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.

Lengthening the foreshortened nose.

The surgically shortened nose is an infrequent but distressing problem that is difficult to repair. This article describes a simple technique to lengthen the nasal profile with a triple-stacked tip graft placed caudal to the medial crura. Fifteen patients have been operated on, and most were undergoing face lifts. The skin inelasticity in older patients allows easy skin redraping over the larger tip volume.

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.

Frequent face lift sequelae: hollow eyes and the lateral sweep: cause and repair.

Traditional face lift and blepharoplasty techniques are based on two consistent principles. Conventional face lift techniques have always incorporated unopposed lateral vector tissue advancement, which is typical of subcutaneous lifts or rhytidectomies that include the platysma muscle (SMAS) or cheek fat (malar fat). When they are not adequately repositioned, the tissues of the lower eyelid and upper cheek continue to age, which may create a "lateral sweep" of the lower face as those malar soft tissues descend at a more rapid rate than the repositioned SMAS. Removal of the lower eyelid fat in conventional blepharoplasties may also lead to a more hollow-appearing lower eyelid. Hollow eyes and the lateral sweep could be prevented with a rhytidectomy technique that includes orbicularis repositioning and preservation of the lower eyelid fat with an arcus marginalis release. All patients who have been operated on who exhibit these unfavorable signs can have an impressive correction by utilizing the principles of superomedial vector orbicularis repositioning to counter the "lateral sweep" and arcus marginalis release to recreate a youthful shallow and narrow lower eyelid contour. This technique is invaluable to patients seeking secondary surgery to regain harmony of the rejuvenated face.

Composite rhytidectomy. Finesse and refinements in technique.

These points of refinement in flap dissection and closure may be helpful to surgeons who perform composite rhytidectomy. My experience in the past 6 years of doing exclusively composite facelifts is that there is consistent improvement in results with shorter and shorter convalescent times after using these refinements. When a primary rhytidectomy is performed, repositioning of all the deep elements of the aging face is necessary to maintain harmony in facial rejuvenation (Fig. 9). Composite rhytidectomy is of enormous benefit in secondary rhytidectomy (Fig. 10) when the surgeon's goal must be to regain harmony, which frequently is lost following conventional rejuvenative procedures.

The role of orbital fat preservation in facial aesthetic surgery. A new concept.

Preservation of lower orbital fat in facial rejuvenation is a new concept for preventing the "operated" appearance that may follow fat removal in conventional blepharoplasty. By creating a narrower, more shallow orbit, the surgeon can create a truly youthful eyelid-cheek complex. Orbital fat advanced over the complete inferior orbital rim hides the bony framework that becomes apparent with normal aging. This technique is used routinely in isolated blepharoplasty and with composite rhytidectomy. It accompanies repositioning of the orbicularis oculi muscle, cheek fat, and facial platysma muscle. It is a procedure that can correct postoperative problems caused by excess orbital fat removal, lower eyelid retraction, and contour problems resulting from malar augmentation. The orbital fat is one of the many deep "pieces" of the human face that must be preserved and repositioned for optimal facial rejuvenation.

Comparison of skin-tissue tensions using the composite and the subcutaneous rhytidectomy techniques.

Controversy as to benefits, risks, and long-term durability of the subcutaneous rhytidectomy as compared with the composite and the subcutaneous musculoaponeurotic system (SMAS) rhytidectomy procedures has persisted over the last several years. Conventional surgical wisdom holds that deep-tissue support would provide both immediate and long-term benefits in rhytidectomy patients. Recent investigations have shown that deep-tissue support using the SMAS technique decreases epidermis closure tension. This effect has potential implications on vascularity, healing, scar formation, duration of results, and tension-related trophic changes. Twelve fresh frozen cadavers were dissected. At random, one side was treated with the composite technique as described by Hamra, whereas the other was treated with a standard subcutaneous rhytidectomy without SMAS intervention. Using this approach, variability between techniques could be more accurately compared. Dissection levels were made as identical as possible on both sides. Tensions were then measured from premarked, standard key points, evaluating (1) the amount of tension required to move the point 2 cm; (2) with a pull of 1.00 kg, the amount of skin that could then be excised; and (3) after securing the composite 2.0 cm reference points using deep-tissue support sutures, the amount of tension needed to advance the skin to closure. We found that the composite method has a higher resistance to stretch than the subcutaneous method, which translates into a lesser amount of skin excision possible at a given tension. The added resistance is most likely the result of the deep fibromuscular layer. Resistance could be overcome by placement of deep support sutures, and the effect of the fibromuscular layer (SMAS) is effectively neutralized through increased viscoelastic support. This effect potentially helps to protect the dermal plexuses from the effects of tension created using the composite technique. The tension necessary to advance the epidermis to closure therefore compares favorably to the subcutaneous rhytidectomy method.

Arcus marginalis release and orbital fat preservation in midface rejuvenation.

With aging, the periorbital area reveals progressive exposure of underlying skeletal anatomy as compared with the lower areas of the face, whose thicker soft tissues continue to cover underlying bony landmarks. With recent techniques in cheek fat repositioning and orbicularis muscle repositioning, rejuvenation results of the midface have been markedly improved. Conventional lower blepharoplasty techniques that remove lower eyelid fat can create a concave contour deformity of the lower eyelids that causes the "operated" appearance. This paper describes a new technique to preserve the lower eyelid fat and to advance it beyond the infraorbital rim. An arcus marginalis release is accomplished, and the subseptal fat is advanced and sutured beyond the entire infraorbital rim and under the repositioned orbicularis muscle. By camouflaging the lower orbital rim anatomy, rejuvenation of the midface is more complete. A total of 152 cases have been done over a 3-year period with impressive results and minimal complications. This procedure is done in all composite rhytidectomies and in isolated blepharoplasty patients without advanced facial aging. It is particularly indicated in secondary procedures correcting overresection of orbital fat or deformities resulting from malar augmentation.

Composite rhytidectomy and the nasolabial fold.

In composite rhytidectomy, all of the deep aging anatomic components of the midface are elevated in the skin flap. The platysma muscle, cheek fat, and orbicularis oculi muscle are repositioned in this bipedicled musculocutaneous flap, which very effectively improves the nasolabial fold. Repositioning of all of the deep elements of the aging face and forehead is obligatory in creating a harmonious rejuvenation.

A comparison of flap vascular anatomy in three rhytidectomy techniques.

The purpose of this study was to examine differences in blood supply to facial flaps created by three rhyditectomy techniques. The techniques chosen for comparison included a two-layer technique, consisting of separate subcutaneous and extended submuscular aponeurotic system (SMAS) dissections, the Composite dissections as described by Hamra, and a subperiosteal dissection. Six cadavers were injected with lead oxide before dissection, and eight were injected after dissection. After allowing the lead oxide to set, the soft tissues were removed from the face. Vascular patterns of the face were interpreted from x-rays taken of the specimens. Results of the injections performed before dissection confirmed contributions of previously described arteries, including the transverse facial, facial, infra-orbital and terminal branches of the ophthalmic. In addition, there are numerous branches that connect these vessels to each other. The most consistent of these include the masseteric, jugal, submental, labial, angular and nasal arteries. The patterns of communications between these vessels allow for the visualization of three vertically oriented vascular zones, each connected to the next by choke zones where anastomoses occur. Dissections performed before injection reveal increased filling of the vessels through more of the flap on the Composite side when compared with the two-layered dissection, absence of vessels in the SMAS, and filling across all three zones on the subperiosteal side. We conclude that there are vascular regions in the face connected by anastomotic choke zones. Separate subcutaneous and sub-SMAS dissections interrupt the vascular connection between zones. Arterial continuity is better-maintained in the Composite lift and is literally undisturbed in the subperiosteal lift.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery of the aging chin.

A technique is described for surgery of the aging chin that I use in every rhytidectomy patient. A mentalis-periosteal flap is developed, advanced downward, and sutured in a "vest over pants" manner over the platysma muscle under the submental crease. The submental crease is obliterated by the double layer of muscle created by the muscle closure. The same technique is used in chin reductions and chin augmentations, as well as normal aging ptosis of the chin. Since muscle and fat are never excised, one can use this simple procedure on every face lift without fear of creating a contour deformity. This technique gives consistently good results but should only be used when combined with face lift surgery which includes a wide cervical dissection.

Repositioning the lateral alar crus.

Malposition of the lateral crus is a normal variant of the nasal alar cartilage as described by Sheen which shows a "parentheses" deformity from the frontal view. The cephalic-positioned lateral crus leaves the alar rims without cartilaginous support, causing deformity and potential destabilization of normal airway competence. The procedure described herein is a modification of the Sheen technique that can be done as either an open or a closed procedure. It is particularly valuable in decreasing the overprojecting nasal tip and preserving the equal height of the alar domes while widening the angle of divergence of the lateral crus. This technique delivers consistently dependable results for an anatomic variant modification frequently overlooked in rhinoplasty surgery.

Crushed cartilage grafts over alar dome reduction in open rhinoplasty.

Primary and secondary nasal tip deformities can be repaired more easily with an open technique rather than with the traditional closed methods that have been used for the over-projecting tip. Division of the alar domes with a side-to-side repair followed by the onlay of a single crushed cartilage graft to prevent postoperative cartilaginous deformities has been shown to be a reliable maneuver in both primary and secondary rhinoplasties.

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.