The multi-vectored rhytidoplasty

CHAPTER 13 The multi-vectored rhytidoplasty

The stigmata of facial aging are well known. They include loss of elasticity and laxity of the cheeks, jowl formation, perioral wrinkles, platysmal bands, and laxity of cervical skin. The possible combinations are infinite, and each patient must be carefully analyzed to formulate a treatment plan. Our challenge as plastic surgeons is to recreate harmony between facial regions and to balance and smoothly blend the transition between these regions. It is important to ascertain what patients looked like early in their lives. Several questions then arise for the plastic surgeon. Do the patients themselves remember? Do we restore their youthful appearance? Do we make them look different, or even better? It is also important to keep in mind that not everyone needs to have everything corrected.

My goals in choosing a procedure for facial rejuvenation are:

The outer layers of the face are similar to a theater curtain in the front of a stage. The curtains are made of two layers – an outer surface (skin) and an inner lining (subcutaneous tissue) which are intimately adherent. The curtain moves by ropes or cables attached at the top and medial side with forces exerted for movement in superior and lateral vectors. Unlike the theater curtain, the face is different, because the contiguous external tissues are attached to the bony skeleton in several areas by strong osseocutaneous ligaments for support and suspension. The muscles of facial expression insert into the skin and move it in vectors perpendicular to their long axis. With the loss of elasticity and thinning of the skin seen in aging, the repetitive movements over time cause wrinkling of the skin perpendicular to the vector of pull of the muscles of facial expression. To correct this problem it is necessary to dissect the skin and subcutaneous tissues from their attachments to the underlying SMAS, releasing the attachments of the osseocutaneous ligaments, and redraping each as a separate vector. If this is not done, the initial good correction will fail and not be long-lasting.

If a foreheadplasty is to be included in the overall plan for facial rejuvenation it is performed primarily, followed by eyelidplasties, and then the facialplasty. Patients are placed under deep sedation with local anesthesia, or more often, they are administered general anesthesia by an anesthesiologist, utilizing narcotic sedation and a continuous propofol drip. Often they are intubated with a laryngeal mask or an endotracheal tube. Prior to performance of the facialplasty, both sides of the face and neck are injected with xylocaine with 1 : 200,000 epinephrine.

The facialplasty is begun by undermining the right side of the face and neck and then the left side. The submental, anterior, and lateral aspects of the neck are undermined and defatted as necessary. Bands may be excised vertically and/or transected transversely (inferiorly), and then the SMAS in the left and right cheeks and neck is tightened. Finally, the submental incision is closed and the flaps on the right and left sides of the face and neck are redraped, the excess skin is excised and the incisions are closed. The incisions must be placed so that they will heal well, and great attention to technique and detail will result in scars that will be almost imperceptible. It does not matter how long the scar is, it matters where it is, and how it looks! (see Fig. 13.1).

Fig. 13.1 Operative location of facialplasty incisions.

Laxity in the lower face and submental areas develops because of loss of support from the SMAS, and especially because of loss of elasticity of the skin and its attachments to the deeper tissues, except where attached to the facial skeleton by the osseocutaneous ligaments. These ligaments do not become lax with time and are the cause for some of the deformities seen in the aging face due to the descensus of the soft tissues, such as the lateral perioral labiomandibular creases and formation of jowls. Therefore it is important to release the zygomatic and mandibular osseocutaneous ligaments (see Figs 13.2, 13.3, and 13.4).

Fig. 13.2 Location of osseocutaneous ligaments.

Fig. 13.3 Release of mandibular osseocutaneous ligaments from above.

Fig. 13.4 Release of mandibular osseocutaneous ligaments from below.

I used to believe that to decrease the prominence of the nasolabial folds and creases it was necessary to do a supra-SMAS dissection medial to the nasolabial fold to allow redraping and produce effacement (see Fig. 13.5). Now I believe that it is preferable to leave the skin and subcutaneous tissues attached to the underlying SMAS medially, so that when it is redraped the nasolabial fold will be less evident and the crease effaced. Dissection only in the sub-SMAS plane prohibits fat contouring in the labiomandibular fold and jowls, especially in an overweight patient. Removal of the subcutaneous adipose tissue in the neck provides improvement in contour, especially when present in excess in an overweight individual, but care must be taken to remove fat in the face in moderation (if at all), especially in a younger, thinner person. Remember that the subcutaneous adipose tissues atrophy as aging progresses (see Fig. 13.6).

Fig. 13.5 Supra-SMAS dissection medial to the nasolabial fold.

Fig. 13.6 Open liposuction of the neck.

For ultimate improvement in the contour of the neck, the platysma needs to be strengthened and utilized as a sling or corset to improve the cervicomental angle, making it more acute. Bringing the two platysma muscles together in the midline (submental, anterior cervical) and tightening and slightly lifting the lateral, posterior border elevates the soft tissues of the neck, including ptotic submandibular glands, obviating the need to partially remove or excise them or the muscles in the submental region (see Figs 13.7, 13.8 and 13.9).

Fig. 13.7 Submental and anterior cervical vectors of platysma plication.

Fig. 13.8 Lateral platysmal bands.

Fig. 13.9 Midline platysma plication extending from submental incision to superior border of thyroid cartilage.

The main surgical objective is to perform a multi-vectored bi-directional resetting of the skin/subcutaneous tissue flap and of the SMAS flap with different tensions to achieve a more youthful appearance (see Figs 13.10, 13.11). This is not possible with a deep plane or composite procedure because all of the tissues are mobilized and moved as a single unit.

Fig. 13.10 SMAS vectors drawn on skin.

Fig. 13.11 Skin vectors.

The need to manipulate the SMAS seems to be generally accepted, however the best method continues to be controversial. My choices for SMAS tightening include plication, lateral SMAS-ectomy, or an extended SMAS flap with or without a post-auricular extension. Permanent sutures of 3-0 Mersilene are used, and they are tiered if necessary. The SMAS tension is set supero-laterally (see Figs 13.12, 13.13). The skin vector is set opposite to the SMAS vector, perpendicular to the nasolabial crease. The preauricular closure is tension-free. The face and neck are “hung” by key tension sutures, which are placed in the superior preauricular and postauricular region, not by the earlobe (see Figs 13.14, 13.15). For perfect scars with no trace of operation behind the ears, 4-0 nylon vertical mattress sutures are placed to approximate the postauricular flap into the sulcus. It is necessary to adjust the posterior retromastoid hairline to avoid a step-off. The earlobe is replaced and repositioned with a vertical mattress suture to the underlying non-mobile deep tissues so that it will not wander inferiorly (see Figs 13.16, 13.17, and 13.18). I prefer to dissect and redrape the tissues in a superficial rather than a deep plane because I have not ever believed that the periosteum or its soft tissue attachments become loose with advancing age. For this reason, it has not made sense to me to perform subperiosteal release of a composite of tissues in order to correct the laxity which has occurred in the more superficial tissues.

Fig. 13.12 Suture line for SMAS plication or repair after open ended flap dissection.

Fig. 13.13 Suture line for SMAS plication or repair after open ended flap dissection.

Fig. 13.14 Draping pre-auricular skin and placement of T tension suture.

Fig. 13.15 Redraping of post-auricular skin and placement of T tension suture.

Fig. 13.16 Postauricular repair.

Fig. 13.17 Completed postauricular and retromastoid repair showing no step-off.

Fig. 13.18 Example of healing one year postop due to precise and careful care.

The following are my thoughts about some new ideas being presented for facial rejuvenation. Increasing the volume of the external tissues of the face by the subcutaneous injection of fat or filling materials is not a permanent solution for long-lasting rejuvenation. Initial improvement is temporary at best. The procedure has to be repeated for maintenance of results and therefore I feel that this should be considered ancillary rather than primary.

Endoscopic approaches satisfy the public’s desire for less invasive, short slide–long haul procedures, but they cannot provide the long-term corrections afforded by an open approach, which in my mind is the gold standard. From observations, and in my hands, these endoscopic procedures have neither taken less operative time nor provided quicker healing due to less trauma, as is promulgated by their proponents.

Inserting barbed sutures under the superficial tissues to elevate and suspend them provides temporary results and is prone to failure. Complications such as injury to the parotid duct or branches of the facial nerve have already been reported. The incidence of these problems may increase in the hands of untrained physicians. The worth of this procedure over a long period of time remains to be proven.

Separating the face into two separate units between the orbits and the mandible (mid- and lower) for the purpose of correcting deformities in those areas by separate techniques, is less effective than considering the area as a whole and dealing with it as a single unit. Similarly, we should not consider separating the cheeks from the neck in terms of correction. The SMAS and platysma need to be considered as a unit and treated as one, rather than separately.

In summary, rejuvenation of the face and neck through a multi-vectored approach equally satisfies the patient’s and the doctor’s goals. The techniques are easily mastered and reproducible. The procedure is safe, it has few, if any, complications, and the results are long-lasting. A careful, delicate dissection performed by a well-trained, experienced surgeon with precise knowledge of the anatomy will provide outstanding results each and every time.

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