Operative Technique

The cheek undermining is performed superficial to the parotid gland above the parotid fascia and the SMAS layer. The dissection is continued above the orbicularis oculi muscle after visualization of the edge of the orbicularis oculi and the undermining goes over the zygomaticus major and minor muscle. The front dissection is carried on to the level of the nasolabial fold, to the modiolus and under the jowl, where the mandibular ligament is released

The plane of dissection is under the adipocutane-ous layer but above the SMAS layer, leaving all fat on the flap, providing good access to all fat that has to be repositioned, molded and recontoured from inside.

The postauricular undermining leads to the anterior border of the sternocleidomastoid muscle. After the platysma muscle has been identified, the dissection can extend across the neck. Special attention has to be paid to the greater auricular nerve.

The cervicofacial soft tissue is dissected in the sub-adipose layer over the SMAS. The platysma fibers on the cheek are identified and the dissection is continued on to the buccal commissure and down to the release of the mandibular ligament. In the zygomatico-malar area is not necessary to change planes. The detachment is still subadipose and in the direction of the nasolabial pouch the fat layer, always remaining on the flap, thickens. The zygomatic muscles stay below the dissection plane. The total liberation of the adipocutaneous layer from the fibromuscular plane and its repositioning will provide 80% of the result.

Fig. 44.5. Spreading of the nasolabial pouch perpendicular to its long axis

The efficiency of eventual actions on the deep layers has to be checked and carried out as plications or SMAS-ectomies according to the requirements in each individual case.

From this access the platysma can be put under tension laterally or, in cases of prominent platysmal bands, a Feldman corset platysmaplasty [6] can be carried out with plication of the platysma in the midline; therefore, a submental incision is necessary.

If the nasolabial pouch is very dense and very thick, it is advisable to incise it parallel to the nasolabial fold and to spread the opened pouch perpendicular to its long axis (Fig. 44.5).

Nasolabial Fold Anatomy
Fig. 44.6. A subcutaneous dissection would injure a large number of perforating vessels and lymphatics. A subadipose dissection encounters far fewer vascular elements, and separates the two anatomical leaflets, without injuring either of them

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