Anatomy is Queen
The zygomatic ligaments are a series of fibrous septa permeating the malar pad, anchoring malar cheek skin to periosteum of zygomatic eminence-They/this area of the face has a special name.
What is the McGregor patch
The facial nerve emerges from this foramen and divides in this gland
Stylomastoid foramen; parotid gland
See picture Number 1. Name at least 2 changes you notice related to aging
- diffuse dyspigmentation (Fitzpatrick 3)
- receding hairline
- transverse static rhytids of the forehead.
Describe Step 1 for the 5 Step facelift
Skin undermining- lateral to zygomaticus major to allow access to SMAS. In neck- visualize platysma medially and laterally. Dissection via sharp dissection and direct visualization. Skin flap with 3mm of SQ fat
This is the most common complication
Hematoma
These ligaments arise from the anterior border of the masseter and the parotid gland and insert into dermis. They have a specific name
What is Lore fascia- the masseteric cutaneous and parotid cutaneous ligaments
Describe the Pitanguy line
*Bonus 100 points- where is the frontal branch of the facial nerve most vulnerable?
0.5cm below the tragus; 1.5 cm above the lateral brow
*as it crosses the zygomatic arch 2.5 cm anterior to the external auditory meatus
Show Picture 2. Name at least 3 changes you notice related to facial aging
-vertical static glabellar rhytids
- dermatochalasis bilaterally
-Static periocular rhytids
-midface descent and deflation with prominent nasolabial folds
Describe Step 2 of the 5 Step Facelift
Submental access to neck- incision placed 1-2 cm behind submental crease. Excision and sculpting of submental fat and removal of supraplatysmal fat; subplatysmal fat sculpting. Platysmalplasty- can resect wedges of inferomedial platysma and approximate edges in midline; plicate platysmal bands in midline
X percent of women and X percent of men get hematomas after facelift
2-3% women; 8% men
These muscles are in the superficial layer of the mimetic muscles. For an extra 200 points, name the Deep layer muscles
Zygomaticus major and minor
Levator labii superioris
Risorius
DAO
Orbic oculi and oris
*Deep layer- Levator anguli oris, buccinator, Depressor labii inferioris and mentalis
Posterior to the facial artery, the marginal mandibular branch is here 80% of the time and here 20% of the time. Anterior to the facial artery, the nerve can be found here
Posterior- above the inferior mandibular border 80%; below in the other 20% with the lowest point 1 cm or less below the border
Anterior- above the border 100% of the time
Show Picture 3. Name at least 2 facial changes related to aging
-marionette lines with the right greater than the left
-Bilateral jowls and pre jowl sulci
-submental crease with an obtuse cervicomental angle on lateral view.
Describe Step 3 of the 5 Stage Neck Lift
Platysma window to achieve lateral tightening. Plication to the posterior mastoid fascia from a point one fingerbreadth below the angle and one fingerbreadth anterior to the SCM- repositions soft tissue away form jowl. Does spanning suture from submental area to mastoid if skin is thick
Most common nerve injured in face and neck lift is what, and how long does it take to regain function?
GAN- most injuries resolve within 12 months
The SMAS connects to what superiorly and inferiorly (name two structures superior and two structures inferior)
Superiorly- Galea, superficial temporal fascia, superficial cervical fascia and platysma
Extra 100 points- How does the external jugular vein relate to the GAN
6.5 cm inferior to the external auditory canal at midbelly of SCM- exits at posterior border of SCM
*most likely place to injure great auricular nerve
*EJug courses parallel and 0.5cm anterior to GAN
In 3 minutes- summarize the facial changes you see related to aging
-Skin- think quality, Fitzpatrick Type II, diffues dyspigmentation
-Upper lid dermatochalasis and lateral brow descent bilaterally
-Tonic frontalis activation in repose supportive of brow ptosis
-Midface deflation and descent, L>R
-Prominent nasolabial folds, R>L
-Deflation and disharmony of lips (upper lip:lower lip ratio departing from 1:1.6 ratio)
-Static perioral rhytids
-Downturned commissures, R>L
-Jowling bilaterally with poor jawline definition
-Passive platysmal banding with L band more laterally displaced vs R, moderate skin neck laxity
-Minimal pre-platysmal fat and prominent submandibular gland
Describe Step 4 of the 5 Step Neck Lift
Release of mandibular septum and mandibular ligament to correct aging jawline- sharply dissect septum from angle of mandible toward menton- 1 cm above inferior mandibular border
-Allows for redraping of skin and fat at mandibular border
These two things have been shown to decrease the rate of ecchymoses
Fibrin glue and drains
What structures are contiguous with the parotidomasseteric fascia superiorly and inferiorly? What VIS (very important structure) lies deep to this fascia?
Deep layer of the cervical fascia and the deep temporal fascia
*The facial nerve!- become more superficial medially
Describe how an injury to the marginal mandibular nerve wound manifest? How would injury to the cervical branch of the facial nerve present?
*Marginal mandibular nerve
-depressor labii inferioris- lower bottom lip
-DAO- lower corner of mouth
-Mentalis- raises and protrudes lower lip
*Cervical branch of facial
-Platysma- draws corner of mouth inferiorly and widens it, pulls neck skin superior with teeth clenching
*Test on exam- ability to purse lips- unique to marg
incision pattern: concave at the level of the side burn, hugging the root of the helix convexity, intra-tragal, sharp 90 degree cut at caudal aspect of tragus to separately define tragal subunit from lobule, leave 1 mm around lobule, post auricular incision up to divergence of inferior and superior crus of antihelix, and incision along hairline beveling perpendicular to hairshafts
Describe Step 5 of the 5 Step Neck Lift
Redraping of SMAS and Skin in appropriate vector- SMAS shaping angle is either oblique or horizontal- based on midfacial analysis of patient's length and width
-Neck skin secured in a posterior and superior vector to ensure natural contour
Name three ways you can perform your facelift that lower the risk of complications
1. Under Sedation and local anesthesia
2. Sx less than 5 hours
3. Control BP- do not hold antihypertensives, pain control, nausea control