The Deep Fascia of the Infraorbital Region, Deep Plane, and Suprafibromuscular Facelift: New Anatomy for Safer Facelifting.

Deep-plane rhytidectomy, first described by Skoog, has had a resurgence in popularity and is in high demand today. We describe anatomical findings that establish the presence of a true deep fascia in the midface, we named as Chiara's fascia, like the first author's first name, which helps to form the facial ligaments and is contiguous with the superficial layer of the deep temporal fascia. This fascia inserts on the periosteum of the inferior orbital rim at the arcus marginalis and separates the suborbicularis oculi fat (SOOF) from the preperiosteal fat. This distinct fascial layer lies under the superficial fascia or superficial musculoaponeurotic system (SMAS) and represents the floor of what is commonly termed the "deep plane." When this fascial highway is identified intraoperatively, blunt dissection immediately superficial to this layer will protect facial nerve branches overlying the muscles lifting the upper lip such as the zygomaticus. Subsequent dissection over the middle and lower face can usually be performed bluntly. Over a 10-year period, a total of 100 hemifaces were dissected with a 100% success rate of identifying this fascia in all specimens. This work was further validated by examining histologic specimens that clearly demonstrate this unique fibrofatty fascial layer. These dissections and new anatomical findings were then correlated to over 300 intraoperative deep-plane facelift cases by the primary and senior authors. We term this operative technique as the suprafibromuscular facelift. Dissection in this plane allows for safe release of facial retaining ligaments with protection of facial nerve branches.

Wide-undermining neck liposuction: tips and tricks for good results.

BACKGROUND: Neck rejuvenation is one of the most sought after procedures in the restoration of the facial contour. Numerous techniques to improve the aesthetic outcome and reduce downtime have been described. In our experience, wide undermining and local anesthesia are key to obtaining good results in selected patients who want a quick recovery. This article presents our experience with liposuction of the neck and proposes some tips and tricks to master wide-undermining neck liposuction. METHODS: From January 2005 to September 2012, a total of 118 patients (34 males, 84 females) underwent neck liposuction. Patient selection was based mainly on age and neck-aging features. The procedure was performed with the patients under local anesthesia. A wide rhomboid-shaped skin undermining of the submandibular and neck area was performed and a very thin fat layer was preserved. Dressing was applied for 3 days. RESULTS: Improvement of the neck's contour was observed in all patients. Redefinition of the cervicomandibular angle and skin redraping of the cervical area occurred in all cases. No further touch-ups were needed. Edema and ecchymosis resolved in a few days. No major complications were observed. CONCLUSIONS: Our results show that wide-undermining neck liposuction performed under local anesthesia is an effective and safe procedure. Patient selection based on age and anatomical features was fundamental to obtain impressive improvement of neck contour. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The suborbicularis oculi fat (SOOF) and the fascial planes: has everything already been explained?

IMPORTANCE: During anatomic and surgical dissections, a connection was seen between the superficial layer of the deep temporal fascia and the prezygomatic area. These findings were in contrast to previous evaluations. This study defines this connection, which is important to understand from both surgical and anatomic standpoints. OBJECTIVE: To define the connection between the superficial layer of the deep temporal fascia and the prezygomatic area and demonstrate the presence of a deep fascial layer in the midface. DESIGN AND SETTING: Anatomical study performed at the Laboratoire d'Anatomie de la Faculté de Médecine de Nice, Sophia Antipolis, France; at the Centre du Don des Corps de l'Université Paris Descartes, Paris, France; and at the Department of Experimental Medicine, Histology, and Embryology Unit of the University of Pavia, Pavia, Italy. Twenty-four hemifaces of 14 white cadavers were dissected to define the relationship between deep temporal fascia and the midface. Four biopsy samples were harvested for histologic analysis. MAIN OUTCOMES AND MEASURES: Dissection of 24 hemifaces from the fresh cadavers revealed the following findings. There is a connection of the deep fascia of the temple (superficial layer of deep temporal fascia) to the midface that divides the fat deep to the orbicularis muscle into 2 layers. One layer of fat is the so-called suborbicularis oculi fat (SOOF), which is superficial to the deep fascia, and the other layer of fat (preperiosteal) is deep to the deep fascia and adherent to malar bone. These findings are in contrast to previous anatomical findings. RESULTS In 12 hemifaces, the superficial layer of the deep temporal fascia directly reached the prezygomatic area as a continuous fascial layer. In 16 hemifaces, the superficial sheet of the deep temporal fascia inserted at the level of the zygomatic and lateral orbital rim and continued as a deep fascial layer over the prezygomatic area. In all specimens, a deep fascial layer was present in the prezygomatic-infraorbital area. This deep fascial layer is adherent to the muscles of the infraorbital area, and it divided the fat located deep to the orbicularis oculi muscle into 2 layers: the SOOF and a deeper layer. Histologic examination of the biopsy samples confirmed these findings. CONCLUSIONS AND RELEVANCE: This study demonstrates the existence of a deep fascial layer in the midface. This fascia is connected to the superficial layer of the deep temporal fascia, and it divides the fat deep to the orbicularis oculi muscle into 2 layers. This new finding carries interesting implications related to the classic concept of the superficial musculoaponeurotic system. LEVEL OF EVIDENCE: NA.

Nasal arterial vasculature: medical and surgical applications.

OBJECTIVES: To analyze the nasal superficial arterial vasculature and to compare these anatomic findings with the results of ultrasonography Doppler investigations to evaluate nasal blood flow in physiological and pathologic conditions. METHODS: We performed 40 ultrasonography Doppler investigations in patient volunteers, 20 facial anatomic dissections in fresh cadavers, and a review of the literature on nasal blood supply. In cadavers, facial arteries were dissected to analyze nasal arterial supply. RESULTS: When the facial artery, the ophthalmic artery, or both were compressed on 1 side in volunteers, blood flow inversion was proved by ultrasonography Doppler investigation at the level of the nasal area. These results confirm anatomic findings that demonstrate a polygonal system. CONCLUSIONS: A schema of nasal blood supply as a polygonal system connecting the external and internal carotid systems is proposed. This facilitates our understanding of anatomic variations, physiological and pathologic modifications of blood flow, and nasal reconstructions with local flaps and medical rhinoplasties using filler injections.

The web lift and posterior pull for the aging face.

There are many factors that contribute to the aging neck. We have recently begun employing a percutaneous suture spanning the submentum combined with a posterior platysma pull. We present our initial results with this technique. In this retrospective study, subjects underwent the combined procedure with and without concomitant rhytidectomy. Cephalometric analysis was used to compare the preoperative cervicomental angle (CMA) and hyomental distance (HMD) with postoperative values at 4 weeks. Subjects also were queried on their postoperative satisfaction. Twenty-five subjects were included in this study. At 4 weeks postoperatively, we achieved significant reductions in the average CMA (134.8 versus 122.8, p = 0.002). The postoperative HMD significant increased an average of 1.9 cm (8.5 versus 10.4, p = 0.009). We achieved a 92.3% satisfaction score at 33 weeks (range = 25 to 44). The combination of a percutaneous suture across the submentum and a posterior platysma pull is a safe and effective method of addressing the many facets of the aging neck. Our initial results are easily reproducible and entail minimal morbidity to the patient.

An anatomical study of the nasal superficial musculoaponeurotic system: surgical applications in rhinoplasty.

OBJECTIVE: To give a unifying description of nasal muscles and ligaments corresponding to anatomical and surgical findings such as the dermocartilaginous ligament described by Pintanguy in 2001. METHODS: In 30 fresh cadavers of white individuals, nasal dissections were performed, divided into 3 different approaches: from radix to nasal tip, from nasal tip to radix, and from midline to lateral. The anatomical and surgical planes of dissection were followed to isolate the nasal superficial musculoaponeurotic system (SMAS). Correlations between the nasal SMAS and the nasal framework were noticed. In 9 specimens, the left nasal wall was resected for histologic examination. RESULTS: The nasal SMAS consists of a unique layer, and it divides at the level of the nasal valve into deep and superficial layers. Each layer has medial and lateral components. The dermocartilaginous ligament corresponds to the deep medial expansion. Both the deep and the superficial medial expansions correspond to the lowering ligaments of the nasal tip; the cephalic rotation of the nasal tip is allowed by their cut. The histological examination showed that the deep lateral expansion is composed of fat. CONCLUSIONS: This description of the nasal SMAS explains the relationship between the nasal muscles and ligaments, including the dermocartilaginous ligament described by Pitanguy. Furthermore, it is helpful to surgeons during rhinoplasty.

The central role of the nose in the face and the psyche: review of the nose and the psyche.

BACKGROUND: According to statistics released by the American Society of Plastic Surgeons in 2006, rhinoplasty is one of the most sought after aesthetic surgeries by ethnic patients and teenagers. It also is the most requested aesthetic operation by patients with body dysmorphic disorder. The psychosocial aspect of rhinoplasty is undeniable. Tagliacozzi in 1567 and Joseph more than a century ago were already aware of this aspect. METHODS: Using the terms "rhinoplasty," "patients selection," "psychological aspect," and psychological outcome," 30 studies were selected through searches of the MEDLINE, PUBMED, and EMBASE databases,. This review aimed to analyze how the most acknowledged experts of psychology, facial plastic surgery, and plastic surgery who have worked on the psychological outcome for rhinoplasty during the past century considered the nose-psyche relationship and the influence of rhinoplasty at the psychological level. RESULTS: The link between rhinoplasty, psychology, and social environment has been discussed by many important authors during the past century. All of them, independently of their field of study, have stressed that it is critical for surgeons to be aware of their responsibility regarding both the physical and emotional levels. There is evidence that an official preoperative interview is lacking. CONCLUSIONS: To recognize the importance of rhinoplasty's psychological implications, it is critical to make a good selection of patients seeking this operation and to have a good outcome. To this end, the preoperative interview is fundamental. Surgeons should be competent at both the psychological and surgical levels.