1. Rhytidectomy Marc Cohen, M.D. David Geffen School of Medicine at UCLA Division of Head & Neck Surgery

2. The Aging Face  Soft tissue changes  Skin changes

3. Soft Tissue Changes  Jowl  Deepened nasolabial folds and perioral jowling  Platysmal banding and submental fullness  Orbicularis oculi and malar fat pad ptosis

4. Skin Changes  Epidermis and subcutaneous fat thins  Flattening of dermal-epidermal junction  Elastosis: progressive loss of organization of elastic fibers and collagen  Photodamaged skin – striking variability

5. SMAS  Superficial Musculoaponeurotic System  1976 Mitz and Pyronie Landmark paper  Fibromuscular fascial extension of the platysmal muscle that arises superiorly from the fascia over the zygomatic arch and is continuous in the inferior cheek with the platysma  Functions to transmit the activity of facial mimetic muscles to the facial skin

6. SMAS  Posteriorly, the SMAS fuses with the fascia overlying the sternocleidomastoid muscle, but it is a distinct layer superficial to the parotid fascia  Anterosuperiorly, the SMAS invests the facial mimetic muscles of the mid-face (i.e., orbicularis oculi, zygomatic major/minor, levator labii superioris)  Anteriorly, the SMAS invests the superficial portions of the orbicularis oris and gives off fibrous septae that insert into the dermis along the melolabial crease and upper lip

8. Facial Nerve  Protected by parotid tissue and lower branches are deep to masseter fascia  Potential space exists between SMAS and masseter fascia in inferior cheek  Important in deep/composite rhytidectomy techniques  Innvervates midfacial mimetic muscles from undersurface

9. Facial Nerve  Temporal branch is most superficial  Crosses junction of anterior 1/3 and posterior 2/3 of zygomatic arch  Above the arch it travels in the temporoparietal fascia to innervate frontalis and orbicularis oculi

10. SMAS & The Facial Nerve

11. Facelifts  Subperiosteal facelift

14. Subperiosteal facelift  Shortcomings  Frontal branch at higher risk  Significant facial edema lasting up to 6 weeks

15. Deep plane facelift  Addresses nasolabial folds  Subcutaneous  2-3 cm in front of tragus  Sub-SMAS  To zygomaticus major  Superficial to zygomaticus major  Upper extent is malar eminence  Inferior extent is jawline

16. Deep plane facelift

17. Composite facelift  Addresses malar eminence  Lower blepharoplasty incision used to elevate orbicularis oculi and malar fat pad  Transition then made superficial to zygomaticus major

19. Nasolabial Fold

20.  Boundary between cheek and upper lip  Laterally, thick subcutaneous layer  Medially, dermis almost approaches orbicularis  Cheek fat sags over time lateral to fold

21.  Upper third – insertion into LLSAN muscle  Middle third – transition btw both muscles  Lower third – insertion into OO  Deep plane and periosteal lifts do not anatomically address this  Controversial – SMAS or not

22. Nasolabial Fold Management  Direct excision (UCLA)  ePTFE (gortex)  Fillers  SMAS  Facelifts? Midface lifts?  Botox (LLSAN)

23. Botox

24. Direct Excision

25. Lift and Peel at same time?  Concern for flap necrosis  Retrospective studies show no increased incidence of flap necrosis or other complications

26. Retaining Ligaments of the Face  Osteocutaneous  Orbital – centered at zygomaticofrontal suture  Zygomatic  Buccal-maxillary – arises from zygomaticomaxillary suture  Mandibular (along with DAO makes up labiomandibular crease)  Fasciocutaneous  Masseteric (anterior border of masseter  Parotidocutaneous

28. Blood Supply  ECA  STA  Transverse facial artery  Zygomaticorbital artery  Facial  Submental  Inferior labial  Superior labial  Angular

29. Blood Supply

30. Complications - Hematoma  HTN is major risk factor (2.6x risk)  Major – usually occur in first 12 hours  reoperation and exploration  Minor – occur during the first week  Evacuated with 18 ga needle or small opening in incision line, pressure dressing, abx

31. Complications – Flap necrosis  Postauricular is most common site  Preauricular is 2 nd most common  Deep-plane facelifts have a decreased incidence of necrosis  Nicotine carries a 12.6x risk for flap necrosis  Must stop at least 2 weeks prior  Treat conservatively with with daily peroxide cleaning, limited debridement, and topical abx ointment  Most heal nicely

32. Complications – Nerve Damage  Most commonly injured nerve is great auricular  If injured, should be repaired with 9-0 nylon  Temporal and Marginal are the most commonly injured motor nerves  Studies differ on which is more commonly injured (which technique, etc.)  Treatment  First 4-8 hours, wait  If prolonged, do NOT re-explore  85% will resolve with time  Reconstruct after 1 year  Patients with a hx of Bell’s palsy are at risk for recurrence after rhytidectomy

33. Complications  Hypertrophic scarring  Occurs with excessive tension on flap closure  More commonly with isolated subcutaneous flap dissections  Treat with steroids  Defer excision and primary closure until at least 6 months postoperatively  Alopecia  Wait 3-6 months, then excise or place grafts

34. Complications  Infection  Common pathogens are staph and strep  Usually respond to oral abx  Rare for abscess to form  Earlobe deformity (pixie ear)  V-Y plasty performed 6 months after surgery

36. Complications  Parotid injury  Sialocele or fistula  Needle aspiration and pressure dressings