Chapter-44-Lamellar High SMAS Face-Lift

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Chapter 44 Lamellar High SMAS Face-Lift

■■ Regardless of how the superior margin of the flap is secured, some trimming of the posterior margin of the flap is needed to facilitate edge-to-edge approximation to the posterior flap incision as overlapping here is artisti- cally inappropriate. This should be done after the supe- rior margin of the flap is secured. ■■ Unlike the superior margin of the flap, it is counterpro- ductive to place tension on the posterior margin of the flap. Thus, the posterior margin should be trimmed con- servatively to avoid a tight closure. ■■ To provide additional support to the anterior neck and improve contour, the excess tissue along the poste- rior margin of the SMAS flap can be trimmed but left attached inferiorly to the platysma and used as a postau- ricular transposition flap (see FIG 1C ). ■■ Skin Flap Repositioning, Trimming, and Closure ■■ Skin flap repositioning should be performed with the patient’s head in a neutral position. To avoid unnatural appearances, the skin flaps must be shifted in a slightly more posterior direction than that of the SMAS. Also, it is critical to remember that the goal of skin excision is to remove redundancy and not tighten the skin flap. ■■ Cheek skin flaps should be shifted along a vector roughly perpendicular to the nasolabial fold, while neck skin should be shifted along a vector parallel to the mandibu- lar border. ■■ There are two points of skin flap suspension that set the stage for the remainder of the closure. The first point is located just above the ear where the anterior-superior most part of the ear joins the scalp. The cheek flap is shifted and the redundancy gauged with a face-lift marker ( TECH FIG 5A ). The flap should be held under just greater than normal skin tension when the mark is made and a small “T” shaped incision made into the flap at the marked point. The flap is then anchored at this point with a half-buried vertical mattress suture of 4-0 nylon with the knot on the scalp side. ■■ The second key point of suspension is in the postauric- ular area at the superior aspect of the occipitomastoid incision. The flap is shifted roughly parallel to the man- dibular border so that skin is suspended under minimal or no tension and that little or no skin needs to be trimmed from the anterior flap border that will be sutured to the postauricular incision. The flap is secured with a simple suture of 4-0 nylon; no incision into the flap is necessary. ■■ Once these two key sutures are placed, the flap overlying the inferior portion of the ear should be carefully divided and the lobule exteriorized. This is a key step and must be performed incrementally and with great care to avoid earlobe malposition. If this is done properly, the apex of the incision should sit snugly against the inferior most portion of the conchal cartilage. ■■ Skin flap trimming and incision closure should begin in the postauricular area along the auriculomastoid sulcus. Little to no skin needs to be trimmed from the ante- rior border of the postauricular flap, and the incision is

■■ Due to the increased length obtained with this transpo- sition flap, it can be sutured to the immobile mastoid fascia by creating a dynamic sling that tightens the sub- mental region when the patient looks down. This tight- ening is obtained because the mastoid moves superiorly with neck flexion pulling the flap up with it. ■■ When designing the postauricular transposition flap, the SMAS must be incised low enough so that this flap exerts its effect on the platysma below the mandibular border so as to improve submental contour. ■■ When using the postauricular transposition flap in con- junction with anterior platysmaplasty, the transposition flap should be secured after anterior platysmaplasty is completed or else it may not be possible to approximate the platysma anteriorly. closed with several interrupted sutures of 4-0 nylon. If it appears that a large amount of skin needs to be excised from this area, the flap has been shifted too far anteriorly and superiorly and should be adjusted. ■■ Next, trimming and closure of the occipital portion of the incision are performed. If the occipital incision has been made along the occipital hairline as usually most appropriate, skin will only be excised along the poste- rior border of the postauricular skin flap. It is incorrect to excise any skin over the apex of the occipitomastoid incision as this will lead to a wide scar ( TECH FIG 5B ). A face-lift marker is used to gauge redundancy, and the flap is trimmed so that closure is performed under no skin tension and the wound edges about one another before sutures are placed. Closure is then performed with mul- tiple half-buried vertical mattress sutures of 4-0 nylon and simple interrupted sutures of 6-0 nylon. ■■ The preauricular area is closed next. Skin flap redun- dancy should be carefully gauged using a face-lift marker, whereas the pretragal portion of the skin flap is held down into the pretragal hollow with an instrument by the assistant. This ensures that enough skin is present to fill the pretragal sulcus and provide natural preauricular contours. The prehelical portion of the flap is trimmed to fill in the prehelical incision without any skin tension. This is closed in one layer using interrupted 6-0 nylon or running 6-0 polypropylene. ■■ The prelobular (subtragal) portion of the cheek skin flap is trimmed next using a similar technique of marking excess with the face-lift marker and closed under no ten- sion in a single layer with several interrupted 6-0 nylon sutures. ■■ Once the prehelical and prelobular areas have been closed, the tragal flap is trimmed. As elsewhere in the preauricular closure, the tragal flap must be trimmed with slight redundancy with the assistant holding the pretragal portion of the skin flap down into the pretra- gal hollow. Trimming the tragal skin flap too short is an error that will result in tragal retraction and an unnatu- ral “chopped off” appearance. The tragal flap does not need to be thinned except at its posterior margin, and closure is done in one layer as above.

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