The Deep Work

Patients age in a slightly different manner. The quantity, quality and vector of soft-tissue descent vary, necessitating an individualized approach based on the physical examination and the patients photographs. The pull vector of the superficial muscolo-aponeu-rotic system (SMAS) and the direction of the redrap-ing of the skin flap must be individually determined, especially when dealing with sun-damaged skin [8].

Skin laxity in the aging face also occurs in different directions. Using the skin envelope as a handle to re-elevate deep facial structures is not reliable, as it will stretch in an unpredictable way and may lead to inadequate rejuvenation and early relapse and subsequent facial distortion, especially in individuals with sun- damaged-skin.

We believe that a good result may be obtained by dealing with these two layers individually, utilizing different vectors.

Most patients undergoing rhytidectomy will benefit from deep structure tightening prior to skin flap redraping. In essence, tightening or molding of the underlying SMAS is a reliable scaffold for better and longer-lasting results.

We undermine the adipocutaneous flap superficially, under direct vision, leaving cobblestone-like, thin fat globules on the under surface of the semi-translucent skin.

The flap is elevated using direct vision, sharp dissection in the dense pre- and postauricular areas and blunt dissection in the central third of the face and neck, using the spatulated-tipped dissection scissors, designed by Trepsat [9] (Fig. 64.7).

Trepsat Facelift Scissors
Fig. 64.7. Trepsat spatulated-tipped dissection scissors used for blunt dissection in the central third of the face and neck
Smas Surgery

Fig. 64.8. The axis of superficial muscolo-aponeurotic system (SMAS)-ectomy is marked, from the malar eminence to the mandibular angle and platysmal border, after excision and before closure

For the last 5 years, we have performed a direct oblique SMAS trim, or lateral SMASectomy (as introduced by Dan Baker from New York), in almost all of our facelift patients, and find this technique rapid, safe, reproducible and long-lasting [10]. In all other (thin and secondary) patients we use direct SMAS plication without trimming.

The axis of SMASectomy is marked, extending on a tangent from the malar eminence to the mandibular angle, directly over to the parotid gland, and caudally along the lateral platysmal border (Fig. 64.8). The SMASectomy is oriented so that the elevation vectors following closure are perpendicular to the vectors of midface and low-face descent.

With forceps, the amount of SMAS laxity is assessed and excised. The first suture is placed from the lateral platysma at 2-4 cm below the mandibular border to the fixed preparotid fascia in front of the ear.

The rest is closed directly with interrupted or running 3/0 PDS sutures from above the malar eminence and down towards the parotid fascia.

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