Facelift (Rhytidectomy)

What are the factors that result in the aging face?

Referred to as elastosis, this process results in loss of collagen and elastin fibers due to:

1. extrinsic factors—actinic damage and gravity

2. intrinsic factors—genetic factors

Name three factors that contribute to less-than-ideal results in facelift.

1. Poor elasticity

2. Heavy actinic damage

3. Deep, coarse facial rhytids

Explain UV light damage.

1. UV light induces photoaging through generation of reactive oxygen species that damage enzymes after being absorbed by chromophores. Alpha-tocopherol, a superoxide scavenging antioxidant, may counter these effects. The mechanism of dermal damage occurs via induction of three metalloproteinases capable of degrading the dermal collagen matrix.

2. UVB light causes direct damage; wavelength: 280 to 315 nm; responsible for most of the DNA damage of the skin.

3. UVA light acts through other active molecules; wavelength: 315 to 400 nm (LONGER than UVB); causes damage 100 to 1,000 times a dose of UVB, with deeper penetration. (unfortunately there is considerably more UVA light making it through the ozone).

What are the endogenous changes that occur with aging?

1. Glycosaminoglycans and proteoglycans decrease with age—this is the rationale for use of Restylane and Hylaform.

2. Collagen decreases by 6% per decade resulting in dermal thinning. The fraction of type 3 collagen decreases.

3. Decreased number of Langerhans cells and keratinizing cells.

4. Increased flattening of the dermal–epidermal junction.

5. Repetitive mimetic muscle contraction contributes to nasolabial fold depth.

Discuss various disorders and whether facelift would be contraindicated.

1. Cutis laxa:

• degeneration of elastic fibers in dermis

• skin does not spring back into position

• autosomal dominant, autosomal recessive, and X-linked forms all exist

• recessive form worst, presents with systemic signs

• surgery may be indicated

2. Pseudoxanthoma elasticum:

• occurs in two dominant and two recessive forms

• recessive form (type II)—entire skin is loose fitting

• diagnose by biopsy to differentiate from cutis laxa

• surgery may be indicated if do not have severe systemic symptoms

3. Ehlers–Danlos syndrome (cutis hyperelastica):

• hypermobile joints

• very thin, friable, and hyperextensible skin

• subcutaneous hemorrhage

• may stretch skin up to 15 cm or more and it will shrink back

• posttraumatic bleeding

• poor wound healing (due to inadequate production of enzyme lysyl oxidase)

• surgery contraindicated

4. Progeria (Hutchinson–Gilford syndrome):

• rare

• unknown etiology

• autosomal recessive

• craniofacial disproportion (due to premature closure of epiphyses)

• baldness

• pinched nose

• protruding ears

• micrognathia

• loss of subcutaneous fat, arteriosclerosis, and cardiac disease

• do not reach reproductive age

• surgery contraindicated

5. Werner syndrome (adult progeria):

• hypo- and hyperpigmentation

• autosomal recessive

• baldness, aging facies

• short stature

• high-pitched voice

• cataracts

• mild DM

• muscle atrophy

• osteoporosis

• premature arteriosclerosis

• various neoplasms

• severe microangiopathy

• surgery contraindicated

6. Meretoja syndrome:

• systemic form of amyloidosis

• excessively lax skin in persons 20 years or older

• facial polyneuropathy

• facial neuropathy helps differentiate this disease

• amyloid deposits in perineurium and endoneurium of peripheral nerves

• surgery contraindicated

7. Idiopathic skin laxity disorders (MDE):

• patchy areas of mid-dermal elastolysis (MDE)

• localized fine wrinkling

• without systemic abnormalities

• pathogenesis is poorly understood

• surgery contraindicated

Discuss the difference between facial soft tissue perfusion over the lateral and the anterior or central face.

1. Anterior face—perfused by numerous small musculocutaneous perforators.

2. Lateral face—perfused by relatively few but large fasciocutaneous perforators.

3. By virtue of elevating facial flaps a significant portion of the fasciocutaneous perforators is disrupted so that the soft tissue must rely on the central musculocutaneous perforators. Medial dissection thus must be performed conservatively to avoid blood flow compromise.

What is the cause of the hollowed outlook in the cheek region following a facelift during which the malar fat was transposed to its preptotic locale?

The malar fat pad itself may atrophy because of disruption of its blood supply resulting in the hollowed outlook of the cheek. The malar fat pad is perfused preferentially by the angular artery musculocutaneous perforators. If this fat is mobilized in the skin layer and aggressively translocated (>2 cm), the blood supply can be disrupted. The malar fat pad should be kept in continuity with the superficial musculoaponeurotic system (SMAS) layer. This maneuver preserves its musculocutaneous perforators if requiring greater than a 2 cm lift.

What is the end point to each of the described dissection layers in the cheeks?

1. Skin elevation: release of the nasolabial fold.

2. SMAS elevation: upturning of the modiolus.

Discuss some of the differences between the male and female faces and implications on facelift.

1. The rate of hematoma (6–8%) in the male is twice that of the female.

2. The vascularity of the skin flap, primarily due to the beard, makes hemostasis more difficult.

3. The beard in the male argues in favor of a pretragal incision, as the beard can obscure the light reflex of the anterior scar. Furthermore, a retrotragal incision may produce unwanted hair growth overlying the tragus.

4. The beard and sideburns of the male can be grown longer to mask superior hairline migration.

Describe the superficial musculoaponeurotic system or SMAS.