness of facial rejuvenation surgical procedures, although the prospective patient is not necessarily better educated. Patients like the concept of a shorter recovery, natural look, and lower risk, and may be willing to sacrifice some degree of efficacy for this. In order for facial plastic surgeons to remain relevant, they must be able to speak to this demand and offer a similar procedure as part of their facial rejuvenation repertoire.
The multivector lift is a technique whereby the SMAS and platysma are re-suspended in a reverse pathophysiological manner. It appreciates that soft tissue descent with age is not a uniform process, and to achieve an effective, yet natural, result, the surgeon should attempt to restore the ptotic soft tissue to its youthful position (see Video 29.1). This chapter describes a technique employed by both authors for well over a thousand patients with a very high level of satisfaction and low level of morbidity, complications, and need for revision.
Background: Basic Science of Procedure
With age, there is increased laxity and loss of tone both in the superficial layers of the face, such as the epidermis and dermis, and in the deeper layers of the face, including the SMAS and platysma. There is also a change in underlying bone structure that affects the skeletal support of the overlying tissues. The principal layers involved in rhytidoplasty are the SMAS and platysma, with a smaller emphasis on the skin and adipose tissue. Without proper elevation of the SMAS and platysma, there will be insignificant postoperative improvement. The procedure would be a skin lift, which may look good during the early postoperative period in the presence of skin edema, but once the induration has resolved, there may be a quick return of the preoperative laxity.
In addressing the aging SMAS and platysma, the authors employ a multivector lift approach that appreciates that the descent of the subcutaneous soft tissue does not occur in a uniform direction or amount throughout its distribution. Consequently, to reverse the aging process, it is appropriate to return each aspect of the SMAS and platysma to its former, youthful position throughout its entire distribution, rather than by an arbitrary amount or direction. While this approach may be more labor intensive than other methods of SMAS/platysma re-suspension, we believe it is more anatomically correct and beneficial in the long term. As the patient continues to age postoperatively, there is a natural recurrence of SMAS/platysmal descent without an operated or artificial appearance.
The concept behind minimal incision face-/necklifting is that, with appropriate patient selection, sufficient re-suspension of the SMAS/platysma complex can be achieved without extensive skin undermining. With a shorter skin flap, there is a hypothetical decreased recovery period with less edema and ecchymosis, less risk of hematoma and infection, shorter operative time, and smaller incisions. Many facial plastic surgery patients have jobs and do not have the luxury of a long postoperative recovery. Consequently, the option of having a procedure with a relatively short downtime is very appealing. Additionally, due to a shorter operative time with less undermining, the option of a decreased level of anesthesia, such as intravenous or oral conscious sedation with local anesthetic, can be attractive to the patient.
The minimal-incision face-/necklift is a modification of the standard rhytidoplasty. The preauricular incision is made in a similar fashion, but the horizontal sideburn limb is often shorter. The postauricular incision may include a horizontal limb, but the decision is often made during skin redraping, depending on the degree of elastosis. The degree of skin undermining is determined by the location of the posterior edge of the platysma and ptotic SMAS ( Fig. 29.1a–c ). To properly elevate the SMAS and platysma, skin undermining must be performed, at a minimum, to the edge of these structures. Failure to adequately undermine and expose the SMAS and platysma will lead to insignificant soft tissue re-suspension and will essentially be a skin lift with poor efficacy and longevity.
The ideal candidate for a minimal-incision face- and necklift is one with early signs of elasticity. In general, there is mild jowl formation with little anterior platysmal banding, submental elastosis, or liposis. Other concerns that should be taken into account include patients who desire a very conservative result and natural look, patients who do not want a horizontal segment of their postauricular incision, patients seeking a very short recovery time, patients seeking very modest, socially unnoticeable results, and patients with compromised blood supply, such as tobacco users and diabetics.
The typical age range for these patients is the late thirties to mid to late forties. However, patients who have undergone a prior rhytidoplasty with recurrence of facial and cervical elastosis are also potential candidates. An important aspect of a successful surgical outcome is preoperative counseling and setting of expectations. Minimal incision procedures often carry the benefit of a faster recovery and lower risk of complications but may not offer as dramatic a postoperative improvement as a more extensive procedure. Unsatisfied patients are often those who expect the improvement of a traditional procedure, but with the cost, recovery, and risk of a less extensive one.
If a patient does exhibit significant anterior submental elastosis and platysmal laxity, the procedure should be combined with a submentoplasty and anterior platysmal plication and liposculpting, as indicated. If there is significant skin flap dimpling with the anterior plication, connecting the undermined regions of the submental and preauricular skin flaps may help avoid contour irregularities.
Technical Aspects of Procedure
The patient is marked in an upright position, prior to the administration of any sedation or anesthetic. The authors feel that the upright position allows better visualization of the true position of facial and cervicomental laxity. Additionally, areas of potential liposculpting may be identified. If a submentoplasty is going to be performed, an incision is made in, or just posterior to, the submental crease in a curvilinear fashion to parallel the crease. This will help to avoid elevation of the lateral aspect of the incision with the rhytidoplasty to where it may become visible. The area of skin undermining is outlined along with any visible platysmal banding. Generally, dissection is performed to the thyroid notch inferiorly, and as far laterally as necessary to expose any platysmal banding.
The face- and necklift incision is then marked ( Fig. 29.2a–c ). It extends along the sideburn superiorly, inferiorly along the helical root, along the apex of the tragus, inferiorly along the perilobular crease, ascending postauricularly lateral to the postauricular crease, and making a lateral limb of variable length at the height of the helical root. The mandibular border and the anterior border of the sternocleidomastoid (SCM) muscle are marked along with any potential areas for facial liposculpting. The extent of soft tissue undermining, corresponding to the leading edge of the ptotic SMAS and posterior edge of the platysma, is marked. Depending on surgeon preference, a small area of hair along the sideburn and horizontal limb of the postauricular incision may be trimmed to facilitate the procedure and reduce the incidence of ingrown hair within the suture line. The remainder of the patient′s hair is gathered within a bouffant cap and secured with paper tape ( Fig. 29.3 ).
At this time, anesthesia is given. This may be oral sedation, intravenous sedation, or induction of general anesthesia. Once the patient is comfortably sedated or intubated, the local anesthetic is infiltrated. The authors prefer a mixture of 1% lidocaine and 0.5% bupivacaine in a 1:1 ratio. Epinephrine may be added to make a dilution of 1:150,000. Preservative-free anesthetic may cause less discomfort than the premixed lidocaine/bupivacaine with epinephrine. The anesthetic is infiltrated in a subcutaneous plane so that ballooning of the tissue is achieved. The order of infiltration is the same as the procedure: submentoplasty, right face and neck, left face and neck. The bouffant cap is resecured and hair retracted with paper tape. The patient is then prepped with a noniodine solution and draped sterilely.
Although the focus of this chapter is on the minimal-incision face- and necklift, for completeness the submentoplasty portion will be briefly described here. The submental incision is made and undermining is performed in a shallow subcutaneous plane. It is important to leave a modest amount of subcutaneous tissue on the superficial flap to improve the flap viability, decrease the incidence of postoperative skin flap discoloration and telangiectasias, and avoid skeletonization of the platysma and possible cobra-neck deformity. Laterally, along the margin of the mandible, it is important to divide the skin from its attachment to the anterior mandibular ligament. This helps reduce the incidence of banding along the prejowl sulcus with skin redraping following the rhytidoplasty. Once the skin flap has been elevated, the decision is made to perform liposculpting. In a thin neck, extremely conservative liposuction is performed only to assist in identifying the platysma. In heavier necks, more aggressive liposuction may be performed, and subplatysmal liposuction may also be required. This should be done conservatively to reduce postoperative cobra-neck deformity. It is important to feather the peripheral areas, especially lateral to the submental pocket, to ensure a smooth contour.
Anterior platysmal plication may be performed in all patients, except those with extremely wide lateral banding of more than 2.5 cm. The plication extends inferiorly at the hyoid bone and continues superior to the junction of the platysma with the mentalis muscle. A 3–0 polypropylene suture is used in a simple continuous fashion and is tied so that the knot is buried beneath the platysma. If there is excess tissue bunching along the suture line, it may be trimmed or cauterized for contour. A bilateral horizontal back cut is made in the platysma just below the hyoid to disrupt the vertical platysmal band and to help create a hinge for posterior platysmal re-suspension. Meticulous hemostasis should be obtained, especially along the platysmal edges. Prior to skin redraping, a small horizontal skin ellipse (< 1 cm) may be excised along the inferior edge of the flap to improve the postoperative submental skin contour. The incision is carefully closed with 5–0 polypropylene in a continuous simple and vertical mattress fashion.
Rhytidoplasty usually starts on the right side of the face. The incision is made in a beveled fashion toward the flap side to promote hair growth through the incision ( Fig. 29.4 ). Postauricular undermining is performed in a subcutaneous plane directly on the mastoid fascia and fascia of the SCM so that adipose tissue is left on the skin flap. In thin necks, it is extremely important to avoid injury to the great auricular nerve, which may have a superficial location in the inferior neck ( Fig. 29.5 ). Preauricular undermining is performed directly on top of the SMAS ( Fig. 29.6 ) so that there is adequate adipose tissue on the skin flap to help reduce any postoperative contour irregularity, ensure adequate skin flap blood supply, and help reduce the postoperative incidence of skin flap discoloration and telangiectasia development.
Once the skin flap has been elevated circumferentially, hemostasis is obtained. If a submentoplasty has been performed, a decision is made regarding the necessity of connecting the submental dissection and rhytidoplasty pockets. If there is submental skin dimpling from the anterior platysmal plication, the dissection pockets may be connected to assist with smooth skin redraping. Connecting the skin flaps is also beneficial in patients with heavier necks because a better-defined mandibular border is possible through improved liposculpting access.
Plication of the SMAS begins along the mandibular border. The edge of the ptotic SMAS is identified and then elevated in a posterior-superior vector to the anterior edge of the ear lobule. It is secured in a buried fashion with 3–0 polypropylene suture ( Fig. 29.7a,b ). This process is repeated approximately midway between the zygomatic arch and the mandible ( Fig. 29.8a,b ). The optimal vector of suspension should be determined by grasping the edge of the ptotic SMAS and elevating it toward the auricle. The edge of the SMAS should elevate smoothly without dimpling. In general, the vector is slightly more posterior than superior at this point, and the SMAS is sutured in the same fashion. The next point of elevation is just inferior to the zygomatic arch and may achieve some effacement of the melolabial groove ( Fig. 29.9a,b ). This vector is mostly posterior and should complete the smooth SMAS elevation as a unit. A fourth plication suture is placed in the region of the malar fat pad and may be considered a “high SMAS” suture for melolabial fold effacement ( Fig. 29.10 ).
Once the SMAS has been re-suspended, the repair is further reinforced, either with several buried, interrupted sutures (HM) or with a continuous 3–0 polypropylene suture with occasional locking sutures (GV) (see Video 29.1 ). The use of polypropylene allows for permanent support with minimal tissue reaction. There may be a concern about monofilament sutures pulling through the soft tissue, though with the use of multiple sutures, this is less likely than if only several SMAS plication sutures are used.
After the SMAS plication, the platysma is elevated in a similar manner, proceeding in an inferior direction. The initial suspension is just below the angle of the mandible, and the posterior edge of the platysma is elevated in a posterior-superior vector to the edge of the SCM fascia and sutured in a buried fashion ( Fig. 29.11a,b ). Another plication suture is performed ~ 1.5 cm inferiorly with a slightly more posterior than superior vector ( Fig. 29.12a,b ). At the inferior edge of the dissection pocket, another suture is placed with a mostly posterior vector ( Fig. 29.13a,b ). As with the SMAS, the suspension is further reinforced with either additional interrupted sutures (HM) or a continuous suture with interval locking (GV).
After the plication is completed, any bunching along the suture line is trimmed. The skin flap is examined for any evidence of dimpling, which may be corrected by additional undermining. The need for liposculpting in the face and neck is also evaluated ( Fig. 29.14 ). In general, it is performed in a conservative fashion with an emphasis on volume preservation. In a heavy neck, face and lateral neck liposculpting is performed prior to the SMAS and platysmal plication. Hemostasis is obtained prior to skin flap redraping.
Skin flap redraping begins preauricularly at the helical root. The skin is elevated in a posterior-superior vector, ensuring a smooth contour. With the assistant supporting the skin flap, a curved iris scissor is used to make a cut along the helix down to the apex of the helical root incision. The skin flap is reapproximated with a 5–0 polypropylene simple interrupted suture or staple ( Fig. 29.15 ). The temporal tuft is now trimmed, and the subcutaneous tissue is reapproximated with two 5–0 polydioxanone (PDS, Ethicon, San Angelo, TX). The skin is then redraped over the auricle in a posterior-superior vector. The assistant supports the skin flap beneath the lobule, and the superior and inferior tragal borders are marked, along with the helical and perilobular margin. The skin is trimmed with curved iris scissors, carefully following along the edge of the preauricular incision. It is important to thin the supratragal skin so that there is a minimal amount of superficial adipose tissue on the flap ( Fig. 29.16 ). This helps to avoid the appearance of a “fatty” tragus.
It is also important to avoid excess thinning of the flap because this can lead to tragal skeletonization and flap contraction. A buried 5–0 PDS suture is placed above and below the tragus. An anchor suture is placed at the apex of the lobule connecting the deep lobular tissue to the dermis of the skin flap using a 5–0 PDS or polypropylene suture. The skin is reapproximated using 5–0 polypropylene in a continuous simple with interval vertical mattress sutures for optimal reapproximation. Vertical mattress sutures are especially important along the anterior aspect of the lobule.
Postauricular skin flap redraping is done in a similar manner with the skin being elevated in an anteriorsuperior vector. The surgical assistant should retract the ear with one hand and then support the skin flap with another. The outline of the new skin edge is drawn and trimmed, ensuring that there is minimal skin tension ( Fig. 29.17 ). A curved iris scissor is used to trim the flap, which is anchored at the apex of the postauricular sulcus with one simple, interrupted 5–0 polypropylene suture. A buried 5–0 PDS suture is placed at the midportion of the horizontal limb of the postauricular suture, suspending the subcutaneous tissue of the skin flap to the mastoid fascia. An additional 5–0 PDS suture is placed at the posterior aspect of the lobule to offer further support. At this point, it is necessary to evaluate the lateral aspect of the incision for any standing cutaneous deformity. If present, a vertical limb, along or just inside the hairline, may be necessary to avoid skin dimpling. The epidermis is reapproximated with a continuous polypropylene suture in a simple and interval vertical mattress fashion ( Fig. 29.18 ). By placing several vertical mattress sutures along the postauricular sulcus, the incidence of poor tissue union upon suture removal is much reduced. Although rarely used postoperatively, a quarter-inch Penrose drain may be placed between the sutures along the postauricular sulcus. This stays in place until the conclusion of the case, when it is removed before applying the pressure dressing.
The procedure is then repeated in an identical fashion for the contralateral side. After the skin incisions have been sutured, the undermined pre- and postauricular skin flaps are aggressively milked to remove any excess serosanguinous fluid. The Penrose drains are removed, and a compressive dressing is placed. Occasionally, a Penrose drain may be needed until the pressure dressing is removed the following day, especially in patients with above-average intraoperative blood loss, hypertension, or significant collections underneath the skin flaps at the conclusion of the case. It is important to explain that these patients may see more drainage on the dressing so that they are not alarmed.