| FACIAL REJUVENATION | PEER-REVIEW The aim of the composite facelift is to reverse the
normal course of ageing, which includes the skeletonisation of the periorbital area as the soft tissue changes lead to the appearance of the underlying bony anatomy. The soft tissue contour of the lower eyelid becomes concave, and an ‘eye socket’ slowly develops. The vertical height of the lower eyelid elongates, and the eyelid–cheek junction becomes clearly defined. The composite facelift, with its arcus marginalis release and septal reset, attempts to re-establish the youthful appearance of the lower eyelid–cheek junction, creating a convex lower eyelid contour. The composite facelift technique has evolved in a
well-documented fashion over 25 years of performing the Skoog facelift. This was followed by a modification in 1978, ‘The Tri-Plane Facelift’, which added a preplatysmal cervical dissection separating the preplatysmal fat from the lower face. Postoperative care is much the same as that for any
facelift operation, except that more care is needed for the eyes owing to the fibrosis and healing of the periorbital area, which results from the surgical attachment of the orbicularis to the periosteum of the lateral orbit. This causes tightness and thickening of the eyelids that prevent adequate closure for a number of weeks. The composite facelift includes periorbital
rejuvenation requiring a superior–medial facelift vector that uses a zygo-orbicular flap for orbicularis repositioning coupled with a septal reset. It creates a harmonious rejuvenation in primary facelift, rhytidectomy, and can return harmony to faces distorted by previous facelifts9
(Figure 2).
Advances in open surgical mid-facial rejuvenation Mid-facial rejuvenation through open approaches has traditionally included either a temporal or periorbital approach. Resorbable biomaterials have opened up another avenue for mid-facial rejuvenation. Here, fallen soft malar tissue can be resuspended with a sturdy resorbable apparatus (in lieu of a suture) deployed through these traditional approaches. Device resorption occurs after mid-facial tissues have healed in a new, elevated position. Temporary postoperative tenderness in the mid-face over the engagement lines has been noted to be the most common disadvantage of these devices. When using any of these devices or suture techniques, caution is warranted when dissecting from the temporal region over the lateral orbital rim because of the close proximity of the temporal branch of the facial nerve superficial to the plane of dissection. The advent of injectable soft tissue fillers has
decreased enthusiasm for ‘hard’ cheek implants for malar augmentation. This is evidenced by the paucity of quality articles on cheek implants from the medical literature over the past year. Concerns with regard to cheek implants include the long-term visibility of the implant as the surrounding face ages, bony resorption deep in the implant, and generalised asymmetry side-to-side.
Figure 2 (A) Middle-aged patient with jowls and sagging of nasolabial area, and (B) postoperative result with better skin and mid-facial contour, as well as an improved mandibular line
As interest has grown for less aggressive facelifts for
the lower third of the face, some pioneers in this field have begun to incorporate the mid-face in their techniques. One such procedure, the minimal access cranial suspension lift (MACS-lift), uses one or two loops of suture that suspend the superficial muscular aponeurotic system (SMAS) to deep temporal fascia through a limited pre-auricular incision. The recently described extended MACS-lift using a third suture that suspends malar fat, and the authors claim that both softening of the nasolabial fold and support for the lower eyelid are achieved.
Although injectable facial
fillers can offer an efficacious alternative to surgery for the
Pros and cons Dermal fillers Although injectable facial fillers can offer an efficacious alternative to surgery for the ageing face, they also have their limitations. It is important for the aesthetic surgeon to recognise specific circumstances that may be best managed with an alternative to fillers, including superficial contour defects too shallow for fillers, areas with significant skin laxity in which filler injection may result in lumpiness, and deep defects or folds in areas of dynamic movement that may result in filler dislodgement or visible filler implants. As with any procedure, surgical or non-surgical,
ageing face, they also have their limitations.
soft-tissue augmentation is not without risks. Many complications have been reported with facial filler use. In fact, interpreting the literature for a particular filler can be frustrating, as it is common to find multiple case series with contradictory
efficacy and side-effect profiles. It is unclear as to the exact aetiology of these contradictions; however, surgeon inexperience with filler injection, improper patient selection, and filler mismatch likely play an integral role. Although most side-effects to facial fillers are transient and minor in nature, it is important to discuss these complications with patients prior to injection. Bleeding is
prime-journal.com | June 2013 ❚ 49
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