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Facelift: Platysmal Muscular Suspension
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Facelift: Platysmal Muscular Suspension



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.




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

  • 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