RhytidectomyMarc Cohen, M.D.David Geffen School of Medicine at UCLADivision of Head & Neck Surgery

The Aging Face

Soft tissue changes

Skin changes

Soft Tissue Changes

Jowl

Deepened nasolabial folds and perioral jowling

Platysmal banding and submental fullness

Orbicularis oculi and malar fat pad ptosis

Skin Changes

Epidermis and subcutaneous fat thins

Flattening of dermal-epidermal junction

Elastosis: progressive loss of organization of elastic fibers and collagen

Photodamaged skin – striking variability

SMAS

Superficial Musculoaponeurotic System

1976 Mitz and Pyronie Landmark paper

Fibromuscular fascial extension of the platysmal muscle that arises superiorly from the fascia over the zygomatic arch and is continuous in the inferior cheek with the platysma

Functions to transmit the activity of facial mimetic muscles to the facial skin

SMAS

Posteriorly, the SMAS fuses with the fascia overlying the sternocleidomastoid muscle, but it is a distinct layer superficial to the parotid fascia

Anterosuperiorly, the SMAS invests the facial mimetic muscles of the mid-face (i.e., orbicularis oculi, zygomatic major/minor, levator labii superioris)

Anteriorly, the SMAS invests the superficial portions of the orbicularis oris and gives off fibrous septae that insert into the dermis along the melolabial crease and upper lip

Facial Nerve Protected by parotid

tissue and lower branches are deep to masseter fascia

Potential space exists between SMAS and masseter fascia in inferior cheek Important in

deep/composite rhytidectomy techniques

Innvervates midfacial mimetic muscles from undersurface

Facial Nerve

Temporal branch is most superficial Crosses junction of

anterior 1/3 and posterior 2/3 of zygomatic arch

Above the arch it travels in the temporoparietal fascia to innervate frontalis and orbicularis oculi

SMAS & The Facial Nerve

Facelifts

Subperiosteal facelift

Subperiosteal facelift

Shortcomings Frontal branch at higher risk Significant facial edema lasting up to 6 weeks

Deep plane facelift

Addresses nasolabial folds

Subcutaneous 2-3 cm in front of tragus

Sub-SMAS To zygomaticus major

Superficial to zygomaticus major

Upper extent is malar eminence

Inferior extent is jawline

Deep plane facelift

Composite facelift

Addresses malar eminence

Lower blepharoplasty incision used to elevate orbicularis oculi and malar fat pad

Transition then made superficial to zygomaticus major

Nasolabial Fold

Nasolabial Fold

Boundary between cheek and upper lip

Laterally, thick subcutaneous layer

Medially, dermis almost approaches orbicularis

Cheek fat sags over time lateral to fold

Upper third – insertion into LLSAN muscle

Middle third – transition btw both muscles

Lower third – insertion into OO

Deep plane and periosteal lifts do not anatomically address this

Controversial – SMAS or not

Nasolabial Fold Management

Direct excision (UCLA)

ePTFE (gortex)

Fillers

SMAS

Facelifts? Midface lifts?

Botox (LLSAN)

Botox

Direct Excision

Lift and Peel at same time?

Concern for flap necrosis

Retrospective studies show no increased incidence of flap necrosis or other complications

Retaining Ligaments of the Face

Osteocutaneous Orbital – centered at zygomaticofrontal suture Zygomatic Buccal-maxillary – arises from

zygomaticomaxillary suture Mandibular (along with DAO makes up

labiomandibular crease)

Fasciocutaneous Masseteric (anterior border of masseter Parotidocutaneous

Blood Supply

ECA STA

Transverse facial artery Zygomaticorbital artery

Facial Submental Inferior labial Superior labial Angular

Blood Supply

Complications - Hematoma

HTN is major risk factor (2.6x risk) Major – usually occur in first 12 hours

reoperation and exploration Minor – occur during the first week

Evacuated with 18 ga needle or small opening in incision line, pressure dressing, abx

Complications – Flap necrosis

Postauricular is most common site Preauricular is 2nd most common Deep-plane facelifts have a decreased incidence

of necrosis Nicotine carries a 12.6x risk for flap necrosis

Must stop at least 2 weeks prior Treat conservatively with with daily peroxide

cleaning, limited debridement, and topical abx ointment

Most heal nicely

Complications – Nerve Damage

Most commonly injured nerve is great auricular If injured, should be repaired with 9-0 nylon

Temporal and Marginal are the most commonly injured motor nerves Studies differ on which is more commonly injured

(which technique, etc.) Treatment

First 4-8 hours, wait If prolonged, do NOT re-explore 85% will resolve with time Reconstruct after 1 year

Patients with a hx of Bell’s palsy are at risk for recurrence after rhytidectomy

Complications

Hypertrophic scarring Occurs with excessive tension on flap closure More commonly with isolated subcutaneous flap

dissections Treat with steroids Defer excision and primary closure until at least

6 months postoperatively

Alopecia Wait 3-6 months, then excise or place grafts

Complications

Infection Common pathogens are

staph and strep Usually respond to oral abx Rare for abscess to form

Earlobe deformity (pixie ear) V-Y plasty performed 6

months after surgery

Complications

Parotid injury Sialocele or fistula Needle aspiration and pressure dressings