Secondary Rhytidectomy

Secondary Rhytidectomy

Improving or Maintaining the Primary Facelift Results: A Conflicting Duality of Perception

Revision Surgery in Otolaryngology

Thieme Medical Publishers

Editor: Norman J. Pastorek, MD

History

The desire to enhance one’s appearance by turning back the “clock of time” has been a pursuit of individuals of our society at lhttp://www.slingshotseo.com/MPS/homeeast since the early 1900’s. Cosmetic surgeons began rejuvenation surgery, in particular facelift surgery, in the early 1900’s. Some of the early efforts were pioneered by the German and French surgeons. In 1906, Lexer was thought to have performed surgery to treat wrinkles, but it was Hollander in 1912 who was the first to report a surgical case. Other European physicians, including Joseph (1921) and Passot (1919), developed their own techniques to treat the sagging, aging face.i Early face-lifting techniques consisted of very limited subcutaneous dissections with skin elevation and tightening relying solely on the skin layer itself (Figure 1). Unfortunately, this often resulted in a very temporary improvement and occasionally an over zealous tightening of the skin resulted in an obvious operated look. Samuel Fomon, M.D., who was a pioneer in facial cosmetic surgery, recognized the limits of this type of facial lifting procedure and of facelifts in general when he was quoted as saying, “The average duration of the beneficial effects, even with the best technical skill, cannot be expected to exceed three or four years.” ii

Many of the early surgical techniques were not well publicized nor talked about by plastic surgeons, as there was a prevailing Victorian attitude against vanity surgery. However, beginning in the late fifties, and certainly by the early 1970’s, there was a significant pursuit toward a surgical procedure for a facelift that would create a long lasting result and yet leave the patient with a cosmetically pleasing, natural look. From a surgeon’s perspective, the ultimate facelift would be one that was predictable, had a low instance of complications, was technically feasible and could be performed in a relatively short, efficient period of time. From the patient’s perspective, the surgical technique would be minimally invasive, yet effective, and last as long as possible, leaving them with a natural appearance. Often there has been a conflict between more invasive procedures, creating fundamentally altered appearances with long lasting results, and a shorter, less invasive operation, improving the patient’s appearance with minimum recovery time, but often without a satisfactory result in terms of longevity of the result. This, therefore, creates the first duality of perception and misconception as to what the surgeon and the patient should expect from a facelift.

It is quite interesting to note that the original facelifts performed were skin lifts only and some of the most recent literature describing an “S-lift” is a return to the same early procedure that was found to be of limited benefit over a long period of time.iii Often “new techniques” such as the

“S-lift” are proposed in today’s cosmetic surgery environment in order to attract patients by a minimally invasive procedure with a short period of recuperation and a reasonably low cost. These techniques rarely satisfy the expectations of the patient or the surgeon.

From a surgeon’s perspective, the pursuit of the ideal facelift procedure has created a great deal of different opinions and philosophies as to how to achieve a natural, long-lasting result and a satisfied patient population. Much of this problem is due to the inherent limitations of the facelift procedure, no matter what technique is employed. It is an expensive operation, which is technically involved, requires significant recovery time for the patient and is inherently flawed. Both the patient and the surgeon are less than completely satisfied no matter how good the result may be for the given individual. The initial discussions compared short skin flap elevations with long complete flap elevations. Cosmetic surgeon’s such as Richard Webster realized and demonstrated that lifting the underlying fascia and muscular layer often gave a nice improvement in jaw and neckline with fewer skin complications and a more natural appearance.iv This fascial layer was anatomically described by Mitz and Peyronnie in 1976 as the SMAS (superficial muscular aponeurotic system) (Figure 2).v Dr. Webster performed a comparison of plication (folding over and suture suspension) of this layer with relatively short skin flap elevation to large skin elevation with skin lifting only. Surgeons such as Skoog realized the benefits of the subfascial plane dissection, as well, and performed large elevations below the SMAS layer, treating the movement of the SMAS and the overall skin subcutaneous tissue as a sliding tectonic plate.vi This imbrication (advancement, shortening and suturing) technique became the mainstay of face-lifting surgery and has been recently repopularized through the extended - SMAS and deep plane techniques.

With the advent of liposuction, direct lipectomy and sculpting of fatty tissues in the submandibular and submental areas became safer with less chance of potential complications to the marginal mandibular nerve. This improved the overall neck result with face-lifting. However, this can lead to asymmetries due to uneven fat removal or recurrent lipoptosis, as well as dermal banding and skeletonization of the submandibular gland.

However, all surgeons were observing in their patients, not only recurrent sagging of the skin and SMAS tissues, but significant recurrent banding of the platysma muscle in the neck

(Figure 3). Techniques, not only to correct the platysma banding but also to prevent it from recurring, were developed including anterior plication techniques, various anterior border muscular myectomy techniques as well as direct transection of each playtsma muscle from side to side.vii Each of these techniques fails to prevent recurrent platysma banding in some patients and can create ridges of platysma or submental “cobra like” appearances.

Finally, in recent years, with the development of the extended SMAS rhytidectomy1, the bi-plane and tri-plane rhytidectomy of Bakerviii, the deep plane techniques of Kamerix, composite rhytidectomies by Hamrax and the subperiosteal dissections by Ramirezxi, more aggressive surgical interventions were driven by the continuous desires of the surgeons to achieve a fundamental improvement that could be counted on to last for a significant length of time. As these techniques became more aggressive, increased levels of complications by relatively less experienced surgeons began occurring. In addition, the greater the degree of surgical intervention, the longer the healing phase or recuperation time for the patient. Patients became disenchanted with six weeks to six months of healing in order to achieve a “natural appearance” from their facelift. Increased competition among surgeons for facelift patients has brought the entire range of surgical techniques full circle. Some surgeons today are advocating “neck only” facelifts, mid-facelifts, “laser” facelifts, and even endoscopic face-lifting with essentially no skin redraping. There are increasing marketing claims of facelifts that can be performed allowing the patient to fully recover and return to work over a weekend. Each of these procedures has significant limitations and significant incidences of recurrence of sagging with return of the aging face appearance, creating a dissatisfied patient population. This type of marketing continues to proliferate the second duality of perception about face-lifting. There is no “perfect” facelift operation and there is significant healing time required. Fortunately, no matter which technique is used in face-lifting, there are procedures which can re-tighten the skin, the SMAS and even the platysma, as well as repeat some lipo-sculpting techniques in order to improve the overall initial result and maintain a longer lasting natural appearance for the patient.

Each patient asks his or her potential surgeon the fundamental question, “How long is my facelift result going to last-” It is generally expected that a given facelift procedure should last in terms of a rejuvenative appearance for at least eight to ten years. However, there are significant variations from patient to patient and preexisting condition to preexisting condition that effect this average. There are certainly cases that one would expect to have significant recurrence of laxity and platysmal banding based on the preexisting condition and these recurrences may be visible to the patient within the first one to two years. This creates relative dissatisfaction in an otherwise happy patient, another conflicting duality of perception. There are also certain patients on whom a facelift result may last twelve to fifteen years or longer in terms of a rejuvenated jaw line and neckline compared to the preop condition. This, mostly, has to do with the preexisting elasticity, or lack thereof, and their individual hereditary tendency. Photoaging and smoking will at least accelerate, or even partially cause, a premature loss of elasticity, increased wrinkling and early relapse of the pre-facelift conditions with a significant diminution of the aesthetic result. Still, each patient can be told with positive expectations that he or she will continue to look younger, by five to ten years, due to having had the face-lifting procedure even though they will continue to age in a normal fashion for their hereditary, preexisting conditions, and lifestyle choices.

However, fundamentally, each patient and, for that matter, each surgeon desires a long-lasting improved jaw line with minimum jowling, a well contoured neckline with minimum to no platysma banding, and a naturalness to the overall look with relatively smooth skin. Therefore, secondary or tuck-up facelift procedures are required and are necessary to improve and maintain the primary facelift result in order to achieve a happy facelift patient population.

Patient Expectations and Facelift Limitations

One of the more common areas that patients have a misunderstanding as to what facelifts will do and what they will not do is in the area of the cheek-lip groove and fold. This is commonly known as the melolabial groove and fold. A standard cheek-neck facelift with most of the SMAS lifting techniques have very little effect on the upper third to upper one-half of this fold. There are techniques involved in midface-lifting, with particular attention to repositioning the middle cheek fat pad, that have some effect on this groove. Unless this is added to the operative procedure, patients need to understand that this is an area where very little improvement will be noted at the six month to one-year result after their facelift (Figure 4). Additionally, another area of common concern is the downward turn to the corner of the mouth. This oral commissure groove, which can extend to a significant “marionette line”, is only partially corrected with standard face-lifting techniques (Figure 5). By lifting the jowl and soft tissues of the lower third of the cheek, the“marionette line” is significantly effaced. However, the oral commissure itself is not effected by standard face-lifting techniques (Figure 6). Recurrence or persistence of this can be an area of dissatisfaction for the patient. Wrinkles or rhytids that exist within the surface of the skin may look better, if not significantly better, with face-lifting. However, when the edema resolves and the tissue rebound relaxation occurs, most of these rhytids will still be present and the patients need to be educated about this fact in the preoperative consultation. None of these issues mentioned above relate to a need for secondary or revision facelift surgery. These are just related to the limits of the procedure itself and the patients’ expectations must be in concert with this prior to surgery. Therefore, these issues are dualities of perception that can be eliminated or minimized through preop counseling.

The issues that may result in the need for revision or secondary procedures have to do with the inherent elasticity or hereditary elastosis of the patient’s skin, acquired loss of elasticity due to smoking, solar exposure, and inherent “give back” or rebound relaxation of both the skin and the deeper subcutaneous tissues.

Areas that seem to persist or recur that often result in the need for a secondary tightening or tuck-up procedure include persistence or recurrence of the jowl, recurrence or persistence of lipoptosis in the submental and submandibular area, and the recurrence or persistence of playtsma banding and skin laxity of the cervical mental angle. It is of worthwhile note that the anatomical existence of a pre-jowl sulcus or geniomandibular groove may need additional augmentation in order to get a satisfactory result from face-lifting and repositioning of the jowl.xii A person with a heavy jowl and a square jaw line with a forward chin as well as a significant pre-jowl groove needs to be aware that this will not be corrected, and may be accentuated, with face-lifting (Figures 7 and 8).

Other sequellae from facelift surgery that may require revision, but not specifically secondary face-lifting or tuck-up procedures, include skin rippling, dimpling, and subcutaneous scar band formation in the submental and cervical neck. Additionally, over skeletonization with relaxation of the submandibular glands creates a fullness that was not obvious in the preoperative condition prior to the facelift. This is a condition that is very difficult to correct satisfactorily. Alterations in the hairline are potentially avoidable but can necessitate revision surgery with hair grafting and/or small hair flap repositions (Figure 9). Small areas of alopecia, if persistent, can be directly removed. Scarring that is visible in the preauricular and postauricular areas is often avoidable by scar placement planning techniques, but adverse healing, whether small skin sloughs or infection may create scarring that is visible, therefore, requiring revision surgery (Figure 10).

Patient Selection as a Predictor of Revision or Tuck-up Facelift

A patient’s preexisting condition may preclude a good result or at least may predict a very short-term result with the need for further surgery, sooner rather than later. Any of these preexisting conditions are easily graded based on the patient’s own anatomy. Dedo has a classification involving the chin and neck that is clinically applicable to this predictionxiii. For example, this includes patients with weaker, hypoplastic mentums, low or anterior hyoids, obesity and significant lipoptosis, and patients with significant elastosis of the skin on a hereditary basis. Patients who have been smokers and have abused their skin in the sun will shorten their overall long-term result, as well.

The skin itself has an inherent “creep” phenomenon, which includes rebound relaxation of both the skin and subcutaneous tissues. “It is inevitable that they (your patients) will experience a certain degree of rebound relaxation in superficial tissues of the face and neck.” 1

Types of surgery in revisional and secondary face-lifting

Revisional surgery by definition is revising something that otherwise did not heal as one would expect from the original procedure. This may involve revising a scar, removing an area of alopecia, correcting a skin slough problem, or tightening one side of the jaw line or neckline that is asymmetrical to the other side. A “tuck-up” is defined as a lesser procedure that is generally performed anywhere from six months to eighteen months after the original facelift. This may involve tightening the submental area or relifting both cheek and jowls as a cheek tuck-up only procedure. Whereas, a secondary facelift is a standard facelift that is a repeat of a prior or several previous facelifts performed by the same or a different surgeon(s). The secondary facelift involves essentially the same standard facelift incisions and most likely involves a similar set of procedures including SMAS dissection, skin elevation and skin redraping. It can be performed anywhere from one-and-one-half to two years after the first facelift to as long as fifteen to twenty years later.

There are planned versus unplanned revisional and tuck-up procedures.xiv In the first six to eighteen months post facelift, it is not uncommon to require retightening of the submental area or correction of the recurrent platysma band. This is often a predictable issue due to preexisting condition and anatomy of a given patient, as previously noted (Figure 11). Similarly, but less common, is the repeat lifting of the cheek and jowl tissues, as these tissues will have settled and rebound relaxation will have occurred, and the effect of gravity and loss of elasticity continues even in the early postoperative period. This, again, can be predicted based on the “cherub cheek” patient or full, heavy jowled patient, especially with a weak chin and ill-defined mandibular margin (Figure 12). Either one of these procedures can be unplanned or unexpected and require intervention to maintain or achieve a satisfied facelift patient in the relatively early postoperative period.

Submentoplasty

A submental tuck-up or modified submentoplasty can involve one of three tissues:

1. Repeat liposuction only for reaccumulation or resettling of an asymmetrical area of fatty tissue (lipoptosis) in the submandibular or submental area (Figure 13).

2. Skin redraping due to rebound relaxation of the skin itself, premature loss of elasticity, or rippling in the skin texture itself. This is often caused by or aggravated if the patient has had a seroma in the early postoperative period (Figures 14 and 15).

3. Platysma band correction that may involve re-plication and undermining with redraping of the skin (Figure 16).

In an article written by Perkins/Gibson in 1993 comparing patients from the senior author’s practice, he noted that of the original facelifts, ninety-six percent had liposuction of the submental area, ten percent had direct excision, thirty-one percent had anterior platysmal resection and thirteen percent had a midline plication of platysma; eighty-nine percent had SMAS plication, eleven percent had SMAS imbrication.xv Of this total patient group, postoperatively, sixty percent had platysma banding; five percent had recurrent or residual fat in the follow-up six to eighteen months. Fifteen percent of the overall group required a submental tuck-up procedure. In 1998, Dr. Perkins/Dayan reviewed the same authors’ facelift patients and noted that the revision submentoplasty had been reduced to two to three percent.1 These senior authors’ primary facelift procedures have been modified and enhanced over this period of time. Currently, ninety eight percent of the patients have liposuction and the “Kelly clamp technique” is used for direct excision of both fat and platysma banding in about sixty percent of the patients (Figure 17). Midline plication was done in one hundred percent of these patients. Additionally, one hundred percent of the patients had SMAS elevation, imbrication and deep plane techniques in the mid cheeks region. Eight-five percent of the patients had long flap elevations in the neck and medium flap elevations in the face (Figure 18). This compares to Perkins/Gibson in 1993 when only sixty-one percent of patients had medium flaps and thirty-nine percent had long flaps.15

The technique of submentoplasty tuck-up procedure performed for primary facelift patients is usually performed at least six months after the initial facelift, but prior to eighteen months. It is a procedure that revises the submental area through the previous submental crease incision. This horizontal crease incision is often converted to a short T-shaped incision as shown in the accompanying illustration (Figure 19). This allows for undermining of the skin, repeat liposuction and repeating the platysma plication. Most importantly, it allows for redraping of the skin in a lateral to medial direction, as well as from posterior to anterior. The surgeon must be careful not to develop redundancy of tissue underneath the mandibular margin at either end of the incision bilaterally. By advancing the tissues posterior to anterior, the vertical length of the T incision is shortened approximately fifty percent. At no time would the vertical limb extend to or even past the anterior cervical mental angle. Normally, the vertical limb of this incision is no more than three centimeters long, ending up one to one-and-a-half centimeters in length at the time of closure. Generally, patients are quite acceptive of this extended incision due to the fact that they realize a small operation will actually further correct and improve the results they expected from their previous facelift. As is the case with any scar, for those patients who depigment the actual scar itself, it can become a visible issue for them, particularly if their surrounding skin is of a more sallow color. A lot of these scars will blend in with natural skin tones, however. This procedure takes approximately one-half hour to forty-five minutes of operating time and can be done under IV sedation in the office or ambulatory operating suites. Currently, I perform this procedure in approximately one to two percent of all facelift patients in the first six months to eighteen months following the primary procedure (Figure 20).

Cheek Tuck-up Facelift

A cheek only tuck-up facelift is indicated for a patient on whom I have performed the initial facelift procedure but who has had some exaggerated rebound relaxation of the mid-cheek or jowl tissues. This creates a disappointment in the patient who is otherwise pleased with their jaw line and neckline. These tissues are the most effected by gravity and are the least improved by liposuction techniques. It is a challenge surgically to permanently suture fixate the cheek and jowl soft tissues in the superior posterior direction where they were repositioned during the facelift. Re-elevating the skin for a medium flap length, re-tightening the SMAS layer, either by a short imbrication technique or by a plication-foldover technique, significantly improves the overall long-term effect of the original facelift. Currently, for the cheek tuck-up, I use a permanent suture such as 3-0 Tevdek to support the SMAS layer, as opposed to a completely absorbable 0 vicryl or 3-0 PDS suture used in the primary facelift. Skin redraping is also an issue and the incision has to be extended along the postauricular sulcus back to the posterior hairline, but not extending posteriorly into the postauricular hair, as in the original facelift. A short degree of undermining in the infra-auricular area is required, but not full neck undermining. Two to three centimeters of SMAS is elevated and imbricated in the preauricular area and just below the level of the angle of the mandible. A re-elevation in the midface deep plane below the SMAS is generally not required. Because of the limited undermining, a smaller two millimeter drain may be all that is required, or no drain at all. Primary facelifts are drained with a four or seven millimeter flat, perforated drain. The procedure takes approximately one-and-one-half hours of operating time and can be done under IV sedation in the operating suite. This procedure is done in approximately one to two percent of all facelift patients in the first eighteen months (Figure 21).

Additional Procedures

Adding new and additional techniques to the primary facelift can further reduce the incidence of revision or tuck-up procedures in the first six months to eighteen months. These procedures include chin augmentation, pre-jowl implants for the geniomandibular sulcus, mid face-lifting of the cheek-lip fold and mid facial malar tissues, etc. These procedures have begun to add improvement to areas that were and are otherwise disappointing in terms of result to the facelift patient (Figure 22).

There are instances where new procedures need to be added to the rejuvenating process that are separate and distinct procedures. These procedures, which technically are considered secondary facelifts or revision surgery, are procedures that become necessary once the cheek and jaw line are adequately rejuvenated and the patient still thinks they have a sagging face. This is often related to the persistence of cheek-lip folds and grooves, sagging mid cheek tissues with mid facial hollows, a tired lower eyelid look and a sagging of the lateral brow and mid glabellar tissues. One of the procedures that is commonly performed today in concert with face-lifting to improve cheek-lip fold and groove is to augment this groove at the time of facelift (Figure 23). Occasionally, this procedure is done in lieu of face-lifting when the patient is not quite ready. It can be done as a secondary procedure to improve the otherwise persistent groove that was not going to be corrected by the initial facelift procedure.12 Augmentation of this groove as well as the downward turn of the oral commissure or marionette region can be done with a person's autologous fat. Autologous fat transfer will improve both of these areas at the time of the original facelift and the fat can easily be obtained from the submental and submandibular liposuction. This auto reinjection of fat has variable persistence, but generally is not considered to be a permanent improvement. It may last from six months to eighteen months depending on the patient. Further augmentation materials include Alloderm (acellular dermal graft which is micronized human cadaveric collagen)xvi or SMAS fascia or temporalis fascia. None of these tissues have longevity that is persistent past one year. The one material that has shown persistence and a great tolerance in the soft tissues is Gore-Tex (Expanded PTFE [polytetrafluoroethylene]).xvii This will provide some degree of augmentation, but does not correct the cheek-lip fold or sagging mid facial tissues. If one recognizes the hypoplasia or loss of subcutaneous fat tissue and atrophy in the mid face, one can suggest augmentation materials at the time of the initial facelift. The augmentation of the midface with a submalar implant often will improve the overall facelift result and assure a happier patient with the initial procedurexviii (Figures 24 and 25).

Patients often wonder how many facelifts are possible or how many facelifts constitute too many. They also ask the question, “Once you have had a facelift, do you have to have another one-” There certainly is a limit to the stretch ability and skin elasticity with rebound relaxation. Some of the rebound relaxation of the skin tissues themselves can add to the natural look of the overall facelift result. However, once the skin itself is tightened, there is a limit to the elasticity and the skin becomes taught and will not rebound. These patients often can be identified as having had a facelift as they have an unnatural look in the mid cheek tissues pulled posteriorly, superiorly and the rhytids which accompany the skin are redirected laterally. This is an unnatural appearance and most patients want to avoid this at all costs. Using deep plane techniques, which rely on repositioning the foundation tissues of the face rather than on skin tightness itself is a good way to avoid this problem. Retightening the SMAS tissues themselves does have limits and, despite a scar tissue plane that forms between the SMAS and subcutaneous tissues of the skin, there is a limit to which the SMAS can be tightened as it will finally thread thin and shred at the time of secondary face-lifting. Certainly, patients need to be told that once they have had a facelift, they do not have to have another and that they will continue to age gracefully. The one exception to this is the patient who is aging faster in the mid face than the lower face and this sets up an unnatural appearance creating laxity in the lateral cheek/jowl region that need to be lifted with a different approach rather than a standard cheek-neck facelift.xix

Cost to the patient is generally an issue when dealing with your own patient population on whom you have done the primary facelift. They have at least a level of preexisting expectation that, despite a relatively expensive operation for the first facelift, this would take care of them until such time in the future that they desired a secondary facelift. It is very important to identify patients in preoperative consultation who most likely will need a tuck-up procedure in the first year to year-and-a-half. You can then prepare the patient for additional costs that may be required at that time. Generally there is no surgeon’s fee to do these modifications if they are done within the first year to eighteen months. If the patient elects to put this off for two years or longer, the costs begin to escalate based on the degree of work that needs to be done and the length of time they have “enjoyed” the benefits of the primary facelift. A cheek tuck-up involves more time and effort and may even generate a physician’s practice fee of approximately one-fourth of the previous face-lifting fee. Generally, submentoplasty is done at no additional cost. However, the patient must be aware that both these procedures require at least a level of anesthesia with intravenous sedation in an accredited operating facility. This will generate a cost that is the patient’s responsibility. It is generally the goal of any surgeon to ultimately have a satisfied patient who is not only willing to refer other patients for face-lifting, but also who will return for other procedures in the future. By entering into a mutually acceptable financial relationship for this secondary procedure, one can maintain a satisfied patient population while doing facelifts on all types of individuals.