Pitanguy, Ivo M.D.
Facial aesthetic surgery has witnessed enormous progress since it was first described in the beginning of the century. Consequently, the expectations of both the patient and the surgeon have increased considerably. Experience gives surgeons a better selection of techniques. Surgeons must be knowledgeable regarding the details of different surgical approaches and variations to attain the best result for each patient. The anatomy of the aging face should be examined carefully for a personalized treatment plan. Currently, a satisfactory result from an aesthetic facial procedure is obtained when the signs of an operation are undetectable and no anatomic landmarks have been altered. The bond created between the patient and surgeon will be frustrated if signs remain revealing the “secret” that surgery was performed. 1–4
This article will describe my personal approach to the surgical treatment of the aging face and cite principles that have offered consistent satisfactory results. Patient assessment is discussed, and technical aspects are detailed and illustrated. Emphasis is given to applying correct traction to the facial flaps (the “round-lifting” technique) and the forehead (“block” lifting) to ensure that all anatomic landmarks are precisely preserved. Finally, complementary surgical procedures that may be useful are presented, with a brief discussion of indications.
The Round-Lifting Technique
Rhytidoplasty is one of the most frequently performed surgeries. A total of 7379 personal consecutive cases have been analyzed to date (Table I).
More recently, a noticeable increase in male patients has been noted. In the 1970s, male patients represented 6 percent of face-lifting procedures; in the 1980s, they received approximately 15 percent of procedures, and currently, 20 percent of face-lift patients are men.
The standard incision is demarcated, beginning in the temporal scalp, and it proceeds in the preauricular area in such a way as to be “broken” by anatomic curves. The incision then follows around the earlobe and, in a curving fashion, finishes in the cervical scalp (Fig. 1). This “S”-shaped incision creates an advancement flap, which prevents a step-off in the hairline and allows the patient to wear her hair up without revealing the scar. In secondary rhytidoplasties, variations of this incision are chosen depending on each case. The following goals should be kept in mind: treating specific regions, resecting previous scars, and maintaining anatomic landmarks. An earlier article discussed the indications and advantages of different incisions. 5
The facial and cervical flaps are undermined in the subcutaneous plane, the extension of which is variable and individualized for each case. A danger area lies beneath the non-hair-bearing skin over the temples; this area is called “no man’s land” and is the location where the most frequent variation of the facial nerve, the temporofrontal branch, is particularly vulnerable. 6–8 Dissection over this area should be superficial, and hemostasis should be performed carefully (Fig. 2).
Often, the dissection proceeds under the mandible to treat very heavy, fatty necks. With the advent of suction-assisted lipectomy, submental lipodystrophy is mostly addressed by liposuction in a criss-cross fashion. 9 Sometimes, this is associated with direct lipectomy using specially designed scissors to defat the heavy submental region, as has been described historically. 10 After this, the treatment of medial platysmal bands is carried out under direct exposure. 11 The approximation of diastasis is done with interrupted sutures, and plication is done down to the level of the hyoid bone.
The undermining of the facial flaps is extended over the zygomatic prominence to free the retaining ligaments of the cheek. 12 Dissection of the deeper elements of the face has evolved over the past 20 years. Almost no treatment was advocated before the publications that first described the superficial musculoaponeurotic system (SMAS). 13 The approach to this structure has been a topic of much discussion. 14–16 It is my preference to determine whether to dissect or simply plicate the SMAS after subcutaneous dissection has been completed. I pull on the SMAS and note the effects of this on the skin.
I have noticed that the plication of the SMAS in the same direction as the skin flaps and the repositioning of the malar fat pad has given me results that are as satisfactory as dissecting the SMAS (Fig. 3). The durability of plication will relate to the individual aging process. Tension on the musculoaponeurotic system supports the subcutaneous layers, corrects the sagging cheek, and reduces tension on the skin flap. 17,18
Techniques that treat the pronounced nasolabial fold include putting traction on skin flaps, the SMAS, or the fascial fatty layer; these techniques have had variable results (Table II). 19–26 Filling the fold with different substances, such as a fat graft or other material, may also be done. Direct excision of the nasolabial fold is reserved for the older male patient. This technique gives a definite solution to the nasolabial fold, with a barely noticeable scar that mimics the fold itself.
The direction of traction on the skin flaps is a fundamental aspect of the round-lifting technique. 14,27 In this technique, the undermined flaps are rotated rather than simply pulled; thus, they act in a direction opposite to that of aging and ensure the repositioning of tissues with the preservation of anatomic landmarks. A second advantage in establishing a precise direction of rotation is that the opposite side is repositioned in the exact manner. This direction is determined by a vector that connects the tragus to Darwin’s tubercle for the facial component. A Pitanguy flap demarcator is placed at the root of the helix and, after precise traction, the point is marked on the skin flap. The edge of the flap is then incised along a curved line that crosses the supra-auricular hairline so that bald skin, not pilose, is resected. A key suture is located here (Fig. 4).
Likewise, the cervical flap should also be pulled in an equally precise manner in a superior and slightly anterior vector to avoid a step-off of the hairline. Key stitches are placed to anchor the flap along the pilose scalp so that no tension is on the thin skin at the peak of the retroauricular incision. Only when the temporary sutures have been placed will excess facial skin be resected. Skin is accommodated and demarcated along the natural curves with no tension whatsoever. Final scars are, thus, not displaced or widened. When performing a brow lift, placing these sutures is mandatory before any traction can be applied to the forehead flap; these sutures essentially “block” the facial flaps (Figs. 5 through 8).
The effects of the round-lifting technique were studied by analyzing the mechanical forces applied and the displacements produced. 28,29 The method of finite elements was used and, by means of computers, the relevant equations were defined. Human skin was modeled as a pseudoelastic, isotropic, noncompressible, and homogeneous membrane, and a computational study of the fields of displacement and the forces applied to the flaps during a rhytidoplasty demonstrated that the direction of traction creates areas of tension that can be either negative or positive. These forces ultimately result in the correction of signs of aging. The vectors described in the round-lifting technique address the main features that suffer distortion with aging and maintain anatomic parameters. Although there were limits to this study because of the variety of factors involved and the complexities of human skin (basic properties and individual variations), this study has a close parallel to a real surgical procedure.
Perhaps the most common unfavorable result after a face lift is patient dissatisfaction. This fact stresses the importance of correctly identifying the patient’s expectations. Complications in rhytidoplasty are infrequent, yet they can bring great distress to the patient and to the surgeon. In the immediate postoperative period, blood pressure should be constantly monitored to prevent hematoma formation. If an expansive hematoma is diagnosed, the surgeon should initially drain the facial pocket at bedside. 30–32 Early identification and treatment of large hematomas is essential to prevent sequela. Other complications can also occur. The complication rates for the 7379 patients treated between 1957 and 1998 were as follows: hematoma, 2.5 percent; alopecia, 0.4 percent; nerve lesion, 0.1 percent; and dehiscence, 0.1 percent.
Aging in the upper face becomes evident with a descent in the level of the eyebrow and the appearance of wrinkles and furrows, sometimes from an early age. These are a direct consequence of muscle dynamics, which are responsible for the multitude of expressions characteristic of humans, and a loss of skin tone. Elements of the upper face are carefully examined; these elements include the length of the forehead, the elasticity of the skin, the position of the anterior hairline, and the quality and quantity of hair. 33
An important decision to be made after considering the above factors is the placement of incisions. There are basically two approaches to a brow lift. The bicoronal incision allows for the treatment of all elements that determine the aging forehead, and it hides the final scar within the hairline. Certain situations, however, preclude this incision. Patients with a very long forehead or those who have had previous surgery who will have an excessively recessed hairline if the forehead is further pulled back. The final aspect will be displeasing and give the patient a permanent look of surprise. The second approach is the prepilose or anterior hairline incision. A variation of this incision is the reduced prepilose lateral incision, which is performed when the patient presents with ptosis of the lateral eyebrow and scant lines of expression on the forehead itself. The short distance required to reach the eyebrow region is easily bridged by subperiosteal blunt dissection. 5 Endoscopic instrumentation has permitted the treatment of the brow through minimal-access incisions and has proved useful in selected cases.
The major points of the technique include the following: wide exposure of the forehead flap using an open approach, weakening the muscles that act in this region by a method of multiple incisions that cut through the aponeurosis and free the muscle fibers, and blocking the facial flaps with key stitches so that once the forehead has been positioned, no alterations in anatomy will occur in the face. 33–36
The entire upper third of the face is undermined in a subgaleal plane until the orbital ridges are reached. In patients in whom the aging process has resulted in a drooping nose, the nasal tip and the membranous septum can be manipulated by dissecting with a long scissors in the subcutaneous plane, starting at the root of the nose. A rotation of the scissors tip will section the dermocartilaginous ligament of the nose. This structure tends to hold the nasal tip downward. 37,38 Once it has been interrupted, the tip of the nose assumes a slightly more superior position (Fig. 9).
For the release of the supraorbital region, when correction of a ptotic eyebrow is indicated, the periosteum is incised along the supraorbital rim and blunt dissection is carried over the rim for approximately 1 cm. This preserves the supraorbital neurovascular bundle.
The “frontalis-procerus-corrugator aponeurotic expansion” is a structure that spreads over the entire upper third of the face and unites the frontalis, procerus, and corrugator muscles. 39 By dividing its fibers, the forehead muscles are weakened, which smooths the lines of expression. This is done in a criss-cross fashion, without the excision of tissue, to avoid surface irregularity.
The three-plane forehead lift is constituted as follows: subgaleal for the most part, subcutaneous down to the membranous septum, and subperiosteal over the supraorbital ridge. Having blocked the facial flaps, the forehead may be pulled in any direction, either straight backward or more laterally. 40 The amount of scalp flap to be resected is determined by the length of the forehead and the effect that traction has on the level of the eyebrow. The midline is positioned, demarcated, incised, and blocked with a temporary suture. Sometimes no traction is necessary, and no scalp is removed in the midline. Two symmetrical flaps are created, and lateral resection can now be performed, which will allow the eyebrow to be raised as necessary (Figs. 10 through 12).
Several procedures are available to enhance surgery on the aging face. 14,40 Procedures of a surgical nature that have been adopted and developed to complement a face lift, including laser resurfacing, will be briefly presented (Fig. 13). Nonsurgical procedures, although useful in many cases, will not be mentioned in this article.
Although changes around the eyes generally accompany the senescence process of the face, it is not uncommon to observe younger patients who complain of precocious signs of aging, with excess skin and baggy lower lids. Several important points should be emphasized regarding the surgical technique. Final scars should be well hidden and lie in the supratarsal fold in the upper lids and along the ciliary margin in the lower lids. The incision should never extend beyond the orbital rim because of the difference in thickness between these two regions. Since the advent of laser resurfacing, more surgeons have used the transconjunctival access to remove the fat pads of the lower lids.
When associated with a face lift and/or forehead lift, as is generally the case, the treatment of the palpebral region is done only after the face and the brow have been blocked because the traction of the flaps may alter orbital folds and creases. 41 The shape of the incision is tailored to each patient to match the individual’s anatomic features and correct for asymmetry when it is present. Both sides are demarcated and double-checked before any infiltration is performed.
Fat pouches are treated by clamping the excess pads as they bulge out spontaneously. Care should be taken to avoid removing too much fat, because this will result in an expressionless, anophthalmic appearance. This is also true of cutaneous resection, especially of the lower eyelids, which is particularly unforgiving of excessive removal of skin. 41–43 Here, skin is readapted, rather than removed, after undermining. The surgeon should not hesitate to reinforce the lower eyelid with a canthopexy procedure if any looseness exists that might result in scleral show. 43
The Aging Lip
The full, sensuous lip is a much-desired feature of a young face. Loss of vermilion definition, size, and regularity denote early aging. This is further enhanced by the lengthening of the upper lip and the presence of radial lines extending to the nasal base. These aspects require specific attention because they are not corrected by the traction of facial flaps. Traditional methods include planing the skin and surgery for increasing the vermilion and shortening the height of the upper lip. 40,44–47
Elimination of skin rhytids along the upper lip remains a challenge. Peeling with chemical substances has been favorably reported by some authors. 40,47 Laser resurfacing has favorable results, yet mechanical abrasion should not be abandoned because it has the following attractive factors: it is a relatively simple procedure, requires unsophisticated equipment, and causes few postoperative restrictions.
Enlargement and definition of the vermilion are achieved by the resection of skin above the mucocutaneous border and result in a scar that softens with time. 44 Repositioning the vermilion also decreases the vertical length of the upper lip. Although less frequent, the same procedure may be performed on the lower lip.
The Senile Chin and Earlobe
Some patients present with a poorly defined chin as an aspect of the aging process; it becomes more evident when submental fat accumulation is removed by liposuction and the skin flap is tightened. One method to correct this uses excess fat under the chin as a superiorly based flap and rotates it cephalically and fixes it over the chin. This requires an external incision. 45
A simpler solution to project the senile chin is to implant a Silastic implant that is custom-made with a soft silicone elastomer. The incision is made along the gingivolabial sulcus, and a pocket is undermined in a supraperiosteal plane. The medial raphe is identified and cut at its lower extremity; it is then brought over the implant as a superiorly based flap. Suturing the flap to the periosteum immediately below the incision securely fixes the implant in place. Traction on this flap also creates an external depression along the midline and improves the mentolabial sulcus. 46,48,49 The raphe may also be created and repositioned without the placement of an implant to bring up and correct a mild “witch’s chin” (Figs. 14 through 16).
As in other anatomic regions, the earlobe also suffers ptosis and elongation, which is unattractive. After a face lift, excess length of the earlobe is easily shortened by means of a crescent resection along its posterior and inferior aspect. Care should be taken to resect a greater amount of skin from the posterior portion of the ear so that the final scar is placed posteriorly. 50
The correction of the senile nose was described under Forehead Lifting.
Laser resurfacing is a safe and efficient procedure when performed by an experienced medical team and when all clinical and technical aspects are understood. The depth of peeling must be absolutely controlled by the surgeon; this requires prolonged training. Laser peeling is an ancillary procedure that enhances surgery for the aging face. 51 It does not, therefore, serve as a substitute for surgery (Fig. 17).
The author would like to express his gratitude to his assistants, Drs. Francisco Salgado and Henrique N. Radwanski, for their close collaboration in the preparation of the manuscript.
1. Pitanguy, I. Les Chemins de la Beauté. Un maitre de la chirurgie plastique témoigne. Paris: J. C. Lattes, 1983.
2. Pitanguy, I. The Aging Face. In L. Carlsen and B. Slatt (Eds.), The Naked Face. Ontario: General Publishing, 1979. P. 27.
3. Rees, T. D. Concepts of Beauty. In T. D. Rees (Ed.), Aesthetic Plastic Surgery. Philadelphia: Saunders, 1980. P. 1.
4. Pitanguy, I.Aging Face Surgery. Presented at the Symposium on Aesthetic Surgery of the Aging Face: A Major Course of the American Academy of Facial Plastic and Reconstructive Surgery, Indianapolis, Ind., March 3–7, 1993.
5. Pitanguy, I. La ritidoplastica: Soluzione eclettica del problema. Minerva Chir. 22:942, 1967.
6. Pitanguy, I., and Ramos, A. The frontal branch of the facial nerve: The importance of its variation in face-lifting. Plast. Reconstr. Surg. 38:352, 1966.
7. Pitanguy, I. Upper Facial Nerve Anatomy and Forehead Lift. In Symposium on Problems and Complications in Aesthetic Plastic Surgery of the Face. Monterrey, Calif.: 1980. P. 45.
8. Pitanguy, I., Ceravolo, M. P., and Dègand, M. Nerve injuries during rhytidectomy: Considerations after 3203 cases. Aesthetic Plast. Surg. 4:257, 1980.
9. Pitanguy, I., Salgado, F., and Radwanski, H. N. Submental liposuction as an ancillary procedure in face-lifting. F.A.C.E. 4:1, 1995.
10. Millard, D. R., Pigott, R. W., and Hedo, A. Submandibular lipectomy. Plast. Reconstr. Surg. 41:513, 1968.
11. de Castro, C. C. The anatomy of the platysma muscle. Plast. Reconstr. Surg. 66:680, 1980.
12. Furnas, D. W. The retaining ligaments of the cheek. Plast. Reconstr. Surg. 83:11, 1989.
13. Mitz, V., and Peyronie, M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast. Reconstr. Surg. 58:80, 1976.
14. Pitanguy, I., Brentano, J. M. S., Salgado, F., Radwanski, H. N., and Carpeggiani, R. Incisions in primary and secondary rhytidoplasties. Rev. Bras. Cir. 85:165, 1995.
15. Mendelson, B. C. Correction of the nasolabial fold: Extended SMAS dissection with periosteal fixation. Plast. Reconstr. Surg. 89:822, 1992.
16. Tom, W. Anatomy of the superficial muscular and aponeurotic system (SMAS) revised. Int. J. Aesthetic Restor. Surg. 1: 2, 1993.
17. Stuzin, J. M., Baker, T. J., and Gordon, H. L. The relationship of the superficial and deep facial fascias: Relevance to rhytidectomy and aging. Plast. Reconstr. Surg. 89:441, 1992.
18. Owsley, J. Q. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast. Reconstr. Surg. 91:463, 1993.
19. Millard, D. R., Jr., Yuan, R. T. W., and Bevine, J. W. A challenge to the undefeated nasolabial folds. Plast. Reconstr. Surg. 80:37, 1987.
20. Horibe, E. K., Horibe, K., and Yamaguchi, C. T. Pronounced nasolabial fold: A surgical correction. Aesthetic Plast. Surg. 13:99, 1989.
21. Mole, B. Le sillon naso-labio-jugal: Analyse et propositions techniques de correction. Ann. Chir. Plast. Esthet. 35:191, 1990.
22. Barton, F. E., Jr. The SMAS and the nasolabial fold. Plast. Reconstr. Surg. 89:1054, 1992.
23. Guyuron, B., and Michelow, B. The nasolabial fold: A challenge, a solution. Plast. Reconstr. Surg. 93:522, 1994.
24. Yousif, N. J., Gosain, A. K., Sanger, J. R., Larson, D. L., and Matloub, H. S. The nasolabial fold: A photogrammetric analysis. Plast. Reconstr. Surg. 93:70, 1994.
25. Pitanguy, I., and Amorim, N. F. G. Treatment of the nasolabial fold. Rev. Bras. Cir. 87:231, 1997.
26. Pitanguy, I., Radwanski, H. N., and Amorim, N. F. G. The aging face: Surgical aspects of the round lift. Aesthetic Surg. J. 19:212, 1999.
27. Pitanguy, I. The Face. In Aesthetic Surgery of Head and Body. Berlin: Springer Verlag, 1984. Pp. 165–200.
28. Pitanguy, I., Pamplona, D. C., Giuntini, M. E., Salgado, F., and Radwanski, H. N. Computational simulation of rhytidectomy by the “round-lifting” technique. Rev. Bras. Cir. 85:213, 1995.
29. Pitanguy, I., Pamplona, D. C., Weber, H. I., Leta, F., Salgado, F., and Radwanski, H. N. Numerical modeling of the aging face. Plast. Reconstr. Surg. 102:200, 1998.
30. Pitanguy, I., and Ceravolo, M. Hematoma postrhytidectomy: How we treat it. Plast. Reconstr. Surg. 67:526, 1981.
31. Pitanguy, I. Aging Face Surgery. In F. J. Stucker (Ed.), Plastic and Reconstructive Surgery of Head and Neck. Philadelphia: Decker, 1991. P. 145.
32. Pitanguy, I., Mayer, B., Brentano, J., et al. Rhytidoplastik: Perioperative richtlinien. Laryngol. Rhinol. Otol. 66:586, 1987.
33. Pitanguy, I. Indication for and treatment of frontal and glabellar wrinkles in an analysis of 3404 consecutive cases of rhitidectomy. Plast. Reconstr. Surg. 67:157, 1981.
34. Pitanguy, I. Section of the frontalis-procerus-corrugator aponeurosis in the correction of frontal and glabellar wrinkles. Ann. Plast. Surg. 2:422, 1979.
35. Pitanguy, I. Tratamento Cirúrgico do Envelhecimento da Face e de Seu Terço Superior. In C. C. De Castro (Ed.), Cirurgia do Rejuvenecimento Facial. Rio de Janeiro, Brazil: MEDSI, 1998. Pp. 233–264.
36. Pitanguy, I., and Radwanski, H. N. Rejuvenation of the brow. Dermatol. Clin. 15:623, 1997.
37. Pitanguy, I. Surgical importance of a dermocartilaginous ligament in bulbous noses. Plast. Reconstr. Surg. 36:247, 1965.
38. Pitanguy, I., Salgado, F. Radwanski, H. N., and Bushkin, S. C. The surgical importance of the dermocartilaginous ligament of the nose. Plast. Reconstr. Surg. 95:790, 1995.
39. Pitanguy, I. Forehead Lifting. In Aesthetic Surgery of Head and Body. Berlin: Springer Verlag, 1984. Pp. 202–214.
40. Pitanguy, I. Ancillary procedures in face-lifting. Clin. Plast. Surg. 5: 51, 1978.
41. Pitanguy, I., Caldeira, A., and Alexandrino, A. Blepharoplasty: Personal experience with 4564 consecutive cases. Ophthalmic Plast. Reconstr. Surg. 1: 9, 1985.
42. Lessa, S., Mayer, B., Sebestia, R. and Pitanguy, I. Die operative behandlung des schweren unterlid-ektropiums mit einem transplantat aus haut und aperichondrium. Klin. Monatsbl. Augenheilkd. 193:207, 1988.
43. Pitanguy, I.Eyelid Surgery and Temporal Lift. Presented at the Fourth Annual Multispecialty Oculoplastic Surgery Symposium, Lexington, September 3–5, 1988.
44. Pitanguy, I. The Aging Lip. In Aesthetic Surgery of Head and Body. Berlin: Springer Verlag, 1984. Pp. 231–238.
45. Pitanguy, I. Augmentation mentoplasty. Plast. Reconstr. Surg. 42:460, 1968.
46. Pitanguy, I. Aesthetic Surgery of the Aging Lip and Chin. In Proceedings of the 4th International Symposium on Plastic and Reconstructive Surgery of the Head and Neck, St. Louis: Mosby, 1984.
47. Pitanguy, I., Muller, P., Piccolo, N., Fieitas, L. Esthetic surgery of the aging lip. Compendium 8:460, 1987.
48. Pitanguy, I.Chin Problems. Presented at the Symposium on Problems and Complications in Aesthetic Plastic Surgery of the Face, Toronto, Canada, 1984.
49. Pitanguy, I., Martello, L., Caldeira, A. M., and Alexandrino, A. Augmentation mentoplasty: A critical analysis. Aesthetic Plast. Surg. 10:161, 1986.
50. Pitanguy, I., Muller, P., Kauak, L., and Freitas, L. Remodeling incisions of the earlobe. Rev. Bras. Cir. 78:149, 1988.
51. Pitanguy, I., Soares, G., Machado, B. H., and de Amorim, N. F. CO2 laser associated with the ‘round-lifting’ approach. J. Cutan. Laser Ther. 1:145, 1999.