The Vertical Periocular and Midface Rhytidectomy

The frontal branch of the facial nerve is marked from a point 1.5 cm in front of the centre of the tragus towards a 0.8 cm2 area around the midpoint between the radix helicis and the lateral canthus. The 3.5 cm temporal incision is marked from a point 3.5 cm vertically above the radix helicis, adding cranially a 2-3 cm anterior extension and caudally, above the ear, a 2 cm posterior extension.

The scalp incision is performed and includes the fascia temporo-parietalis and subgaleal fascia, which covers the fascia temporalis. The lateral two thirds of the forehead, brow and infrabrow segment is undermined with Castañares scissors (Fig. 41.5).

With downward-curved blunt scissors sliding on the fascia temporalis and the maxillo-malar periosteum downward, the SMAS of the anterior midface in front of the upper marking is dissected towards the naso-labial fold with finger protection of the infra-orbital bundle (Fig. 41.6). The author's double-angulat-ed scissors (Padgett) may be useful. A fingertip revision of the complete dissection towards the eyebrow, the midface and the naso-labial fold as well as posteriorly in front of the upper ear down to 0.5 cm from the marking of the frontal branch is also performed, with the purpose of detaching any residual adhesions. Also the raphe is liberated at the lateral canthus.

The complete undermining with transection of the three ligaments (malar, orbital and inferior orbicu-laris), permits us to vertically upwardly rotate the midface and the lateral periocular frame. It demands, however, that we stabilize the deep plane apart from the scalp fixation. The stabilization is performed with two or three 2-0 polyester Ti-Cron sutures, which immobilizes the temporo-parietalis fascia to the temporalis fascia (Fig. 41.7). While the anterior temporal flap is forcefully pulled upwards with forceps, the posterior scalp is displaced downward. With the help of d'Assumpcao forceps a possible anterior scalp excess of a few millimetres is marked and excised and the first staples are placed. Also the upper anterior and lower posterior extensions are determined, excised and stapled and a suction drain towards the naso-labial fold is inserted.

Steri-strips are applied to the forehead, eyelids and midface for the first 3 days to prevent skin distension due to the postoperative oedema. The suction drain is removed the next morning (Figs. 41.8-41.10).

Midface Procedure Incisions
  1. 41.5. Top: The marking of the pathway of the frontal ramus the infrabrow segment, leaving the subgaleal fascia attached and of the scalp incision. Bottom: Dissection with Castañares to the temporo-parietalis fascia. Dissection of the brow and and curved blunt scissors along the temporalis fascia down to infrabrow segment with protection of the supraorbital bundle
  2. 41.5. Top: The marking of the pathway of the frontal ramus the infrabrow segment, leaving the subgaleal fascia attached and of the scalp incision. Bottom: Dissection with Castañares to the temporo-parietalis fascia. Dissection of the brow and and curved blunt scissors along the temporalis fascia down to infrabrow segment with protection of the supraorbital bundle
Temporo Labial Crease
  1. 41.6. Top: With protection of the infraorbital bundle, the anterior face is dissected down to the naso complete undermining is verified, dislodging any residual adhesions by fingertip dissection i-labial fold. Bottom: The
  2. 41.6. Top: With protection of the infraorbital bundle, the anterior face is dissected down to the naso complete undermining is verified, dislodging any residual adhesions by fingertip dissection i-labial fold. Bottom: The
Labial Adhesion
  1. 41.7. The stabilization of the upwardly displaced anterior flap strongly upward, a strip of the anterior scalp is removed scalp is performed by two or three 2-0 Ti-Cron sutures to join if necessary and the borders are stapled, followed by excision the temporo-parietalis fascia to the temporalis fascia. While of the anterior and posterior extensions and closure. A suction the posterior scalp is displaced downward and the anterior drain is inserted towards the naso-labial sulcus
  2. 41.7. The stabilization of the upwardly displaced anterior flap strongly upward, a strip of the anterior scalp is removed scalp is performed by two or three 2-0 Ti-Cron sutures to join if necessary and the borders are stapled, followed by excision the temporo-parietalis fascia to the temporalis fascia. While of the anterior and posterior extensions and closure. A suction the posterior scalp is displaced downward and the anterior drain is inserted towards the naso-labial sulcus
Fig. 41.8. Preoperative and postoperative result of the vertical rhytidectomy and at 4 and 8 years
Malar Augmentation
Fig. 41.9. Preoperative and 1 year postoperative result after vertical rhytidec-tomy, rhinoplasty, malar augmentation and lower cervico-facial rhytidectomy with submandibular fat removal
Minimal Access Face Lift
Fig. 41.10. Result after vertical rhyt-idectomy with prehairline forehead correction and cervico-facial correction by minimal access cranial suspension (MACS) lift and malar augmentation. One-year postoperative result

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