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 ) .

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.