Howard L. Gordon

The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging.

Controversy persists regarding the relationship of the superficial facial fascia (SMAS) to the mimetic muscles, deep facial fascia, and underlying facial nerve branches. Using fresh cadaver dissection, and supplemented by several hundred intraoperative dissections, we studied facial soft-tissue anatomy. The facial soft-tissue architecture can be described as being arranged in a series of concentric layers: skin, subcutaneous fat, superficial fascia, mimetic muscle, deep facial fascia (parotidomasseteric fascia), and the plane containing the facial nerve, parotid duct, and buccal fat pad. The anatomic relationships existing within the facial soft-tissue layers are (1) the superficial facial fascia invests the superficially situated mimetic muscles (platysma, orbicularis oculi, and zygomaticus major and minor); (2) the deep facial fascia represents a continuation of the deep cervical fascia cephalad into the face, the importance of which lies in the fact that the facial nerve branches within the cheek lie deep to this deep fascial layer; and (3) two types of relationships exist between the superficial and deep facial fascias: In some regions of the face, these fascial planes are separated by an areolar plane, and in other regions of the face, the superficial and deep fascia are intimately adherent to one another through a series of dense fibrous attachments. The layers of the facial soft tissue are supported in normal anatomic position by a series of retaining ligaments that run from deep, fixed facial structures to the overlying dermis. Two types of retaining ligaments are noted as defined by their origin, either from bone or from other fixed structures within the face. The significance of the retaining ligaments lies in the fact that as people age, the support from this ligamentous system becomes attenuated, leading to many of the stigmata of the aging face, such as the development of jowling and prominent nasolabial folds. The anatomic changes that occur in the aging face are delineated. With an adequate understanding of the anatomic changes that occur with aging, rhytidectomy can be approached as a reconstructive procedure, restoring facial soft tissue to its original anatomic state and location.

Long-term histologic follow-up of phenol face peels.

Deep phenol peels were done on 11 middle-aged white women with severe actinic damage. Subsequently, face lifts were carried out after periods of 1.5 to 20 years. This made it possible to obtain a full-thickness specimen extending several centimeters on either side of the border between peeled and unpeeled skin. In contrast to the markedly abnormal elastotic appearance of unpeeled skin, a new band of connective tissue 2 to 3 mm in width was laid down in the subepidermal region. Fine elastic fibers formed a dense network in the band of regenerated collagen. The disarray and cytologic abnormalities of sun-damaged epidermis were also largely corrected. Melanocytes were not eliminated, but melanin synthesis was evidently impaired, accounting for the bleaching effects. The effects of a phenol peel are very long lasting and adequately account for the effacement of wrinkles and obliteration of actinic keratoses, mottling, and freckling.

Cosmetic Surgery of the Skin

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Chemical Face Peeling and Dermabrasion

While there are many similarities between dermabrasion and chemosurgery, their indications are clearly different, and the histological changes produced are not the same.

Chemical peel: a change in the routine.

The use of occlusive taping following phenol chemical peel has become a standard technique. Many studies have demonstrated the effectiveness of tape occlusion in producing a deeper, more profound chemical peel. For the last 18 months, we have abandoned tape occlusion following phenol peel and have substituted an occlusive dressing using a thick layer of petroleum jelly (Vaseline). The occlusiveness provided by the petroleum jelly has proved to be almost as effective as the standard tape mask, and the results using this technique parallel those with a tape mask. The advantages of Vaseline occlusive dressing include greater patient comfort, the ability to evaluate the wound beneath the petroleum jelly, and the prevention of streaking, which can occur from uneven tape application. Eschar formation and crust separation are avoided after the peel by the constant use of facial lubricants, our preference being A & D ointment.

Upper lid blepharoplasty.

We reviewed, retrospectively, our upper lid blepharoplasties to critically compare our own postoperative results after (1) conventional blepharoplasty, or (2) fixation of the levator aponeurosis to the lower margin of the orbicularis, or (3) fixation of the levator to the lower margins of the orbicularis and the skin. We found no demonstrable difference in our results with these 3 techniques. It is our opinion that the standard conventional blepharoplasty (including excision of a strip of orbicularis muscle) is preferable for use in most caucasian eyelids. The results are as good, it is simple, and it is less likely to cause problems.

Midazolam (versed) in ambulatory surgery

Midazolam is a very useful drug in outpatient aesthetic surgery. Its principal advantages are (1) short duration of action (a half-life of 2.3 hours), (2) painless injection, (3) no incidence of postoperative phlebitis (as compared with diazepam), and (4) a high degree of safety and effectiveness. Since one of the main objectives in outpatient surgery is to have the patient recover as quickly as possible and be discharged without any significant drug hangover, we recommend the incorporation of midazolam into the armamentarium of the aesthetic surgeon. Subsequent to the presentation of this paper (Twentieth Annual Meeting of the American Society for Aesthetic Plastic Surgery, in Los Angeles, California, March 23, 1987), we have administered midazolam to an additional 400 patients undergoing outpatient surgery and no apnea has occurred requiring an airway or supportive respiratory measures.