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The deep plane facelift
The Deep Plane Facelift A 20-Year Evolution of Technique Henry I. Baylis, MD, Robert Alan Goldberg, MD, Norman Shorr, MD Purpose: This report reviews the unique technical and conceptual oculoplastic innovations in the discipline of facelift surgery by analyzing the evolution of facelift technique at a university-based oculoplastic program. Designed: Retrospective, noncomparative case series. Participants: We analyzed 313 patients undergoing a facelift from 1980 through 1997. Most procedures were performed by the senior author. Methods: Three primary eras of surgical technique were identified: limited skin flap with superficial musculoaponeurotic system plication (25 patients), extended skin flap with neck dissection and superficial musculoaponeurotic system plication (210 patients), and deep plane facelift with robust superficial musculo-aponeurotic system flap (78 patients). Results: The steps in the evolution were designed to improve the results of the surgery regarding rejuvenation of the neck, jowls, and nasolabial fold, and to reduce the “tattletale signs” of facelift surgery including postauricular scarring, change in the position of the sideburn and temporal hairline, and unnatural results caused by pulling the tissues posteriorly, rather than repositioning them vertically. There were no complications in the skin flap only group. In the extended skin flap and superficial musculo-aponeurotic system plication group, there was one mandibular paresis which partially resolved. In the deep plane facelift (n ⫽ 78), there was one laceration of the parotid duct, successfully stented during surgery. Conclusions: The deep plane facelift, with vertical elevation of the midface, jowls, and neck, is a logical extension of the mid-facelifting techniques that have been used by oculoplastic surgeons. Compared with cutaneous undermining with superficial musculo-aponeurotic system plication, we found patient and physician acceptance higher using the deep plane technique. Ophthalmology 2000;107:490 – 495 © 2000 by the American Academy of Ophthalmology. Our concepts of rejuvenation of the face continue to evolve. Years ago, we thought of blepharoplasty as an operation to remove skin and fat from the eyelids. We now recognize that aging changes often involve loss of fat, so that preservation and redistribution of fat often takes the place of fat removal. Also, oculoplastic surgeons have come to recognize that eyelid contours are inexorably linked to contours of the extended eyelid complex encompassing the eyebrow and midface, and aging changes affect this extended eyelid complex in ways that cannot be effectively addressed by surgery that is limited to the eyelids themselves. Rather, rejuvenation must include the midface and brow. These structures descend vertically, and descent of the midface is therefore addressed by vertical elevation. This necessarily involves the orbit and eyelid, and therefore management of midface descent is the responsibility of the eyelid surgeon. In this paper, we discuss the management of the lower face,
midface, and extended lower eyelid complex through the facelift operation. We focus on the evolution of technique of the senior author, spanning 15 years and over 300 patients.
Methods We reviewed the charts, including pre- and postoperative photographs, of representative facelift patients from three eras: 1982 through l989 (limited skin and superficial musculo-aponeurotic system [SMAS] flap; n ⫽ 25), 1990 through 1994 (extended skin and SMAS flaps; n ⫽ 210), and 1995 through 1997 (deep plane facelift; n ⫽ 78). Cases performed primarily by oculoplastic fellows were excluded, but cases performed by fellows under the direct supervision of the authors were included in the review. Procedures performed before 1990, and most subsequent procedures, were performed by the senior author.
Surgical Technique Originally received: November 29, 1998. Accepted: November 2, 1999. Manuscript no. 98759. Aesthetic Reconstructive Service, Orbital and Ophthalmic Plastic Surgery Division, Jules Stein Eye Institute, Los Angeles, California. Modified from the Wendell Hughes Lecture, American Academy of Ophthalmology annual meeting, San Francisco, October 1997. Reprint requests to Henry I. Baylis, MD, 100 Stein Plaza, Los Angeles, CA 90095-7006.
490
© 2000 by the American Academy of Ophthalmology Published by Elsevier Science Inc.
Under intravenous sedation, the face is anesthetized and tumesced using 150 ml of 0.25% lidocaine with 1:1,000,000 epinephrine. Surgery begins with a standard preauricular incision. The sideburn is preserved. A separate small 3- to 4-cm incision is made in the temporal brow, similar to the temporal incision of an endoscopic forehead lift (Fig 1). The preauricular incision is carried below the ear lobe and onto the posterior edge of the conchal bowl. The incision is not carried into the posterior hairline. ISSN 0161-6420/00/$–see front matter PII S0161-6420(99)00125-6
Baylis et al 䡠 The Deep Plane Facelift Table 1. Three Surgical Eras Surgery Type
Dates
n
Patient Satisfaction
Skin flap with SMAS imbrication Extended skin flap with neck dissection, short SMAS flap plicated
1982–1989
25
fair
Wound complications only
1990–1994
210
fair
Deep plane SMAS flap, limited neck dissection
1995–1997
78
Mandibular nerve paresis, partial recovery (n ⫽ 1) Orbicularis palsy, full recovery in 3 months (n ⫽ 1) Laceration parotid duct, successfully stented (n ⫽ 1)
good
Complications
SMAS ⫽ superficial musculo-aponeurotic system.
A subdermal dissection is carried forward approximately 3 cm. Most of this skin will be excised after the SMAS is tightened. A SMAS flap is then developed.1– 4 A scalpel blade is used to define the leading edge of the SMAS flap beginning superiorly at the zygomatic arch and extending the incision inferiorly for 5 to 6 cm (Fig 2). A plane is then developed on the inferior surface of the SMAS flap. A useful technique involves inserting a delicate blunttipped facelift scissor under the flap along the direction of the plane of dissection (toward the nasolabial fold) and gently spreading in a vertical fashion. Multiple blunt passes are made and the scissor tip is spread vertically. This creates a series of “posts” of the sub-SMAS tissue (Fig 3). The scissors can then be used to cut off the tops of these posts, where they intercept with the deep edge of the SMAS flap. By lifting the flap with the scissors away from the muscular plane deep to the SMAS, the risk of injury to the underlying facial nerves and parotid duct can be minimized.5– 8 The dissection is not carried beneath the orbicularis for more than 1 cm to decrease the risk of orbicularis weakness. Careful hemostasis is maintained throughout the procedure, using precise monopolar cautery, to decrease the incidence of postoperative hematoma. Tight attachments are present at the origin of the zygomatic major and minor muscles.2,9 –12 After these are lysed, the dissection proceeds to the area of the cheek fat pad. At this point, the SMAS is amputated. The dissection plane is carried out through the cheek fat pad, with the finger of the opposite hand along the nasolabial fold helping to identify by feel the proper dissection plane. This dissection splits the cheek fat pad into a superficial layer attached to the skin, and a deep layer left down below the flap. The dissection is carried through the cheek fat pad to the nasolabial fold (Fig 4). Inferiorly, the flap is taken in the plane just inferior to the platysma, down to the angle of the mandible. After the flap is completely dissected, the cheek fat is visualized beneath the flap using a long retractor. A sturdy, slippery suture such as 2-0 braided nylon is passed in mattress fashion from the temporal scalp, into the wound, through the deep subcutaneous tissue within the cheek fat pad, and back out through the scalp incision (Figs 5 and 6). Three or more mattress sutures can be placed to stabilize, lift, and contour the cheek fat pad and to flatten the nasolabial fold. The SMAS flap is then trimmed and attached to the parotid fascia (Fig 7). The skin is tailored and closed under minimal tension using removable permanent sutures such as 5-0 polypropylene. The hangback, removable sutures are individually adjusted for tension and tied over bolsters on the scalp. With tension taken off the skin flap, it can be tailored and then closed at the preauricular incision with minimal tension. The flap is rotated superiorly and posteriorly (Fig 8), forming a rotational flap based at the earlobe. This provides some vertical lift along the jaw line without recruiting skin behind the ear. This avoids the need for a postauricular dissection and flap. A drain is placed before closure and exits behind the ear; this is removed at the first postoperative visit 2 to 3 days after surgery.
Broad spectrum antibiotics are optionally given at the beginning of the procedure and for 1 week after surgery: not all of the authors of this paper routinely use them, and their routine use in this setting is at the discretion of the operating surgeon. The patients typically recover in an aftercare facility, although many of our patients recover at home. The skin sutures are removed at 1 week after surgery. The hangback sutures can be removed 10 to 14 days after surgery. If one of the sutures is causing a deep dimple or asymmetry, it can be removed early, at the first postoperative visit.
Results The data are summarized in Table 1. In the early experience, from 1982 through 1989, a skin flap was created for 3 to 4 cm, with a SMAS imbrication but no sub-SMAS dissection. As one would expect from this “mini-lift” technique, the complications were limited to standard wound complications, such as hematoma, which were managed without adverse sequelae. However, in retrospect the results were only fair in the subjective judgment of the patient and surgeon (Fig 9). In an effort to achieve more significant rejuvenation, particularly in the neck, the skin flap was extended over the sternocleidomastoid muscle and across the neck in the second group of surgical patients, extending from 1990 through 1994. In combination with the extensive skin dissection and elevation, a short SMAS flap measuring several centimeters was dissected and plicated. The more extensive dissection in this group of patients resulted in one significant complication, a mandibular nerve paresis that resolved only partially and that was presumably related to the nerve damage during the dissection over the angle of the jaw. Although the results in the second group of patients were judged by the surgeon, and by review of pre- and postoperative photographs, to provide some increased improvement in rejuvenation of the jowl and neck area, the overall improvement was still judged to be only fair considering the additional dissection that was required. This motivated the senior author to continue the evolution of his technique. The third stage in the evolution involved a deep plane technique, with dissection of a substantial flap containing the SMAS all the way to the nasolabial fold.13–16 The dissection onto the neck was minimized, eliminating the need for an extensive postauricular dissection; rather, the tissues were rotated around the earlobe and repositioned vertically. Of the different techniques (and recognizing that our overall experience with facelift surgery was much greater by the time the deep plane technique was introduced), the deep plane lift provided the greatest degree of patient satisfaction (Fig 10). Despite the lack of postauricular dissection, we noted improvement in the neck (Fig 11) and found that the occasional creasing behind the ear (Fig 12) was a reasonable tradeoff compared with the scarring and hair disruption that can be created by the extended postauricular dissection (Fig 13).
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Ophthalmology Volume 107, Number 3, March 2000
Figure 1. Preauricular facelift incision. The incision follows the earlobe but is not extended into the postauricular hairline. Figure 2. Subdermal dissection with superficial musculo-aponeurotic system flap exposure. Figure 3. The superficial musculo-aponeurotic system flap is dissected by creating long pockets and lysing the pillars between them, lifting the flap off the underlying facial nerve branches. Figure 4. The completed flap extends to the nasolabial fold and jawline. Deep structures include the zygomatic muscles, the parotid duct (green), and the distal buccal branch of the facial nerve. Figure 5. A 2-0 braided nylon suture is passed through the superficial portion of the bisected cheek fat pad, which remains attached to the skin. Figure 6. The cheek fat pad sutures are tied on the scalp as removable mattress hangback sutures. Figure 7. The superficial musculo-aponeurotic system flap is tightened onto the parotid fascia, preauricular cartilage, or as an externalized mattress hangback suture, onto the scalp above the ear. Figure 8. The flap is rotated superiorly and posteriorly, pivoting around the earlobe.
Discussion A combination of gravity and loss of elasticity and tone causes facial aging. As a result, the tissues descend vertically. Therefore, the appropriate vector for rejuvenation is
492
vertically upward. Facelift surgical designs that involve pulling tissues backward do not most appropriately address these aging changes and produce a “surgical look.”17 These principles are particularly true in the midface. This is one reason that traditional facelift surgeries have been so
Figure 9. A 58-year-old patient before (A) and 9 months after (B) superficial musculo-aponeurotic system plication facelift surgery and upper blepharoplasty. Typical modest improvement in jowling along the mandible and softening of the nasolabial fold. Figure 10. A 63-year-old patient before (A) and 12 months after (B) deep plane facelift surgery and blepharoplasty. Improvement in mandibular definition, jowling, and nasolabial fold. Figure 11. A 59-year-old patient before (A) and 7 months after (B) deep plane facelift. Improvement in neck redundancy without postauricular dissection. Figure 12. The rotational flap without postauricular dissection can result in creasing behind the ear. Figure 13. Extended skin dissection, including postauricular flap. Postauricular scarring can occur despite careful construction of the wound.
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Ophthalmology Volume 107, Number 3, March 2000 disappointing in the midfacial area and the reason that oculoplastic surgeons, who have long recognized the rationale for vertical elevation of the midfacial tissues through an eyelid approach, have been leaders in midfacial rejuvenation. One of the difficulties in midfacial rejuvenation has been dealing with the excess skin that is recruited laterally.18 Facelift surgery with a temporal incision allows us to address the geometry of the skin in this area and simultaneously to treat the jowl and neck tissues that descend with gravity. The evolution of the facelift has been about trying to address these vertical changes by vertically elevating and recontouring the superficial and deep tissues, while trying to minimize scarring and other hallmarks of facelift surgery. These hallmarks include pulling back of the sideburn, scarring and hair disruption in the postauricular area, and earlobe distortion (Fig 13). To avoid extensive postauricular scarring, dissection and incisions behind the ear are minimized, rather, the flap is pivoted around the earlobe and elevated vertically. To eliminate pulling back the sideburn, the incision is made in front of the sideburn. To minimize disruption of the shape of the earlobe, the incision is designed and closed carefully around the base of the earlobe. Because the flap pivots around the earlobe, and because the tension is taken off the skin via the multiple point deep fixation of the SMAS flap, there is no tension on the cutaneous wound. Any tendency for widening of the scar and for inferior displacement of the earlobe or straightening of its sulcus (“devil’s ear” deformity) is minimized. This study is substantially limited by the lack of objective measurement of outcome. Not only is it burdened by the limitations of a retrospective chart review, but the analysis of the outcome, both from the standpoint of anatomic change and from the standpoint of patient satisfaction, is entirely subjective. The conclusions, based on the anecdotal 15-year experience of a seasoned oculoplastic surgeon, must be verified by a more scientifically rigorous prospective study. Facelift surgery has significant potential complications. Training for a surgeon adding deep plane dissection to his or her practice may include cadaver dissection, hands-on experience, and participation with an experienced surgeon. Perhaps the most worrisome potential complication is facial palsy: damage to the facial nerve can result in significant morbidity for the patient. The deep plane dissection, on the inferior aspect of the SMAS flap, is just above the facial nerve and therefore the risk of facial nerve injury is greater than with the more superficial approaches. This places a significant responsibility on the surgeon performing deep plane facelift to know the anatomy and gain sufficient training to minimize the complication of nerve injury. Parotid duct injury can also occur; if this is recognized during surgery, the duct can be stented across silicone tubing in a fashion familiar to stenting of the lacrimal canaliculi. Flap necrosis can occur in any patient, but is more common when the vascular supply is compromised by risk factors such as cigarette smoking, or by deleterious postoperative mechanical conditions such as hematoma or excessive tension. Hyperbaric oxygen and topical nitroglycerin paste, com-
494
bined with drainage of any hematoma, may help to salvage the viable portions of the flap. Facelift surgery is in constant evolution. It is not uncommon to analyze the publications of a renowned expert over the years, and note that they progress through different techniques, occasionally returning to the place that they started.19,20 Perhaps most of all, this reflects the fact that facelift surgery is somewhat limited: the aging changes of the lower face cannot be completely reversed in most patients. Oculoplastic surgeons who are accustomed to highly effective tissue repositioning with blepharoplasty and periocular surgery must focus on realistic expectations, as they extend their midface lifting technique to include the preauricular incision and lower facelift. This is not to say, of course, that facelift is a bad operation or that it should not be performed. Patients are happy with facelift surgery, and they refer their friends for the operation. To obtain harmonious results in facial rejuvenation, it is necessary to address the neck, jowls, and nasolabial fold. As long as patients have realistic expectations, patient satisfaction with facelift surgery is excellent. The limitations of the surgery should be recognized and should serve as a continual source of motivation to examine surgical principles and techniques and to continue to innovate and improve our understanding of facelift surgery. Facelift surgery is an integral part of facial rejuvenation. Midface lift performed in conjunction with blepharoplasty addresses vertical descent of the cheek tissues and is well known to oculoplastic surgeons. However, midface lift results in temporal skin redundancy that cannot entirely be addressed with temporal brow lift alone. A preauricular incision and superolateral elevation of tissues improves the ability to address the complicated geometry of this area. Furthermore, facelift addresses aging changes of the lower face, including the nasolabial fold and marionette lines and the jowls and neck. The deep plane lift with pivot, incorporating a thick, well vascularized SMAS flap, has in our hands provided robust rejuvenation of the lower face and is our current preferred technique. Aesthetic facial surgery is an appropriate and inevitable part of the evolution of ophthalmic plastic surgery.
References 1. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast Reconstr Surg 1996;12:77– 88. 2. Ruess W, Owsley JQ. The anatomy of the skin and fascial layers of the face in aesthetic surgery. Clin Plast Surg 1987; 14:677– 82. 3. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976;58:80 – 8. 4. Gosain AK, Yousif NJ, Madiedo G, et al. Surgical anatomy of the SMAS: a reinvestigation. Plast Reconstr Surg 1993;92: 1254 – 63; discussion 1264 –5. 5. Pina DP. Aesthetic and safety considerations in composite rhytidectomy: a review of 145 patients over a 3-year period. Plast Reconstr Surg 1997; 99:670 – 8; discussion 679.
Baylis et al 䡠 The Deep Plane Facelift 6. Rudolph R. Depth of the facial nerve in face lift dissections. Plast Reconstr Surg 1990;85:537– 44. 7. Larrabee WF Jr, Makielski KH. Surgical Anatomy of the Face. New York: Raven Press, 1993. 8. Seckel BR. Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery. St. Louis: Quality Medical Pub., 1994. 9. Vosse JP, Longlois P, Papillon J. The SMA and facial expression in deep face-lifting techniques. In Psillakis JM, ed. New York: Thieme Medical, 1994; 103–21. 10. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89:441–9; discussion 450 –1. 11. Furnas DW. The superficial musculoaponeurotic plane and the retaining ligaments of the face in deep face-lifting techniques. In Psillakis JM, ed. New York: Thieme Medical, 1994. 12. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89:441–9; discussion 450 –1 13. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg 1992;90:1–13.
14. Keller GS, Cray J. Suprafibromuscular facelifting with periosteal suspension of the superficial musculoaponeurotic system and fat pad of Bichat rotation. Tightening the net. Arch Otolaryngol Head Neck Surg 1996;122:377– 84. 15. Hamra ST. The deep plane rhytidectomy. Plast Reconstr Surg 1990;86:53– 61; discussion 62–3. 16. Owsley JQ. Lifting the malar fat pad for correction for prominent nasolabial folds. Plast Reconstr Surg 1993; 91:463–74. 17. Hamra ST. Frequent face lift sequelae: hollow eyes and the lateral sweep: cause and repair. Plast Reconstr Surg 1998;102: 1658 – 66. 18. Hester TR, Codner MA, McCord CD. The “centrofacial” approach for correction of facial aging using the transblepharoplasty subperiosteal cheek lift. Aesth Surg J 1997;17:149 –56. 19. Ellenbogen R. A 15-year follow-up study of the non-SMAS skin-tightening facelift with midface defatting. Equal or better than deeper plane procedures in result, duration, safety, and patient satisfaction. Clin Plast Surg 1997; 24:247– 67. 20. Ivy EJ, Lorenc ZP, Aston SJ. Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies. Plast Reconstr Surg 1996;98:1135– 43.
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midface, and extended lower eyelid complex through the facelift operation. We focus on the evolution of technique of the senior author, spanning 15 years and over 300 patients.
Methods We reviewed the charts, including pre- and postoperative photographs, of representative facelift patients from three eras: 1982 through l989 (limited skin and superficial musculo-aponeurotic system [SMAS] flap; n ⫽ 25), 1990 through 1994 (extended skin and SMAS flaps; n ⫽ 210), and 1995 through 1997 (deep plane facelift; n ⫽ 78). Cases performed primarily by oculoplastic fellows were excluded, but cases performed by fellows under the direct supervision of the authors were included in the review. Procedures performed before 1990, and most subsequent procedures, were performed by the senior author.
Surgical Technique Originally received: November 29, 1998. Accepted: November 2, 1999. Manuscript no. 98759. Aesthetic Reconstructive Service, Orbital and Ophthalmic Plastic Surgery Division, Jules Stein Eye Institute, Los Angeles, California. Modified from the Wendell Hughes Lecture, American Academy of Ophthalmology annual meeting, San Francisco, October 1997. Reprint requests to Henry I. Baylis, MD, 100 Stein Plaza, Los Angeles, CA 90095-7006.
490
© 2000 by the American Academy of Ophthalmology Published by Elsevier Science Inc.
Under intravenous sedation, the face is anesthetized and tumesced using 150 ml of 0.25% lidocaine with 1:1,000,000 epinephrine. Surgery begins with a standard preauricular incision. The sideburn is preserved. A separate small 3- to 4-cm incision is made in the temporal brow, similar to the temporal incision of an endoscopic forehead lift (Fig 1). The preauricular incision is carried below the ear lobe and onto the posterior edge of the conchal bowl. The incision is not carried into the posterior hairline. ISSN 0161-6420/00/$–see front matter PII S0161-6420(99)00125-6
Baylis et al 䡠 The Deep Plane Facelift Table 1. Three Surgical Eras Surgery Type
Dates
n
Patient Satisfaction
Skin flap with SMAS imbrication Extended skin flap with neck dissection, short SMAS flap plicated
1982–1989
25
fair
Wound complications only
1990–1994
210
fair
Deep plane SMAS flap, limited neck dissection
1995–1997
78
Mandibular nerve paresis, partial recovery (n ⫽ 1) Orbicularis palsy, full recovery in 3 months (n ⫽ 1) Laceration parotid duct, successfully stented (n ⫽ 1)
good
Complications
SMAS ⫽ superficial musculo-aponeurotic system.
A subdermal dissection is carried forward approximately 3 cm. Most of this skin will be excised after the SMAS is tightened. A SMAS flap is then developed.1– 4 A scalpel blade is used to define the leading edge of the SMAS flap beginning superiorly at the zygomatic arch and extending the incision inferiorly for 5 to 6 cm (Fig 2). A plane is then developed on the inferior surface of the SMAS flap. A useful technique involves inserting a delicate blunttipped facelift scissor under the flap along the direction of the plane of dissection (toward the nasolabial fold) and gently spreading in a vertical fashion. Multiple blunt passes are made and the scissor tip is spread vertically. This creates a series of “posts” of the sub-SMAS tissue (Fig 3). The scissors can then be used to cut off the tops of these posts, where they intercept with the deep edge of the SMAS flap. By lifting the flap with the scissors away from the muscular plane deep to the SMAS, the risk of injury to the underlying facial nerves and parotid duct can be minimized.5– 8 The dissection is not carried beneath the orbicularis for more than 1 cm to decrease the risk of orbicularis weakness. Careful hemostasis is maintained throughout the procedure, using precise monopolar cautery, to decrease the incidence of postoperative hematoma. Tight attachments are present at the origin of the zygomatic major and minor muscles.2,9 –12 After these are lysed, the dissection proceeds to the area of the cheek fat pad. At this point, the SMAS is amputated. The dissection plane is carried out through the cheek fat pad, with the finger of the opposite hand along the nasolabial fold helping to identify by feel the proper dissection plane. This dissection splits the cheek fat pad into a superficial layer attached to the skin, and a deep layer left down below the flap. The dissection is carried through the cheek fat pad to the nasolabial fold (Fig 4). Inferiorly, the flap is taken in the plane just inferior to the platysma, down to the angle of the mandible. After the flap is completely dissected, the cheek fat is visualized beneath the flap using a long retractor. A sturdy, slippery suture such as 2-0 braided nylon is passed in mattress fashion from the temporal scalp, into the wound, through the deep subcutaneous tissue within the cheek fat pad, and back out through the scalp incision (Figs 5 and 6). Three or more mattress sutures can be placed to stabilize, lift, and contour the cheek fat pad and to flatten the nasolabial fold. The SMAS flap is then trimmed and attached to the parotid fascia (Fig 7). The skin is tailored and closed under minimal tension using removable permanent sutures such as 5-0 polypropylene. The hangback, removable sutures are individually adjusted for tension and tied over bolsters on the scalp. With tension taken off the skin flap, it can be tailored and then closed at the preauricular incision with minimal tension. The flap is rotated superiorly and posteriorly (Fig 8), forming a rotational flap based at the earlobe. This provides some vertical lift along the jaw line without recruiting skin behind the ear. This avoids the need for a postauricular dissection and flap. A drain is placed before closure and exits behind the ear; this is removed at the first postoperative visit 2 to 3 days after surgery.
Broad spectrum antibiotics are optionally given at the beginning of the procedure and for 1 week after surgery: not all of the authors of this paper routinely use them, and their routine use in this setting is at the discretion of the operating surgeon. The patients typically recover in an aftercare facility, although many of our patients recover at home. The skin sutures are removed at 1 week after surgery. The hangback sutures can be removed 10 to 14 days after surgery. If one of the sutures is causing a deep dimple or asymmetry, it can be removed early, at the first postoperative visit.
Results The data are summarized in Table 1. In the early experience, from 1982 through 1989, a skin flap was created for 3 to 4 cm, with a SMAS imbrication but no sub-SMAS dissection. As one would expect from this “mini-lift” technique, the complications were limited to standard wound complications, such as hematoma, which were managed without adverse sequelae. However, in retrospect the results were only fair in the subjective judgment of the patient and surgeon (Fig 9). In an effort to achieve more significant rejuvenation, particularly in the neck, the skin flap was extended over the sternocleidomastoid muscle and across the neck in the second group of surgical patients, extending from 1990 through 1994. In combination with the extensive skin dissection and elevation, a short SMAS flap measuring several centimeters was dissected and plicated. The more extensive dissection in this group of patients resulted in one significant complication, a mandibular nerve paresis that resolved only partially and that was presumably related to the nerve damage during the dissection over the angle of the jaw. Although the results in the second group of patients were judged by the surgeon, and by review of pre- and postoperative photographs, to provide some increased improvement in rejuvenation of the jowl and neck area, the overall improvement was still judged to be only fair considering the additional dissection that was required. This motivated the senior author to continue the evolution of his technique. The third stage in the evolution involved a deep plane technique, with dissection of a substantial flap containing the SMAS all the way to the nasolabial fold.13–16 The dissection onto the neck was minimized, eliminating the need for an extensive postauricular dissection; rather, the tissues were rotated around the earlobe and repositioned vertically. Of the different techniques (and recognizing that our overall experience with facelift surgery was much greater by the time the deep plane technique was introduced), the deep plane lift provided the greatest degree of patient satisfaction (Fig 10). Despite the lack of postauricular dissection, we noted improvement in the neck (Fig 11) and found that the occasional creasing behind the ear (Fig 12) was a reasonable tradeoff compared with the scarring and hair disruption that can be created by the extended postauricular dissection (Fig 13).
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Ophthalmology Volume 107, Number 3, March 2000
Figure 1. Preauricular facelift incision. The incision follows the earlobe but is not extended into the postauricular hairline. Figure 2. Subdermal dissection with superficial musculo-aponeurotic system flap exposure. Figure 3. The superficial musculo-aponeurotic system flap is dissected by creating long pockets and lysing the pillars between them, lifting the flap off the underlying facial nerve branches. Figure 4. The completed flap extends to the nasolabial fold and jawline. Deep structures include the zygomatic muscles, the parotid duct (green), and the distal buccal branch of the facial nerve. Figure 5. A 2-0 braided nylon suture is passed through the superficial portion of the bisected cheek fat pad, which remains attached to the skin. Figure 6. The cheek fat pad sutures are tied on the scalp as removable mattress hangback sutures. Figure 7. The superficial musculo-aponeurotic system flap is tightened onto the parotid fascia, preauricular cartilage, or as an externalized mattress hangback suture, onto the scalp above the ear. Figure 8. The flap is rotated superiorly and posteriorly, pivoting around the earlobe.
Discussion A combination of gravity and loss of elasticity and tone causes facial aging. As a result, the tissues descend vertically. Therefore, the appropriate vector for rejuvenation is
492
vertically upward. Facelift surgical designs that involve pulling tissues backward do not most appropriately address these aging changes and produce a “surgical look.”17 These principles are particularly true in the midface. This is one reason that traditional facelift surgeries have been so
Figure 9. A 58-year-old patient before (A) and 9 months after (B) superficial musculo-aponeurotic system plication facelift surgery and upper blepharoplasty. Typical modest improvement in jowling along the mandible and softening of the nasolabial fold. Figure 10. A 63-year-old patient before (A) and 12 months after (B) deep plane facelift surgery and blepharoplasty. Improvement in mandibular definition, jowling, and nasolabial fold. Figure 11. A 59-year-old patient before (A) and 7 months after (B) deep plane facelift. Improvement in neck redundancy without postauricular dissection. Figure 12. The rotational flap without postauricular dissection can result in creasing behind the ear. Figure 13. Extended skin dissection, including postauricular flap. Postauricular scarring can occur despite careful construction of the wound.
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Ophthalmology Volume 107, Number 3, March 2000 disappointing in the midfacial area and the reason that oculoplastic surgeons, who have long recognized the rationale for vertical elevation of the midfacial tissues through an eyelid approach, have been leaders in midfacial rejuvenation. One of the difficulties in midfacial rejuvenation has been dealing with the excess skin that is recruited laterally.18 Facelift surgery with a temporal incision allows us to address the geometry of the skin in this area and simultaneously to treat the jowl and neck tissues that descend with gravity. The evolution of the facelift has been about trying to address these vertical changes by vertically elevating and recontouring the superficial and deep tissues, while trying to minimize scarring and other hallmarks of facelift surgery. These hallmarks include pulling back of the sideburn, scarring and hair disruption in the postauricular area, and earlobe distortion (Fig 13). To avoid extensive postauricular scarring, dissection and incisions behind the ear are minimized, rather, the flap is pivoted around the earlobe and elevated vertically. To eliminate pulling back the sideburn, the incision is made in front of the sideburn. To minimize disruption of the shape of the earlobe, the incision is designed and closed carefully around the base of the earlobe. Because the flap pivots around the earlobe, and because the tension is taken off the skin via the multiple point deep fixation of the SMAS flap, there is no tension on the cutaneous wound. Any tendency for widening of the scar and for inferior displacement of the earlobe or straightening of its sulcus (“devil’s ear” deformity) is minimized. This study is substantially limited by the lack of objective measurement of outcome. Not only is it burdened by the limitations of a retrospective chart review, but the analysis of the outcome, both from the standpoint of anatomic change and from the standpoint of patient satisfaction, is entirely subjective. The conclusions, based on the anecdotal 15-year experience of a seasoned oculoplastic surgeon, must be verified by a more scientifically rigorous prospective study. Facelift surgery has significant potential complications. Training for a surgeon adding deep plane dissection to his or her practice may include cadaver dissection, hands-on experience, and participation with an experienced surgeon. Perhaps the most worrisome potential complication is facial palsy: damage to the facial nerve can result in significant morbidity for the patient. The deep plane dissection, on the inferior aspect of the SMAS flap, is just above the facial nerve and therefore the risk of facial nerve injury is greater than with the more superficial approaches. This places a significant responsibility on the surgeon performing deep plane facelift to know the anatomy and gain sufficient training to minimize the complication of nerve injury. Parotid duct injury can also occur; if this is recognized during surgery, the duct can be stented across silicone tubing in a fashion familiar to stenting of the lacrimal canaliculi. Flap necrosis can occur in any patient, but is more common when the vascular supply is compromised by risk factors such as cigarette smoking, or by deleterious postoperative mechanical conditions such as hematoma or excessive tension. Hyperbaric oxygen and topical nitroglycerin paste, com-
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bined with drainage of any hematoma, may help to salvage the viable portions of the flap. Facelift surgery is in constant evolution. It is not uncommon to analyze the publications of a renowned expert over the years, and note that they progress through different techniques, occasionally returning to the place that they started.19,20 Perhaps most of all, this reflects the fact that facelift surgery is somewhat limited: the aging changes of the lower face cannot be completely reversed in most patients. Oculoplastic surgeons who are accustomed to highly effective tissue repositioning with blepharoplasty and periocular surgery must focus on realistic expectations, as they extend their midface lifting technique to include the preauricular incision and lower facelift. This is not to say, of course, that facelift is a bad operation or that it should not be performed. Patients are happy with facelift surgery, and they refer their friends for the operation. To obtain harmonious results in facial rejuvenation, it is necessary to address the neck, jowls, and nasolabial fold. As long as patients have realistic expectations, patient satisfaction with facelift surgery is excellent. The limitations of the surgery should be recognized and should serve as a continual source of motivation to examine surgical principles and techniques and to continue to innovate and improve our understanding of facelift surgery. Facelift surgery is an integral part of facial rejuvenation. Midface lift performed in conjunction with blepharoplasty addresses vertical descent of the cheek tissues and is well known to oculoplastic surgeons. However, midface lift results in temporal skin redundancy that cannot entirely be addressed with temporal brow lift alone. A preauricular incision and superolateral elevation of tissues improves the ability to address the complicated geometry of this area. Furthermore, facelift addresses aging changes of the lower face, including the nasolabial fold and marionette lines and the jowls and neck. The deep plane lift with pivot, incorporating a thick, well vascularized SMAS flap, has in our hands provided robust rejuvenation of the lower face and is our current preferred technique. Aesthetic facial surgery is an appropriate and inevitable part of the evolution of ophthalmic plastic surgery.
References 1. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast Reconstr Surg 1996;12:77– 88. 2. Ruess W, Owsley JQ. The anatomy of the skin and fascial layers of the face in aesthetic surgery. Clin Plast Surg 1987; 14:677– 82. 3. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976;58:80 – 8. 4. Gosain AK, Yousif NJ, Madiedo G, et al. Surgical anatomy of the SMAS: a reinvestigation. Plast Reconstr Surg 1993;92: 1254 – 63; discussion 1264 –5. 5. Pina DP. Aesthetic and safety considerations in composite rhytidectomy: a review of 145 patients over a 3-year period. Plast Reconstr Surg 1997; 99:670 – 8; discussion 679.
Baylis et al 䡠 The Deep Plane Facelift 6. Rudolph R. Depth of the facial nerve in face lift dissections. Plast Reconstr Surg 1990;85:537– 44. 7. Larrabee WF Jr, Makielski KH. Surgical Anatomy of the Face. New York: Raven Press, 1993. 8. Seckel BR. Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery. St. Louis: Quality Medical Pub., 1994. 9. Vosse JP, Longlois P, Papillon J. The SMA and facial expression in deep face-lifting techniques. In Psillakis JM, ed. New York: Thieme Medical, 1994; 103–21. 10. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89:441–9; discussion 450 –1. 11. Furnas DW. The superficial musculoaponeurotic plane and the retaining ligaments of the face in deep face-lifting techniques. In Psillakis JM, ed. New York: Thieme Medical, 1994. 12. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89:441–9; discussion 450 –1 13. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg 1992;90:1–13.
14. Keller GS, Cray J. Suprafibromuscular facelifting with periosteal suspension of the superficial musculoaponeurotic system and fat pad of Bichat rotation. Tightening the net. Arch Otolaryngol Head Neck Surg 1996;122:377– 84. 15. Hamra ST. The deep plane rhytidectomy. Plast Reconstr Surg 1990;86:53– 61; discussion 62–3. 16. Owsley JQ. Lifting the malar fat pad for correction for prominent nasolabial folds. Plast Reconstr Surg 1993; 91:463–74. 17. Hamra ST. Frequent face lift sequelae: hollow eyes and the lateral sweep: cause and repair. Plast Reconstr Surg 1998;102: 1658 – 66. 18. Hester TR, Codner MA, McCord CD. The “centrofacial” approach for correction of facial aging using the transblepharoplasty subperiosteal cheek lift. Aesth Surg J 1997;17:149 –56. 19. Ellenbogen R. A 15-year follow-up study of the non-SMAS skin-tightening facelift with midface defatting. Equal or better than deeper plane procedures in result, duration, safety, and patient satisfaction. Clin Plast Surg 1997; 24:247– 67. 20. Ivy EJ, Lorenc ZP, Aston SJ. Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies. Plast Reconstr Surg 1996;98:1135– 43.
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