Indications and Techniques for Face-Lifting and Neck Lifting
David A. Hidalgo
Sammy Sinno
GENERAL CONCEPTS
Facial aging is a result of progressive degenerative changes in the skin, deeper soft tissues, and underlying skeletal structures, often occurring independently and each to variable degrees.
Although new nonsurgical techniques that attempt to restore a more youthful facial appearance continue to develop, surgical rejuvenation remains the most powerful approach.
Face-lifting and neck lifting involves dissection and manipulation of facial skin and deeper soft tissues to create an aesthetically rejuvenated facial appearance and youthful contour in the neck.
The superficial musculoaponeurotic system (SMAS) layer of the face can be manipulated independent of facial skin in several ways to provide more natural and long-lasting results.
SMAS technique options include SMAS flap, SMASectomy, and SMAS plication.1,2,3 Facial contour, skin quality, soft tissue volume, and bone structure all influence the choice of technique.
There are various strategies applicable to treating aging changes in the neck that address visible muscle banding, skin laxity, and general neck contour.
Adjunctive procedures involving periorbital surgery, regional resurfacing, soft tissue volume augmentation, skeletal augmentation, and others enhance the results of facelifting and neck lifting.
ANATOMY
The face is a lamellar structure that, from superficial to deep, consists of skin, subcutaneous fat, SMAS, deep fascia (parotidomasseteric fascia), the mimetic muscles, facial nerve branches and the parotid gland, muscles of mastication, deep fat compartments, and bone.
The facial nerve innervates most muscles of facial expression on their deep surface and is protected in the area over the parotid by the parotidomasseteric fascia.4
The SMAS is contiguous with the platysma muscle inferiorly and the galea aponeurotica superiorly.5 Tightening of this layer repositions ptotic facial tissues and is a key component of restoring youthful facial contour.
The platysma muscle in the neck typically develops ligamentous laxity with aging. This commonly results in the development of visible medial muscle edges (bands) anteriorly that exhibit variable thickness, length, and spacing between them. Excess subcutaneous fat superficial to the muscle can also contribute to the appearance of an aging neck.
Structures deep to the platysma including subplatysmal fat, submandibular glands, digastric muscles, and the hyoid bone can also contribute to contour problems independent of the aging process, as can skeletal conditions such as microgenia.
PATIENT HISTORY AND PHYSICAL FINDINGS
Patients typically present for surgical rejuvenation of the face and neck over the age of 50, but some seeking correction of minimal deformities can present in their early 40s.
Patients presenting for the first time in their 70s are also reasonable candidates provided there are no prohibitive medical conditions.
The best candidates for surgery are those with significant aging changes who are motivated for the right reasons; good candidates should be psychologically stable and have realistic expectations.
Characteristic signs of facial aging include deepening of the nasolabial folds with associated midface ptosis and deflation; progressive actinic skin damage and laxity; subcutaneous atrophy; development of jowls, “marionette lines,” and adjacent prejowl hollowing; and platysma laxity leading to anterior bands and an obtuse cervicomental angle laterally.
Smoking increases the risk of wound complications, particularly in the setting of wide skin undermining. Therefore, complete cessation of smoking is required for at least 3 weeks prior to surgery. Nicotine substitutes of all types are also prohibited.
Strategies to minimize complications when uncertainty exists regarding compliance include avoiding retrotragal incisions, limiting the extent of the retroauricular incision design (short-scar option if appropriate), avoiding opening the anterior neck, and limiting skin undermining.
Patients with a BMI over 30 and significant medical conditions such as obstructive sleep apnea, severe diabetes, or cardiovascular disease are unfavorable candidates for surgery in an office-based setting. Men with a history of obstructive urinary symptoms should have a urology consultation prior to surgery.
IMAGING
Although 3D scanning is available today, it does not significantly enhance communication between the surgeon and patient beyond what high-quality facial photographs and mirror examination can achieve.
SURGICAL MANAGEMENT
Preoperative Planning
Skin quality is assessed including thickness, elasticity, and degree of actinic damage.
Many patients will benefit from simultaneous regional skin resurfacing with a chemical peel such as 30% trichloroacetic acid for the thinner periorbital skin or dermabrasion for the thicker perioral skin.
Lasers are an alternative resurfacing modality, perhaps best suited to full face treatment with fractionated laserbased technology subsequent to surgery.
Patients with high sideburns are advised that their hairline may move slightly or that a subsideburn incision may be necessary to prevent excessive movement. The latter is more common in secondary or tertiary cases.
Pretrichial temporal incisions are another option but can cause variable scar quality and generally are not well accepted by patients.
The choice between a pretragal and retrotragal incision is influenced by tragal anatomy, its overlying skin quality, and adjacent preauricular skin thickness and texture.
Retrotragal incisions effectively break up the continuity of the preauricular incision but must be carefully crafted to avoid an unnatural-appearing tragus.
Women who have a large, projecting tragus with thin, delicate overlying skin and adjacent thick cheek skin are better suited to a pretragal incision.
Most men are also good candidates for pretragal incisions to avoid the transposition of thicker, hair-bearing skin over the tragus and to avoid a more feminized appearance in this area.
Women under 60 years with minimal neck changes seeking improvement for early jowls and nascent lateral check laxity are often good candidates for a posterior incision pattern limited to the postauricular sulcus (shortscar technique).6 This is particularly advantageous in those who habitually expose this area due to hairstyle preferences.
Nevertheless, well-designed and expertly executed full postauricular scar patterns are preferred to a more limited incision approach that fails to correct cervical skin laxity.
Most women and even men with complete alopecia are best served with a complete postauricular scar pattern.
Individual bone structure, soft tissue volume, and surgical timing (primary or secondary, tertiary) are all influential in selecting the optimal SMAS technique for each patient. Those with strong mandibular or maxillary bone contours generally require less SMAS manipulation, as do those with lighter soft tissue volumes. The opposite scenarios argue for more extensive SMAS manipulation.
For patients with prominent facial bone structure and light or medium thickness soft tissues, a SMASectomy is indicated.
For patients with normal or small facial bone structure who require more extensive repositioning of heavier facial soft tissues, an extended SMAS flap is more effective.
For patients with thin, minimally ptotic soft tissues, or in secondary or tertiary cases, a SMAS plication is appropriate.
Facial fat volume and distribution are assessed.
If significant hollowing in the prejowl sulcus or deflation of the malar compartment is observed, adjunctive fat grafting of these areas should be considered at the time of the primary procedure.
Prominent lateral cheek hollowing, seen less commonly, is best treated with a separate fat grafting procedure at a later procedure.
The extent of cervical skin laxity and the underlying neck contour are evaluated.
Older patients with very loose skin of poor quality that extends to the base of the neck are always counseled that they may need a limited secondary procedure at 1 year to obtain an optimal, durable result. This also applies to younger patients having a single strong midline submental skin band.
It is important to discuss this preoperatively with those having either of these characteristics.
Anterior neck surgery is indicated for platysmal bands that are prominent and generally no further apart than 2.5 cm. Patients are advised that a 2.5- to 3-cm submental incision will be necessary to accomplish this.
Subplatysmal fat excision is a helpful adjunct for improving an obtuse cervicomental angle and can be an indication alone for opening the neck in the absence of platysmal bands.
Partial excision of the submandibular glands and digastric muscles is a much more aggressive and controversial approach for contour improvement and is not routinely recommended.
Patients are counseled on the option of having a chin implant placed when microgenia is present. Even in subtle cases, an extra small implant is often beneficial.
Ptotic chin pads (witch’s chin deformity) and more subtle chin/neck junction depressions should be noted and addressed in the surgical plan.
Perioral resurfacing is often indicated in conjunction with face-lifting and neck lifting.
Upper lip rhytides are usually the first to appear and tend to be the deepest. The oral commissures, prejowl sulcus, and chin are also affected to variable degrees but usually much less than the upper lip.
Chemical peels, laser resurfacing, and mechanical dermabrasion are all effective at improving rhytides but also can cause depigmentation of the treated areas.
Nevertheless, even conservative rhytide ablation significantly enhances the overall result of surgery. Dermabrasion, perhaps the least technically sophisticated and oldest tool, allows precise depth control of treatment in experienced hands.
Simultaneous periorbital rejuvenation is frequently requested and discussed and, less commonly, a nasal tip plasty to address concerns regarding a bulbous or drooping tip.
Earlobe reductions or repair of elongated or lacerated earlobe piercings are also sometimes requested during the preoperative evaluation.
Patient Preparation
All patients have standardized multiview facial photographs taken, with additional views of areas where adjunctive treatment is planned.
These photographs are used for preoperative planning and communication, intraoperative reference, and postoperative outcome discussions.
Medical clearance is routinely obtained in patients over 60 or in younger patients with specific medical conditions of concern.
Patients taking blood-thinning medications for cardiac stents or arrhythmias must be evaluated by their cardiologist to determine the safety of discontinuance for a suitable interval both before and after surgery. The same applies to patients on prophylactic low-dose aspirin.
Strict blood pressure control is necessary perioperatively to facilitate surgery and minimize the potential for a postoperative hematoma. Therefore, patients with hypertension must optimize their medical regimen for blood pressure control prior to surgery.
Clonidine can be administered from either an oral or transdermal route immediately prior to surgery to manage blood pressure that remains refractory to tight control.
Hospital employees, such as anesthesiologists and nurses, or others with a prior history of MRSA should be screened with a nasal swab culture.
Patients who test positive should be treated with Bactroban (mupirocin) prior to surgery to eliminate their carrier status.
The benefits of perioperative homeopathic use such as Arnica montana for ecchymosis and bromelain for edema are unproven but can be safely employed at the surgeon’s discretion.
Excessive doses of Arnica may increase the risk of hemorrhage.
Patients are instructed to wash their face and hair thoroughly the night before surgery, remain nothing by mouth (NPO) after midnight, and take their blood pressure medication on the morning of surgery.
Patient Positioning
The patient is positioned supine on the operative table with the knees slightly bent to optimize lower extremity venous return.
The arms are carefully immobilized and a warming blanket is placed.
A triangular headpiece facilitates performing the procedure.
Anesthesia is induced, either an oral airway or laryngeal mask airway (LMA) placed, and the patient typically maintained on propofol for the duration of the procedure.
Normotensive anesthesia is preferred throughout the procedure in order to minimize the prospect of hematoma development.
Consideration should be given for placement of a urinary catheter for long procedures and for men with a history of obstructive symptoms.
One preoperative dose of cephalosporin is administered.
If the patient is a hospital employee or has a history of MRSA, vancomycin is given instead.
The incisions and key reference points are marked, the sites of injection prepped with Betadine swabs, and the areas of dissection infiltrated with a dilute lidocaine and epinephrine solution (100-cc normal saline, 100 cc 1% lidocaine, 1 cc of epinephrine).
Tumescent technique is not necessary, and typically 200-cc total is used for the face and neck.
The face is then prepped with Zephiran Chloride (benzalkonium chloride) and a head drape applied.
TECHNIQUES
▪ Incisions
Incisions are all made using a no. 10 blade scalpel.
Temporal incisions within the scalp angle back approximately 20 to 30 degrees above the ear to avoid the course of the superficial temporal artery (TECH FIG 1A).
Pretrichial incisions are avoided in the temporal area due to their inconsistent healing quality.
Subsideburn incisions are positioned at the root of the helix and extend transversely for no more than 2 cm when needed.
A commitment for making subsideburn incisions is generally not necessary until skin redraping at the time of closure.
The retrotragal incision is positioned slightly posterior to the free edge of the tragus and defines its superior and inferior borders. The inferior portion of the incision then extends anterior to the tragus for several millimeters before making a sharp angle to parallel the attached portion of lobule (see TECH FIG 1A).
Pretragal incisions parallel the curve of the helix to its root and then inflect downward with a short mirror image curve that then straightens to parallel the tragus down to the lobule (TECH FIG 1B).Related posts:
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