Chapter-44-Lamellar High SMAS Face-Lift

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Part 1 Facial Aesthetic

■■ The patient is placed supine on a warmed and well-padded operating table with special effort made to ensure that all pressure points are well protected. ■■ The patient’s lower extremities are then elevated and anti- embolic pedal compression devices applied. ■■ Each patient receives a full surgical scrub of the entire scalp, face, ears, nose, neck, shoulders, and upper chest with full- strength (1:750) benzalkonium chloride (Zephran) solution. The head is then placed through the opening of a “split sheet” leaving the entire head and neck region including the scalp unobstructed from the clavicles up. ■■ The breathing circuit is draped separately from the patient by wrapping it with a sterile sheet that allows it to move during the procedure as the patient’s head is turned from side to side. ■■ After the general prep and draping, the surface of the ear is prepped with Betadine using cotton swabs, and then Kittner “peanut” sponges are placed in each auditory meatus. Approach ■■ 0.25% bupivacaine with epinephrine 1:200 000 is used for sensory nerve blocks and for infiltrating the area marked for incision. Areas of subcutaneous dissection are infiltrated with 0.1% lidocaine with epinephrine 1:1 000 000. ■■ All incisions on the scalp or along scalp-skin interfaces must be made precisely parallel to hair follicles to avoid injury to them that can result in peri-incisional alopecia. FIG 7  • Plan for incision along the occipital hairline. An incision along the occipital hairline should be considered whenever objectionable dis- placement of the occipital hairline is predicted. This incision plan protects the hairline and prevents hairline displacement. (Courtesy of T. J. Marten, MD, FACS.)

■■ Patients are required to avoid all medications or supple- ments that increase the risk of bleeding for 2 weeks prior to surgery. ■■ All patients who smoke are asked to quit 4 weeks before their procedure and are required to avoid smoking and all secondhand smoke for 2 weeks after. Patients who smoke or have a significant history of smoking are advised in writing that their risk of serious complications is significantly higher than is that of nonsmokers. ■■ Patients are instructed no to color, “perm,” or otherwise chemically treat their hair for 2 weeks before surgery and after surgery as this can result in hair breakage and hair loss. ■■ It is important that adequate OR time be allotted for con- temporary face-lift procedures. A high SMAS face-lift, when performed in conjunction with foreheadplasty, eyelid sur- gery, fat injections, or other facial procedures, will often take up to 6 to 8 hours or more. It is strongly recommended that any surgeon new to these techniques consider stag- ing a full-face rejuvenation over 2 separate days. Typically, face-lift and neck lift are performed the first day, and the patient is then kept overnight and then returned to the OR the following day or a few days later for the remainder of the procedures. Positioning ■■ The majority of our face-lifts are performed under deep sedation administered by an anesthesiologist using a laryn- geal mask airway (LMA). FIG 5  • Assessing “temporal skin show.” The distance between the lat- eral orbit and the temple hairline and how it will change with skin flap shift must be considered when planning the temple portion of the face- lift incision.

A B FIG 6  • A. Plan for incision on the temporal scalp. This plan is used for patients predicted to have minimal or modest shift of sideburn and temple hair after elevation of the cheek flap. It will not be appropriate for all patients. B. Plan for incision along the temporal hairline. An incision along the temporal hairline should be considered whenever objectionable displacement of the sideburn and temple hair is predicted.