The sections on the face, neck, and brow include descriptions of facelift, neck lift, and open brow lift techniques, anesthesia, treatment goals, procedural approaches, complications, management, preoperative and postoperative care, rehabilitation, recovery, and outcomes. The approach to facial rejuvenation the midface and periorbital area is detailed. These operations are often and easily performed entirely with the use of local anesthesia and mild oral sedation. There are very high satisfaction rates.
Key points
- •
Full and limited or mini facelifts and neck lifts can easily be performed entirely with local anesthesia without IV sedation or general anesthesia.
- •
Open brow lifts can be combined with face and neck lifts all with local anesthesia, and with appropriate patient selection.
- •
The brow is often an under-appreciated but important area for facial rejuvenation.
- •
The neck is a very sensual area in the overall facial appearance.
- •
Eyelid surgery is one of the most delicate and unforgiving areas of facial rejuvenation.
The face
- 1.
Skin incisions
- 2.
SMAS manipulation
- 3.
Anesthesia options
Introduction
Cosmetic facial surgery can have a profound effect on the psychological well-being and many other areas of a person’s life ( Figs. 1 and 2 ).
Over the last several decades there have been many approaches to facial rejuvenation. Some of the approaches have included skin only, a loop suspension, a MACS-lift, the lateral SMASectomy, SMAS-lift, and the FAME technique. People have tried different approaches with skin incisions including the S lift, as well as the quick-lift.
There have also been various approaches to the levels of anesthesia involved in facial rejuvenation. Some people have consistently used general anesthesia with controlled hypotension, as well as conscious sedation. Total intravenous anesthesia, as well as simple local anesthesia, is an alternative method of delivering anesthesia.
Michael Jackson did not die from any of his multiple cosmetic surgeries. He died of a poorly administered general anesthetic, by someone who was not adequately trained to do so. Clearly, mistakes can happen and to “keep it simple” may leave less room for human error. There may be some value to minimizing sedation and avoiding general anesthesia in procedures of the face, neck, and brow if the local anesthesia is properly administered.
Facial Anatomy
Although there may be as many different types of facial procedures as there are faces, the basic principles still remain the same. Some factors to consider in facial rejuvenation include the following:
- 1.
Skin type
- 2.
Facial structure including cheek bones, jaw, and chin shape
- 3.
Skin laxity as well as the anterior hairline and sideburn
- 4.
Nasolabial fold formation
- 5.
Jowls
- 6.
The submental fat
- 7.
Cervical bands
- 8.
Skin laxity, as well as many other factors.
Although the combination of techniques may be used to target the areas in need of improvement, the surgeon must also direct the procedure toward the potential complications, anesthesia type, as well as the patient’s own desires.
As the youthful face ages, there is some consistency that is often found. There is often an increase in the laxity of cutaneous ligaments as well as a descent in well-known fat pads. This descent particularly occurs around the lower lid (preseptal space of fat pads), the malar fat pads (prezygomatic space), the nasolabial folds (vestibule of the oral cavity), jowls (premasseter space), and the labial mandibular folds (masticator space).
It is the understanding of the facial anatomy that allows the surgeon to determine the layer of the face in which the dissection is best performed and used for redraping.
The 2 key factors in facial rejuvenation include appropriate release and appropriate repositioning or suspension.
It is the senior author’s opinion that barbed threads do not produce long-term results that are even comparable to traditional surgical lifting techniques. It is also thought that the face that is less aged may require a less aggressive approach with less dissection and possibly smaller incisions. The authors have completely stopped using barbed threads in 2006, for the poor performance at the time.
Local Anesthesia
Although there are many approaches to the anesthesia to be used in facial rejuvenation, the senior author has had the opportunity and the experience to evaluate most of the commonly described facelift techniques, as well as the different anesthetic techniques used. After performing hundreds of facelifts with different approaches in the last 6 years, it has been found that most patients can in fact tolerate a local anesthetic facelift without the need for any intravenous sedation or general anesthesia. Although some authors use a local anesthetic of 100 mL or 0.25% Lidocaine with 100,000 and 200,000 units epinephrine, there are other authors such as Aston who recommend a different combination of local anesthetic solution. The MACS lift uses a standard anesthetic solution of 100 mL sodium chloride 0.9%, 20 mL Lidocaine 2%, 10 mL Ropivacaine at 10 mg/mL, 2 mL sodium bicarbonate 8.4%, 0.2 mL Levorenin at 1 mg/mL, and 10 mg Triamcinolone. The anesthetic solution of choice is really up to the experience and preference of the surgeon.
Some authors use a tumescent approach similar to the amount of infiltration used in liposuction cases. It is the senior author’s opinion that the tissue does not mobilize as well when too much infiltration has been used.
The authors have found it useful to maintain a consistency in all infiltration and all procedures to help eliminate human error ( Fig. 3 ). The authors routinely start on the left side of the face and infiltrate it in a similar fashion, starting from above and behind the left ear, and moving in a sequential fashion anteriorly along the areas of marking where the local anesthetic will end in the subcutaneous plane ( Fig. 4 ). It is helpful to first infiltrate the area of the infraorbital nerve and the great auricular nerve, as this may decrease the sensation of the needle around the ear ( Fig. 5 ).
Although mild oral sedation with Tylenol-Codeine, oral Gravol® or sublingual lorazepam (Ativan™) has routinely been used, the authors have never used intravenous sedation in an office setting ( Fig. 6 ). Mild intravenous sedation can be administered by a surgeon; however, heavy sedation should probably be monitored by a separate person. It is noted that oral sedation with Ativan alone may have unpredictable absorption and will often have late onset, and a relatively, unnecessarily long, half-life.
Treatment Goals and Planned Outcomes
The goal of facial rejuvenation procedures is to gain harmony of the upper and lower parts of the face with the desired replenished look.
Preoperative Planning and Preparation
The surgeon should evaluate and document the following areas, which include the bone structure of the entire face, the skin quality and laxity, location of particular fat deposits as well as the mid face thickness, laxity and mobility, the deepness in mobility of the nasolabial folds, the neck shape, size, and platysmal muscle anatomy. Furthermore, the malar areas and lower lids should be noted and other areas outside of the actual face and neck lift area, including the brow and location of the posterior auricular hair skin. The surgeon must determine the patient’s main areas of concern and motivation for surgery and note detailed photographs.
Patient Positioning
It is the senior author’s opinion to keep the head in a neutral position and not turn the head from left to right during the surgery. It is also recommended to avoid hyperextending the neck. It is best to keep a headrest and possibly a donut-type pillow to allow access to the face with minimal turning or repositioning of the head. Minimal turning will allow for the maximal amount of SMAS and platysmal repositioning and tension, as well as a natural position to compare the left and right sides of the face for appropriate symmetry and contouring.
Procedural Approach
For most rhytidectomies, the face should be marked on both sides for the incision pattern, as well as the area for the infiltration. Areas requiring attention to elevation and key landmarks for movement and redraping should also be marked.
The pretragal and retrotragal incisions have been well described and this is primarily a surgeon’s preference. The senior author prefers the retrotragal incision for both male and female patients, and the hair follicles are simply trimmed out of the skin flap for male patients.
If the patient seeks a “ponytail friendly” incision, it is best to end the incision at the area of the earlobe. It may depend on the amount of laxity on the tissue around the face and the neck regarding how far anterior to the ear the incision has to go. If there is considerable laxity in the neck, then a posterior auricular incision may be necessary.
The posterior auricular incision only needs to cross over the posterior concha for a few millimeters to allow some space for possible scar migration. The point where the hairline meets the ear at the superior aspect of the posterior ear should be noted, and the incision can be curved in this direction. It is noted that the amount of skin and neck movement over the mastoid may vary and this may change the posterior hairline position. The scar may go into the posterior scalp to hide the scar, or come down in an inferior fashion to keep the hairline in a similar position; however, the scar may still be present.
A W-plasty-type incision is made in the hair in front of the ear no higher than the level of the takeoff of the helix anteriorly. A second incision is made superior to the helix in a more posterior fashion. After the skin is elevated, the skin is rotated posteriorly, which decreases the large temporal dog ear, and the scar rarely goes anterior to the sideburn and never elevates the hair above the takeoff of the helix. This approach was used in a comparative study of 4 different, popular facelifts by Alpert and colleagues.
After the flaps were elevated appropriately, according to the techniques of Baker, the surgeon has the ability to reposition the SMAS in the appropriate vector in a primarily vertical fashion. The senior author generally start from an inferior portion of platysma, tacking this in a posterior but more superior direction toward the mastoid using a figure-of-8 cruciate stitch. The cruciate stitch produces a 4-strand type of repair over the area and is fairly quick and efficient as used in flexor tendons. The SMAS is split at the area of the platysma and the lateral SMASectomy is performed anterior as previously described by other authors. The 3-0 clear PDS™ is used in a similar circuiting fashion anterior to the ear suturing in a direction toward the cartilaginous portion, anterior to the tragus near the external auditory canal. Further plication may be performed more superiorly, if necessary, in the area where one would dissect along tension for a high lateral SMAS or the anterior third loop stitch over the malar prominence. The SMAS may also be plicated up toward the temporalis fascia.
Various types of sutures have been used in the plication and the senior author have seen that Vicryl™ clearly does not suspend sufficiently for long-term results. Mersilene™ sometimes will stick out and will have to be removed through the skin. Nylon is sometimes palpable; however, if not cut too short, it can be less problematic. It is noted on redo or revision facelift surgery and on secondary or even tertiary surgery where the Nylon sutures are identified from previous lifts; that tension seems to be very loose and is not holding tissue at that point. The senior author found 3-0 PDS™ strong enough and large enough to be able to give a lasting resuspension of the tissue, and the authors have not had any problems thus far with the thread protruding from the wound or getting infected. The senior author occasionally augment the PDS™ with a 4-0 clear Nylon for added lasting suspension of the SMAS and platysma.
With the advancement of facial rejuvenations, surgeons have been able to combine the SMAS platysma type of facelift with the FAME technique to help improve the mid face in the nasolabial folds.
It is noted that the dissection of tissue can be performed in many different ways including the finger-assisted technique. It has been found that the spreading of tissue in a superior to inferior direction or with traditional facelift-type scissors or Kaye scissors works very efficiently, and skin flaps can be elevated in a matter of minutes in the appropriate plane, including over the SMAS and platysma ( Fig. 7 ).
After the SMAS and platysma have been plicated and/or repositioned in the appropriate positions, the skin is redraped with relatively small amounts of tension, with the face in the neutral position. The position of the earlobe is determined first and a buried 3-0 PDS is placed in the subcutaneous plane from the new corner of the new skin, to the new position from where the medial aspect of the earlobe will sit. The 3-0 PDS™ is buried and left behind the ear ( Figs. 8 and 9 ). The rest of the skin is trimmed for the appropriate positioning and buried 4-0 Vicryl™ is used for the tacking sutures ( Fig. 10 ). The skin is defatted in the area of the tragus, and just in front of the tragus a single buried 4-0 Vicryl™ is used to help prevent distortion of the tragus ( Fig. 11 ). To prevent scar migration behind or in front of the ear into the cartilaginous areas, 4-0 Vicryl is also used. Staples can be used in the hair baring scalp area or 3-0 Vicryl Rapide™. For the rest of the skin closures, 5-0 Vicryl Rapide™ has been used.
Potential Complications and Management
The standard complications for any facelift operation include bleeding (hematoma, ecchymosis), edema, infection, pathologic scars, seromas, contour irregularities, asymmetry, alopecia, motor or sensory nerve damage, and skin loss. Fortunately these complications are fairly rare and each complication should be treated on an individual basis according to the surgeon’s experience and tailored to that patient.
The use of drains has been compared in previous studies. It is the authors’ experience that even trying to place a drain on only one side of the face, the swelling and local anesthesia are removed faster in the area that is drained. It is found by patients and documented by the senior author’s experience that the drain itself is inconvenient, and beyond 1 week there is no difference between both sides, whether they are drained or not.
Tisseel™ has been described for the prevention of the use of drains and to decrease hematomas. The authors have not found any significant difference in very small hematoma rates or ecchymosis with the use of Tisseel™.
Postprocedural Care
A light compression bandage is worn for the first 24 to 48 hours and the patients are encouraged to shower. If a small Penrose drain is used, it can be removed in the shower. The patient is to apply a light amount of Polysporin around the incisions and the facelift garment is then worn, if there is any residual swelling over the next few days. The garment is worn for longer periods if neck or facial liposuction is used.
Rehabilitation and Recovery
The patient may have difficulty in opening the mouth widely for eating. The patient is encouraged to stick with mechanically soft food and small bites, especially simple foods, like soup. Most patients are able to return to work 2 weeks postoperatively.
Outcomes
As described above, infection and bleeding are the major complications; however, with proper surgical techniques and postprocedural care, patients can expect high satisfaction rates. Figs. 12–19 show preoperative and postoperative photographs of a patient who had rhytidectomy with upper and lower blepharoplasty.
Summary
The SMAS and FAME techniques can be used in combination with one another, to achieve a natural contour and appearance to the upper and lower parts of the face. The procedural approach and skill of the surgeon are major determinants of the procedural outcome. With proper postoperative care, patients will achieve satisfactory results.
The face
- 1.
Skin incisions
- 2.
SMAS manipulation
- 3.
Anesthesia options
Introduction
Cosmetic facial surgery can have a profound effect on the psychological well-being and many other areas of a person’s life ( Figs. 1 and 2 ).
Over the last several decades there have been many approaches to facial rejuvenation. Some of the approaches have included skin only, a loop suspension, a MACS-lift, the lateral SMASectomy, SMAS-lift, and the FAME technique. People have tried different approaches with skin incisions including the S lift, as well as the quick-lift.
There have also been various approaches to the levels of anesthesia involved in facial rejuvenation. Some people have consistently used general anesthesia with controlled hypotension, as well as conscious sedation. Total intravenous anesthesia, as well as simple local anesthesia, is an alternative method of delivering anesthesia.
Michael Jackson did not die from any of his multiple cosmetic surgeries. He died of a poorly administered general anesthetic, by someone who was not adequately trained to do so. Clearly, mistakes can happen and to “keep it simple” may leave less room for human error. There may be some value to minimizing sedation and avoiding general anesthesia in procedures of the face, neck, and brow if the local anesthesia is properly administered.
Facial Anatomy
Although there may be as many different types of facial procedures as there are faces, the basic principles still remain the same. Some factors to consider in facial rejuvenation include the following:
- 1.
Skin type
- 2.
Facial structure including cheek bones, jaw, and chin shape
- 3.
Skin laxity as well as the anterior hairline and sideburn
- 4.
Nasolabial fold formation
- 5.
Jowls
- 6.
The submental fat
- 7.
Cervical bands
- 8.
Skin laxity, as well as many other factors.
Although the combination of techniques may be used to target the areas in need of improvement, the surgeon must also direct the procedure toward the potential complications, anesthesia type, as well as the patient’s own desires.
As the youthful face ages, there is some consistency that is often found. There is often an increase in the laxity of cutaneous ligaments as well as a descent in well-known fat pads. This descent particularly occurs around the lower lid (preseptal space of fat pads), the malar fat pads (prezygomatic space), the nasolabial folds (vestibule of the oral cavity), jowls (premasseter space), and the labial mandibular folds (masticator space).
It is the understanding of the facial anatomy that allows the surgeon to determine the layer of the face in which the dissection is best performed and used for redraping.
The 2 key factors in facial rejuvenation include appropriate release and appropriate repositioning or suspension.
It is the senior author’s opinion that barbed threads do not produce long-term results that are even comparable to traditional surgical lifting techniques. It is also thought that the face that is less aged may require a less aggressive approach with less dissection and possibly smaller incisions. The authors have completely stopped using barbed threads in 2006, for the poor performance at the time.
Local Anesthesia
Although there are many approaches to the anesthesia to be used in facial rejuvenation, the senior author has had the opportunity and the experience to evaluate most of the commonly described facelift techniques, as well as the different anesthetic techniques used. After performing hundreds of facelifts with different approaches in the last 6 years, it has been found that most patients can in fact tolerate a local anesthetic facelift without the need for any intravenous sedation or general anesthesia. Although some authors use a local anesthetic of 100 mL or 0.25% Lidocaine with 100,000 and 200,000 units epinephrine, there are other authors such as Aston who recommend a different combination of local anesthetic solution. The MACS lift uses a standard anesthetic solution of 100 mL sodium chloride 0.9%, 20 mL Lidocaine 2%, 10 mL Ropivacaine at 10 mg/mL, 2 mL sodium bicarbonate 8.4%, 0.2 mL Levorenin at 1 mg/mL, and 10 mg Triamcinolone. The anesthetic solution of choice is really up to the experience and preference of the surgeon.
Some authors use a tumescent approach similar to the amount of infiltration used in liposuction cases. It is the senior author’s opinion that the tissue does not mobilize as well when too much infiltration has been used.
The authors have found it useful to maintain a consistency in all infiltration and all procedures to help eliminate human error ( Fig. 3 ). The authors routinely start on the left side of the face and infiltrate it in a similar fashion, starting from above and behind the left ear, and moving in a sequential fashion anteriorly along the areas of marking where the local anesthetic will end in the subcutaneous plane ( Fig. 4 ). It is helpful to first infiltrate the area of the infraorbital nerve and the great auricular nerve, as this may decrease the sensation of the needle around the ear ( Fig. 5 ).
