Positioning

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.

Anesthesia

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.

Marking the patient

Prior to surgery, anatomic landmarks are drawn on the face and neck with the patient standing (Fig. 10.6). The drawn lines indicate:

Fig. 10.6 Patient is shown following induction. Anatomic landmarks and line of submental incision were drawn preoperatively with the patient standing. Ink lines denote the point of origin and course of the zygomaticus major and minor, the nasolabial and labiomental folds, the inferior border of the mandible, the anterior border of the parotid gland in the face, and the lateral border of the platysma in the neck. This last line is a continuation of the approximate anterior border of the parotid gland in the face. A transverse line across the lower neck indicates the approximate inferior limit of the cervical dissection.

The line of the submental incision is also marked preoperatively with the patient standing so the surgeon can plan the incision in the least visible area (Fig. 10.7).

Fig. 10.7 The submental incision is a four centimeter transverse line placed in the most inconspicuous position adjacent and parallel to the submental crease. The incision may be in the crease itself or slightly caudad to the crease, as shown here. The incision is placed wherever it is best hidden.

The remainder of the incision lines is drawn after intubation. The periauricular incision starts in the temporal area (Fig. 10.6). A vertical incision extending three or four centimeters into the hairline cephalad to the roll of the helix is used when access is required to the temporal area for a temporal and/or brow lift. The incision continues caudad along the helical roll to the tragus where, for most patients, it follows the edge of the tragus, and then continues along the prelobular crease (Fig. 10.6) before coming around the lobule to the retroauricular crease (Fig. 10.8). The incision follows the course of the retroauricular crease cephalad before traversing the retroauricular skin and then proceeding along the occipital hairline for three centimeters after which it turns posterior into the occipital hair.

Fig. 10.8 Retroauricular and occipital portion of the incision.

When a temporal and/or browlift is not performed, the incision starts as a horizontal line extending from the point at which the helical rim joins the face to the anterior portion of the temporal hairline (Fig. 10.9). This incision can be extended vertically along the temporal hairline to take out excess skin. A pretragal incision is used when the preauricular skin is excessively thick and would blunt fine tragal detail if used to cover the tragus.

Fig. 10.9 Dotted lines indicate alternative incisions at temporal hairline and in preauricular crease.

Lastly, if there is little excess skin in the neck, the postauricular incision can be limited to the retroauricular crease (Fig. 10.10).

Fig. 10.10 Planned retroauriclar incision limited to the retroauricular crease.

Operation

The entire face and neck operative area is infiltrated with lidocaine 0.25% with epinephrine 1 : 200,000. Approximately 100 mL is used for each side of the face and neck.

The head and neck are prepped with sterile povidone-iodine solution prior to draping.

Surgery starts 20 minutes after injection. Following an initial preauricular incision, a thick skin flap is elevated superficial to the parotid fascia. Dissection stops at the line demarcating the anterior border of the parotid (Fig. 10.11).

Fig. 10.11 Limit of initial preauricular dissection. Skin flap includes most of fat superficial to parotid fascia.

The skin with a thin layer of subcutaneous fat is elevated with the scalpel from the retroauricular and occipital area as far as the inked line denoting the lateral border of the platysma in the neck. This dissection is joined to the lower cheek dissection (Fig. 10.12).

Fig. 10.12 Dissection in the retroauricular and occipital area. Flap contains skin and 2–3 mm of subcutaneous fat. Initial dissection is to lateral border of platysma indicated by ink line on skin.

The skin of the neck overlying the platysma is also elevated using a long curved Mayo scissors. A 2–3 mm thickness of subcutaneous fat is kept with the skin. Residual fat on the platysma is excised with scissors or cautery. This dissection exposes the platysma from the mandibular border to as low in the neck as necessary. If laxity in the neck is severe, dissection will extend to the clavicle (Fig. 10.13A,B).

Fig. 10.13 Dissection superficial to platysma in upper (A) and lower (B) cervical area. Skin flap is raised with 2–3 mm of fat attached. Excess fat remaining on platysma is excised using scissors or cautery.

Subcutaneous dissection of the cheek flap is extended to the temporal area in the plane superficial to the superficial temporal fascia. This dissection continues to the region of the lateral border of the orbicularis oculi and the origin of the zygomaticus major and minor (Fig. 10.14).

Fig. 10.14 Superficial dissection of cheek flap completed. Dissection in the superficial plane ends 1 cm before reaching the anterior border of the parotid gland. The inked line beneath flap is drawn superficial to the parotid gland from near the origin of the zygomaticus major, above, to the region of the tail of the parotid gland, below. This inked line will be the line of entry to the deep plane.

Entry to the deep plane is via scalpel incision through the SMAS-platysma along a line parallel to and 1 cm posterior to the anterior border of the parotid gland (Fig. 10.15). The surgeon grasps the cut edge of the platysma and begins separation of the platysma from the underlying parotid fascia using a pair of Stevens scissors (Fig. 10.16). As soon as the dissection proceeds in an anterior direction beyond the edge of the parotid gland, the platysma becomes much less adherent to the underlying masseteric fascia, and spreading of the scissors in a plane perpendicular to the plane of dissection easily separates the platysma from the masseteric and adjacent buccal fascia. Dissection is rapid and bloodless to the region of the modiolus and labiomental line (Fig. 10.17).

Fig. 10.15 Incision through the SMAS-platysma along a line 1 cm posterior to the anterior border of the parotid gland. Note separation of SMAS-platysma tissues along line of incision. Parotid fascia is exposed in the depth of the caudad portion of the incision.

Fig. 10.16 Sharp and blunt separation of the platysma from the underlying parotid fascia.

Fig. 10.17 Completed dissection in the lower cheek. Retractor elevates platysma. Beginning at the line of the incision to the deep plane (purple ink line) one sees parotid fascia, and masseteric fascia covering facial nerve branches.

The upper cheek is dissected in the deep plane by finding the origin of the zygomaticus major near the most prominent portion of the malar eminence and then dissecting superficial to the zygomaticus major until the surgeon reaches the nasolabial fold (Fig. 10.18). The malar fat pad remains with the skin and is part of the elevated upper cheek flap. The upper and lower cheek dissections are connected by bluntly separating the remainder of the connections between the zygomaticus major and the skin.

Fig. 10.18 Retractor holds superficial tissues of upper cheek including malar fat pad. Zygomaticus major muscle is limit of deep dissection. Purple line in mid and lower cheek is the cut edge of entry into the deep plane in the mid and the lower cheek.

Upon completion of the dissection of the right cheek and neck, the patient’s head is turned to the right and an identical dissection is performed on the left side. If the cervical soft tissues are lax, or, there is excess fat in the submental area, the anterior neck is approached through a 4 cm transverse submental incision (see Fig. 10.7). The submental skin is dissected away from the underlying platysma, leaving a 2–3 mm layer of fat on the undersurface of the skin. This dissection joins with the lateral dissections from the right and left sides. The entire submental and submandibular areas are then exposed, and any excess fat overlying the platysma is excised through the central submental and right and left lateral incisions. If necessary, the platysma is imbricated in the midline with a running 3-0 Monocryl suture (www.ethicon.com).

The patient’s head is turned to the left and the right SMAS-platysma flap is used to elevate and tighten the lower cheek and upper neck tissues (Fig. 10.19). The undersurface of the platysma and overlying subcutaneous tissue of the upper neck and cheek are sutured to the parotid fascia anterior to the earlobe with two sutures of 2-0 Maxon (www.ussurgical.com) (Fig. 10.20).

Fig. 10.19 SMAS-platysma and attached overlying skin are elevated and tightened using Bonney forceps.

Fig. 10.20 A, A 2-0 Maxon is placed in the undersurface of the platysma and B, sutured to the fixed parotid fascia anterior to the right earlobe. Two such sutures are placed, one above the other. When the sutures are tied the skin will be elevated and tightened.

The upper portion of the cheek flap is pulled upwards and laterally enough to increase dental show but not under extreme tension (Fig. 10.21). The upper cheek flap is then sutured with 3-0 Monocryl to the skin anterior to the point at which the helical rim joins the preauricular skin (Fig. 10.22). The suture also includes a bite of the deep temporal fascia to prevent anterior migration of the helix.

Fig. 10.21 Skin of upper cheek pulled vertically upwards and laterally. Note increased dental show.

Fig. 10.22 Appearance of cheek after suturing upper platysma to parotid fascia and placement of pilot suture from skin flap to skin anterior to helical rim.

With the cervical skin under minimal tension, the excess skin behind the ear is marked and excised (Fig. 10.23). A suction drain is placed under the cervical flap at its most dependent area and leads out through an occipital stab wound. The occipital and hairline incisions are closed with staples (Fig. 10.24). The skin flap at the retroauricular crease will be sutured to the ear under no tension with absorbable 4-0 plain sutures.

Fig. 10.23 A, Postauricular skin placed under no tension and excess marked. B, Skin of occipital flap shown after excision of excess with single staple holding flap in place. Note absence of tension and alignment of occipital hairline.

Fig. 10.24 Closure of occipital hairline over Jackson–Pratt suction drain.

Excess skin in front of the ear is marked and trimmed so that skin edges touch the ear. The skin overlying the tragus is thinned by excising the subcutaneous fat with Stevens scissors. The cheek flap is sutured to the ear with interrupted 5-0 nylon sutures. The neotragal skin is sutured with 5-0 fast-absorbing plain gut (www.ethicon.com) (Fig. 10.25).

Fig. 10.25 Preauricular closure with 5-0 plain gut approximating skin over the tragus. Remainder of preauricular incision is closed with 5-0 nylon. Note lobule is angled back 30°. Transverse ink mark caudad to temporal hair will be used to lower the hairline.

Excess skin in the temporal area is removed and the temporal hairline is lowered by incising the previously drawn transverse temporal hairline incision (Fig. 10.25). A triangle of skin is marked and excised at the point of insertion of the helical rim to the cheek (Fig. 10.26). After removing the excess skin above the point of insertion of the helical rim, the temporal hair flap is brought down and approximated to the adjacent skin in front of the ear, thus lowering the temporal hairline (Fig. 10.27).

Fig. 10.26 Incision at bottom of temporal hairline has been made, and temporal hair-bearing skin flap is elevated with hook. Excess non hair-bearing skin has been marked with ink and will be excised.

Fig. 10.27 Excess non hair-bearing skin has been excised from in front of ear. Hair-bearing temporal flap has been stapled into position. Hairline is lowered and reapproximated.