Lifting the Anterior Midcheek and Nasolabial Fold: Introduction to the Melo Fat Pad Anatomy and Its Role in Longevity and Recurrence.

BACKGROUND: A limitation of current facelift techniques is the early postoperative reappearance of anterior midcheek laxity associated with recurrence of the nasolabial fold (NLF). OBJECTIVES: This study was undertaken to examine the regional anatomy of the anterior midcheek and NLF with a focus on explaining the early recurrence phenomenon and to explore the possibility of alternative surgical methods that prolong NLF correction. METHODS: Fifty cadaver heads were studied (16 embalmed, 34 fresh; mean age, 75 years). Following preliminary dissections and macrosectioning, a series of standardized layered dissections were performed, complemented by histology, sheet plastination, and microcomputed tomography. Mechanical testing of the melo fat pad (MFP) and skin was performed to gain insight on which structure is responsible for transmission of the lifting tension in a composite facelift procedure. RESULTS: Anatomic dissections, sheet plastination, and microcomputed tomography demonstrated the 3-dimensional architecture and borders of the MFP. Histology of a lifted midcheek demonstrated that a composite MFP lift causes a change in connective tissue organization from a hanging-down pattern into a pulled-upward pattern, suggesting traction on the skin. Mechanical testing confirmed that, in a composite lift, despite the sutures being placed directly into the deep aspect of the MFP, the lifting tension distal to the suture is transmitted through the skin and not through the MFP. CONCLUSIONS: The usual method of performing a composite midcheek lift results in the skin, and not the MFP itself, bearing the load of the nondissected tissues distal to the lifting suture. For this reason, early recurrence of the NLF occurs following skin relaxation in the postoperative period. Accordingly, specific surgical procedures for remodeling the MFP should be explored, possibly in combination with volume restoration of the fat and bone, for more lasting improvement of the NLF.

The Functional Anatomy and Innervation of the Platysma is Segmental: Implications for Lower Lip Dysfunction, Recurrent Platysmal Bands, and Surgical Rejuvenation.

BACKGROUND: Despite the central role of the platysma in face and neck rejuvenation, much confusion exists regarding its surgical anatomy. OBJECTIVES: This study was undertaken to clarify the regional anatomy of the platysma and its innervation pattern and to explain clinical phenomena, such as the origin of platysmal bands and their recurrence, and the etiology of lower lip dysfunction after neck lift procedures. METHODS: Fifty-five cadaver heads were studied (16 embalmed, 39 fresh, mean age 75 years). Following preliminary dissections and macro-sectioning, a series of standardized layered dissections were performed, complemented by histology and sheet plastination. RESULTS: In addition to its origin and insertion, the platysma is attached to the skin and deep fascia across its entire superficial and deep surfaces. This composite system explains the age-related formation of static platysmal bands, recurrent platysmal bands after complete platysma transection, and recurrent anterior neck laxity after no-release lifting. The facial part of the platysma is primarily innervated by the marginal mandibular branch of the facial nerve, whereas the submandibular platysma is innervated by the "first" cervical branches, which terminate at the mandibular origin of the depressor labii inferioris. This pattern has implications for postoperative dysfunction of the lower lip, including pseudoparalysis, and potential targeted surgical denervation. CONCLUSIONS: This anatomical study, comprised of layered dissections, large histology, and sheet plastination, fully describes the anatomy of the platysma including its bony, fascial, and dermal attachments, as well as its segmental innervation including its nerve danger zones. It provides a sound anatomical basis for the further development of surgical techniques to rejuvenate the neck with prevention of recurrent platysmal banding.

"The Deep Fascia of the Head and Neck Revisited: Relationship with the Facial Nerve and Implications for Rhytidectomy".

INTRODUCTION: The deep fascia is important in facelift surgery as it is relied on for protection of the facial nerve during surgical dissection. Lack of consistency with the term may be due to the term deep fascia having two different meanings. It is a specific type of connective tissue, classically, thin, fibrous and flat. Whereas, in the description of the layers of the face and neck, the deep fascia layer includes all the connective tissue deep to the superficial fascia layer. This cadaver study was undertaken to clarify the layered anatomy of the face and neck and its relationship with the facial nerve branches. MATERIALS METHODS: Preliminary dissections and macro sectioning, followed by a conclusive series of standardized layered dissections, histology and sheet plastination, was performed on fifty cadaver heads. RESULTS: The deep fascia is thin in convex areas of the face and neck, while thicker in concave areas, it being interspersed with deep fat. The facial nerve branches, after emerging from the parotid gland, are embedded within the deep fascia, not deep to it. They transition from deep within the deep fascia at specific locations to course in the most superficial part of the deep fascia where they underlie their target superficial fascia muscles and are at risk from deep plane facelift dissection. CONCLUSION: The deep fascia layer is a multilamellar fibrofatty layer of variable thickness, which includes the deep fat in which the facial nerve branches are embedded. In deep plane facelift surgery, dissection must be performed in the most superficial level of this deep fascia layer. LEVEL OF EVIDENCE: No level of evidence is needed for Cadaver Study Articles.

The Superficial Musculo-Aponeurotic System (SMAS): Does it Really Exist as an Anatomic Entity?

INTRODUCTION: The exact anatomic entity behind the term superficial musculoaponeurotic system (SMAS) remains poorly understood. The different interpretations of the term SMAS by anatomists, surgeons and histologists have caused confusion. This study aims to provide clarity regarding this term and the relevant anatomy. MATERIALS METHODS: A literature review was conducted to uncover the variety of descriptions of the term SMAS. A feasibility study, followed by a conclusive series of standardized layered dissections, complemented by histology and sheet plastination was performed on fifty cadaver heads (16 embalmed, 34 fresh, mean age 75 years). RESULTS: Most literature considers the SMAS as layer 3, i.e., a musculoaponeurotic layer that separates the subcutaneous fat of the superficial fascia from the deep fat of the deep fascia. Our dissections, histology and sheet plastination demonstrated that a layer 3 is present only where there are flat mimetic muscles and platysma-auricular fascia over the posterior part of the parotid gland as the evolutionary remnant of the platysma, but not between the flat mimetic muscles. Here, the subcutaneous fat is in direct contact with the deep fat without the interposition of a musculo-aponeurotic layer 3. CONCLUSION: Due to the absence of a distinct and complete layer 3 connecting the flat mimetic muscles, we conclude that the SMAS as originally concepted does not exist as a specific anatomical entity. In retrospect, the surgically created compound layered flap composed of a variable thickness of subcutaneous fat, mimetic muscles (platysma, orbicularis oculi, …), and a thin layer of deep fascia, is what is known as the "SMAS". LEVEL OF EVIDENCE: No level of evidence is needed for Cadaver Study Articles.

Aesthetic Enhancement of the Brow using Hydroxyapatite.

BACKGROUND: An aesthetically pleasing appearance of the 'eyes' usually includes good projection of the outer brow. Weak bony projection of the superolateral periorbital region tends to be not only less attractive, but also predisposes to hooding over the temporal part of the upper lid. Congenital lack of skeletal volume is exacerbated by ageing due to lipoatrophy and soft tissue laxity. The rationale and technique for performing skeletal augmentation of the superolateral orbital rim is described, along with long-term results from a series of cases. MATERIAL AND METHODS: A series of patients having augmentation of the superolateral orbital rim, using the technique described, were evaluated. A forehead crease incision was used, then a precise subperiosteal pocket developed in the lateral brow region between the supraorbital foramen and the superior temporal septum. The hydroxyapatite granule mixture was incrementally placed using modified syringes. The patients were followed to assess the long-term results. RESULTS: Two hundred and fifty patients, 80% women, mean age = 53 years [range 23-78] underwent supraorbital rim augmentation using subperiosteal hydroxyapatite granules, during a 12-year period, commencing in 2007. The mean follow-up was 41 months (range 1-12 years). The mean volume used for augmentation was 1.0 mL per side (range 0.4-2.3 mL). Projection of the upper lateral periorbital prominence was effectively increased, resulting in enhancement of the brow position and shape. Twenty-seven patients (11%) had an undercorrection, requiring additional volume augmentation, all during the first three years of the experience. Twelve patients (5%) required correction of contour irregularities. There were no infections and no long-term complications. Resorption of the hydroxyapatite volume over time was not noted. CONCLUSION: The aesthetic significance of superolateral orbital rim projection is introduced. Patients who have a degree of skeletal deficiency of the zygomatic process of the frontal bone should be considered for hydroxyapatite augmentation of the bone as a complement to upper lid blepharoplasty and brow elevation. This procedure should be considered in the spectrum of upper periorbital aesthetic procedures. LEVEL OF EVIDENCE IV: 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 .

Upper Blepharoplasty - Nuances for Success.

Given the central importance of the "eyes," meaning the periorbital region, to facial appearance, the motivated blepharoplasty patient has the opportunity to improve appearance significantly beyond the minimum of age reversal, to reveal inner beauty or add attractiveness. Bright and beautiful eyes have good three-dimensional contouring. The benefits of a quality eyelid crease enable the surgical focus to be on lid contouring with a reduced requirement for lid skin and fat excision. A durable crease maintains fixation of both the tarsal and infrabrow segments. The softness of youthful eyes can be regained by precise, but cautious, use of lipofilling.

The Lymphatic Anatomy of the Lower Eyelid and Conjunctiva and Correlation with Postoperative Chemosis and Edema.

BACKGROUND: There are minimal data in the literature regarding the lymphatic drainage of the conjunctiva and lower eyelid and the relationship with postoperative chemosis and edema. METHODS: Injection, microdissection, and histologic and radiologic studies were conducted on 12 hemifacial fresh cadaver specimens. Indocyanine green lymphography was conducted in five volunteers. RESULTS: Histology identified lymphatic vessels superficial and deep to the orbicularis oculi. Cadaveric dissection, injection, and radiographic studies identified interconnecting superficial and deep facial lymphatic systems and a conjunctival lymphatic network draining through the tarsal plate to the deep lymphatic system. The superficial lymphatic collectors traveled in subcutaneous fat within the lateral orbital and nasolabial fat compartments. The lateral deep lymphatic collectors traveled beneath orbicularis oculi, then through the superficial orbicularis retaining ligament, and into the sub-orbicularis oculi fat in the roof of the prezygomatic space. These vessels descended to preperiosteal fat at the level of zygomaticocutaneous ligaments to travel adjacent to the facial nerve into preauricular nodes. Indocyanine green lymphography identified correlating draining pathways laterally to the parotid nodes and medially to submandibular nodes. CONCLUSIONS: The authors have found that the lower eyelid and conjunctiva are drained by interconnecting superficial and deep lymphatic systems of the face. The superficial system is vulnerable to damage in incisions and dissection in the infraorbital area. The deep system is vulnerable to damage in dissection around the orbicularis retaining ligament and the zygomaticocutaneous ligaments. The authors suggest that concurrent damage to both the superficial and deep lymphatic systems, especially laterally, may be responsible for postoperative chemosis and edema.

Biologic Behavior of Hydroxyapatite Used in Facial Augmentation.

INTRODUCTION: The recent finding that shrinkage of key areas of the facial skeleton contributes to the aging appearance of the face has prompted a search for the most appropriate bone-like implant material. Evidence that hydroxyapatite, in granular form, maintains volume in the long term supports its use in the correction of aging, in addition to its use in the correction of inherently deficient areas of the facial skeleton. The biologic response of hydroxyapatite needs to be fully understood for its use to be confidently recommended. MATERIALS AND METHODS: Samples of 'living' hydroxyapatite from the anterior maxilla, zygoma, and mandible of 17 patients were analyzed. These were obtained during revision procedures performed between 6 months and 15 years following original placement on the facial skeleton. RESULTS: Histology showed that in every case, the individual granules were embedded within a mass of collagen that made up about half of the total implant volume. The collagen mass also contained fine elastin, fibroblasts, lymphocytes, occasional granulomas, and vessels. By 2 years, a new compact bone containing osteoblasts and osteocytes was present in all specimens in the deep (osseous) aspect. Bone progressively replaced the original collagen between the granules with a sharply defined transition at the interface. CONCLUSIONS: This study confirmed a two-stage biologic change following onlay placement of hydroxyapatite granules on the facial skeleton, i.e., initial collagen formation with subsequent conversion to bone. This integrates the implant with the host bone which stabilizes the implant position and shape initially and in long term. NO LEVEL ASSIGNED: 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 .

Submandibular Gland Reduction in Aesthetic Surgery of the Neck: Review of 112 Consecutive Cases.

BACKGROUND: The indications for reduction of excessive submandibular gland volume in aesthetic rejuvenation of the neck have been well described, as has the surgical anatomy and the surgical technique. Despite this, submandibular gland reduction does not appear to be widely adopted, nor have significant case series been reported in the literature. This review of a consecutive series of aesthetic submandibular gland reductions was undertaken to provide a perspective about its place in neck contouring. METHODS: A retrospective chart review was conducted of all patients on whom the senior author (B.C.M.) had performed submandibular gland reduction for aesthetic reasons. Complications and reoperations were specifically analyzed. RESULTS: Submandibular gland reduction was performed in 112 of 736 consecutive face lifts between 2002 and 2013, an incidence of 13 percent in primary face lifts and 25 percent in secondary face lifts. The median patient age was 57 years, and 87 percent were women. Major complications were those requiring early reoperation (1.8 percent) to manage significant hematomas; one was potentially fatal. Minor complications (10.8 percent) were managed nonoperatively. Submandibular sialocele (4.5 percent) and marginal mandibular branch neurapraxia (4.5 percent) were the most frequent, and all resolved fully by 3 months. Significantly, no patient reported a permanent dry mouth. CONCLUSIONS: The complication rate with submandibular gland reduction is comparable to that of a neck lift with platysma plication alone, with some additional specific risks: (1) catastrophic airway compression from bleeding deep in the neck, (2) significant increase of neurapraxias in secondary neck lifts, and (3) a moderate incidence of benign submandibular sialocele. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Secondary upper lid blepharoplasty: a clinical series using the tarsal fixation technique.

BACKGROUND: One hundred consecutive secondary upper lid blepharoplasties were reviewed retrospectively to determine the lid characteristics of patients undergoing secondary blepharoplasty and the outcomes of all the procedures, which were performed using a tarsal fixation technique performed by one surgeon. METHODS: The median age of the patients was 54 years, and 99 percent of the patients were women. The median time since primary blepharoplasty was 8.7 years (range, 2 to 22 years). At surgery, no additional skin was removed in 37 percent, and the median amount excised in the remainder was only 2 mm. Revision surgery was performed in 13 percent, mainly for incomplete correction of asymmetry (5 percent) or ptosis (4 percent). Nonsurgical complications were mainly ocular (8 percent). There were no cases of persistent postoperative lagophthalmos or dry eyes. RESULTS: The term "postblepharoplasty look" was introduced to describe the different aging changes that follow primary blepharoplasty, mainly dermatochalasis (70 percent), with a high or absent and often poorly defined lid fold, with fat distribution irregularities. The tarsal fixation technique is advantageous in secondary blepharoplasty, as its benefit does not depend on further skin removal, minimizing the risk of lagophthalmos and dry eye syndrome. Lipoinfiltration for volume contouring is another major advance. The higher revision rate in secondary blepharoplasty reflects the incidence of asymmetry, lid ptosis, and scar from the original blepharoplasty, and from ongoing aging. CONCLUSIONS: The postblepharoplasty look of patients undergoing secondary upper lid blepharoplasty differs from the lid appearance of patients presenting for primary blepharoplasty. Tarsal fixation and lipoinfiltration are major advances in secondary upper lid blepharoplasty.

Surgical anatomy of the middle premasseter space and its application in sub-SMAS face lift surgery.

BACKGROUND: The premasseter space is a recognized, sub-superficial musculoaponeurotic system (SMAS) soft-tissue space overlying the lower masseter immediately anterior to the parotid. The performance, safety, and effectiveness of composite face lifts are enhanced when the space is used. This has drawn attention to the need for better understanding of the premasseter anatomy above the space. METHODS: The anatomy of the upper premasseter region was investigated in 20 fresh cadaver dissections as well as intraoperatively in hundreds of composite face lifts. RESULTS: A small, transverse, rectangular soft-tissue space overlies the upper masseter and was named the middle premasseter space. The space (transverse width, 25 to 28 mm; vertical width, 10 mm) is separated from the originally described (lower) premasseter space by a double membrane. It is a safe space between the upper and lower buccal trunks of the facial nerve, which are immediately outside the space and separated from it by the respective upper and lower boundary membranes. The parotid duct immediately beneath the floor of the space usually underlies the upper boundary membrane. CONCLUSIONS: The middle premasseter space is significant, as it is the center of the key anatomy immediately cephalad to the lower premasseter space. When used in composite face lifts, the space provides predictable sub-SMAS dissection between the buccal trunks of the facial nerve to the mobile area beyond the anterior border of the masseter where the SMAS overlies the buccal fat pad.

New perspectives on the surgical anatomy and nomenclature of the temporal region: literature review and dissection study.

BACKGROUND: Understanding of the temporal region remains confused, largely because of the ambiguous nomenclature. Aspects of the anatomy also remain unclear and are variably reported in the literature. The aim of this study was twofold: (1) to clarify details of the anatomy, using fresh cadaver dissections; and (2) to propose a standardized nomenclature that is based on recognized principles of nomenclature, contemporary use, and correct anatomical detail. METHODS: A cadaver dissection study on 24 fresh hemifaces (13 male, 11 female; mean age, 72 years) was undertaken at the University of Melbourne to clarify the anatomy of the tissue layers and dissection planes of the region. A comprehensive literature review was undertaken to clarify the nomenclature of the region and to investigate the current understanding of the anatomy itself. RESULTS: The tissue layers, ligamentous structures, and anatomy of two separate soft-tissue compartments within the temporal region were consistently identified across all dissection specimens. A standardized nomenclature system for the temporal region has been proposed. CONCLUSIONS: The use of consistent nomenclature to describe the structures in the temporal region facilitates understanding and discussion of the anatomy. Two separate soft-tissue compartments exist in the temporal region, bounded by ligamentous structures. The tissue layers differ considerably between the two compartments, and anatomical landmarks within these layers provide useful information to the surgeon operating in the temporal region.

Face lift.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Identify and describe the anatomy of and changes to the aging face, including changes in bone mass and structure and changes to the skin, tissue, and muscles. 2. Assess each individual's unique anatomy before embarking on face-lift surgery and incorporate various surgical techniques, including fat grafting and other corrective procedures in addition to shifting existing fat to a higher position on the face, into discussions with patients. 3. Identify risk factors and potential complications in prospective patients. 4. Describe the benefits and risks of various techniques. SUMMARY: The ability to surgically rejuvenate the aging face has progressed in parallel with plastic surgeons' understanding of facial anatomy. In turn, a more clear explanation now exists for the visible changes seen in the aging face. This article and its associated video content review the current understanding of facial anatomy as it relates to facial aging. The standard face-lift techniques are explained and their various features, both good and bad, are reviewed. The objective is for surgeons to make a better aesthetic diagnosis before embarking on face-lift surgery, and to have the ability to use the appropriate technique depending on the clinical situation.