Reducing complications in cervicofacial rhytidectomy by tumescent infiltration: a comparative trial evaluating 678 consecutive face lifts

Tumescent infiltration has been widely used in body-contouring surgery to facilitate dissection and reduce blood loss. Although its use in facial surgery has been suggested, there are presently no comparative studies of its efficacy. The aim of this study was to investigate the long-term outcome in a large series of consecutive face lifts performed with and without tumescence. During a 6-year period, 678 consecutive face lifts were performed: 449 without tumescence and 229 with tumescent infiltration using 200 ml on each side of the face. The spectrum of techniques included the extended superficial musculoaponeurotic system (SMAS) procedure, the lateral SMASectomy, the extended supraplatysmal plane lift, and the cutaneous face lift. Complications, such as hematoma, skin necrosis, alopecia, and scar quality, were compared between groups using Fisher's exact test. The use of tumescent infiltration facilitated dissection, particularly in the neck. Postoperative swelling and bruising were reduced in the tumescent group. In comparisons of major complications between groups, no difference was seen in hematoma rate (p > 0.5), although the incidence of other complications was significantly reduced by tumescent infiltration. Significant reduction was observed in the rate of skin necrosis (p = 0.03), alopecia (p = 0.006), hypertrophic scarring (p = 0.001), stretched scarring (p = 0.003), and scar revision (p < 0.001). This is the first comparative study of tumescent infiltration in facial rejuvenation surgery. Tumescence made dissection easier and significantly reduced the incidence of troublesome complications. The surgical technique and aesthetic implications for rejuvenation surgery are discussed.     

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.     

A study of the long-term effect of malar fat repositioning in face lift surgery: short-term success but long-term failure

In 1990, the author reported on a series of 403 cases of deep plane face lifts, the first published technique describing the repositioning of the cheek fat, known as malar fat, in face lift surgery. This study examines the long-term results of 20 of the original series in an attempt to determine what areas of the rejuvenated face (specifically, the malar fat) showed long-term improvement. The results were judged by comparing the preoperative and long-term postoperative views in a half-and-half same-side hemiface photograph. The anatomy of the jawline (superficial musculoaponeurotic system [SMAS]), the nasolabial fold (malar fat), and the periorbital diameter were evaluated. The results confirmed that repositioning of the SMAS remained for longer than improvement in the nasolabial fold and that the vertical diameter of the periorbit did not change at all. The early results of malar fat repositioning shown at 1 to 2 years were successful, but the long-term results showed failure of the early improvement, manifested by recurrence of the nasolabial folds. There was, however, continuation of the improved results of the forehead lift and SMAS maneuvers of the original procedure. The conclusion is that only a direct excision will produce a permanent correction of the aging nasolabial fold.     

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.     

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.     

Short-scar face lift with extended SMAS platysma dissection and lifting and limited skin undermining

In the past 8 years, short-scar cervicofacial rhytidectomy has been used with great success and a high level of patient satisfaction. The operation involves limited incisions in the sideburn and preauricular areas, extending just around the fold of the ear lobule. Extensive undermining of the superficial musculoaponeurotic system (SMAS)/platysma is performed, and lifting of the face and neck is performed mainly at this level. Skin undermining is kept to a minimum, eliminating the need for extended incisions to reduce dog-ears. The preservation of fibrous bands between the skin and the SMAS/platysma unit is an important factor in making such an operation practical and is the reason why the skin incisions can be kept short. Dissection of large areas of skin and separation of the skin from the underlying SMAS necessitate larger incisions. The operation is safe, speedy, less traumatic, and well tolerated among patients at high risk, such as smokers. The risks of complications are also reduced with this operation.     

Refinements in face lifting: enhanced facial contour using vicryl mesh incorporated into SMAS fixation

As we have gained experience with the extended superficial musculoaponeurotic system (SMAS) technique in face lifting, refinements in our procedure have led to increased consistency in results. The important factors that have led to our technical modifications include the following: (1) the significance of the retaining ligaments of the midface, which determine the degree of surgical dissection required for both skin and SMAS in rhytidectomy; (2) the changes in facial shape that occur with aging, secondary to the descent of facial fat; (3) the possibility of modifying facial shape through the repositioning of facial fat in an extended SMAS face lift; (4) the improved longevity of result to be obtained by incorporating Vicryl mesh into SMAS fixation; (5) the artistic nuances of incision design that help to minimize scar perceptibility. Understanding these factors enables surgeons to use the extended SMAS technique successfully with more challenging cases, enhancing facial appearance while minimizing signs that the patient has undergone a surgical procedure.     

Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation

The SMAS was described more than 25 years ago, yet its full potential in face-lift surgery has become appreciated only more recently. A reappraisal of the various aspects of SMAS surgery is now appropriate. These include aspects of its release from the deep fascia, the several considerations underlying the vectors of flap redistribution, and the rationale underlying the methods of flap fixation. These are unique, compared with the traditional considerations in subcutaneous face lifts and en bloc subperiosteal lifts.     

Avoiding hematoma in cervicofacial rhytidectomy: a personal 8-year quest. Reviewing 910 patients

Hematoma remains the most common complication of rhytidectomy and can lead to prolonged facial edema and skin necrosis. A number of ancillary procedures have been suggested to reduce hematoma, including dressings, drains, fibrin glue, tumescence, and adrenaline. The aim of this study was to investigate the statistical effect of these parameters on hematoma incidence in a large series of face lifts. Over an initial 6-year period, 678 consecutive face lifts were performed and included in the first part of the study. The effect of dressings, drains, fibrin glue, and tumescence on hematoma rate was investigated retrospectively. In the second part of the study, the specific effect of adrenaline was analyzed while all other parameters were kept constant. The 229 patients with adrenaline-containing infiltrations were compared with the 232 patients whose infiltration had no adrenaline. Retrospective analysis of both groups was performed using Fisher's exact test. In the first part of the study investigating 678 consecutive face lifts, no difference in hematoma rate (4.4 percent overall) was observed with the use of dressings (p > 0.5), drains (p > 0.4), fibrin glue (p > 0.6), or tumescence (p > 0.5). In the second part of the study, the specific effect of withdrawing adrenaline in a comparative group of 461 face lifts significantly reduced the incidence of hematoma requiring surgical evacuation (p < 0.0001). There was also a significant reduction in the incidence of minor hematoma requiring only aspiration (p = 0.02). There was no change in the incidence of any other face lift complications observed during this part of the study. This study found a significant reduction in the incidence of hematoma following face lifting. Although many of the suggested ancillary methods used to reduce hematoma did not produce any statistical reduction in the incidence of this complication, the exclusion of adrenaline had a profound effect. The technique and implications with respect to safety and outcome are described.     

The SMAS and the nasolabial fold.

In a series of histologic sections and clinical and cadaver dissections, the superficial musculoaponeurotic system (SMAS) is seen to become the investing fascia of the zygomaticus major and minor muscles in the medial cheek. The pull on the cheek flap during rhytidectomy is diffused by the attachment of the SMAS to these muscles. I believe that this attachment accounts for the minimal change in the nasolabial crease after a Skoog-type sub-SMAS face lift.     

Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to avoid a face lift for unsuitable candidates

Patients with submental fullness may not be candidates for a full or short-scar face lift because of medical contraindications, uncontrolled hypertension, a refractory nicotine habit, or anticoagulant medications, or patients may disqualify themselves because of cost, unavailable recovery time, or emotional resistance. Submental suction-assisted lipectomy has traditionally been reserved for younger patients. For older patients, suction-assisted lipectomy is typically used as an adjunct for face/neck lifts. This report describes experiences with suction-assisted lipectomy for older patients who were not face lift candidates, for the aforementioned reasons. The study goals were to better delineate the indications for submental suction-assisted lipectomy, as opposed to a face lift, and to obtain improved results with a less-invasive procedure. A 6-year study involving 132 patients (21 to 73 years of age), of whom 4.5 percent were men, was performed. Eighty-eight patients (67 percent), the primary focus of this study, were more than 40 years of age. Of those 88 patients, 24 patients (18 percent of the 132 patients in this series) were in their forties, 45 (34 percent) were in their fifties, 16 (12 percent) were in their sixties, and three (2.3 percent) were at least 70 years of age. The median follow-up time in this series was more than 1 year. The results were assessed with the five criteria for facial rejuvenation described by Ellenbogen and Karlin. All patients demonstrated improvement, with three to five of the Ellenbogen-Karlin neck rejuvenation criteria being met for each patient. All patients demonstrated an improved submandibular border, a more visible anterior sternocleidomastoid muscle border, and an improved neck angle (as determined with angle measurements). For many patients, all five of the Ellenbogen-Karlin criteria were met. A visible subhyoid depression and a visible thyroid cartilage bulge were the two criteria most often not met. A retrospective evaluation using Baker's preoperative classification of patient types for short-scar face lifts was performed. Results for patients more than 64 years of age (11 patients) were less satisfactory, often with redundant or crepe paper-like skin. Submental suction-assisted lipectomy, as opposed to a face lift, was observed to be a reasonable alternative for older patients who were unable or unwilling to undergo a face lift. Localized fullness in the midline was observed to be the best predictor of a good outcome (even better than age or skin tone). A crepe paper appearance of the skin preoperatively was the best predictor of failure. The surgical anatomical features, technique, advantages, disadvantages, and principles are discussed. Complications and their treatment are addressed. It is concluded that submental suction-assisted lipectomy alone, without platysmaplasty, can be helpful for patients with submental fullness who are unsuitable candidates for a face lift and who accept the limitations of liposuction without platysmaplasty. Suction-assisted lipectomy can sufficiently contract and smooth the skin envelope for selected patients, with less consideration for age than previously proposed.     

The role of plastic surgery in congenital cutis laxa: a 10-year follow-up

The clinical features and the plastic surgery management of a 23-year-old woman with cutis laxa are presented. Two rhytidectomies were performed in this patient within 1 year. The first was associated with a SMAS flap; the second employed a prehairline incision. The evolution of the aging facial appearance 10 years after the last face lift was evaluated and compared with the preoperative situation. Repeated face lifts seem to be an interesting way to manage patients with cutis laxa. Unlike patients with other disorders of the connective tissue, those with cutis laxa have no vascular fragility and heal well. The role of plastic surgery and the clinical features and timing for operation are reviewed and discussed.     

Combined erbium:YAG laser resurfacing and face lifting

Facial aging occurs secondary to gravity-induced tissue ptosis and photoaging. Combined face lifting and carbon dioxide laser resurfacing provides a comprehensive one-stage approach to facial rejuvenation but is condemned by many plastic surgeons due to the nonspecific thermal effects of the laser and risk of skin necrosis. Newer high-energy erbium:YAG lasers allow precise tissue ablation with minimal thermal effect. In this study, various facial rejuvenation techniques were combined with simultaneous erbium:YAG laser resurfacing to assess results and complications. A total of 257 patients from Florida, Melbourne, Australia, and Tel Aviv, Israel, underwent combined erbium:YAG laser resurfacing and surgical facial rejuvenation. Various face-lift methods were used, including endoscopic, deep plane, and subcutaneous. Simultaneous, full-facial laser resurfacing was performed using a variety of erbium:YAG lasers. It was found that combined laser resurfacing and face lifting was successful in greater than 95 percent of patients with minimal morbidity. Two patients (1 percent) (both heavy smokers) developed small areas of skin necrosis that healed with minor pigment changes. Five patients (2 percent) developed synechia that was treated with no residual effect. Two additional patients (1 percent) developed temporary ectropion. There were no other cases of scarring, infection, or cosmetically obvious hypopigmentation. Although larger studies are necessary, it seems that the lack of thermal injury from the erbium:YAG laser makes it possible to safely perform laser resurfacing with surgical facial rejuvenation in nonsmokers. However, the authors caution that familiarity with the nuances of erbium:YAG laser resurfacing be obtained before performing combined laser resurfacing and face lifting.     

Lip augmentation with superficial musculoaponeurotic system grafts: report of 103 cases.

Many patients suitable for a lip augmentation are of face lift age, and could benefit from a simultaneous lip enhancement during the rhytidectomy procedure. The healthy, live superficial musculoaponeurotic system (SMAS) tissue obtained from the face lift can be recycled and grafted with minimal additional operating time. From April of 1995 to January of 2000, 103 patients (99 women and four men) underwent a lip augmentation procedure by the senior author (N.L.) using SMAS grafts harvested from a simultaneous rhytidectomy. Indications for surgery were purely aesthetic in all 103 cases. The surgical technique used for the SMAS graft lip augmentation is as follows: Using a narrow tenotomy scissors, an intramuscular tunnel was created with blunt and sharp dissection across the lip. The graft, obtained from the posterior edge of the SMAS dissection, is left as long as possible, and is pulled through the tunnel with a tendon forceps. The lips are then stretched manually from the central point upward and downward, respectively. It is important to avoid suturing the ends of the graft into the closure; the grafts should be allowed to move freely, to avoid postoperative tethering on smiling or mouth opening.Most patients expressed some initial concern with their early appearances caused mainly by the swelling. By 2 weeks, most patients were extremely pleased with the size and shape, and their main concern was that the lip fullness would shrink even more. By 3 to 4 weeks, shrinkage largely ceased and the correction remained for varying periods, some as long as 5 years. A sampling of the results was obtained by means of a questionnaire mailed to all patients having undergone the SMAS graft lip augmentation. Fifty-four patients (52 percent) returned the questionnaire with their responses. Of those who responded to the survey, 42 patients (78 percent) reported fuller lips than before their operation. Significantly, 11 of 14 patients (79 percent) followed up after 24 months postoperatively reported fuller lips and excellent or good results. Complications and unsatisfactory results were very rare, occurring generally at the beginning of the learning curve of the series.SMAS grafts are useful for long-lasting lip augmentation, producing a youthful appearance by adding natural, soft roundness and fullness to lips without the artificial look and feel of synthetic material.     

Correction of the nasolabial fold: extended SMAS dissection with periosteal fixation.

The nasolabial fold has defied satisfactory correction with the face lift operation. This is despite variations of the SMAS technique over the last 20 years. In this study, the nasolabial fold is shown to be part of the overall aging deformity that affects the cheek and perioral region. The key to surgical correction, not previously appreciated, is the complete release of the anterior SMAS from the zygoma and zygomaticus major muscle. This allows a dramatic mobilization of the nasolabial fold without tension. The advanced SMAS is then reattached to the zygomatic periosteum by a series of permanent sutures. Each suture, by its location and direction of lift, corrects one of the four nasolabial regions including the jowl. The relevant anatomy is reviewed and the safety of the procedure is assessed in a personal series of 135 patients. It is concluded that the two principles of this technique, i.e., complete SMAS release and reattachment to the zygoma, safely and effectively achieve a natural-appearing rejuvenation of the cheek and nasolabial fold.     

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.     

Occlusion following laser resurfacing promotes reepithelialization and wound healing

One of the critical parameters that has not been examined carefully following laser skin resurfacing is the effect of eschar on the wound healing process. Because occlusive dressings minimize the occurrence of eschar, the present study was undertaken to evaluate the effect of occlusion following laser resurfacing. It is clear that CO2 lasers promote epidermal cell loss and variable amounts of dermal injury. To characterize the wound repair process after laser treatment, biopsy specimens were obtained 2 to 4 days after treatment. Specimens from 15 patients were examined; the preauricular biopsy specimens were paired such that one specimen was from skin that had been occluded and the other specimen (from the same patient) was from skin treated without occlusion. Skin specimens were examined by indirect immunofluorescence using antibodies to specific epidermal and dermal antigens. The results indicate that the keratinocytes that repopulate the epidermis migrate from the hair follicles and express keratin 17, an intermediate filament protein expressed in keratinocytes during the early stages of wound healing. The migration of keratin 17-expressing cells begins 48 hours following laser resurfacing in skin treated with occlusion, whereas cell migration from the follicles of skin treated without occlusion is delayed. In summary, occlusion promotes enhanced cell migration and diminished eschar formation, resulting in more rapid healing.     

Stretching and tissue expansion for rhytidectomy: an improved approach

Intraoperative expansion of the skin of the face supplies additional tissue that permits closure of the face lift incision with minimal tension. This paper presents the findings in rhytidectomy patients over the last 3 years using both intraoperative stretching and intraoperative stretching combined with tissue expansion utilizing the Man face lift expander. Sixty-seven patients underwent rhytidectomy surgery, of whom 50 were treated with stretching techniques alone and 17 were treated with the combined stretching and expansion method. The patients' ages ranged from 28 to 78 years. Results indicate that the patients treated with combined stretching and expansion had significantly more skin removed. This new technique appears to offer significant clinical advantages over usual face lifts.     

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.