RESUMO
BACKGROUND: Despite the significant roles it plays in the functions of the platysma and lower lip, the cervical branch of the facial nerve is often overlooked compared to other branches, but its consideration is critical for ensuring the safety of neck surgeries. OBJECTIVES: The aim of this study was to clarify the anatomical discrepancies associated with the cervical branch of the facial nerve to enhance surgical safety. METHODS: The study utilized 20 fresh-frozen hemiheads. A 2-stage surgical procedure was employed, beginning with an initial deep-plane facelift including extensive neck dissection, followed by a superficial parotidectomy on fresh-frozen cadavers. This approach allowed for a thorough exploration and mapping of the cervical nerve in relation to its surrounding anatomical structures. RESULTS: Upon exiting the parotid gland, the cervical nerve consistently traveled beneath the investing layer of the deep cervical fascia for a brief distance, traversing the deep fascia to travel within the areolar connective tissue before terminating anteriorly in the platysma muscle. A single branch was observed in 2 cases, while 2 branches were noted in 18 cases. CONCLUSIONS: The cervical nerve's relatively deeper position below the mandible's angle facilitates a safer subplatysmal dissection via a lateral approach for the release of the cervical retaining ligaments. Due to the absence of a protective barrier, the nerve is more susceptible to injuries from direct trauma or thermal damage caused by electrocautery, especially during median approaches.
Assuntos
Cadáver , Nervo Facial , Ritidoplastia , Humanos , Ritidoplastia/métodos , Ritidoplastia/efeitos adversos , Feminino , Nervo Facial/anatomia & histologia , Masculino , Idoso , Pescoço/anatomia & histologia , Pescoço/inervação , Pescoço/cirurgia , Pessoa de Meia-Idade , Esvaziamento Cervical/efeitos adversos , Sistema Musculoaponeurótico Superficial/anatomia & histologia , Sistema Musculoaponeurótico Superficial/cirurgia , Glândula Parótida/anatomia & histologia , Glândula Parótida/cirurgia , Glândula Parótida/inervação , Músculos do Pescoço/inervação , Músculos do Pescoço/anatomia & histologia , Idoso de 80 Anos ou maisRESUMO
A deep comprehension of key anatomical issues, along with the targeted application of suitable therapies, is vital for attaining exceptional neck contours. Traditional surgical approaches often focus solely on modifying subcutaneous fat and, occasionally, the platysma muscle, neglecting subplatysmal structures. This narrow focus may yield less-than-ideal results and potentially exacerbate existing issues, leading to additional contour abnormalities that prove challenging to correct. In fact, in most cases, there are additional factors deep to the platysma-such as subplatysmal fat, the anterior bellies of the digastric muscles, perihyoid fascia, and the submandibular glands-that contribute to obtuse neck contours. For these patients, accessing the neck through a submental incision allows for precise management of these deep neck structures as required. Unfamiliarity with deep anatomical structures can deter surgeons from performing subplatysmal procedures due to unwarranted concerns about increased complication risks. However, both published clinical series and our clinical experience indicate favorable long-term outcomes with natural, refined, harmonious neck contours and a minimal rate of complications. This article serves as a comprehensive guide, describing indications, strategies, and providing a step-by-step description of the senior author's techniques for mastering deep neck contouring.
RESUMO
BACKGROUND: Opening the neck through a submental incision allows accurate management of deep neck structures and results in exceptional neck contours. OBJECTIVES: The authors aimed to evaluate the distribution of deep neck structures and investigate the detailed vascular anatomy of the submandibular gland. METHODS: A total of 26 fresh frozen cadaver heads (15 female, 11 male) were utilized. The authors evaluated the weights of the excised tissues simulating cosmetic resections, including subcutaneous fat, subplatysmal fat, the anterior belly of the digastric muscle, and submandibular glands. The vascular supply of the submandibular gland and intracapsular vessel diameters were also investigated. RESULTS: Whereas female cadavers had greater mean tissue weight removed from the supraplatysmal plane (mean 20.9 g, 56.6%) than the subplatysmal plane (16 g, 43.4%), male cadavers had higher mean tissue weight removed from the subplatysmal plane (10.5 g, 60.7%) than the supraplatysmal plane (mean 6.8 g, 39.3%). The mean subcutaneous (6.8 g) and subplatysmal (6.4 g) fat weights were almost equal in male cadavers; mean subcutaneous fat weight (20.9 g) was 3 times higher than subplatysmal fat weight (6.8 g) in female cadavers. There was a statistically significant relationship between body mass index and fat removed. The intraglandular vessel diameters increased as resections approached the main feeding vessels located posterosuperior (facial artery) and anterosuperior (submental artery) to the submandibular gland. CONCLUSIONS: The results suggest that to achieve exceptional neck contour the structures deep to the platysma often need to be addressed. The submandibular gland reduction can be safely performed with comprehensive understanding of its vascular anatomy.
Assuntos
Procedimentos de Cirurgia Plástica , Glândula Submandibular , Humanos , Masculino , Feminino , Glândula Submandibular/cirurgia , Glândula Submandibular/anatomia & histologia , Pescoço/cirurgia , Músculos do Pescoço/anatomia & histologia , Músculos do Pescoço/cirurgia , CadáverRESUMO
Facelift techniques can be classified according to the depth and extent of the dissection applied. Imbrication and plication of the superficial musculoaponeurotic system (SMAS) referred to as "SMAS lifts" or "classical facelifts" are the most commonly used techniques. Plication techniques involve in-folding of the SMAS and suture suspension without any SMAS incision whereas imbrication techniques involve a SMAS incision with a portion of the SMAS either removed or transposed with or without limited sub-SMAS dissection. Aging changes in the lower face and neck can be successfully treated with SMAS lift techniques. However, there is no lifting effect at midface level or improvement in the nasolabial folds since the retaining (zygomatic cutaneous and masseteric cutaneous) ligaments that prevent the transmission of traction to the malar portion of the facelift dissection are not released. Extended facelift techniques involve surgical release of these ligaments, and produce combined, balanced, and harmonious rejuvenation of the midface, cheek, and lower face without requiring a separate midface lift procedure. There are different techniques having similar extended midface dissections with some variations: The extended SMAS technique involves a long skin flap and a distinct SMAS flap dissected and pulled separately. The high SMAS technique has a similar dissection but involves a higher SMAS flap along the superior border of the zygomatic arch. The deep plane facelift involves undermining of skin-SMAS flap as a single unit following a more limited subcutaneous dissection. In the composite plane facelift, in addition to deep plane facelift dissection, the lower part of the orbicularis oculi muscle is also dissected and included in the flap. As they have a single unit, deep and composite flap facelifts allow excellent blood supply to the overlying skin. In this article, various facelift techniques are discussed in detail in line with the relevant surgical anatomy.
Assuntos
Ritidoplastia , Sistema Musculoaponeurótico Superficial , Humanos , Ritidoplastia/métodos , Sistema Musculoaponeurótico Superficial/cirurgia , Pescoço/cirurgia , Retalhos Cirúrgicos , Sulco Nasogeniano/cirurgiaRESUMO
The attenuation of retaining ligaments with aging leads to downward displacement of facial fat compartments and is responsible for many of the stigmata that occur with aging. The zygomatic cutaneous and masseteric cutaneous ligaments prevent the transmission of adequate traction to the malar portion of the dissection during traditional low superficial muscular aponeurotic system (SMAS) facelift techniques which involve plication or imbrication of the exposed surface of the SMAS because they do not include surgical release of these ligaments. Inadequate release of these ligaments, especially the zygomatic cutaneous ligament may lead to an unbalanced, unnatural appearance with unopposed nasolabial folds. In contrast, extended facelift techniques (extended SMAS, high SMAS, deep plane facelift, and composite plane facelift) involving the release of these ligaments and can reposition the ptotic malar fat and diminish the nasolabial folds. Additionally, the composite and modified composite plane facelifts include orbicularis oculi muscle elevation and can achieve a more harmonious rejuvenation. However, due to facial nerve injury risk, many facelift surgeons either inadequately release these ligamentous attachments or prefer less-invasive techniques. Modified composite plane facelift allows safe release of the zygomatic cutaneous ligament, and safe entry into the right plane leaving all malar fat pad attached to the skin. Modified composite plane facelift technique also produces combined, balanced, and harmonious rejuvenation of the midface, cheek, lower face, and neck without requiring a separate midface lift procedure or a transblepharoplasty approach. Extending the sub-SMAS/subplatysmal dissection inferior to the angle of mandible, releasing of the cervical retaining ligaments, and adding a horizontal platysma myotomy below the angle of the mandible significantly improve the cervical contouring and enhances the jawline rejuvenation. This study explains modified composite-flap facelift with extended neck dissection in a step-by-step manner and highlights anatomical details to perform a safe, effective, and successful extended face and neck lift surgery.
Assuntos
Ritidoplastia , Sistema Musculoaponeurótico Superficial , Humanos , Ritidoplastia/métodos , Esvaziamento Cervical , Sistema Musculoaponeurótico Superficial/cirurgia , Pescoço/cirurgia , Retalhos CirúrgicosAssuntos
Ritidoplastia , Envelhecimento da Pele , Livros , Humanos , Rejuvenescimento , Ritidoplastia/métodosRESUMO
The subciliary lower eyelid blepharoplasty has evolved considerably to create a more harmonious natural appearance with a fuller and unoperated look and also to minimize the complications. While lower eyelid malposition was very common in the past, now this complication is significantly reduced by attention to preoperative evaluation, meticulous surgical planning, precise surgical technique, and postoperative care. Various prophylactic maneuvers maintaining/strengthening lower lid support can be utilized to prevent lower lid malposition including preservation of the pretarsal orbicularis oculi muscle, conservative resection of skin and muscle, and suspension of the orbicularis oculi muscle and/or tarsus to the periosteum of the lateral orbital rim. The release of the orbicularis retaining ligament and surgical transposition of orbital fat over the rim rather than excision allows for smoothing of the lid-cheek junction, filling the tear trough deformity, and reducing the appearance of bulging fat in the lower eyelid. In this article the reader will find a comprehensive approach for achieving a smooth contour with gradual blending at the lower eyelid-cheek junction while maintaining/restoring normal lower lid support. A descriptive outline of postoperative care is also provided to help in optimal healing for the patient.
Assuntos
Blefaroplastia , Doenças Palpebrais , Bochecha/cirurgia , Pálpebras/cirurgia , Músculos Faciais , HumanosRESUMO
Preservation of the facial nerve is crucial in any type of facial procedure. This is even more important when performing plastic surgery on the face. An intricate knowledge of the course of the facial nerve is a requisite prior to performing facelifts, regardless of the technique used. The complex relationship of the ligaments and the facial nerve may put the nerve at an increased risk of damage, especially if its anatomy is not fully understood. There are several danger zones during dissection where the nerve is more likely to be injured. These include the areas where the nerve branches become more superficial in the dissection plane, and where they traverse between the retaining ligaments of the face. Addressing these ligaments is crucial, as they prevent the transmission of traction during facelifts. Without sufficient release, a satisfying pull on the soft tissues may be limited. Traditional superficial musculoaponeurotic system techniques such as plication or imbrication do not include surgical release of these attachments. Extended facelift techniques include additional dissection to release the retaining ligaments to obtain a more balanced and healthier look. However, these techniques are often the subject of much debate due to the extended dissection that carries a higher risk of nerve complications. In this article we aim to present the relationship of both the nerve and ligaments with an emphasis on the exact location of these structures, both in regard to one another and to their locations within the facial soft tissues, to perform extended techniques safely.
Assuntos
Ritidoplastia , Sistema Musculoaponeurótico Superficial/cirurgia , Face/cirurgia , Nervo Facial , Ligamentos/cirurgiaRESUMO
BACKGROUND: Inadequate release of retaining ligaments during facelift surgery may lead to an unnatural appearance. However, most facelift surgeons are hesitant in transecting these ligaments to avoid possible injury to facial subbranches. OBJECTIVES: In the authors' surgical practice for modified composite flap rhytidectomy, the authors employed the finger-assisted malar elevation (FAME) technique in order to enable safe release of the zygomatic cutaneous ligaments through the prezygomatic space under direct vision. The aim was to evaluate the anatomical basis and safety measures of this technique through a cadaveric dissection study. METHODS: Modified composite-flap facelift with the FAME technique was carried out in 22 fresh cadaver hemi-faces. All facial nerve subbranches were dissected thoroughly to assess for any evidence of injury during facelift, and to evaluate the safety of the operation. The relations among the facial nerve, zygomatic cutaneous and masseteric ligaments, orbicularis oculi muscle, and malar fat pad were investigated. RESULTS: Finger dissection of the prezygomatic space allows safe release of the zygomatic cutaneous ligaments as well as adequate entry to a proper surgical plane above the zygomatici muscles under direct vision, while leaving the malar fat pad and overlying structures attached to the skin without the need of a transblepharoplasty approach. CONCLUSIONS: This study by the authors shows that a modified composite-flap facelift with FAME technique is a safe procedure that allows adequate and effective repositioning of an en-bloc composite flap that produces balanced and harmonious rejuvenation of the midface and lower face without the need of a separate midface lift.
Assuntos
Retalho Miocutâneo , Rejuvenescimento , Ritidoplastia/métodos , Adulto , Idoso , Cadáver , Bochecha , Músculos Faciais/transplante , Feminino , Humanos , Ligamentos/cirurgia , Masculino , Pessoa de Meia-IdadeRESUMO
Patients with thick skin typically present with a redundant, baggy, lax skin envelope together with prominent nasolabial folds, jowls, and a heavy neck. Durable and natural-appearing rejuvenation is not possible unless the deformities are addressed adequately and harmoniously in these patients. Traditional superficial musculoaponeurotic system techniques do not include surgical release of the zygomatic cutaneous ligaments and repositioning of descendent malar fat pad, and may lead to an unbalanced, unnatural appearance and the lateral sweep phenomenon. Additional attempts to improve unopposed nasolabial folds such as fat grafting to malar region are more likely to result with a "stuffed" look, far from a natural and rejuvenated appearance, and must therefore be avoided. The facelift techniques including true release of the anchoring ligaments of the midface and allowing adequate repositioning of saggy tissues are ideal for these patients to obtain harmonious, natural result. Despite the extensive dissections, maximal release, and maximal lateral pull, additional maneuvers, e.g., platysmaplasty, subplatysmal fat removal, or partial resection of submandibular glands may be required for satisfying result in patients with heavy neck. In this article, the authors outline the relevant anatomy of the facial retaining ligaments and their implications to surgical management of patients with heavy skin are discussed.
Assuntos
Ligamentos/cirurgia , Sulco Nasogeniano/cirurgia , Pescoço/cirurgia , Ritidoplastia/métodos , Cicatrização/fisiologia , Cicatriz/prevenção & controle , Estética , Feminino , Humanos , Ligamentos/anatomia & histologia , Masculino , Sulco Nasogeniano/anatomia & histologia , Pescoço/anatomia & histologia , Rejuvenescimento/fisiologia , Medição de Risco , Envelhecimento da Pele/fisiologia , Técnicas de SuturaRESUMO
IMPORTANCE: The saddle nose deformity is one of the most challenging problems in nasal surgery with a less predictable and reproducible result than other nasal procedures. The main feature of this deformity is loss of septal support with both functional and aesthetic implications. Most reports on saddle nose have focused on aesthetic improvement and neglected the reestablishment of septal support to improve airway. OBJECTIVES: To explain how the Cakmak algorithm, an algorithm that describes various fixation techniques and grafts in different types of saddle nose deformities, aids in identifying saddle nose reconstructions that restore supportive nasal framework and provide the aesthetic improvements typically associated with procedures to correct saddle nose deformities. DESIGN, SETTING, AND PARTICIPANTS: This algorithm presents septal support reconstruction of patients with saddle nose deformity based on the experience of the senior author in 206 patients with saddle nose deformity. Preoperative examination, intraoperative assessment, reconstruction techniques, graft materials, and patient evaluation of aesthetic success were documented, and 4 different types of saddle nose deformities were defined. MAIN OUTCOMES AND MEASURES: The Cakmak algorithm classifies varying degrees of saddle nose deformity from type 0 to type 4 and helps identify the most appropriate surgical procedure to restore the supportive nasal framework and aesthetic dorsum. RESULTS: Among the 206 patients, 110 women and 96 men, mean (range) age was 39.7 years (15-68 years), and mean (range) of follow-up was 32 months (6-148 months). All but 12 patients had a history of previous nasal surgeries. Application of the Cakmak algorithm resulted in 36 patients categorized with type 0 saddle nose deformities; 79, type 1; 50, type 2; 20, type 3a; 7, type 3b; and 14, type 4. Postoperative photographs showed improvement of deformities, and patient surveys revealed aesthetic improvement in 201 patients and improvement in nasal breathing in 195 patients. Three patients developed postoperative infection and 21 patients underwent revision septal surgery. CONCLUSIONS AND RELEVANCE: The goal of saddle nose reconstruction should be not only to restore an aesthetic dorsum but also to restore the supportive nasal framework. The surgeon should provide more projected and strengthened septal support before augmentation of saddle nose deformity to improve breathing and achieve a stable long-term result. The Cakmak algorithm is a mechanism that helps surgeons identify the most effective way to maximize septal support and aesthetic appeal. LEVEL OF EVIDENCE: 4.
Assuntos
Algoritmos , Técnicas de Apoio para a Decisão , Septo Nasal/cirurgia , Deformidades Adquiridas Nasais/cirurgia , Rinoplastia/métodos , Adolescente , Adulto , Idoso , Estética , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Reoperação , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVES/HYPOTHESIS: To achieve injectable tissue-engineered cartilage using a commercially available fibrin sealant, and to determine the most suitable fibrin glue concentration, cartilage source, and cultured chondrocyte concentration. STUDY DESIGN: Animal research. METHODS: A total of 28 immunocompetent New Zealand white rabbits were divided into four groups. The cultured chondrocytes from different anatomical sources carried in fibrin glue with and without aprotinin in different concentrations of fibrinogen and thrombin (Tisseell), were injected into forehead and interocular regions of the rabbits. The new tissue formation was harvested at 8 weeks and analyzed through gross and histological analysis. RESULTS: The new tissue formations were found in round, elliptical, and flat forms. The mean value of Tisseell and cell suspension was 0.8 cc in all of the rabbits' injection regions, but the mean volume of the samples in which immature cartilage matrix and mature cartilage was 0.1 cc. In the 20 of the 55 injection regions of rabbits (36, 36%), mature and/or immature cartilage formation were observed. We observed inflammatory reactions, abscess formation, and foreign body reactions around the new cartilage tissue of tissue-engineered cartilage. The comparison of results using different cartilage sources, chondrocyte concentrations, or different fibrin glue concentrations did not show any significant difference. CONCLUSIONS: We observed that changing the concentrations of ingredients of commercially available fibrin glue, the source of the cartilage, or the cultured chondrocyte concentration did not have significant effect on neocartilage formation.
Assuntos
Cartilagem/transplante , Anormalidades Craniofaciais/cirurgia , Adesivo Tecidual de Fibrina/administração & dosagem , Engenharia Tecidual/métodos , Animais , Células Cultivadas , Condrócitos/citologia , Condrócitos/transplante , Modelos Animais de Doenças , Injeções , Coelhos , Adesivos Teciduais/administração & dosagemRESUMO
Currently, filling, smoothing, or recontouring the face through the use of injectable fillers is one of the most popular forms of cosmetic surgery. Because these materials promise a more youthful appearance without anesthesia in a noninvasive way, various fillers have been used widely in different parts of the world. However, most of these fillers have not been approved by the Food and Drug Administration, and their applications might cause unpleasant disfiguring complications. This report describes a case of foreign body granuloma in the cheeks secondary to polyethylene glycol injection and shows the possible complications associated with the use of facial fillers.
Assuntos
Implantes Absorvíveis/efeitos adversos , Técnicas Cosméticas/efeitos adversos , Granuloma de Corpo Estranho/etiologia , Polietilenoglicóis/efeitos adversos , Adulto , Bochecha , Feminino , Granuloma de Corpo Estranho/patologia , Humanos , Injeções , Imageamento por Ressonância Magnética , Polietilenoglicóis/administração & dosagemRESUMO
BACKGROUND: Cartilage grafts are frequently used in nasal surgery for structural and/or aesthetic purposes. The literature holds contradictory reports concerning the effect of crushing on the viability of cartilage grafts. METHODS: Nasal septal and costal cartilage grafts were harvested from 12 New Zealand rabbits. Each nasal septal and costal cartilage was divided into five equal pieces. One of the pieces was left intact and the remaining four were prepared as slightly, moderately, severely, or significantly crushed. The cartilage pieces were then autoimplanted into the paravertebral skin of the rabbits. The animals were euthanized 4 months later and the effect of crushing on cartilage grafts was assessed pathologically. RESULTS: The viability of the chondrocytes was found to be decreased as the level of crushing increased. The mean chondrocyte viability rates for the intact, slightly crushed, moderately crushed, severely crushed, and significantly crushed cartilages were 88, 75, 51, 41, and 13 percent for the septal cartilages and 94, 83, 62, 32, and 26 percent for the costal cartilages, respectively. The differences between the mean viability rates of septal and costal cartilage groups were statistically not significant. CONCLUSIONS: The level of crushing determines the rate of viability for the crushed cartilage. Viability rates and the clinical properties of the slightly crushed cartilage grafts at long-term follow-up may be similar to those of the intact cartilage grafts. However, severe or significant crushing leads to a decrement in the viability of the chondrocytes and may cause unpredictable degrees of volume loss at long-term follow-up.