Connell diverged from the original composite lift and instead elevated the skin flap as a separate layer from the SMAS.69,70 This allowed independent manipulation of the skin and SMAS layers and segmentation of the SMAS flap to create multiple vectors of suspension.
Reports of bifurcating the SMAS flap and using the preauricular posterior margin to suspend the neck separately were initially published in the early 1980s.71,72 Barton uses a similar bivectored approach in the high SMAS (Fig. 10). Connell and Marten furthered this concept with the “trifurcated SMAS flap” in 1995, which incised the SMAS flap into three segments to provide three independent vectors of elevation.70 The superior segment is anchored vertically to the temporal fascia to suspend the midface and malar tissues. The middle segment is anchored to the cut edge of the SMAS over the zygomatic arch to correct the cheek and jowl. Lastly, the inferior segment is transposed in a primarily posterior vector to the mastoid fascia to correct the neck.
In 1995, Stuzin et al. described a similar two-layer lift, which came to be known as the “extended SMAS” (Fig. 12).10 Stuzin’s extended SMAS is similar to Barton’s high SMAS in that the SMAS dissection in both techniques extends anteriorly in a plane just superficial to the zygomaticus muscles in an effort to better mobilize the cheek. Conversely, in the extended SMAS, the skin and SMAS layers are raised as two completely separate flaps with varying vectors, whereas Barton’s high SMAS is a composite skin and SMAS flap, separated only in its lateral portions over the parotid to bifurcate the ear. In addition, the excess SMAS in the extended SMAS is rolled onto itself to provide bulk rather than discarded in the high SMAS technique.
The late 1990s subsequently observed the spectrum swing from extensive sub-SMAS dissections back to subcutaneous rhytidectomies, with the addition of SMAS manipulation. These techniques limit preauricular incisions and skin undermining to only that needed for SMAS plication, thus minimizing morbidity, recovery time, and scar visibility while still providing reliable results. Proponents of the limited lift argue that SMAS plication is just as effective as formal SMAS elevation, and that complete release of the retaining ligaments is unnecessary, as they are already attenuated with age.74 Adversaries argue that superior results are achieved with formal SMAS elevation and complete release of the deep cheek attachments.14 Regardless, SMAS plication can be a useful alternative if the SMAS is thin and prone to tearing with attempted elevation.10
In 1999, Saylan proposed the “S-lift,” in which purse-string sutures are used to plicate the SMAS.77 The S-lift refers to the S-shaped preauricular skin excision made to access the SMAS. Tonnard et al. modified this procedure 3 years later with the “minimal access cranial suspension,” or “MACS lift.”78 Through a limited preauricular incision, Tonnard et al. similarly placed purse-string sutures in various locations in the SMAS, suspending ptotic facial tissues to the deep temporal fascia above the arch (Fig. 14). Although limited by the occasional suture tear-through and anecdotally transient effects, the minimal access cranial suspension lift has quickly become one of the more popular face-lift procedures performed today.58
Recent publications in the face-lift literature have focused on individualized treatment plans to accommodate patient-specific facial shapes, vectors, and volumetric requirements. In 2007, Stuzin described an algorithm for SMAS procedures tailored to the long versus wide face.79 For the long face, he recommends extending the SMAS dissection medially with resuspension in an oblique vector to restore malar volume and width. For the wide face, he proposes limiting SMAS dissection medially and suspending the soft tissues in a vertical vector to reposition the submalar fat superiorly.
Similarly, the “individualized component” face-lift approach described by Rohrich et al. in 2009 advocates extensive skin undermining and SMAS stacking in the oblique vector to enhance cheek fullness in the long, narrow face (Fig. 15).74 For the short, wide face, Rohrich et al. recommend limited skin undermining, with SMAS excision (SMASectomy) and resuspension in the vertical vector to enhance submalar hollowing. To further customize his results, Rohrich et al. added fat compartment–guided fat transfers for a simultaneous “lift-and-fill” face lift.80
Hematoma is the most common early complication following face-lift surgery. Resorption of adrenalin in the early postoperative period can lead to rebound hypertension and subsequent hematoma.81 The incidence in nonhypertensive patients is approximately 3 percent, but the incidence rises approximately 8 percent in hypertensive patients and in male patients (Level of Evidence: Therapeutic, IV).82
The most common cause of hematoma is related to uncontrolled blood pressure. Patients who preoperatively have a history of hypertension should be instructed to take their blood pressure medications on the morning of surgery. As an adjunct, oral clonidine (0.1 to 0.3 mg) or a transdermal patch (0.1 to 0.2 mg) can be administered preoperatively or intraoperatively, respectively, to keep blood pressure low in the perioperative period, especially as the injected adrenalin absorbs. Intraoperative hypertension should be well controlled, and maintenance of postoperative systolic blood pressure below 140 mmHg is desirable.7 Beta-blockers (5 to 10 mg of labetalol) or calcium channel blockers (0.25-mg bolus of nicardipine) can maintain blood pressure intraoperatively. Of note, one should avoid additional beta-blockers for patients currently receiving beta-blockers to prevent relative bradycardia. Injected adrenalin from the local anesthetic solution is slowly absorbed, such that postoperative hematomas usually occur 4 to 10 hours after surgery. Postoperatively, blood pressure can be controlled with beta blockade (100 mg of oral labetalol) or an alpha agonist (0.1 to 0.3 mg of clonidine).7 Concurrently, pain, restlessness, and/or nausea must be controlled, as each factor may increase blood pressure and the development of a hematoma.83
The incidence of hematoma is increased in patients taking platelet-inhibiting medications such as aspirin and other nonsteroidal antiinflammatory drugs. Supplements with antiplatelet or anticoagulant properties can also increase perioperative bleeding risk. These agents include but are not limited to garlic, ginger, vitamin E, fish oil, glucosamine, and green tea.84 Such medications should be discontinued 2 to 3 weeks before elective surgery.83,84 Intravenous desmopressin may be administered for intraoperative bleeding associated with presumed platelet inhibition.85 Furthermore, a concurrent open anterior platysmaplasty with rhytidectomy significantly increases the risk of hematoma.86,87 Of note, the most important aspect in preventing hematoma after blood pressure is meticulous hemostasis.83
An expanding hematoma is most likely to occur in the first 24 hours after surgery and should be evacuated promptly. Early intervention will prevent subsequent necrosis of skin flaps caused by edema and tissue ischemia.7,83 Although return to the operating room for exploration is the classic treatment, bedside evacuation with a suction catheter has been successful in managing early, acute unilateral hematomas in cooperative patients with controlled blood pressure.88
The incidence of skin necrosis following cervical rhytidectomy ranges from 1 percent in sub-SMAS procedures to 3.6 percent in subcutaneous face lifts.81 The incidence of skin flap ischemia is significantly higher with overly thin flap dissections, excessive tension, hematoma, constrictive dressings, and vascular occlusive disorders, particularly smokers.81,89 Skin necrosis should be addressed conservatively with local wound care; the majority of cases will eventually heal spontaneously.
Adaptations in the postoperative regimen can minimize flap edema and subsequent ischemia. Postoperative drains will collect perioperative serum, preventing fluid from collecting under the skin flaps. However, drains do not prevent or remove significant hematoma. In addition, avoidance of neck dressings will prevent pressure necrosis of the thin neck flaps and allow appropriate venous return. Furthermore, restriction of salt and water intake may limit postoperative edema, which affects not only tissue ischemia but also stress relaxation of the skin flaps.14
The incidence of wound infections is very rare following cervical rhytidectomy. Intravenous perioperative antibiotics for Staphylococcus aureus or Staphylococcus epidermidis prophylaxis (typically a cephalosporin or vancomycin) are routinely given, even though there is little evidence to support their administration. Preauricular infections may result from Pseudomonas aeruginosa colonizing the otic canal.90 Pseudomonas infections usually respond to oral ciprofloxacin but may require incision and drainage.
In known carriers or those at risk (health care professionals) for methicillin-resistant S. aureus, nasal and ear canal cultures can be swabbed for screening.91 If present, patients can treat mucosal colonizations and skin flora with topical mupirocin ointment for 7 to 10 days and chlorhexidine soap body washes for 5 days preoperatively.92 Postoperative methicillin-resistant S. aureus infections are treated by oral trimethoprim/ sulfamethoxazole or intravenous vancomycin.
Historically, the incidence of a permanent facial nerve motor branch injury following a subcutaneous or sub-SMAS face lift is less than 1 percent.81 Transient nerve dysfunction in the first few hours postoperatively is very common and attributable to the lingering effects of local anesthetic.93 Prolonged nerve dysfunction identified days later may be attributable to traction, cautery, sutures, or surgical division.83 Spontaneous recovery is usually noted within 3 to 4 months. The most commonly injured motor branches are likely buccal; however, they often go unnoticed or are more forgiving because of the rich collateralization of the branches.24,83,93 The frontal branch and the marginal mandibular branch are less tolerant to injury because of their minimal arborization and are most likely to result in clinically significant sequelae after injury.24,94 Temporary paralysis of contralateral mimetic muscles with botulinum toxin can improve symmetry while the patient is waiting for motor nerve recovery in unilateral marginal or cervical branch palsy.
Sensory innervation of the skin flap is always disrupted following rhytidectomy; however, patients typically recover spontaneously, usually within 12 months. The most commonly injured sensory nerve is the great auricular nerve. A recognized injury should be repaired immediately intraoperatively. A painful neuroma may form after injury and/or repair, but this sequela is fortunately rare.83
Improper incision placement can lead to obvious scars, distortion of the ear, and unnatural shifting of the hairline. Excessive tension can lead to loss of hair, depigmentation, and widened scars.83,93 Incisions within the hairline should be beveled to preserve the hair follicles so that hair may grow through the incision to camouflage any scar.14
In the early postoperative period, antibiotic ointment applied daily will epithelialize wounds faster and improve scar outcomes. Widened or irregular scars can be improved with scar revision, which should be deferred to at least 6 months postoperatively, when tissues have relaxed. Hypertrophic scars can be treated with intralesional steroid injections at monthly intervals.14
The incidence of face-lift skin flap necrosis is 12.5 times greater in smokers than in nonsmokers.95 Smoking acutely induces temporary vasospasm96 and chronically stimulates permanent obliterative endarteritis.97 Consequently, smoking creates an environment of relative tissue hypoxia and delayed wound healing mediated by vasoconstriction, abnormal cellular function, and thrombogenesis.98
Patients should abstain from smoking 4 weeks before surgery and 4 weeks after surgery. Sudden withdrawal of nicotine products is often unsuccessful because of their addictive nature. A gradual transition course with nicotine gum or patch, supplemented with psychotherapeutic drugs, may be more effective for smoking cessation.7
Of note, patients typically underreport their smoking habits. Given the potential ischemic complications of smoking, surgeons may be advised to screen suspicious patients. Cotinine, the metabolic byproduct of nicotine, can be detected for up to 4 days after smoking.99 A urinary or salivary cotinine test is available for practitioners and is equally efficacious.100,101
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