Rhytidectomy and Neck Rejuvenation

Chapter 28

Rhytidectomy and Neck Rejuvenation

Essential Facial Anatomy

1. Continuous facial layers (see Figure 28.1)

Figure 28.1 The facial layers of the scalp, face, and neck. SMAS, Superficial muscular aponeurotic system. (Reprinted from Neligan, P.C., Rodriguez, E.D. [Eds.], 2013. Plastic Surgery, vol. 3, 3rd ed. Elsevier, 1–22.)

• Motor nerve innervation of the muscles of facial expression (see Table 28.1 and Figure 28.2)

Table 28.1

Extratemporal Facial Nerve Branches

NERVE BRANCH	LOCATION	INNERVATED MUSCLES	BRANCH INJURY	NOTES
Temporal/frontal	Pitanguy’s line (0.5 cm below tragus to 1 cm above and lateral to brow); often travels with “sentinel vein”; deep to SMAS at level of the zygoma and deep to temporoparietal fascia above zygoma	Frontalis muscle, orbicularis oculi	Inability to elevate the brow, weak eyelid closure	Often neurapraxia injury from stretch; susceptible to injury at level of the zygoma with sub-SMAS techniques; neuropraxia
Zygomatic	Pierce the deep parotidomasseteric fascia 4 cm anterior to the tragus and travel toward lower lid and midcheek	Lower orbicularis oculi (primarily); also some innervation of zygomaticus major, buccinator, orbicularis oris, levator labii	Often asymptomatic because of arborization with buccal branch
Buccal	Pierce deep parotidomasseteric fascia at anterior border of masseter	Orbicularis oculi, zygomaticus major and minor, levator labii superioris, buccinator, orbicularis oris	Often asymptomatic because of arborization with buccal branch; occasional inability to compress cheeks	Most common motor nerve injury with facelift
Marginal mandibular	Deep to platysma, can travel up to 3 to 4 cm below the mandibular border	Lower lip depressors, mentalis, orbicularis	Inability to depress lower lip (injured side higher during smile) or to purse lips	Treatment: Observation unless known direct injury; Botox to uninjured side can improve symmetry
Cervical	Deep to platysma, below mandibular border	Platysma	Inability to depress lower lip (pseudoparalysis of marginal mandibular n.)	Treatment: Observation

Figure 28.2 The facial nerves. (Reprinted from Neligan, P.C., Rodriguez, E.D. [Eds.], 2013. Plastic Surgery, vol. 3, 3rd ed. Elsevier, 1–22.)

• Sensory innervation of the face and neck (see Figure 28.3)

Figure 28.3 The sensory supply of the face. (Reprinted from Neligan, P.C., Rodriguez, E.D. [Eds.], 2013. Plastic Surgery, vol. 3, 3rd ed. Elsevier, 1–22.)

3. Anatomy of the aging face (see Figure 28.4)

Figure 28.4 The aging face exhibits changes in the skin, superficial wrinkles, deeper folds, soft-tissue ptosis, loss of volume in the upper third and middle third, and increased volume in the lower third. (Reprinted from Neligan, P.C., Warren, R.J. [Eds.], 2013. Plastic Surgery, vol. 2, 3rd ed. Elsevier, 184–207.)

Rhytidectomy

1. Techniques (see Table 28.2 and Figures 28.5–28.10)

Table 28.2

Facelift Techniques

TECHNIQUE	DESCRIPTION	ADVANTAGES/DISADVANTAGES
Subcutaneous facelift	Dissection and tightening of excess skin only	Advantages: Safe, rapid recovery Disadvantages: Recurrence of ptosis because tightening relies on skin tension alone
SMAS plication	Dissection in subcutaneous plane with suture plication of the SMAS over the parotid gland	Advantages: Relatively safe, long-lasting results without need for sub-SMAS dissection Disadvantages: Potential loss of effect from suture failure
MACS lift	Limited preauricular/pretemporal hairline incision with skin elevation and purse-string suture of lower SMAS to deep temporal fascia (extended MACS lift places a 3rd suture in the SMAS to suspend the malar fat pad)	Advantages: Similar to SMAS plication, but firmer point of fixation to deep temporal fascia Disadvantages: Similar to SMAS plication
Subcutaneous facelift with SMASectomy	Similar dissection as SMAS plication, but limited strip of SMAS is removed obliquely across the cheek, and the defect is closed primarily with sutures	Advantages: Allows for skin and SMAS to be moved in different vectors, more secure than plication, more rapid than sub-SMAS lifts Disadvantages: Possible nerve injury
Deep plane facelift	Skin, fat, and SMAS are elevated in a single layer	Advantages: Long-lasting results, retaining ligaments are thoroughly released Disadvantages: Potential for nerve injury, more complex than supra-SMAS techniques above
Subperiosteal facelift	Dissection of the midface in a subperiosteal plane; occasionally adds a lower lid or intraoral incision	Advantages: Deep to all critical structures, relatively short incision, no tension on skin, can combine rejuvenation of lower lid and brow Disadvantages: Relatively complex procedure, limited effect on lower face/neck, and excess skin

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Tags: Review of Plastic Surgery

Sep 2, 2016 | Posted by admin in Aesthetic plastic surgery | Comments Off

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