anatomy for facelift surgery anatomy for facial fillers antiaging surgery

1. By
Ahmed Fawzy El-Sayed MSc.
Eygptian fellowship of Plastic surgery In
Plastic & Reconstructive Surgery and Burn Department,
Tanta University

2. A thorough
knowledge of the
layers, planes, and
structures of
facial anatomy is
critical when
performing
aesthetic surgery.

3. *The youthful
face is inherently
attractive as it
conveys an
overall look of
freshness .
*It is the primary
structure for
both nonverbal
and verbal
communication.
*In fact, aged or
tired faces often
falsely express a
negative
emotion (anger,
fatigue,
disappointment)

4. The entire face is similar
to the scalp in being
composed of five basic
layers:
(1) the skin.
(2) the subcutaneous
layer.
(3) the
musculoaponeurotic
layer.
(4) loose areolar
tissue(ie, spaces and
retaining ligaments).
(5) the fixed periosteum
and deep fascia

5. Layer 2: subcutaneous
tissue
The subcutaneous layer
has two components: the
subcutaneous fat
(discussed later)
, which provides volume,
and the fibrous
retinacular cutis that
binds the dermis to the
underlying SMAS.

6. the musculoaponeurotic layer (layer 3)
is described as the (SMAS).
The SMAS contains the intrinsic
muscles of the cheek, which have a
limited attachment to skeleton and a
more extensive attachment to
the soft tissues that they move.
The musculoaponeurotic layer (layer
3) is attached by retinacular cutis
fibers within the subcutaneous layer
(layer 2) to the skin (layer 1).

7. • The fascia of the
platysma muscle is
part of the superficial
cervical fascia and is
continuous with the
SMAS below.
• The temporoparietal
fascia (superficial
temporal fascia) is an
extension of the SMAS
over the temporal
region above.

9. SMAS
• The SMAS is a well-defined portion of the superficial
facial fascia.
• SMAS thickness varies by patient and region of the face. It
is thickest over the parotid and becomes thinner medially.
Forms a continuous sheath through the face and neck
Extends into malar region, lip, and nose, covering the
mimetic muscles

10. *Facial muscles
*flat muscles forming the superficial layer that covers
the anterior aspect of the face.
*The frontalis covers the upper, orbicularis oculi,the
middle and the platysma, cover lower thirds
*frontalis is fixed by the superior temporal septum.
orbicularis oculi by lateral orbital thickening and the
main zygomatic ligament .
*the platysma at its upper border by the lower
masseteric ligament

11. *The deeper muscles in
layer 3 provide greater
functional control of the
sphincters over the bony
cavities.
*For the upper third,
these are the
corrugators and
procerus

12. around the oral cavity,
the elevators (zygomaticus major and minor, levator labii
superioris, levator anguli oris), and
the depressors (depressor anguli oris, depressor labii
inferioris) around the oral sphincter and the mentalis.

13. The facial mimetic
muscles are protected
in deep plane facelift
surgery because they
are innervated from
their inferior
(under)surfaces. The
exception is the
buccinator, levator
labii superioris, and the
mentalis, which are the
deepest lying muscles
and are innervated on
their outer surfaces.

14. The fourth layer
*In the scalp, this layer is formed by the galea and flat
muscles, the occipitofrontalis. The outer three layers are
fused and form a functional unit, which is seen when a
scalp flap is elevated
*loose areolar tissue (layer 4) permits gliding movement
of the composite scalp over the fixed deep fascia
(periosteum and deep temporal fascia, layer 5)

15. The fourth layer
the plane of dissection in subSMAS facelifts.
contains the following structures:
(1) soft tissue spaces.
(2) retaining ligaments.
(3) deep layers of the intrinsic muscles passing from their
bone attachment to their more superficial soft tissue
origin
(4) facial nerve branches, passing from deep to
superficial.

16. The fourth layer
has two opposing functions.
 Within this layer are the
facial ligaments that fix the
overlying composite soft
tissue to the facial skeleton.
 is more than a simple areolar
tissue seen in the scalp, but
it being a glide plane also
 The ligaments within the
midcheek are the orbicularis
retaining, zygomatic, and the
upper masseteric ligaments.

17. Retaining Ligaments
A highly organized
and consistent
three-dimensional
connective tissue
framework supports
the overlying skin
and soft tissues.

18. The retaining ligaments of the face can be likened to a tree. The
ligaments attach the soft tissues to the facial skeleton or deep muscle
fascia, passing through all five layers of the soft tissues. It fans out in
a series of branches and inserts into the dermis. At different levels of
dissection, it is given different names, such as the retinacular cutis in
the subcutaneous layer and ligaments in the subSMAS level .

19. The regional nerves and
vessels display constant
and
Predictable
relationships with both
the fascial planes and
their ligamentous
attachments.

20. *

21. *The orbitomalar ligament and zygomaticocutaneous ligament
have been referred to as the orbital retaining ligament and
malar membrane, respectively. Both structures are important
in development of the tear trough deformity and malar bags.

22. *1. Osteocutaneous
ligaments
Zygomatic
osteocutaneous
ligament
extends from the
zygomatic arch
and body, through
the malar fat pad,
to the overlying
dermis
McGregor’s
patch: Part of the
ligament over the
zygomatic body

23. Mandibular
osteocutaneous
ligament
extends from the
parasymphyseal
mandibular region
to the overlying
dermis

24. 2. Parotid and
masseteric cutaneous
ligaments
Formed by coalescence of the
superficial and deep facial
fascia Fixes these facial
layers to the parotid and
masseter, and attaches to the
overlying dermis by fibrous
septa

26. Weakening of the
masseteric
ligaments
Causes downward
migration of the
cheek tissue,
thereby creating
marionette
lines
and jowls
(descent below
the mandibular
margin)
Jowls formed
from tethering by
the mandibular
ligament Stigmata of facial aging as they relate to retaining
ligaments of the face in the form of grooves.

27. Jowl formation
is a result of
weakening of the
mandibular
septum and the
shifting of fat in
the lower face as
well as generalized
soft tissue ptosis.

28. marionette lines

31. The orbicularis oculi muscle is fixed to the bone by the orbicularis
retaining ligament. the area of convergence of both orbicularis
retaining ligament and zygomatico-cutaneous ligament is tear trough
ligament . The angular vein lies inferior to it at the level of the
nasojugal groove.

32. The facial nerve
branches, spaces
and retaining
ligaments.
The nerves stay deep to
and outside of the
spaces at all times in
the lateral face. In the
boundary between the
lateral and anterior
face, the facial nerve
branches transition
from under layer 5 to
enter layer 3, always in
close association
with the retaining
ligaments of the face.

33. temporal
branches of the
facial nerve pass
just medial and
parallel to The
inferior temporal
septum .
the zygomatic
br of facial nerve
has an intimate
relationship to
main Zygomatic
ligament and
masseteric
ligament.

34. The masseteric ligaments are
important landmarks for the buccal
facial nerve branches.
It guard the nerves, which
penetrate the deep fascia and
become superficial on top of the
buccal fat pad, just distal to the
masseteric ligaments.
Releasing the masseteric retaining
ligaments in a sub-SMAS plane
may cause herniation and
exposure of the buccal fat pad,
with the buccal facial branches
lying superficial to it.

35. The marginal mandibular
nerve run just posterior to
the mandibular ligament.
The great auricular nerve
related to the subcutaneous
extension of the platysma-
auricular ligament.
PAL separates the lateral
temporal–cheek fat
compartment from the
postauricular compartment,
and the great auricular nerve
travels through this septum.

36. A representation of facial
ligaments (1) the
zygomatic and
(2)mandibular,
(3) the masseteric
retaining ligament and (4)
the parotid retaining
ligament join deeper soft-
tissue structures to the
dermis.
Collectively, these
ligaments support the
facial structures and facial
nerve branches that may
be violated during facelift
dissection.

37. Regions of the face
 The mobile anterior face is
adapted for facial expressions
 the relatively fixed lateral face
(shaded), which overlies masticatory
structures.
separated by
A vertical line of retaining ligaments (red)
from above:
temporal, lateral orbital, zygomatic,
masseteric, and mandibular ligaments.
In the anterior face, the mid-
cheek is split obliquely into two
separate functional parts by the mid-
cheek groove (dotted line) related to two
cavities:
1. the periorbital part above
(blue)
2. the perioral part below
(yellow).

38. Spatial anatomy of the
midcheek showing :
The orbicularis retaining
ligament (above)
Separates
the preseptal space of the lower
lid
from the prezygomatic
space.
The zygomaticocutaneous
ligaments (below)
Separate
the prezygomatic space from the
masticator space.

39. Facial Fat Compartments

40. *

42. Superficial Facial Fat
Compartments
1.Nasolabial fat compartment
2.Cheek fat compartments
3.Forehead and temporal fat
compartments
4.Orbital fat compartments
5.Jowl fat compartment

44. Deep Facial Fat
Compartments
*are anterior or posterior to the
mimetic muscles, and enable
sliding during animation or
mastication
1.Deep medial fat
compartment
2. Suborbicularis oculi fat
(SOOF)
3. Retroorbicularis oculi fat
(ROOF)
4.buccal fat pads

46. Nasolabial fat
compartment
 anterior to
medial cheek fat.
overlaps jowl fat.
 Orbicularis
retaining ligament
is superior border.
 adherent to lower
border of
zygomaticus major.

47. Medial cheek fat

48. *Middle cheek fat
Anterior and superficial
to the parotid gland
At its superior portion,
the zygomaticus major
muscle is adherent.
A confluence of septa is
present at this location,
where the zygomatic
ligament has been
described.

49. Lateral temporal-cheek
compartment
 superficial to the
parotid gland,
connecting the temporal
fat to cervical
subcutaneous fat.
The lateral cheek
septum
located anterior to it.(a
true septum, and is the
first septal boundary
encountered during a face
lift).

50. *Forehead and
temporal fat
compartments
*• Composed of three
compartments
*1. Central

51. 2. Middle
on either side of it
(superior temporal
septum forms
the lateral border)
3. Lateral
temporal-cheek
compartment
(described above)

52. *Orbital fat compartments
*• Composed of three
compartments
*1. Superior compartment,
bounded by orbital retaining
ligament (ORL) above and
the
*canthi medially and
laterally

53. 2. Inferior
compartment,
bounded by ORL
inferiorly and
the canthi
medially and
laterally

54. 3. Lateral
compartment,
bounded superiorly
by the inferior
temporal septum,
inferiorly by
the superior cheek
septum, where the
zygomaticus major
muscle is adherent

55. Jowl fat compartment
• Adheres to the
depressor anguli oris
muscle
• Bounded medially by
the depressor labii,
superiorly and laterally
by the cheek
compartments.

56. Bounded inferiorly by
the membranous fusion
of the platysma
muscle. This occurs at
the region of the
mandibular retaining
ligament.

57. Malar Fat Pad
refers to the youthful cheek.
the nasolabial and medial cheek
fat compartments.
The inferior orbital fat
Triangular in shape, overlies the
zygomaticus major, the
zygomaticus minor, and the
lower orbicularis oculi.
Its base is along the nasolabial
sulcus, and its apex is toward
the zygomatic prominence.
With age the fat pad descends
and loses volume, which creates
fullness and deepening of the
nasolabial sulcus.

58. Deep compartments

59. These include
the sub– orbicularis oculi and oris, buccal fat
pads, deep medial cheek fat, and lateral deep
cheek compartment.

60. *The deep
medialcheek fat
is stained with
methylene blue.
*This fat lies beneath
the superficial
subcutaneous fat
compartments.
*The zygomaticus
major (ZM) and
buccal fat (B)
represent the lateral
boundaries

61. *Deep medial cheek fat
(DMCF) surrounds the
levator anguli oris
muscle (LAO). Buccal
fat (B) and
* suborbicularis fat
(SOOF) are distinct
from the deep medial
cheek fat.

62. (Above) The main blood supply to
the deep medial cheek fat was noted
to be the infraorbital
artery (IOF).
The transverse facial (TFA) and
the angular arteries provided small
branches to this fat pad

63. (Left) Photograph of a deflated midface (arrow). (Right) Saline injected
specifically
into the deep medial cheek fat
restores anterior projection, diminishes the nasolabial fold,
effaces the nasojugal trough, and improves the malar region.
the cheek has a natural appearance, the reason being that the deep
medial fat boundaries determine the anatomical position of the cheek.

64. SO
IF fat is injected deep and medial to the zygomaticus
major muscle,This technique improves midface
projection and recreates a youthful cheek. In addition,
the V-deformity of the lower lid is improved and the
prominence of the nasolabial fold is diminished.

66. Buccal Fat Pad
The buccal fat pad is an
important structure that
contributes to cheek and
facial contour.
It consists of a central
body and three
extensions: Temporal,
pterygoid, and buccal.
The central body and
buccal extensions
contribute to cheek contour.

67. The buccal fat pad is
similar to an egg yolk in
color, size, and consistency.
The zygomatic and buccal
branches of the facial nerve
lie superficial to the buccal
extension, with the parotid
duct passing through it.
In select cases, the buccal
extension can be removed
using an intraoral approach
with alongitudinal incision
in the buccal sulcus to
reduce cheek fullness and
enhance the malar
eminence.

68. Key fat compartments for
augmentation.

69. pathophysiology of the aging face
• These ligaments attenuate and relax with
age, causing creases by pivoting facial tissue.
• The characteristics of facial aging are the
result of these ligaments relaxing, along
with loss of skin elasticity and atrophy of
soft tissues.

70. Weakening of
the zygomatic
ligaments
Causes
downward
migration of the
malar soft
tissues Creates
redundant skin
that hangs over
the fixed
nasolabial fold .

71. * the
masseteric
ligaments
marionette
lines
jowls
mandibular
ligament

72. All tissues change
characteristics with age
tissues are subject to
atrophoderma,
redistribution, and sagging.
The skin loses some
collagen and elastin in the
dermis, and the dermis
loses some hyaluronic acid,
becoming dry, inelastic,
and wrinkly.
Understanding the
characteristics of aging is
the key foundation for fi
ller and botulinum toxin
treatment

73. Fat tissue shows different aging processes
In the superfi cial fat, drooping appears due to gravity.
In the deep fat, relocation and atrophy due to the
unbalanced change of the volume of fat compartments.

74. Face lipofilling
Indications were simplified by
Shiffman, (2010) into three main
groups.
The first to fill defects such
as
 Congenital disease as Romberg
disease.
Traumatic.
Disease as acne .
Iatrogenic (e.g following drug
injection).

75. *The second group is
for cosmetic
indications
 furrows or
wrinkles,
 acne scars.
enhancement and
refill lost supportive
tissue due to aging

76. the third group is for non cosmetic purposes,
 migraine headache
vocal cord problems
lipoinjection was used in treating sphincteric
incontinence (Shafik, 1995),
 filling first web space atrophy in ulnar nerve
palsies,
 pacemaker pocket neuralgia and
restoration of planter fat pad