1 Plastic sergery History History Clinical Evaluation Clinical Evaluation Preoperative workupPreoperative workup Analysis of faceAnalysis of face Anatomy.

11

Plastic sergeryPlastic sergery

HistoryHistory Clinical EvaluationClinical Evaluation

• Preoperative workupPreoperative workup• Analysis of faceAnalysis of face

AnatomyAnatomy SMAS FaceliftSMAS Facelift

• Deep Plane/Composite FaceliftDeep Plane/Composite Facelift• S-LiftS-Lift• ComplicationsComplications

22

HistoryHistory Few early historical Few early historical

detailsdetails• Early 20Early 20thth century: century:

Germans/FrenchGermans/French• Techniques guardedTechniques guarded• Pre-antibiotic era– low Pre-antibiotic era– low

profileprofile• Published Published

reconstructions not reconstructions not cosmeticscosmetics

Elliptical excisions of Elliptical excisions of skinskin

SQ underminingSQ undermining

33

HistoryHistory

1950’s “classic facelift” (Swanker)1950’s “classic facelift” (Swanker) 1974: Skoog describes subfascial 1974: Skoog describes subfascial

dissectiondissection 1976: SMAS named by Mitz/Peyronie1976: SMAS named by Mitz/Peyronie 1970’s-80’s: short flap vs. long flap1970’s-80’s: short flap vs. long flap 1990’s-today: deep plane, 1990’s-today: deep plane,

composite rhytidectomies, laser composite rhytidectomies, laser resurfacing, S-liftingresurfacing, S-lifting

44

Clinical EvaluationClinical Evaluation

HistoryHistory• Find patient desires/motivationsFind patient desires/motivations• SAFESAFE

Self-imageSelf-image AnxietyAnxiety FearFear ExpectationsExpectations

• Don’t operate if you don’t feel positiveDon’t operate if you don’t feel positive• ComplianceCompliance

55

Clinical EvaluationClinical Evaluation

HistoryHistory• Relevant medical historyRelevant medical history

DM, smoking, CVD, psychiatric problems, DM, smoking, CVD, psychiatric problems, steroid use, HTN, prior surgeries/scarringsteroid use, HTN, prior surgeries/scarring

Medicine use: ASA/NSAIDs, steroids, vitamin Medicine use: ASA/NSAIDs, steroids, vitamin E, OTC herbal supplementsE, OTC herbal supplements

66

Physical Physical ExaminationExamination• Anatomic Anatomic

EvaluationEvaluation Checklists may helpChecklists may help

• Skin CharacteristicsSkin Characteristics• PhotosPhotos

77

Clinical EvaluationClinical Evaluation

88

Clinical EvaluationClinical Evaluation

““Face-lift”Face-lift”• Chin/neck liftChin/neck lift• Nasolabial foldNasolabial fold• Fine or deep rhytidsFine or deep rhytids

Ideal patientIdeal patient• Elastic skinElastic skin• Distinct bony landmarksDistinct bony landmarks• Little SQ fatLittle SQ fat• Good bone structure Good bone structure

(hyoid)(hyoid) Adjunctive techniques Adjunctive techniques

99

Clinical EvaluationClinical Evaluation

Adjunctive Adjunctive TechniquesTechniques• Laser peelLaser peel• DermabrasionDermabrasion• Chemical peelChemical peel• Neck treatmentNeck treatment• ImplantsImplants• BlepharoplastyBlepharoplasty• ForeheadForehead• RhinoplastyRhinoplasty

1010

Clinical EvaluationClinical Evaluation

Other adjunctive Other adjunctive techniquestechniques

1111

Clinical EvaluationClinical Evaluation

Important to Important to assess hyoid assess hyoid positionposition• High hyoid is ideal High hyoid is ideal

for cervicomental for cervicomental angleangle

1212

Clinical EvaluationClinical Evaluation

Less than ideal Less than ideal candidatescandidates• Discuss Discuss

expectations in expectations in detaildetail

• Need for other Need for other proceduresprocedures

1313

Clinical EvaluationClinical Evaluation

Develop operative planDevelop operative plan Plan adjunctive proceduresPlan adjunctive procedures Prescriptions (pain meds, antibiotics)Prescriptions (pain meds, antibiotics) Instruction sheetInstruction sheet

1414

AnatomyAnatomy

SMASSMAS• Superficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System• 1974 Skoog, 1976 Mitz/Peyronie1974 Skoog, 1976 Mitz/Peyronie• Distinct fascial layer from platysma to Distinct fascial layer from platysma to

frontalis and into the galeafrontalis and into the galea Discontinuous at zygomaDiscontinuous at zygoma Envelopes zygomaticus major—NL foldEnvelopes zygomaticus major—NL fold

• Septal connections to skinSeptal connections to skin• Transmits forces of facial expressionTransmits forces of facial expression

1515

SMASSMAS

1616

SMASSMAS

1717

SMASSMAS

1818

SMASSMAS

1919

SMASSMAS

2020

PlatysmaPlatysma

2121

SMAS FaceliftSMAS Facelift

Preoperative MarkingPreoperative Marking• In holding with patient uprightIn holding with patient upright

NL folds, jowl lines, platysmal bands, 2 cm NL folds, jowl lines, platysmal bands, 2 cm from oral commissure, angle of mandible, from oral commissure, angle of mandible, frontal branch coursefrontal branch course

Incisions including submental incisionIncisions including submental incision Rubber band hairRubber band hair

AnesthesiaAnesthesia

2222

SMAS FaceliftSMAS Facelift

Preop phisohex Preop phisohex evening and evening and morningmorning

Perioperative Perioperative antibioticsantibiotics

Head holder Head holder beneficialbeneficial

No paralysisNo paralysis

2323

SMAS FaceliftSMAS Facelift

2424

SMAS FaceliftSMAS Facelift

2525

SMAS FaceliftSMAS Facelift

2626

SMAS FaceliftSMAS Facelift

2727

SMAS FaceliftSMAS Facelift

2828

SMAS FaceliftSMAS Facelift

2929

SMAS FaceliftSMAS Facelift

3030

SMAS FaceliftSMAS Facelift

3131

SMAS FaceliftSMAS Facelift

3232

SMAS FaceliftSMAS Facelift

3333

SMAS FaceliftSMAS Facelift

Postop CarePostop Care• DrainDrain• Pain medsPain meds• HTN medsHTN meds• Wound careWound care• Instruction sheetInstruction sheet

3434

SMAS FaceliftSMAS Facelift

ComplicationsComplications• Hematoma (8.5%)Hematoma (8.5%)• Skin Slough (1-6%)Skin Slough (1-6%)• Ear lobe deformitiesEar lobe deformities• InfectionsInfections• Widening of scarsWidening of scars• Hairline changes (1%)Hairline changes (1%)• Nerve Injury(0.4-2.6%)Nerve Injury(0.4-2.6%)

Greater auricularGreater auricular Frontal/MarginalFrontal/Marginal

3535

SMAS FaceliftSMAS Facelift

3636

SMAS FaceliftSMAS Facelift

3737

SMAS FaceliftSMAS Facelift

3838

SMAS FaceliftSMAS Facelift

3939

SMAS FaceliftSMAS Facelift

4040

SMAS FaceliftSMAS Facelift

4141

Deep Plane FaceliftDeep Plane Facelift

4242

Composite Face LiftComposite Face Lift

4343

Composite Face LiftComposite Face Lift

4444

S-Lift S-Lift Minimal Access Cranial SuspensionMinimal Access Cranial Suspension

Devised for less dramatic facial Devised for less dramatic facial rejuvenationrejuvenation• Less healing time/prolonged disfigurementLess healing time/prolonged disfigurement• Lower complication ratesLower complication rates• Less “operated on” lookLess “operated on” look

4545

ReferencesReferences Rees, T: Aesthetic Plastic Surgery. Philadelphia, W. B. Saunders Company, 1980. Teimourian, B. The multiplane face lift. Plastic and Rees, T: Aesthetic Plastic Surgery. Philadelphia, W. B. Saunders Company, 1980. Teimourian, B. The multiplane face lift. Plastic and

Reconstructive Surgery. 93(1):78, 1994. Reconstructive Surgery. 93(1):78, 1994. Rees T, Aston S. Complications of rhytidectomy. Clin Plast Surg 1978;5:109. Rees T, Aston S. Complications of rhytidectomy. Clin Plast Surg 1978;5:109. Webster RC. Comparison of SMAS plication with SMAS imbrication in facelifting. Laryngoscope 1982;92:901.Webster RC. Comparison of SMAS plication with SMAS imbrication in facelifting. Laryngoscope 1982;92:901. Thompson, C, Calhoun, KH. Rhytidectomy, Grand Rounds, Dept of Otolaryngology, 1996. Thompson, C, Calhoun, KH. Rhytidectomy, Grand Rounds, Dept of Otolaryngology, 1996. Kridel RW. Complications of rhytidectomy. Ear Nose Throat J 1985;64:44. Kridel RW. Complications of rhytidectomy. Ear Nose Throat J 1985;64:44. Kamer F. One hundred consecutive deep plane face-lifts. Arch Otolaryngol Head Neck Surg 1996;122(1):17. Kamer F. One hundred consecutive deep plane face-lifts. Arch Otolaryngol Head Neck Surg 1996;122(1):17. Beeson WH. Selection of “successful” candidates for rhytidectomy surgery. Beeson WH. Selection of “successful” candidates for rhytidectomy surgery. Facial Plastic Surgery Clinics of North AmericaFacial Plastic Surgery Clinics of North America 1(2): 131- 1(2): 131-

4, 1993.4, 1993. Beeson WH. Extended posterior rhytidectomy. Beeson WH. Extended posterior rhytidectomy. Facial Plastic Surgery Clinics of North AmericaFacial Plastic Surgery Clinics of North America 1(2): 197-216, 1993. 1(2): 197-216, 1993. Berman WE. Rhytidectomy. In CJ Krause (ed.) Berman WE. Rhytidectomy. In CJ Krause (ed.) Aesthetic Facial SurgeryAesthetic Facial Surgery. Lippincott, 1991, pp 513-31.. Lippincott, 1991, pp 513-31. Brennan HG. Rhytidectomy: Mandibular and submandibular contouring. Brennan HG. Rhytidectomy: Mandibular and submandibular contouring. Facial Plastic Surgery Clinics of North AmericaFacial Plastic Surgery Clinics of North America 1(2): 181-96, 1(2): 181-96,

1993.1993. Dedo DD. The aging neck. In BJ Bailey (ed.): Dedo DD. The aging neck. In BJ Bailey (ed.): Head & Neck Surgery – OtolaryngologyHead & Neck Surgery – Otolaryngology, 2nd edition. Lippincott – Raven, 1998, pp. 2717-, 2nd edition. Lippincott – Raven, 1998, pp. 2717-

32.32. Hamra ST. The deep-plane rhytidectomy. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr SurgPlast Reconstr Surg 86: 53-61, 1990. 86: 53-61, 1990. Hamra ST. Composite rhytidectomy. Hamra ST. Composite rhytidectomy. Plast Reconstr SurgPlast Reconstr Surg 90:1-13, 1992. 90:1-13, 1992. Hamra ST. Repositioning the orbicularis oculi muscle in the composite rhytidectomy. Hamra ST. Repositioning the orbicularis oculi muscle in the composite rhytidectomy. Plast Reconstr SurgPlast Reconstr Surg 90:14-22, 1992. 90:14-22, 1992. Kridell RWH, Covello LV. The aging face (rhytidectomy). In BJ Bailey (ed.): Kridell RWH, Covello LV. The aging face (rhytidectomy). In BJ Bailey (ed.): Head & Neck Surgery – OtolaryngologyHead & Neck Surgery – Otolaryngology, 2nd edition. , 2nd edition.

Lippincott – Raven, 1998, pp. 2693-716.Lippincott – Raven, 1998, pp. 2693-716. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr SurgPlast Reconstr Surg 58: 80- 58: 80-

88, 1976. 88, 1976. Larabee WF, Makielski KH, Cupp C. Facelift anatomy.Larabee WF, Makielski KH, Cupp C. Facelift anatomy. Facial Plastic Surgery Clinics of North America Facial Plastic Surgery Clinics of North America 1(2): 135-52, 1993. 1(2): 135-52, 1993. Larabee WF, Ridenour BD. Rhytidectomy: technique and complications. Larabee WF, Ridenour BD. Rhytidectomy: technique and complications. American Journal of OtolaryngologyAmerican Journal of Otolaryngology 13(1): 1-15, 1992. 13(1): 1-15, 1992. Lawson W, Naidu RK. The male facelift: An analysis of 115 cases. Lawson W, Naidu RK. The male facelift: An analysis of 115 cases. Arch Otolaryngol Head Neck SurgArch Otolaryngol Head Neck Surg 119: 535-39, 1993. 119: 535-39, 1993. McCoullough EG, Perkins SW, Langsdon PR. SMAS suspension rhytidectomy. McCoullough EG, Perkins SW, Langsdon PR. SMAS suspension rhytidectomy. Arch Otolaryngol Head Neck SurgArch Otolaryngol Head Neck Surg 115: 228-34, 1989. 115: 228-34, 1989. Seckel BR. Seckel BR. Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic SurgeryFacial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery. Quality Medical Publishing, St. Louis, 1994. . Quality Medical Publishing, St. Louis, 1994. Webster RC, Smith RC, Papsidero MJ, et al. Comparison of SMAS plication with SMAS imbrication in face lifting. Webster RC, Smith RC, Papsidero MJ, et al. Comparison of SMAS plication with SMAS imbrication in face lifting. LaryngoscopeLaryngoscope 92: 92:

901-12, 1982. 901-12, 1982.