Anatomical conditions and type of face lift

The basic decision on the type of surgical face-lift that will be applied to a particular patient is based, first of all, on the patient's condition, fixed at the time of physical examination during the consultation. Not all patients need the same surgical intervention to achieve a satisfactory result. There are three main types of facelift operations, based on the general categories of surgical intervention required to achieve a satisfactory outcome. This chapter will describe the operations with minimal cutting, folding or lapping of the underlying SMAS, with the treatment of the hypodermic neck muscles or penetrating deeper layers of the face, including the subperiosteal access. Most decisions are made based on the patient's condition, the views of the surgeon as to what he expects as a distant outcome of the surgical intervention.

At the heart of the fundamental idea of facelift, certain anatomical interrelationships of the tissues lie first. Here, the elasticity and condition of the covering skin is important, including the degree of damage to sunlight and the formation of wrinkles. It is necessary to take into account the relationship with the subcutaneous fat tissue, including the change in position under the influence of gravity, true omission or incorrect accumulation and distribution. The fascial structure of the face, its middle zone and neck is such that the facial musculature is enveloped by a continuous fascia that extends to the parotid region. This fascia, bordering the subcutaneous muscle of the neck, is SMAS, first described by Mitz and Peyronnie as a dynamic contractile and fibromuscular network. The fascia, which lies even deeper, is a superficial leaf of the deep fascia of the neck, enveloping and covering the sternocleidomastoid muscle, and also the parotid tissue. It is located on top of the surface layer of the fascia of the temporal muscle, as well as the periosteum of the frontal bone. SMAS is bordered by a sinewy helmet of the cranial vault. On the neck in front, the subcutaneous muscle can be combed, forming connecting loops. Often there is ptosis and a discrepancy of the anterior edges of the subcutaneous muscle of the neck, which forms bands on the neck. It is very important that there is a layer of SMAS, which allows surgical facelift in a deeper plane than was done with the first rhytidectomy. In the cephalic and posterior directions, only the skin was isolated, cut off, excised and sutured, which, due to its inherent phenomenon of crawling and reverse contraction, was often not kept in place for a long time. Therefore, when the intervention was carried out only in this layer, the effectiveness of surgical braces was short-lived. Skin, especially in the middle and central zones of the face, is directly related to SMAS with durable fibrous fibers of the dermis. Often these fibers are accompanied by vessels penetrating from the deep vascular systems into the superficial skin plexus. It is easy to demonstrate that lifting and moving the SMAS layer with its inalienable connections to the subcutaneous muscle of the neck and the muscles of the middle part of the face lifts and moves the skin in the same way. The upper posterior tension vector of this fascia moves the tissues of the face to a position giving it a more youthful appearance. The impact of gravity on these anatomical structures is directly corrected by surgical facelift operations.

It is also important to understand the anatomical relationships of the sensory and motor nerve branches of the face that provide the sensitivity of the skin, as well as the functioning of facial muscles. This refers to the consequences of surgical braces for all patients, since loss of sensitivity and paresthesia, which are usually temporary, can become permanent. V pair of cranial nerves provides sensitivity to the skin surfaces of the face, head and neck. The fact that the performance of any type of surgical facelift requires the removal of a certain part of the skin in the parotid and behind-the-ear areas makes it necessary to separate the innervation of this part of the face. Usually, if the main branch of the large ear nerve is not damaged, the skin sensitivity is restored in a relatively short time. The patient may notice this in the first 6-8 weeks, but sometimes for a full recovery it takes from 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 commonly damaged in the face lift is a large auricular nerve at the point of its intersection with the sternocleidomastoid muscle, this rarely leads to a permanent loss of sensitivity of the ear and parotid. Direct damage to this very large and noticeable nervous branch can occur during the separation of the skin from its attachments to the superficial layer of the fascia of the sternocleidomastoid muscle, when this fascia is dissected. If the lesion is found during surgery, nerve stitching is shown; restoration of its function should be expected within 1-2 years.

The motor branches to the mimic muscles of the face are in potential danger with a surgical suspender. After leaving the parotid masticatory fascia, the branches of the facial nerve become very superficial. The branch at the edge of the lower jaw is at risk, at the junction of the bone edge of the jaw, deeper than the subcutaneous muscle and the superficial layer of the deep fascia of the neck. Techniques that require the removal of the deep layer, provide for the intersection of SMAS in the middle zone of the face, in connection with which there is a risk of damage to the branches going to the circular, malar and buccal muscles. The innervation of these muscles is carried out from the side of their inner surface, and even dissection in the deep plane will pass superficially. Direct nerve visualization is the stage of the operation and will be discussed later in this chapter.

During the surgical facelift, with or without a forehead lift, the frontal branch of the facial nerve is most often damaged. At the level of the zygomatic arch, it is very superficial and goes immediately deeper than the subcutaneous tissues, under a thin layer of the temporal part of the SMAS, and then innervates the inner surface of the frontal muscle, the greatest risk of damage to this branch when crossing this area is about 1.5-2 cm anterior to ear, in the middle of the distance between the lateral edge of the orbit and the temporal bundle of hair. To prevent nerve injury, it is necessary for the surgeon to understand the anatomical relationships between the layers of the face and the temporal region. You can lift the skin all over the space to the lateral corner of the eye, the skin of the parotid region, covering the zygomatic arch, to the circular muscle, and also to carry out dissection directly in the subcutaneous layer. In addition, the surgeon can freely conduct dissection under the frontal fascia, under the tendon helmet, superficial periosteum and superficial fascia of the temporal muscle without damaging the frontal branch of the facial nerve that is superficial than this avascular layer. However, at the level of the zygomatic arch, it is necessary to pass under the periosteum, otherwise the facial nerve will be damaged, which is located in the same tissue plane that covers the zygomatic arch. Reinnervation of the frontal muscle with nerve damage in this area may occur, or may not occur.

[1], [2], [3], [4], [5], [6], [7], [8]