An Overview of Surgical Strategy

The Scar Solution Natural Scar Removal

Scar Solution Book By Sean Lowry

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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 producing.

The skin and the SMAS are elevated independently, and the SMAS is advanced along a mostly superior vector. Composite tissue shifts do not permit the restoration of the beauty of the patient's younger face and neck as well as separate skin and SMAS flaps.

Additional modifications are made to the platysma and other deep-layer structures, including the orbicu-laris oculi muscles, submandibular glands and digastric muscles, when indicated. If problems of these structures are not identified and addressed, improvement will be compromised (Fig. 38.9).

Skin is redraped under normal tension along diagonal or posterior vectors. Skin tension is unnecessary for rejuvenating the face. Dismissing the skin tension concept exists as a major stumbling block to achieving a natural postoperative appearance (Fig. 38.5b).

Skin is trimmed in such a manner that wound edges touch and no gaps are present before sutures are placed to make one-layer closure, which approximates the deep and superficial skin edges without any buried suture. Support of ptotic tissue and improvement in face and neck contour are by modification of the SMAS, platysma and other deep-layer structures, and not by pulling on the skin. The use of incisions along hairlines, rather than within the scalp, may prevent objectionable hairline displacement. Hairline displacement is a major shortcoming of poorly planned incisions and is a common cause of unnatural appearances. Incisions made along hairlines will result in scars, which are usually difficult to detect once healed when deep-layer support is provided by the SMAS and skin incisions are carefully planned, placed, made and closed under no tension. A fine scar along the hairline is less noticeable and is preferable to deforming hairline displacement.

The SMAS, which has been used for more than two decades, is safe and can restore a natural youthful appearance as well as produce new, beautiful contours. This basic technique is modified for each patient and for each side of the face according to the specific and precise anatomical findings. The patient's younger photographs are reviewed for designing a natural-appearing surgical rejuvenation [1-3].

  1. 38.9. a The transverse sausage like fullness in the submental area is typical of a very large anterior belly of the digastric muscle. b A face and neck lift using a high SMAS flap and a rotated flap from anterior to the ear under the angle of the jaw and sutured to the mas-toid area along with tangential excision of 90% of the large anterior belly of the digastric muscle
  2. 38.9. a The transverse sausage like fullness in the submental area is typical of a very large anterior belly of the digastric muscle. b A face and neck lift using a high SMAS flap and a rotated flap from anterior to the ear under the angle of the jaw and sutured to the mas-toid area along with tangential excision of 90% of the large anterior belly of the digastric muscle

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/'¿/¿.!t^try' A - SMAS temporal Transposition flap

B = Centra! SMAS flap C = SMAS mastoid transposition flap

Fig. 38.10. On rare occasions when the transverse transection of the SMAS at a high level does not permit a precise vector to elevate the angle of the mouth, upper nasolabial fold and nasojugal groove, a third flap can be made from the upper portion of the SMAS to move to the desired precise vector needed for elevation. Excellent surgeons use this design for almost all facelift patients

Unfortunately utilization of the SMAS for rejuvenation is not an easy surgical technique. Skill for precise separation of the overlying tissues from the SMAS is essential [4]. This dissection must neither thin the SMAS nor injure the subdermal plexus of arteries and veins. The SMAS is always thick enough to hold sutures unless the dissection thins or removes some of the SMAS while elevating the skin flap. If during the surgical dissection the ability to recognize the SMAS layer and to precisely surgically uncover the intact SMAS is lacking, then some other less efficient technique for deep-layer support must be used [1, 5].

For all except those with only excessive skin, a satisfactory facelift result requires modification of the deep-layer support composed of the SMAS, which in cludes fascia and the platysma [6-8]. When utilized appropriately, the SMAS will move cheek fat into the eyelid-cheek depression and change the direction of the nasojugal groove from diagonal of old age to horizontal as it was at a younger age (Figs. 38.3, 38.10).

Rotation and posterior-superior cheek SMAS shift can provide support to the cheeks, restore the jowl fat to the youthful cheek contours, eliminate the hanging jowls, flatten nasolabial folds and even form a sling support to the submental area across the midline between the hyoid and chin (Fig.38.5). If the transverse incision of the SMAS is made over the upper part of the zygomatic arch, a very good support to many additional areas is possible. These areas include the or-bicularis oculi and orbital septum, nasojugal groove, movement of cheek fat into the depressed lid-cheek junction, the upper nasolabial fold, and exposure of more vermillion of the lateral upper lip. Also, elevation of the angle of the mouth can change a down-in-the-mouth or "fish mouth" to a more pleasant and content appearance [9, 10].

Patients with vertically short platysma muscles or tight bands are treated by muscle interruption and release at the level of the cricoid cartilage. The vertical SMAS incision overlying the parotid is about 1 cm anterior to the ear and continues to become the pla-tysma incision anterior to the sternocleidomastoid muscle. When complete platysma transection is planned, the incision is passed within the approximately 1 cm wide avascular area anterior to the anterior border of the sternocleidomastoid muscle and crosses the neck at the cricoid level. Usually anterior submental platysma muscle invagination is planned. Approximation of the platysma muscle completes the three-vector sling formed by upward cheek-SMAS shift and rotated SMAS flap to mastoid fascia [11].

Bulges in the submental area must be assessed as to bands or sagging platysma muscles, fat, digastric muscles or submandibular glands (Figs. 38.9; 38.11) [12]. As indicated by the anatomical findings, the SMAS sling support is used for sagging platysma muscles, transection for platysma bands, partial excision of fat and submandibular glands and tangential transection of large digastric muscles [13]. The osseo-cutaneous connections of the mandibular ligament and mental crease should be completely liberated for the SMAS support to extend to the midline of the chin and submental area (Fig. 38.11).

Smas Scars

Fig. 38.11. a The best rejuvenation of the face requires release of the mandibular osseocutaneous ligaments. This ligament permits the jowl to fall over this osseocutaneous connection. Release not only enables a better smoothing of the tissues extending to the midline of the chin, but also prevents the jowl from falling over this connection as the patient ages. b A submental incision behind the submental crease is mobile for inspecting the anterior belly of the digastric muscle and the submaxillary glands as well as for making a transection of the platysma muscle at the cricoid. c The osseocutaneous connections from the chin, which not only form the submental crease but also make other wrinkles in the anterior face, are always released from a subcutaneous position by scissor dissection

Fig. 38.11. a The best rejuvenation of the face requires release of the mandibular osseocutaneous ligaments. This ligament permits the jowl to fall over this osseocutaneous connection. Release not only enables a better smoothing of the tissues extending to the midline of the chin, but also prevents the jowl from falling over this connection as the patient ages. b A submental incision behind the submental crease is mobile for inspecting the anterior belly of the digastric muscle and the submaxillary glands as well as for making a transection of the platysma muscle at the cricoid. c The osseocutaneous connections from the chin, which not only form the submental crease but also make other wrinkles in the anterior face, are always released from a subcutaneous position by scissor dissection

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