Cigarette smoking and face lift: conservative versus wide undermining

The effects of cigarette smoking on the skin flaps of the face lift procedure are discussed. Reported elsewhere is a significant incidence of skin slough in smokers with use of wide undermining techniques. This complication is thought to be due to the vasoconstrictive effects of nicotine on the peripheral circulation. Our group has employed a conservative bilateral undermining technique in 407 face lifts. Of these, 32.4 percent were smokers and 67.6 percent were nonsmokers. No cases of skin slough were encountered. Our conservative undermining technique is briefly discussed. Among its advantages are shorter operative time, use of less local and/or general anesthesia, less intraoperative bleeding, adequate exposure for SMAS and platysmal surgery, and snugger skin closure without the risk of flap necrosis. As shown by our statistics, it is a safer procedure in smokers than the usually performed more radical procedure.     

Endoscopic forehead lift: review of technique,cases, and complications

Endoscopy has provided a significant improvement in the surgical rejuvenation of the upper face. It offers a minimally invasive alternative that avoids many of the undesirable effects associated with the coronal approach. The standard minimal access forehead endoscopic procedure consists of a subperiosteal undermining through three small triangular prehairline incisions. To successfully elevate the eyebrows, it is essential to release the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the glabella. Until the periosteum reattaches itself, elevation is maintained by a temporary suspension suture between staples at the incision sites and 5 cm posterior to the hairline. The transverse closure of the triangular skin incisions achieves some additional elevation. The biplanar approach adds a partial subcutaneous undermining of the forehead to the endoscopic technique and allows plication of the frontalis muscle and excision of excess forehead skin. It is offered to patients with very ptotic eyebrows, deep transverse wrinkles, or a high forehead. The prehairline incision is a disadvantage but is tolerated quite well in older patients. The medical records of 393 consecutive patients who underwent endoscopic forehead lift from 1994 to 2000 were reviewed. Because seven patients had the endoscopic forehead lift repeated, the number of forehead endoscopies totaled 400. The complication rate was quite acceptable and did not markedly increase when a forehead lift was performed in combination with other facial procedures. The endoscopic forehead lift consistently attenuated the transverse forehead wrinkles, reduced the glabellar frown lines, and raised the eyebrows. It provided an appearance that was less tired and angry in addition to opening the area around the eyes. Long-term follow-up has shown that the endoscopic forehead lift produces lasting and predictable results.     

The retaining ligaments of the cheek

The zygomatic ligaments (McGregor's patch) anchor the skin of the cheek to the inferior border of the zygoma just posterior to the origin of the zygomaticus minor muscle. The mandibular ligaments tether the overlying skin to the anterior mandible. Both these ligaments are obstacles to surgical maneuvers intended to advance the overlying skin. They also restrain the facial skin against gravitational changes, and they delineate the anterior border of the "jowl" area. The platysma-auricular ligament is a thin fascial sheet that extends from the posterosuperior border of the platysma and that is intimately attached to the periauricular skin; it serves as a surgical guide to the posterosuperior border of the platysma. The anterior platysma-cutaneous ligaments are variable fascial condensations that anchor the SMAS and platysma to the dermis. They can cause anatomic disorientation with dissection of false planes into the dermis. These four ligaments are useful as anatomic landmarks during facial dissections. The tethering effects of the zygomatic and mandibular ligaments must be interrupted if a maximum upward movement of the facial skin is desired.     

The submuscular aponeurotic system (SMAS): a histologic and comparative anatomy evaluation

The submuscular aponeurotic system (SMAS) has been steeped in controversy. The goal of our anatomic study was to further clarify the existence of the SMAS. With an operating microscope, we performed dissections in 10 fresh cadaver heads (20 hemiheads) exposing the SMAS through a face lift incision. Through the operating microscope we were able to identify the SMAS and its relationship to other anatomic structures. Full-thickness longitudinal sections were obtained for routine histologic studies along various surgically relevant regions of the SMAS. In addition, dissections were accomplished with the operating microscope on 12 rhesus monkey fetuses ranging in age from a few weeks to 8 months. Data obtained from the fresh cadaver microdissections, topographic histology, and comparative anatomy revealed the presence of the SMAS as a distinct fibromuscular layer composed of the platysma muscle, parotid fascia, and fibromuscular layer covering the cheek.     

Composite rhytidectomy.

Signs of aging in the face reflect the change in position of deep anatomic elements, which are the platysma muscle, cheek fat, and the orbicularis oculi muscle. These changes occur from progressive ptosis of these elements, which continue to keep their intimate relationship with each other throughout the aging process. Conventional face lift procedures disrupt this normal relationship by separating the skin from these elements. All SMAS techniques reposition only the platysma muscle without repositioning the cheek fat and orbicularis muscle. This composite rhytidectomy allows elevation of a composite musculocutaneous flap containing all three elements for repositioning while maintaining their intimate relationship with each other and with the skin. One-hundred and sixty-seven composite rhytidectomies have been done with impressive results and minimal complications.     

Facial skeletal growth after timed soft-tissue undermining.

This study was designed to answer the following questions: (1) Does aggressive bilateral soft-tissue undermining of the nasomaxillary complex in an immature animal without an iatrogenically produced cleft lip significantly inhibit growth? (2) If so, is the early timing of this undermining crucial? Fifty New Zealand White rabbits were used in this study, and bilateral buccal sulcus incisions with extensive nasomaxillary supraperiosteal undermining were performed in the experimental groups. There were five groups: (1) control, (2) undermining at 3 to 4 days, (3) undermining at 7 to 10 days, (4) undermining at 18 to 21 days, and (5) undermining at 50 to 56 days. The animals were sacrificed at 6 months of age, and direct osteometric measurements were made. Results demonstrated that a significantly retruded, constricted, and vertically shortened maxilla was produced as a direct result of bilateral nasomaxillary soft-tissue undermining alone regardless of the timing.     

Face lifting: problems, solutions, and an outcome study

The superficial musculoaponeurotic system (SMAS) platysma rotation flap with platysmal transection from the deep surface has been the author's face-lift technique to correct jowls, submental laxity, and platysma bands since 1982. An outcome study of 10 consecutive face-lift operations is presented to demonstrate the efficacy of correction of lower face and neck aging and the duration of the improvement. Reappearance of platysma bands has been the earliest and most frequent sign of recurrent aging changes. A technique for directly dealing with platysma bands in the submental and cervicomental location is described, and follow-up results up to 3 years are shown.     

Frey's syndrome: a preventable phenomenon.

Gustatory sweating, or Frey's syndrome, is a fairly common sequela of partial or radical parotidectomy, submaxillary gland surgery, or radical neck dissection. It is caused by an anastomotic communication with facial sweat glands by parasympathetic secretomotor nerve fibers intended for the excised parotid gland; treatments, whether surgical or topical, generally have been less than satisfactory. We present the first documented prophylactic approach to Frey's syndrome that is performed during and as part of parotidectomy. The surgery involves use of the superficial aponeurotic system (SMAS) as an interposing flap to interrupt the anastomotic nerve communication with the sweat glands. The SMAS is derived from the fascia in the periauricular cheek and neck area that is continuous with the platysma muscle. In a prospective study in 55 patients undergoing elective parotidectomy, the SMAS flap was elevated during the beginning of the operative procedure once it had been determined that fashioning of the flap would in no way compromise tumor excision. In all cases, at follow-up, there has been no clinical evidence of development of Frey's syndrome. We have shown that the development of the SMAS flap in parotid gland resections is an effective new approach both as a preventative measure against Frey's syndrome and as an aesthetic improvement over the usual defect typical of parotidectomies.     

Does a superficial musculoaponeurotic system exist in the face and neck? An anatomical study by the tissue plastination technique

An exact knowledge of the subcutaneous layers in the different regions of the face and neck is important in several surgical disciplines. In the parotid region, a superficial musculoaponeurotic system (SMAS) has been described. The existence of a SMAS as a guiding structure for the surgeon in the other regions of the face and neck has been discussed but is controversial. Therefore, the authors investigated the development of the subcutaneous connective-tissue layers in the different facial regions and in the neck. They studied these regions in 22 human fetuses using the technique of plastination histology and in three newborn and three adult specimens using sheet plastination. In addition, they dissected the neck and face in 10 fresh adult cadavers to identify the SMAS as in the surgical situation. The results show that no SMAS could be detected in any facial regions other than the parotid region. In the parotid region, it is thick and attached to the parotid sheath. However, it becomes very thin, discontinuous, and undissectable in the cheek area. No SMAS can be found in the neck, in which the authors are the first to describe a fascia covering both sides of the platysma. This fascia has close topographical connections to the subcutaneous layers of the adjoining regions. On the basis of these findings, the surgical pathways have to be defined regionally in the face. A "platysma fascia" can be considered as a surgical landmark in the neck. Therefore, the authors conclude that it is not justified to generalize a SMAS as a surgical guiding structure.     

The cessation of cervical nerve root pain following modified SMAS rhytidectomy

The cessation of cervical nerve root pain following modified SMAS rhytidectomy is reported. CAT scans and radiographs demonstrating substantial changes in the intervertebral relationships are documented. No previous report exists demonstrating the biomechanical response to platysma muscle surgery. The potential for alterations in the cervical spine either positive, as in this case, or perhaps negative with exacerbation or creation of symptoms not existing prior to surgery, is presented. The complex biomechanical influence of the procedure indicates that further study and appreciation of the biomechanical changes are necessary to thoroughly understand the ramifications of the SMAS rhytidectomy.     

Face lifts with hidden scars: the vertical U incision

The authors present their latest development of a strictly vertical retroauricular incision to minimize a sequela of a face lift, namely, a visible scar. The temporal preauricular vertical incision and the retroauricular vertical incision form two parallel arms of a U-shaped incision. Anteriorly, a downward rotation flap is made to maintain the horizontal temporal line at the right level, and posteriorly, the scalp is incised vertically, followed by extensive superficial retroauricular undermining. In both temporal and retroauricular areas, skin and scalp undergo a redistribution rather than resection, which is extremely limited. The authors' experience with 100 patients who were operated on with vertical U incisions since April of 2000 is described. A total of 35 patients were evaluated after a 6-month follow-up by using clinical and photographic examinations. There were very few complications because the extensive retroauricular flap has good viability. There were no problems with sensitivity, hair loss, or scar spreading, and the hairline was not displaced. The quality of the scar was excellent in the majority of cases. We experienced only a few hypertrophic but well-hidden scars. This approach can also be used in secondary cases when the primary scar is of good quality. The neck pull is as effective as that in the classic approach with a traverse retroauricular incision. The nondetectability of the retroauricular scar is of special interest in young patients and in men. The authors believe there is no contraindication for this technique. It does not significantly prolong the operating time. It includes a large undermining in the retroauricular area (6 cm from the sulcus), but this dissection is easily performed in the superficial plane. In addition to using fibrin glue in the undermined areas, the authors drain the neck. They do not use dressings. Recovery was fast, and there were only two instances of hematomas and two instances of subcutaneous cervical fluid collections in which patients required treatment.     

Purse string-formed plication of the SMAS with fixation to the zygomatic bone

The superficial musculoaponeurotic system (SMAS) operation revolutionized face-lift procedures. The idea of having one direction of traction with suturing and fixation of SMAS to a stable structure is gaining popularity. The author's contribution is the fixation of the SMAS and the extension of the supraplatysmal plane to the zygomatic bone periosteum to achieve stable traction and fixation. This procedure has not been described before in medical literature. The purse string-formed plication of the SMAS is a procedure in which the soft tissue (SMAS, parotid fascia, and the extension of the supraplatysmal plane) is plicated and fixed to the periosteum of the zygomatic bone. This superficial operation avoids entering the deeper planes, which could result in severe complications. The procedure fills the cheeks and gives a more natural look than standard face lifts. A total of 250 patients underwent this procedure. The suspension achieved seemed to be more stable than some SMASectomy techniques. Complication rates and recovery times were low. The purse string-formed plication of the SMAS is a safe, quick, and simple procedure with effective results suitable for younger patients with good skin conditions.     

The biomechanical effects of deep tissue support as related to brow and facelift procedures

The adverse effects of increased tension across a healing wound are well known. However, the effect of closing a wound in layers in order to decrease tension on the epidermis has been a source of controversy. It is hypothesized that deep tissue support decreases skin tension upon wound closure. In order to clarify this issue, a two-part study was designed to address the immediate effects of deep tissue support in vitro using fresh-frozen cadavers and in vivo on patients undergoing scheduled surgery. Closing skin tension was measured at standard reference points in coronal brow lift and rhytidectomy procedures performed with and without galeal closure and superficial musculoaponeurotic system (SMAS) procedures, respectively. Deep tissue support was found to significantly (p less than 0.05) decrease skin tension at the time of skin closure at standard reference points in coronal brow lift and rhytidectomy procedures performed on fresh-frozen cadavers. Similar significant (p less than 0.05) decreases in closing skin tension also were found in vivo in patients undergoing similar surgical procedures. Stress relaxation was not found to play a significant role in contributing to this immediate decrease in closing skin tension. It would appear, therefore, that deep tissue support, in the form of galeal closure and an SMAS procedure in coronal brow lift and rhytidectomy procedures, respectively, provides increased viscoelastic support, producing immediate significant decreases in closing skin tension in these procedures. The beneficial effects on wound healing, scar formation, tension-related trophic skin changes, and possible improved long-term results are discussed.     

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.     

An elastic-viscoplastic model for excised facial tissues.

Unified constitutive equations for elastic-viscoplastic materials were modified and used to model the highly nonlinear elastic and rate-dependent inelastic response exhibited in recent experiments on excised facial tissues. These included the skin and the underlying supportive tissue SMAS (the Superficial Musculoaponeurotic System). This study indicates a number of relevant results: The skin is more strain rate dependent than the SMAS; the nonlinearity of the elasticity of the skin is greater than that of the SMAS; both tissues exhibit a hardening effect indicated by increased resistance to inelastic deformation due to stress acting over a time period; the hardening effect leads to a decrease in time dependence and an increased elastic range, which is more pronounced for SMAS. Consequently, the SMAS can be viewed as the firmer elastic foundation of the more viscous skin. Moreover, the relaxation time for the skin is fairly short so the skin would be expected to conform to the deformation of the SMAS if it remained attached to the SMAS during stretching. This is relevant when it is undesirable to separate the skin from the SMAS for physiological reasons.     

Stretching skin: undermining is more important than intraoperative expansion

The efficacy of intraoperative expansion in reducing the tension of wound closure was tested in young pigs. The young piglet as a model for studying human skin was characterized by finding a close similarity between the modulus of elasticity of young piglet skin and human abdominoplasty and mammaplasty skin (range 12.8 to 23.7 N/mm2 for piglet skin, 14.3 to 19 N/mm2 for human skin). The tension required to close a standardized wound was determined before undermining, after undermining, and finally after intraoperative expansion. These measurements were performed in 10 young pigs with an average weight of 11.5 kg. Undermining the wound edges resulted in a significant decrease in the force required to close the wounds (p less than 0.0001). Intraoperative expansion did not significantly decrease the tension. Previous work showing the importance of site and direction of pull on the tension for wound closure was confirmed in this study. Analysis of variance demonstrated that the tension required to close a standard wound is greater high on the pig's back than near the belly and near the shoulder as opposed to the hip for midflank wounds (p less than 0.0001). Increasing the extent of undermining from 62 to 136 cm2 significantly decreased the tension for wound closure (p less than 0.05). Further undermining did not result in a significant decrease in wound closure tension. In this model, intraoperative expansion offers no advantage over simple undermining. We suggest that the benefit reported by clinicians using intraoperative expansion may derive from an increase in the extent of undermining required to place expanders under the wound margins.     

A 5-year study of the transmalar subperiosteal midface lift with minimal skin and superficial musculoaponeurotic system dissection: a durable, natural-appearing lift with less surgery and recovery time

The transmalar subperiosteal midface lift is a simple, direct-approach procedure to be performed with a meloplasty. The entry into the midface is at the site of maximum suture tension, which allows for more elevation. The skin is elevated enough to expose the entry site, which is on the zygoma just cephalad to the origins of the zygomaticus muscles. Through a small hole at that site, a periosteal elevator is used for the midface dissection. This is a blind dissection, and the technique is described. The advantages of the technique are that there is (1) no lower-lid incision or risk of an ectropion, (2) a resultant tightening and elevation of the lower lid, (3) more elevation and durability because the zygomaticus muscle origins are elevated with the periosteum and are sutured to the very substantial deep temporal fascia, (4) a simple and fast procedure, and (5) no telltale sign of a face lift. Both the superficial musculoaponeurotic system (SMAS) and the skin are substantially elevated with the transmalar subperiosteal midface lift to the extent that they should be only minimally dissected. In the author's opinion, the extended dissection of the skin and/or the SMAS does not increase the amount of tissue lift and probably reduces it in most cases, considering that the goal is a natural look and not one that appears pulled or stretched. The skin is elevated only for exposure, and the SMAS is elevated only enough to create a preauricular SMAS-platysma flap to tighten the neck. With two fewer layers of dissection, there is significantly less postoperative swelling and recovery time. The article presents the technique, the results on 272 patients over a period of 5 years, and a discussion. No patients described have had secondary procedures such as lasers, so the transmalar subperiosteal midface lift can be evaluated on its own merit.     

Fascial anchoring technique in medial thigh lifts

The medical thigh lift has not gained widespread acceptance since its introduction 20 years ago because of problems such as inferior scar migration, labial separation, and early recurrence of ptosis. Anchoring of the inferior skin flap to the tough, inelastic deep layer of the superficial perineal fascia has reduced such complications. Originally described by Colles in 1811, this fascial layer helps define the perineal-thigh crease. Eighteen patients having medial thigh lifts in combination with liposuction were followed for 6 to 24 months. The technique involves initial liposuction followed by resection of a crescent of redundant skin and fat at the superior medial thigh. The inferior skin flap is suspended from Colles' fascia of the perineum with subdermal PDS sutures. No undermining or deepithelialization of flaps is performed. Complications are few, and patient satisfaction is high.     

Purse-string suture for nipple projection

A simple and useful technique for nipple projection is reported. A buried, subcutaneous, purse-string suture is placed through prick holes and, when tied, gives a nipple mound, without the need of skin incisions, flaps, or undermining. This procedure can be applied to inverted, missing, and/or ill-defined nipples.     

Tension decrease during skin stretching in undermined versus not undermined skin: an experimental study in piglets

In a controlled study using 15 piglets, the efficacy of skin stretching using a skin stretching device was tested by quantifying the tension decrease during skin stretching in undermined and not undermined wounds. The viability of the skin margins was examined in both situations. Thirty standardized wounds was created: around 15 wounds on one flank, the surrounding skin was undermined; whereas around the 15 wounds on the opposite flank, the surrounding skin was not undermined. The force required to close the 9 x 9 cm defect was measured at the beginning, after undermining, and after 30 minutes of skin stretching. Also examined was the wound healing after 1 day and 1 week. A tension decrease of 3.02 N (13.6 percent reduction of the total force that is required to close the wound at the beginning) was seen due to undermining the surrounding skin. Skin stretching for 30 minutes without undermining the skin showed a tension decrease of 6.10 N (26.5 percent). Therefore, the tension decrease due to skin stretching was twice as high in comparison with undermining the skin margins alone. This has been statistically proven to be significant (-d (difference) = 3.08, 95 percent confidence interval = 2.16; 4.00, p < 0.001). When the undermined skin of the wound was stretched for 30 minutes, we measured a total tension decrease of 7.60 N (34.1 percent). There was a statistically significant but small difference in total tension decrease as a result of undermining combined with skin stretching in comparison with skin stretching without undermining (-d = 1.51, 95 percent confidence interval = 0.77; 2.23, p < 0.001). Undermining the surrounding skin involved cutting musculocutaneous perforating vessels. Looking at the viability of the skin, seven wounds, all found in the undermined group, showed skin necrosis after 1 week. Excessive seroma formation was seen in all wounds around which the skin was undermined. In the not undermined wounds, there were no problems in wound healing. In conclusion, skin stretching for only 30 minutes using a skin stretching device significantly reduces wound closing tension. The additional advantage of skin stretching over that of undermining alone is clearly shown. Undermining the wound margins before skin stretching gives a small additional tension decrease but has well-known complications, such as skin-edge necrosis and seroma formation.