Facelift: Platysmal Muscular Suspension

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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

  1. 1. CPMS (Complete Platysmal Muscular Suspension) ANIL R. SHAH, MD CLINICAL INSTRUCTOR, UNIVERSITY OF CHICAGO DIVISION OF OTOLARYNOGLOGY/ FACIAL PLASTIC SURGERY 845 N MICHIGAN AVENUE
  2. 2. Facelift • Beauty • Physiology of Aging • Anatomy • Application of Knowledge
  3. 3. Goals in Face-lift • More Youthful Appearance • Beauty- Want to Look Better • Natural appearance • Minimal Recovery
  4. 4. Science of Beauty • “I can't define it but I know it when it walks into the room”. Aaron Spelling
  5. 5. 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
  6. 6. Science of Beauty • Harvard psychologist Nancy Etcoff – Found similar findings in delicate jawline, delicate mouths and jawlines in females
  7. 7. Science of Aging- The Ogee Curve • Ogee is a shape consisting of a concave arc flowing into a convex arc
  8. 8. The Ogee Curve • In facelift surgery the goal is to restore the cheekbone hence the Ogee curve
  9. 9. Science of Aging • Pyramid and Inverted Pyramid
  10. 10. Dedo classification of cervical abnormalities
  11. 11. Goal of Facelift • Emphasize jawline • Create a delicate neck • Emphasize cheekbones- Reverse the pyramid
  12. 12. Facelift Anatomy • Safety • Restorative
  13. 13. Greater Auricular Nerve Anatomy • Originates from anterior rami of second and third cervical nerves • Bends around posterior aspect of SCM
  14. 14. Greater Auricular Nerve Anatomy
  15. 15. Greater Auricular Nerve • Care must be taken when plicating platysma
  16. 16. 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.
  17. 17. 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.
  18. 18. 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)
  19. 19. 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
  20. 20. 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
  21. 21. Zygomatic Branch VII Nerve Anatomy • Zygomatic branch lies deep to zygomaticus major • Can be located by utilizing the Zygomaticus insertion point
  22. 22. 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
  23. 23. Course of the zygomaticus major muscle  Insertion- modiolus  Origin- not as clear  Various methods of predicting the course of the zm muscle
  24. 24. 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
  25. 25. Course of Marginal Mandibular Nerve • Runs deep to platysma until approximately 2 cm from oral commisure
  26. 26. Cervical branch VII Nerve • Lies underneath platysma muscle 2 cm below mandible
  27. 27. Lymphatics of the face • Most of persistent edema is found medially • Recent study regarding lymphatic drainage confirms clinical suspicion
  28. 28. 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
  29. 29. Anatomy of the Facial Ligaments • Zygomatic Cutaneous Ligament • Mandibular Ligament • Masseteric Ligaments • Cervical Elements – Short versus Long Flap
  30. 30. Short versus Long Flap Release of skin will allow further redraping of neck/ platysmal cutaneous fibers
  31. 31. Anatomy of the Platysma Muscle
  32. 32. 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
  33. 33. CPMS • Complete Platysma Muscle Suspension • Repositioning the Platysma Muscle is Critical to Rejuvenating the Aging Face
  34. 34. CPMS • Modification of Deep Plane Rhytidectomy • Purported disadvantages to deep plane: – Risk of facial nerve injury – Delayed healing – Increased swelling
  35. 35. 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
  36. 36. 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
  37. 37. Isolate platysma muscle • Cervical- Midline • Face- Lateral Border • Cervical- Posterior Border
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. Skin mark incision Marking indicates the position of platysma cords
  42. 42. Submental & Submandibular Liposuction
  43. 43. 10 mm fiber optic retractor
  44. 44. Separating skin from platysma
  45. 45. Suturing anterior bands of platysma in midline
  46. 46. CPMS-Addressing the Face • Mark a line from Zygomatic Insertion Point to Mandibular Angle • Identify Platsyma Muscle Within Face First • Release Masseteric Fibers
  47. 47. CPMS-Addressing the Face • Release Zygomatic Cutaneous Ligaments (aka) MacGregor's Patch
  48. 48. Subcutaneous dissection Elevation above the platysma
  49. 49. Superficial Temporalis facsia & VII nv. Deep Temporalis fascia
  50. 50. In the deep plane beneath Platysma over Masseter
  51. 51. Entering the deep plane Platysma under platysma over Masseter Masseter
  52. 52. Dissection over the Zygomaticus
  53. 53. Zygomaticus Major
  54. 54. Zygomaticus Major
  55. 55. Zygomaticus Major
  56. 56. Zygomaticus Major
  57. 57. CPMS-Addressing the Posterior Neck • Dissect Along Platysmal Border Inferiorly Along to Neck • Place Platysma Along Neck • Beware of Cervical Branch of Facial Nerve
  58. 58. CPMS-Addressing the Posterior Neck • Release Platysma From Deeper Elements • Create a Platysma Flap
  59. 59. Posterior border of Platysma
  60. 60. Posterior border of Platysma
  61. 61. Zygomaticus Below the platysma Platysma attached along the mandible Masseter Above the Platysma
  62. 62. CPMS-Suspending the Platysma Muscle • Suspend to the Ligament of Earlobe • Suspend to the Temporalis (Horizontal) • Suspend to the Mastoid Periosteum
  63. 63. 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
  64. 64. 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.
  65. 65. Suturing mandibular angle Platysma to fascia beneath ear lobe
  66. 66. Suturing Suturing mandibular angle Platysma to fascia beneath ear lobe
  67. 67. 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
  68. 68. Title • Content
  69. 69. Title • Content
  70. 70. Fibrin glue
  71. 71. Suturing temporal dermis to deep temporal fascia
  72. 72. Deep dermis to deep temporalis suture

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