Chapter-44-Lamellar High SMAS Face-Lift

T E C H N I Q U E S 220 Part 1 Facial Aesthetic ■■

and the flap is easier to dissect; however, care should be taken to remain in a subcutaneous plane. Compared to the cheek skin flap that must be kept thin, a thicker layer of fat can be kept on the undersurface of the cervical flap. However, the majority of preplatysmal fat should be kept on the platysmal surface as this makes fat sculpting easier later in the procedure. ■■ If a submental incision is planned, completing dissec- tion of the anterior neck skin flap will be more easily performed through it rather than the postauricular inci- sions. (For planning the submental incision, see “Neck Lift” chapter). ■■ The neck should be undermined completely in most cases, but it should not arbitrarily include the entire face ( TECH FIG 1C ). Preservation of the anterior pla- tysma-cutaneous ligaments will create attractive and youthful appearing elevation of perioral tissue that cannot be obtained with wide undermining. If these platysma-cutaneous ligaments are divided in the perioral cheek, the SMAS effect on this area will be negated, and the benefit of SMAS elevation will be lost. of the facial nerve lies anterior and inferior to this vessel and is safe. ■■ This method of dissection promotes the two planes of dissection to be joined to improve exposure. ■■ When an incision along the temporal portion of the anterior hairline is indicated, it is made a few millime- ters within it with a slight bevel or parallel to the hair follicles. ■■ The incision should be made no higher than the junction of the temporal hairline with the frontotemporal hair- line. If carried any higher, the scar can be visible as hair tends to grow posteriorly in this area. ■■ After the incision is made along the hairline, the skin flap is raised in the subcutaneous plane connecting with the cheek skin flap dissection, and no transition between planes is necessary ( TECH FIG 2B ).

Some visual clues can be helpful in determining the proper plane for dissection. This will require proper lighting and transillumination of skin flaps. If dissection is too deep, the underside of the flap will appear smooth and cloudy when transilluminated. If dissection is in the proper plane, however, transilluminated flaps will have a rough, “pebbled,” or “cobblestone” appearance ( TECH FIG 1B ). ■■ Postauricular skin flap undermining is most easily begun inferiorly if the occipital incision is made along the occip- ital hairline as more subcutaneous fat is usually present and the proper plane is easier to identify compared to more superiorly where less subcutaneous fat is present and the skin and fascia lie in close proximity. Once the proper plane is established, two large double-pronged skin hooks are placed by the assistant, and the dissection continues posterior to anterior rather than superior to inferior. ■■ As the dissection progresses toward the upper lateral neck, care must be taken to avoid injury to the greater auricular nerve. ■■ As dissection is continued further anteriorly into the cer- vical region, subcutaneous fat becomes more abundant, ■■ The temple incision is made either on the temporal scalp or along the anterior hairline based on the preoperative plan. ■■ When on the temporal scalp, the incision is taken down to the deep temporal fascia, and the temporal hair-bear- ing flap is undermined in the subgaleal plane anteriorly to the lateral brow, inferiorly to the mid temple, and superiorly to the temporal line. ■■ The bridge of fascia (mesotemporalis) between the deep dissection in the temple and the subcutaneous dissec- tion in the cheek can be partially divided posterior to the temporal hairline ( TECH FIG 2A ). Usually, this bridge of tissue contains the anterior branch of the superficial temporal artery and must be ligated. The frontal branch ■■ Temple Dissection

TECH FIG 2  • A. Dividing the mesotemporalis. The bridge of tissue situated between the subfascial (subgaleal) dissection in the temple and the subcutaneous dissection in the cheek can safely be divided posterior to the course of the frontal branch of the facial nerve ( white dotted line ). This bridge of tissue usually contains the anterior branch of the superficial temporal artery which must be divided and cauterized or ligated ( black arrows ). B. Flap dissection with hairline incision. When an incision along the temporal hairline is used, all dissection will be in a subcuta- neous plane, no transition between planes will be necessary, and the superficial temporal vessels are left undisturbed, beneath the superficial temporal fascia.