Chapter-44-Lamellar High SMAS Face-Lift

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Chapter 44 Lamellar High SMAS Face-Lift

PEARLS AND PITFALLS Incision planning

■■ Proper analysis, careful planning, and the use of an incision along the hairline when indicated can avert hairline notching and displacement without compromising the overall outcome. ■■ This is particularly true of patients with marked skin redundancy and those presenting for secondary problems. ■■ Skin was not meant to support sagging tissues, only redundant tissue is removed, and closure must be made under normal skin tension. ■■ Planning the SMAS flap “high” over the zygomatic arch provides an improvement to the midface in addition to the jawline. ■■ Key zygomatic and masseteric cutaneous ligaments must be released, but the endpoint of the dissection is clinical and not anatomic. ■■ A lamellar dissection allows the SMAS to be suspended in a more superior vector compared to the skin. ■■ Inappropriate excision of the skin over the apex of the occipitomastoid defect is the cause of hypertrophic healing in the postauricular area.

Skin tension

SMAS design

SMAS elevation

SMAS suspension

Skin trimming

POSTOPERATIVE CARE

■■ Patients are asked to set aside 2 to 3 weeks to recover from surgery. If the patient is doing well, they can return to light office work and casual social activity 9 to 10 days after sur- gery. Patients are advised to avoid all strenuous activity dur- ing the first 2 weeks after surgery. Two to three weeks after surgery, they are allowed to begin light exercise and gradu- ally work up their activity as tolerated by 6 weeks. ■■ Patients are informed that it will often take 2 to 3 months to look good in a photo or to be seen at an important social function.

■■ Most patients are discharged to an aftercare specialist for the first night with specific instructions. Patients are asked to rest quietly and apply ice compresses to their eyes for 15 to 20 minutes every hour they are awake for the first 3 days. ■■ All patients are provided oral analgesics, sleeping pills, anti- emetics, ophthalmic ointment, and eye drops. ■■ All patients are instructed to sleep flat on their backs with- out a pillow or with a small cylindrical neck roll. This pos- ture assures an open cervicomental angle and averts folding of the neck skin flap. Patients are also shown an “elbow on knees” position to ensure an open cervicomental angle while sitting. ■■ Patients begin a daily routine of showering and shampooing no later than 3 days after their procedure to help remove crusting at suture lines, keep bacteria count down, and improve overall well-being. Patients should be warned that their scalp and parts of their face may be partially numb and should be careful when showering that water is not too hot and that hairdryers are not on high settings. ■■ Drains are usually left in the neck until the first postopera- tive visit 4 to 5 days after surgery. Sutures are removed in two visits over a period of 7 days.

OUTCOMES

■■ See FIGS 8 to 10

COMPLICATIONS

■■ The most common complication is a hematoma. The inci- dence ranges from 2% to as high as 10%. The incidence is higher in men and patients with a history of hypertension. Preoperative measures to reduce the risk include control of blood pressure and avoidance of medications and supplements that may affect bleeding. Intraoperative maneuvers include close cooperation with the anesthesiologist to rigorously control blood pressure along with meticulous hemostasis.

FIG 8  • A. AP view. On the left, preoperative view of a woman, age 65. She has had previous upper and lower eyelifts performed by another surgeon. Note midface, cheek, and jawline laxity and poor transition from lower eyelid to malar area. On the right, same patient, 13 months after high SMAS face- lift, neck lift, hairline lowering forehead lift, upper and lower eyelifts, perioral dermabrasion, and fat transfer to the cheeks and lips. No skin resurfacing, facial implants, or other ancillary procedures were performed. The midface, cheek, and jowl have been repositioned harmoniously and in a uniform and balanced manner. Note smooth facial contours, more youthful facial shape, and absence of a pulled or a “face-lifted” appearance. B. AP view smiling. On the left, preoperative view of a woman, age 65. She has had previous upper and lower eyelifts performed by another surgeon. Note that but improvement along the jawline can be seen when the patient smiles, but midface ptosis and cheek laxity are accentuated. On the right, same patient, 13 months after high SMAS face-lift, neck lift, hairline lowering forehead lift, upper and lower eyelifts, perioral dermabrasion, and fat transfer to the cheeks and lips. The midface, cheek, and jowl have been repositioned harmoniously and in a uniform and balanced manner. Note soft, natural facial contours and the absence of a tight, pulled, or “face-lifted” appearance.