Rhytidectomy
Marc Cohen, M.D.
David Geffen School of Medicine
at UCLA
Division of Head & Neck Surgery
The Aging Face
 Soft tissue changes
 Skin changes
Soft Tissue Changes
 Jowl
 Deepened nasolabial
folds and perioral jowling
 Platysmal banding and
submental fullness
 Orbicularis oculi and
malar fat pad ptosis
Skin Changes
 Epidermis and subcutaneous fat thins
 Flattening of dermal-epidermal junction
 Elastosis: progressive loss of organization of
elastic fibers and collagen
 Photodamaged skin – striking variability
SMAS
 Superficial Musculoaponeurotic System
 1976 Mitz and Pyronie Landmark paper
 Fibromuscular fascial extension of the
platysmal muscle that arises superiorly
from the fascia over the zygomatic arch
and is continuous in the inferior cheek
with the platysma
 Functions to transmit the activity of facial
mimetic muscles to the facial skin
SMAS
 Posteriorly, the SMAS fuses with the fascia
overlying the sternocleidomastoid muscle, but it
is a distinct layer superficial to the parotid fascia
 Anterosuperiorly, the SMAS invests the facial
mimetic muscles of the mid-face (i.e., orbicularis
oculi, zygomatic major/minor, levator labii
superioris)
 Anteriorly, the SMAS invests the superficial
portions of the orbicularis oris and gives off
fibrous septae that insert into the dermis along
the melolabial crease and upper lip
Facial Nerve
 Protected by parotid
tissue and lower
branches are deep to
masseter fascia
 Potential space exists
between SMAS and
masseter fascia in
inferior cheek
 Important in
deep/composite
rhytidectomy
techniques
 Innvervates midfacial
mimetic muscles from
undersurface
Facial Nerve
 Temporal branch is
most superficial
 Crosses junction of
anterior 1/3 and
posterior 2/3 of
zygomatic arch
 Above the arch it
travels in the
temporoparietal
fascia to innervate
frontalis and orbicularis
oculi
SMAS & The Facial Nerve
Facelifts
 Subperiosteal facelift
Subperiosteal facelift
 Shortcomings
 Frontal branch at higher risk
 Significant facial edema lasting up to 6 weeks
Deep plane facelift
 Addresses nasolabial folds
 Subcutaneous
 2-3 cm in front of tragus
 Sub-SMAS
 To zygomaticus major
 Superficial to zygomaticus major
 Upper extent is malar eminence
 Inferior extent is jawline
Deep plane facelift
Composite facelift
 Addresses malar eminence
 Lower blepharoplasty incision used to elevate
orbicularis oculi and malar fat pad
 Transition then made superficial to zygomaticus
major
Nasolabial Fold
Nasolabial Fold
 Boundary between cheek and upper lip
 Laterally, thick subcutaneous layer
 Medially, dermis almost approaches orbicularis
 Cheek fat sags over time lateral to fold
 Upper third – insertion
into LLSAN muscle
 Middle third –
transition btw both
muscles
 Lower third – insertion
into OO
 Deep plane and
periosteal lifts do not
anatomically address
this
 Controversial – SMAS
or not
Nasolabial Fold Management
 Direct excision (UCLA)
 ePTFE (gortex)
 Fillers
 SMAS
 Facelifts? Midface lifts?
 Botox (LLSAN)
Botox
Direct Excision
Lift and Peel at same time?
 Concern for flap necrosis
 Retrospective studies show no increased
incidence of flap necrosis or other complications
Retaining Ligaments of the
Face
 Osteocutaneous
 Orbital – centered at zygomaticofrontal suture
 Zygomatic
 Buccal-maxillary – arises from zygomaticomaxillary
suture
 Mandibular (along with DAO makes up
labiomandibular crease)
 Fasciocutaneous
 Masseteric (anterior border of masseter
 Parotidocutaneous
Blood Supply
 ECA
 STA
 Transverse facial artery
 Zygomaticorbital artery
 Facial
 Submental
 Inferior labial
 Superior labial
 Angular
Blood Supply
Complications - Hematoma
 HTN is major risk factor (2.6x risk)
 Major – usually occur in first 12 hours
 reoperation and exploration
 Minor – occur during the first week
 Evacuated with 18 ga needle or small opening in
incision line, pressure dressing, abx
Complications – Flap necrosis
 Postauricular is most common site
 Preauricular is 2nd most common
 Deep-plane facelifts have a decreased incidence
of necrosis
 Nicotine carries a 12.6x risk for flap necrosis
 Must stop at least 2 weeks prior
 Treat conservatively with with daily peroxide
cleaning, limited debridement, and topical abx
ointment
 Most heal nicely
Complications – Nerve
Damage
 Most commonly injured nerve is great auricular
 If injured, should be repaired with 9-0 nylon
 Temporal and Marginal are the most commonly
injured motor nerves
 Studies differ on which is more commonly injured (which
technique, etc.)
 Treatment
 First 4-8 hours, wait
 If prolonged, do NOT re-explore
 85% will resolve with time
 Reconstruct after 1 year
 Patients with a hx of Bell’s palsy are at risk for recurrence
after rhytidectomy
Complications
 Hypertrophic scarring
 Occurs with excessive tension on flap closure
 More commonly with isolated subcutaneous flap
dissections
 Treat with steroids
 Defer excision and primary closure until at least 6
months postoperatively
 Alopecia
 Wait 3-6 months, then excise or place grafts
Complications
 Infection
 Common pathogens are
staph and strep
 Usually respond to oral abx
 Rare for abscess to form
 Earlobe deformity (pixie ear)
 V-Y plasty performed 6
months after surgery
Complications
 Parotid injury
 Sialocele or fistula
 Needle aspiration and pressure dressings