Andrew A. Jacono

Three-Dimensional Analysis of Long-Term Midface Volume Change After Vertical Vector Deep-Plane Rhytidectomy

BACKGROUND Facial aging is a complicated process that includes volume loss and soft tissue descent. This study provides quantitative 3-dimensional (3D) data on the long-term effect of vertical vector deep-plane rhytidectomy on restoring volume to the midface. OBJECTIVE To determine if primary vertical vector deep-plane rhytidectomy resulted in long-term volume change in the midface. METHODS We performed a prospective study on patients undergoing primary vertical vector deep-plane rhytidectomy to quantitate 3D volume changes in the midface. Quantitative analysis of volume changes was made using the Vectra 3D imaging software (Canfield Scientific, Inc, Fairfield, New Jersey) at a minimum follow-up of 1 year. RESULTS Forty-three patients (86 hemifaces) were analyzed. The average volume gained in each hemi-midface after vertical vector deep-plane rhytidectomy was 3.2 mL. CONCLUSIONS Vertical vector deep-plane rhytidectomy provides significant long-term augmentation of volume in the midface. These quantitative data demonstrate that some midface volume loss is related to gravitational descent of the cheek fat compartments and that vertical vector deep-plane rhytidectomy may obviate the need for other volumization procedures such as autologous fat grafting in selected cases. LEVEL OF EVIDENCE 4 Therapeutic.

Deep-Plane Face-lift as an Alternative in the Smoking Patient

O ver the past 30 years, face-lift surgery has progressed from a more limited skin elevation with no treatment of the superficial muscular aponeurotic system (SMAS) to more extended elevation of the skin and SMAS. Hamra popularized the traditional deep-plane technique lifting the SMAS and skin as a compound unit with a thicker, well-vascularized flap. This flap is elevated in a sub-SMAS dissection in the inferior cheek and superiorly transitioning to a supra-SMAS plane just superficial to the zygomaticus muscles in the superior medial cheek. The effects of nicotine on wound healing and flap viability have been associated with superficial skin necrosis and hematoma in the patient undergoing a face-lift. The risk of complications is increased with extensive subcutaneous face-lifts. There have been numerous studies examining the detrimental effects of smoking and wound healing (eg, Rees et al and Mosely and Finseth). The major effect of nicotine on wound healing is that it increases platelet adhesiveness and increases blood viscosity, leading to an increase in thrombotic microvascular occlusion and eventually tissue ischemia. The survival of a face-lift flap depends on adequate blood supply and oxygenation. Most surgeons consider smoking a relative contraindication to performing any type of face-lift. To decrease the chance of skin necrosis, some have adjusted their techniques by performing more limited undermining of the skin. This compromises the degree of correction of facial laxity and long-term results. Smoking can double the chances of hematoma collection postoperatively. The purpose of our study is to show that a deep-plane face-lift with extensive undermining can be performed safely in smokers with limited postoperative complications.

Patient-Specific Rhytidectomy: Finding the Angle of Maximal Rejuvenation

BACKGROUND Rhytidectomy is fundamentally an operation of tissue release and resuspension, although the manner and direction of suspension are subject to perpetual debate. OBJECTIVES The authors describe a method for identifying the angle of maximal rejuvenation during rhytidectomy and quantify the resulting angle and its relationship to patient age. METHODS Patients were prospectively enrolled; demographic data, history, and operative details were recorded. Rhytidectomies were performed by the senior author (AAJ). After complete elevation, the face-lift flap was rotated in a medially-based arc (0-90°) while attention was given to the submental area, jawline, and midface. The angle of maximal rejuvenation for each hemiface was identified as described, and the flap was resuspended. During redraping, measurements of vertical and horizontal skin excess were recorded in situ. The resulting angle of lift was then calculated for each hemiface using trigonometry. Symmetry between sides was determined, and the effect of patient age on this angle was assessed. RESULTS Three hundred hemifaces were operated (147 women; 3 men). Mean age was 60 years (range, 37-80 years). Mean resulting angle for the cohort was 60° from horizontal (range, 46-77°). This was inversely correlated with patient age (r = -.3). Younger patients (<50 years, 64°) had a significantly more vertical angle than older patients (≥70 years, 56°; P < .0002). No significant intersubject difference was found between hemifaces (P = .53). CONCLUSIONS The authors present a method for identifying the angle of maximal rejuvenation during rhytidectomy. This angle was more superior than posterior in all cases and is intimately related to patient age. Lasting results demand a detailed anatomical understanding and strict attention to the direction and degree of laxity.

Anatomical Comparison of Platysmal Tightening Using Superficial Musculoaponeurotic System Plication vs Deep-Plane Rhytidectomy Techniques

OBJECTIVES To quantify the degree of submental platysmal tightening that can be accomplished with superficial musculoaponeurotic system (SMAS) plication vs deep-plane rhytidectomy techniques in a cadaveric anatomical study to help dictate the need for midline platysmal surgery when using different rhytidectomy techniques. METHODS The lateral distraction of the medial edge of the platysma muscle was measured during tightening of the SMAS-platysmal complex on 5 cadaver heads. The measurements were taken after the following 3 rhytidectomy techniques: SMAS-platysmal plication, deep-plane rhytidectomy, and extended deep-plane rhytidectomy continuing the flap below the angle of the mandible into the neck with release of the platysma and cervical retaining ligaments. RESULTS The medial edge of the platysma muscle was distracted laterally 427% more with deep-plane rhytidectomy compared with SMAS-platysmal plication (P < .001). Extending the deep-plane rhytidectomy flap into the neck to release the cervical retaining ligaments resulted in 554% greater lateral distraction of the medial edge of the platysma muscle compared with SMAS-platysmal plication (P < .001). This represents 30% greater advancement compared with the traditional deep-plane technique (P = .05). CONCLUSIONS Extending a traditional deep-plane rhytidectomy inferiorly to release the lateral platysma and cervical retaining ligaments to the sternocleidomastoid muscle achieves the greatest lateral motion of the midline platysma, theoretically obviating the need for midline platysmal plication except in cases of severe platysmal laxity and banding. Because of the limited platysmal motion during SMAS plication, midline platysmal plication should routinely be used as an adjunct procedure except in cases of no or minimal platysmal laxity.

Characterization of the Cervical Retaining Ligaments During Subplatysmal Facelift Dissection and its Implications

Background: The cervical retaining ligaments anchor the platysma and soft tissues of the neck to the deep cervical fascia and deeper skeletal structures. The cervical retaining ligaments tether the platysma and prohibit free mobilization and redraping of the platysma muscle in rhytidectomy. This ligament system has previously been described in the literature only qualitatively. Objectives: To define the anatomic dimensions of the cervical retaining ligaments and their relation to the platysma muscle in order to better understand the cervical retaining ligament system and how it limits motion of the platysma during rhytidectomy. Methods: Extended deep plane rhytidectomy was performed on 20 fresh cadaveric hemifaces. The extent cervical retaining ligaments were dissected and measured. The anterior extent (width) of the cervical ligament were recorded at three anatomic points on each hemiface: (1) at the level of the inferior border of the mandible; (2) at the top of the thyroid cartilage at the thyroid notch; and (3) at the level of the cricoid. Results: The average width of the cervical retaining ligaments in the neck was 15.3 mm. The width significantly decreased as they became more inferiorly positioned from the top of the neck at the anatomic measurement points, measuring 17.1 mm, 16.1 mm, and 12.6 mm (P < 0.05). Conclusions: The cervical retaining ligaments are the support mechanisms of the platysma muscle in the neck. While previously described in only a qualitative manner, this study quantifies the anterior extent of these ligaments and how they invest the lateral platysma muscle. As these ligaments tether the platysma for an average of 1.5 cm, lateral platysma elevation of this distance during rhytidectomy surgery can improve platysmal redraping during rhytidectomy and potentially improve neck rejuvenation.

Stop Blaming the Septum

Purpose: To identify if isolated surgical violation of the orbital septum predisposes to “middle lamellar” scarring and subsequent postblepharoplasty lower eyelid retraction. Methods: A retrospective review of patients who underwent transconjunctival blepharoplasty in either a postseptal (orbital septum undisturbed) or preseptal (septal incision required) plane was performed. Patients undergoing skin excision, orbicularis muscle plication, and canthal suspension were excluded. The presence of clinically apparent postoperative lower eyelid retraction and limitation of forced superior eyelid excursion (forced traction testing) were assessed. Results: Two hundred eighty-eight patients (576 eyelids) were evaluated. One hundred fifty-eight patients (316 eyelids, 55%) had transconjunctival blepharoplasty performed in a postseptal plane and 130 patients (260 eyelids, 45%) in a preseptal plane. Two hundred two patients (404 eyelids, 70%) had forced traction testing performed postoperatively. After surgery, there were no patient complaints of change in lower eyelid position, subjective physician assessment of clinically apparent lower eyelid retraction, and only 1 case (0.5%) of a positive forced traction test in a patient with conjunctival scarring after significant postoperative infection. Conclusions: Lower eyelid scars leading to eyelid retraction after blepharoplasty are not likely related to “isolated” orbital septal scars (middle lamellar scars). Their designation as a “multilamellar scar” is more appropriate.

Comparing Rates of Distal Edge Necrosis in Deep-Plane vs Subcutaneous Cervicofacial Rotation-Advancement Flaps for Facial Cutaneous Mohs Defects

IMPORTANCE The cervicofacial rotation-advancement flap is commonly used for facial defects. Decreasing the rate of distal edge necrosis (DEN) encountered with this flap would help prevent complications in sensitive areas such as the eyelid, lip, and nose. OBJECTIVE To compare the untoward occurrence of DEN between 2 surgical dissection methods for reconstructive cervicofacial rotation-advancement flaps. DESIGN, SETTING, PARTICIPANTS, AND EXPOSURE: A review was conducted of 88 patients who underwent cervicofacial flap reconstruction for Mohs ablative surgery between January 1, 2003, and June 30, 2012, by the senior author (A.A.J.). All patients had periorbital, midfacial, cervical, and/or lateral temporal/forehead defects following Mohs surgical ablation. Patients were categorized into 1 of 2 groups on the basis of the surgical technique used: subcutaneous (SC) cervicofacial elevation or deep-plane (DP) cervicofacial elevation. Subcategories of smokers and nonsmokers within each group were further reviewed. Statistical analysis of DEN between categories and subcategories was performed. RESULTS Sixty-nine patients were in the SC group and 19 were in the DP group. The mean defect size among both groups was 14.3 cm(2). The rate of active or recent smokers was 23% in the SC group and 11% in the DP group. The rate of DEN among nonsmokers in the SC group was 23% (n = 53) compared with 0% in the 17 DP nonsmokers (P = .03). The rate of smokers with DEN in the SC group was 75% and 0% in the DP group (P = .09). The mean area of DEN in the SC group was 0.8 cm(2). CONCLUSIONS AND RELEVANCE Our statistically significant data indicate that DP dissection is a superior technique for avoiding DEN in nonsmokers. We found better outcomes in smokers as well. Thus, we strongly advocate the use of the DP approach as the criterion standard in cervicofacial flap elevation. LEVEL OF EVIDENCE 3.

An algorithmic approach to multimodality midfacial rejuvenation using a new classification system for midfacial aging.

Midfacial aging is the result of the complex interplay between the osseous skeleton, facial retaining ligaments, soft tissues envelope, facial fat compartments, and the overlying skin elasticity. As a result of the many anatomic components involved in midfacial aging, the authors proposed a classification system based on distinct anatomic factors to direct surgical treatment. Evidence based data suggest that midface rejuvenation often requires a multimodality approach to obtain desired results, especially in patients with more advanced aging and poor tissue elasticity, or those with hypoplastic midfacial skeletal structure.

Double-Opposing Rotation-Advancement Flaps for Closure of Forehead Defects

OBJECTIVE To describe a local flap for closure of forehead defects of all sizes that does not alter the brow position or hairline. METHODS Retrospective review of 16 cases in which the double-opposing rotation-advancement flaps were used for closure of small (<10 cm2), medium (10-20 cm2), and large (>20 cm2) forehead defects. This technique was developed from Orticocheas method for closure of large scalp wounds. RESULTS All 16 patients underwent single-stage closure of forehead defects using our design. Six patients were men, 8 were women (mean age, 71 years). Preoperative defect sizes ranged from 3 to 30 cm2 (mean, 18 cm2). All wounds resulted from Mohs surgery for cutaneous malignant neoplasms; 2 were adjacent to previous reconstructions. No recurrence of tumor was seen during the study period. No permanent frontal branch injuries occurred. One patient developed a moderate cellulitis. Photographic analysis showed that brow position and hairline contour were maintained in all cases. CONCLUSIONS The double-opposing rotation-advancement flap closure is a versatile reconstructive option for small, medium, and large forehead defects. The technique involves elevation of opposing, asymmetric flaps, with subsequent rotation of one side and advancement of the contralateral side. Single-stage closure may be accomplished without unappealing changes to the brow position or hairline.

Deep Plane Rhytidectomy Modifications

Abstract: These anatomic studies strongly support repositioning of ptotic midfacial tissues as a primary modality for midface rejuvenation and revolumization. This can be accomplished with the deep plane procedure and its modifications described within this chapter.