References

The frontal branch of the facial nerve The importance of its variation in the face-lifting. Plast. Reconstr. Surg. 38 352-356, 1966 2. Pitanguy, I. Ancillary procedures in face-lifting. Clin. Plast. Surg. 5 51-69, 1978 3. Pitanguy, I. Frontalis-procerus-corrugator apponeurosis in the correction of frontal and glabellar wrinkles. Ann. Plast. Surgery 2 422-427, 1979 4. Pitanguy, I. The aging face. In Carlsen, L., Slatt, B. The Naked Face. Ontario, General Publishing, 1979,...

Patient Selection Criteria

Well over half of the complaints after facelift can be easily avoided. Most are based on failures of communication and or patient selection criteria, not on technical faults. Patient selection, however, is the ultimate inexact science. It is a mixture of surgical judgment, gut feelings, personality interactions, the surgeon's ego strength and, regrettably, economic considerations. Regardless of technical ability, a surgeon who appears cold, arrogant or insensitive is more likely to be sued than...

Acknowledgements

I have learned from many excellent surgeons, older and younger than me. First place among them takes Gottfried Lemperle not only as my teacher, one of co-authors in this book, but also as a sincere friend. As I cannot pay him back all what he has given to me, I am giving my knowledge further to the coming generation of plastic surgeons with this book. I am also thankful to all my patients who gave to me their trust. Special thanks has to be paid to those of them, who agreed to publish their...

Low Frequency Sonophoresis

Low-frequency sonophoresis (about 20 kHz) was first described in 1996 and has become the most effective way to enhance penetration. Up to 4,000 better penetration may occur after only 3 minutes of treatment 38 . Low-frequency sonophoresis should not be confused with ultrasound (about 1.1 MHz), which does not have the same powerful properties. The advantage of low-frequency sonophoresis is that it can be used on nonpolar molecules as well. Cavitation develops rapidly and is maintained for...

Masseteric Cutaneous Ligament

Fig. 12.5. e Facial retaining ligaments the first three ligaments auricula ligament (false), 3 Masseteric cutaneous ligament we detouch regularly performing facelift surgery, and last (false), 4 Orbital retaining ligament, 5 Buccal-maxillary re-three we resect seldom. 1 Zygomatic ligament, 2 Platysma- taining ligament (false), 6 Mandibular retaining ligament Fig. 12.5. e Facial retaining ligaments the first three ligaments auricula ligament (false), 3 Masseteric cutaneous ligament we detouch...

Advantages and Disadvantages

It is possible to perform additional procedures helpful to make a facial contour smoother and smaller and to avoid having a larger facial surface. In this way, we can minimize the inherent contradiction in facelift and get more effective rejuvena-tive results in facelift. 2. Effective rejuvenative effects can be expected in making a small and smooth facial contour without extensive undermining thus, less undermining of soft tissue is required, and less damage is caused to patients who are...

Initial Consultation16

The first contact our patients have with our office is mostly through our staff by phone. This first communication should avoid difficulties which could arise. Our staff should note the patient's name and should call him her by name when answering questions. The information should be general, even average costs could be given, if asked, but this communication should be friendly and interesting. At the end of telephone conversation, an appointment could be politely suggested. One should assure...

Anger a Root Cause of Malpractice Claims

Patients feel both anxious and bewildered when elective surgery does not go smoothly. The borderline between anxiety and anger is tenuous, and the conversion factor is uncertainty - fear of the unknown. A patient frightened by a postoperative complication or uncertain about the future may surmise If it is the doctor's fault, then the responsibility for correction falls on the doctor. The patient's perceptions may clash with the physician's anxieties, insecurities and wounded pride. The patient...

Cheek and Neck Exposure of the SMAS

The most common cause of damage to the SMAS or to making the SMAS appear thin is a lack of precision in elevating the skin. If the dissection is not precise, part of the SMAS may be carried upward with the skin flap and the utilization of the SMAS will be limited and then the less efficient method of plication or other techniques may have to be used. This precision and elevation of the skin-cheek without damaging the SMAS is greatly helped by transillumination of the skin however, for surgical...

Neck Lift

Malar Segment

The posterior bordure of the platysma muscle is fixed by a subcutaneous retroauricular approach to the fascia of Lore. After the suspension, the residual cervical detachment remains minor with a low risk of haema-toma. The neck is repositioned following a horizontal vector, thus tightening the mandibular line. In short, we create a vertical vector on the face and a horizontal vector on the neck. Both sides are performed symmetrically. Fig. 45.10. A 40-year-old woman. Before (left) and 1 year...

Technique of Infiltration

The infiltration should begin with a very fine needle, injecting slowly, because rapid distension of tissues is painful. Once the skin has been anesthetized, the fine needle is changed for a longer one or for a cannula. The inner side of an Abbocatt no. 16 or a spinal needle are also very useful. In general, I infiltrate the whole forehead, face and neck at the beginning of the surgery. This way, when the second or third region is approached, it already has an appropriate vasoconstriction. The...

Facial Architecture and Fine Arts9

The human being is an emotional sculpture which cries and smiles. Physical disorders, defects, or imperfections can be surgically improved on condition that our emotional costume is not damaged. Hardly anyone will opt for an operation merely because he she has too much time or money. It is psychological suffering that brings people to ask a plastic surgeon for help. Michelangelo said See the shape within the Fig. 9.1. a A 25-year-old person it helps us when our patients bring us their pictures...

Bibliography

Fig. 21.7. a Microlipofilling in lower face and platysma bands of the neck the upper part to be corrected by corseting, the lower part by notching. b Bottom view of a male face with submental witch's chin correction, autologous microlipofilling, nose correction, and mini-facelift Fig. 21.7. a Microlipofilling in lower face and platysma bands of the neck the upper part to be corrected by corseting, the lower part by notching. b Bottom view of a male face with submental witch's chin correction,...

The Neck

The delineation of the cervicomandibular angle plays an important role in the appearance of the attractive, youthful neck 11, 12 . Occasionally, patients are more concerned with the appearance of their necks than that of their faces. As a direct continuation of the aging process of the lower face, the aging neck is mainly attributed to loss of platysmal tone, loose skin, together with periplatysmal fat deposits. We manage most necks today by combining lipo-suction with lateral muscle tightening...

Operative Technique

The periauricular incision is before the hairline in front of the ear the postauricular incision is never before the hairline but extends into the hair-bearing zone dorsal to the mastoid. After a soft-tissue undermining in the cheek and neck area and hemostases (the anesthetist raises the blood pressure to about 110 mmHg during that period) and application of the two-component fibrin seal (Tissucol), the key stapler clamps in front and behind the ear are positioned, followed by stepwise...

Operating Room22

The operating room is the heart of any surgical clinic. As we deal with physically healthy patients, the possible risks should be reduced to a minimum. Nosocomial infections should be avoided and such clinics should in the optimal situation only be used for plastic surgery and aesthetic-cosmetic operations. Surgical specialities which deal with inflammatory and septical indications, like abdominal surgery and proctology, do not match the extreme need for aseptic work we require. The operating...

Summary

The endoscope now allows extensive subperiosteal undermining of facial soft tissue through minimalaccess incisions. Improved understanding of facial anatomy and the facial aging process now allow surgeons to reposition and remodel the soft-tissue envelope with excellent aesthetic results. Restoration of facial volume following the multicurvilinear line of beauty or double ogee line can be achieved with the endoscopic subperiosteal techniques described in this chapter. Further aesthetic...

The Brow and the Forehead

Hair Elevations And Angles

That could result in skin adhesion to the calvarium and an unnatural appearance of a frozen forehead without expression. In elevation of the forehead, the scar should be in W shape to avoid a visible track. Even sometimes it will be necessary to implant hair plugs to minimize that scar. Do not remove the retro-orbicularis oculi fat under the brow since it could result in brow adhesion to the orbit and prevent its movement. Do not fix the brow to the orbit by...

Skin Analysis

At your first consultation with the patient you should 1. The overall colour of the skin. This will give you a good idea of the care against photoageing that the patient is taking. All of these signs will respond to competent skin care combined with intensive treatments to enhance penetration through the skin. At times it may be necessary to employ serial light peels. a) Are they excessively tanned or too pale b) Are there pigmentary blemishes Check if the patient has been on hydroquinone,...

Introduction

The author's concept and strategy in facial rejuvenation can be summarized as follows. Facial contouring means an even distribution of volume. Tightening has been replaced by repositioning, distributing, balancing, reducing and or replacing volumes according to the requirements of each facial area. The direction of repositioning is mainly vertical 1. Endoforehead to raise the brows and the upper third of the face. 2. Vertical subperiosteal midface advancement to elevate the cheek mound. 3....

Defining the Beautiful Face

Historically, noted contributions have been made to describe a beautiful sunset, bird, flower, opera, ballet, or masterpiece. These contributions have somewhat answered a bold challenge that pales in one's attempts to define a beautiful face. Although Hungerford stated that Beauty is in the eye of the beholder, I must correct this and say that attraction is in the eye of the beholder, while beauty is shared by all. How do we define beauty in human faces The areas of the face that add the most...

Foreword by RM Goldwyn

Throughout recorded history and earlier, the human being has modified the appearance of his face through, for example, tribal markings, growing, trimming, or shaving a beard, distorting parts, inserting foreign bodies, or applying cosmetics. The face is the most conspicuous part of our body it is our identity, so much so that if a person wishes to be incognito, he or she will wear a mask or adopt a disguise. The plastic surgeon today in changing the appearance of the face is continuing a primal...

Successful Office Clinic Management Organization of a Beauty Clinic

Wellness Team Organogram

The idea of organizing a clinic is certainly fascinating and captivating. However, not only the organizational aspect must be analyzed but the whole context, which includes motivation and favorable and unfavorable conditions. The size of the physical structure and the team, what to offer, the organizational structure, maintenance and continuity at long term must also be taken into consideration. The doctor himself herself is not an entrepreneur and at the moment the clinic has been set up the...

Crows Feet

Lateral to the canthus there are often radially spread wrinkles, especially if the patient smiles. It is possible to reduce these smiling wrinkles by Botox injections - temporarily. For permanent removal, there is a possibility to treat them from outside through epidermal ablation with laser resurfacing or radiosurgi-cal, chemical, or mechanical peel (dermabrasion). Bruce Connell has shown that we can mark these smiling wrinkles on the skin and by doing the facelift surgery we remove these...

The Tragal Area

The placement of the face-lift incision behind the tra-gus reduces the appearance of the preauricular scars however, a few important points must be kept in mind. Avoiding tension on the skin flap will prevent the distortion of the tragus, which is pulled forward and leaves the ear canal open. Although it might be necessary to defat the flap going over the tragal cartilage, excessive defatting will lead to skin necrosis thus the maneuver should be done with care. Before suturing the skin flap,...

Liposuction

An incision of 0.4-0.5 cm in length is done at three points around the ear near the earlobe, near the upper pole and on the posterior sulcus and also on submental region (Fig. 39.2). Those reference points are placed on the incision line marked for rhytidoplasty. A 3 mm Illouz cannula is introduced and, with the suction machine not connected, back and forth movements are done just below the overlying skin all over the face and neck on one side. The surgeon must fold the skin while he she does...

Evolution of the Face3

And part of this world was Charles Darwin. I feel free to respect both God and evolution. We are unable to understand that our earth is 4.5 billion years old. How long is that Brian Bates and John Cleese have compressed the history of the earth into just 1 year. Life appears relatively early on the earth on 14 February. That is Valentine's Day. 1. The first living beings were bacteria, as almost the whole earth was under water. Some 580 million years ago there were...

Fourth Dimension of the Face

The most important surface full of secrets which we face is the face. It is curved and has its anatomical depth of muscles, nerves, vessels, fat tissues, and ligaments. But it also has a fourth dimension - its spiritual deepness reflecting our mind and soul. It is the tool expressing our emotions, thoughts and messages of surprisingly deep contents in endless floating nuances. We breathe, eat, drink, speak, and hear with the face. Four senses are concentrated here even the fifth - tactile sense...

Facelift Related Anatomy

Topography Facial Nerv

Anatom a clavis et clavis medicinae, said Gabriele Fallopio, Italian pioneer of anatomy. It is the key and helm of the whole medicine. Profound knowledge of anatomic variations is the prerequisite for any physician who is thinking of becoming a surgeon. We will pay attention especially to the topographic anatomy of the face. Epidermis - the upper layer of the skin - renews itself. In babies this process is completed within 7 days in our 70s, it takes 4-6 weeks. Below is the corium, which is...

Ageing Antiageing

Simone de Beauvoir wrote in her autobiography I hate my reflection in the mirror, a cap over my eyes, bags under them, the face too full, the mouth sadly tugged down, creating wrinkles. People who meet me see, perhaps, only a fifty-year-old, neither well nor badly preserved. She just has the age that she has. But I see my earlier face. Attacked by a plague from which I will never recover. Levy Strauss discovered that Nambiquara Indians have just one and the same word for young and beautiful and...

The Consequences of operating on Patients with BDD

Dysmorphic Concern Questionnaire

All surgeons have had or will have the unfortunate experience of operating on patients who become profoundly dissatisfied with the surgical outcome even when objectively the result is satisfactory. It is likely that many of these patients were not diagnosed with BDD prior to them becoming unwittingly operated on. A minor problem such as wound healing, scar, numbness or persistent bruising can trigger profound dissatisfaction or the BDD attack, No amount of encouragement or support will mitigate...

Eyelids

Fissure Surgery Stitches Pictures

The first type of skin to become wrinkled is the skin of the eyelids, because it is the thinnest skin of the entire human body. When we communicate with each other, we usually look each other in the eye. Lax eyelids do not allow the inner energy of a person, which is possibly present to a large extent, to become apparent such a person's capability and even vitality go unrecognized. Excessive reading, PC work, watching TV, working under neon-light illumination, and hereditary factors play a role...

Deep Mental Crease

Witch Chin Plastic Surgery

Fig. 56.1. a Wide chin turning the triangle of youth upside down. b Reversion of this triangle makes the appearance more feminine, and more youthful Fig. 56.2. a Submental skin excision with simulating cannula for liposuction above the skin. b Liposuction performed below the skin. Witch's chin c before and d after its correction performed together with face-neck-lift If the submental crease is too deep, we make skin excision. We cut the underlying slice of connecting and fat tissue so that a...

Aftercare61

Facelift Week

At the end of facelift surgery, we make a head net bandage. Some years ago we used a head and neck garment and observed frequent ecchymosis in the neck area now we have stopped doing this. There is no need for compressive bandages but we put some more gauze strips behind the ears as a small or big collection of residual blood can be expected there. When I started my career as a facelift surgeon, I spend almost a third of the operating time completing meticulous haemostasis - mostly through...

The Terrace Like Cranial Extension of the Temporal Prehairline Incision

Hairline Incision

If there is a bunching up of skin in the temporal area, the prehairline technique can be extended cranially by a stepwise superposition of fusiform skin excisions in the temporal zone and the lateral forehead 13, 17 . These complementary incisions are done without any skin undermining just to flatten down the skin cranial to the point where the prehairline sideburn incision ends, to redrape bunching-up skin higher up. To strictly avoid visible scars, it is of special importance that these...

Anatomy

Supra Labial Folds

The superficial plane just under the skin with a thin layer on facial fat of the skin flap does not correspond to a proper anatomical plane. Too many vessels especially of the subdermal plexus are divided. Anatomically the subadipose dissection encounters and damages far fewer of the important vascular elements and separates the two anatomical leaflets without injuring either of them (Fig. 44.6). A Trepsat dissector in different sizes (Fig. 44.7a, b) may be helpful to perform a wide undermining...

Eyebrow Manoeuvres

The form and position of the eyebrows signalize various moods. Knitted eyebrows and a lined brow betray worry and apprehension. If one eyebrow is lowered and the other raised, this pattern resembles a horizontal question mark and indicates suspicion. Eyebrows drawn obliquely together betray sorrow. A quick movement with the eyebrows is interpreted as a signal of greeting among humans. The lowering of eyebrows is seen as expressing an unpleasant surprise. Wide-open eyes indicate a real surprise....

Five Topographic Levels of the Face and Four Layers of Surgical Acting

Five topographic levels of the face Fig. 13.1. Five topographic levels of the face The perception of the countenance happens below the conscious level, but it is determinative for the intercourse of two human beings. Harmonious order of facial proportions can be divided in five facial lev- There are four layers of surgical acting 2. Skin with subcutaneous fat layer 3. Muscle-superficial musculo-aponeurotic system-muscle layer . .1,1 Fig. 13.2. Mona Lisa with mimic units There are...

More Conservative Open Frontal Lift

Even though the endoscopic frontal lift appeared to replace the traditional open techniques, the initial enthusiasm has been decreasing in the last few years. According to recent papers, in the USA half of the plastic surgeons still prefer the open techniques 2-5 . There are two standard open frontal lifts the in-tracapillary or coronal lift and the precapillary one 3 . In both, surgeons transect the galea and revert the frontal flap to treat the frontal, corrugator and proc-erous muscles 6-8 ....

Introduction Bioptron Phototherapy

The application of light as a therapeutic remedy has been known since ancient times. As early as in the age of ancient Egyptian culture, the beneficial action of sunlight on the human organism was noted. The favorable effects of polarized light rays were discovered during the studies of laser light rays, and in 1981 a group of Hungarian physicists and physicians 1-3 proved that polarized light has a stimulating effect on natural defensive and reparatory functions of an organism. Bioptron...

The Cosmetic Surgery Junkie

Up to 6-15 of patients presenting to the plastic surgeon for cosmetic surgery may suffer from BDD 13 . Patients previously operated upon, especially if multiple times and the patients are still dissatisfied, could likely be afflicted by BDD. The cosmetic surgery junkie is a red flag candidate. In rhinoplastic surgery, it is estimated that men are three times more likely to be dissatisfied with their surgery than women 7 . The outcome of cosmetic surgery for each patient must be judged in...

Prerequisites of the Surgeon

Ursula Schmidt Tintemann

Which qualities does the ideal surgeon require The ideal surgeon should - Posses a strong capacity for understanding and patience, both while operating and when listening to patients - Have undergone the right training, but also have kept abreast of the current literature after completing the specialist training - Attend congresses and courses at which the latest methods of treatment are demonstrated, and have work-shadowing experience with prominent surgeons who produce particularly good...

The Beautiful Neck

Artistically, the beautiful neck should be smooth and long. The platysmal muscle bands should not be apparent or be minimally visible. The submaxillary glands should be supported and hidden. The Adam's apple or laryngeal cartilage should be minimally defined. Fig. 11.3. A beautiful face. A summary of the measured parameters of a beautiful face. A beautiful face differs from a normal face in that it possesses uplifted angles and full, volumetric highlights. A The average width of the eye is 30.7...

An Overview of Surgical Strategy

Smas Scars

The surgical procedure described comprises a variety of designs, which must be applied as indicated by the patient's specific needs. Each patient will present with a unique set of problems, which require precise anatomical diagnosis and an appropriately planned and individualized repair. The SMAS and the platysma are used to reposition ptotic tissues and reestablish a more youthful cervico-facial contour and make a deep support to the submental area, which skin tension alone is not capable of...

Techniques for SMAS Utilization

Vector Zygomatic Arch

Experience has confirmed the utility of the SMAS in rejuvenating the face and it has come to be an integral part of many techniques. How the SMAS is used, however, determines its overall effectiveness, and not all procedures can be expected to produce equivalent results. Many techniques have evolved for utilization of the SMAS. These include Skoog or composite dissections in which the SMAS and skin are elevated as a single unit and advanced along the same vector, bidirectional dissections in...

Hydroxy Acids

Environ Quel Before After

AHAs have been the most misused and misunderstood molecules in skin rejuvenation. Very largely they are simply exfoliants and should mainly be used as penetrant enhancers. In patients with thick rough skin, AHAs have a place to help refine the skin. Once the natural qualities of the horny layer have been restored, then the use of AHAs should fall away. Care should be taken because they do impair the natural protection from the sun and they should always be used in conjunction with vitamin A....

Orbitomalar and Zygomatic Subperiosteal Detachment

The procedure begins with the subciliary approach. The lower-eyelid skin is undermined to approximately 1 cm to expose the orbicular muscle. On its lateral aspect, the orbicular muscle is opened to reach the orbital rim. The deep subperiosteal plane is reached and the arcus marginalis must always be respected. Tessier's periosteal elevator is introduced deeply to detach the totality of the orbital rim, the orbitomalar and the zygomatic areas. Special care must be taken to respect the...

The Double Ogee

The youthful face, when viewed at an oblique angle, maintains a characteristic volume distribution of its soft tissues, previously described in the midface by an architectural ogee or single S-shaped curve 10 however, on more precise examination, the entire contour the youthful face generates follows a double ogee or double sigma when analyzed in a three-quarter view. To view this reciprocal multicurvilinear line of beauty, the face must be viewed in an oblique position that allows...

Plane of Undermining and Incision Lines

Surgical Scar Healing Stages

When Performing a face-neck rhytidectomy, the first question will be which is the best plane to operate with the purpose of redistributing the various volumes and which will be the incision lines to get access to the tissues responsible for the volume displacement and alteration. Avoiding hairline distortion is a must in modern facial rejuvenation surgery. A facial aesthetic surgery creating a juvenile contour of the jawline but leaving a zone of baldness in the temporal hair is...

SMAS Elevation

The SMAS should be freed from below in two crucial areas. The parotid ligaments should be released as well as the malar ligaments. During surgery the repeated elevation of the SMAS will eventually determine the ideal point of release and exhibits an increased lower face elevation which will indicate the complete freeing of these ligaments. The suturing of the SMAS on the arch should be carefully performed in order to avoid injuries to the motor branch of the facial nerve. The SMAS should be...

Indications for Double Ogee Facial Rejuvenation

Patients with considerable aging and ptosis of the central facial structures can benefit most from our endoscopic approach. The eyebrows, eyelid commissures, nasoglabellar soft tissues, nose, nasolabial folds, cheeks, angle of the mouth, and jowls are effectively treated with this approach. Tear trough deformities as well as deep infraorbital hollows can be corrected with the endoscopic techniques. The endoscopic forehead and midface procedures allow recreation of the double ogee that is...

Double Ogee Facial Rejuvenation a Volumetric Approach

Double Facial

Traditional rhytidectomy techniques provide rejuvenation of the aging face through oblique and lateral lifting or through vertical and superolateral lifting maneuvers. These standard techniques address rhytid formation and skin laxity but fail to address the volumetric deflation that is characteristic of facial aging. In addition, these two-dimensional or dual-vector techniques often give patients an exaggerated windswept or operated appearance. By contrast, our approach addresses the...

Age Group

Darwin Tubercle

Proportion of face-lift cases Fig. 40.2. Proportion of face-lift cases tomical landmarks. Secondary face-lifts especially present elements that require different incisions. An earlier publication has established the indications and advantages of each different incision. Undermining of the facial and cervical flaps is performed in a subcutaneous plane, the extension of which is variable and individualized for each case. A danger area lies beneath the non-hair-bearing skin over the...

MIDI Facelift

Facelift With Tricuspidal Smas Flap

Looking tired is reason enough for many 35-45-year-olds to ask a plastic surgeon for prophylactic rejuvenation. They want to achieve good and long-lasting effects with harmonious features, small scars, and -as they are still very active in their professional and private lives - a quick recovery is very important for them. We have developed a modification of the short-scar facelift with solid deep support. We call it the MIDI facelift. MIDI stands for Minimal-Invasive, Deep-Intensive. The...

Malar Cheek and Orbicular Suspensions

Sum Lift Ergebnis

We first begin with the malar cheek suspension and we use a kind of Hagedorn needle specially described by Besins for this procedure. The M point Fig. 45.5 is used to insert the percutaneous suspension of the malar cheek Fig. 45.6 . The needle is inserted straight into the bone pinching the ptotic malar fat pad toward the outer corner of the eye incision, where the 2 Vicryl or Dexon threads are introduced. A roundtrip movement allows a thick grip without any dimples. The thread is carried to...

Direction of the Traction of the Cutaneous Facial and Neck Flap and its Resection

This step of the operation is done by pulling the cutaneous flap posteriorly and superiorly Fig. 39.13 . Using Pitanguy's forceps Fig. 39.13 to mark the projection of the incisions on the skin, we do a temporary determine the excess of skin to be resected. b An incision is done with scissors where a temporary stitch is carried out determine the excess of skin to be resected. b An incision is done with scissors where a temporary stitch is carried out Fig. 39.14. Peroperative photographs showing...

Periorbital Rejuvenation34

In managing periorbital ageing, one must evaluate the brow, the upper lid, the lower lid position, amount of skin, muscle and herniated fat pads , the anti-Mongoloid fissure, the wrinkles frontal, corrugator, pro-cerus, static and dynamic crow's-feet , the width of the forehead level of the hairline , the tear trough deformity and the very important position of the globe in the orbit enophthalmia . As we age, the hairline recedes and the brow comes down. The width of the forehead increases, an...

Microneedling of Skin

Not everyone can manage to have the specialised treatments of iontophoresis and sonophoresis, so mi-croneedling offers an important way for patients to enhance penetration. Minute holes are made through the stratum corneum only, so this is not a painful procedure. I have designed a special instrument to do this and patients are requested to use it daily before applying their skin care 3 . Significant improvement may be achieved in those patients who are diligent about using the tool every day...

Minimal Access Cranial Suspension Lift

Pre Auricular Fat

When different surgical techniques in plastic surgery and especially in facial rejuvenation surgery are compared, one is tempted to look only at the end result and not at the global risk-benefit ratio that should be considered with any intervention. Some interventions can lead to superb final results but this at the cost of a possibly high complication rate and a long postoperative recovery period. It is not always the most aggressive and extreme surgery that delivers the happiest patient....

Mini Facelift as Prophylactic Preservation of Youth

Acne Scars Facelift Photos

When we have situation where the neck skin is not very affected and the face could require some support, then we take into account only preauricular access for a so-called minilift. The deep layer, however, should be done well. For decades the majority of plastic surgery patients were older there is now an increasing number of younger patients in their mid-40s, sometimes even in their early 30s. The question occurs whether facelifting at such an early age is at all reasonable If we conduct...

The Beautiful Chin and Mandible

Artistically, the beautiful chin and mandible should be soft, slightly curved, and well defined. A delicate menton is associated with more feminine beauty. The chin should have adequate projection. The tip of the chin should just touch a vertical line, dropped from the nasion through the nasal spine and perpendicular to the Frankfurt plane. On frontal view, two attractive mental Faberge eggs, lying against one another should be seen centrally. The Faberge eggs at the angle of the jaw are...

Is the Result Long Lasting

Malar Implant

The result has proven to be long lasting for a minimum of 7 years and usually for more than 10 years as compared with the preoperative appearance Figs. 41.15-41.17 . Fig. 41.15. Seven years after vertical rhytidectomy of the periocular frame of the eyelids and midface, the oblique view shows improvement of the eyelids and of the oblique facial contour achieved by elevation of the soft tissues filling the submalar hollow contour and malar volume without the need of malar implants. The deep...

Flap Insetting

The redraped skin flap is closed with no tension whatsoever except for two anchoring points. The superior fixation suture anchors the cheek flap to the superficial temporal fascia, under moderate to high tension. A second suture anchors the more caudal portion of the posterior flap, to the mastoid fascia. The rest of the skin surface is sutured with essentially no tension. To emphasize a natural pretragal crease, a distinct depression is created by a through-and-through suture entering the skin...

Forehead and Midface Videoendoscopic Surgery

Nasojugal Fold

Ruth Graf, Daniele Pace, Luiz Roberto de Araujo Since the introduction of endoscopic brow lifting in the mid-1990s, videoendoscopic surgery has become widely accepted as a method for rejuvenation of the upper third of the face, mainly to achieve eyebrow and forehead elevation. It has many indications and it is performed to correct eyebrow ptosis and to treat glabellar rhytids created by corrugators, and depressor supercilii and procerus muscles. Several factors, including natural aging, facial...

Incisions Planning and Execution

Planning Incision

Our keys to fine scars are comprehensive preopera-tive planning, particularly regarding the auricular contour, the sideburn, the temporal hairline, and posterior scalp hairline, and flap inset with no tension. Today, our scars are only as long as necessary to directly correct an area that needs improvement. Any facelift incision should preserve the anatomic details of the ear and hairlines. The length, orientation and location of the temporal incision may vary, depending on individual...

Occipital SMAS Flap

Occipital Rotational Flap

If there is a need to provide support to the hyoid area or maximum support to submaxillary glands, an occipital transposed cheek SMAS flap may be useful 11 . A flap as wide as possible is made from the posterior margin of the SMAS flap by closure of the donor site before cutting the flap. The donor site closure is made from the posterior margin of the SMAS flap anterior to the tragus of the ear and below the mandibular angle Fig. 38.12 . This SMAS flap is rotated to the mastoid area and sutured...

Facelift in Males52

Huge Forehead Skin Grafts

For more than two decades the author's practice has been almost exclusively face and neck rejuvenation. The specialization has enabled concentrated evaluation of both primary and secondary results. The technique described for facial rejuvenation for men has been found to be safe, produces a natural-looking appearance and restores a lost handsome appearance or reveals pleasing masculine contours. The basic technique has been used for several decades and can be modified for each patient and as...

The Importance of the Superficial Musculoaponeurotic System in Rejuvenation of the Face

Smas Incisions

Skin is elastic and accommodates changes in the shape of our faces during movement and expression. It cannot provide sustained support for sagging deeper facial tissues Fig. 38.1 . Skin is a covering, not a support. The superficial musculoaponeurotic system SMAS is closely connected to sagging facial tissues and is a logical vehicle to reposition them. The SMAS is elastic and can provide a strong and sustained support of the midface, cheek and jowl and periorbital area Figs. 38.2-38.4 . Pulling...

Operative Instruments

Instrumentos Enfermeiros

Every surgeon is used to using certain instruments which he she learned to work with during his her training. Worldwide there are very competent manufacturers of surgical instruments, and facial plastic surgery is constantly developing. New ideas are growing and arising with every new generation of plastic surgeons. For each surgery a fundamental set of instruments should be packed into special containers and very common instruments are separately packed as single packages to be available if...

Correction of the Aging

Aesthetic Fascia

In the middle-aged patient, an elongated upper lip with loss of concavity, reduced vermilion, descent of the corner of the mouth and deep vertical wrinkles code bars show the real chronological age. The correction is performed by means of a complete skin undermining to the vermilion through a skin excision at the naso-labial junction and nostril base 20 . A trapezoidal graft of temporal subgaleal fascia is sutured at both naso-labial folds to cover the orbicularis oris muscle. An extra strip...

Utilization of Composite Rhytidectomy to Correct the Unfavorable Outcomes Following Facelift Surgery

Deeper Hollow Eye

If one examines the typical surgical appearance of patients who have had facelifts, it becomes easy to analyze the problems and why they result. The best way would be to understand the long-term changes of the vectors of conventional facelifts as shown in Fig. 42.11. If one judges the vectors of aging of patients in the standing position, they are the same for all humans and are predictable for every person after a certain age Fig. 42.11a . Without question the conventional facelift can create...

Bichats Fat Pad Excision

There are a subset of patients who present for facial rejuvenation that demonstrate chubby cheeks, significant bulk, and pseudoherniation of Bichat's fat pad, and good malar bone support. These patients benefit from excision of Bichat's fat pad rather than suspension. Dissection of the fat pad proceeds as previously outlined however, care must be taken during resection of the fat pad. Undue traction of the fat pad can result in injury to neurovascular structures and or Stensen's duct....

Forehead28

Rasparatorium Surgery

The upper third of the face is limited by the hairline above and the eyebrows below. The most powerful muscles, innervated by fronto-temporal branches of n. facialis, are m. frontalis and mm. corrugatores supercilii. The hyperaction of frontalis ingraves the horizontal wrinkles of concentration and corruga-tors produce vertical glabellar wrinkles of anger or worry wrinkles. The superficial wrinkles can be treated by peeling mechanical dermabrasion, chemical abrasion, laser abrasion, or by...

Symmetry of the Face

Chirurgie Esth Tique Corps Entier

Michelangelo acknowledged the Roman architect from the first century B.c. Vitruvius to be his teacher. And it was Vitruvius who said Symmetria forma absoluta est. The ultimate absolute shape is symmetry. Good healthy colour of skin, exuberant healthy hair, and symmetry are conditions which suggest health of a human being and this anticipates the capability of Fig. 8.1 a-e. High-grade asymmetry of a male patient who only wanted to symmetrize the nose. His left face seems to be 10 years older...

Dermography

Microlipofiling

It is possible to make drawings on the skin with special water-resistant felt pens. We have learned to use drawings in liposuction in different body areas because fat tissue has a different arrangement and form when we stand or lie. Also the face has a different shape when we are standing, lying on the back, or if we are in a forward prone position. As we grow older the changes will be more and more obvious. In breast surgery, we make drawings and markings when we plan surgery with the patient...

Anterior Nasal Spine Surgery

Nose Muscle

Ewaldo Bol var de Souza Pinto, Priscila C.S.P. Abdalla, Rodrigo P.M. de Souza, Eduardo Hentschel, Sergio Pita The study of the anatomy of the nasolabial region has been very important in the last few years because it has contributed to the aesthetic rhinoplasty concerning the search for harmony between the nose and the upper lip, and more importantly, the smile 1 . Inspired by other surgeons' experience in the treatment of Negroid nose, in which the substantial subperiosteal displacement for...

Liposuction in Face and Neck

Skin Fold Behind Ear

Since 1972 we have possessed a very simple and effective method of improving bodily contours through liposuction. The first person to attach a hollow can-nula to a vacuum machine was Ulrich Kesselring in Lausanne in 1972. The blunt tunnelling technique of liquid imbibed and anaesthetized fatty tissue was invented by Yves Gerard Illouz from France. The first cannulas were very robust, 1 cm in diameter. Now we have smaller-diameter cannulas - 5, 4, 3, 2, and even 1.6 mm - which allow us to do...

Partial Resection of the Submandibular Gland

Face After Submandibular Gland

As our skills at facial rejuvenation have advanced, so has our attention to the submental area in our aesthetic assessment and surgical approach 1, 3 . Despite thorough preparation and the best surgical efforts, the rejuvenating results of a neck lift and platysma-plasty can be marred by ptotic or enlarged subman-dibular glands. Unnoticed preoperatively, following the effects of skin muscle tightening and fat resection in the aged neck, previously undetected ptotic or enlarged submandibular...

Autologous Fat Transfer

Penis Fat Pad

Charles Conrad Miller from the USA described his method with infiltration of fatty tissue through hollow metal cannulas in 1926. He wrote The end-results in free fat transplantation depend, aside from various local and general factors, on the method and technique. As Miller was some kind of controversial physician and not a real surgeon, his work was soon forgotten. The reinventor of this method was Yves Gerard Illouz known as the father of liposuction from France, but the real breakthrough was...

Endoforehead Procedure

The endoscopic forehead procedure involves the placement of four incisions in the scalp Fig. 43.3 . The first two incisions are located approximately 2.0 cm on either side of the midline, 1.0-2.0 cm posterior to the hairline. For patients with excessively long foreheads more than 8 cm , these paramedian incisions are placed directly at the hairline. It is important to keep the forehead incisions as anterior as possible. Otherwise, visualization and dissection in the glabellar region will be...

The Subperiosteal Browlift

Glabella Muscle Cut

Most surgeons today practicing aesthetic surgery advocate an endoscopic subperiosteal technique for elevation of the brow and elimination of the glabella furrows and wrinkles 1-10 . The reason for this is of course the ability to avoid the bicoronal scar with possible hair loss 7, 11 , the avoidance of transection of the supraorbital nerves and the subsequent numbness of the scalp behind the scar. The transection of the supraorbital nerves at the incision is also believed to be the cause of a...

Skin Incision and Dissection in Primary Cases

Retroauricular Sulcus Define

The preauricular portion of the U incision is marked from the edge of the tragus upward along the root of the helix and then vertically into the hair-bearing area for approximately 5 cm along the axis of the tragus. The incision is designed with a gentle curve to become horizontal, stopping at 1 cm from the frontal hairline Fig. 47.1 . Fig. 47.1. The vertical U incision. Vertical in the temporal area above the ear, and vertical as well in the retroauricular sulcus, continuing in the scalp,...

Inherent Contradiction in Facelift Operation

Facial Contradiction

Usually, in a facelift operation performed for rejuvenation, drooping cheeks are eliminated by pulling drooping soft tissue back and upward. In this method, a contour is corrected into a round shape to a certain degree, and wrinkles and irregularities on a facial surface are decreased. But by pulling soft tissue backward, the hairline of a forehead in a front view is not only retreated, but sideburns in a profile view are also retreated thus, an enlarged facial surface unavoidably results Fig....

Biplanar Face Lift

Malar Fat Pads

Different vectors for skin and superficial musculo-aponeurotic system SMAS redraping are useful in order to achieve an efficient and natural face lift. Our technique fulfills the rotation and advancement concept described by Millard 16 for cleft-lip repair. In the cure of a double-chin pelican's neck, the SMAS is rotated up and inward, the platysma is advanced toward the mastoid area and pulled backwards after being freed. We have used this technique since 1975, and are greatly indebted to...

Secondary Facelift

Recovery Facelift Stages

Even celebrities in our profession - the best plastic surgeons in the world - are not able to stop the biological clock. Very good results after rejuvenative procedures are subject to the ageing process and these faces will lose their freshness and attractiveness as time goes by. In well-performed rhytidoplasties we will have fewer problems from facelift surgery, even after 15 or 20 years. Sometimes it could be sufficient to perform only a mini or a minimal-invasive, deep-intensive MIDI...

Rhytidoplasty Step by Step

Retroauricular Nerves

Volumetric sculpturing of the lower two thirds of the face and neck is the contemporary attempt to beautify the facial appearance which has been called for many decades classic facelift. Since the 1970s we have done it in two layers, including superficial musculo-apo-neurotic system SMAS manoeuvres, and since the early 1990s the third dimension has been included and we have started to think and act volumetrically. At home, before coming to the clinic or office, patients are advised to take...

Facial Analysis

Facial Symmetry Analysis

Many anthropometric rules have been related to the face since ancient times. There is a relation between the whole body and the head, or the face. The head should have an eighth of the body length and the face a tenth of it. Leonardo da Vinci in his Trattato della Pittura gives the relations of the nose, ear, and thumb - they should have the same length. Also Leonardo's quadrangle incorporates the nose and ear in profile and should have edges of the same length. The Frankfurt line goes through...

Tunnelization

Left Side Right Side Face Comparison

After liposuction itself or when creating small tunnels with a cannula without suction, we start tunnel-ization with nontraumatic instruments with progressive width, specially developed for this purpose Fig. 39.5 . These instruments are introduced one by one - first the thinnest one Fig. 39.6 and then progressively a wider one Fig. 39.7 until the widest one Fig. 39.5. Surgical instruments specially developed to perform rhytidoplasty. 1 An instrument similar to an Illouz cannula, but without an...

Submental Manoeuvres

Submental Muscle

Mostly we can achieve fairly good definition of the mento-cervical angle by lateral mobilization and fixation of skin and platysma and by liposuction of the submental region. Sometimes, however, it will not be enough to harmonize the entire neck. We can excise a spindle-like part of the submental skin and subcutaneous fat to tighten the skin. If there are platysma bands with muscle fibres we can mobilize them, cut them, or suture them together. We can provoke the real platysma bands by asking...

Volumetric Maneuvers Below the Jawline Fine Tunneling and Superficial Liposuction

Submental Area

In the late 30s or early 40s with the beginning of the early stage of jowling, a wide soft-tissue undermining is not yet required. A detachment in the deep subcutaneous layer limited to the midcheeck and the lateral third of the neck combined with a submandibular and submental superficial liposuction 9 will provide a regular clean jawline with flattening down of the jowls Figs. 44.1 . The surgery is performed under general anesthesia with intravenous Propofol, the headrest allowing a smooth...

Malar Crescent

The malar crescent Fig. 42.12 is an obvious topographical landmark that cannot be corrected without repositioning the total orbicularis oculi muscle. The malar crescent is the inferior portion of the orbicu-laris oculi muscle which is never moved in conventional facelift techniques. If it preexists, it will become more obvious after facelifts. Strong vectors created by malar fat procedures can create what appears to be a crescent that was not present prior to surgery. This deformity can be...

Treatment of the Superficial Musculoaponeurotic System

The treatment of the SMAS is performed according to the surgical planning when the surgeon evaluates the degree of muscular flaccidity. Usually when the pla-tysma muscle is flabby one can see its border laterally and medially Fig. 39.11 . After the tunnelization procedure the lateral border of the platysma is pulled using fine forceps with- Fig. 39.11 a-f. A 75-year-old patient presenting abundant surgery. d, e, f One year after rhytidoplasty with plication of wrinkles with skin and muscle...

The Beautiful Cheek

Artistically, the beautiful cheek is one of the most important and attractive facial features. For centuries, this beautiful eminence has been highlighted with makeup and festive painting. The beautiful cheek should be well defined, full, and ovoid like a definite highlighted egg. The peak of the highlighted cheekbone or malar eminence should be high and full. The full egg volume should be sitting at an angled position, marked from the upper lip to the upper ear with its pointed end toward the...

The Lateral Sweep

The lateral sweep Figs. 42.11c, 42.16 continues to be a postfacelift deformity which is most recognized by the lay public. This is an appearance seen frequently at affluent social gatherings since it is the affluent population of the USA that has undergone most facelift procedures. It is an appearance most often recognized by people and seen frequently by celebrities and is usually called the pulled look. It is an appearance that seems more obvious in patients with sun-damaged skin or excessive...

Secondary Cases

In secondary cases, the same technique can be applied. In the temporal area, the same flap is elevated with the same downward shift minimal or no resection of the scalp at the upper part is necessary. In the retroauricular area, when the primary transversal retroauricular scar is of good quality, one can ignore the old scar and perform a vertical incision as if it were a primary case. Apart from occasional adhesions Fig. 47.8. Secondary cases. Left When the old transversal scar is of good...

Evaluation of 100 Cases

Top Reconstructive Ear Surgeons

The vertical approach has been used since April 2000. The first 100 cases 4 , from April 2000 to July 2001, were carefully evaluated and the results are as follows. The 100 consecutive patients, ranging in age from 44 to 80 years, were operated on either for primary or secondary face lifts. The subjects included 94 women and six men. Total excision of excess cervical skin ranged from 6 to 14 cm, with an average of 8.4 cm i.e., 4.2 cm on each side . The distance between the retroauricular sulcus...

Discussion

In both the temporal and the retroauricular areas, we favor a technique of wide undermining and repositioning of tissues with very limited skin and scalp resection. It is more a redistribution than a resection. In the temporal area, the backward displacement of the hairline is no longer acceptable. The precapillary incision is the old way to avoid compromising the hairline. Studies by Connell 8 , Camirand 9 , and Cami-rand and Doucet 10 , have shown that a precise technique can produce...

Looking at a Face Using a Scientific Approach

Mentocervical Angle

Technological advances in the military have given pilots the ability to look at an imaginary computerized windshield and to know the exact location and position of their targets. Special helmets and eyeglasses can measure exactly where a pilot looks. Similar technology can be used in determining where we look when looking at a beautiful face. Visually, we perceive light highlights and dark shadows as shapes. This perception allows us to assess the position, volume, and shape of objects. We are...

Eyelid Eversion

Eyelid eversion occurred in seven cases. The incidence fell from 12 in the first 50 cases to 2 in the following 50 cases and to zero in the next 50 , thus showing the importance of the learning curve at the onset of this complication 6 . The eyelid eversion always appears early, within 3 weeks seven cases . Two kinds of eyelid eversion are commonly described ectropial evolution by excess skin excision and ectropial evolution by orbital septum retraction with a worse prognosis. In the first 50...

Differences in Technique

Because of the confusion in various words in the facelift literature, both patients and surgeons may not have a clear understanding of the potential result of various techniques since descriptions have overlapping meanings. Historically, one thinks of the traditional facelift as a subcutaneous dissection where the skin is lifted off the deep structures of the face and redraped in a superior lateral vector. In the mid-1970s the tension was directed to the platysma muscle of the lower face in the...