Anatomical conditions and the type of facelift to be performed

The fundamental decision about the type of facelift surgery that will be performed on a particular patient is based primarily on the patient's condition as recorded during the physical examination during the consultation. Not all patients require the same surgical procedure to achieve a satisfactory result. There are three basic types of facelift procedures, based on the general categories of surgical procedure required to achieve a satisfactory result. This chapter will describe procedures that involve minimal dissection, create folds or overlap sutures of the underlying SMAS, treat the platysma, or penetrate deeper into the face, including a subperiosteal approach. Most decisions are made based on the patient's condition and the surgeon's views on what he or she expects as the long-term results of the surgery.

The fundamental idea of the facelift is based primarily on certain anatomical relationships of the tissues. The elasticity and condition of the overlying skin, including the degree of sun damage and wrinkle formation, are important. The relationship with the subcutaneous fat must be taken into account, including changes in position due to gravity, true sagging, or abnormal accumulation and distribution. The fascial structure of the face, midface, and neck is such that the facial musculature is enveloped by a continuous fascia extending to the parotid region. This fascia, bordering the platysma, is the SMAS, first described by Mitz and Peyronnie as a dynamic contractile and fibromuscular network. The fascia lying even deeper is the superficial layer of the deep neck fascia, which envelops and covers the sternocleidomastoid muscle and the parotid tissues. It lies on top of the superficial layer of the fascia of the temporalis muscle and the periosteum of the frontal bone. The SMAS borders the tendinous helmet of the cranial vault. On the neck in front, the platysma muscle may be pectinate, forming connecting loops. Ptosis and divergence of the anterior edges of the platysma muscle are often noted, which forms stripes on the neck. It is very important that there is a SMAS layer, which allows surgical facelifting to be performed in a deeper plane than was done in the first rhytidectomies. In the cephalic and posterior directions, only the skin was isolated, separated, excised and sutured, which, due to its inherent phenomenon of creeping and reverse contraction, was often not held in place for a long time. Therefore, when the intervention was carried out only in this layer, the effectiveness of the surgical lift was short-lived. The skin, especially in the middle and central areas of the face, is directly connected to the SMAS by strong fibrous fibers of the dermis. Often these fibers are accompanied by vessels penetrating from the deep vascular systems into the superficial cutaneous plexus. It is easy to demonstrate that lifting and moving the SMAS layer with its integral connections to the platysma and midface muscles lifts and moves the skin in the same manner. The superoposterior vector of tension of this fascia moves the facial tissues into a position that gives a more youthful appearance. The effects of gravity on these anatomical structures are directly corrected by facelift surgery.

It is also important to understand the anatomical relationships of the sensory and motor nerve branches of the face, which provide skin sensitivity and the functioning of the facial muscles. This applies to the consequences of surgical lifting for all patients, since the loss of sensitivity and paresthesia, which are usually temporary, can become permanent. The 5th pair of cranial nerves provides sensitivity to the skin surfaces of the face, head and neck. The fact that any type of surgical facelift requires separation of a certain part of the skin in the parotid and retroauricular areas makes it necessary to disconnect the innervation of this part of the face. Usually, if the main branch of the great auricular nerve is not damaged, skin sensitivity is restored in a relatively short time. The patient may notice this in the first 6-8 weeks, but sometimes complete recovery requires 6 months to a year. In rare cases, the patient may complain of a general decrease in skin sensitivity compared to the preoperative level for more than a year. Sympathetic and parasympathetic reinnervation of the skin occurs faster in the postoperative period. Although the most common site of injury during a facelift is the great auricular nerve at its intersection with the sternocleidomastoid muscle, this rarely results in permanent loss of sensation in the ear and parotid skin. Direct injury to this very large and prominent nerve branch may occur during the process of separating the skin from its attachments to the superficial fascia of the sternocleidomastoid muscle by incising this fascia. If injury is discovered during surgery, suturing of the nerve is indicated; recovery of function should be expected within 1 to 2 years.

The motor branches to the facial muscles are at potential risk during surgical lifting. The branches of the facial nerve become very superficial after they extend beyond the parotid masseter fascia. The branch at the border of the mandible is at risk at the intersection of the bony border of the jaw deep to the subcutaneous muscle and the superficial layer of the deep fascia of the neck. Techniques that require separation of the deep layer involve undercutting the SMAS in the midface, which poses a risk of damaging the branches to the orbicularis, zygomaticus, and buccinator muscles. These muscles are innervated from their inner surfaces, and even a dissection in the deep plane will be more superficial than them. Direct visualization of the nerve is a step in the operation and will be discussed later in this chapter.

During facelift surgery, with or without a forehead lift, the frontal branch of the facial nerve is most often injured. At the level of the zygomatic arch, it is located very superficially and goes immediately deeper than the subcutaneous tissues, located under a thin layer of the temporal part of the SMAS, and then innervates the inner surface of the frontalis muscle, the greatest risk of injury to this branch when crossing this area approximately 1.5-2 cm in front of the ear, midway between the lateral edge of the orbit and the temporal hair bundle. To prevent nerve injury, it is necessary for the surgeon to understand the anatomical relationships of the layers of the face and the temporal region. It is possible to lift the skin all the way to the lateral angle of the eye, the skin of the parotid region covering the zygomatic arch, to the orbicularis muscle, and also to dissect directly in the subcutaneous layer. In addition, the surgeon can freely dissect under the frontal fascia, under the tendinous helmet, superficial to the periosteum and superficial fascia of the temporalis muscle without damaging the frontal branch of the facial nerve, which is superficial to this avascular layer. However, at the level of the zygomatic arch, it is necessary to go under the periosteum, otherwise damage to the facial nerve will occur, which is located in the same tissue plane covering the zygomatic arch. Reinnervation of the frontal muscle may or may not occur if the nerve in this area is damaged.

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