Lower Face and Neck Rejuvenation
During preoperative evaluation, the face and neck should be considered as a single cosmetic unit. Correction of the cosmetic subunits of the upper face and midface without addressing the lower face and neck can create an unbalanced appearance. At the very least, these concerns must be discussed with the patient preoperatively, along with surgical options.
Figure 13-4 Endoscopic approach to subperiosteal midface-lift. A, Undermining between the temporoparietal fascia and the deep temporal fascia to approach the anterior face of the maxilla. B, Midface subperiosteal dissection and suture fixation.
(Illustration by Christine Gralapp.)
The most commonly performed procedures include the vintage (subcutaneous) rhytidectomy, the rhytidectomy with superficial elevation and refixation of the superficial musculo-aponeurotic system (SMAS) (Fig 13-5), and the deep-plane rhytidectomy. Rhytidectomies typically include surgical management of the jowls and neck, including liposuction with or without platysmaplasty (Fig 13-6). The 3 rhytidectomy procedures mentioned differ mainly in the location and extent of dissection. Although the more superficial procedures are less likely to cause facial nerve damage, they may produce shorter-lasting results. The more extensive procedures have greater risks (eg, facial nerve injury), but the likelihood that they will produce dramatic, longer-lasting improvement is also greater.
Figure 13-5 The common goal of rhytidectomy procedures is modification of the superficial musculoaponeurotic system (SMAS) that translates to changes in the overlying anatomy. After release of the SMAS (dotted line), the SMAS is pulled laterally and superiorly for elevation of the jowls and lower face.
(Illustration by Christine Gralapp.)
Complications of rhytidectomy are directly related to the extent of subcutaneous undermining; they include hematoma, seroma, skin necrosis, hair loss, paresthesias, motor deficits, incisional scarring, asymmetry, earlobe distraction (pixie-ear deformity), and contour irregularities. Hematoma is the leading surgical face-lift complication, but patient dissatisfaction may be the most common issue postoperatively.
Neck liposuction enhances the neckline and is often done in conjunction with other cosmetic procedures. Stab incisions, or adits, are made just posterior to the earlobe on each side and along the submental incision line; if liposuction is performed as a stand-alone procedure, they are made just anterior to the submental crease. Small liposuction cannulas are used for fat removal. A layer of fat is left on the dermis, and the liposuction cannula openings are always oriented away from the dermis to avoid injury to the vascular plexus deep to the dermis. In addition to abnormalities in skin quality, damage in this area can lead to unsightly scarring of the dermis of the underlying neck musculature. The adits are left open or sutured, and a compression bandage is worn for 1 week after the procedure.
Figure 13-6 Photographs of a patient who underwent rhytidectomy with submental liposuction. A, Images taken prior to surgery. B, Images taken after the procedure. Note the improvement in the jowls and sharpening of the cervicomental angle.
(Courtesy of Robert G. Fante, MD.)
Figure 13-7 Cervicoplasty. A, Undermining of the skin. B, Platysmaplasty.
(Illustrations by Christine Gralapp.)
Platysmaplasty is performed to correct platysmal bands and is typically done in conjunction with a lower face-lift. A subcutaneous dissection is carried out in the preplatysmal plane centrally under the chin to the level of the thyroid cartilage (Fig 13-7A). Lateral platysmal undermining and suspension may be performed as part of a rhytidectomy. Midline platysma resection and reconstruction (Fig 13-7B) are performed if midline neck support is needed. A drain and a light compression dressing are placed. Postoperatively, the cervicomental angle is more acute, yielding a more youthful look.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.