Chapter-44-Lamellar High SMAS Face-Lift

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Chapter 44 Lamellar High SMAS Face-Lift

■■ The prehelical portion of the preauricular incision should be made as a soft curve paralleling the curve of the anterior border of the helix. As the tragus is approached, the incision is carried into the depression superior to it. ■■ Next, the incision is carried precisely along the posterior margin of the tragus in a retrotragal position. This location provides for the best option for avoiding a color or texture mismatch in the preauricular skin and the best concealment of the scar.

■■ At the inferior portion of the tragus, the incision must turn anteriorly and then again inferiorly into the crease between the anterior lobule and cheek. This creates a distinct inferior tragal border. ■■ The incision will then continue around the lobule and then precisely within the auriculomastoid crease. The occipital and temple portions of the incision are made according to the preoperative plan (see above).

T E C H N I Q U E S

■■ Skin Flap Elevation

■■ Proper assistance will require two team members scrubbed with the surgeon. One team member will need to be committed to providing retraction, while a second member is needed to manage all tasks related to passing of instruments. ■■ The assistant must be taught to not apply excessive force on delicate skin flaps, and the surgeon must avoid retracting for herself or himself as this invariably leads to rough handling of the flap. ■■ Skin flaps should be elevated sharply under direct vision and blind dissections avoided. This is especially important in the preauricular area and over the cheek where a deep dissection can injure the underlying superficial musculoaponeurotic system (SMAS) and compromise its use as a flap. However, dissection too close to the posterior surface of the skin flap can result in injury to the subdermal microcirculation.

■■ Cheek flap dissection is begun using Adson forceps and a small Kaye scissors or scalpel grasping only tissue edges that will later be excised. Once the edge is elevated, gentle traction is applied by the assistant with double- pronged skin hooks. ■■ Dissection is then carried out using mediumMetzenbaum scissors with the surgeon and assistant working together using a “four-handed” technique ( TECH FIG 1A ): ■■ The assistant applies gentle skin traction upon the skin flap directed toward the surgeon with one double- pronged skin hook in each hand, while the surgeon dis- sects and provides gentle countertraction toward the assistant with the fingertips of the nondominant hand. ■■ As the dissection advances, one skin hook is exchanged for a small Deavor malleable-type retractor, and the remain- ing skin hook is used to drape the flap over the retractor.

TECH FIG 1  • “Four-handed” technique. A. The assistant applies gentle traction upon the skin flap toward the surgeon with two large double-pronged skin hooks with one retractor held in each hand. The surgeon then dissects while providing gentle countertraction toward the assistant with the fingertips of the opposite hand. B. Appearance of a transilluminated skin flap in the cheek. If dissection is in the proper plane as in this case, the undersurface of the flap will have a rough, “cobblestone” appearance to the fat. C. Extent of subcutaneous undermining. Shaded area shows area of subcutaneous undermining. Note that the platysma-cutaneous ligaments ( black dots ) are not undermined and are preserved. Preservation of platysma-cutaneous ligaments and proper elevation and fixation of the SMAS will provide support of lateral perioral tissues. C