Reshaping Rhytidectomy




History


The history of facial rejuvenation has mainly focused on addressing cervicofacial laxity. In 1919 Bettman and Bourget simultaneously presented their experience with subcutaneous rhytidectomy . In 1960 Aufricht was the first to describe plication of the tissue deep to the superficial fat plane . Webster and other facelift surgeons used similar techniques of suturing the “deeper layers” to improve their results . During the same period Skoog had started performing facelifts utilizing the skin and platysma as a musculocutaneous advancement flap . In 1976 Mitz and Peyronie advanced the rhytidectomy procedure into the modern era by describing the anatomy of the superficial musculoaponeurotic system (SMAS) . They showed that a deeper fascial tissue layer exists between the subcutaneous fat and the parotidomasseteric fascia. Their anatomic studies established that the SMAS invests the muscles of facial expression and is contiguous with the frontalis and platysma muscles. Following Mitz and Peyronie’s description, the incorporation of the SMAS layer in cervicofacial rhytidectomy gained significant popularity . In the 1990s, the deep plane facelift and subperiosteal facelift also became increasingly used, specifically to address nasolabial folds . The deep plane rhytidectomy eventually became touted as the gold standard among all facelift techniques.


It was not until the latter half of the 20th century when surgeons started considering that facial rejuvenation requires three-dimensional considerations. In the 1970s Hinderer published studies on the use of alloplastic implants for chin and cheek skeletal enhancement . In the 1980s Binder introduced the concept of using midface implants for three-dimensional volume restoration and facial rejuvenation . The introduction of liposuction by Illouz in the 1980s gradually led to the use of autologous fat grafting for soft tissue augmentation, which was further advanced by Coleman and Glasgold in the 1990s and 2000s . In the 2000s and 2010s, Pessa, and Mendelson elucidated through elegant anatomic and radiographic studies that the aging process is not just due to gravitational laxity, but perhaps more importantly related to changes in the superficial and deep facial fat compartments, as well as facial skeletal remodeling .




Personal Philosophy


Aging is a multifactorial process that affects the skin, subcutaneous, and deep fat compartments, as well as the craniofacial skeleton ( Figs. 19.1–19.4 ) . The ultimate goal of facial rejuvenation is to improve the appearance of patients in a natural, youthful, attractive, and appropriate manner. Over the past decade, the author’s view relating to rhytidectomy as the cornerstone of facial rejuvenation has significantly changed due to a much better understanding of the anatomic changes that occur in the aging process . The principles of “facial anatomic subunits” that have long been the guiding principles in facial and nasal reconstruction but rarely considered in aesthetic procedures are now utilized by the author to improve the facial shape and surface topography of patients, as well as to create smooth transitions between the temple, zygomatic arch, lateral cheeks, lower eyelids, anterior midface, buccal space, mandibular jaw line, and neck to obtain ideal results ( Figs. 19.5 19.6 ) .








Figure 19.1


The progression of the aging face. The aging process is illustrated in this individual in her 20s (A), 40s (B), and 60s (C). The face continuously and gradually changes, resulting in prominent nasolabial folds, jowl formation, marionette furrows, neck laxity, volume loss, facial shape alteration, and rhytids in the perioral and periorbital region.





Figure 19.2


Facial shape. The aging process reverses the triangle of youth (A) by widening the lower third of the face (B).





Figure 19.3


Skeletal remodeling. Underlying skeletal changes in the face (A) and the resultant effect on facial aging include widening and deepening of the eye socket, resorption of the pyriform aperture, enlargement of nasal bones leading to nasal tip drooping, development of prejowl sulcus, and mentum (B).

(Adapted from Mendelson B, Wong CH: Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plastic Surgery 2012;36(4):753.)



Figure 19.4


Schematic illustration of superficial and deep facial fat compartments. Facial fat compartments resorb at different rates during the aging process. SOOF , Suborbicularis oculi fat.

(Adapted from Pessa JE, Rohrich RJ. Facial Topography: Clinical Anatomy of the Face. St. Louis: Quality Medical Publishing, 2012.)



Figure 19.5


Facial aesthetic subunits. The surface anatomy of the head and neck region is divided into several aesthetic units. Some of the units such as the nose, forehead, lips, and cheek are further divided into additional subunits. These units and subunits represent regions of the face that have similar surface topography and three-dimensional qualities based on the underlying anatomic structures, superficial and deep facial fat compartments, skin thickness, facial muscle activity, and curvature (flat, convex, or concave). 1 , Forehead unit ( 1a , central subunit; 1b , temple; 1c , eyebrow subunit); 2 , nasal unit; 3 , eye lid units ( 3a , lower lid unit; 3b , upper lid unit; 3c , lateral canthal subunit; 3d , medial canthal subunit); 4 , cheek unit ( 4a , medial subunit; 4b , zygomatic subunit; 4c , buccal subunit; 4d , lateral subunit); 5 , upper lip unit ( 5a , philtrum subunit; 5b , lateral subunit; 5c , mucosal subunit); 6 , lower lip unit ( 6a , central subunit; 6b , mucosal subunit); 7 , Mental unit; 8 , Auricular unit; 9 , Neck unit.

(Adapted from Fattahi TT. An overview of facial aesthetic units. Journal of oral and maxillofacial surgery 2003;61(10):1207–11.)



Figure 19.6


Surface anatomy. Smooth transition between the various compartments of the face is paramount in creating natural, youthful, and beautiful facial aesthetics.


Henceforth, the rhytidectomy technique and complementary procedures should be modified to address a more holistic approach to facial rejuvenation. Whereas in the past, rhytidectomy was a standardized procedure performed in a cookie-cutter fashion for all patients with aging faces, it is now a customized procedure and just one of many tools in our armamentarium for comprehensive facial rejuvenation. Procedures such as autologous fat grafting, chin augmentation, conservative periorbital rejuvenation, and buccal space modification are often utilized in conjunction with rhytidectomy to create facial harmony and enhance youthful contours and shape . Today, we modify the SMAS technique, undermining, and suspension vectors to not only address jowls, cervico­facial laxity, and platysmal banding, but also to restore the triangle of youth that is more “heart shaped” and aesthetic .


The key components of our rhytidectomy procedure include limited skin undermining in the facial region, tunneling the undissected facial and cervical tissue with a cannula to create pockets of mechanical adhesions in the healing process, customizing the extent of sub-SMAS dissection depending on the desired outcome, performing the SMAS suspension in a vector that provides appropriate lifting and reshaping of the face, implementing horizontal platysmal myotomy at the level of cervicomental junction with corset platysmaplasty for individuals with prominent banding, and using judicious cervical suction-assisted lipectomy. By limiting facial skin flap dissection, we maintain the anterior dermal-SMAS attachments, which allow aggressive suspension of the face without significant tension on the skin . The SMAS serves as the carrier of the facelift flap. The undissected areas could safely undergo simultaneous cutaneous skin resurfacing and autologous fat grafting to address photodamage, fine or deep rhytids, volume restoration, as well as reshaping a more youthful appearance.


The vector of SMAS suspension is typically more posteriolateral in gaunt patients with major rhytids and vertical in individuals with a round, square, and rectangular facial shape. This approach addresses all aspects of the aging process beyond just cervicofacial laxity.


We have found our rhytidectomy technique to produce an extremely reasonable operative time, minimal complication rate, and postoperative recovery time. By limiting the subcutaneous dissection, the risk of facial hematoma formation and facial nerve injury is also likely reduced. Short skin flaps diminish the chance of flap necrosis in patients who have compromised vascularity, such as smokers, diabetics, and elderly patients . We have also seen less long-term skin atrophy and telangiectasias.


The general criticism of SMAS facelift in the 1980s and 1990s was that it did not address the “midface,” since it did not “flatten” the nasolabial fold. In that era, effacement of the nasolabial fold was an important goal of facelifts. In the past decade, our enthusiasm for effacing the nasolabial fold for midface rejuvenation has been largely replaced by facial reshaping and volume modification using the aesthetic subunit approach. The author no longer arbitrarily separates the upper, mid, and lower face. We focus more on the entire face as a continuum and look at creating soft transitions between the various facial subunits to address double-cheek convexity, infraorbital rim hollowness, tear trough deformity, retrusion of pyriform aperture, as well as the lateral cheek and buccal space disproportion. This approach results in a more natural facial aesthetic that creates an appropriate lateral projection of the zygomatic arch, restores an attractive facial shape, and improves the youthful arcs and highlights of the face . Our methodology is to combine a customized SMAS facelift with autologous fat grafting, fillers, conservative transconjunctival lower blepharoplasty (with or without fat repositioning), buccal space modification (augmentation or reduction), and preauricular volume adjustment (typically augmenting in skeletonized faces and narrowing in patients with round, square, or rectangular facial shape). Alloplastic midface and angle of the mandible implants may also be considered for patients with significant volume deficits, but must be used with caution due to potential risk of infection and steep learning curve .


Long-flap facelifts (SMAS or subcutaneous techniques) incorporating extensive skin undermining have long been advocated as a way of releasing the fascioosteocutaneous ligaments . In attempting to accomplish the ligamentous release, extensive flap elevation in the subcutaneous plane can destroy the dermal-SMAS attachments, hence invalidating the SMAS support for the lift. Anatomic studies by Muzaffar and Mendelson have also demonstrated that the release of retaining ligaments in the prezygomatic space through extensive subcutaneous dissection can potentially cause nerve injury to the motor branch of the orbicularis oculi . It is also well known that the facial nerve has a more superficial course near the oral commissure and midportion of the zygomatic arch, placing it at risk during the dissection of long skin flaps . If a surgeon desires release of the fascioosteocutaneous ligaments, we recommend utilizing the sub-SMAS plane, which can easily be done with the current technique.


The deep plane facelift also incorporates a short skin flap elevation and is an excellent rhytidectomy method. The true deep plane or composite facelift, however, does not have significant flexibility and requires complete sub-SMAS dissection over the zygomatic major muscle all the way to the nasolabial fold in all patients, regardless of their aging process and aesthetic goals . A lengthy anteromedial dissection can cause extensive postoperative edema as well as place the branches of the facial nerve at risk in every patient. In our experience as well as that of others, the results of the deep plane facelift and a well-executed SMAS rhytidectomy are similar, with the exception of outcomes in older patients with extensive rhytidosis . The outlined SMAS rhytidectomy may incorporate a significant sub-SMAS dissection similar to deep plane rhytidectomy benefiting older patients with significant cervicofacial laxity; however, it is customized to the aging process of the patient in terms of vector of suspension and extent of sub-SMAS dissection.




Facial Anatomy


The salient features of the facial anatomy have been discussed in detail in other chapters. In consideration of obtaining an ideal aesthetic outcome with rhytidectomy and complementary procedures, the principles of facial anatomic subunits must be discussed in further detail. The surface anatomy of the head and neck region is divided into the various aesthetic units, including the nose, periorbital region, forehead, upper and lower lip, cheek, ear, neck, and chin ( Fig. 19.5 ). Some areas such as the nose, forehead, lips, and cheeks are further divided into additional subunits. These units and subunits represent regions of the face that have similar surface topography and three-dimensional quality based on the underlying anatomic structures, superficial and deep facial fat compartments, skin thickness, facial muscle activity, and curvature (flat, convex, or concave) . The confluence of and transitions between these subunits from the forehead to the neck formulate the patient’s facial shape and youthfulness. Although historically these units and subunits have been used as landmarks for planning scar revisions and facial/nasal reconstruction, the author has used the concept in obtaining a more natural and aesthetic facial rejuvenation outcome. Furthermore, a smooth transition between the various compartments of the face is paramount in creating a natural, youthful, and beautiful surface anatomy ( Fig. 19.6 ).


Although the ideal facial shape can differ depending on gender and ethnicity, there are some general characteristics that convey youth and beauty. The central oval of the face comprising the nose, eyelids, and lips is three-dimensional and forms the primary focus of an individual’s appearance. Even though the lateral subunits consisting of the cheeks and temple frame a secondary visual significance, these regions play an important role in an individual’s facial shape, attractiveness, and youthfulness. In the author’s view, the zygomatic cheek subunit (4b in Fig. 19.5 ) is the primary framework of a person’s facial shape, as it should form the most lateral position of the face. The tissue in this region is relatively fixed over the zygomatic arch (malar eminence), and as a result soft tissue laxity is not a concern during the aging process in this region. Patients with prominent malar eminence in the zygomatic subunit that softly transitions to the surrounding subunits will obtain better results from the rhytidectomy procedure . This subunit must be augmented if the area is underdeveloped due to congenital maxillary hypoplasia, remodeling, lipoatrophy, or trauma. The zygomatic subunit should not be augmented if patients have skeletonized, prominent, and/or excessive bizygomatic width. In fact, patients may have to have volume augmentation of the surrounding regions to improve the transition zones ( Fig. 19.7 ).














Figure 19.7


Preoperative (A, C, and E) and 6-month postoperative (B, D, and F) photos of a 61-year-old female who desired aesthetic improvement of her appearance. The zygomatic cheek subunit is the primary framework of facial shape as it should form the most lateral apex position of the face. This patient preoperatively has a skeletonized and prominent zygomatic subunit with atrophy of the temple subunit and lateral cheek subunit. This patient’s zygomatic cheek subunit should not be augmented. She underwent rhytidectomy (horizontal platysma myotomy, corset platysmaplasty, extensive cervical subcutaneous dissection, 5-cm subcutaneous facial dissection, tunneling of the perioral region, superolateral vector suspension of SMAS with folding of SMAS on itself in the lateral cheek subunit to augment the region and improve the transition to the zygomatic arch subunit) and autologous fat grafting (temple, pyriform aperture, prejowl sulcus). Note that the patient also underwent rhinoplasty but did not desire laser resurfacing that was recommended for perioral rhytids. Postoperatively, the patient has a more harmonious appearance with soft transitions between the zygomatic arch to angle of the mandible.


Superior to the zygoma lies the temple subunit (1b in Fig. 19.5 ) of the forehead. The temple subunit is comprised of the superior portion of the lateral temporal-cheek fat compartment, temporalis muscle, and superior extension of the buccal fat pad . The region should be flat or convex, and positioned slightly medial to the zygomatic subunit from the front view. Deep concavity of the temple subunit creates a gaunt and aged appearance, as well as significantly alters the shape of the face ( Fig. 19.8 ) . Volume augmentation with autologous fat grafting or fillers must be considered in every patient who presents with temple atrophy.




Figure 19.8


Temple and lateral cheek subunit atrophy. The photo shows a young female with facial lipoatrophy involving the temple, buccal, and lateral cheek subunits (right) and immediate results after poly- l -lactic acid (left). Light reflection and shadows revealed by the black and white photos clearly demonstrate how significant temple atrophy and cheek atrophy can play a role in one’s facial shape and topography .

(Courtesy Dr. Rebecca Fitzgerald.)


Inferior to the zygomatic subunit are the lateral (4d in Fig. 19.5 ) and buccal (4c in Fig. 19.5 ) subunits of the cheek. The lateral cheek subunit is comprised of the inferior portion of the lateral temporal-cheek fat compartment, parotid gland, and masseter muscles . The lateral cheek compartment is one of the main areas where gender differences are crucial in clinical outcomes. Male attractiveness is related to a more prominent lateral projection of this region and more defined angle of the mandible that forms the subunit’s inferior border. In females, the area should be more narrow, with a soft transition zone to the zygomatic arch. Regardless of gender, the subunit should be relatively flat and never be more lateral than the zygomatic arch ( Fig. 19.9 ). Careful attention must be paid to address this region if there is an underlying disproportion. For patients with prominent and hypertrophic masseters, neuromodulators may be used to reduce the bulk of the muscle ( Fig. 19.10 ). Customized SMAS imbrication techniques may also be used during rhytidectomy to narrow prominent parotid and masseteric fullness. Individuals who present with congenital or senile atrophy of the region must have volume augmentation at the time of the rhytidectomy utilizing SMAS folding, alloplastic implants, and/or autologous fat grafting (see Fig. 19.7 ).






Figure 19.9


Lateral cheek subunit prominence. Preoperative (A) and early postoperative (B) photos of a young female with bilateral chronic sialadenitis of parotid glands who required functional bilateral parotidectomy. Just below the zygomatic subunit are the lateral and buccal subunits of the cheeks. The lateral cheek subunit is comprised of the lateral temporal-cheek fat compartment, parotid gland, and masseter muscle. Regardless of gender, the lateral cheek subunit should never be more lateral than the zygomatic arch. In the preoperative photo, the patient has a prominent lateral cheek subunit due to the chronic parotitis (arrow) . The zygomatic subunit is more medial than the parotid region, leading to a disfavored facial shape. The postoperative photo following bilateral parotidectomy reveals a more aesthetic and ideal facial shape, with the zygomatic subunit having a more favored position smoothly transitioning to the lateral cheek subunit.



Figure 19.10


Preoperative (A) and early postoperative (B) photos of a young female who underwent botulinum toxin A injection for masseter hypertrophy. The lateral cheek subunit is comprised of the lateral temporal-cheek fat compartment, parotid gland, and masseter muscle. Ideally, this subunit should be more medial than the zygomatic subunit. For patients with prominent and hypertrophic masseters (arrow) , neuromodulators may be used to reduce the bulk of the muscle, leading to a more attractive facial shape and appearance. In the preoperative photo, the patient has a prominent lateral cheek subunit. The zygomatic subunit is more medial, leading to a disfavored facial shape. The postoperative photo reveals a more aesthetic and ideal facial shape with the zygomatic subunit having a more favored lateral position than the lateral cheek subunit.

(Courtesy Dr. Rebecca Fitzgerald.)


The buccal subunit lies medial to the lateral cheek subunit and inferior to the zygomatic subunit. The subunit encompasses the buccal space and midportion of the body of the mandible where jowling is visualized. Although jowls are one of the most common reasons individuals seek the rhytidectomy procedure, the buccal space plays just as important a role in one’s beauty and aesthetics. The buccal space is at the level of the oral commissure and comprised of the buccinator and buccal fat pads ( Fig. 19.11 ) . The buccal fat pad has multiple ligamentous attachments and extends beyond the buccal space into the pterygomandibular and temporal regions. The average volume is 8.9 and 10.2 mL for females and males, respectively . The parotid (Stenson’s) duct emerges from the parotid gland, travels along the masseter muscle in the buccal space, and pierces the buccinator muscle entering the oral cavity near the second superior molar . If the buccal fat pad is prominent, the shape of the face appears more round. The buccal fat pad may also be ptotic, leading to a more exaggerated jowling at the level of the mandible. The buccal space should be slightly medial to the zygomatic arch, with curvature that is either flat or slightly concave. The buccal space must always be addressed if the region has excessive convexity or concavity. Significant concavity gives an emaciated appearance, which is a sign of advanced aging. Convexity of the region results in rounding of the face, which is perceived as less attractive. As a result, addressing the buccal space is extremely important in our approach to facial rejuvenation, as some patients may require removal of buccal fat pad whereas others may require volume augmentation of the area. The most inferior portion of the buccal subunit, which overlies the midportion of the mandible, should be flat, smooth, and in the same plane as the mental subunit (7 in Fig. 19.5 ) and inferior portion of the lateral cheek subunit (4d in Fig. 19.5 ). This is the area that is directly addressed with most rhytidectomy procedures.




Figure 19.11


Anatomy of the buccal space. The buccal subunit is comprised of the buccal space superiorly and mid portion of the mandibular body where jowling presents during the aging process. Although jowls are one of the most common reasons individuals seek rhytidectomy procedure, the buccal space plays just as important a role in one’s beauty and aesthetics. The buccal space is at the level of the oral commissure and comprised of buccinator and buccal fat pad. The parotid (Stenson’s) duct emerges from the parotid gland, traveling along the masseter muscle in the buccal space and piercing the buccinator and entering the oral cavity near the second superior molar. The buccal fat pad has multiple ligamentous attachments and extends beyond the buccal space into the pterygomandibular and temporal regions. m , Muscle.


The medial cheek subunit (4a in Fig. 19.5 ) is positioned medially to the zygomatic and buccal cheek subunit, and is the region most commonly associated with the “midface” in traditional facial analysis. The pathophysiology of the aging process of this area involves inferomedial tissue descent, remodeling of the maxilla and orbit, as well as variable atrophy of the superficial and deep fat pockets (see Figs. 19.3 19.4 ). The lower eyelid subunit (3a in Fig. 19.5 ) forms the superior border of this subunit; the aging process of the two regions is therefore intimately associated with one another. The nasolabial fold, which separates the medial cheek and upper lip subunit (5b in Fig. 19.5 ), is an area where the cutaneous insertions of the lip elevators fuse onto the ligamentous structure formed by the SMAS and deeper facial fascia. The nasolabial fold becomes more prominent as the maxillary pyriform aperture remodels, various midface fat compartments atrophy, and the malar fat pad and suborbicularis oculi fat (SOOF) begin to descend . Progressive remodeling of the orbitomaxillary complex and facial fat atrophy results in pseudoherniation of the orbital fat pad, tear trough formation, as well as flattening and cavitary depressions of the medial cheek, contributing to the overall aging appearance. Our treatment of the region must therefore focus on creating soft transitions between the various surrounding subunits: zygomatic, lower lid, buccal, medial cheek, and upper lip. As a result of our improved understanding of these processes, the concept of volumization rather than “lifting” of medial cheek has significantly improved outcomes ( Fig. 19.12 ) .






Figure 19.12


Preoperative (A) and 6-month postoperative (B) photos of a 58-year-old female who desired improvement of her appearance. The patient’s preoperative analysis revealed overall aging appearance and poor facial topography. She had cervicofacial laxity, brow ptosis, upper lid dermatochalasia, pseudoherniated orbital fat pad with significant tear trough deformity and moderate malar edema, and medial cheek subunit atrophy due to pyriform aperture retrusion and superficial and deep fat pad atrophy. She underwent autologous fat grafting (temple, prejowl sulcus, medial cheek subunit, and tear trough), upper blepharoplasty, transconjunctival lower blepharoplasty, endoscopic brow lift, fractional CO 2 laser resurfacing, and rhytidectomy (corset platysmaplasty, 5-cm facial subcutaneous dissection with type 1 sub-superficial muscular aponeurotic system [SMAS] undermining, vertical vector suspension of SMAS to augment the zygomatic subunit, and narrowing of the lateral cheek subunit utilizing a posterior SMAS-mastoid imbrication).


The mental unit is made of the most anterior aspect of the mandible with the overlying soft tissue and muscles (7 in Fig. 19.5 ). The neck unit is inferior to the cheek and mental units (9 in Fig. 19.5 ). Ideally, patients should have well-defined cervicomental angles, with limited submental fat accumulation, minimal cervical platysmal banding, and sharp transition between the neck to the cheek and mental units. Male patients ideally should have a more projected mental unit, as discussed in earlier chapters. Individuals with poor chin projection and prominent prejowl sulcus will require further evaluation for simultaneous chin augmentation, autologous fat grafting, and/or fillers to enhance the results of the rhytidectomy. Submental fat accumulation can judiciously undergo suction-assisted lipectomy, and platysmal banding can be addressed with platysmal myotomy and corset platysmaplasty. Finally, patients with low and anteriorly positioned hyoid bone in the neck unit must be cautioned about the aesthetic outcome in cervicomental contour . Unlike the other skeletal regions, the hyoid cannot be manipulated during the rhytidectomy procedure.


Finally, the safety of the facial nerve is perhaps the most important aspect of facelift surgery. The facial nerve exits the stylomastoid foramen and enters the body of the parotid gland ( Fig. 19.13 ). Within the parotid gland it bifurcates into an upper and lower division. It further divides into five main branches, namely temporal (frontal), zygomatic, buccal, marginal mandibular, and cervical. Permanent iatrogenic facial paralysis is rare owing to the extensive arborization of the buccal and zygomatic branches of the facial nerve. The marginal and cervical branches also may have arborization as the lower division separates from the upper division. The frontal branch is a terminal branch with limited redundancy. Injury to the frontal branch has the highest risk of causing permanent paralysis. The overall risk of permanent facial nerve paralysis in standard rhytidectomy is between 0.53% and 2.6% . There have been very few reports in the literature regarding the risk of facial nerve injury associated with more invasive facelifting procedures.




Figure 19.13


The facial nerve. The facial nerve bifurcates in the parotid into an upper and lower division. It then divides into five main branches: temporal (frontal), zygomatic, buccal, marginal mandibular, and cervical.




Preoperative Assessment


Rhytidectomy is typically indicated for patients with moderate-to-severe facial aging, as manifested by a change in facial shape, jowl formation, volume loss, and neck banding. Patients typically present for rhytidectomy between the ages of 45 and 65 years. Younger individuals with significant congenital jowling and a round or rectangular facial shape may also benefit from reshaping facial surgery that utilizes SMAS rhytidectomy, buccal fat pad removal, and autologous fat grafting to the zygomatic arch ( Fig. 19.14 ).














Figure 19.14


Preoperative (A, C, and E) and 13-month postoperative (B, D, and F) photos of a 34-year-old female who desired improvement of her appearance. The patient’s preoperative analysis revealed poor facial shape and topography due to inadequate zygomatic subunit, prominent lateral cheek and buccal subunits, significant submental liposis, as well as microgenia leading to an inadequate mental subunit and premature jowling. She underwent buccal fat pad removal, chin augmentation, submental liposuction, and rhytidectomy (extensive cervical subcutaneous dissection, 5-cm facial subcutaneous dissection with type 2 sub-superficial muscular aponeurotic system [SMAS] undermining, vertical vector suspension of SMAS to augment the zygomatic subunit, and narrowing of the lateral cheek subunit utilizing a posterior SMAS-mastoid imbrication). Note that the patient did not desire lash ptosis repair.

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Mar 23, 2019 | Posted by in Craniofacial surgery | Comments Off on Reshaping Rhytidectomy
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