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Facelift: Platysmal Muscular Suspension
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Facelift: Platysmal Muscular Suspension

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Chicago facial plastic surgeron, Dr. Anil Shah, discusses his latest technique for facelift procedures.

Chicago facial plastic surgeron, Dr. Anil Shah, discusses his latest technique for facelift procedures.

www.shahmd.com

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Facelift: Platysmal Muscular Suspension Facelift: Platysmal Muscular Suspension Presentation Transcript

  • CPMS (Complete Platysmal Muscular Suspension) ANIL R. SHAH, MD CLINICAL INSTRUCTOR, UNIVERSITY OF CHICAGO DIVISION OF OTOLARYNOGLOGY/ FACIAL PLASTIC SURGERY 845 N MICHIGAN AVENUE
  • Facelift • Beauty • Physiology of Aging • Anatomy • Application of Knowledge
  • Goals in Face-lift • More Youthful Appearance • Beauty- Want to Look Better • Natural appearance • Minimal Recovery
  • Science of Beauty • “I can't define it but I know it when it walks into the room”. Aaron Spelling
  • Science of Beauty • Anthropologists Kim Hall Jones – Compared beauty amongst South American tribes with urban South Americans, North Americans and Asians – Found that delicate chins, delicate jaws, and smooth skin appeared to be most responsible for beauty
  • Science of Beauty • Harvard psychologist Nancy Etcoff – Found similar findings in delicate jawline, delicate mouths and jawlines in females
  • Science of Aging- The Ogee Curve • Ogee is a shape consisting of a concave arc flowing into a convex arc
  • The Ogee Curve • In facelift surgery the goal is to restore the cheekbone hence the Ogee curve
  • Science of Aging • Pyramid and Inverted Pyramid
  • Dedo classification of cervical abnormalities
  • Goal of Facelift • Emphasize jawline • Create a delicate neck • Emphasize cheekbones- Reverse the pyramid
  • Facelift Anatomy • Safety • Restorative
  • Greater Auricular Nerve Anatomy • Originates from anterior rami of second and third cervical nerves • Bends around posterior aspect of SCM
  • Greater Auricular Nerve Anatomy
  • Greater Auricular Nerve • Care must be taken when plicating platysma
  • Applying local anesthetic to the greater auricular nerve results in anesthesia of the : • Entire auricle • Inferior auricle and skin over the mastoid. • Superior auricle and preauricular skin. • Entire posterior surface of the auricle. • Tragus and preauricular skin.
  • Applying local anesthetic to the greater auricular nerve results in anesthesia of the : • Entire auricle 1.Inferior auricle and skin over the mastoid. • Superior auricle and preauricular skin. • Entire posterior surface of the auricle. • Tragus and preauricular skin.
  • Does it matter if you clip a branch of the great auricular nerve? • No difference seen in parotidectomy patients in post- operative sensation at 2 weeks, 2 months, 6 months, one year when posterior branch clipped verus preserved • (Preservation of the great auricular nerve during parotidectomy M.J. PORTER • & S.J. WOOD ENT Department, St. Michael's Hospital, Bristol, UK)
  • Facial Nerve • Critical Structure to avoid • Arborization of nerve makes chances of nerve damage less likely • Most commonly injured branch – Depends on what study is quoted
  • Temporal Branch (CN VII) • How do you find it preoperatively? • Quatela – Tragus to lateral canthus (first line) – Inferior aspect of ear lobe to forehead through a point that bissects first line • Pitanguay – Inferior ear lobe to lateral eyebrow
  • Zygomatic Branch VII Nerve Anatomy • Zygomatic branch lies deep to zygomaticus major • Can be located by utilizing the Zygomaticus insertion point
  • Zygomaticus major muscle  Deep plane facelift surgery  Landmark for depth  Dissection medially to zygomatic cutaneous ligament (MacGregor’s patch)  Plicated or shortened in facial rejuvenation  Botox  Avoid ZM injections during periorbital injections
  • Course of the zygomaticus major muscle  Insertion- modiolus  Origin- not as clear  Various methods of predicting the course of the zm muscle
  • Mandibular branch VII Nerve • Superficial anterior to facial notch • Avoid dissection medial to facial notch • Avoid dissection deep to the platysma and parotidomassetric fascia muscle near mandibular border
  • Course of Marginal Mandibular Nerve • Runs deep to platysma until approximately 2 cm from oral commisure
  • Cervical branch VII Nerve • Lies underneath platysma muscle 2 cm below mandible
  • Lymphatics of the face • Most of persistent edema is found medially • Recent study regarding lymphatic drainage confirms clinical suspicion
  • Anatomy of the Facial Ligaments • Facial Ligaments resist pull of deeper tissues • Release of ligaments allow for mobilization of tissue without tension • Measured in amount of cervical skin release
  • Anatomy of the Facial Ligaments • Zygomatic Cutaneous Ligament • Mandibular Ligament • Masseteric Ligaments • Cervical Elements – Short versus Long Flap
  • Short versus Long Flap Release of skin will allow further redraping of neck/ platysmal cutaneous fibers
  • Anatomy of the Platysma Muscle
  • Defining the Superior Extent of the Platysma Muscle: A Review of 72 Consecutive Facelifts • MML (Malar Mandibular Line) • 3.98 cm from mandible • 3.09 cm from ME • 56% of MML
  • CPMS • Complete Platysma Muscle Suspension • Repositioning the Platysma Muscle is Critical to Rejuvenating the Aging Face
  • CPMS • Modification of Deep Plane Rhytidectomy • Purported disadvantages to deep plane: – Risk of facial nerve injury – Delayed healing – Increased swelling
  • CPMS-Advantages • Risk of facial nerve injury- 0% in over 1250 cases • Delayed healing- Less hematoma 4 out of 1250 and no facial hematomas • Infection- 4 out of 1250
  • CPMS-Advantages • Risk of facial nerve injury- Safer because you can manipulate plane rather than placing a blind suture • Swelling/Hematoma- Less because based on embryologic glide plane which is avascular versus subcutaneous. Avoid drains
  • Isolate platysma muscle • Cervical- Midline • Face- Lateral Border • Cervical- Posterior Border
  • CPMS-Addressing the Neck • Almost every patient needs cervical redraping • Not every patient needs a platysmaplasty • Release the mandibular ligaments • Address subplatysmal fat • Address platysmal bands • Release platysmal dermal attachements
  • CPMS-Addressing the Neck • Incision just anterior to the submental crease • Even defatting along the submentum • Locations failure: – Leave extra fat along the skin flap near incision – Failure to address subplatysmal fat
  • Artistic Components • Neck Sculpting- Volumetric Replacement • Amount of Skin to be Excised – Skin laxity, amount of fat removed, etc • Vector of Pull • Amount of Cheek Bone Enhancement
  • Skin mark incision Marking indicates the position of platysma cords
  • Submental & Submandibular Liposuction
  • 10 mm fiber optic retractor
  • Separating skin from platysma
  • Suturing anterior bands of platysma in midline
  • CPMS-Addressing the Face • Mark a line from Zygomatic Insertion Point to Mandibular Angle • Identify Platsyma Muscle Within Face First • Release Masseteric Fibers
  • CPMS-Addressing the Face • Release Zygomatic Cutaneous Ligaments (aka) MacGregor's Patch
  • Subcutaneous dissection Elevation above the platysma
  • Superficial Temporalis facsia & VII nv. Deep Temporalis fascia
  • In the deep plane beneath Platysma over Masseter
  • Entering the deep plane Platysma under platysma over Masseter Masseter
  • Dissection over the Zygomaticus
  • Zygomaticus Major
  • Zygomaticus Major
  • Zygomaticus Major
  • Zygomaticus Major
  • CPMS-Addressing the Posterior Neck • Dissect Along Platysmal Border Inferiorly Along to Neck • Place Platysma Along Neck • Beware of Cervical Branch of Facial Nerve
  • CPMS-Addressing the Posterior Neck • Release Platysma From Deeper Elements • Create a Platysma Flap
  • Posterior border of Platysma
  • Posterior border of Platysma
  • Zygomaticus Below the platysma Platysma attached along the mandible Masseter Above the Platysma
  • CPMS-Suspending the Platysma Muscle • Suspend to the Ligament of Earlobe • Suspend to the Temporalis (Horizontal) • Suspend to the Mastoid Periosteum
  • Analysis of Anchoring Points in Rhytidectomy • Previous authors have determined that a composite flap resisted tearing more than skin, smas • Looked at anchoring points in facelift
  • Anchoring Points Facelift • Root of zygoma was (7.01kg) versus for temporalis fascia (3.44kg) (p<.05) .  • Iinfralobular tissue (5.05kg) versus for SMAS (4.09 kg) located 1 cm anterior to the infralobular tissue (p<.05). • The fascia of the sternocleidomastoid was (3.89kg) compared to the fascia of the mastoid (5.557kg) (p<.05).  • There was a statistical difference between vertical bites of the temporalis fascia 1.90kg versus horizontal bites of the temporalis 5.01kg.
  • Suturing mandibular angle Platysma to fascia beneath ear lobe
  • Suturing Suturing mandibular angle Platysma to fascia beneath ear lobe
  • CPMS-Skin Redraping • Do not put tension on the skin • Redrape along the direction of the angle of the mandible • Place deep sutures irregardless of no tension
  • Title • Content
  • Title • Content
  • Fibrin glue
  • Suturing temporal dermis to deep temporal fascia
  • Deep dermis to deep temporalis suture