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Temporofrontal Branch Facial Nerve
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 temples, that we have called "no man's land," where most of the temporo-frontal branches of the facial nerve are more frequently found. Dissection over "no man's land" should be superficial, and hemostasis carefully performed, if at all. Larger vessels should be tied (Fig. 40.4).

The treatment of the very heavy, fatty neck requires that the dissection proceed all the way to the other side under the mandible. With the advent of suction-assisted lipectomy, submental lipodystrophy is mostly addressed by liposuction, in a crisscross fashion

(Fig. 40.5). Sometimes this is still done with direct li-pectomy using specially designed scissors, defatting the submental region, as has been described historically. Following this, treatment of medial platysmal bands is carried out under direct vision. Approximation of diastasis is done with interrupted sutures, pli-cating down to the level of the hyoid bone.

Undermining of the facial flaps is extended over the zygomatic prominence to free the retaining ligaments of the cheek. Dissection of the deeper elements of the face has evolved over the past 20 years. Almost no treatment was advocated before the publications that first described the superficial musculo-aponeu-rotic system (SMAS). The approach to this structure has been a topic of much discussion. Currently, we determine whether to dissect or simply plicate the SMAS only after subcutaneous dissection has been completed. Pulling of the SMAS is done, noting the effects on the skin (Fig. 40.6).

Fig. 40.3. The classic incision, as described for the round-lifting, curves around the anatomical landmarks, and finishes in a sinuous italic S in the cervical scalp
Fig. 40.5. Liposuction has been useful to complement a facelift, and permits the removal of fatty tissue from the cervical region. This maneuver should be done in a crisscross fashion to assure an even plane of subcutaneous tissue
Fig. 40.4. The variation in the anatomical distribution of the frontal branch of the facial nerve determines an area termed by the author as "no man's land," where this nerve is particularly vulnerable to lesion by electrocoagulation
Darwin Tubercle
Fig. 40.6. After appropriate dissection is complete, the superficial musculo-aponeurotic system (SMAS) is pulled superiorly to check the effect of pulling on this structure
Pulled Tragus After Facelift
  1. 40.7. Plication of the SMAS and repositioning of the malar Fig. 40.8. The round-lifting technique describes the direction pad is done after subcutaneous dissection has been completed of traction of the anterior or facial flap, which follows a vector that connects the tragus to Darwin's tubercle. Excess tissue is marked with a Pitanguy flap demarcator
  2. 40.7. Plication of the SMAS and repositioning of the malar Fig. 40.8. The round-lifting technique describes the direction pad is done after subcutaneous dissection has been completed of traction of the anterior or facial flap, which follows a vector that connects the tragus to Darwin's tubercle. Excess tissue is marked with a Pitanguy flap demarcator
Darwin Tubercle

Fig. 40.9. A key suture is placed at point A to maintain the facial flap

Although extensive undermining of the SMAS was performed in an earlier period, it has been noted that plication of this structure in the same direction as the skin flaps, with repositioning of the malar fat pad, has given satisfactory and natural results (Fig. 40.7). The durability of this maneuver is relative to the individual aging process. Tension on the musculo-aponeurotic system allows support of the subcutaneous layers, corrects the sagging cheek and reduces tension on the skin flap.

Techniques that treat the pronounced nasolabial fold include traction of skin flaps, the SMAS, or the fascial fatty layer, with variable results. Filling with different substances may also be done at the end of surgery, either with fat grafting or other material. Direct excision of the nasolabial fold is reserved for the older male patient. In very selected cases this technique gives a definite solution to the nasolabial fold, with a barely noticeable scar that mimics the nasola-bial fold itself.

The direction of traction of the skin flaps is a fundamental aspect of the round-lifting technique. In this manner, the undermined flaps are rotated rather than simply pulled, acting in a direction opposite to that of aging, and assuring a repositioning of tissues with preservation of anatomical landmarks. A second advantage in establishing a precise vector of rotation is that the opposite side is repositioned in the exact manner.

This vector of traction connects the tragus to Darwin's tubercle for the facial - or anterior - flap. A Pitanguy flap demarcator is placed at the root of the

Pitanguy Demarcator
Fig. 40.10. The posterior flap has been rotated and fixed at Fig. 40.11. Excess facial skin is demarcated with no tension on point B, assuring continuation of the cervical hairline the flap

helix to mark point A on the skin flap (Fig. 40.8). The edge of the flap is then incised along a curved line crossing the supra-auricular hairline so that bald skin, not pilose, is resected. A key suture is located here (Fig. 40.9).

Likewise, the cervical flap should also be pulled in an equally precise manner, in a superior and slightly anterior vector of traction, to avoid a step-off of the hairline. Key stitches are placed to anchor the flap along the pilose scalp at point B so that there is no tension on the thin skin at the peak of the retro-auricular incision (Fig. 40.10).1

Only when the temporary sutures have been placed will excess facial skin be resected. Skin is accommodated and demarcated along the natural curves of the ear, with no tension whatsoever (Fig. 40.11). Final scars are thus not displaced or widened. The tragus is preserved in its anatomical position, and the skin of the flap is trimmed so as to perfectly match the fine skin of this region.

When performing a brow-lift, placing these key sutures at points A and B is mandatory before any traction is applied to the forehead flap, essentially "blocking" the facial flaps (Clinical Cases 40.1-40.3).

1) The effects of the round-lifting technique have been studied by analyzing the mechanical forces applied and the displacements produced. The method of finite elements was employed and, by means of computers, the relevant equations were defined. Human skin was modeled as a pseudo-elastic, isotropic, noncompressible and homogeneous membrane, and a computational study of the fields of displacement and the forces applied to the flaps during a rhytidoplasty demonstrated that the direction of traction creates areas of tension that can be either negative or positive. These forces ultimately result in the correction of signs of aging. Interestingly, the vectors described in the round-lifting technique address both the main features that suffer distortion with aging as well as maintenance of anatomical parameters. Although there were limits owing to the variety of factors involved because of the complexities of human skin (basic properties and individual variations), the study holds a close parallel to a real surgical procedure.

Clinical Case 40.1. A round-lifting procedure was performed in this 41-year-old woman, with a simple plication of the superficial musculo-aponeurotic system. Left: The patient is seen pre-operatively. Right: The patient is seen at 18 months follow-up

Clinical Case 40.2. Submental lipectomy was a primary concern in this 58-year-old patient. This was done by ample liposuction, together with a round-lifting technique to reposition facial and cervical tissues. Left: The patient is seen preoperatively. Right: The patient is seen at 2 years follow-up

Clinical Case 40.3. Male patients are seen more frequently in the office of the plastic surgeon, and many seek rejuvenation procedures. This 63-year-old man was submitted to a face-lift with blepharoplasty, with special attention given to correction of platysmal bands. Left: The patient is seen preoperatively. Right: The patient is seen at 2 years follow-up

Clinical Case 40.3. Male patients are seen more frequently in the office of the plastic surgeon, and many seek rejuvenation procedures. This 63-year-old man was submitted to a face-lift with blepharoplasty, with special attention given to correction of platysmal bands. Left: The patient is seen preoperatively. Right: The patient is seen at 2 years follow-up

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