Skin Lifting and Lifting

The length of the cut depends on the amount of excess skin on the neck and, to some extent, the tissues on the face. When using the SMAS braces, the degree of the cut is much less than with the old, classical methods of rhytidectomy. A larger amount of the incision increases the risk of impaired blood supply, as well as the development of small gray, bruising and unevenness. However, when there is a large excess of the skin and subcutaneous muscle on the neck, it is often necessary to separate the skin from the underlying muscle, then to sew them consistently, thereby achieving the maximum improvement. In general, the lifting of SMAS and deep facial tissues is effective and much safer than separating the skin all the way to the buccal-labial fold. Although some surgeons still prefer this old technique, today it is shown that such a large amount of skin separation is not more effective than SMAS moving techniques when correcting the cheeks and deep cheek-labial furrows.

Skin cutting starts in the behind-the-eye area and can be performed using special scissors, by moving and breeding brunches. An alternative is a straight cut with a scalpel. Cutting in this area is important to start deeper than the level of the hair follicles, so as not to damage them and create permanent alopecia. However, when the dissection moves forward from the border of hair growth behind the ear, it must be fairly shallow, directly under the skin. This subcutaneous layer in the BTE area is minimal and the skin is very close to the fascia of the sternocleidomastoid muscle. Here, the skin should be carefully separated until dissection passes anterior to this muscle. As mentioned above, here, because of the reduction in the thickness of the subcutaneous layer and the close fit of the dermis to the fascia, damage to the large ear nerve can occur. Then, the excretion continues in the subcutaneous plane, superficial to the subcutaneous muscle, and as far forward as it is required to interfere with the neck. Often the crossing of the skin is complete and merges with the cavity, which was previously created in the sub-chin. Although the skin can be isolated slightly above the edge of the lower jaw, this process is usually limited to the neck area.

After the selection on the neck begins the cutting of the skin in the temporal region. A lift in the temporal areas is required to create a smoothness of the skin of the lateral part of the eyebrow and from the outer corner of the eye to the temple. The incisions are made down, through the scalp tissue, the surface layer of the tendon helmet and the surface layer of the temporal fascia. In this layer, the dissection can be performed all the way to the lateral part of the eyebrow and the upper edge of the zygomatic arch. Elevation of the temporal block is not required for all types of facelift, in particular, it is usually not required for type I. This is usually done when there is tissue weakness in the area of the orbital part of the orbit and eyebrows that must be moved so as not to create wrinkling when the cheek tissues are raised upward. The temporal lift can be combined with other methods of tightening the frontal-eyebrow complex, and maybe also an isolated one. Then, the separation of tissues in front of xa, at the level of the temporal fascicle of the hair, begins directly in the subcutaneous layer. This layer differs markedly from that in dissection in the temporal region. Here, the SMAS bridge and the neurovascular bundles going upward, in the direction of the frontal muscle, should be left intact. Keeping this "suspension bridge" of the tissue, the surgeon will not damage the frontal branch of the facial nerve. The incision can continue into the zygomatic area, extending from the ear forward by 4-6 cm, depending on the elasticity of the skin. This process advances in the fatty layer, easily separating the surface portion of the subcutaneous fat left on the skin flap from its deep portion covering the SMAS. This vestibular space is connected to the same level of dissection on the subcutaneous muscle of the neck. Be sure to make a thorough hemostasis.

Depending on the type of face lift, it is necessary to determine the degree of interference and manipulation in the SMAS layer. Even type I braces may require overlapping or manipulation in deep layers, depending on the need for lifting the tissues of the middle part of the face. If only a small amount of tissue is moved from the area of the lower jaw and cheeks and the subcutaneous muscle is displaced posteriorly, the only action can be the formation of a fold of SMAS. However, it is necessary to remove adipose tissue of the semilunar form, which still remains on top of the SMAS, in front of the ear, so that it is possible to superimpose SMAS on itself when stitching. Otherwise, the fibrous seams of SMAS will not develop and the effect of braces may collapse after resorption of the joints. Some surgeons prefer to create this duplication with non-resorbable sutures because it is necessary to maintain it at a given position for a long time.

In general, the suspenders require some overlapping of the SMAS layer and the subcutaneous muscle, so that they can be pushed back and up. The degree of this undercut will be dictated by the need for a tightening of the cheek, subcutaneous muscle and tissues of the middle part of the face. This is determined by the extent of SMAS overlapping, when SMAS rises, moves, truncates and stitches the end to the end. This can be done with long-lasting, but not permanent, stitches.

Those patients who are required to perform a tightening of the subcutaneous tissues of the middle part of the face, at least, a modification of the braces in the deep plane is performed. This requires raising the SMAS layer to the level of the zygomatic arch, above the cheekbone elevation, and the superficial zygomatic muscle. The techniques of full tightening in the deep plane provide for the intersection of the SMAS layer all the way anteriorly, to the front edge of the masticatory muscle, and its connection with the raised tissues of the neck is superficial to the subcutaneous muscle. However, in the middle part of the cheek, it is necessary to go to the surface layer covering the zygomatic muscle, otherwise damage to the nervous branch innervating this muscle or the buccal muscle may occur.

After the appropriate separation of the tissues of the middle part of the face with the corresponding sections of the SMAS and the subcutaneous muscle, this layer moves in the required posterior-upper direction. A direct view allows one to see the movement of the buccal-labial tissues, as well as the lower part of the cheek, back and up, into a position corresponding to a more youthful appearance. Often, the fascia fascia of SMAS is fixed to strong tissues in front of the ear. That is, SMAS intersects at the level of the auricle and the lower band of SMAS and subcutaneous muscle is sewn with Vicril 0 thread, as a suspending belt to the mastoid fascia and periosteum. This provides a rigid, clear contouring of the cervical-chin angle. Excesses of the subcutaneous muscle and SMAS are cut off, and several seams are superimposed on the posterior BTE. The front of the SMAS intersects, and the excess is removed; SMAS is sewn end-to-end with long-absorbable monofilament sutures, such as 3/0 PDS.

[1]