Composite Rhytidectomy Research Articles

Facelift Part II: Surgical Techniques and Complications.

Although previous publications have reviewed face and neck-lift anatomy and technique from different perspectives, seldom were the most-relevant anatomical details and widely practiced techniques comprehensively summarized in a single work. As a result, the beginner is left with a plethora of varied publications that require sorting, re-arrangement, and critical reading. A recent survey of US plastic surgery residents and program directors disclosed less facility with facelift surgery when compared to aesthetic surgery of the breast and trunk. To this end four of the widely practiced facelift techniques (ie, MACS-lift, lateral-SMASectomy, extended-SMAS, and composite rhytidectomy) are described in an easy review format. The highlights of each are formatted followed by a summary of complications. Finally, the merits and limitations of these individual techniques are thoroughly compared and discussed.

Building the Composite Face Lift: A Personal Odyssey.

This article is a 42-year history of the development of a comprehensive face-lift technique by the author. It describes how the composite rhytidectomy has been constructed, anatomical area by anatomical area, over the author's lifetime career as a plastic surgeon. Over the course of these years, beginning with Skoog's 1973 description of using the platysma muscle of the lower face, it describes how progressively the other significant structures of anatomy necessary to be used in achieving significant rejuvenation have been analyzed by the author and in turn surgically repositioned. The theory was based on creating a composite flap of the face, keeping the orbicularis oculi muscle, facial platysma muscle, and cheek fat in their normal anatomical and intimate relationship with each other by using the skin as the carriage. In addition, differences of vectors between the composite rhytidectomy and traditional techniques are demonstrated. The gradual and persistent pursuit of periorbital rejuvenation using the lower eyelid fat and the septal orbitale is described. Each of the anatomical structures involved and the description of their importance and surgical execution have been published over the surgical career of the author, including use of the same principles for reversing suboptimal face-lift results.

Morphology of the Zygomaticus Minor and Its Relationship With the Orbicularis Oculi Muscle

The aim of this study was to examine in detail the anatomic variations in the orbicularis oculi muscle (OOc) and relationship of the zygomaticus minor muscle (ZMi) with the OOc, thereby providing an anatomic basis for explaining facial animation and attachment to the periorbital muscle. Sixty-one hemifaces from embalmed Korean adult cadavers (34 males, 27 females; age range, 45-85 years; mean age, 62.6 years) were used in this study. The prevalence of cases in which the ZMi did not run straight from the upper lip, rather running straight to the corner of the levator labii superioris, was 36.1% (22/61), because the origin of ZMi covered the inferior border of the OOc. The prevalence of mixing of the belly of the orbital part of the outer edge of the OOc with the ZMi was 88.5%, and that of blending of the ZMi band into the lower inner corner of the OOc was 55.7%. The area of blending of the OOc and ZMi was located 17.8 mm down from the Frankfort plane and 8.9 mm lateral to the vertical line between the lateral canthus and the Frankfort plane in the lateral part of the OOc. At this position, the mixed belly extends medially for a distance of 16 mm. This research has identified the exact location where the ZMi and OOc blend and determined the relationship between the ZMi and the suborbicularis oculi fat. This result will be given as basic data for understanding facial expressions and for performing composite rhytidectomy.

Nuances of the Composite Face-lift Technique

The composite face-lift is a well-described, comprehensive facial rejuvenation technique that results in harmonious repositioning of all components of the aging face. It is distinguished by the superior-medial movement of the cheek and the septal reset maneuver. The composite rhytidectomy reverses the unbalanced vectors of the traditional face-lift in patients with the lateral sweep and may reestablish the youthful convexity in patients with hollow eyes.

Identical Twin Face Lifts with Differing Techniques: A 10-Year Follow-Up

To evaluate the efficacies of four different surgical techniques in facial rejuvenation, two sets of identical twins were operated on by four different surgeons. The technical approaches to facial rejuvenation included lateral superficial musculoaponeurotic system (SMAS)-ectomy with extensive skin undermining, composite rhytidectomy, SMAS-platysma flap with bidirectional lift, and endoscopic midface lift with an open anterior platysmaplasty. All patients were photographed by an independent surgeon at 1, 6, and 10 years postoperatively. At the same time interval, the cases were presented and discussed in a panel format at the annual meeting of the American Society for Aesthetic Plastic Surgery. Each operating surgeon was allowed to critique the results and discuss how his methods had changed over the intervening 10-year interval. Postoperative photographs at 1, 6, and 10 years after surgery are included to allow the reader to examine long-term results utilizing various approaches to facial rejuvenation in identical twins.

Subperiosteal Deep Plane Rhytidectomy: The Composite Midface Lift

Techniques for facial rejuvenation have long involved specific remedies for each facial segment affected by the aging process. Traditional facial rejuvenation techniques have addressed the anterior neck and platysma complex as well as the acquired jaw deformity. These techniques often left the nasolabial complex and the "infraorbital hollow" un-addressed. Modern techniques, including the composite rhytidectomy, the subperiosteal midface lift, and the deep-plane and the triplane rhytidectomy, have contributed to redefining the challenge of correcting the problem of the orbicularis-malar soft tissue complex descent and as such focus on a particular segment of the facial rejuvenation. This evolution of the facelift demonstrates that one size does not fit all and that surgeons should consider their rejuvenations to be not a generic facelift but a midface, lower face, and neck lift. This concept has evolved into our appreciation of distinct surgical zones. This is especially important in males, and adjunctive techniques such as the ones we describe may add benefit and enhance the final result in male patients. As discussed, the male anatomy, because of its increased surface area and weight, is more difficult to gain leverage with in rejuvenation procedures. The author describes his preferred technique for facial rejuvenation in males, the subperiosteal deep plane rhytidectomy (SPDPR), which combines a deep plane rhytidectomy with a subperiosteal dissection. Although combining subperiosteal "release" of midfacial anatomy has been reviewed by other authors, the combination of subperiosteal release and deep-plane rhytidectomy has not been previously reported or advocated. The operative technique, complications, and results of this combined technique are reviewed. The procedure as described is used as an isolated procedure for midfacial descent as well as an incorporated technique when completing a "full" rhytidectomy.

Facelift

Facelift surgery is the ultimate rejuvenative procedure. Over the past 50 years, evolution of various facelift techniques has addressed both conservative and aggressive approaches. This procedure can be as simple as a small skin flap or as aggressive as deep plane subperiosteal techniques. Regardless of the technique, significant complications can occur with facelift surgery in the preoperative, intraoperative, and postoperative phase. It is imperative that the surgeon anticipate, recognize, and be able to treat the common complications associated with this procedure. The following problems can occur with facelift surgery and will be discussed. Optimal candidate selectionThe poor risk facelift patientPreoperative incision designPreoperative hypertensionPreoperative coagulopathyPreoperative anesthetic considerationsIntraoperative flap designIntraoperative SMAS managementIntraoperative nerve and danger zonesPostoperative hypertensionPostoperative hematomaPostoperative neuropathyPostoperative contour irregularitiesPostoperative scar problemsPostoperative hair lossRevision facelift considerations The above topics will be discussed in a multimedia presentation with emphasis placed on the recognition, management, and prevention of these complications. References Niamtu J: Cosmetic facial surgery. Oral Maxillofac Surg Clin North Am 12:579, 2000 Ramirez OM: Three-dimensional endoscopic midface enhancement: A personal quest for the ideal cheek rejuvenation. Plast Reconstr Surg 109:329, 2002; discussion 341 Hamra ST: The zygorbicular dissection in composite rhytidectomy: An ideal midface plane. Plast Reconstr Surg 102:1646, 1998 Tobin HA, Cuzalina A, Tharanon W, et al: The biplane facelift: An opportunistic approach. J Oral Maxillofac Surg 58:76, 2002

The Role of the Septal Reset in Creating a Youthful Eyelid-Cheek Complex in Facial Rejuvenation

Resetting of the septum orbitale over the orbital rim, or "septal reset," is the latest step in achieving periorbital rejuvenation in composite rhytidectomy. The first significant step was the addition of orbicularis repositioning to conventional lateral vector deep plane rhytidectomy, followed by orbital fat preservation using the arcus marginalis release and fat transposition over the orbital rim. Those early procedures have been further refined to include the zygomaticus muscles with the orbicularis oculi in the composite flap, or zygorbicular cheek flap, and a septal reset. The septum orbitale reset has distinct advantages over transposition of orbital fat alone, as it creates a firmer undersurface for the lower eyelid. This maneuver will create a truly youthful lower eyelid-cheek complex, as the normal concave aging skeletonization of the periorbit is transformed to a convex contour of youth. The effectiveness of this operation can be demonstrated in most variations of human anatomy, whether congenital or iatrogenic, allowing the plastic surgeon to utilize the septal reset in virtually every patient undergoing and desiring a harmonious facial rejuvenation.

A method of augmenting the cheek area through SMAS, subSMAS, and subcutaneous tissue recruitment during facelift surgery.

As the human face ages, there is a depletion of fat that occurs in the submalar region. Various techniques such as fat transfers, fillers, alloplastic implants, and composite rhytidectomies have been used to augment this area in the past. To describe a technique that augments the submalar areas during facelift surgery without the use of fat transfer, fillers, alloplastic implants, or a risky composite technique. An oval is scribed over the depressed submalar areas preoperatively. During facelift surgery, a fusiform area is scribed over the SMAS. This fusiform is scribed so that the medial end is directed at the center of the submalar depression, and the lateral end is toward the posterior earlobe. A defect is created within the lateral aspect of the fusiform, but not the medial portion. The fusiform is subsequently closed with a 2-0 Ethibond suture using three horizontal mattress sutures and two interrupted sutures. Upon closure of this defect, SMAS, subSMAS, and subcutaneous tissue overlying the SMAS are recruited into the submalar defect by the simple phenomenon of dog-ear formation. Additionally, there is a component of frank elevation of the tissues inferior to the medial aspect of the fusiform and submalar space. The aforementioned technique has been performed on 123 patients over 7 years and has resulted in consistently good improvement in the submalar space. The procedure is not difficult to learn, and good results can be achieved with initial cases. The learning curve was not found to be steep, with good results being achieved quickly. Depression of the submalar space plays a significant role in creating an aged face. In the past, various fillers and/or alloplastic implants have been used to augment this region. A low-risk method is described that mobilizes SMAS, subSMAS, and subcutaneous tissues into the submalar space through the phenomenon of dog-ear formation after fusiform closure.

Reinforced orbitotemporal lift: contribution to midface rejuvenation.

The changes in the aging face occur from progressive ptosis of the skin, fat, and muscle, in conjunction with bone absorption and cartilage atrophy. In the orbital region, hollowness and compartmentalization occur. Conventional face lift procedures correct only the skin flaccidity, and superficial musculoaponeurotic system techniques reposition the skin and platysma without repositioning the middle third of the face, creating an artificial jawline. Subperiosteal rhytidectomy disrupts the anatomy of the periorbita, which gives the patient a certain scarecrow aspect. Composite rhytidectomy associated with brow lift and blepharoplasty may offer better results, with improvement in the malar and orbital regions. The reinforced orbitotemporal lift (ROTEL) is a new procedure in a face lift that allows the orbicularis oculi muscle and all the structures connected to it to be elevated and stretched and the orbitotemporal skin to be raised, repositioning these structures and ending orbital compartmentalization. The result is an impressive improvement in the malar-orbitotemporal region, resulting in a natural and youthful appearance.

Biomechanical and viscoelastic properties of skin, SMAS, and composite flaps as they pertain to rhytidectomy.

Previous studies have focused on biomechanical and viscoelastic properties of the superficial musculoaponeurotic system (SMAS) flap and the skin flap lifted in traditional rhytidectomy procedures. The authors compared these two layers with the composite rhytidectomy flap to explain their clinical observations that the composite dissection allows greater tension and lateral pull to be placed on the facial and cervical flaps, with less long-term stress-relaxation and tissue creep. Eight fresh cadavers were dissected by elevating flaps on one side of the face and neck as skin and SMAS flaps and on the other side as a standard composite rhytidectomy flap. The tissue samples were tested for breaking strength, tissue tearing force, stress-relaxation, and tissue creep. For breaking strength, uniform samples were pulled at a rate of 1 inch per minute, and the stress required to rupture the tissues was measured. Tissue tearing force was measured by attaching a 3-0 suture to the tissues and pulling at the same rate as that used for breaking strength. The force required to tear the suture out of the tissues was then measured. Stress-relaxation was assessed by tensing the uniformly sized strips of tissue to 80 percent of their breaking strength, and the amount of tissue relaxation was measured at 1-minute intervals for a total of 5 minutes. This measurement is expressed as the percentage of tissue relaxation per minute. Tissue creep was assessed by using a 3-0 suture and calibrated pressure gauge attached to the facial flaps. The constant tension applied to the flaps was 80 percent of the tissue tearing force. The distance crept was measured in millimeters after 2 and 3 minutes of constant tension. Breaking strength measurements demonstrated significantly greater breaking strength of skin and composite flaps as compared with SMAS flaps (p < 0.05). No significant difference was noted between skin and composite flaps. However, tissue tearing force demonstrated that the composite flaps were able to withstand a significantly greater force as compared with both skin and SMAS flaps (p < 0.05). Stress-relaxation analysis revealed the skin flaps to have the highest degree of stress-relaxation over each of five 1-minute intervals. In contrast, the SMAS and composite flaps demonstrated a significantly lower degree of stress-relaxation over the five 1-minute intervals (p < 0.05). There was no difference noted between the SMAS flaps and composite flaps with regard to stress-relaxation. Tissue creep correlated with the stress-relaxation data. The skin flaps demonstrated the greatest degree of tissue creep, which was significantly greater than that noted for the SMAS flaps or composite flaps (p < 0.05). Comparison of facial flaps with cervical flaps revealed that cervical skin, SMAS, and composite flaps tolerated significantly greater tissue tearing forces and demonstrated significantly greater tissue creep as compared with facial skin, SMAS, and composite flaps (p < 0.05). These biomechanical studies on facial and cervical rhytidectomy flaps indicate that the skin and composite flaps are substantially stronger than the SMAS flap, allowing significantly greater tension to be applied for repositioning of the flap and surrounding subcutaneous tissues. The authors confirmed that the SMAS layer exhibits significantly less stress-relaxation and creep as compared with the skin flap, a property that has led aesthetic surgeons to incorporate the SMAS into the face lift procedure. On the basis of the authors' findings in this study, it seems that that composite flap, although composed of both the skin and SMAS, acquires the viscoelastic properties of the SMAS layer, demonstrating significantly less stress-relaxation and tissue creep as compared with the skin flap. This finding may play a role in maintaining long-term results after rhytidectomy. In addition, it is noteworthy that the cervical flaps, despite their increased strength, demonstrate significantly greater tissue creep as compared with facial flaps, suggesting earlier relaxation of the neck as compared with the face after rhytidectomy.

Correcting the Unfavorable Outcomes Following Facelift Surgery

Although many deformities formerly observed after rhinoplasties are seen less because of more sophisticated techniques, the deformities that may occur after conventional facelifts seem to be growing by epidemic numbers because of the widespread and almost universal use of conventional facelift and blepharoplasty techniques. The unfortunate appearance of these patients is the fault neither of the surgeon nor of the patient, but frequently both get blamed. Throughout every step of the history of medicine there have been improvements made that cause the physician to abandon a technique or medications that clearly are shown to be suboptimal. Unfortunately, this has not happened with rejuvenative surgery. More sophisticated techniques like composite rhytidectomy have a steeper learning curve, take more time to perform, and require longer periods of convalescence for the patient. Many experts in aesthetic surgery continue to teach conventional techniques because the public does not seem to know the difference. Fashion magazine articles on aesthetic surgery promote simple and easy techniques without bothering to explain the unfortunate and minimal results that are obtained. The obligation of any surgeon doing aesthetic surgery is the same as any physician must have in any medical field. If any operation would give a patient a suboptimal or negative result, then attempts must be made to improve these techniques. Although traditional techniques will continue to be used, there are certain conclusions that can be made: 1. More people who have undergone plastic surgery are showing eventual signs of surgery that are neither attractive nor youthful. It is clear that results of conventional facelift techniques are not predictable and are often unfavorable. 2. Facelift deformities are not the fault of the surgeon but are natural byproducts of the techniques that are used. These techniques must be improved. 3. Composite rhytidectomy with orbital fat preservation as a primary procedure will create a harmonious facial rejuvenation that will disallow the appearance of unwanted deformities such as hollow eyes and the lateral sweep. 4. Composite rhytidectomy as a secondary procedure produces the most effective correction of the unintentional but unfavorable results that follow traditional rejuvenative surgery.

Minimal-incision endoscopic face-lift.

Ptosis of the midfacial tissues with resultant deepening of the melolabial folds, vertical lengthening of the lower eyelid, and depression of the oral commissure are generally only slightly improved with traditional superficial musculoaponeurotic system (SMAS) suspension or rhytidectomy techniques. Subperiosteal, deep plane, and composite rhytidectomies have evolved in an attempt to rejuvenate these areas. This article reviews a series of patients who underwent an endoscopic subperiosteal face-lift either as an isolated procedure or in conjunction with an SMAS rhytidectomy. Although all patients showed good initial improvement, patients with thin faces and well-defined facial bone structure maintained the best long-term result. Complications were minimal, with no permanent facial nerve injuries observed. The endoscopic subperiosteal face-lift is a useful technique as an isolated procedure or in conjunction with facial liposuction or SMAS suspension rhytidectomy. Arch Facial Plast Surg. 2000;2:274-278

Prevention and correction of the "face-lifted" appearance.

In spite of the increasing demand and popularity of facial rejuvenation procedures, there has been little real change of traditional techniques over the past few decades. Face lifts continue to be lateral vector techniques, whether skin lifts, superficial musculoaponeurotic system (SMAS) lifts, or deep plane malar fat maneuvers are done. Lower eyelid procedures continue to include removal of orbital fat in most cases. Laser blepharoplasties combine transconjunctival fat removal with laser skin abrasion. Forehead lifts continue to be optional in most cases, in spite of clear indications. The unfortunate results of these traditional procedures that may occur are becoming easy to recognize. The unopposed tension of lateral vector face lifts allows the cheek tissues to descend eventually over the tightened jawline, creating a "lateral sweep" or pulled appearance of the face. A crescent-shaped mound over the malar area is the inferior orbicularis oculi muscle, not repositioned with conventional procedures. Following conventional blepharoplasty, the lower eyelid contour becomes deeper, and often an hollow appearance develops. A composite face lift combined with an arcus marginalis release can correct these typical problems. The primary vector of the face is superiomedial, which will reverse the unopposed tension of lateral vector techniques and reposition the cheek tissues to their original position. The arcus marginalis release combined with repositioning of the complete orbicularis muscle in a zygorbicular midface flap can be used to correct the most severe hollow lower eyelid. Unwanted and unattractive results are not the fault of the surgeon or the patient but are caused by the surgical technique. As a primary rejuvenative procedure, a composite rhytidectomy will deliver an impressive result that will disallow the ultimate lateral sweep and hollow eyes. In patients that have the unhappy signs of surgery this procedure can effectively correct the face-lifted appearance.

The zygorbicular dissection in composite rhytidectomy: an ideal midface plane.

Composite rhytidectomy added the repositioning of the orbicularis oculi muscle to the deep plane face lift to achieve a more harmonious appearance of the face by adding periorbital rejuvenation. By not separating the orbicularis oculi from the zygomaticus minor and by extending the dissection under medial portions of the zygomaticus major and minor muscles, a more significant improvement in composite rhytidectomy can now be achieved. A thin nonrestrictive mesentery between the deep plane face lift dissection and the zygorbicular dissection still allows vertical movement of the composite face lift flap without interrupting the intimate relationship between the platysma, cheek fat, and orbicularis oculi muscle. This modification eliminates the occasional prolonged edema and occasional temporary dystonia previously observed. It allows the continuation of the use of the arcus marginalis release, which has also been modified by resetting the septum orbitale over the orbital rim. These two modifications allow a more predictable and impressive result. They reinforce the concept of periorbital rejuvenation as an integral part of facial rejuvenation, which not only produces a more harmonious immediate result but prevents the possible unfavorable sequelae of conventional rhytidectomy and lower blepharoplasty.

Periorbital rejuvenation in composite rhytidectomy

Conventional blepharoplasty and rhytidectomy techniques do not adequately address the periorbital area in facial rejuvenation. Conventional blepharoplasty, whether transcutaneous or transconjunctival, normally removes lower-eyelid fat when present and only redrapes the skin from the incision line to the orbital rim. The eyelid frequently appears more hollow after surgery. The diameter of the periorbit does not become youthful, and narrow because the complete orbicularis muscle has not been repositioned. Traditional rhytidectomy techniques redrape facial tissues in a lateral direction toward the ear without repositioning of the orbicularis muscle. Composite rhytidectomy and arcus marginalis release create periorbital rejuvenation by preservation and repositioning of the lower-eyelid fat and repositioning of the orbicularis oculi muscle. This procedure satisfies the goal of harmonious facial rejuvenation by making the lower-eyelid-cheek complex appear as young as the remaining parts of the face that have been surgically rejuvenated. Recent modifications of the arcus marginalis release and the orbicularis repositioning allow more predictable results. These modifications are a zygorbicular (zygorbicular-orbicularis) cheek dissection with an arcus marginalis release and septal reset. A transcanthal canthopexy stabilizes the lateral canthal position. Creation of a firm suborbicularis convex surface with this periorbital rejuvenative technique prevents a hollow lower eyelid and improves the appearance of redraped eyelid skin.

A case for superficial rhytidectomy

The first written accounts of the development of face-lift operations are credited to surgeons such as Miller, Kolle, and Bettman.le5 These early rejuvenation techniques were primarily designed to rid the patient of lateral facial wrinkling. Over the past two decades, the need for superficial musculoaponeurotic system (SMAS) manipulation during rhytidectomy has been widely accepted by most surgeons. In recent years, more complex aesthetic facial procedures, such as the deep-plane and composite rhytidectomies, have been popularized in the literature. Although numerous articles have attempted to show the benefits of these more complex, multilayered face-lift techniques, none definitively show a longer-lasting result.6-10 It is not the intent of this article to describe in detail the various rhytidectomy techniques in current use, but rather to present evidence supporting the superficial plane rhytidectomy with SMAS manipulation as the procedure of choice for facial rejuvenation. We believe it provides predictable, long-lasting results with minimal risks and a short recovery period. To avoid confusion in discussing this issue, the nomenclature used in rhytidectomy must be reviewed. Most authors categorize major rhytidectomy techniques into four generations (Table 1).7111 The subcutaneous rhytidectomy (first-generation) involves total subcutaneous undermining, while leaving the deep anatomic structures unchanged.5J2-14 Secondgeneration rhytidcctomies use various SMAS and platysmal suturing techniques (plication or imbrication) to reposition the facial soft tissues.11115-18 The deep-plane techniques (third generation) involve both platysmal and cheek fat repositioning; the classic planes of dissection are prezygomaticus in the cheek, subplatysmal in the lower face, and preplatysmal in the neck.6,7 The

Composite rhytidectomy: Finesse and refinements in technique: Hamra ST, Clin Plast Surg 24:337, 1997

Composite rhytidectomy: Finesse and refinements in technique: Hamra ST, Clin Plast Surg 24:337, 1997

Composite Rhytidectomy: Finesse and Refinements in Technique

Composite rhytidectomy is an integrated facelift technique that has been developed with the philosophy that every area of the aging face undergoes topographic changes that are created by changes in deep anatomic structures. The goal of harmonious facial rejuvenation is youthful contours of every area of the face, including an elevated forehead and a youthful neck contour. Most importantly, the midface must have a narrow, more shallow orbital appearance to be compatible with an improved nasolabial fold and jawline. There have been several refinements in technique, outlined in this article, that have contributed to consistent and dependable results.

Aesthetic and safety considerations in composite rhytidectomy: a review of 145 patients over a 3-year period.

Since Hamra described the composite rhytidectomy, many surgeons have been using the technique, but few have published their experience concerning this subject. A series of 145 composite rhytidectomies (133 primary, 8 secondary, and 4 tertiary) in a 3-year period (from September of 1992 through October of 1995), including male and female patients ranging in age from 40 to 74 years, was selected to evaluate my personal approach to the technique, the indications, the aesthetic results, and complications. In this series, all patients were operated on by the same surgeon, from incision to complete closure of the skin. All the preoperative and postoperative photographs were taken by the same photographer. The tripronged hallmark of my contribution to the original technique is (1) cheek fat undermining through the upper approach instead of the lateral approach (easy to perform with low risk of nerve injury), (2) systematized surgical steps (reduced amount of anesthetic solution, low surgical risk, significant reduction in bleeding, lower cost, and easier and quicker recovery phase), and (3) a low complication rate. The postoperative results have been improved with this technique, satisfying both patient and surgeon.