PPT - UCLA Head and Neck Surgery
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Transcript PPT - UCLA Head and Neck Surgery
Rhytidectomy
Marc Cohen, M.D.
David Geffen School of Medicine
at UCLA
Division of Head & Neck Surgery
The Aging Face
Soft tissue changes
Skin changes
Soft Tissue Changes
Jowl
Deepened nasolabial
folds and perioral jowling
Platysmal banding and
submental fullness
Orbicularis oculi and
malar fat pad ptosis
Skin Changes
Epidermis and subcutaneous fat thins
Flattening of dermal-epidermal junction
Elastosis: progressive loss of organization of
elastic fibers and collagen
Photodamaged skin – striking variability
SMAS
Superficial Musculoaponeurotic System
1976 Mitz and Pyronie Landmark paper
Fibromuscular fascial extension of the
platysmal muscle that arises superiorly
from the fascia over the zygomatic arch
and is continuous in the inferior cheek
with the platysma
Functions to transmit the activity of facial
mimetic muscles to the facial skin
SMAS
Posteriorly, the SMAS fuses with the fascia
overlying the sternocleidomastoid muscle, but it
is a distinct layer superficial to the parotid fascia
Anterosuperiorly, the SMAS invests the facial
mimetic muscles of the mid-face (i.e., orbicularis
oculi, zygomatic major/minor, levator labii
superioris)
Anteriorly, the SMAS invests the superficial
portions of the orbicularis oris and gives off
fibrous septae that insert into the dermis along
the melolabial crease and upper lip
Facial Nerve
Protected by parotid
tissue and lower
branches are deep to
masseter fascia
Potential space exists
between SMAS and
masseter fascia in
inferior cheek
Important in
deep/composite
rhytidectomy
techniques
Innvervates midfacial
mimetic muscles from
undersurface
Facial Nerve
Temporal branch is
most superficial
Crosses junction of
anterior 1/3 and
posterior 2/3 of
zygomatic arch
Above the arch it
travels in the
temporoparietal
fascia to innervate
frontalis and orbicularis
oculi
SMAS & The Facial Nerve
Facelifts
Subperiosteal facelift
Subperiosteal facelift
Shortcomings
Frontal branch at higher risk
Significant facial edema lasting up to 6 weeks
Deep plane facelift
Addresses nasolabial folds
Subcutaneous
2-3 cm in front of tragus
Sub-SMAS
To zygomaticus major
Superficial to zygomaticus major
Upper extent is malar eminence
Inferior extent is jawline
Deep plane facelift
Composite facelift
Addresses malar eminence
Lower blepharoplasty incision used to elevate
orbicularis oculi and malar fat pad
Transition then made superficial to zygomaticus
major
Nasolabial Fold
Nasolabial Fold
Boundary between cheek and upper lip
Laterally, thick subcutaneous layer
Medially, dermis almost approaches orbicularis
Cheek fat sags over time lateral to fold
Upper third – insertion
into LLSAN muscle
Middle third –
transition btw both
muscles
Lower third – insertion
into OO
Deep plane and
periosteal lifts do not
anatomically address
this
Controversial – SMAS
or not
Nasolabial Fold Management
Direct excision (UCLA)
ePTFE (gortex)
Fillers
SMAS
Facelifts? Midface lifts?
Botox (LLSAN)
Botox
Direct Excision
Lift and Peel at same time?
Concern for flap necrosis
Retrospective studies show no increased
incidence of flap necrosis or other complications
Retaining Ligaments of the
Face
Osteocutaneous
Orbital – centered at zygomaticofrontal suture
Zygomatic
Buccal-maxillary – arises from zygomaticomaxillary
suture
Mandibular (along with DAO makes up
labiomandibular crease)
Fasciocutaneous
Masseteric (anterior border of masseter
Parotidocutaneous
Blood Supply
ECA
STA
Transverse facial artery
Zygomaticorbital artery
Facial
Submental
Inferior labial
Superior labial
Angular
Blood Supply
Complications - Hematoma
HTN is major risk factor (2.6x risk)
Major – usually occur in first 12 hours
reoperation and exploration
Minor – occur during the first week
Evacuated with 18 ga needle or small opening in
incision line, pressure dressing, abx
Complications – Flap necrosis
Postauricular is most common site
Preauricular is 2nd most common
Deep-plane facelifts have a decreased incidence
of necrosis
Nicotine carries a 12.6x risk for flap necrosis
Must stop at least 2 weeks prior
Treat conservatively with with daily peroxide
cleaning, limited debridement, and topical abx
ointment
Most heal nicely
Complications – Nerve
Damage
Most commonly injured nerve is great auricular
If injured, should be repaired with 9-0 nylon
Temporal and Marginal are the most commonly
injured motor nerves
Studies differ on which is more commonly injured (which
technique, etc.)
Treatment
First 4-8 hours, wait
If prolonged, do NOT re-explore
85% will resolve with time
Reconstruct after 1 year
Patients with a hx of Bell’s palsy are at risk for recurrence
after rhytidectomy
Complications
Hypertrophic scarring
Occurs with excessive tension on flap closure
More commonly with isolated subcutaneous flap
dissections
Treat with steroids
Defer excision and primary closure until at least 6
months postoperatively
Alopecia
Wait 3-6 months, then excise or place grafts
Complications
Infection
Common pathogens are
staph and strep
Usually respond to oral abx
Rare for abscess to form
Earlobe deformity (pixie ear)
V-Y plasty performed 6
months after surgery
Complications
Parotid injury
Sialocele or fistula
Needle aspiration and pressure dressings