CHAPTER 10 Foundation facelift
Foundation facelift, formerly known as deep-plane lift, is characterized by elevation of a composite musculo-cutaneous flap of facial and upper cervical soft tissues. As the flap is rotated to a more lateral and cephalad position, it dramatically corrects tissue laxity, and rejuvenates the face. The foundation facelift is particularly effective in softening the nasolabial fold. The thickness and excellent vascularity of the flap produce long-lasting and natural results.
Skoog described use of a composite flap for facelift in his landmark textbook, published in 1974. In 1980, Lemmon and Hamra reported their experience with Skoog’s technique. Hamra subsequently combined the foundation facelift with a trans-palpebral, vertical mid-facelift and named the dual operation composite rhytidectomy. Pina reported his experience with composite rhytidectomy in 1997. Pitman created a video in 2000, clarifying the applied anatomy of the operation’s composite, musculo-cutaneous flap.
• Patients who have had a previous SMAS-platysma operation and in whom the remaining SMAS-platysma may be insubstantial and/or scarred can still have a robust flap when the subcutaneous tissues and skin remain integrated with the SMAS-platysma as in the foundation facelift.
• Because the foundation facelift flap has a particularly strong blood supply, typical of musculo-cutaneous flaps, this operation is a good choice for smokers and other patients in whom the vascularity of the facelift flap may be suboptimal.
• The dissection plane deep to the SMAS-platysma is an avascular plane, and operations in this plane are bloodless, rarely eventuating in hematomas. The foundation lift, then, is a good choice for patients at increased risk for postoperative bleeding.
• Because the foundation facelift flap is thick and has a robust blood supply, it can be elevated to the nasolabial fold and even on to the lip without fear of flap necrosis, even when the flap is pulled up under some tension. This operation, is a champion technique for flattening deep nasolabial folds.
Patient evaluation is directed towards identifying anatomical features which will be particularly well treated with the foundation facelift. Conversely, some anatomical features are better treated with other techniques. Evaluation proceeds as follows.
• Evaluate the skin of the face and neck and underlying soft tissues for laxity and loss of elasticity. Laxity is characterized by excess and redundant skin. Loss of elasticity means that the skin does not easily snap back after being put under stretch, and mitigates against a superior and long-lasting result. These patients should be warned that an early secondary operation may be necessary.
• Severe sun damage, as evidenced by rhytids, thinning of the skin, and pigmentary changes, should also be noted and pointed out to the patient. These actinic changes are little improved by facelifting, and the patient should be aware of the limitations imposed by solar damage to the skin.
• The quality and thickness of the preauricular skin and the presence of fine hairs on the skin should be noted in women and men. Thick, hair-bearing skin in either sex is a relative contraindication to using a retrotragal incision, since transposing the thickened, hair-bearing skin to cover the tragus will obscure the fine detail of this important anatomic landmark.
From its origin in the lower neck, the platysma muscle extends to the lower cheek, covering a portion of the lower parotid gland before inserting into the perioral muscles at the corner of the mouth (Fig. 10.1). The investing fascia of the platysma continues cephalad in the cheek as the SMAS (superficial musculo-aponeurotic system). The SMAS lies superficial to the masseter muscle and the buccal fat pad, before continuing in a cephalic direction to invest the deep and superficial layers of the zygomatic major and minor.
The defining feature of the foundation facelift is elevation of the SMAS-platysma, subcutaneous fat, and overlying skin as a unified flap. The SMAS-platysma is the integrated foundation of this musculo-cutaneous, composite flap. In the upper neck and lower cheek, the platysma is the deepest layer of the flap (Fig. 10.2); in the mid and upper cheek, the platysma continues as the SMAS and forms the deepest layer of the flap (Fig. 10.3).
Safe and facile performance of the foundation lift requires the surgeon to possess an intimate knowledge of the three-dimensional course of the facial nerve as its branches traverse the musculo-fascial planes of the cheek and upper neck.
• A more complete understanding of the anatomy of the foundation facelift is obtained by studying an artist’s representation of the surgeon’s view when the flap is elevated (Fig. 10.5). The platysma is elevated with the subcutaneous fat and skin in the lower cheek. In the mid and upper cheek, the platysma becomes the SMAS and is also elevated with the subcutaneous fat and skin. The malar fat pad in the upper cheek also remains attached to the skin and is elevated as the skin is mobilized and repositioned. Note the course of the branches of the facial nerve as they exit the anterior border of the parotid gland, but remain covered by masseteric fascia, buccal fascia, and the zygomaticus major.
Cadaver dissection by David A. Stoker, M.D., from Pitman GH. Foundation facelift. In: Nahai F. The art of aesthetic surgery: Principles and techniques. St. Louis: Quality Medical Publishing, 2005. (With permission.)
Fig. 10.5 Surgeon’s view of foundation facelift flap. Facial nerve branches lie within the parotid gland until they exit from the anterior border of the gland at which time they are deep to the masseteric fascia, the buccal fascia, and the zygomaticus major. Nerve branches are shaded to indicate they are covered by the aforementioned structures.
David A. Stoker, M.D., from Pitman GH. Foundation facelift. In: Nahai F. The art of aesthetic surgery: Principles and techniques. St. Louis: Quality Medical Publishing, 2005. (With permission.)
The patient is placed supine on the operating table. Intermittent compression boots are placed on the calves and ankles prior to induction. The operating table is flexed slightly at the hips and knees. The head is kept in a neutral position except when working in the neck at which time the headpiece is dropped towards the floor so that the neck can be easily extended, improving visualization deep in the neck.
If only the face and upper neck are treated, the operation can be performed under local anesthesia. When eyelids, brow and lower neck are treated synchronously with the face, the procedure will last more than two hours, and general anesthesia is used for patient comfort and safety.
Oral endotracheal intubation ensures a secure airway, permitting the anesthesiologist to move well away from the head of the table and out of the operative field, yet still have control over the airway and ability to monitor end-tidal carbon dioxide.
The endotracheal tube is sutured to an upper incisor and wrapped with sterile drapes. The anesthesia circuit remains in the operative field, on top of the drapes, and is easily repositioned during surgery as the patient’s head is turned side to side.
Prior to surgery, anatomic landmarks are drawn on the face and neck with the patient standing (Fig. 10.6). The drawn lines indicate: