Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Anesthesia
Inject subcutaneous anesthetic superficially in the area to be resected. Upper lid blepharoplasty alone is
generally done under local anesthesia but additional procedures or patients’ characteristics may dictate
the use of intravenous (IV) sedation or general anesthesia.
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Skin Resection
Incise the skin along the marked incision lines with a no. 15 blade. Some surgeons prefer to use a CO2
laser or Colorado microdissection needle to incise the skin. Excise the marked area of skin by taking care
to excise skin only and leaving the orbicularis intact.
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Muscle Resection
Although not always needed, removal of muscle may be done to decrease fullness or to create a crisp
supratarsal fold. A strip of 3 to 5 mm is removed, and cautery is used to achieve hemostasis from the
muscle vessels.
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Fat Removal
Fat removal may or may not be needed. If needed, the orbicularis and septum are opened with scissors or
cautery to expose the fat pads. Gentle pressure on the globe will further prolapse the fat. The medial
orbital fat pad typically requires debulking more often than the central pad. The fat can be resected with
needle tip cautery or by clamping the fat with a hemostat, excising it and then cauterizing the cut end.
Great care is taken to avoid any traction on the fat as this can lead to bleeding posterior to the septum and
a retro-orbital hemorrhage. Aggressive fat debulking of the eyelids can result in a hollowed appearance
and has fallen out of favor. Minimal conservative fat removal is recommended.
Some patients have a prominent fat fad under the lateral third of the brow, which is below the orbicularis.
This is called retro-orbicularis oculi fat and can be resected at the time of blepharoplasty. Dissection is
carried out superiorly beneath the orbicularis where the fat is resected. Browpexy may also be performed
in this space by placing sutures to secure the lateral orbicularis and brow to the periosteum at the desired
position at or above the superior orbital rim.
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Lacrimal Gland
A prolapsed lacrimal gland presents as a mass below the brow and lateral orbital rim. Double armed
sutures can be used to engage the inferior tip of the gland and secure it to the periosteum just inside the
superior orbital rim at the lacrimal fossa. Excision of the gland tissue should be avoided, as this can lead
to dry eye.
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Skin Closure
Many different skin closures are successful; running or interrupted sutures and absorbable and
nonabsorbable sutures can be used. Fine suture (6-0 to 8-0 suture) is used in a single layer, and sutures are
typically removed 7 days after surgery (Figure 50.12).
FIGURE 50.12 Upper lid blepharoplasty: preoperative (A) and postoperative (B).
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Lower Lid Techniques
Unlike upper eyelid blepharoplasty, there are multiple approaches to a lower eyelid blepharoplasty.
Variation in patient anatomy will influence the chosen technique. Older patients with excess skin may
warrant a transcutaneous lower eyelid blepharoplasty. If lower eyelid laxity is also present, a lower eyelid
tightening procedure (i.e., lateral tarsal strip) can be performed at the same time. Patients with fat
prolapse or tear trough deformity and minimal excess skin can be approached with a transconjunctival
lower lid blepharoplasty with fat excision or redraping. Different surgeons prefer different techniques.
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Markings
A subciliary skin incision is marked 2 mm below the lower eyelid lashes. The marking is extended
inferotemporally along a crow’s foot crease to the lateral orbital rim. The lower incision should be 5 to
7 mm inferior to the upper lid incision. The location and the planned amount of fat pad resection is noted
or marked. Fat pad anatomy can be better visualized by gentle pressure on the globe. The tear trough is
marked.
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Anesthesia and Shields
Various surgeons use local, IV sedation, or general anesthesia. A corneal shield may be used for lower lid
surgery to protect the globe.
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Transcutaneous Approach
The marked subciliary incision is made with a knife or sharp scissors. The incision is then stairstepped so
that the muscle incision is made 5 mm below the lashes to spare the pretarsal orbicularis. A skin-muscle
flap is dissected inferiorly to below the orbital rim. The orbitomalar ligament is completely released so
that the skin is no longer fixed to the bone.
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Fat Removal, Relocation, and Augmentation
The orbital septum may be opened with iris scissors or cautery to expose the lower eyelid fat pads. Fat
may then be resected in a similar fashion as was described in the upper eyelid blepharoplasty or can be
redraped over the inferior orbital rim to address any tear trough deformity. It may also be harvested to
use as free fat grafts. Care must be taken to avoid injury to the inferior oblique muscle that divides the
nasal and central fat pads.
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Skin/Muscle Resection
The skin-muscle flap is then redraped superiorly and laterally and any excess overlapping skin and
muscle is excised. It is important to be conservative in the amount of skin resected because this can cause
retraction of the lower eyelid. Generally, only a few mm of skin is excised. Vicryl suture is used to
resuspend the orbicularis to the soft tissue and periosteum in the area of the lateral orbital rim to provide
mechanical support for the lower lid and prevent ectropion.
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Lateral Canthal Tightening
If the patient was found to have significant lower eyelid laxity during the preoperative evaluation, they
are at higher risk for ectropion with any skin resection and a lateral canthal tightening procedure should
be performed. A canthopexy can be used for mild laxity. This is performed by placing a mattress suture
through the edge of the tarsal ligament or tarsal plate and securing it to the periosteum inside the lateral
orbital rim. A canthoplasty or lateral tarsal strip addresses moderate to severe lower lid laxity. A
canthoplasty divides the tarsal ligament and reinserts it. In a lateral tarsal strip, the lid is redraped
laterally. The anterior lamella and lid margin in the area of excess lid overlapping the lateral canthus is
separated from the tarsus, and the extra lateral tarsus is removed. A mattress suture is then placed
through the new lateral end of the shortened tarsus and secured to the periosteum. When placing the
periosteal stitch, it is important to ensure proper height of the lateral canthus (2 mm above the medial
canthus).
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Closure
Close the skin with running fine suture (6-0 to 8-0). Sutures are removed in 7 days (Figure 50.13).
FIGURE 50.13 Four-lid blepharoplasty: preoperative (A) and postoperative (B).
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Transconjunctival Approach
The lower eyelid is retracted anteriorly to expose the palpebral conjunctiva. A scalpel or cutting cautery is
used to incise the conjunctiva just below the tarsal plate. The lower eyelid retractors are divided.
Dissection proceeds inferiorly, between the septum and orbicularis, to expose the fat pads and orbital
rim. The orbital malar ligament is completely released. Fat resection or relocation proceeds as earlier.
Some surgeons use a lower conjunctival incision, at about 4 to 5 mm below the tarsus, and go directly into
the fat pads. Lateral canthal support is generally not needed in a transconjunctival approach, as the
orbicularis is not weakened by division. If necessary, a small pinch of pretarsal skin can be resected. The
conjunctival incision can be closed with two or three interrupted absorbable sutures or may be left open
after the procedure.
Adjunct procedures, such as browlift, peels, laser, fillers, and muscle denervation can be added at the
time of blepharoplasty or can be performed later in the office. Severe festoons may require muscle
resection, redraping, or suspension along with midface lift, liposuction, or direct excision.
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Postoperative Care
Patients are advised to elevate their heads and apply cool compresses or ice to the eyelids for the first 24
to 48 hours. They may apply antibiotic ointment to the surgical incisions twice daily for 1 week. Patients
should avoid strenuous activity or bending below the waist for 2 weeks. Nonabsorbable sutures can be
removed 7 days after surgery. Patients should expect postoperative swelling and bruising to persist for
up to 2 weeks after surgery.
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Complications
Fortunately, complications are rare in blepharoplasty, but when present, can be devastating both
aesthetically and functionally. A full discussion of possible complications with documentation in the
record is prudent for every patient. Complications can be divided into acute and long-term risks.
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Acute Complications
Orbital Hematoma
The most feared complication of eyelid surgery is hemorrhage behind the orbital septum, which can
result in an orbital compartment syndrome and vision loss. Although rare, this needs immediate
attention. It generally happens in the operating room or in the first 24 hours postop and presents as
severe pain, pressure, and decreased vision. Examination is diagnostic as there is proptosis, limitation of
extraocular movements, and increased intraorbital pressure. This complication can be averted by careful
tissue handling to avoid traction of the fat pads and careful hemostasis of the base of the fat pad.
Preoperative considerations such as control of hypertension and the avoidance of aspirin and blood
thinners can decrease this risk as well. In the case of vision threatening hematomas, treatment is directed
at urgent opening of the incision for evacuation of the hematoma. A lateral canthotomy can be performed
to relieve intraorbital pressure. If the patient has developed vision loss, high-dose IV steroids should be
initiated to maximize visual recovery. Operative drainage of the hematoma is a surgical emergency.
Small eyelid hematomas without vision changes can be treated conservatively with elevation and ice.
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Corneal Abrasion
The patient presents immediately postoperatively with severe eye pain, tearing, and blurred vision with a
foreign body sensation. Ophthalmology consultation may use fluorescein and a Wood’s lamp to
document an abrasion. Abrasions are treated with frequent use of ophthalmic antibiotic ointment. The
use of scleral shields can help prevent this problem. Pain beyond 24 hours requires further
ophthalmologic evaluation.
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Lagophthalmos
Mild postoperative lagophthalmos (inability to completely close the eyes) is common and typically
resolves in the first few days after surgery. This can be managed with lubrication of the eyes. If is present
beyond the first week, it can typically be managed with ointment and massage of the upper eyelids.
Persistent lagophthalmos is usually the result of aggressive skin removal or scarring of the orbital
septum. Reoperation with lysis of scar tissue and/or skin grafting may be required in severe cases.
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Chemosis
Conjunctival edema is common after surgery and is usually self-limited. Artificial tears and a steroid
eyedrop/ointment can be prescribed if the swelling is severe. Topical ophthalmic steroid use should
always be temporary or monitored by an ophthalmologist as it can lead to elevated intraocular pressures
and glaucoma with long-term use.
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Infection
Infection is rare because of the excellent vascularity of the face. Eyelid surgery is considered clean surgery
and antibiotics are not generally used. Erythema and purulent discharge should be treated with
antibiotics and culture, and computed tomography may be necessary to evaluate for an orbital abscess.
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Corneal Exposure/Dry Eye
Dryness can be transient in the postoperative period and can be corrected with aggressive use of artificial
tears and lubricating ointments.
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Diplopia
The superior and inferior oblique muscles are the most commonly injured extraocular muscles in upper
and lower blepharoplasty, respectively. They can be injured either during fat resection, transconjunctival
dissection, or by traction. Diplopia is usually transient and is managed conservatively. Should it persists,
ophthalmologic evaluation is needed. Strabismus surgery or prism glasses may be used to correct
persistent diplopia.
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Epiphora
Tearing can result from irritation, inflammation, or rarely injury to the puncta or the canalicular pump
system. An altered lid position may also cause tearing. Tearing is usually transient.
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Long-Term Complications
Asymmetry
Asymmetry of the lid position or contour can occur in the immediate postoperative period as a result of
swelling and should be monitored initially. Asymmetry of the upper lid creases can be avoided by careful
and equal marking of the eyelid crease at the beginning of the procedure as well as uniform dissection of
fat.
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Lid Malposition
Ptosis of the upper eyelids can occur because of injury to the levator aponeurosis if surgical dissection
was carried too deep into the eyelid structures. Complications of lower eyelid blepharoplasty include
lower eyelid retraction, ectropion, and inferior scleral show. These typically occur when there is excessive
removal of skin and muscle. Upward massage of the lids can be attempted in the acute postoperative
period. Persistent ectropion and/or retraction may require surgical revision with skin grafting.
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Dry Eye Syndrome
Ocular surface irritation and dryness can persist despite good position of the lids and short-term use of
artificial tears. In these situations, it would be most appropriate to refer the patient to an ophthalmologist
for further evaluation and management.
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Unsightly Scars
Careful camouflage of the incisions in the upper crease and close to the lower eyelid are key to avoid a
noticeable scar. Medial scar extension can cause noticeable webbing.
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Outcomes
Interestingly, there are few outcome studies from the patients’ point of view. One outcome study used
the Face Q. They reported that the most common patient-reported adverse effects after eyelid surgery
included obvious, noticeable, or uneven scars (37%); dry eyes (35%), eye irritation (itching or redness) (33%); and
excessive tearing (25%). This is significantly different from physician-reported complications, although
global satisfaction is generally positive. Fortunately, most adverse effects are self-limited and fully
resolve.
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Conclusion
Blepharoplasty is a procedure that can improve both the function and the aesthetics of the eyelids. It is a
short operation, often under local anesthesia, with generally acceptable risk. Success of the procedure is
dependent on a detailed understanding of the eyelid anatomy as well as careful preoperative evaluation
and planning. Meticulous surgical technique helps the surgeon to attain the desired goals while avoiding
postoperative complications. Long-lasting improvement and satisfied patients make blepharoplasty a
popular operation in men and women of many age groups.
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Questions
1. A 56-year-old woman who desires a blepharoplasty is evaluated for ptosis. With the eye in
primary gaze, the margin of the upper lid should not be lower than which of the following positions?
a. 1 to 2 mm above the superior limbus
b. The level of the superior limbus
c. 1 to 2 mm below the superior limbus
d. The level of the superior pupil
2. A 39-year-old woman comes to the office complaining of dark circles under her lower eyelids that
make her look tired. Physical examination shows a prominent tear trough. What is the anatomic
basis of the tear trough?
a. Prominence of the orbital rim following ptosis of the malar fat pad
b. Osteocutaneous ligament between the palpebral and orbital parts of the orbicularis oculi
c. Herniation of the medial fat compartment over the arcus marginalis
d. Depression between the orbicularis oculi and levator labii superioris
3. As compared with an upper lid blepharoplasty with orbicularis muscle resection, a muscle sparing
upper lid blepharoplasty results in which of the following?
a. Less lagophthalmos
b. Faster recurrence of blepharochalasis
c. A superior aesthetic result
d. More dry eye symptoms
4. A 49-year-old man complains of double vision 2 weeks after a four-lid blepharoplasty. On
examination, he has vertical diplopia in primary gaze, and it increases in adducted upgaze. An injury
to which of the following muscles is probable?
a. Superior oblique
b. Inferior oblique
c. Inferior rectus
d. Superior rectus
5. Three days after a four-lid blepharoplasty, a patient complains of excessive tearing. Physical
findings include normal lid position and mild globe irritation without abrasion. The most
appropriate next step in management is
a. Observation
b. Jones I test
c. Anticholinergic drops
d. Pensieve test
6. Canthoplasty is differentiated from canthopexy by which of the following?
a. Disinsertion of the lateral canthus
b. Tightening of the canthus
c. Corrects lower lid laxity
d. Use of suture fixation
7. A 69-year-old woman who underwent a four-lid blepharoplasty complains of left eye pain,
pressure, and decreased vision in the recovery room. Examination shows left eye proptosis,
limitation of extraocular movements, and increased intraorbital pressure. A retrobulbar hematoma is
suspected. The sutures are released. Which of the following is the next most appropriate step?
a. Steroid bolus
b. Anterior compartment paracentesis
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c. CO2 inhalation
d. Lateral canthotomy
8. The threshold for adding a lid-supporting procedure to a lower lid blepharoplasty is a lower lid
distraction test of which of the following?
a. 4 mm
b. 6 mm
c. 8 mm
d. 10 mm
1. Answer: c. The normal eyelid is 1 to 2 mm below the superior limbus. A lid that is lower than this
needs to be recognized as ptotic, and this can be addressed surgically at the time of blepharoplasty. A
higher lid position suggests thyroid disease.
2. Answer: b. The tear trough ligament is an osteocutaneous ligament between the palpebral and
orbital portions of the muscle. It extends inferolaterally from the medial canthus to approximately
the midpupillary line, where it connects with the orbitomalar ligament.
3. Answer: a. If muscle is not resected, there is less retraction, and lagophthalmos is less likely.
Recurrence, outcome, and dry eye symptoms are equivalent.
4. Answer: b. The inferior oblique arises from the orbital surface of the maxilla, lateral to the lacrimal
sac and inserts into the scleral surface. Its primary action is extorsion (external rotation); secondary
action is elevation; tertiary action is abduction. The field of maximal inferior oblique elevation is in
the adducted position. A superior rectus palsy would present with limitation of upgaze in abduction,
and a superior oblique injury would have limited downgaze in adduction. An inferior rectus palsy
would limit abducted downgaze.
5. Answer: a. Acute tearing is usually self-limited and will resolve within weeks. Prolonged tearing
may be due to poor lid position or, rarely, an injured canalicular system. A Jones test evaluates
lacrimal outflow by placing fluorescein into the conjunctiva and then testing for it in the inferior
nasal meatus.
6. Answer: a. A canthoplasty divides the canthus before reinserting it. Both procedures tighten the
canthus by suture fixation and are used to correct lid laxity.
7. Answer: d. A lateral canthotomy should be done immediately to decrease pressure. Other
treatments such as steroids, mannitol, beta blockers, and acetazolamide all take longer to lower
pressure and are secondary measures.
8. Answer: b. A distraction of the lid from the globe of more than 6 mm is indicative of poor lid tone,
and lower blepharoplasty alone will cause ectropion. A canthopexy, canthoplasty, or lateral tarsal
strip is needed.
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BIBLIOGRAPHY
Cahill, KV, Bradley, EA, Meyer, DR, et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the
American Academy of Ophthalmology. Ophthalmology. 2011;118(12):2510.A review of 13 studies that demonstrate the improvement in vision,
peripheral vision, and quality of life activities with repair of upper lid dermatochalasis and blepharoptosis.
Damasceno, RW, Cariello, AJ, Cardoso, EB, et al. Upper blepharoplasty with or without resection of the orbicularis oculi muscle: a
randomized double blind left right study. Ophthal Plast Reconstr Surg. 2011;27:195.
Drolet, BG Sullivan, PK. Evidence based medicine medicine: blepharoplasty. Plast Reconstr Surg. 2014;133:1195.
Espinoza, GM, Holds, JB. Evaluation and treatment of the tear trough deformity in lower. Blepharoplasty Semin Plast Surg. 2007;21:57.
Faigen, S. Advanced rejuvenation upper blepharoplasty. Plast Reconstr Surg. 2002;110:278.
Fleury, CM, Schwitzer, JA, Hung, RW, Baker, SB. Adverse event incidences following facial plastic surgery procedures: incorporating FACE-
Q data to improve patient preparation. Plast Recosntr Surg. 2018;141:28e.
Ghabrial, R, Lisman, R, Kane, M, et al. Diplopia following transconjunctival blepharoplasty. Plast Reconstr Surg. 1998;102:1219.
Hashem, AM, Couto, RA, Waltzman, JT, et al. Evidence-based medicine: a graded approach to lower lid blepharoplasty. Plast Reconstr Surg.
2017;139(1):139e-150e.Accurate diagnosis of the problems in the lower lids is used for a graded, individualized correction of fat excess, tear trough, lid-
cheek junction abnormalities.
Hoorntje, LE, Lei, BV, Stollenwerck, GA, Kon, MJ. Resecting orbicularis oculi muscle in upper eyelid blepharoplasty: a review of the
literature. Plast Reconstr Aesthet Surg. 2010;63(5):787-792.
Jindal, K, Sarcia, M, Codner, M. Functional considerations in aesthetic eyelid surgery. Plast Reconstr Surg. 2014;134:1154.
Kiang, L, Deptula, P, Mazhar, M, et al. Muscle-sparing blepharoplasty: a prospective left-right comparative study. Arch Plast Surg.
2014;41(5):576-583.A randomized prospective study of 22 patients with skin-only upper lip blepharoplasty on one side and muscle-skin resection on the
other.
Kiranantawar, K, Suhk, JH, Nguyen, AH. The Asian eyelid: relevant anatomy. Semin Plast Surg. 2015;29:158.Thorough discussion of the various
types of Asian eye anatomy variations in crease, skin, fat, and epicanthal folds.
Korn, BS, Kikkawa, DO, Cohen, SR. Transcutaneous lower eyelid blepharoplasty with orbitomalar suspension: retrospective review of 212
consecutive cases. Plast Reconstr Surg. 2010;125(1):315-323.
Kpodzo, DS, Nahai, FC, McCord, CD. Malar mounds and festoons: review of current management. Aesthet Surg J. 2014;34(2):235.Reviews the
terminology and anatomy of mounds and festoons, and gives a treatment algorithm for these difficult problems.
Friedland, JA, Lalonde, D, Rohrich, R. An evidence-based approach to blepharoplasty. Plast Reconstr Surg. 2010;126:2222.
Lellli, GJ, Lisman, RD. Blepharoplasty complications. Plast Reconstr Surg. 2010;125:1007.
LoPiccolo, MC, Mahmoud, BH, Liu, A, et al. Evaluation of orbicularis oculi muscle stripping on the cosmetic outcome of upper lid
blepharoplasty: a randomized, controlled study. Dermatol Surg. 2013;39:739.
Miranda, SG, Codner, MA. Micro free orbital fat grafts to the tear trough deformity during lower blepharoplasty. Plast Reconstr Surg.
2017;139:1335.
Muzaffar, AR, Mendelson, BC, Adams, WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast
Reconstr Surg. 2002;110(3):873.Excellent cadaver study that describes the anatomy of the orbicularis retaining ligament (also called the orbitomalar
ligament) and discusses its implications in the aging eyelid.
Pacella, S, Codner, M. Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show. Plast Reconstr
Surg. 2010;125:709.
Ramil, M. Fat grafting in hollow upper eyelids and volumetric upper blepharoplasty. Plast Reconstr Surg. 2017;140:889.
Rohrich, R, Pezeshk, R, Sieber, D. The six step lower blepharoplasty: using fractionated fat to enhance blending of the lid cheek junction.
Plast Reconstr Surg. 2017;139:1381.A step-by-step guide to a lower lid blepharoplasty with additional video demonstrations.
Tonnard, PL, Verpaele, AM, Zeltzer, AA. Augmentation blepharoplasty: a review of 500 consecutive patients. Aesthet Surg J.
2013;33(3):341.The modern concept of fat replacement rather than resection is highlighted here as fat obtained by liposuction is used as micrografts in
500 consecutive upper and lower blepharoplasties.
Wong, CH, Mendelson, B. Extended transconjunctival lower lid blepharoplasty with release of the tear trough ligament and fat
redistribution. Plast Reconstr Surg. 2017;140:273.
Zoumalan, CI, Roostaeian, J. Simplifying blepharoplasty. Plast Reconstr Surg. 2017;137:196e.
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C H A P T E R 5 1
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Facelift and Necklift
Gabriele C. Miotto and Foad Nahai
Key Points
Facial anatomy as it is applied to facial rejuvenation
Patient evaluation by thorough history, physical examination in the preoperative planning; safety
checklist
Surgical technique selection and different applications
Postoperative care and patient management
Common complications and adequate management strategies for good results and patient
satisfaction
Facial aging is a multifactorial process involving the skin, soft tissues, and facial skeleton. The major goal
of facial rejuvenation is to restore smooth contours and soft transitions between facial units. As the face
ages there are predictable surface, volume, and positional changes acting as landmarks for soft tissue
manipulation and repositioning. Facial skeleton work is limited in facelift. Soft tissue augmentation with
autologous fat transfer can significantly improve structural bony deficiencies and is included frequently
to enhance results in facial rejuvenation surgery. 1,2
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Anatomy
Skin
Intrinsic and extrinsic factors contribute to aging of the skin. Intrinsic factors such as epidermal thinning,
dermal elastosis, decreased elasticity, and decreased collagen production are hallmarks of normal aging.
Chronic UVA exposure, smoking, radiation, and chronic diseases are extrinsic factors that accelerate skin
aging.
Permanent skin wrinkling and dark spots are visual characteristics of photoaging. They are best treated
through skin care and resurfacing procedures such as chemical peels and lasers. Skin wrinkling with
dynamic movements is best treated with neuromodulators or selective muscle ablation procedures, such
as corrugator muscle resection. Facelifting techniques have little effect on skin texture, elasticity, and
discoloration, but they improve folds resulting from tissue shifting and descent.
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Retaining Ligaments and Fat Compartments
Described by Furnas in 1989, retaining ligaments are fibrous structures in predictable locations of the face
connecting bone to the overlying facial skin, crossing all layers of soft tissue. Alghoul and Codner
reviewed and clarified the nomenclature of the retaining ligaments of the face by integrating earlier
descriptions. 3 Retaining ligaments are landmarks for facial rejuvenation procedures as they separate
facial fat compartment, are intimately related to the branches of the facial nerve, and are structural
components of facial support and aged appearance (Figure 51.1). Laxity of the ligaments and fat
compartment deflation create visible surface depressions and creases seen with aging.
FIGURE 51.1 The retaining ligaments of the face and different nomenclatures since the initial description by Furnas in 1989.
(Adapted from Alghoul, M, Codner, MA. Retaining ligaments of the face: review of anatomy and clinical applications. Aesthet Surg J. 2013;33(6):769-782.
Reproduced by permission of The American Society for Aesthetic Plastic Surgery, Inc.)
The facial fat compartments are pockets of facial adipose tissue confined within a relatively impermeable
membrane (the septum). Fat compartments are divided into superficial and deep in relationship to the
superficial musculoaponeurotic system (SMAS). 4 They exist in the forehead, periocular, cheek, and
perioral areas, and are separated by retaining ligaments and septa that determine the location of the fat
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compartments. 5 During facelift, the deep and superficial cheek compartments may be repositioned
and/or refilled.
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Superficial Musculoaponeurotic System and Mimetic Muscles
The term superficial musculoaponeurotic system (SMAS) was popularized by Mitz and Peyronie in 1976,
describing the SMAS as a superficial fascia investing the face and the superficial mimetic muscles. It is
contiguous with the galea aponeurotica, the temporoparietal fascia, parotid masseteric fascia, platysma
muscle, and superficial cervical fascia. The SMAS is an important anatomical structure for facial
rejuvenation and is often divided into mobile and fixed SMAS. The fixed SMAS is firm and lateral over
the parotid gland. The mobile SMAS is softer and medial, over to the zygomatic and masseteric retaining
ligaments toward the central face. The mobilization and suspension of the mobile SMAS to the fixed
SMAS is an essential step in any SMAS facelift. It lifts and repositions descended facial tissues. The SMAS
lies on top of the deep facial fascia, a layer protecting the branches of the facial nerve. Sub-SMAS
dissections may result in facial nerve injury if the deep fascia is violated.
The mimetic muscles of the face are arranged in layers according to their origin and insertion. The
superficial mimetic muscles include the zygomaticus major and minor, levator labii superioris, risorius,
depressor anguli oris, orbicularis oculi, and orbicularis oris. The deeper facial muscles include the
buccinator, mentalis, and depressor labii. The most superficial layer of muscles is intimately related to the
medial extension of the SMAS. Traction and suspension of the SMAS will also suspend the muscles.
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Motor and Sensory Nerves
The facial nerve (seventh cranial nerve) innervates the mimetic muscles and has five main branches:
temporal, zygomatic, buccal, mandibular, and cervical. The facial nerve emerges from the stylomastoid
foramen and enters the parotid gland where it branches. Within the parotid gland, the branches of the
facial nerves are deeply located, deep to the parotid fascia, and they become more superficial at the
anterior boarder of the gland. The facial nerve branches transition from the deep superficial fascia
through SMAS fusion zones and retaining ligaments. They run as deep as possible until they reach the
edge of the muscles they innervate. 6
The facial nerve usually innervates the superficial mimetic muscles through their deep surfaces (the
zygomaticus major and minor, levator labii superioris, risorius, depressor anguli oris, orbicularis oculi,
and orbicularis oris) and the deeper facial muscles such as the buccinator, mentalis, and depressor labii,
from the superficial surface. Facial nerve injury is rare in facelift surgery with an estimated incidence of
below 1%. Permanent loss of function from injury is estimated to be around 0.1% in most cases.
The trigeminal nerve (fifth cranial nerve) is the sensory nerve of the face. The great auricular nerve is a
nerve of the cervical plexus (C2, C3) that provides the dominant sensory innervation to the ear (lobule,
concha, and posterior auricle). It is also the most common nerve injured in facelift surgery. 7
These are known as “zones of danger” of the face, where the main nerves are most vulnerable to injury
during face and necklift dissections (Figure 51.2). 8
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FIGURE 51.2 Zones of danger for nerve injury during face and necklift. The eight zones are indicated and correspond to both
sensory and motor nerve danger areas. (1) The frontal branch is vulnerable to injury as it crosses the zygomatic arch 2.5 cm
anterior to the external auditory meatus deep into the temporoparietal fascia. (2) The zygomatic branch is vulnerable during the
zygomatic retaining ligaments release. (3) The buccal branch is vulnerable during dissection at the anterior edge of the parotid
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and during buccal fat pad manipulation. (4) The marginal mandibular branch is vulnerable during lateral platysma work and
submental dissections as it exits the parotid inferiorly and runs along the mandibular angle. (5) The great auricular nerve branch
is vulnerable when dissecting the posterior neck, as it emerges at the posterior border of the sternocleidomastoid muscle, about
6.5 cm inferior to the exterior auditory canal. (6) The supraorbital and supratrochlear nerves are vulnerable during brow lifts and
dissections along the supraorbital rim, such as during transpalpebral corrugator resections. (7) The infraorbital nerve is
vulnerable during deep dissections of the midface in subperiostal or supraperiostal midfacelift. (8) The mental nerve is
vulnerable during deep fat grafting injection in the prejowl sulci and during chin augmentation procedures.
(Adapted by permission from Seckel, BR. Facial danger zones: avoiding nerve injury in facial plastic surgery. Can J Plast Surg. 1994;2(2):59-66. Copyright ©
1994 SAGE Publications.)
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Vascular Supply
The main blood supply to the soft tissues of the face comes from branches of the external carotid artery
and internal jugular vein (Figure 51.3). The main arterial supply to the central face is the facial artery. The
facial artery branches off the external carotid in the neck and crosses over the mandible approximately
3 cm from its angle to run into the face, deep into the mimetic muscles. Its branches are the submental
artery, upper and lower labial arteries, angular artery, and nasal artery. This rich arterial network allows
for the elevation of a facelift flap. The infraorbital artery, another branch of the external carotid artery
(from the maxillary artery), also supplies the medial cheek and lower lid. The lateral face is supplied by
the transverse facial artery. The transverse facial artery branches off the superficial temporal artery at the
level of the external auditory meatus and travels anteriorly supplying the lateral face and lateral orbital
area. The territories of the facial artery and transverse facial artery overlap in the cheek. The superficial
temporal artery provides blood supply to the lateral forehead and scalp.
FIGURE 51.3 Vascular supply to the face.
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The facial vein provides the main venous drainage of the face. It runs parallel to and behind the facial
artery and flows into the internal jugular vein.
The internal carotid artery and vein also contribute to the vascular supply of the face, mainly in the
periocular area and forehead through the supratrochlear and supraorbital vessels.
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Patient Evaluation
Good results in facial surgery rely on facial analysis and understanding of the patient’s anatomy,
including morphology and the extent of aging. Aesthetic analysis is done by dividing the face into
horizontal thirds and vertical fifths (Figure 51.4). It includes assessment of the skin surface, facial volume,
and position of facial structures. The neck is included in the lower horizontal third of the facial analysis,
because neck aging is also addressed with a facial rejuvenation surgery. Differences in width and length
of each side of the face should be noted. The volume and position of tissues will define the need for
asymmetrical undermining and SMAS elevation, or a combination of a facelift with fat grafting. 9
FIGURE 51.4 Upper third (periorbital zone) starts at the hairline (trichion) to mid cheek. Middle third (perioral zone) starts at the
mid cheek (line over zygomatic arches) to the chin (mentum). Lower third goes from the mentum to the sternal notch and upper
border of the clavicles. Lines crossing the inner and lateral canthus divide the face into vertical fifths.
Evaluation of the skin includes skin type, pigment changes, wrinkles, elasticity, and thickness.
Dyschromias are common concerns for patients looking for facial rejuvenation and the choice of skin
resurfacing often depends on the skin type. Poor skin elasticity and severe degree of wrinkling should
alert the surgeon that a combination of surgery and resurfacing procedures would provide the best
results.
The Fitzpatrick classification is a useful guide for planning skin-resurfacing procedures. 10 Patients with
Fitzpatrick skin type I–III are generally good candidates for skin resurfacing procedures such as
dermabrasion, with lower risk of postinflammatory hyperpigmentation, hypopigmentation, and
blotchiness. For patients with skin types IV–VI, the risks are weighed against potential benefits, and other
treatments (nonablative laser rejuvenation, microneedling, and superficial chemical peels) may be
considered.
Special consideration should be given to certain skin pathologies. Patients diagnosed with cutis laxa, a
rare connective tissue disorder that presents with varied degrees of loose hypoelastic skin throughout the
body, are candidates for elective aesthetic surgery because there is no underlying issue with wound
healing. Patients with genetic connective tissue disorders such as Ehlers-Danlos syndrome,
pseudoxanthoma elasticum, elastoderma, progeria, and Werner syndrome have limited and
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unpredictable wound healing and should not undergo elective procedures. 11
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Anesthesia Evaluation
Preoperative evaluation is performed by a thorough history and physical examination with the assistance
of the anesthesia team. According to the American Society of Anesthesiology preoperative evaluation
guidelines, preoperative tests should not be ordered routinely but may be required for purposes of
guiding or optimizing perioperative management of selected patients. 12 If the patient has chronic medical
issues, the preoperative evaluation may include an ECG, clearance from a specialist, X-rays, and
adjustment of current medications. Secondary facelift patients are usually older and may require a more
extensive preoperative evaluation and management in the postoperative period. Identification of high-
risk patients for VTE events is done with the use of a modified Caprini risk assessment scale as proposed
by the American Society of Plastic Surgery. 13 Perioperative pneumatic compression pump and early
ambulation are useful for all facelift patients. For patients with Caprini scores higher than 7, 40 mg of
subcutaneous enoxaparin is used as a single dose 8 to 12 hours postoperatively or extended to a week of
treatment according to preoperative clinical evaluation.
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Facelift Techniques
Incisions
Facelift and necklift techniques include periauricular skin incisions, varying degrees of skin undermining,
and different SMAS manipulation maneuvers. Incisions in front of the ear extend from the base of the ear
lobe, into the pretragal or retrotragal area, and then transition along the hairline or into the temporal
scalp. Incisions behind the ear are placed just anterior to the retroauricular crease and usually curve
posteriorly at the level of the tragus into the hairline or into the occipital scalp (Figure 51.5). The term
short-scar facelift was coined by Baker, referring to a limited incision length around the ear for patients
who do not have severe skin laxity in the neck. 14
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