Combined Rhytidectomy and Alloplastic Facial Implants Daniel Schwartz, MD, DMD, Faisal A. Quereshy, MD, DDS* KEYWORDS Rhytidectomy Alloplastic Facial implants Combined KEY POINTS Volume restoration is an important aspect of facial rejuvenation. Rhytidectomy techniques vary but must always address the patient’s concerns, offer acceptable downtime, and be a safe and efficient option in the hands of the operating surgeon. Combining volume restoration with rhytidectomy can offer a superb result, which individual procedures may be unable to achieve. Many complications of rhytidectomy and alloplastic facial implants are easily avoided with patient selection, proper preoperative discussion and documentation, and meticulous surgical technique.
Introduction From as early as the late nineteenth century, patients have sought the advice and expertise of surgeons to address undesirable changes of the aging face. Rhytids, being one of the major concerns, were initially treated by simple excision and stretching of skin. However, this method proved to be ineffective, because it left patients with unsightly scars and led to recurrence of wrinkles.1 It was not until the late 1960s that Tord Skoog, a Swedish surgeon, introduced the idea of a deeper dissection, allowing for suspension of subcutaneous tissues rather than merely relying on the suspension of skin alone.2 This concept was further explored and developed by Mitz and Peyronie, who described the superficial muscular aponeurotic system (SMAS).3 SMAS plication and imbrication along with deeper plane dissections have since been the accepted methods of rhytidectomy. Although these techniques have greatly improved aesthetic outcomes and success of face-lift procedures, they do have their shortcomings. Rhytidectomy alone can achieve elimination or minimization of wrinkles and can address sagging tissues of the face; however, the goal of a more youthful face is difficult to attain without addressing facial volume loss. The general concept of removing tissue such as excess skin and fat, as is routine in traditional rhytidectomy, left many patients with a hollowed, and perhaps more aged, appearance. These results led to a paradigm shift in the treatment of the aging face. The idea of adding volume in desired amounts and
Disclosure: The authors have nothing to disclose. Oral & Maxillofacial Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 2124 Cornell Road, Cleveland, OH 44106, USA * Corresponding author. E-mail address: [email protected] Atlas Oral Maxillofacial Surg Clin N Am 22 (2014) 69–73 1061-3315/14/$ - see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cxom.2013.11.002
locations instead of only resuspension of soft tissues quickly became an important tenet of facial rejuvenation. In addition to, and in conjunction with, autologous materials, alloplastic facial implants have been more widely used to restore lost volume. These procedures are successfully used as both a stand-alone therapy to treat volume loss and as combined therapy with rhytidectomy for a more comprehensive and effective approach to the treatment of the aging face.4 In this article, the basic principles and methods of each procedure are outlined individually, and then their use together as a combined therapy is discussed.
Rhytidectomy The face-lift procedure is one that has evolved since its beginnings and continues to be modified and reinvented. There are multiple accepted techniques, and each surgeon has preferences based on specific circumstance and experience. Minimally invasive lifts offer the obvious advantage of limited downtime; however, they often sacrifice longevity of the effects of the procedure. Deep plane or subperiosteal face-lifts have been argued to result in a more natural appearance, but they introduce greater risk of facial nerve damage. The traditional or SMAS face-lift is probably the most widely used technique; it generally offers acceptable downtime for the patient and produces a desirable and lasting outcome.5 This article focuses on the SMAS face-lift technique, its basic principles, and how it can be used together with facial implants for a superb aesthetic result. When considering rhytidectomy, patient selection is of the utmost importance. When a patient presents for initial consultation, the surgeon must gain a clear understanding of the patient’s desires and expectations. Similarly, the patient must be educated by the surgeon as to what the possibilities, limitations, and realistic expectations of the procedure are. This mutual understanding can eliminate most complications
oralmaxsurgeryatlas.theclinics.com
70
Schwartz & Quereshy
involving unsatisfactory cosmetic results. The medical condition of the patient that is required for elective surgery is not discussed; however, there are considerations for rhytidectomy patients that should be mentioned. Cessation of smoking is imperative, because it can significantly compromise blood supply to the flap, which may lead to necrosis. Bleeding disorders or anticoagulating medications place the patient at increased risk for hematoma formation, which also may lead to flap necrosis or infection. Any other factors that may contribute to delayed or poor wound healing, such as steroids, immunosuppressants, uncontrolled diabetes, must be addressed before surgery.6 Appropriate photographic documentation is also an important part of the presurgical evaluation and should be completed for any patient undergoing rhytidectomy. This documentation allows for thorough evaluation of the patient’s facial features, thereby assisting in preoperative planning. It can also help the surgeon, together with the patient, identify specific areas of concern or interest. To ensure that the patient has undergone all necessary evaluation and preparation, a presurgical visit is recommended. On the day of the procedure, the skin is marked to delineate both the incision design and the extent of anticipated undermining. The patient should be marked while sitting upright and before the administration of any local anesthetic.7 Many facelift incision designs have been described, most of which consist of some variation involving starting in the temporal hairline, following the preauricular crease, and following the hairline posteriorly. There are some specific considerations when the patient is male, because of sideburn hairlines (Figs. 1 and 2). Anesthetic technique can range from only local injection of the incision lines to general anesthesia. Often, the area of the incision is injected using 2% lidocaine with 1:100,000 epinephrine. A tumescent solution containing epinephrine is usually used for hydrodissection and hemostasis of the appropriate plane. In appropriate cases, plication of the platysma edges can be performed through a submental incision to treat banding. This procedure complements the face-lift procedure well and should be addressed in the preoperative discussions. If this procedure is planned, the area should be anesthetized as well. Once the patient is adequately anesthetized, a subcutaneous plane is developed along the incision lines. Care should be taken to keep the incision parallel to the hair follicles to avoid potential damage and alopecia. The skin flap should have adequate subdermal fat intact to provide adequate blood supply, thereby helping to prevent ischemic injury. Three to
Fig. 1
Example of preoperative marking in female patient.
Fig. 2
Example of preoperative marking in male patient.
4 mm thick subdermal fat usually accomplishes this objective. The plane of dissection should also not be carried medially past a line halfway between the lateral canthus and the ear.7,8 An important consideration in the temporal area of dissection is the frontal branch of the facial nerve. It can be found just above the superficial temporal fascia. In addition, this layer contains the superficial temporal artery. The surgeon should be sure to keep the dissection superficial to this layer to avoid damage.9 When carrying the dissection inferiorly below the ear, great caution must be taken to keep the great auricular nerve intact. This is the most commonly injured nerve in rhytidectomy procedures. It travels over the middle of the sternocleidomastoid muscle 6.5 cm inferior to the bony external auditory canal in the plane just superficial to the sternocleidomastoid.10 It is imperative that the plane of dissection be kept to the subcutaneous layer in this region, because carrying it any deeper puts the great auricular nerve at risk. Once the dissection is complete, SMAS plication or imbrication can be used to achieve the desired result. With plication, the SMAS is pulled and then folded back down on to itself using suture. To achieve a good result, 3 key areas need to be addressed, including the jowls, the nasolabial fold, and the cheek area or nasojugal fold (Fig. 3). Imbrication consists of excising a portion of the SMAS and then reapproximating it to
Fig. 3
Plication using suture to secure the SMAS to itself.
Rhytidectomy and Alloplastic Facial Implants itself in order to tighten the layer. The safe zone for this excision lies between the zygomatic arch and the angle of the mandible. It is important to remain in this anatomic area where the facial nerve is located deep to the SMAS. After either plication or imbrication is used to address the targeted areas, the overlying skin can be redraped. Before the skin can be trimmed, it must be draped in a superior and posterior direction, with little tension. The flap should then be sutured or stapled both directly above the ear and at the most superior part of the flap in the postauricular portion. Once these areas are secured and the appropriate vectors visualized, the excess skin can be cut away, leaving smooth edges to be well approximated. The incision can then be closed according to the surgeon’s preference. In the postoperative period, the patient should be given adequate instructions for home care and what to expect. Important instructions include keeping the incisions clean and free of debris or scabbing. This goal can be achieved by using a cotton tip applicator to dab the area with a peroxide and normal saline mixture. The incisions should then be covered with a layer of bacitracin ointment. In addition, the patient must be made aware that they should immediately contact the surgeon if there is sudden and excessive bleeding, discharge from incisions, fever, or injury to the face. Postoperative complications to be particularly aware of include hematoma, infection, nerve injury (specifically to the great auricular and branches of the facial nerve), and flap necrosis. The surgeon must address them appropriately and in a timely fashion to avoid serious medical and cosmetic sequelae.
Alloplastic facial implants Alloplastic facial implants have been successfully used to address congenital deficiencies or asymmetries and volume loss caused by aging. Although both of these indications are important when discussing general facial cosmesis, this article focuses mainly on implants as they pertain to the restoration of volume loss caused by facial aging.
Fig. 5
71
Fig. 4 Evaluating placement of a chin implant through a submental incision.
Although rhytidectomy can provide a great deal of cosmetic improvement, in the aging patient, there is often a need for volume restoration as well. Much like the skin that overlies it, the fat that gives the face its youthful appearance tends to change over time as a result of both gravity and atrophy of the tissues. Any underlying skeletal deficiencies may also become more apparent, particularly in the cheek and chin areas. Although alloplastic implants have been used in many areas of the face, cheek and chin implants are the most commonly used, especially in the setting of more complex facial rejuvenation treatment plans.11 Many materials have been used for alloplastic facial implants over the years. Most implant materials have been shown to be nontoxic and noncarcinogenic12; however, there is a great deal of variability in their malleability, mobility, pricing, and so on. Some implants are fixated in place with either sutures or screws, whereas others rely on the dissected pocket and contouring for immobilization. Each surgeon has their preference, but it seems that the most popular materials include silastic and polytetrafluoroethylene.11,13 Because
Preoperative (left) and postoperative (right) profile of chin implant patient.
72
Schwartz & Quereshy
Fig. 6
Malar implant through transoral approach.
these implants do not resorb or reform, it is of the utmost importance that the surgeon be specific in the shape and size of the implant that is selected for placement. As with rhytidectomy, one of the most important factors that determines the outcome of the procedure is patient selection. The surgeon must be mindful of both the patient’s desires and expectations, along with the limitations of the procedure, and the materials. The mental prominence, or chin area, can often be a source of concern for patients both in the setting of aging and in skeletal deficiencies. Shape of the implant in this case is particularly important. Depending on the shape of the patient’s mandible and jowl area, an implant that is too small may create an unnatural step where the implant ends. Shapes are available that more softly fade as they extend laterally into the prejowl and jowl areas. Once the appropriate implant is chosen, appropriate local anesthetic is administered via bilateral inferior alveolar nerve blocks. The area in which the implant is to be placed should also be hydrodissected with local anesthetic. Either an intraoral or a submental approach can be used (Fig. 4). In both settings, it is important that the dissection stays on bone in a subperiosteal plane. Care should be
Fig. 7
taken not to injure the mental nerves during dissection or during placement of the implant. If, when the implant is tried in place, it is apparent that it will impinge on the mental nerves, the implant can be relieved before final placement (Fig. 5).13 When placing malar implants, 1 of 2 approaches is generally used to access the appropriate subperiosteal plane. One is the subciliary incision and the other an intraoral approach in the maxillary vestibule above the canine (Fig. 6). A diluted tumescent solution including local anesthesia and epinephrine should be deposited into the subperiosteal plane. This procedure helps with both hemostasis and hydrodissection of the proposed implant site. With either incision, the dissection is carried down to bone, with special care taken to avoid damage to the infraorbital nerve. When undermining the area, it is important that the subperiosteal pocket be made large enough to house the proposed implant. On the other hand, if the pocket is too large, there is increased risk of the implant becoming mobile.14 Complications with this procedure are uncommon. They include infection, malposition of implants, damage to infraorbital or mental nerves, and hematoma. As with rhytidectomy, an unsatisfactory result can often be avoided by ensuring that proper patient education and open communication are a priority.
Considerations for combined procedure Both the rhytidectomy and alloplastic facial implant procedures are staples in the armamentarium of the cosmetic surgeon when it comes to facial rejuvenation. Although both procedures have their own indications, it is important to be able to see the big picture to ensure that all aspects of the aging face are addressed. When combining both procedures, in the appropriate patient, a synergistic effect can be achieved, because each therapy enhances the other (Fig. 7). The technique, for the most part, is unchanged when implants are placed at the time of rhytidectomy. However, there are a few
Preoperative (left) and postoperative (right) of combined rhytidectomy and malar implant patient.
Rhytidectomy and Alloplastic Facial Implants important considerations that the surgeon must keep in mind to optimize both procedures. The placement of the implants should be completed before redraping of the skin flap from the rhytidectomy. If not performed in this sequence, there is risk for having an overtightened appearance caused by the addition of volume under the newly suspended facial tissues. More importantly, this added tension can compromise the skin flap and lead to possible complications. More than 1 approach has been discussed for placement of implants, but we prefer to place implants through a transoral approach when being performed with rhytidectomy. This strategy helps to avoid changes in tension lines on the skin after manipulation.
Summary It is the responsibility of the cosmetic surgeon to offer the best treatment options to patients. Rhytidectomy and alloplastic implants are 2 procedures that together can provide a more comprehensive enhancement of the aging face. Consideration of these combined techniques and others when devising surgical plans can be the difference between simply acceptable results and those that are outstanding.
References 1. Rogers BO. The development of aesthetic plastic surgery: a history. Aesthetic Plast Surg 1976;1:3e24. 2. Skoog T. Useful techniques in face lifting. Presented at the meeting of the American Association of Plastic Surgeons. San Francisco, April 1969.
73 3. Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976; 58:80. 4. Binder WJ. Facial rejuvenation and volumization using implants. Facial Plast Surg 2011;27(1):86e97. 5. Lihong R, Daping Y, Zhibo X, et al. Longevity of SMAS facial rejuvenation and support. Plast Reconstr Surg 2011;127(2):989e90. 6. Ho T, Brissett AE. Preoperative assessment of the aging patient. Facial Plast Surg 2006;22(2):85e90. 7. Myint AS. Standard facelifting. In: Erian A, Shiffman MA, editors. Advanced surgical facial rejuvenation, art and clinical practice. Berlin: Springer; 2012. p. 329e34. 8. Ghali GE, William Evans T. Rhytidectomy. In: Miloro M, editor. Peterson’s principles of oral and maxillofacial surgery. London: Hamilton; 2004. p. 1365e81. 9. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variation and pitfalls. Plast Reconstr Surg 1979;64: 781e95. 10. McKinney P, Katrana DJ. Prevention of injury to the greater auricular nerve during rhytidectomy. Plast Reconstr Surg 1980;66: 675e9. 11. Glasgold RA, Lam SM, Glasgold MJ, et al. Solid implants: mentoplasty and malar augmentation. In: Shiffman MA, Mirrafati S, Lam SM, et al, editors. Simplified facial rejuvenation. Berlin: Springer; 2008. p. 237e43. 12. Yaremchuk MJ, Rubin JP, Posnick JC, et al. Implantable materials in facial aesthetic and reconstructive surgery: biocompatibility and clinical application. J Craniofac Surg 1996;7:473e84. 13. Epker BN. Alloplastic esthetic facial augmentation. In: Miloro M, editor. Peterson’s principles of oral and maxillofacial surgery. London: Hamilton; 2004. p. 1435e47. 14. Terino EO, Edward M. The magic of mid-face three-dimensional contour alterations combining alloplastic and soft tissue suspension technologies. Clin Plast Surg 2008;35(3):419e50.
Introduction From as early as the late nineteenth century, patients have sought the advice and expertise of surgeons to address undesirable changes of the aging face. Rhytids, being one of the major concerns, were initially treated by simple excision and stretching of skin. However, this method proved to be ineffective, because it left patients with unsightly scars and led to recurrence of wrinkles.1 It was not until the late 1960s that Tord Skoog, a Swedish surgeon, introduced the idea of a deeper dissection, allowing for suspension of subcutaneous tissues rather than merely relying on the suspension of skin alone.2 This concept was further explored and developed by Mitz and Peyronie, who described the superficial muscular aponeurotic system (SMAS).3 SMAS plication and imbrication along with deeper plane dissections have since been the accepted methods of rhytidectomy. Although these techniques have greatly improved aesthetic outcomes and success of face-lift procedures, they do have their shortcomings. Rhytidectomy alone can achieve elimination or minimization of wrinkles and can address sagging tissues of the face; however, the goal of a more youthful face is difficult to attain without addressing facial volume loss. The general concept of removing tissue such as excess skin and fat, as is routine in traditional rhytidectomy, left many patients with a hollowed, and perhaps more aged, appearance. These results led to a paradigm shift in the treatment of the aging face. The idea of adding volume in desired amounts and
Disclosure: The authors have nothing to disclose. Oral & Maxillofacial Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 2124 Cornell Road, Cleveland, OH 44106, USA * Corresponding author. E-mail address: [email protected] Atlas Oral Maxillofacial Surg Clin N Am 22 (2014) 69–73 1061-3315/14/$ - see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cxom.2013.11.002
locations instead of only resuspension of soft tissues quickly became an important tenet of facial rejuvenation. In addition to, and in conjunction with, autologous materials, alloplastic facial implants have been more widely used to restore lost volume. These procedures are successfully used as both a stand-alone therapy to treat volume loss and as combined therapy with rhytidectomy for a more comprehensive and effective approach to the treatment of the aging face.4 In this article, the basic principles and methods of each procedure are outlined individually, and then their use together as a combined therapy is discussed.
Rhytidectomy The face-lift procedure is one that has evolved since its beginnings and continues to be modified and reinvented. There are multiple accepted techniques, and each surgeon has preferences based on specific circumstance and experience. Minimally invasive lifts offer the obvious advantage of limited downtime; however, they often sacrifice longevity of the effects of the procedure. Deep plane or subperiosteal face-lifts have been argued to result in a more natural appearance, but they introduce greater risk of facial nerve damage. The traditional or SMAS face-lift is probably the most widely used technique; it generally offers acceptable downtime for the patient and produces a desirable and lasting outcome.5 This article focuses on the SMAS face-lift technique, its basic principles, and how it can be used together with facial implants for a superb aesthetic result. When considering rhytidectomy, patient selection is of the utmost importance. When a patient presents for initial consultation, the surgeon must gain a clear understanding of the patient’s desires and expectations. Similarly, the patient must be educated by the surgeon as to what the possibilities, limitations, and realistic expectations of the procedure are. This mutual understanding can eliminate most complications
oralmaxsurgeryatlas.theclinics.com
70
Schwartz & Quereshy
involving unsatisfactory cosmetic results. The medical condition of the patient that is required for elective surgery is not discussed; however, there are considerations for rhytidectomy patients that should be mentioned. Cessation of smoking is imperative, because it can significantly compromise blood supply to the flap, which may lead to necrosis. Bleeding disorders or anticoagulating medications place the patient at increased risk for hematoma formation, which also may lead to flap necrosis or infection. Any other factors that may contribute to delayed or poor wound healing, such as steroids, immunosuppressants, uncontrolled diabetes, must be addressed before surgery.6 Appropriate photographic documentation is also an important part of the presurgical evaluation and should be completed for any patient undergoing rhytidectomy. This documentation allows for thorough evaluation of the patient’s facial features, thereby assisting in preoperative planning. It can also help the surgeon, together with the patient, identify specific areas of concern or interest. To ensure that the patient has undergone all necessary evaluation and preparation, a presurgical visit is recommended. On the day of the procedure, the skin is marked to delineate both the incision design and the extent of anticipated undermining. The patient should be marked while sitting upright and before the administration of any local anesthetic.7 Many facelift incision designs have been described, most of which consist of some variation involving starting in the temporal hairline, following the preauricular crease, and following the hairline posteriorly. There are some specific considerations when the patient is male, because of sideburn hairlines (Figs. 1 and 2). Anesthetic technique can range from only local injection of the incision lines to general anesthesia. Often, the area of the incision is injected using 2% lidocaine with 1:100,000 epinephrine. A tumescent solution containing epinephrine is usually used for hydrodissection and hemostasis of the appropriate plane. In appropriate cases, plication of the platysma edges can be performed through a submental incision to treat banding. This procedure complements the face-lift procedure well and should be addressed in the preoperative discussions. If this procedure is planned, the area should be anesthetized as well. Once the patient is adequately anesthetized, a subcutaneous plane is developed along the incision lines. Care should be taken to keep the incision parallel to the hair follicles to avoid potential damage and alopecia. The skin flap should have adequate subdermal fat intact to provide adequate blood supply, thereby helping to prevent ischemic injury. Three to
Fig. 1
Example of preoperative marking in female patient.
Fig. 2
Example of preoperative marking in male patient.
4 mm thick subdermal fat usually accomplishes this objective. The plane of dissection should also not be carried medially past a line halfway between the lateral canthus and the ear.7,8 An important consideration in the temporal area of dissection is the frontal branch of the facial nerve. It can be found just above the superficial temporal fascia. In addition, this layer contains the superficial temporal artery. The surgeon should be sure to keep the dissection superficial to this layer to avoid damage.9 When carrying the dissection inferiorly below the ear, great caution must be taken to keep the great auricular nerve intact. This is the most commonly injured nerve in rhytidectomy procedures. It travels over the middle of the sternocleidomastoid muscle 6.5 cm inferior to the bony external auditory canal in the plane just superficial to the sternocleidomastoid.10 It is imperative that the plane of dissection be kept to the subcutaneous layer in this region, because carrying it any deeper puts the great auricular nerve at risk. Once the dissection is complete, SMAS plication or imbrication can be used to achieve the desired result. With plication, the SMAS is pulled and then folded back down on to itself using suture. To achieve a good result, 3 key areas need to be addressed, including the jowls, the nasolabial fold, and the cheek area or nasojugal fold (Fig. 3). Imbrication consists of excising a portion of the SMAS and then reapproximating it to
Fig. 3
Plication using suture to secure the SMAS to itself.
Rhytidectomy and Alloplastic Facial Implants itself in order to tighten the layer. The safe zone for this excision lies between the zygomatic arch and the angle of the mandible. It is important to remain in this anatomic area where the facial nerve is located deep to the SMAS. After either plication or imbrication is used to address the targeted areas, the overlying skin can be redraped. Before the skin can be trimmed, it must be draped in a superior and posterior direction, with little tension. The flap should then be sutured or stapled both directly above the ear and at the most superior part of the flap in the postauricular portion. Once these areas are secured and the appropriate vectors visualized, the excess skin can be cut away, leaving smooth edges to be well approximated. The incision can then be closed according to the surgeon’s preference. In the postoperative period, the patient should be given adequate instructions for home care and what to expect. Important instructions include keeping the incisions clean and free of debris or scabbing. This goal can be achieved by using a cotton tip applicator to dab the area with a peroxide and normal saline mixture. The incisions should then be covered with a layer of bacitracin ointment. In addition, the patient must be made aware that they should immediately contact the surgeon if there is sudden and excessive bleeding, discharge from incisions, fever, or injury to the face. Postoperative complications to be particularly aware of include hematoma, infection, nerve injury (specifically to the great auricular and branches of the facial nerve), and flap necrosis. The surgeon must address them appropriately and in a timely fashion to avoid serious medical and cosmetic sequelae.
Alloplastic facial implants Alloplastic facial implants have been successfully used to address congenital deficiencies or asymmetries and volume loss caused by aging. Although both of these indications are important when discussing general facial cosmesis, this article focuses mainly on implants as they pertain to the restoration of volume loss caused by facial aging.
Fig. 5
71
Fig. 4 Evaluating placement of a chin implant through a submental incision.
Although rhytidectomy can provide a great deal of cosmetic improvement, in the aging patient, there is often a need for volume restoration as well. Much like the skin that overlies it, the fat that gives the face its youthful appearance tends to change over time as a result of both gravity and atrophy of the tissues. Any underlying skeletal deficiencies may also become more apparent, particularly in the cheek and chin areas. Although alloplastic implants have been used in many areas of the face, cheek and chin implants are the most commonly used, especially in the setting of more complex facial rejuvenation treatment plans.11 Many materials have been used for alloplastic facial implants over the years. Most implant materials have been shown to be nontoxic and noncarcinogenic12; however, there is a great deal of variability in their malleability, mobility, pricing, and so on. Some implants are fixated in place with either sutures or screws, whereas others rely on the dissected pocket and contouring for immobilization. Each surgeon has their preference, but it seems that the most popular materials include silastic and polytetrafluoroethylene.11,13 Because
Preoperative (left) and postoperative (right) profile of chin implant patient.
72
Schwartz & Quereshy
Fig. 6
Malar implant through transoral approach.
these implants do not resorb or reform, it is of the utmost importance that the surgeon be specific in the shape and size of the implant that is selected for placement. As with rhytidectomy, one of the most important factors that determines the outcome of the procedure is patient selection. The surgeon must be mindful of both the patient’s desires and expectations, along with the limitations of the procedure, and the materials. The mental prominence, or chin area, can often be a source of concern for patients both in the setting of aging and in skeletal deficiencies. Shape of the implant in this case is particularly important. Depending on the shape of the patient’s mandible and jowl area, an implant that is too small may create an unnatural step where the implant ends. Shapes are available that more softly fade as they extend laterally into the prejowl and jowl areas. Once the appropriate implant is chosen, appropriate local anesthetic is administered via bilateral inferior alveolar nerve blocks. The area in which the implant is to be placed should also be hydrodissected with local anesthetic. Either an intraoral or a submental approach can be used (Fig. 4). In both settings, it is important that the dissection stays on bone in a subperiosteal plane. Care should be
Fig. 7
taken not to injure the mental nerves during dissection or during placement of the implant. If, when the implant is tried in place, it is apparent that it will impinge on the mental nerves, the implant can be relieved before final placement (Fig. 5).13 When placing malar implants, 1 of 2 approaches is generally used to access the appropriate subperiosteal plane. One is the subciliary incision and the other an intraoral approach in the maxillary vestibule above the canine (Fig. 6). A diluted tumescent solution including local anesthesia and epinephrine should be deposited into the subperiosteal plane. This procedure helps with both hemostasis and hydrodissection of the proposed implant site. With either incision, the dissection is carried down to bone, with special care taken to avoid damage to the infraorbital nerve. When undermining the area, it is important that the subperiosteal pocket be made large enough to house the proposed implant. On the other hand, if the pocket is too large, there is increased risk of the implant becoming mobile.14 Complications with this procedure are uncommon. They include infection, malposition of implants, damage to infraorbital or mental nerves, and hematoma. As with rhytidectomy, an unsatisfactory result can often be avoided by ensuring that proper patient education and open communication are a priority.
Considerations for combined procedure Both the rhytidectomy and alloplastic facial implant procedures are staples in the armamentarium of the cosmetic surgeon when it comes to facial rejuvenation. Although both procedures have their own indications, it is important to be able to see the big picture to ensure that all aspects of the aging face are addressed. When combining both procedures, in the appropriate patient, a synergistic effect can be achieved, because each therapy enhances the other (Fig. 7). The technique, for the most part, is unchanged when implants are placed at the time of rhytidectomy. However, there are a few
Preoperative (left) and postoperative (right) of combined rhytidectomy and malar implant patient.
Rhytidectomy and Alloplastic Facial Implants important considerations that the surgeon must keep in mind to optimize both procedures. The placement of the implants should be completed before redraping of the skin flap from the rhytidectomy. If not performed in this sequence, there is risk for having an overtightened appearance caused by the addition of volume under the newly suspended facial tissues. More importantly, this added tension can compromise the skin flap and lead to possible complications. More than 1 approach has been discussed for placement of implants, but we prefer to place implants through a transoral approach when being performed with rhytidectomy. This strategy helps to avoid changes in tension lines on the skin after manipulation.
Summary It is the responsibility of the cosmetic surgeon to offer the best treatment options to patients. Rhytidectomy and alloplastic implants are 2 procedures that together can provide a more comprehensive enhancement of the aging face. Consideration of these combined techniques and others when devising surgical plans can be the difference between simply acceptable results and those that are outstanding.
References 1. Rogers BO. The development of aesthetic plastic surgery: a history. Aesthetic Plast Surg 1976;1:3e24. 2. Skoog T. Useful techniques in face lifting. Presented at the meeting of the American Association of Plastic Surgeons. San Francisco, April 1969.
73 3. Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976; 58:80. 4. Binder WJ. Facial rejuvenation and volumization using implants. Facial Plast Surg 2011;27(1):86e97. 5. Lihong R, Daping Y, Zhibo X, et al. Longevity of SMAS facial rejuvenation and support. Plast Reconstr Surg 2011;127(2):989e90. 6. Ho T, Brissett AE. Preoperative assessment of the aging patient. Facial Plast Surg 2006;22(2):85e90. 7. Myint AS. Standard facelifting. In: Erian A, Shiffman MA, editors. Advanced surgical facial rejuvenation, art and clinical practice. Berlin: Springer; 2012. p. 329e34. 8. Ghali GE, William Evans T. Rhytidectomy. In: Miloro M, editor. Peterson’s principles of oral and maxillofacial surgery. London: Hamilton; 2004. p. 1365e81. 9. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variation and pitfalls. Plast Reconstr Surg 1979;64: 781e95. 10. McKinney P, Katrana DJ. Prevention of injury to the greater auricular nerve during rhytidectomy. Plast Reconstr Surg 1980;66: 675e9. 11. Glasgold RA, Lam SM, Glasgold MJ, et al. Solid implants: mentoplasty and malar augmentation. In: Shiffman MA, Mirrafati S, Lam SM, et al, editors. Simplified facial rejuvenation. Berlin: Springer; 2008. p. 237e43. 12. Yaremchuk MJ, Rubin JP, Posnick JC, et al. Implantable materials in facial aesthetic and reconstructive surgery: biocompatibility and clinical application. J Craniofac Surg 1996;7:473e84. 13. Epker BN. Alloplastic esthetic facial augmentation. In: Miloro M, editor. Peterson’s principles of oral and maxillofacial surgery. London: Hamilton; 2004. p. 1435e47. 14. Terino EO, Edward M. The magic of mid-face three-dimensional contour alterations combining alloplastic and soft tissue suspension technologies. Clin Plast Surg 2008;35(3):419e50.
