Bryan C. Mendelson

Changes in the Facial Skeleton With Aging: Implications and Clinical Applications in Facial Rejuvenation

In principle, to achieve the most natural and harmonious rejuvenation of the face, all changes that result from the aging process should be corrected. Traditionally, soft tissue lifting and redraping have constituted the cornerstone of most facial rejuvenation procedures. Changes in the facial skeleton that occur with aging and their impact on facial appearance have not been well appreciated. Accordingly, failure to address changes in the skeletal foundation of the face may limit the potential benefit of any rejuvenation procedure. Correction of the skeletal framework is increasingly viewed as the new frontier in facial rejuvenation. It currently is clear that certain areas of the facial skeleton undergo resorption with aging. Areas with a strong predisposition to resorption include the midface skeleton, particularly the maxilla including the pyriform region of the nose, the superomedial and inferolateral aspects of the orbital rim, and the prejowl area of the mandible. These areas resorb in a specific and predictable manner with aging. The resultant deficiencies of the skeletal foundation contribute to the stigmata of the aging face. In patients with a congenitally weak skeletal structure, the skeleton may be the primary cause for the manifestations of premature aging. These areas should be specifically examined in patients undergoing facial rejuvenation and addressed to obtain superior aesthetic results.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Age-Related Changes of the Orbit and Midcheek and the Implications for Facial Rejuvenation

BackgroundAging of the midface is complex and poorly understood. Changes occur not only in the facial soft tissues, but also in the underlying bony structure. Computed tomography (CT) imaging was used for investigating characteristics of the bony orbit and the anterior wall of the maxilla in patients of different ages and genders.MethodsFacial CT scans were performed for 62 patients ranging in age from 21 to 70 years, who were divided into three age groups: 21–30 years, 41–50 years, and 61–70 years. Patients also were grouped by gender. The lengths of the orbital roof and floor and the angle of the anterior wall of the maxilla were recorded on parasagittal images through the midline of the orbit for each patient.ResultsThe lengths of the orbital roof and floor at their midpoints showed no significant differences between the age groups. When grouped by gender, the lengths were found to be statistically longer for males than for females. The angle between the anterior maxillary wall and the orbital floor was found to have a statistically significant decrease with advancing age among both sexes.ConclusionBony changes occur in the skeleton of the midcheek with advancing age for both males and females. The anterior maxillary wall retrudes in relation to the bony orbit, which maintains a fixed anteroposterior dimension at its midpoint. These changes should be considered in addressing the aging midface.

Surgical Anatomy of the Lower Face: The Premasseter Space, the Jowl, and the Labiomandibular Fold

The anatomic basis for the jowl has not been fully described. A formal analysis was performed of the sub-superficial musculoaponeurotic system (SMAS) areolar tissue layer, which overlies the lower part of the masseter. For this research, facial dissections were performed on 16 fresh cadavers ages 12 to 89 years, and detailed anatomic observations were made during the course of several hundred rhytidectomy procedures. Tissue samples from varying age groups were examined histologically. The areolar cleavage plane overlying the lower masseter has specific boundaries and is a true space named the “premasseter space.” This space is rhomboidal in shape, lined by membrane, and reinforced by retaining ligaments. The masseter fascia lines the floor, and branches of the facial nerve pass under its deep surface. Histologically, the floor is formed by a thin layer of dense connective tissue, which undergoes minor deterioration in architectural arrangement with age. The roof, lined by a thin transparent and adherent membrane on the underside of the platysma, has a less dense collagen network and contains more elastin. With age, there is a significant reduction in the collagen density of the roof. Expansion of the space with aging, secondary to weakness of the anterior and inferior boundaries, results in formation of the jowl. Medial to the premasseter space is the buccal fat in the masticator space, which descends with aging and contributes to the labiomandibular fold and jowl. Application of the premasseter space in surgery provides significant benefits. The SMAS incision should be forward of the traditional preauricular location to be over the space, not behind. Because the space is a naturally occurring cleavage plane, dissection is bloodless and safe, as all facial nerve branches are outside. The premasseter space should be considered as the preferred dissection plane for lower (cervicofacial) facelifts.

Histologic and Ultrastructural Evaluation of Sutures Used for Surgical Fixation of the SMAS

In extensive SMAS face-lift surgery, retaining ligaments are released, and the SMAS is resutured to the deep fascia to maintain the advanced position. The suture used to reattach the SMAS should replicate the quality of support provided by the original ligaments. Nonabsorbable sutures (monofilament and braided) retrieved intraoperatively from 22 patients undergoing secondary face-lift procedures were examined by light microscopy and transmission electronmicroscopy. A distinctive enclosure of dense collagen and elastin formed around both types of suture. Based on the presence of inflammatory cells, fibroblasts, collagen, and elastin, the tissue reaction to monofilament suture was less than with the braided suture. The collagen and elastin were thicker around the braided suture, and, additionally the collagen matrix infiltrated between the individual filaments. Ultrastructural analysis of the braided suture showed significant collagen binding around each individual filament. The greater quantity of connective tissue around the thread which continued into the interstices of the braided suture has the characteristics of a ligament. This suggests a stronger and more lasting tissue fixation.

Anatomic Study of the Retaining Ligaments of the Face and Applications for Facial Rejuvenation

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of

Aesthetic/Cosmetic Surgery and Ethical Challenges

This article is a valuable resource for reviewing some of the complex issues surrounding the life of aesthetic plastic surgeons. It is thoroughly researched and well written and the issues are presented without idealism, sentimentality, or plastic surgeons’ sense of entitlement. The sense of disquiet experienced by many plastic surgeons, whatever the stage of their career, becomes more understandable. Clinicians may be surprised by the amount and depth of available supporting material, which is included in the extensive bibliography. Within the span of just one generation the world of aesthetic plastic surgery has become entangled in the greater society. The immense challenges from the media, consumer advertising, opportunist nonspecialist practitioners, and commercial interests are testing the traditional ethics under which plastic surgeons trained. The rate of change in the environment has escalated so rapidly that it is almost impossible for a plastic surgeon to comprehend. The review commences with a brief review of the ‘‘demand,’’ which is driven by the powerful human desire for self-improvement. The ‘‘hierarchy of needs’’ inherent in the human makeup, as described by Maslow [1], helps explain the aesthetic surgery phenomenon. As modern civilization has become successful in meeting the more basic survival and safety needs of the masses, an increasing proportion of the population now live in a time where more is attainable for the individual. This is the setting in which the higher levels of need, of self-esteem, and of self-image of the community and of individuals are being addressed. While analysis of the subconscious driving forces may be more in the realm of sociologists and psychologists, it is a reminder that plastic surgeons neither created the market nor do they have an exclusive place in satisfying the demand. Plastic surgery evolved out of other specialties to fill the basic need to restore appearance and function of those suffering from the ravages of nature and major trauma, especially of warfare. The success of plastic surgery resulted from focusing on an advanced understanding of the body and developing unique technical skills. Subsequently, these special skills were used in the application in the new and higher level of need: appearance (self-esteem) surgery for ‘‘normal’’ people. Concurrent technologic advances in contemporary society enabled the great increase of the influence of the media, which are primarily visually focused (glossy magazines, television, film, and the cyberspace) on appearance at the expense of appreciation of other less apparent qualities such as intelligence! The dominance of visual identification may explain society’s obsession with appearance or vice versa. Analysis of this desirability is in the realm of social scientists. In the end, the fact that so many people want to look younger and prettier is simply a modern-day fact of life. Given this context, the central thesis of the review is whether aesthetic plastic surgery remains where it commenced, in the realm of the medical system where it was intended to seriously benefit patients, or whether it should cross into the commercial world, which contrasts in having the immediate focus on benefiting the business. These issues involve all plastic surgeons to a degree, whether they consciously analyze their direction or uncomfortably try to ignore the moral and ethical aspects inherent in having been granted a privileged place in society by virtue of the traditional and almost reverential respect society has for surgical training. B. C. Mendelson (&) 109 Mathoura Road, Toorak, VIC 3142, Australia e-mail: bcm@bmendelson.com.au; bmendelson@bigpond.au

Temporoparietal Fascia Plication in Rhytidectomy

This interesting article presents, for the first time, a method for correction of the temple using an adaption of the face-lift technique used by many surgeons for the cheek (i.e., supraplatysma dissection with external plication of the exposed superficial musculoaponeurotic system [SMAS]) [3,6,10]. This technique is favored for its simplicity and safety. There is a certain logic in this because, as the authors clearly point out, the general layout of the temple anatomy is similar to that elsewhere on the face in that it has a mobile superficial fascia, termed the ‘‘temporoparietal fascia’’ in this article, or ‘‘the SMAS’’ in the context of the cheek. These are the names given for the same general structure in different regions of the face. The major benefit of the described procedure is the safety and the freedom from complications experienced by 16 patients, not unexpectedly, over a 10-year period. A key question is whether the temporoparietal fascia plication itself actually delivers the result claimed by the authors in providing an extra measure of lift and tightening in the outer brow and lateral canthal regions. The two cases presented to support their claim suggest that this is so. However, it is clear from the description of the technique, as demonstrated in Fig. 2B, that a wide subcutaneous undermining is a necessary and integral part of the procedure. Some respected surgeons, such as Dr Bruce Connell, have long held that a wide subcutaneous release alone can improve periorbital wrinkles by 70% or more [2]. Accordingly, it is difficult to ascribe the result to the temporoparietal fascia plication component alone, because itmaybe that thewide skin release and redrape provide a significant part of the benefit. There are alternative methods for tightening the temporoparietal fascia, as there are for the cheek SMAS. One method is direct excision to achieve a tightening from closure of the excised gap in the temporoparietal fascia. A temporoparietalectomy is similar to Dr. Dan Baker s SMASectomy in the cheek [1]. Another approach, also discussed by the authors, involves the equivalent of a deep-plane [4] sub-SMAS dissection under the temporoparietal fascia. For the temple, this once was regarded as a procedure involving real risk because of the difficulty defining the exact location of the temporal branches of the facial nerve intraoperatively. Partway through the author s 10-year experience, in April 2000, a study was published showing a safe course of dissection relative to the facial nerve. As described by Abul-Hassan et al. [5], the temporal branches course in a thin wafer of fat suspended from the underside of the temporoparietal fascia. The nerve is in this location immediately inferior to the zygomatic arch. It courses across the temple immediately on the inferior aspect of the inferior temporal septum, which is most significant anatomically for being a reliable intraoperative visual landmark for the surgeon [9]. As the author s note, the SMAS is a heterogenous layer continuous in all directions with other structures of the same system, and its function has to do with mobility of the superficial layers. However, the authors do not mention that the SMAS layer has specific ligamentous attachments to the underlying deep fascia (periosteum and muscle fascia of temporalis and masseter). As a result, although there is movement of the SMAS layer in some regions, there is restricted or no movement in the areas of ligamentous fixation. Therefore, surgical reattachment of the SMAS is not necessarily ‘‘unnatural’’ [8]. When a subtemporoparietal and subgalea release of the outer forehead is performed, it is necessary to release the ligamentous fixation along the superior temporal line and superolateral orbital rim to achieve sufficient elevation of the outer brow. Even with these ligament releases, it is difficult to obtain an excessive elevation by temporoparietal fascia elevation alone because there is so much mobility within the subcutaneous layer over the temple. In fact, most of the temple s mobility is superficial Correspondence to Bryan C. Mendelson, email: bcm@ bmendelson.com.au Aesth. Plast. Surg. 30:181 182, 2006 DOI: 10.1007/s00266-005-0064-6