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 manner of Skoog [1]. Skoog is clearly the first surgeon who developed the technique where the deep structure was moved as well as the skin. In the Skoog technique the skin of the lower face remains attached to the platysma of the lower face, which he called superficial fascia. Lemmon and Hamra [2] presented the only large series of Skoog facelifts which was done between 1973 and 1978. Following the basic principles of the Skoog technique, Tessier coined the expression superficial musculo-aponeurotic system (SMAS) and Mitz and Peyronie [3], working under the direction of Tessier published the paper on SMAS techniques.

Following the emphasis on neck procedures in the early 1970s the second step in the development of composite rhytidectomy was the triplane facelift technique [4] published in 1982. In this technique, the Skoog flap of the face is separated from a preplatysma neck dissection . The maintenance of the meso-man-dibularis mesentery separated the face from the neck dissections since the neck dissection was preplatys-mal and the face dissection was subplatysmal. This mesentery was a structure that included the rami-mandibularis but allowed movement of the neck and

Fig. 42.1. Traditional facelift. The direction of lift in the traditional facelift is singular and lateral toward the ear. This is the only direction of pull. (Courtesy of S. Hamra, Dallas)

TRADITIONAL FACELIFT

Fig. 42.1. Traditional facelift. The direction of lift in the traditional facelift is singular and lateral toward the ear. This is the only direction of pull. (Courtesy of S. Hamra, Dallas)

Fig. 42.2. Composite facelift. The composite facelift direction of lift is multidirectional and oblique toward the eye and ear rather than just toward the ear. The movement of the cheek returns the aging eyelid muscle and cheek fat to their original positions, preventing the pull toward the ear. The forehead also is lifted up. (Courtesy of S. Hamra, Dallas)

COMPOSITE FACELIFT

Fig. 42.2. Composite facelift. The composite facelift direction of lift is multidirectional and oblique toward the eye and ear rather than just toward the ear. The movement of the cheek returns the aging eyelid muscle and cheek fat to their original positions, preventing the pull toward the ear. The forehead also is lifted up. (Courtesy of S. Hamra, Dallas)

face tissues without inhibition owing to the principle of mesentery movement. In 1985, the third structure in composite rhytidectomy was included, which was the fat overlying the zygomaticus major and minor muscles. It was clear that the safety of elevation of the fat overlying the muscles allowed inclusion of the cheek fat or "malar fat" in the deep subcutaneous plane facelift flap which now included the fat of the naso-labial fold and the platysma muscle and the skin. This technique, which was called a deep plane facelift [5] was published in 1990 and ushered in an era of "malar fat" procedures championed by many authors and surgeons [6-10]. Thus, when one mentions conventional facelifts they may be subcutaneous lifts, SMAS lifts or deep plane facelifts. It should be noted that these are all lateral vector facelifts and in spite of various names and acronyms all basically accomplish the same correction of the face from the bottom portion of the soft tissue orbit to the jawline. Thus, when one uses the term "conventional facelifts" the reference will include either subcutaneous facelifts, or deep plane (malar fat) facelifts or SMAS lifts, as seen in Fig. 42.1.

It was at this point in 1990 that the continuation of the evolution of the composite facelift took a major turn away from the conventional technique. In 1992 the composite [11, 12] facelift was published which incorporated the orbicularis oculi muscle with the facelift flap so that the orbicularis, malar fat, and platys-ma muscle would all be left with the skin and the repositioning of all three deep anatomical parts of the aging face could be accomplished while maintaining their intimate relationship with one another. One should remember that when the surgeon or the patient simulates a facelift by putting pressure with their hands on the face in an upward direction, they are essentially doing a composite movement of the underlying tissues rather than just a movement of skin lift or a deep plane facelift. When one thinks in terms of a composite facelift, the vectors are dramatically different from the vectors of a conventional facelift since there is a strong superior medial vector of the upper face (Fig. 42.2) and an obligatory medial vector of the forehead lift as opposed to the superior lateral vector of the face with conventional facelifts or conventional forehead lifts.

Even though the orbicularis muscle became the fourth part of the composite facelift there was still a suboptimal lower eyelid created by conventional blepharoplasties whether transconjuncital or trans-cutaneous, since conventional lower blepharoplasties have always called for removal of some of the lower-eyelid fat. (Fig. 42.3) In 1995 the lower eyelid fat was preserved with a technique called the arcus margina-lis release [13] that advocated repositioning the lower-eyelid fat over the orbital rim. (Fig. 42.4). In this way the junction of the lower eyelid and cheek could be totally camouflaged, achieving a much more youthful contour of the upper face. As the composite facelift continued to be developed, the zygomaticus musculature was included with the orbicularis movement with development of a zygomaticus-orbicularis flap

Fig. 42.3. Traditional blepharoplasty. In traditional facelifts, the lower-eyelid lift, or lower blepharoplasty, is optional. Typically, in a lower-eyelid procedure, the fat pads that cause puffines are removed without regard to the possible long-term effects. Over time, this wholesale removal of fat can create a hollow or concave appearance of the eye. (Courtesy of S. Ham-ra, Dallas)

TRADITIONAL BLEPHAKOPLASTY

Fig. 42.3. Traditional blepharoplasty. In traditional facelifts, the lower-eyelid lift, or lower blepharoplasty, is optional. Typically, in a lower-eyelid procedure, the fat pads that cause puffines are removed without regard to the possible long-term effects. Over time, this wholesale removal of fat can create a hollow or concave appearance of the eye. (Courtesy of S. Ham-ra, Dallas)

Fig. 42.4. Composite blepharoplasty. The lower blepharoplasty is an integral part of the composite facelift. To create a natural transition between the soft under-eye tissue and the cheekbone, the composite facelift incorporates a special technique in which the fat under the eye is preserved and repositioned over the orbital bone. This method creates a smooth youthful contour. (Courtesy of S. Hamra, Dallas)

COMPOSITE BLEPHAROPLASTY"

Fig. 42.4. Composite blepharoplasty. The lower blepharoplasty is an integral part of the composite facelift. To create a natural transition between the soft under-eye tissue and the cheekbone, the composite facelift incorporates a special technique in which the fat under the eye is preserved and repositioned over the orbital bone. This method creates a smooth youthful contour. (Courtesy of S. Hamra, Dallas)

called "a zygorbicular flap" [14]. This created a second mesentery with a facelift called a meso-zygomaticus. In addition, the lower-eyelid fat was kept attached to the septum orbitale so that a septum orbitale reset could be accomplished following the arcus marginalis release.

It is this final maneuver which has created the present state of the art for composite facelifting.

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