Dissection and closure
The right face followed by the left face is then dissected. The periauricular incision is made following the pre-operative markings and the proper subcutaneous plane developed sharply. A 2.7 mm liposuction cannula, without suction, is used to pretunnel the cheek flap in the developed subcutaneous plane. The posterior skin flap is then sharply elevated in a subcutaneous plane and connected with the previous cervical dissection. Care is taken to preserve the greater auricular and spinal accessory nerves as they emerge from the posterior border of the SCM muscle. The greater auricular nerve is the most common nerve injury during rhytidectomy and may be at increased risk with revision surgery. It emerges from Erb’s point, which can be found at the posterior border of the SCM muscle, at the junction of the superior and inferior half of the muscle, approximately 6.5 cm below the external auditory canal. It travels under the SMAS and platysma to reach the anterior border of the SCM. Terminal branches from the main trunk travel in the groove between the SCM and the parotid fascia inferior to the ear and preauricular area. Care should be taken when dissecting as the skin can be quite thin and adherent to the muscle below the earlobe and violation of the SMAS/platysma layer can occur inadvertently, especially in revision surgery10. If the nerve is injured, primary repair is recommended.
In general, cheek skin elevation is then carried out subcutaneously for approximately 6 cm and connected with the previously elevated cervical flap. The SMAS is then incised approximately 3 cm in front of the ear from the inferior border of the zygoma to the mandibular border and a sub-SMAS elevation carried out for 3–4 cm. Vertical spreading dissection is recommended in the direction of the facial nerve with care to be directly beneath the SMAS layer. A strip of SMAS is then removed from in front of the ear and may be used for soft tissue grafting if needed. The SMAS flap is then retro-displaced posteriorly and superiorly and secured with 3–0 PDS horizontal mattress sutures. The first suture is placed at the point of maximum flap mobility, which is determined pre-operatively at the time of marking and is usually located about 3cm inferior to the EAC at a point 3 cm anterior to the ear. It is then secured to the parotico-masseteric fascia at a point about level with the EAC just in front of the ear. Multiple sutures are then used to complete the SMAS imbrication.
Bi-polar cautery on a low setting is used throughout the procedure and meticulous haemostasis is confirmed prior to wound closure. The skin is then brushed with a surgical gauze sponge posteriorly and superiorly, not pulled tightly, and the flap secured with temporary staples at the helical root and at the high point of the flap posteriorly. The excess skin is then trimmed following the contours of the ear. The skin flap is left a bit excessive at the tragus and trimmed of all subcutaneous fat. In a male facelift, a Colorado tip cautery is used to ablate hair follicles in the area of the tragus. When trimming the flap, the earlobe is intentionally bunched upward slightly to avoid post-operative inferior displacement. Posteriorly along the hairline, the skin flap excess is determined using a Pitanguy flap-marking forceps and trimmed. The judgment of flap re-direction, tension of pull and amount of skin excision can only be gleaned from experience.
[pull_quote align=”left” ]It is important to keep in mind that as cosmetic surgeons, our primary goal is to make that individual feel good about themselves.[/pull_quote]
Closure begins by recreating the anatomically important pre-tragal depression. A buried 4–0 vicryl suture is placed in the SMAS just anterior to the tragal cartilage and then through the dermal undersurface of the neo-tragal skin, which pulls it down in this area, thus recreating this crucial anatomic feature. Without this manoeuvre, the tragus may be blunted or lost altogether, which is an indication that a facelift has been done. The anterior ear incision is then closed with interrupted 5–0 prolene sutures supplemented by a running 6–0 prolene in front of the ear. Post-auricular closure is accomplished with a running, 5–0 plain gut suture. The temple and posterior hairline incision are closed in layers using buried, interrupted 4–0 vicryl or monocryl sutures and a running 5–0 prolene suture for the skin closure. The holding staples are then removed. No drains are used. They have never been shown to reduce haematoma formation and may leave marks on the skin, and create anxiety for the patient. A non-constricting, sterile dressing is applied consisting of antibiotic ointment, telfa, 4 × 4s, cotton fluff and a #9 surgiflex bandage.
Post-operatively, adequate analgesia and anti-emetic medication should be provided to reduce pain and vomiting, as both are known to elevate blood pressure and predispose to haematoma formation. Additionally, a course of oral antibiotics covering gram-positive bacteria is prescribed and wound care reviewed with the patient and their care provider. This should supplement comprehensive pre-operative education.
On post-operative day 1, the non-constricting, sterile bandage placed at surgery is removed. An elastic facial support is then placed, which is to be worn for 22 hours per day in week 1, and then worn only during sleep for 2 weeks. The patient is encouraged to shower and wash their hair with baby shampoo daily. All incisions are cleaned with peroxide and dressed with mupirocin 2% ointment twice per day. A professional care provider is recommended for all patients recovering from cervicofacial rhytidectomy for the first 24 hours. Finally, all non-absorbable sutures are removed at 1 week post-operatively. Routine follow-up care intervals from the day of surgery, after the first week, are at 3 and 6 weeks, 3 and 6 months, 1 year and then yearly if the patient is willing to return.
Conclusions
Secondary cervicofacial rhytidectomy is commonly combined with other facial cosmetic procedures to address multiple age-related changes. These may include mid-face lifting, brow lifting, blepharoplasty, skin resurfacing, rhinoplasty, fat transfer, facial implants, ear lobule reduction, hair grafting and other ancillary procedures intended to enhance facial harmony and create youthful attractiveness.
When a patient presents for secondary facial aesthetic enhancement, it is important to keep in mind that as cosmetic surgeons, our primary goal is to make that individual feel good about themselves. The patient may have been quite pleased with their initial cosmetic surgery experience or may have been left feeling dissatisfied, or in some cases frustrated or angry as a result of legitimate aesthetic complaints. In order to minimise risk to the patient, choose procedures that work best in your hands. This is not meant to stifle professional growth, but does stress the point that cosmetic surgery should entail minimal risk while delivering consistent and reproducibly excellent aesthetic results. If you deliver complication-free facial aesthetic enhancement, which appears natural and respects both the patient’s desires and youthful anatomy, you will have a satisfied and happy patient.
