Vertical Vector Face Lift with Local Anesthesia

Anatomy

Face and neck anatomy is discussed in detail in Chapters 1 and 38 . The relevant aesthetic considerations for face-lift surgery and the pertinent anatomy will be succinctly summarized.

The foundation of Western facial analysis is based on proportion. Vertically, the face is divided into thirds. Though the eyes are included in discussions about the upper face, anatomically the upper-third of the face is defined superiorly by the hairline, and by the inferior extent of the eyebrow. The mid-face extends from this level to the nasal sill. The lower-third is bounded by the base of the nose (nasal sill) and the chin. Each third is equal in height ( Fig. 39.1 ). A weak chin or microgenia is the most common cause of loss of facial proportions and is easily corrected by a chin implant. Chin augmentation with an implant is frequently performed at the same time as a face lift.

The two major anatomic structures that influence the appearance of the lower face are the SMAS and the platysma. The SMAS is fascia that invests the facial mimetic musculature, and is intimately related to the skin by ligamentous attachments. It connects with the galea superiorly and inferiorly with the platysma.

The platysma is the shield-like thin muscle that originates from the pectoralis fascia, extends to the neck, interdigitates with the SMAS, and attaches to the risorius muscle. In most individuals, the platysma decussates/intertwines at the midline. Yet, in a significant minority, 39% in one study, the platysma divides at the midline. Combined with concomitant hypertrophy from years of lower facial expression, platysmal banding results in a gobbler-like appearance of the neck.

The relationship of the face to the neck can be measured in several ways. The classic method is to determine the angle between the vertical neck and the submandibular plane. This cervicomental angle should be less than 120°. Ellenbogen and Karlin referred to the angle bound by the submentum and the sternocleidomastoid muscle because it was easier to visually assess. The submentum–sternocleidomastoid angle should be 90° to provide a youthful look.

The lower face is bounded superiorly by an imaginary horizontal line from the earlobe, traversing across the cheek to the base of the columella, and extending across the contralateral cheek and earlobe. The inferior border of the lower face is demarcated by the mandibular line. The superior portion of the neck extends from the mandibular line to the thyroid notch. In the lower face, the soft tissue envelope includes skin, subcutaneous fat, SMAS, and muscle. In the upper neck, the layers are similar, though the platysma is continuous with the SMAS. A subplatysmal fat pad is located in the midline. Other structures include the submandibular glands that are located in the fascial plane at the anterior aspect of the mandible bilaterally, and the hyoid bone, which is located in the anterior neck deep to the strap musculature.

The vertical vector face lift is a subcutaneous procedure that is designed to avoid injury to the motor or sensory nerves of the face and neck; however, an understanding of the nerve anatomy of the face and neck is important. The sensory innervation of the lower face is provided by the third branch of the trigeminal nerve. In the postauricular region, C2 and C3 contribute to the greater auricular nerve, which innervates the lower portion of the auricle. The lesser occipital nerve emerges from behind the posterior border of the sternocleidomastoid muscle superior to the greater auricular nerve and courses upward to innervate the neck and the scalp skin posterior to the ear. The general area of emergence of the greater auricular, transverse cervical, and lesser occipital nerves from behind the sternocleidomastoid has been designated Erb's point. Its importance is underscored by the fact that the spinal accessory cranial nerve (XI), the motor innervation to the trapezius muscle, also emerges within this vicinity. Erb's point is located by connecting a line from the angle of the jaw to the mastoid process. From the midpoint of this line, a vertical line is dropped 6 cm until it intersects the sternocleidomastoid muscle (see Fig. 1.33 ). These sensory nerves are vulnerable during undermining of the postauricular flap over the sternocleidomastoid muscle (SCM).

The facial nerve supplies motor innervations to the face. The temporal branch innervates the frontalis muscle and courses most superficially at the zygomatic arch. The marginal mandibular branch innervates the lip depressor muscles. It runs slightly inferior to the mandible before traveling more superficially as it reaches the oral commissures. While the zygomatic and buccal branches are less susceptible to injury during subcutaneous dissection, there are many anastomoses between them, so that functional impairment if traumatized is usually minimal and transient. In the neck, the platysma is innervated by the cervical branch of the facial nerve. The spinal accessory nerve is found in the posterior triangle, but runs across the body of the SCM, and is susceptible to injury. Injuries to facial motor nerves during a vertical vector face lift are avoided by proper marking of the flap extent and ensuring undermining remains in the subcutaneous plane.

The blood supply of the lower face consists of branches of the facial arteries. There is an analogous venous system, which has many perforators. Branches from the external carotid supply the majority of the neck.

Facial aesthetics and goals of the vertical vector face lift

Many factors contribute to the structural changes of the aging face. For many years, it was felt that gravity played the dominant role in the aged face. While it certainly is a significant contributor, photodamage, loss and redistribution of fat, muscle atrophy and hypertrophy, bony reabsorption, and genetics play important roles in facial sagging and jowling. Solar elastosis and collagen damage in the skin create rhytides and a superficial flaccidity. Loss of fat in the periorbital region, malar region, and lower cheeks causes a hollowness and volumetric decrease that contributes to sagging. Fat accumulation in the upper neck blunts the cervicomental angle. Muscle atrophy, particularly in the temporal region, leads to volumetric changes, decreasing anchoring points, and consequently increases the sagging of the more superficial tissues. Hypertrophy as well as separation of the platysma produces bands that disrupt the cervicomental angle and the smooth neck contour. Over time, the face's bony foundation, which provides buttresses for the soft tissues, reabsorbs. This reabsorption is particularly apparent in the lower face. Notably, resorption of the mid-lateral mandible and chin leads to more volume depletion and hollowing to create the pre-jowl sulcus that accentuates the sagging of the jowls.

The vertical vector face lift is designed to remove excess adipose tissue of the neck and jawline, reverse the gravity-associated descent of the SMAS, and restore a youthful balance to the aging face. The addition of an extended chin implant in patients with chin recession provides a synergistic outcome by adding volume and restoring youthful facial proportions. Skin resurfacing with fractional or ultrapulsed carbon dioxide lasers provides wrinkle reduction to complement the improved neck and jawline from the vertical vector lift. Blepharoplasty or brow-lift surgery is easily incorporated in the face-lift procedure. Lastly, volumetric enhancement with fillers is best performed at least 3 months following the vertical vector face lift to allow resolution of surgical swelling and determine the best volume to enhance the residual volume loss uncorrected by the lift.