Basics of plastic facial surgery

After taking into account all the general considerations, evaluation of the areas of the face is performed. Practical technique consists in the system evaluation of individual aesthetic units of the face.

These units represent the forehead and eyebrows, the peri-ocular region, the cheeks, the nose, the circumoral region and the chin, and also the neck. However, one should remember that one must take into account how the features of different units interact with each other, creating a harmonious or inharmonious appearance.

[1], [2]

Plastic surgery of the forehead

Probably, no other area of the face experiences as many surgical interventions as an aging forehead and eyebrows. Knowledge of anatomy and aesthetics of the upper third of the face is necessary to perform adequate rejuvenation operations. The layers of the frontal region are the continuation of the layers of the scalp (scalp). Mnemonically, the word "scalp" (SCALP) describes five layers of the forehead: S (skin) - skin, C (subcutaneous tissue) - subcutaneous tissue, A (galea aponeurotica) - tendon helmet, L (loose areolar tissue) - loose connective tissue, and P (pericranium) is the periosteum of the bones of the cranial vault. The skin is attached to the subcutaneous tissue. The tendon helmet surrounds the entire cranial vault, front and back intertwining into the frontal and occipital muscles. Below the upper temporal line the helmet becomes a temporoparietal fascia. Loose areolar tissue (the under-layer layer) is between the tendon helmet and the periosteum. This is an avascular layer, allowing the helmet and more superficial tissues to slide over the periosteum. The latter is a thick layer of connective tissue attached to the outer plate of the bones of the cranial vault. In the place where the upper and lower temporal lines meet, the periosteum merges with the temporal fascia. The pacifier also passes into the perior-bital fascia at the level of the upper edge of the orbit.

The movements of the forehead and eyebrows are provided by four muscles: the frontal muscle, the muscle of the proud, the muscle that wrinkles the eyebrow, and the ocular part of the circular eye muscle. Paired frontal muscles have a clear separation along the middle line. The frontal muscle departs from the tendon helmet and merges with the muscles of the proud, the muscle that wrinkles the eyebrow, and the circular eye muscle. The frontal muscle has no bone attachments. It interacts with the occipital muscle through attachment to the tendon helmet, displacing the scalp. The frontal muscle raises an eyebrow. Transverse frontal folds are caused by a chronic contraction of the frontal muscle. The loss of innervation of the frontal muscle leads to the omission of eyebrows on the injured side.

The paired muscle, wrinkling eyebrow, departs from the frontal bone near the uppermost edge of the orbit and goes through the frontal and circular muscles of the eye, penetrating into the dermis of the middle part of the eyebrow. She pulls her eyebrow medially and down; excess stress (shearing of the eyebrows) causes the formation of vertical furrows over the bridge of the nose. The muscles of the proud have a pyramidal shape and come from the surface of the upper lateral cartilage and the bones of the nose, penetrating into the skin in the region of the glabella (glabella). Reduction causes the lowering of the medial edges of the eyebrows and the formation of horizontal lines above the root of the nose. Circular muscles surround each orbit and pass to the eyelids. They come from the periosteum of the medial edges of the orbit and are introduced into the derma of the eyebrows. These muscles are divided into the ophthalmic, eyelid (upper and lower) and tear parts. The upper medial fibers of the circular muscle lower the medial part of the eyebrow. These fibers are called a muscle that lowers the eyebrow. The muscle, the wrinkling eyebrow, the muscle of the proud and the circular muscle of the eye interact, closing the eye, and are antagonists of the movements of the frontal muscle; their excessive use causes horizontal and vertical lines above the bridge of the nose.

Classically described position of the eyebrows in a woman has the following criteria: 1) the eyebrow begins medially at the vertical line drawn through the base of the nose wing; 2) the eyebrow ends laterally in an oblique line drawn through the outer corner of the eye and the base of the nose wing; 3) the medial and lateral ends of the eyebrows are approximately at one horizontal level; 4) the medial end of the eyebrow is clavate and gradually thinens laterally; 5) the upper point of the eyebrow lies on a vertical line drawn directly through the lateral limb of the eye. Some believe that the top, or the upper part of the eyebrow, should ideally be more lateral; that is, the vertex is located on a vertical line drawn through the outer corner of the eye, which is opposite to the lateral limb.

Some classical criteria apply to men, including the location of the top, although the entire eyebrow has a minimal bend and is located on the upper edge of the orbit or immediately above it. Excessive lateral rise of the eyebrow, causing bending of the eyebrows, can feminize the male eyebrow. Excessive medial lifting causes a "bewildered" appearance. In comparison with the male, the female forehead is smoother and more rounded, with less pronounced superciliary arches and a less sharp nasolobic angle.

The two main, age-related changes in the upper third of the face are the omission of the eyebrows and lines, the appearance of which is associated with excessive mobility of the face. Omission of the eyebrows is mainly caused by gravity and loss of the elastic component of the dermis. This can give a gloomy or angry look to the eyes and eyebrows. The eyebrow should be inspected for any asymmetry that accompanies bilateral sagging. When unilateral omission, one should think about etiological factors (such as paralysis of the temporal nervous branch). What at first may seem like an excess of the skin of the upper eyelid (dermatochalasis), in fact, may be the omission of the forehead skin. Clinically, this most obviously looks like "side bags" over the upper eyelids. They can be large enough to limit the upper-side visual fields, giving functional indications for surgical intervention. Attempts to excise the saccate skin folds exclusively by blepharoplasty will only lower the lateral edge of the eyebrow down, exacerbating the ptosis of the eyebrow.

In addition to lowering the eyebrows, the aging upper third of the face is characterized by lines of increased mobility. These furrows are caused by repeated stretches of the skin, produced by the facial muscles subject to facial muscles. Chronic contraction of the frontal muscle in the upper position leads to the formation of transverse furrows on the forehead: in general, the frontal muscle gives its own, non-surgical lifting. Repeated frowning excessively uses muscles of the proud and muscles, wrinkled brows. This, respectively, leads to the formation of horizontal furrows at the root of the nose, as well as vertical furrows between the eyebrows.

With excess skin of the upper eyelids, additional actions such as blepharoplasty are necessary, since this allows you to mask the incision in the eyebrow area. The height of the forehead should also be assessed, because some interventions not only perform lifting, but also improve (increase or decrease) the vertical height of the forehead for a second time. In general, whereas all operations on the forehead raise armor and forehead. Eyebrow lifting has a different effect (if this is the case) on the forehead.

Plastic surgery of the circumorbital area

The peripheral region includes the upper and lower eyelids, the areas of the inner and outer corners of the eyes, and the eyeball. Again, you need to evaluate the size, shape, location and symmetry of the individual components. In assessing, it is necessary to take into account the characteristics of the rest of the face. The distance between the corners of the eyes should roughly correspond to the width of one eye. In Europeoids, this distance should also be equal to the distance between the wings of the nose at its base. Negroids and Mongoloids do not always have this rule because of the wider base of the nose.

The main muscle in this area is the circular muscle of the eye. This muscle is innervated by the temporal and zygomatic branches of the facial nerve. The glabular part of this muscle surrounds the orbit and contracts like a sphincter, causing blinking. This part of the muscle on the side is attached to the skin of the temporal and zygomatic areas, which creates wrinkles and crow's feet as the face ages.

The earliest signs of aging often appear on the eyelids. This is mainly due to sagging of the skin (dermatochalasis), the formation of false hernial protrusions of orbital fat through the orbital septum, as well as hypertrophy of the circular muscle. The most frequent problem of the upper eyelids is derma-tohalasis, followed by the formation of protruding fat pads. This problem is coping well with the traditional musculoskeletal upper blepharoplasty with the removal of fat.

On the lower eyelids, skin, fat and muscle problems are often observed in isolation or in combination. Isolated false fatty hernias are often observed in fairly young patients and are corrected by transconjunctival blepharoplasty. A small dermatochalysis can be affected by limited excision of the skin, chemical peeling or laser polishing. Many very young patients have isolated hypertrophy of the circular eye muscle, usually following frequent glances to the side. This is often observed in people who smile professionally, such as leading news programs or politicians. The manifestation of such hypertrophy is a thin cushion but the edge of the lower eyelid, which requires the excision of the muscle or the reduction of its volume.

Skull sacks should be distinguished from festons. Skull sacs are edematous, sagging areas bordering on the aesthetic region of the cheek, accumulating fat or liquid with age. They sometimes require direct excision. On the other hand, festons usually contain an invaginated muscle and skin. They can be corrected during extended lower blepharoplasty.

Other ocular problems such as ovulation, anophthalmos, proptosis, exophthalmos, sagging or dislocation of the lower eyelids and the formation of lateral sacs should be evaluated. As noted above, the side bags are formed due to the lowering of the eyebrows, as well as the presence of excess skin of the eyelids. To assess the sagging of the lower eyelid, a plucked test is usually used when the lower eyelid is caught between the thumb and forefinger and pulled from the eyeball. An abnormal result is a delayed return of the eyelid to the surface of the eyeball or its return only after blinking. Also noted is the exposure of the sclera under the lower eyelid or ectropion (eyelid turn of the century). Approximately 10% of the normal population has a scleral outcrop under the lower eyelid, not related to age. Enophthalmus may indicate anterior orbital trauma and may require its reconstruction. Exophthalmos may be due to Graves' orbitopathy, which makes endocrinology necessary. Incorrect position of the eyeball or dysfunction of the extraocular muscle requires consultation of an ophthalmologist and taking pictures of the orbit.

Ptosis, entropion (the turn of the edge of the century), ectropion and excessive sagging of the lower eyelid can be corrected during blepharoplasty. Lines of excess mobility, such as "crow's feet," can not be eliminated without interference on the facial muscles. This can be achieved by paralyzing or destroying the branches of the facial nerve that innervate the muscles. In practice, the method of chemical paralysis by botulinum toxin is used.

Plastic surgery of cheeks

The cheeks form an aesthetic unit that extends to the parotid fold laterally, to the nasolabial fold medially, as well as to the zygomatic arch and the lower edge of the orbit to the top and to the lower edge of the lower jaw to the bottom. The most noticeable reference point on the cheek is the cheek (paint) elevation. The skulal elevation consists of the malar and maxillary bones. The pronounced zygomatic prominence is a sign of youth and beauty. The spine elevation gives the person a form and strength. Underdevelopment of the cheekbones can be caused by underdevelopment of the anterior surface of the maxillary bone or, laterally, by the undeveloped protuberance of the malar bone.

The cheeks can be divided into three layers. The deepest layer consists of the buccal muscle (trumpet muscles), which extends from the deep fascia of the face and interlace with the circular muscle of the mouth at the mouth commissure. The next layer is represented by m. Caninus (according to the Paris nomenclature, the muscle that lifts the corner of the mouth) that comes from the canine fossa and the square muscle of the upper lip, which has three sections that extend from the region of the upper lip (according to the Paris nomenclature it is a small zygomatic muscle, a muscle that lifts the upper lip and muscle Lifting the upper lip and the wing of the nose).

How m. Caninus, and the square muscle of the upper lip are embedded in the circular muscle of the mouth. Finally, the large zygomatic muscle and the muscle of laughter are connected at the side commissure. All these muscles move away from the bony projections on the upper jaw or the wing-and-jaw joint. They end either in the superficial fascia of the perioral skin, or in the deep musculature of the upper lip. They are innervated by the zygomatic and buccal branches of the facial nerve. These muscles cause the movement of the middle third of the face upwards and laterally, which gives it a happy expression.

The fatty body of the cheek is a constant component of the chewing space. Interestingly, its severity is not related to the general degree of obesity of a person. It consists of the main part and three main processes: the temporal, buccal and pterygium. Significant cheekbones can be partially associated with the lowering of the buccal fat. Clinically lowered buccal fat may look like an excess of the volume of the lower cheeks or cheeks full in the middle part of the body of the lower jaw.

The fatty body of the cheek is detected through an intraoral incision above the third maxillary molar. Here, surgically important formations are the excretory duct of the parotid salivary gland and the buccal branch of the facial nerve. Thus, it is important not to chase after all the chew fat, but to remove only the fat that tends to perform.

Depending on the nasolabial border and the severity of the nasolabial fold, part of the cheek lateral and immediately at the border, consisting of a painting fat pad and skin covering it, undergoes age-related changes. Nasolabial fold is probably the most prominent fold on the face. It is the result of the direct attachment of facial muscles to the skin or movement forces transmitted by the superficial muscular-aponeurotic system (SMAS) to the skin through vertical fibrous septa. With age, fat atrophy occurs in the upper and middle parts of the face, as well as its deposition in the sub-chin. Formation with the aging of the submarine cavity leads to the form of sunken cheeks.

The spinal elevation can be enlarged by implants, which can be installed through intraoral access. A rhytidectomy with the right direction of tension combined with an increase in the zygomatic exaltation can help reduce the severity of the nasolabial fold. The nasolabial border can be directly smoothened by implantation or advanced rhytidectomy. A complete elimination of this fold is impossible; and this is probably undesirable, since it is an important element of the person separating the buccal aesthetic unit and the nasolabial area. Rhytidectomy can also improve the outline of the lower edge of the lower jaw and move the buccal fat pad.

Plastic surgery of the nose

The nose is the most prominent of the aesthetic units of the face because of its central location in the frontal plane and protrusion in the sagittal plane. The slightest asymmetry and deviations are more noticeable here than in other areas of the face. Proportions of the nose should be in harmony with the rest of the face and body structure. A long, thin nose looks inappropriate for a short, stocky man with a broad face, as well as a broad, short nose in a tall, slender man with an elongated face.

Muscles of the nose pyramid are rudimentary in nature and have a small effect on the static and dynamic appearance of the nose. Exceptions are the muscles widening the nostrils and lowering the nasal septum, which come from the upper lip and go to the bottom of the nose and nasal septum.

The nose is usually described with the indication of its length, width, protrusion and turn. To describe the nose and its relationship with the rest of the face, different angles and dimensions are used. In general, the back of the nose allows a smooth bend downward, from the medial borders of the eyebrows to the area above the tip of the nose. A small hump in the bone-cartilage transition is acceptable in both sexes, but is probably more suitable for men. The tip should consist of two parts, and, ideally, 2-4 mm of the base of the nasal septum should be visible in the profile. In Caucasians, the base of the nose approaches an equilateral triangle. The wider distance between the wings of the nose is normal for the Mongoloids and Negroids. In people with less growth, a large rotation of the tip of the nose is perceived better than in people with large growth.

Over time, the cartilaginous framework of the tip of the nose weakens, which leads to enlargement, tip lowering, elongation and, potentially, overlapping of the airways. The nostrils can expand, the angle between the base of the nose and the upper lip can become sharper and lowered. There may also be a thickening of the skin of the nose, as, for example, with rosacea.

The protruding nose, combined with the hypoplastic lower jaw, is aesthetically inconsistent and can usually be corrected by combining reduction rhinoplasty with increasing coping. In contrast, the reduction of the nose should be reserved in patients with a protruding lower jaw and chin, to maintain balance and harmony of the face, and to prevent exacerbation of the prognathic species, especially in the profile.

Plastic surgery of the perioral region and chin

The circumoral area includes a part of the face from the subnasal and nasolabial folds to the menthone, the lower boundary of the soft-tissue chin contour. The outline of the chin is determined by the shape and position of the mandibular bone, as well as the soft tissues covering it, in the case of the chin dropping. Following the nose, the chin is the most common cause of abnormalities when viewed in a profile.

The muscles responsible for the mimic actions around the mouth include the chin muscle, the square muscle of the lower lip and the triangular muscles that lie in the plane deeper than the subcutaneous muscle of the neck (according to the Paris nomenclature, the last two groups - the muscle, lowering the corner of the mouth, the muscle lowering the lower lip, and transverse muscle of the chin). These muscle groups are intertwined in the circular muscle of the mouth in the region of the lower lip. The innervation of these muscle groups is carried out from the marginal branch of the lower jaw, from the facial nerve system. These muscles cut and lower the lower lip. All of them are introduced into the lower edge of the mandibular bone.

The literary analogue of the term microgenia is "a small chin." In patients with normal bite (Angle class I: the mesial-buccal tubercle of the first maxillary painter is compared with the mesial-buccal groove of the first mandibular malaria), microgenia is diagnosed by holding a vertical line from the red border of the lower lip to the chin. If this line passes anterior to the soft tissue pursinion, microgenia is established. Particular attention before the operation should be given to the side view, since the task of the surgeon is to push the chin up to the vertical line of the lower lip. A slight hypercorrection is acceptable for men, while hypocorrection is more acceptable in women.

The overall balance of the face in the profile is best assessed additionally taking into account the projection of the back of the nose. Many times the computer reconstruction of images helped to illustrate the possible positive contribution of increasing the chin in the results of rhinoplasty. The main surgical approaches to the correction of microgenia are implantation and genioplasty. For alloplastic implantation on the lower jaw, the most often used is silastic.

Hypoplasia of the lower jaw is an acquired condition secondary to a different degree of bone resorption of the lower jaw. An adequate restorative orthodontic design can help in controlling the overall decrease in the size of the lower jaw, especially due to the height of the alveolar process. With age, there is also a progressive atrophy of soft tissues and a decrease in bone mass in the area between the chin and jaw. The resulting furrow is called the premaxillary furrow. This is important because, although a well-made facelift can improve the area of the lower jaw, this conspicuous furrow will remain.

The examination of the patient with hypoplasia of the lower jaw is similar to the examination with microgenia, with special attention to the presence of a normal occlusion. It is impossible to confuse hypoplasia of the lower jaw with retrognathy. The latter condition gives the second class bite in Angle and is corrected with the help of bone plasty, such as sagittally splitting the osteotomy.

Surgical approach to hypoplasia of the lower jaw is the same as described for microgenia. The main difference is in the type of silastic implant used. If there is a significant hypoplasia of the body of the lower jaw, an implant of a larger size is chosen. The shape of the implant also helps to correct the microgenia again, if there is evidence for this. Some patients do not have a pronounced mandibular angle (usually congenital), and this can benefit them.

Like hypoplasia of the lower jaw, the bite plays an important role in the formation of the lower part of the face. Ortho-donic correction, in addition to the normalization of occlusion, can restore normal lip relationships. Changes in bite, especially those associated with bone resorption in the toothless lower jaw, can disrupt the proportions of the middle and lower parts of the face. There may be a resorption of the alveolar part of the bone, a decrease in the vertical distance between the upper and lower jaws and significant soft tissue disorders. Such changes can only partially be compensated by dentures.

With age, lengthening of the upper lip, thinning of the red border of the lips and displacement (retraction) of the middle part of the face occur. Also formed are perioral wrinkles, which vertically move away from the edge of the red border of the lips. Another phenomenon is the appearance and deepening of the "puppet" lines, which represent a two-sided continuation of the downward nasolabial folds, similar to the vertical lines in the lower part of the face of the ventriloquist's doll. Chin and cheekbones can act less as a result of redistribution of the skin covering them and subcutaneous tissues. A decrease in the height of the skeletal component of the middle and lower parts of the face is noted.

Most of the operations on the lips are aimed at reducing or increasing them. At the present time, full lips are preferred. The upper lip should be fuller and in the profile protrude slightly forward over the lower lip. Lip enlargement is performed using a variety of materials, including autogenous skin and fat, homo- or xenocollagen, as well as porous polytetraf-lyuoroethylene.

Neck Plastic Surgery

Restoration of the cervico-chin angle is an important component of the rejuvenating operation. The neck in youth has a well-defined mandibular line, which discards the submaxillary shadow. The skin in the sub-chin triangle is flat and stretched. The subcutaneous muscle (platism) is smooth and has a good tonus. In addition, the muscles that attach to the hyoid bone create a cervical-chin angle of 90 ° or less. These factors give the neck a youthful outline and look.

An unattractive neck can be the result of congenital or acquired anatomical causes. Congenital causes include a low location of the sublingual-thyroid complex and a cluster of cervical fat, both above and below the platysm. With age, the expected changes are occurring in the lower part of the face and neck. These include prolapse of the hyoid gland, striation of the subcutaneous muscle and excess of the skin. The neck is also strongly influenced by microgenia, hypoplasia of the lower jaw, malocclusion, chin drop and pre-miter furrow, which were discussed above.

Patients should always be examined for the conditions mentioned. Standardization of the plan for preoperative examination of the lower part of the face and neck area will guarantee the selection of the correct surgical technique. Evaluation before surgical rejuvenation of the neck is performed according to the following plan: 1) assessment of the adequacy of skeletal support, 2) the need for the involvement of a muscular complex SMAS - platism, 3) the need for contouring of adipose tissue, and 4) the need for skin tightening.

The ideal location of the hyoid bone is the level of the fourth cervical vertebra. Patients with anatomically low position of the hyoid bone have a blunt cervical-chin angle, which limits surgical possibilities. The main surgical approach to contouring fat tissue is liposculpture, either by liposuction, or by direct lipectomy. Surgical correction of the striation of the subcutaneous muscle consists in a limited anterior horizontal myotomy with excision of elevated hypertrophied muscular margins. The newly formed anterior edges of the subcutaneous muscle are joined by sutures. Tension of the subcutaneous muscle will also help correct the prolapse of the hyoid.

The preferred method of eliminating excess neck skin is to move the upper side flap when lifting the face. This double-sided tension tightens the skin component of the cervico-chin "suspension". If there is an excess of skin on the front surface of the neck, a subcutaneous incision with local excision of the skin is required. Excessive excision of the skin should be avoided, as this leads to the formation of protruding cones along the sides of the sewn incision. Excessive excision of the skin can also change the neck line, which breaks the young cervico-chin contour.

In a number of patients with fat deposition in the neck and young elastic skin, with its minimal excess, only liposuction may be required. This type of skin is not yet relaxed and retains the memory of the form. There is no need for local excision of the skin, since the neck skin will be pulled upward and retain the sub-chin contour.

Plastic surgery of the ears

Aesthetic surgery may be useful for some patients with protruding ears. The top of the auricle should be at the level of the outer end of the eyebrow. The lower attachment of the ear should be at the level of the connection of the wing of the nose with the plane of the face. In profile, the ear is tilted posteriorly. During rhytidectomy, it is important to remember that you can not create a forward-looking ears that will expose the fact of surgical intervention. The width / length ratio for the ear is 0.6: 1. The ears should form an angle of about 20-25 ° with the skin of the back of the scalp, and the middle part of the ear should not be more than 2 cm from the head.

With age, the size of the ears increases. Also, their protrusion increases due to the increase in the concho-skaphoid angle, and the fold of the counter-wrack can be partially lost. The change in the earlobe may be due to the long wearing of the earrings.