|Fig. 18 – 13. Results of bilateral facelifting, in a white skinned patient which achieved excellent results. The scar is hardly visible after two months.|
- arch. The plane is extended downward until the superficial temporal fat pad is first visualized. The inferior dissection stops at this landmark so that structures in this area, such as the frontal branch of the facial nerve and the middle temporal artery, are not damaged. These structures lie just superior to the temporalis fascia or galea.
- Elevation of the periosteum continues around the ocular rim to the position where the conjoint tendon is found, i.e., the area where the temporalis fascia attaches to the frontal bone. Along the way, the sentinal vein is encountered on the lateral side of the ocular rim. Identification and avoidance of this structure will keep the dissection from extending too far medially and prevents postoperative hemorrhage and haematoma.
- The next major landmark to be identified is the supraorbital nerve, which should be avoided. The corrigator muscles are more medial. The extent of the dissection of this region will vary among patients and with the degree of a scowl appearance which they portray.
- The corrigator muscles are cut high so that one can identify and easily control any bleeding in the area. If heamostasis is required, a foot-pedal-operated tonsillectomy suction and bovie device provides a simple means for controlling bleeding while maintaining adequate visualization of the surgical field. A laser may also be used, if available, for cutting the muscles in this area.
- Slightly deeper, the supercilious muscles are identified and may be cut (Fig. 18 – 12B). At this point the dissection extends through the periosteum, and the procerus muscle is identified, which may also be cut.
- The supraorbital nerve on the opposite side may be identified at this time. The same steps are performed on the opposite side for the complete release of the periosteal flap around both orbital trims. The composite flaps of the periosteum and galea are now established.
The rhytids in the male are surgically approached from the subgaleal plane. These are corrected by scoring the tissues of the forehead parallel to the rhytids. Depending upon the exposure, this is performed with either the endoscope or direct vision.
- Next, a similar mark is made at the anterior edge of the iris incision, which is in a changed position because of the retraction of the frontalis and occipitalis muscles. These two marks are used for an accurate measurement of the extent of the skin retraction, which is usually about ten to fifteen mm. This measurement may be performed with a protractor which measures in millimeters. Measurements are made from both sides and recorded. Frequently, the contraction of the frontalis and the occipitalis muscles will `self-correct’ brow asymmetry.
- Once symmetry has been determined, the last drill holes are made and used for placement of a twelve mm screw into the skull to secure the periosteal flap in place.
- With the periosteal flap elevated and retracted posteriorly, the brows are raised. The degree of brow elevation is determined by the posterior relocation of the periosteal flap. This flap is secured in position by suturing both the flaps together anteriorly to the screws on each side using the 4-0 Gortex suture. This establishes and maintains the level of brow elevation and symmetry during the initial healing phase.
- A drain (Hemovac #6) maybe inserted to the right temporal region behind the hairline, and placed across the entire forehead just above the brow. The drain is placed on a bulb suction and may be removed the next day. Many times the drain is unnecessary and is used only in those cases where fluid collection is anticipated. The right and left iris incisions are closed with staples. Staples are also used for closure of the remaining incisions. A pressure dressing bandage is applied around the head. The dressing is replaced the next day and removed after three days.
- A head band is worn for added pressure and protection during the healing process, for the next nine days. The two screws remain in place for twelve days to give adequate time for the fascia to reattach to the skull and maintain the set relationship of the brows to the orbital rim.
The general principle of the endoscopic forehead and brow lift is that, once the scalp is fully mobilized, the natural contraction of the frontalis muscle will draw the forehead skin brow back towards the occipital area. This will provide the lift automatically, without extensive incisions and without tissue removal.
Possible complications are:
- Undercorrection: unsatisfied patient.
- Asymmetry of correction of eyebrow and forehead rhytids.
- Frontal branch of VII nerve injury.
- Numbness due to supraorbital or supratrocheal nerve injury.
- Early bleeding, haematoma, bruises.
- Loss of hair at site of incisions.
Patients who have submental fatty deposits and relatively tight skin that has maintained its elasticity.
Patients who have submental redundant skin or skin that has lost its elasticity because it is impossible for the redundant skin to shrink and favourably conform.
- A horizontal one cm submental incision is made through the skin.
- A 100cc of Klien solution (100 ml normal saline + 10cc Xylocaine 10% in 1:200,000 Adrenaline + 2cc NaHBC02) is injected using cannula and Klien pump. It is injected to the submental and neck area which is marked for liposuction. (Fig. 18 – 26)
- Then wait for twenty minutes.
- Now, using a fine liposuction cannula, the fatty deposits are extracted. The cannula is directed toward the muscle in order to extract the fatty tissue on the muscular layer while preserving a uniformly thick skin cover.
- The wound is closed with one suture 4/0 Nylon.
- Pressure bandage is applied for five days.