- Changes in the Aging Face
- Skin
- Intrinsic Process: epidermis becomes thinner, flattening of dermal/epidermal junction
- Cell turnover decreases
- Decreased fibroblasts
- Subdermal adipose decreases
- Number and diameter of collagen fibers decrease, ratio of III:I increases (type III collagen decreases)
- Extrinsic Process: photoaging
- Sun exposure, smoking
- Dryness, rhytids, irregular pigmentation, loss of elasticity
- Basophilic degeneration
- Remember the different skin disorders:
- Cutis laxa: genetic disorder with variable penetrance, lax skin –> results in poor elastic tissues with due to degeneration of elastic fibers. Patients present with coarse loose skin throughout their body. Surgery can correct the appearance.
- Elastoderma: Unknown etiology- clinical manifestations include pendulous skin laxity involving trunk and extremity that progresses to entire body. Do not operate!
- Ehlers Danlos: Genetic disorder affecting collagen and connective tissue. Presents as joint hyperextensibility, thinness of skin, joint hypermobility, poor wound healing, aortic anuerysms. Do not operate!
- Werner Syndrome: autosomal recessive disorder presenting with pigmented skin and indurated plaques, osteoporosis, muscle atrophy, small vessel angiopathy, poor wound healing. Do not operate!
- Progeria: (Hutchinson Gilford Syndrome) autosomal recessive- present with premature aging, lax skin, growth retardation, cardiac abnormalities, and poor wound healing. Do not operate!
- Wrinkles
- Animation wrinkles, fine shallow wrinkles from disruption of skin elasticity, course deep wrinkles from solar elastosis and epidermal atrophy
- Histology
- Loss of dermoepidermal papillae
- Fewer melanocytes and langerhans cells
- Less dermal collagen, thinner skin
- Loss of reticular dermis with reduced dermal organization
- Decreases in ground substance (elastic fibers, collagen, glycoasminoglyacan)
- Larger sebaceous glands
- Soft Tissue
- Descent from gravitational forces
- Deflation and volume loss: particularly from upper and middle thirds of the face
- Tissue along inferior orbital rim appears to become ptotic over time
- Fat accumulation in lower third, especially in neck and jowl
- Radial expansion: repeated animation stretches the retaining ligaments away from the face
- Deepens folds
- Bone
- Inferior orbital rim and anterior maxilla retrude with time, contributing to tear trough deformity and negative vector relationship (where the globe protrudes anterior to the malar eminence)
- Orbit expands inferolaterally and superomedially
- Adult facial skeleton continues to grow while facial height is shortened from loss of height in mandible
- Anatomy
- Layers of the face:
- Skin
- Subcutanous tissue and superficial fat compartments
- SMAS, temporopareital fasica above, skin platysma below
- Facial muscles
- Deep facial fascia
- Neurovascular structures
- Bone
- Neurovascular plane contains the facial nerve, parotid duct, buccal fat pad, and facial vessels
- SMAS: superficial facial fascia (remember lies under skin and SUBQ)
- The smas is thickest over the parotid gland, becomes attenuated medially
- SMAS continuous with the cervical fascia of the neck, temporoparietal fascia, and the galea, and the frontalis
- Remember the layers of fascia of the temporal region
- Temporopareital fascia
- Facial nerve
- Superficial layer of the deep temporal fascial
- Superficial temporal fat pad (superior orbital margin to the
- Deep layer of deep temporal fascial
- Fixed and mobile SMAS
- Deep Facial Fascia
- Continuation of the superficial layer of the deep cervical fascia
- Investing fascia of the parotid
- Masseteric fascia
- Deep temporal fasica
- Covers the facial nerve branches, buccal fat pad, parotid duct, facial artery and vein
- Facial nerve pierces deep facial fascia on anterior edge of masseter to innervate mimetic muscles
- Facial fat compartments
- Superficial fat compartments: superficial to the SMAS
- Nasolabial fat compartment- consistent in volume regardless of age; anterior to medial cheek fat
- Cheek fat compartments: medial cheek fat, middle cheek fat, lateral temporal cheek compartment
- Lateral cheek septum is a true septum and is located anterior to lateral temporal cheek compartment, first septal boundary encountered during a facelift
- Forehead and temporal fat compartments
- Orbital fat compartments: superior compartment, inferior compartment, lateral compartment
- Jowl fat: occurs at region of mandibular retaining ligament. Adheres to depressor anguli oris
- Malar fat pad: superficial fat compartment over cheek thought to give youthful appearance
- Primary components are nasolabial and medial cheek fat compartments, inferior orbital fat pad
- Fat pad descends with age, and loses volume which causes fullness and deepening of nasolabial folds
- Deep facial fat compartments:
- Deep medial fat compartment
- SOOF: suborbicularis fat compartments
- ROOF: retroorbicularis oculi fat compartments
- Loss of volume in deep fat compartments can be a source of aging in the midface, causes superficial fat compartments to descend “pseudoptosis”
- Buccal fat pad: important structures in facial and cheek contour
- Has central body and three extensions: temporal, pterygoid, and buccal
- Zygomatic and buccal branches of the facial nerve lie superficial to buccal extension, parotid duct passes through it
- Buccal extension may be removed through an intra-oral incision to reduce cheek fullness
- Ligaments of the face
- Retaining ligaments: anchored the fixed deep structures such as bone or muscular fascia to the overlying soft tissue
- Fascial boundaries of some fat compartments
- Orbital malar ligament and malar membrane- responsible for tear trough deformity and malar bags
- Ligaments and Adhesions of middle and lower face: 1) osteocutaneous ligaments 2) parotidomasseteric cutaneous ligaments
- Osteocutaneous ligaments:
- Zygomatic osteocutaneous ligament: extends from zygomatic arch, through malar fat pad to dermis (also known as McGregors patch)
- Mandibular osteocutaneous ligament: extends from parasymphyseal region to overlying dermis
- Parotid and masseteric cutaneous ligaments: formed by coalescence of superficial and deep facial fascia (also known as Lore fascia)
- Fixes facial layers to parotid and masseter by fibrous septa
- Ligaments attenuate with age causing wrinkles in facial tissues (along with atrophy and attenuation of soft tissues)
- Weakening of the zygomatic ligament causes downward migration of the malar soft tissues
- Creates redundant skin that hangs over fixed nasolabial fold
- Weakening of masseteric ligaments- causes downward migration of cheek tissue which creates marionnette lines and jowls
- Jowls formed from tethering of mandibular ligament
- Muscles of the face: four layers of muscles
- First three layers of muscles innervated by facial nerve on deep surface
- Depressor anguli oris, zygmoaticus minor, orbicularis
- Depressor labii inferioris, risorius, platysma
- Zygomaticus major, levator labii superiorus alaque nasi
- Fourth layer innervated by facial nerve on superficial surface
- Mentalis, levator anguli oris, buccinator
- Blood supply
- Mainly supplied by external carotid arteries with small contributions to eyelid/brow from ophthalmic division of internal carotid artery
- Facial vessels lie in deep plane along with parotid duct, buccal and zygomatic branches of the facial nerve. At the level of the mandible, the facial vessels cross 3cm medial to it and course over the masseter. The vein lies posterior to the artery. Remember, nerve runs over the facial vessels!
- Remember, anterior region of the face supplied by myocutaneous perforators, lateral face supplied by fasciocutaneous perforators
- Skin after facelift will be dependent on myocutaneous perforators as fasciocutaneous perforators are divided
- Anterior face arteries: facial, superior and inferior labial, supratrochlear and supraorbital (these lie directly under the smas layer)
- Lateral face arteries: transverse, submental, zygomaticoorbital, anterior auricular
- Scalp and forehead: superficial temporal, frontal and temporal branches, posterior auricular, occipital
- Sensory nerves: via the trigeminal nerve V1-3
- Nerves disrupted at the skin should regenerate
- Great Auricular Nerve: most commonly injured nerve during a facelift
- McKinney’s point: point at greatest risk of injury, 6.5cm below tragus where it is superficial in location along posterior border of SCM
- Provides sensation to lower half of ear
- Deep to superficial cervical fascia, however platysma is absent here placing nerve at risk
- Auriculotemporal Nerve
- Courses with superficial temporal artery
- Frey Syndrome: sympathetic reinnervation of facial skin flap after division causing gustatory sweating
- Lesser Occipital Nerve
- Travels over SCM, runs between muscle fascia and superficial fascial fascia
- Innervates superior third of ear
- Courses posterior to great auricular nerve
- V1: supraorbital/supratrochlear: forehead and scalp
- V2: includes zygomaticotemporal, zygomaticofacial (sensation over lateral orbit) and infraorbital
- Motor nerves
- Facial Nerve: emerges from stylomastoid foramen, then protected by parotid gland –> divides into upper and lower portion
- Frontal:
- More at risk of permanent injury during facelift because of lack of arborization
- Courses superficial above the arch (at midpoint between tragus and lateral canthus)
- Remember braches travel below the SMAS or below temporoparietal fascia
- Pitanguy’s line: travels from 0.5cm below the tragus to a point 1.5cm above lateral brow
- Found 5mm lateral the the frontozygomatic suture
- Zygomatic: both zygomatic and buccal branches emerge from anterior parotid, their course lies in loose areolar tissue and fat superficial to masseter
- Injury rarely leads to permanent deficit
- Buccal: see above
- Marginal Mandibular: protected by deep cervical fascia layer after exiting the anterior inferior border of the parotid at the angle of the mandible (?)
- More at risk of permanent injury during facelift because of lack of arborization
- “water under the bridge”, courses above the facial vessels
- Remember, posterior to facial vessels, 81% of patients mm nerve run above the mandibular border, in 19% of patients, may course as deep as 1cm below border
- Runs deep to platysma throughout its course (between deep cervical fascia and platysma)
- Vulnerable point for injury: after it exits the deep cervical fascia and courses up over the anterior mandible in the region of the facial artery
- Should dissect above the platysma laterally, and inferior to the mandibular border centrally to prevent injury to the nerv
- Cervical: located half the distance from the mentum to the mastoid and about 1cm below this line at the level of the angle of the mandible
- Exits inferior portion of parotid
- Perforates deep cervical fascia and runs in fibroareolar tissue that attaches platysma to superolateral border
- Injury results in asymmetrical smile, however, the patient is still able to evert and purse the lower lip (unlike marginal mandibular)
- Facial Danger zones
- McKinneys point (6.5cm below the EAC)– great auricular nerve
- Pitanguy’s line (0.5cm below tragus – to 1.5 cm above lateral brow)– frontal branch
- Midmandible 2cm posterior to oral commissure—marginal mandibular nerve
- Superior orbital rim—supraorbital and supratrochlear nerves (anterior to SMAS)
- 1cm below inferior orbital rim—infraorbital (anterior to SMAS)
- Below second pre-molar—mental (anterior to SMAS)
- Spinal Accessory Nerve: weakness of shoulder and inability to lift shoulder girdle, usually from dissection of lateral neck
- Exits the jugular foramen –> innervates the SCM –> leaves the posterior border of SCM 7-9cm from the clavicle –> passes posterior to innervate trapezius
- Vulnerable to injury as it leaves SCM, stays deep to investing layer of deep cervical fascia on levator scapulae, separated from muscle by the prevertebral layer of the deep cervical fascia and adipose tissue
- Pre-operative facial Analysis: Remember that the face should be analyzed in equal horizontal thirds and vertical fifths.
- Thirds: forehead to brows, glabella to subnasalel, subnasale to menton
- Fifths: draw lines from lateral canthi to medial canthi
- Periorbital zone
- Brow position
- Forehead height
- Glabellar creases
- Temporal region
- Lower eyelid
- Lateral canthal position
- Tear trough deformity
- Malar projectiona and negative vs positive vector
- Malar descent/atrophy
- Perioral Zone
- Nasolabial folds and marionette grooves- marionette lines develop due to descent of facial fat and intact mandibular ligament
- Angle of mouth
- Upper lip
- Lower lip
- Chin
- Nose
- Ear position
- Neck
- Excess skin
- Platysmal banding
- Jawline and submandibular glands
- Facial Proportions
- Operative Technique
- Incision placement
- Temple Incision: prehairline and post hairline
- Widening of distance between lateral canthus and the anterior part of temporal hairline can create unnatural appearance
- Prehairline: ideal with short sideburns, secondary facelifts, and when excision of excess skin would widen lateral canthus
- Posthairline: a continuation of the open coronal brow lift, allows for more pure posterior vector
- Preauricular: incision made between anatomic margin of face and ear taking notice of width of root of helix
- Incision curved along anterior border of helix
- Intratragal best suited to hide scar
- Pretragal best suited in men
- Postauricular
- Incision best placed at the retroauricular sulcus
- Occipital incision may be pre-hairline or post-hairline in to the scalp. With pre hairline incision, aligning scar not issue- worry about scar hypertrophy and visible scars
- High retroauricular crossing into hairline best suited for modest redundancy of neck skin
- Lower retroauricular crossing hairline good for modest to excessive skin redundancy of neck (posthairline is better than prehairline due to lack of visible scar), question from 2018
- Occipital prehairline incision best suited for those with massive skin redundancy especially in lower neck
- Vectors and Fixation
- SMAS should be fixed and elevated in more vertical or diagonal vertical direction
- Skin should be more posterior and vertical
- Diagonal vertical on platysma improves neck and submental, vertical is critical and improves peri-oral, high SMAS improves midface
- SMAS fixation provides a longevity of result- tension should be placed on SMAS not on skin
- Subcutaneous facelift-for historic relevance only
- Deep Subq facelift- for historic relevance only
- Subq facelift with plication or imbrication
- SMAS stacking
- Skoog facelift- deep plane of dissection, shown fixed SMAS must be dissected for vector pull
- Sub SMAS –high and low- Barton advocated high SMAS technique in which one could suspend the SMAS above the zygomatic arch ensuring release of zygomatic ligaments allowing superior pull of malar and zygomatic soft tissues, Barton high SMAS is composite technique, Stuzin extended SMAS lift is two layered technique high SMAS with release of
- Composite face lift-en bloc suspension of skin, platysma/SMAS, malar fat, orbicularis oculi, and composite musculocutaneous flap
- Lamellar SMAS
- MACS lift: short scar rhytidectomy technique that elevates tissues with a vertical vector only. Skin flaps elevated through preauricular and pretemporal hairline incision, deep stitches purse string the SMAS and are anchored to deep temporal fascia above the zygomatic arch. Good for jowling with minimal cervical skin.
- Foundation facelift
- Subperiosteal
- Temporal supraperiosteal dissection
- Other considerations
- Malar Enhancement: discuss placement
- Nasolabial Folds
- Aging lip
- Jawline
- Chin Ptosis
- Fat Injections
- Perioperative Management:
- Recommendations: NSAIDS to be stopped two weeks prior to surgery
- Fish oils, garlic, ginkgo, ginger should not be taken prior to surgery
- If patient is on anticoagulation facelift not advisable
- Contraindications include smoking, obesity, uncontrolled DM, HTN
- Different skin conditions contraindicated for facelift- ehlers danlos, progeria, elastoderma, werner syndrome (cutis laxa is okay)
- Procedures over six hours not advised in an office setting, over four hours may lead to higher incidence of urinary retention and postoperative nausea and vomiting
- Intraoperative Considerations:
- Remember, epinephrine takes 25 minutes to take full effect so plan accordingly
- Careful management of blood pressure is important- conscious sedation can lower blood pressure, use fluids to resuscitate initially (up to 20% of people)
- Conscious sedation has been shown to decrease DVT as opposed to general anesthesia
- Face should not be dependent
- Hair should be washed
- Postoperative Management
- Hematoma prevention: HOB elevation at all times, strict blood pressure control, evaluate all incisions POD1
- Drains, used to collect hematoma and prevent airway compromise, remove early
- Dressings not to be too tight
- Small fluid collections may be aspirated with 18-20 gauge needle
- Hematomas are treated by immediate return to OR if active bleeding, small hematomas past 3-4 days can also be treated with aspiration after the hematoma has liquified
- Complications
- Hematoma: most common complication
- Requires meticulous hemostasis and perioperative blood pressure control
- 2-3% in female patients
- Males have higher incidence about 8%
- Increased incidence with: simultaneous open neck su rgery, NSAIDS, HTN
- Most likely to occur first 24 hours post-op
- Sealant glue does not decrease incidence, however does decrease drainage and ecchymosis
- Tumescent decreased hematoma without decreasing intraoperative bleeding
- Sensory nerve injury
- Sensory innervation to skin flap always damaged, typically resolves within 12 months
- Great auricular nerve most commonly recognized nerve injury- up to 7% (if noticed during OR repair)
- Motor nerve injury
- Motor function common after OR, typically due to local anesthetic
- Buccal branch most commonly injured after facelift
- Paralysis of marginal mandibular nerve results in inability to evert or purse lips
- Platysma or cervical branch causes asymmetrical smile but patients are still able to purse
- If there is nerve injury, EMG at 3 weeks to 3 months, surgical exploration at 3 months with neurolysis and repair
- Skin slough
- Subcutaneous dissection has higher rates of skin necrosis than sub smas
- Skin slough preceded by hematoma or infection, most common in retroauricular region
- Higher in patients with PVD and smokers, tension on flaps
- Release sutures if tension too much
- Once eschar has formed, perform local wound care until wounds have healed, then may perform scar revision at a later date
- Infection
- Rare and less than 1%
- Typically presents as erythema
- Preauricular infections are usually pseudomonas
- MRSA can be transmitted from nasal carriers (MSSA 21% MRSA 5%) –> use topical mucoporin and chlorhexidine washes pre-operatively
- Otherwise, abx 1-2 weeks
- Hypertrophic scars
- Post-auricular scars most common where tension is highest
- Intralesional steroids can be injected directly into scar tissue
- Wait to revise scars 6 months
- Stigmata
- Unnatural or pulled appearance:
- Excessive tension or improper vectors
- Lateral sweep: made from a strong lateral pull in lower face without treatment in midface creating a pleat with time
- Joker’s lines: result from submalar hollowing that becomes accentuated with by facelift –> prevent this with fat grafting or more limited release and vertical pull
- Smile Blocks: hypodynamic cheek mounds, corrected by soft tissue augmentation
- Remember to give tension on SMAS and not skin
- Visible scars: due to improper incision placement (typically too anterior) and due to tension
- Hairline distortion:
- Temporal hairline should be no more than 4-5cm from the orbit
- If superolateral movement of midface expected, should plan incision along sideburn
- Alopecia
- Can be caused by electrocautery or excessive tension
- Tragal deformities
- “blunting” of pretragal depression, fullness, or hair growth
- Pixie ear deformity
- Inferior migration and axis distortion of the lobule
- Caused by excessive trimming of skin flap near ear lobule
- Prevent by not placing tension on the lobule, transfer caudal forces to post-auricular fascia and skin
- Divide excess portion of the SMAS flap, transpose posteriorly, attach to mastoid fascia and brace to ear
- Contour deformity
- Secondary facelifts
- Need thorough medical evaluation as these patients have aged and are likely to have more co-morbid conditions
- SMAS layer typically thinner
- Scarring increases risk for tissue plane injury
- Skin flap is more robust due to delay phenomenon
