Composite Repositioning

In conventional rhytidectomy one utilizes a lateral vector, which allows a surgeon to do a facelift without a blepharoplasty since the skin can be redraped toward the temple or helix of the ear. This is impossible in composite rhytidectomy since the strong superior medial movement of the upper face dictates a superior movement of the forehead. As discussed earlier, there are three distinct mesenteries (Fig. 42.7) created that contain the facial nerves. Because of the theory of mesentery movement, the surgeon can effectively move the tissues of the face in an uninhibited fashion (Fig 42.7b) which is done in a superior medial direction rather than in a vertical or superior-lateral direction. The meso-temporalis mesentery has long been recognized and is it contains the frontal branch of the facial nerve. The meso-zygomaticus and meso-mandibularis are unique to the composite facelift. As opposed to the composite movement of the SMAS, malar fat, and orbicularis muscle, the neck continues to be done much like the original triplane facelift procedure except that much more vertical movement can be accomplished in the lower face area at the junction of the face and neck. Since the dissection is in a preplatysmal plane the amount of fact that is present can be evaluated after elevation of the flap and then defatting can be done with a scissor technique. Following defatting and reapproximation of the anterior bands, the neck skin is redraped in a posterior direction, while the skin and muscle of the jowl and lower face are moved in a more superior direction. The pla-tysma of the neck is moved in a medial direction toward the midline. One should remember that the evaluation of the aging neck is done when the patient is in a standing position and it is the gravitational force of aging that creates the midline looseness of the neck which one can correct with excision of extra muscle and fat and approximation of the platysma bands.

Subperiosteal Facelift
Fig. 42.8. The origin of the zygomaticus muscle does not change following a composite facelift. The origin does change following subperiosteal cheeklift or facelift by widening the soft tissue intermalar distance, which thereby changes the patient's appearance. (Courtesy of S. Hamra, Dallas)

The more impressive and predictable results with composite facelifts have been accomplished since 1996 after development of the zygorbicular dissection of the midface. Subperiosteal facelifts may create the appearance of a more widened inframalar distance owing to repositioning of the origin of the zygomaticus major and minor (Fig. 42.8). This will not occur with composite rhytidectomy. In composite rhytidectomy, the origin of the zygomaticus musculature is not disturbed as the zygorbicular flap dissection extends both medial and lateral to the osseous origin of the zygomaticus major and minor. As the muscle origin stays intact, the meso-mandibularis and meso-zy-gomaticus allow composite movement of the orbital area in a superior medial direction.

While subperiosteal dissections are of great benefit in secondary facelifts requiring reconstruction of the lower eyelid, they are not routinely practiced in composite facelift since the tissues of the face appear to reveal more aging of the skin down to fat and muscle rather than the periosteum. While the periosteum does furnish a strong platform for movement of the cheek, the stretch of the soft tissues of the zygorbicu-lar flap create a normal and softer appearance of the upper cheek and lower eyelid.

The rejuvenation of the face following composite facelifts can produce a very harmonious appearance (Fig. 42.9) [2] The best way to assay the effects of reju-venative facelift surgery is with a half-and-half photograph showing the preoperative hemiface juxtaposed with the postoperative same-side hemiface photograph as shown in Fig. 42.9. Up to this point there has been no quantitative procedure to evaluate facelift results. Because of the harmonious appearance of the youthful orbit as seen in the frontal views, a very definite difference can be now understood between conventional rhytidectomy and composite rhyitdectomy. Following conventional rhytidectomy, there will be no changes in the vertical height of the soft tissue orbit. If malar fat procedures or a SMAS procedure is utilized with a conventional blepharoplasty, one cannot achieve a shortened vertical height of the lower eyelid. Moreover, if lower eyelid fat is removed it is quite possible that a normal concave lower eyelid will appear more hollow, which will never be the case with preservation of the lower-eyelid fat in composite rhytidectomy (Fig. 42.10).

Arcus MarginalisArcus Marginalis ReleaseArcus Marginalis
  1. 42.9. a Preoperative patient with a negative lower-eyelid vector with typical signs of aging. b Postoperative primary composite facelift, browlift and blepharoplasty with arcus marginalis release. All orbital fat was preserved. c Preoperative right hemiface compared with postoperative right hemiface. d The hemiface comparisons prove that all three zones have been rejuvenated significantly for facial harmony. (Courtesy of S. Hamra, Dallas).
  2. 42.9. a Preoperative patient with a negative lower-eyelid vector with typical signs of aging. b Postoperative primary composite facelift, browlift and blepharoplasty with arcus marginalis release. All orbital fat was preserved. c Preoperative right hemiface compared with postoperative right hemiface. d The hemiface comparisons prove that all three zones have been rejuvenated significantly for facial harmony. (Courtesy of S. Hamra, Dallas).
Orbital Fat Transfer Photos
Fig. 42.10. A preoperative view of a 44-year-old with normal signs of aging. One-year post-operative views showing no signs of underlying orbital anatomy following arcus release and septal reset in composite facelift. Hairline forehead lift narrowed the hairline 2 cm.
Arcus Marginalis Release

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