Rhytidectomy

Jaishree Palanisamy PGY2

McLaren Oakland
Overview
• Introduction
• Anatomy
• Pre-op analysis
• Non-surgical management
• Surgical Technique
• Complications
Introduction
• We are our face – seat of our prime identity
• Cervicofacial rhytidectomy - reverses gravitational and aging changes in the lower
face and neck
• Rhytidectomy involves rejuvenating the aging face by reversing the gravitational
effects of aging.
• The loose skin of the neck is most improved, followed by the jowls and the melolabial
fold (MLF)
Anatomy
Anatomy - Platysma
• Superficial muscle
• External jugular just deep
• Innervated by cervical branch of facial n.
• Supplied by submental artery and
suprascapular artery
• Change in the platysma with age:
• In youth, muscles fibers often decussate with
fibers from the opposite side
• With age, the medial fibers separate
• There is a weakening of the muscle and sagging,
resulting in typical "platysmal bands"
• Ptosis of the muscle results in further laxity of
neck structures.
Anatomy - SMAS
• Facial nerve lies deep to SMAS
• Posteriorly, SMAS fuses with fascia
overlying SCM (superficial to parotid
fascia)
• Anteriosuperiorly, SMAS invests
mid-facial mimetic muscles (Orbic,
ZMa, ZMi, Levator labii superioris)
and melolabial crease/upper lip
Anatomy – Greater Auricular Nerve (GAN)
• Arises from C2/C3 cervical plexus
• GAN supplies sensation to the
inferior auricle and periauricular area
• Emerges along the posterior surface
of the SCM muscle, approximately 6.5
cm inferior to the bony external
auditory canal
• At this point the nerve is relatively
superficial, which renders it
vulnerable to injury during skin flap
elevation. Superiorly, it travels deep
to the SMAS, where it is protected
from injury
Anatomy- Retaining Ligaments

• Retaining ligaments located in

constant anatomic locations
• Separate facial spaces and compartments

• Originate from periosteum or deep

facial fascia and insert onto dermis
• True ligaments = zygomatic (McGregor’s
patch), masseteric, orbitomalar

• Release of these ligaments is important

for better pull and redrape of tissue
• Branches of facial nerve in close
proximity
Anatomy – Vascular Supply
• ECA
• Sup. Temporal artery -> Transverse
facial a.
• Infraorbital ar. 

• These anastomose in the subdermal

plexus
• For facelifts
• Based on subdermal plexus supplied
by transverse facial and infraorbital
aa.
Normal Aging
• Aging happens in the skin, soft
tissue, and bony facial skeleton
• Skin
• Increased laxity, decreased elasticity,
actinic damage, telangiectasias, coarse
and fine rhytids

• Soft tissue
• Facial lipoatrophy – leads to
formation of hollows in temporal area,
infracommissural area, prejowl, and
cheeks

• Bony - resorption
Normal Aging
Key point
• Development of the melolabial,
infracommissural, and nasojugal
folds—are observed as a
consequence of facial lipoatrophy,
dermatochalasis, skeletal resorption,
and aging of the skin
Festoons vs. Dermatochalasis
• Festoon (*)
• Weakened orbicularis oculi and lax
skin form cascading drape of
edematous excess skin
• Inferior to inferior orbital rim and
overlies malar eminence

• Dermatochalasis (.)
• Acquired draping of excess skin over
lids with prolapse of orbital fat
Tear Trough Deformity
• Deep indentation between eye and
nose
• Due to overlying skin that thins out
with age and underlying muscle and
lower eyelid fat bags that become
more prominent
• Best managed with volume
• i.e. Belotero injectable filler

• Can also consider lower eyelid

blepharoplasty
Pre-op Analysis
• Ideal Patient
• Elastic and not too much skin
• Little fat
• Good bone structure (hyoid)
• Less than ideal patient
• Discuss expectations in detail
• Need for other procedures
Who is the ideal patient?
• Ptosis of jowl, submentum, anterior
neck = primary areas addressed
• Malar ptosis will have modest improvement
• Issues not well addressed
• Intrinsic changes to tissues
• Deeply etched wrinkles, fine lines, 
• Use resurfacing techniques – may be done
several weeks post lift
• *areas not undermined can be addressed at the
same time
• Age?  No age limitations
• Psychological status – a thorough discussion
of goals and objectives can provide clues
Pre-op Analysis
• Potential contraindications
• Diabetes
• Smoking
• Collagen-vascular disease
• Psychiatric history
• Steroid use
• Medical health
• Obese, sagging skin = not as good of a
candidate
• May require a tuck procedure down the
road or liposuction 
• Weight loss planned – hold off
• Smoking – 12 times greater risk of skin
slough, increased risk of hematoma
formation
• At minimum stop smoking 1 month prior
and after surgery
• Better candidates for deep plane face lift
• ETOH abuse
Pre-op Analysis
• Important to assess hyoid position
• Dedo classification
• High hyoid (posterior/superior) ideal for
youthful cervicomental angle

• Hyoid to mandible relationship defines

the course of suprahyoid musculature
• Limits the maximum improvement
possible in the cervicomental angle
• High and posterior hyoid is ideal
• Allows max elevation of the submental
contour

• Low and anterior hyoid – limits

improvement
Adjunctive Techniques
• Laser peel
• Dermabrasion
• Chemical peel
• Neck treatment
• Implants/Fillers
• Blepharoplasty
• Forehead lift
• Rhinoplasty
Non-invasive Methods of Facial Rejuvenation
• Fillers
• Implants
• Fat grafting
 Fat Grafting
• Gold standard for facial • Nonideal patients:
voluminzation • Young
• “Permanent filler” • Unstable in weight

• Fat from abdomen and thigh have
best retention rate but more
susceptible to weight gain
• Variable 50-90% take
• Hard to predict how fat will mature
over time as person ages
• May need fillers/additional fat
Lam SM. Integrating injectable fillers and fat in facial rejuvenation. Facial Plast Surg. 2015;31(1):35‐42. doi:10.1055/s-0035-
1544245
• Desire fat for isolated reconstructive
purposes
• Author prefers single session fat graft
followed by filler touch ups at 9
months to 1 year after
• Not good for folds (fillers) or fine
wrinkles (lasers)
• Good for voluminization of entire
face, not isolated areas
 Fat Grafting + Fillers

Lam SM. Integrating injectable fillers and fat in facial rejuvenation. Facial Plast Surg. 2015;31(1):35‐42. doi:10.1055/s-0035-
1544245
 Fillers
• Risk with any filler using needle =
tissue necrosis and blindness
• Avoid with 27 G needle/cannula (can’t
pass through a vessel)

• Largest limitation is cost

• Can inject 20-40 syringes to look natural
(lady in pic had 20)

• Greatest benefit is accuracy

• Also bioinert – doesn’t change with
weight

• Divide face into upper (temple, brow,

lower lid) and lower (cheek to jawline)

Lam SM. Integrating injectable fillers and fat in facial rejuvenation. Facial Plast Surg. 2015;31(1):35‐42. doi:10.1055/s-0035-
1544245
 Alloplastic Implants
• Replace soft tissue with same (fat,
filler) – “like should replace like”
• Author does not like malar implants
• Exacerbates malar bony appearance
• Higher chance of infection
• Hard to create consistently symmetric
results

• Benefit = easily removable

Lam SM. Integrating injectable fillers and fat in facial rejuvenation. Facial Plast Surg. 2015;31(1):35‐42. doi:10.1055/s-0035-1544245
 Conclusion
• Fat transfer for older individuals
with stable weight
• Solid implants for younger patients,
pts with unstable weight, but mostly
for weak bone architecture
• Minimize shadows, improve
highlights

Lam SM. Integrating injectable fillers and fat in facial rejuvenation. Facial Plast Surg. 2015;31(1):35‐42. doi:10.1055/s-0035-1544245
Surgical Management - Types of Facelift
• Subcutaneous Lift
• Short-Scar (Weekend Facelift)/ S-Lift
• SMAS rhytidectomy
• SMAS flap (dissected from parotid fascia) starting from incision to anterior border of parotid

• Deep-plane rhytidectomy
• Dissect sub-SMAS ant. to parotid then transition to supra-SMAS plane and dissect all of the
cheek fat with attached overlying skin away from the zygomatic musculature

• Composite lift
• Same as above, but, includes supraperiosteal dissection of superior aspect of midface through
lower eyelid incision – “biplane dissection”

• Subperiosteal lift
 Incisions
• Temporal hair incision
• Anterior hairline incision
• Incision in the hair + a transverse
extension at the base of sideburn
• Pretragal
• Tragal edge incision
• Short scar technique (limited to
retro auricular sulcus, no occipital
incision
Overview
Dissection through a space in a sub-
SMAS plane can be performed in a
blunt fashion, while dissection through
the boundaries of the space (the
retaining ligaments) requires sharp
dissection
Subcutaneous Rhytidectomy
• Main purpose is to tighten loose
facial skin and remove excess
• DOES NOT address deeper tissues
• Easy, safe procedure resulting in
improvement in lower face & neck
• Flap is raised in subcutaneous plane
• Lift is in a vertical vector
• Fails to address ptosis of the midface
and does not address the effects of
aging on structures deep to the skin
Subcutaneous Rhytidectomy
• Expose platysma from border of
mandible to lowest cervical crease
• Resect fat
• Leave 3-5 mm of fat on skin flap for
viability & scarring avoidance

• +/- Submentoplasty
• Midline platysmal plication if laxity
Subcutaneous Rhytidectomy
• Skin of upper neck dissected in
subcutaneous or preplatysmal plane
• Dissection can continue forward in
neck to midline
• Extent of anterior dissection based on
surgeon preference and skin laxity

• Exposed SMAS imbricated using

sutures to suspend to periparotid
fascia
• Closure
Short-Scar (Weekend Facelift)
• Ideal for:
• Young patients with minimal aging
• Slightly older patients with minimal to
moderate jowl and neck aging
• Patients who have medical problems that
preclude a larger facelift or anesthesia
• Patients with budget or recovery
limitations who cannot have a larger lift
• Involve preauricular incision with
some mastoid extension but NO
posterior auricular incision
• Postauricular incision is a requirement
to tighten neck with lasting result
• Advantages:
• Simple to learn and perform
• Can be done under local anesthesia
• Do not require bandages
• Shorter recoveries
• Easier to market; cheaper
• Disadvantages:
• DO NOT address moderate and
advanced aging
• Result will not be as “tight” and won’t
last as long
• Less effect on jowls and neck aging
Short-Scar (Weekend Facelift)
Short-Scar (Weekend Facelift)
• Subcutaneous dissection –
superficial to SMAS
Short-Scar (Weekend Facelift)
• Addressing SMAS:
• SMAS plication – most conservative;
less swelling and faster recovery
• Purse string fixation
• SMASectomy
Short-Scar (Weekend Facelift)

• Addressing skin
• Place proper traction
• Try multiple vectors to see which
direction gives best result
Short-Scar (Weekend Facelift)
Short-Scar (Weekend Facelift)
Short-Scar (Weekend Facelift)
SMAS Rhytidectomy
• Skin flaps are 6-7 cm long
• Completely elevate flaps to obtain
adequate exposure of SMAS
• SMAS flap elevated to area over parotid
• Extended SMAS lift – dissection carried
anterior to parotid

• SMAS advancement
• Plication
• Imbrication

• Good for jaw-neck line

• Less effective in rejuvenation of the
midface, jowls, and melolabial fold
SMAS Rhytidectomy
• Flap elevation
• Start at peri-auricular area
• Temple: subfollicular/subcutaneous
• Parotid: subcutaneous to a line from
lateral canthus to angle of mandible
• Posterior scalp:
subfollicular/superficial subcutaneous
• Neck: over SCM and superficial to
platysma
SMAS Rhytidectomy
• SMAS plication
• Consists of sutures that fold the SMAS
onto itself to shorten it
• Pulled in posterosuperior direction
• First suture is applied at the jaw line
and is anchored at the mastoid
periosteum or deep tissues in the pre-
auricular area
SMAS Rhytidectomy
• SMAS imbrication/SMASectomy
• Closure
Deep Plane Rhytidectomy
• Advantages:
• Thicker, healthier flap – good for
patients with circulation issues
• Improved viability of skin edges
• Enables broader repositioning of
SMAS
• Addresses nasolabial fold and ptotic
malar fat pad
• Disadvantages:
• Steep learning curve
• Descent of the cheek fat is
responsible for the increasing
redundancy of the nasolabial fold
with aging
• Cheek fat has to be lifted from the
zygomaticus major and minor
muscles
• Deep-plane facelift consists of skin,
subcutaneous tissue, cheek fat and
platysma
Deep Plane Rhytidectomy
• Markings
• Temporal branch of facial nerve
• Deep plane entry point (line from
angle of mandible to lateral canthus)
• Horizontal line at level of cricoid to
mark inferior extent of neck skin
elevation
• Submental crease
• Incision line in temporal hairline (at
height of lateral brow) to preauricular
area then around lobule then into
occipital hairline
Submental Liposuction
• Perform before beginning
rhytidectomy procedure

Submentoplasty/Platysmaplasty
• Perform before beginning
rhytidectomhy procedure
• Can do after submental liposuction
• Caution when dissection in sub-
platysmal plane laterally – marg.
• Perform adequate fat removal with
liposuction and sharp dissection
• Plicate medial edges of platysma
• Redundant neck skin can be excised
prior to closing
Deep Plane Rhytidectomy
• Bevel incision in hair bearing areas
• After submentoplasty, preauricular
skin flap elevated in the subcutaneous
plane just deep to the reticular dermis
• 2-3 cm in front of tragus

• Dotted line connecting the angle of the

mandible to the lateral canthus and an
incision is made into the posterior
border of the SMAS at the location of
this line
• Sub-SMAS dissection from malar
eminence to jaw line moving
superiorly
Deep Plane Rhytidectomy
• Borders of sub-SMAS dissection
• Superior: orbicularis oculi and
zygomaticus major & minor
• Medial: zygomaticus major & minor,
nasolabial fold, buccal fat pad
• Inferior: tail of parotid and masseter
• Deep: parotidomasseteric fascia
Deep Plane Rhytidectomy
• Dissection level changes to
superficial to zygomaticus
musculature when lateral edge of
zygomaticus major is reached
• Extends medial to the nasolabial fold
• Lateral brow area
• Inferior to zygoma, Facial N. deep to
SMAS and orbicularis oculi
• Over zygoma, close to periosteum,
elevate superficial layer of deep
temporal fascia
Composite Rhytidectomy
• Based on the deep-plane
rhytidectomy
• Intended to improve the
inferolateral descent of the
orbicularis oculi
• Composite face lift flap consisting of
orbicularis, cheek fat, and
platysma en bloc
Subperiosteal Rhytidectomy
• Lifting of cheek tissues by dissecting in
subperiosteal plane over maxilla and
zygoma
• All soft tissues of midface are lifted
• Difference b/w supra-SMAS rhytidectomy
and subperiosteal rhytidectomy is superior
displacement of midfacial muscles
• Extended supra-SMAS and deep plane
rhytidectomy only elevate the cheek fat
and skin and not the muscles of the
midface
• Subperiosteal mid-facelifts do not
significantly correct the jowl and have no
influence on the upper neck
Subperiosteal Rhytidectomy
• Advantages
• Tension remains in deeper tissue and
less tension on skin
• Better preserved bloody supply to the
flap
• Better correction of mid-face

• Disadvantages
• Increased horizontal width of face
• Greater swelling and ecchymosis
• Increased risk of nerve injury
• Infraorbital n., temporal branch
Subperiosteal Rhytidectomy
• Subperiosteal has tendency to increase the
horizontal width of the face by displacing the
origin of the zygomatic major muscle to a more
superior and lateral position
• Can enhance malar eminence

• 4 surgical approaches
• (1) transtemporal usually using an endoscope
• (2) transorbital through a lower eyelid or
transconjunctival incision
• (3) transoral through an upper gingival buccal
incision
• (4) combined using two or more of the previously
listed approaches

• Need to release periosteum from lateral and

inferior bony orbital rim and from entire
zygoma/maxilla
 Techniques for Rejuvenation of the Neck Platysma
• Procedural • Adjuvant techniques for neck
• Cervical rhytidectomy
rejuvenation
• Neuromodulators
• Direct excision (Grecian Urn)
• Botox for platysmal banding
• Laser skin resurfacing
• Submental liposuction

Farrior E, Eisler L, Wright HV. Techniques for rejuvenation of the neck platysma. Facial Plast Surg Clin North Am.
2014;22(2):243‐252. doi:10.1016/j.fsc.2014.01.012
 Direct Excision (Grecian Urn)
• Addresses:
• Excess skin
• Platysmal banding
• Submental adiposity

Farrior E, Eisler L, Wright HV. Techniques for rejuvenation of the neck platysma. Facial Plast Surg Clin North Am.
2014;22(2):243‐252. doi:10.1016/j.fsc.2014.01.012
 Direct Excision (Grecian Urn)

Farrior E, Eisler L, Wright HV. Techniques for rejuvenation of the neck platysma. Facial Plast Surg Clin North Am.
2014;22(2):243‐252. doi:10.1016/j.fsc.2014.01.012
 Direct Excision (Grecian Urn)

Farrior E, Eisler L, Wright HV. Techniques for rejuvenation of the neck platysma. Facial Plast Surg Clin North Am.
2014;22(2):243‐252. doi:10.1016/j.fsc.2014.01.012
 Direct Excision (Grecian Urn)

Farrior E, Eisler L, Wright HV. Techniques for rejuvenation of the neck platysma. Facial Plast Surg Clin North Am.
2014;22(2):243‐252. doi:10.1016/j.fsc.2014.01.012
Complications
• Hematoma (2-15%)
• Most common complication
• Characterized by pain and increasing
facial edema
• Risk factors = hypertension, anticoagulant
medication, vitamin E, , Ehlers-Danlos
syndrome, and various herbal medications
• Halt all anticoagulations 3 weeks prior and
after rhytidectomy
• Minor hematomas can be managed with
needle aspiration
• Major/expanding hematomas most
common in first 12 hours
• True emergency – go to OR STAT
• Skin flap necrosis can result if not taken care
of
Complications
• Flap necrosis
• Occurs if bloody supply is
compromised to distal portion of flap
• Increased risk with smoking,
extended subcutaneous skin flap
elevation, excessive tension,
hematoma, and certain medical
conditions
Complications
• Nerve injury
• Most commonly injured nerve is great auricular (1-7%)
• If injury unrepaired, pt will have regional hypoesthesia
• Most commonly injured Facial n. branch is marginal mandibular in cervical rhytidectomy (0.53-
2.6%)
• Avoid by staying in supraplatysmal plane and utilizing blunt dissection
Complications
• Earlobe deformities
• Pixie ear
• V-Y scar revision
• Delay for at least 6 months
Complications
• Incision abnormalities
• Dehiscence
• Infection
• Necrosis