Title: the Rationale for Endoscopic and Open Combined Face-Lifting

Title: The Rationale for Endoscopic and Open Combined Face-Lifting

Authors: Oscar A. Zimman, MD, PhD, Fernando Tuccillo, MD, and

Gabriel Repetti, MD.

Objectives and Purpose: The Endoscopic facial surgery provides a new tool in the treatment of facial rejuvenation. Through a fronto-temporal approach we can produce tissue reposition and tissue fixation. But there are different areas in the face and neck which do not require the same treatment. Can we do an endofull face lifting? It is well known that endoforehead, endoperioculoplasty and endomidface facial rejuvenation are possible1 and we can obtain very nice results. But is it the same with the endolower face? The question is: Can we treat properly the full face endocopically? In order to achieve the objective we propose to combine in a full face lift the Endoscopic and the open approaches, removing skin just only down from the sideburn. The key to understand this combined technique is to know the muscular derivations of the SMAS2. The upper face and associated SMAS develop from the Sphincter Colli Profundus. The SMAS in the lower face is derived from the Primitive Platysma3,4 . The Frontalis muscle, Superficial Temporal fascia, Orbicularis Oculi muscle, Elevators of the Lip and the Orbicularis Oris muscle constitute the upper division. The lower division includes the true Platysma and its Fascia, Risorius muscle, Depressor Anguli Oris muscle and Posterior Auricular muscle(Fig 1). The muscles of the upper face have any kind of bony insertion, but in the lower face the muscles have just only skin attachments. So, in the upper face it is possible a tissue repositioning but in the lower face it is not enough tissue repositioning and it is necessary a skin removal, and it is very difficult to perform a SMAS technique from any fronto-temporal Endoscopic approach. For an endofull face lifting, Isse proposes a submental approach to combine the Endoscopic issue, with a midline platysmaplasty and liposuction of the neck. Even though there is skin redundancy and a complementary removal is needed.

Methods and materials: We analyze preliminary results over 18 patients during the period January 2002-February 2003, with a follow-up of 12 to 24 months. In this period we performed a combination of endobrow and/or endomidface lifting with an open approach to the lateral mid-third of the face and neck. In some cases liposuction of the neck and medial platysmaplasty were necessary. In case of a forehead and mid-third of the face lifting here it is proposed to join both vectors at one point to achieve a better symmetry, a good balance of tension, and final adjustments in both sides before the sutures are secured. We used reabsorbable screws. Finally all the vectors we preferred are analyzed.

Results: In all the cases no skin resection was done above the sideburn, repositioning the deep structures and redraping the skin. From the sideburn down, a conventional approach with SMASplasty and replacement vectors in each area according with tissue distopia. Not only the skin but the SMAS vectors must be the same. With this rationale we avoid scarring the temporal and frontal areas, alopecia or visible scars, and upward displacement of the sideburn, with a good patient satisfaction.

Conclusions: The origin of muscular derivations of the SMAS developed from the Sphincter Colli Profundus in the upper face and the Primitive Platysma in the lower face give the explanation through which it is possible to perform an Endoscopic or an open approach. Even though the postoperative evaluation is considered in a short-term period we believe me must considered this technique as a good choice for a full-face lifting.

Fig.1. Embriological origin of SMAS and the associated facial and cervical muscles. Upper division derived from the sphincter colli profundus includes temporoparietalis fascia and frontal, orbicularis, lip elevators and orbicularis oris muscles. Lower division derived from the primitive platysma includes platysma and its fascia, risorius, depressor anguli oris and posterior auricular muscles. (drawing taken from Larrabee, W. and Makielski, K. Surgical anatomy of the face. Philadelphia, 1993. Raven Press).

References

1)  Isse, N.: Endoscopic facial rejuvenation.
Clin Plast Surg. 1997 Apr;24(2):213-31.

2)  Ouviña, J.M.: Triplanar concept of the SMAS (in Spanish). Presented at the Sociedad de Cirugía Plástica de Buenos Aires, 2001 (not published)

3)  Keller, G.S.: Endoscopic Facial Plastic Surgery. St.Louis, 1997.

Mosby

4)  Larrabee,W, Makielski, K. Surgical anatomy of the face.

Philadelphia, 1993. Raven Press