Lecture 3 facial cosmetic surgery

- Rhytidectomy, or removal of wrinkles, is the
workhorse of facial rejuvenation for the cosmetic
oral maxillofacial surgeon.
- More commonly known as the “ face lift ” .
- The nomenclature surrounding these procedures
can be quite confusing, even among surgeons.
Lower Facial Third
Lower face and neck lift

- The primary goal in the rhytidectomy procedure
is to elevate and reposition the sagging or
deflated tissues of the face.
- Initially, this was performed only at the skin level
and resulted in short-lived and often poor results.

- Techniques have evolved to include treatment of
not only skin but also the underlying fascia, facial
muscles, and fat pads
- Fortunately, most of the underlying tissues can
be manipulated at the level of the superficial
musculo-aponeurotic system (SMAS).

- Many variations exist, but the
typical face lift incision involves
a component in the temporal
hair tuft that proceeds inferiorly
either anterior or posterior to
the tragal cartilage of the ear,
courses around the earlobe,
turns superiorly along the
postauricular crease, and tapers
off into the occipital hair tuft.

A- Typical face lift incision. The blue and green lines denote
a combined full lower face and neck lift versus a mini–face
lift used alone. The anterior component best treats the
lower face and jowls, whereas the posterior component
best treats the anterior neck.
B- Incision at 2 weeks after surgery. C- Incision 6 months
after surgery. These incisions may take up to a year to fully
mature and fade.

- A mini-rhytidectomy typically incorporates either
the anterior component to treat minor jowling or,
less commonly, the posterior component to treat
neck laxity.

Preoperative (A) and postoperative (B) results in a patient after full
lower face and neck lift.
- This patient also underwent an endoscopic forehead and brow lift.

- The isolated rhytidectomy has now become
uncommon and is often combined with fat
transfer to atrophic, sunken areas of the face as
well as laser or chemical resurfacing to improve
photo-aging.
- Recovery after a face lift typically requires 10 to
14 days.
- Occasionally, drains may be placed and are often
removed within the first 24 to 48 hours.

Potential complications include :-
- hematoma .

• Isolated wound healing problems .

- Fortunately, the most dreaded complications
such as permanent facial nerve injury and tissue
necrosis are exceedingly rare.

GENIOPLASTY
- One prominent feature of facial aging is loss of
jawline definition.
- This is an unavoidable change for most patients
but even more apparent in those who have an
underdeveloped mandible.

- In the setting of retrognathia (a retruded mandible)
or retrogenia or microgenia (an unusually small or
deformed chin), laxity in the lower face and neck
tend to occur earlier and with greater severity
because of the lack of skeletal support.

- Although advancement genioplasty is a popular
technique for correction of retrogenia, in some
situations an alloplastic augmentation may be
the ideal treatment.
- Alloplastic materials currently used for chin
augmentation include porous polyethylene and
solid silicone.

- Underlying bone resorption is usually cited as
a drawback to placement of a solid silicone chin
implant.

-However, with anatomically shaped implants
placed in the proper position on the mandibular
border (where the bone is very dense) and rigidly
secured to avoid micromotion, significant
resorption is quite rare.
ideal placement location for a
silicone chin implant.
many surgeons choose to fixate the
implant with a small titanium screw
or a suture.

- The implants may be placed through either an
intraoral incision or a small submental incision. -
- Typical recovery from genioplasty or alloplastic
augmentation takes approximately 1 week.

- Silicone facial implants often elicit significant
postoperative swelling that may require several
weeks to resolve fully.
- Because of their flexible nature and the collagen
encapsulation that occurs, chin implants are
usually imperceptible by the patient once fully
healed.

- Complications .
which are rare, include nerve paresthesias,
asymmetry, and displacement.

Lip augmentation or reduction
- Lip augmentation can increase the thickness and
vertical exposure of the upper or lower lip.

- However, this procedure is most commonly
performed on the upper lip to accent the perioral
region.

- Generally, the lower lip is 30% larger in vertical
dimension (i.e., vermilion to wet line) compared
with the upper lip.

Many methods for lip augmentation are available and
include implantation of synthetic materials as :-
- Human cadaveric dermis.
- Autologous fat or dermis .
- Each material has its own advantages and
disadvantages.

- The selected material is placed to plump the lip’s
central vermilion and to define the vermilion border.
Lip augmentation. Preoperative view
(A) and postoperative photo (B). Note
the increased vertical dimension of
the upper and lower lips.

- lip reduction, or cheiloplasty, is also possible.
- Excess tissue is removed from the intraoral portion
of the protuberant lip, and the lip mucosa is
undermined and sutured in a more internally
rotated position.

Neck liposuction
- Facial liposuction can be used to reduce submental
and neck fullness.

- These excessive fat deposits are typically located
superficial to the platysma.
Profile anatomic cross-section showing fat between
skin and the platysma muscle as well as fat
underneath the platysma muscle.
- Fat between skin and the platysma is removed
with liposuction,
- whereas fat under the platysma requires an
open approach for treatment.

- This can be detected by having patients tense
the platysma muscle by asking them to show
their lower teeth while grasping the neck
fullness between the thumb and forefinger
(pinch test).

- The purpose of liposuction is to remove the
underlying coalesced fatty deposits, allowing
the overlying skin to redrape over a newly
formed neckline.

- This occurs partially because of the direct
removal of fat.
- Further “shrinkage” of fat deposits occurs as a
result of circumferential scarring of the fat as a
result of instrumentation with the suction
cannula during fat removal .

- Younger patients often have facial liposuction as a single
procedure because they have good skin tone that redrapes
and adapts well.
- Older patients with skin laxity can also benefit from facial
liposuction but often also need additional face lift and
neck lift surgery to tighten the skin or a platysmal muscle
plication ( tightening by suturing techniques) to repair or
tighten a central platysmal dehiscence.

- During liposuction, the fat is removed using a
tubular cannula under vacuum suction.
A, Liposuction cannula in place through single small submental
incision. B and C, Preoperative and postoperative results in a
patient who underwent concomitant lower jaw advancement and
neck liposuction.

- After surgery, a tight pressure dressing is applied
to eliminate dead space and allow overlying skin
to adapt closely to underlying soft tissue.

- Recovery takes 7 to 10 days, but 3 to 6 months are
needed for the final results to be fully appreciated.
- This delay is caused by the gradual process of
remaining fat atrophy, remodeling, and skin
tightening.
- Potential complications include uneven contours,
infection, or marginal mandibular nerve injury
( facial nerve motor branch).

Lecture 3 facial cosmetic surgery

Lecture 3 facial cosmetic surgery

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