The Clinical Problem ( Fig. 11.1 )
The patient looks in the mirror and at recent photographs and thinks that he or she looks old and tired. She or he comments, “how I feel is much younger then how I look” and may state that the work environment is competitive and many cohorts look much younger. An associated loss of self-confidence may be claimed.
Synopsis
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Changes of facial aging of the cheeks, jowls, and neck are characterized by anterior and inferior descent of soft tissues over the facial skeleton.
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The challenge is to restore a natural youthful appearance by moving the descended soft tissues in a superior and posterior vector without distortion of the patient’s original appearance (i.e., looking pulled, stretched, or different.)
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A high superficial musculoaponeurotic system (SMAS) platysmal flap is used as the primary vehicle for restoring soft tissues to a youthful position.
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Neck defatting, combined with a full-width platysma transection, is effective for girth reduction of the neck.
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A sub–SMAS-platysma dissection extends until easy movement of the overlying skin and subcutaneous tissues, from cheeks to neck, is obtained by traction on the flap.
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The skin is redraped in a custom fashion for the individual’s face and closed without tension.
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A great majority of patients are comfortable in public after 2 weeks. The procedure entails extremely low morbidity and high patient and surgeon satisfaction.
The Aesthetic Problem
Facial aging is characterized by a change in appearance associated with the obligatory descent of the soft tissues of the face over the facial skeleton. Progressive loss of elasticity, combined with gravitational impact over time, produces this descent. There is an associated decrease in fullness over the cheek bones and an associated prominence of the nasolabial folds, jowls, and neck laxity, together with redundant soft tissues and platysmal banding to varying degrees.
The vectors of soft tissue descent are anterior and inferior. There are true and perceived alterations in facial shape and volume, with a progressive change from the heart-shaped face of youth to a vertically rectangular (boxy) shape of aging. There is a loss of definition of the cheek bone and jaw line, with angularity replaced by obliquity ( Fig. 11.2 ).
The surgical challenge is to restore the soft tissues to their place of origin and accomplish this without altering the patient’s native appearance. In my experience, most patients desire to “look like myself.”
Surgical Preparation and Technique
Facial aging issues addressed are the cheeks, jowls, and neck. The eyes and forehead are not subjects of this discussion. Much has been written about the plane(s) of dissection in face lifting, with advocates for subcutaneous, SMAS, subperiosteal, and combinations (e.g., deep plane, composite, zygo-orbicular) of these demonstrating excellent results. The addition of fat grafting as a modality useful in face lifting has become well established, and is commonly used in conjunction with all the aforementioned techniques. The SMAS has been used in various fashions (e.g., imbrication, SMASectomy with plication, elevation, and transposition, with or without the platysma) and has remained a time-tested vehicle as a prime force for tissue repositioning.
I find the use of one flap (high SMAS-platysma), dissected in one plane, to be an extremely useful and reproducible method of approaching the correction of the cheeks, jowls, and neck changes of aging. This avoids changing planes as one moves across the face, which can result in smaller flaps, with associated potential decreased strength and utility, and difficulties with exposure and visualization.
The flap described is broad, allowing excellent exposure in the dissection required for elevation and transposition. The size of the flap allows for its use as the prime tissue mover with variations of SMAS and platysma thickness, as well as for the occurrence of buttonholing. This approach also has the benefit of tension distribution over a large area, as opposed to techniques that rely on a minimal number of tension points. Direct apposition suturing of tissue to tissue avoids relying on the suspension sutures used in other techniques. The flap is extremely strong, absorbing all of the work of the procedure and allowing no tension to be placed on the skin, a potential cause of a pulled or done look.
This approach maintains the surgeon’s choice of a vector for skin movement to be different than that of the SMAS-platysma flap, which is primarily vertical. Skin undermining for redraping can be tailored to the requirements of the patient’s anatomy independently from the primary SMAS-platysma movement. In the technique described here, the high SMAS-platysma flap is associated with a full-thickness platysma transection. The benefits of this are related both to the facility of flap rotation and to a reduction in neck girth when compared to that at the jaw line level. In patients with heavy necks associated with excess subcutaneous fat, a more pleasing neck contour may be achieved by the combination of fat removal with full-thickness platysma transection.
In addition, platysma transection helps decrease the severity of transverse lines in the neck, heretofore infrequently addressed or successfully corrected. These lines, which are perpendicular to platysma contractions, are the analogues of the transverse forehead lines associated with frontalis muscle action and of the crow’s feet lines in relation to the dynamics of the vertically oriented fibers of the orbicularis oculi at the lateral orbit.
Primary risks associated with the high SMAS-platysma flap relate to delamination in a plane in proximity to the facial nerve. A secure knowledge of the anatomy, along with the broad exposure afforded by the flap breadth, allows the dissection to be performed safely. Similarly, the full-thickness platysma transection must be performed with sound anatomic knowledge to avoid injury to the marginal mandibular branch of the facial nerve as well as deeper structures. With such care, this procedure may be performed safely and with minimal difficulty.
Treatment and Operative Technique
Preoperatively, the patient is marked in the sitting position, noting the cardinal landmarks of the jaw line, platysma bands, and estimated skin undermining of the face and neck ( Fig. 11.3 ). The patients all receive the antiemetic agent aprepitant (Emend) preoperatively.
