Bruce F. Connell
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 indicated can be modified for each side of the face according to the specific anatomical problem (Fig. 52.1).
A precise diagnosis, appropriate anatomical architectural planning and skillfully executed surgical repair are required for each patient's individual problems. For accurate diagnosis of facial aesthetic problems, it is essential that the surgeon be aware of all aspects of pleasing facial features, as well as the attractiveness of natural facial asymmetry. The best face and neck rejuvenation addresses the entire face, forehead, glabellar area, nose, eyes and hair. Male patients complaining about their neck or jowls may not be aware of their inappropriate and unintentional expression of annoyance, anger, fatigue or sadness . The forehead rejuvenation produces very pleasing results and happy patients (Figs. 52.2, 52.3a, b).
During the initial consultation with a male patient, the wishes and goals are matched with the possibilities for improvement. It is of great help for the surgeon to be able to examine photographs that were taken when the patient was younger and most pleased with his appearance, for the assessment of eyebrow position, angle of the nasojugal groove (tear trough), eyelids, amount of malar prominence, location of angles of the mouth, and the deep and superficial contours. In addition, the texture and amount of excessive skin of the forehead, face and neck is recorded. While looking in the mirror, the skin and deep tissues are placed in an optimal position. The patient then comments as to whether the position of the eyebrows, malar prominence, jaw line, angle of the mouth and the face and neck contours are pleasing to him (Fig. 52.2).
The assessment and documentation of facial asymmetry during animation and rest is noted during a 1 h consultation and is reviewed during the preoperative evaluation. This assessment is for precise diagnosis and planning of the surgery [2, 4]. Discussion of normal asymmetry may eliminate postoperative misinterpretation by the patient who will closely examine the face after the surgery. All persons have a large side of the face, with a larger eyelid, wider half of the lips and larger bone structure. The smaller side of the face appears older and there is more rejuvenation improvement on the smaller side of the face than the larger side of the face. Abnormal fat accumulations, platys-ma laxity and abnormal contours caused by bulges of the salivary glands and digastric muscles are noted. If the patient smiles and looks much older because of the smile creases (crow's-feet), this problem will be corrected (Fig. 52.4).
The amount of skin excess and the direction of the necessary tissue shift are determined by pinching the excessive skin in five or more sites. Also, the goals to be achieved by shifting the superficial musculoapo-neurotic system (SMAS) are recorded. For example, the SMAS can be utilized to eliminate or restore the position of the nasojugal groove as well as to eliminate much of the excessive lower-eyelid skin without making an eyelid skin incision if the restricting attachments between the skin and orbicularis oculi muscles are released. In addition, the vertical shift of the lower-eyelid-cheek junction restores the appearance to a shorter, more youthful appearance. These results are helped by a transection of the SMAS high along the superior border of the zygomatic arch and rarely utilizing a third SMAS flap after the retaining ligaments, which are muscle-skin attachments forming the smile creases (crow's-feet) that have been detached from the muscle-skin attachments. This permits the facelift skin shift to decrease very much the amount of excessive skin in the lower eyelids without making an incision below the eyelashes (Fig. 52.3) .
Fig. 52.3. a, b A 52-year-old male patient who had an inappropriate annoyed and angry appearance at rest. Correction resulted in a pleasing more friendly body language. The lower-eyelid improvement was accomplished by utilizing a high superficial musculoaponeu-rotic system (SMAS) flap and liberation of the smile creases from the orbicularis oculi muscle to permit the facelift skin shift to change the diagonal direction of the nasojugual groove to horizontal, elevate the cheek fat to soften the junction of the eyelid with the cheek and to give a shortened appearance of the eyelid. No incision was made through eyelid skin below the eyelashes. c, d He had a low hyoid and very large anterior belly of the digastric muscle. Forehead, face and neck lift with transection of the platysma muscle at the level of the cricoid produced results that were very pleasing to the patient. It was possible to avoid a shift of his temporal hair by having the incision go along the hairline
With the improved results and the very long lasting improvement accomplished by fat transfer there is an increasing need for the use of fat for correction of special facial problems and for restoration to a more youthful appearance. For example, the patient who had elimination of his inappropriate annoyed appearance because of his glabellar frown still looked tense and annoyed because of the loss of volume in his lips (Fig. 52.5). Older persons and those who are taking medications such as medicine for HIV treatment may have subcutaneous wasting of the facial fat. The restoration to correct the facial skeletonization is excellent and long-lasting using autogenous fat.
In addition to the informed consent form, each patient has had a recent annual physical performed by an internist or family physician before surgery. The blood studies include HIV for each patient. A cardiologist, ophthalmologist or other specialist that the patient has seen is asked for recommendations as to the patient's fitness for surgery. The consent for photography is included in the informed operative consent and a separate consent is used for the anesthetist or anesthesiologist.
To achieve nondetectable surgical scars an appreciation of skin color is required. The apparent sizes of the features such as the tragus and the helix of the ears are defined by the skin color changes and not by the size of the underlying cartilage (Fig. 52.6).
Patients may be disfigured by hair shifts and may be annoyed as well as they must restyle the hair to hide the deformities. Some men may have the temporal incision placed behind the hairline . However, if the temporal hairline is moved more than 4 cm away from the lateral canthus, the incision should be placed a few millimeters within the temporal hair (Fig. 52.7c, d). The rare suboptimally healed incision along the temporal hair can be revised, concealed with
In order for the scar to be nondetectable, the superior portion of the preauricular incision should be curved and placed within the skin color change from cheek to helix. If the incision is placed outside the color change of the helix, the scar will be visible because there will be a color change before the scar, then the scar, then another color change before the helix skin color is reached (Figs. 52.6, 52.8).
Tragal Incision, Peri-earlobe Incisions, Postauricular Incision
Most patients have increasing redness, altered pigmentation or texture changes in the skin proceeding anteriorly toward the nose. A color or texture mismatch may reveal the facelift procedure despite excellent healing with an almost nondetectable scar. Most incisions are placed within the 3-mm-wide edge of the tragus to avoid the risk of a detectable scar. The height of the tragus is produced by a color change. The incision to define the lower edge of the tragus must be perpendicular to the edge of the tragus and then must descend inferiorly just along the junction of the ear with the cheek. If this transverse incision is not made at a 90° angle to the skin, a fold may result and produce an indistinct visual ending to the tragus, which looks very unnatural.
So that no beard hairs are shifted onto the tragus hairless area, beard hair bulbs can be excised and electrocoagulated when the cheek skin is folded over the finger. The hair bulbs are not in the skin but are below the skin and they project very well when the skin is wrapped around a finger (Fig. 52.9). The hair bulbs are either just excised or touched with a needle. Use of a blade may make too much heat and damage the tragal flap.
The earlobe looks as if there has not been a facelift performed if the distance from the long axis of the ear is 12-15° posteriorly. Also, the earlobe's natural transition at the ear-cheek junction should be preserved by placing an incision 2-3 mm below this junction, which also avoids beard growth in an area that is difficult to shave (Figs. 52.6, 52.10).
Whether or not a postauricular incision is needed is determined by drawing a perpendicular line to the lowest point on the fold of the neck skin when the chin-neck angle is 90° . Some patients do not need to have an occipital incision. The proper flap shift of the neck skin is perpendicular to the vertical skin folds and follows a posterior and slightly superior
Incision Between Occipital Hair and Ear and Occipital Incision
The level of the postauricular incision from the ear to the occipital hair depends on the amount of excessive neck skin . This incision can always be placed higher at the end of the surgery but it cannot be moved lower. If the postauricular incision is placed too high in an attempt to hide the scar, the surgeon must make an anterior superior rotation of the flap to close the resulting defect and this rotation compromises the improvement of the neck and submental areas. In addition, it may make the neck creases misplaced and appear to be folds of drapery when the patient looks downward.
The incision may pass above the occipital hair in rare cases, which requires neck contouring but does not have any excessive skin to be shifted laterally or the amount is less than 1 cm.
Larger skin shifts would result in an unnatural displacement of the occipital hair. With larger amounts of skin to be excised, the incision should curve along the thick occipital hair and where the hair becomes thin should go above to be shifted upward by excising the occipital recipient site (Figs. 52.11, 52.12).
A submental incision is made for releasing the osseo-cutaneous ligaments, which form an unsightly submental crease when the patient looks downward. This incision is used to release the mandibular ligaments, which form jowls. In addition, a mobile submental incision can be used for decreasing the size of the anterior bellies of the digastric muscle, or partial excision of the submaxillary glands, augmenting chin or transecting the platysma muscles at the cricoid. This incision is never made in the immobile location of the submental crease formed by the osseocutaneous ligaments. The osseocutaneous ligaments never reform if completely released. The submental incision is approximately 2.5 cm in length, located posterior to the submental crease and in the shadow of the chin, which is usually about half way between the chin and the hyoid.
Almost all patients benefit from a posterior superior rotation of the cheek SMAS about a pivot point situated over the malar eminence. This rotation and posterior cheek SMAS shift will provide a strong immediately visible support to the cheeks, restoration of the jowl fat to the youthful position, flattening of nasola-bial folds and even a sling support to the submental area extending across the midline from the hyoid to the chin . If the transverse incision of the SMAS is over the upper part of the zygomatic arch and high onto the malar bone, a very good support to the orbi-cularis oculi and orbital septum, the upper nasolabial fold and lateral upper lip will be achieved. 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 (Fig. 52.13).
If the shifts of the deep layers are not visible at the time of surgery, this means the SMAS liberation and shift was inadequate. Patients with vertically short platysma muscles or tight bands are best treated by some form of localized muscle interruption and release. The improved neck contour is immediate, dramatic and long-lasting. If lateral bands are present or there is lack of mandibular definition owing to short lateral platysma muscles, this transection is brought superolaterally along the approximately 1 cm wide avascular area in front of the anterior border of the sternocleidomastoid muscle and into continuity with the vertical SMAS incision overlying the parotid about 1 cm anterior to the ear. In most cases, anterior submental platysma invagination is planned as well to add support to the submental tissues (Fig. 52.14). Wedge resections and vertical excisions of anterior bands are unnecessary if the aforementioned techniques are used .
Deep periorbital smile creases can make the rejuvenated face appear much older in animation than repose. This creates an upsetting disharmony (Fig. 52.4a, b). Marking all objectionable smile creases pre-operatively assists in performing a complete "release." The depth of skin dissection should be determined by transillumination and palpation. When the lateral brow is pulled downward by the orbicularis oculi muscle when smiling, the muscle is then transected in a line ending 15° below the lateral canthal raphae. The transection begins 5 mm anterior to the lateral orbi-cularis oculi muscle edge to avoid injury to the frontal branch of the facial nerve.
There will remain smile creases that are due to inelastic skin. A patient in whom most of the creases are due to pushing inelastic skin upward would benefit very little from this method of "crow's-feet" correction .
A youthful attractive appearance depends very much upon a well-contoured neck without abnormal upper neck bulges [4, 7]. Abnormal bulges may result from subcutaneous or subplatysmal fat, prominent sub-mandibular glands, platysma muscle or large anterior bellies of the digastric muscle with interdigastric muscle fat (Fig. 52.5c, d). Often contour problems
The improvement to submental neck contour resulting from tangential resection of bulging, large anterior bellies of the digastric contributes greatly to the formation of a youthful submental area contour (Fig. 52.15).
We have performed tangential resection in 560 digastric muscles with great improvement in cervical contour with no morbidity. Not all patients with double chins have bulging digastric muscles; some have only huge submandibular glands or subplatysmal fat.
During the preoperative examination of the neck, the patient extends the chin and contracts the platys-
ma muscles to reveal the amount of fat external to the platysma muscles. The neck is palpated and the skin, fat, platysma, submandibular gland, muscle, and bony and cartilaginous structures are assessed.
With regard to the anatomical architectural planning, the submental support of the neck is accomplished by utilizing the SMAS tissues. The submental platysma muscles may be used as a sling or hammock, which is formed by the upward SMAS face shift along with invagination of the submental platysma muscle. In addition, a transposed flap of preauricular cheek SMAS to the mastoid fascia provides a third different vector of support at the hyoid without displacing the sternocleidomastoid muscles anteriorly. The transec-tion of the platysma muscles at the level of the cricoid permits a greater upward shift of the SMAS and pla-tysma muscle for those patients who have tight bands or short platysma muscles (Fig. 52.14).
After correction of the excessive subcutaneous and subplatysmal fat, the neck is flexed during surgery to observe persistent objectionable submental bulges. If the anterior bellies of the digastric muscles cause bulges, these muscles should be tangentially decreased. Frequently, 90% of the muscle is removed tangentially from the anterior belly, since complete removal may allow the muscle to slip through the sling through which the intermediate tendon passes. A complete set of neck photographs should include preoperative and postoperative profile views of the patient looking straight ahead and downward.
Rhytidectomy incisions and a 2.8-cm-long submental incision located about half the distance between the hyoid cartilage and the submental crease are used to approach the subcutaneous tissues of the neck .
If the neck bulges are due to very large subman-dibular glands, the capsule can be opened centrally or medially and the gland carefully separated from its capsule (Fig. 52.16). Excision is by clamping portions of the submandibular gland and then coagulating with the clamp or the tissues can be removed by a needle electrocoagulation. Following removal of the
major portion of the gland, which causes the bulge when the neck is flexed, the capsule does not have to be sutured. As long as the dissection is kept within the capsule injuries to nerves or surrounding structures are not expected. The platysma is invaginated with two rows of inverted 4-0 nylon sutures with buried knots through the submental incision. Subplatys-mal round, perforated suction drains are placed by passing a closed long hemostat through each side of the closure line and pulling the drain between the remaining anterior bellies of the digastric muscles and the platysma muscle. Whenever submandibular glands have been decreased in volume or the anterior bellies of the digastric muscle decreased, a drain is passed under the repaired platysma muscle (Fig. 52.17).
The contour correction of the submental area always gives the appearance of a stronger chin projection and release of the submental osseocutaneous ligament permits great improvement of the ptotic chin. Occasionally, excision of ptotic skin muscle is indicated. Sometimes an alloplastic chin implant or injected fat may improves the vertical height of the chin. The youthful appearance of the neck as well as rejuvenation of the upper third of the face is of great importance for patient satisfaction.
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