Rhytidectomy

Author Credentials 

Jeffrey Teixeira, MD
Assistant Professor
Department of Surgery
Uniformed Services University of the Health Sciences
Bethesda, MD 20814

Module Summary

Rhytidectomy is a popular surgical treatment option for the aging face.  Preoperative evaluation and preparation ensure appropriate patient selection who are considered good surgical candidates which results in higher patient satisfaction and a reduction in complications.  As the field evolves, there continues to be advances in surgical techniques that the surgeon must be abreast of.  Furthermore, as with any surgical procedure, rhytidectomy has its own set of unique complications that a surgeon must be familiar with as well as treatment options for each.  With the appropriate patient selection and individualized surgical technique, rhytidectomy continues to provide high levels of patient satisfaction. 

 

Module Learning Objectives 
  1. Explain the aesthetic changes that occur with the aging face.
  2. Evaluate and determine appropriate surgical candidates and management with respect to the aging face.
  3. Describe anatomical variations in patients. 
  4. Explain varying surgical techniques with respect to rhytidectomy.
  5. Recognize intraoperative and postoperative complications and treatment. 

 

Anatomy

Learning Objectives 
  • Identify the different layers and planes of the face 
  • Describe the course of the facial nerve and areas prone to injury 
    • Sub-SMAS danger zone
    • Facial nerve relationship to SMAS
    • Temporal Branch relationship to Pitanguy’s line
  • Review the Superficial Musculoaponeurotic System (SMAS)
  • Describe the anatomy and role of retaining ligaments
  • Be familiar with different Fat compartments of the face 
    • Superficial, intermediate, and deep 

 

References 
  1. Khan HA, Bagheri S. Surgical Anatomy of the superficial musculoaponeurotic system (SMAS). Atlas Oral Maxillofac Surg Clin North Am. 2014 Mar;22(1):9-15.
  2. Hashem AM, Couto RA, Duraes EFR, Cakmakoglu C, Swanson M, Surek C, Zins JE. Facelift Part I: History, Anatomy, and Clinical Assessment. Aesthet Surg J. 2019 Mar 7. [epub ahead of print].

 

Pathogenesis

Learning Objectives 
  • Explain age-related changes to the following 
    • Skin
    • Subcutaneous Tissue
    • Skeletal Framework
    • Platysma 

 

References 
  1. Ko AC, Korn BS, Kikkawa DO. The Aging Face. Surv Opthalmol. 2017 Mar-Apr;62(2):190-202.
  2. Gierloff M, Stohring C, Buder T, Gassling V, Acil Y, Wiltfang J. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg. 2012 Jan;129(1):263-73.

 

Basic Science

Learning Objectives 
  • Recognize the physiology of skin flaps 
  • Summarize clinical considerations in wound healing
    • wound closure technique
    • wound desiccation
    • wound tissue ischemia 
    • factors that impede wound healing 
      • metabolic/endocrine, cardiovascular disease, other systemic diseases, local factors, drugs

 

References 
  1. Lucas JB. The physiology and Biomechanics of Skin Flaps. Facial Plast Surg Clin North Am. 2017 Aug;25(3):303-311. 
  2. Honrado CP, Murakami CS. Wound healing and physiology of skin flaps. Facial Plast Surg Clin North Am. 2005 May;13(2):203-14.

 

Patient Evaluation

Learning Objectives 
  • Recognize psychological and social influences with respect to patient selection
  • Be able to perform standard photo documentation preoperatively 
  • Be able to determine appropriate surgical candidate with respect to anatomy
    • Assessment of skeletal framework adequacy
    • Need for management of the SMAS-platysma muscle complex 
    • Need for fat contouring 
    • Need for skin tightening
  • Explain GloGau Scale and Dedo Classification 
  • Summarize relative and absolute contraindications to rhytidectomy
    • Autoimmune disease 
    • History of radiation exposure to the face 
  • Recognize agents or conditions that increased the risk of bleeding intraoperative and postoperative 
    • Vitamins and supplements
    • Hematologic conditions 

 

References 
  1. Brennan HG, Koch RJ. Management of the aging neck. Facial Plast Surg 1996;12(3):241-255.
  2. Perkins SW, Waters HH. Rhytidectomy. In: Papel ID, editor. Facial Plastic and Reconstructive Surgery. 4th ed. New York. Thieme; 2016. p 139-158.
  3. Griffin G, Azizzadeh B. Rhytidectomy. In: Cheney ML, Hadlock TA, editor. Facial Surgery. 2nd ed. Boca Raton, FL. CRC Press;2015. p 857-879.

 

Imaging

Learning Objectives 
  • Be familiar with photo documentation for rhytidectomy 
References 
  1. Swamy RS, Most SP. Pre- and postoperative portrait photography: standardized photos for various procedures. Facial Plast Surg Clin North Am. 2010 May;18(2):245-52.

Treatment

Learning Objectives 
  • Explain the role of rhytidectomy with respect to full-face rejuvenation
  • Describe non-surgical treatment options in combination with rhytidectomy 
  • Explain the need to address the following during rhytidectomy 
    • Skeletal framework adequacy and fat grafting
    • Need for management of the SMAS-platysma muscle complex 
    • Need for fat contouring 
    • Need for skin tightening

 

References 
  1. Perkins SW, Waters HH. Rhytidectomy. In: Papel ID, editor. Facial Plastic and Reconstructive Surgery. 4th ed. New York. Thieme; 2016. p 139-158.
  2. Griffin G, Azizzadeh B. Rhytidectomy. In: Cheney ML, Hadlock TA, editor. Facial Surgery. 2nd ed. Boca Raton, FL. CRC Press;2015. p 857-879.

 

Pharmacology

Learning Objectives 
  • Explain the use of local anesthetic, dosing limits, and toxicity with an overdose
References 
  1. Perkins SW, Waters HH. Rhytidectomy. In: Papel ID, editor. Facial Plastic and Reconstructive Surgery. 4th ed. New York. Thieme; 2016. p 139-158.
  2. Garcia-Rodriguez L, Spiegel JH. Are surgeons overdosing patients with lidocaine? Am J Otolaryngol. 2018 May-Jun;39(3):370-371.

 

Surgical Therapies

Learning Objectives 
  • Review the different techniques of Rhytidectomy 
    • Skin only 
    • SMAS
      • Imbrication vs Plication
      • Lateral-SMAS excision 
      • High 
      • Extended
    • Deep Plane
      • sub-SMAS
      • subperiosteal 
    • Composite 
  • Explain the different components of Rhytidectomy 
    • Incision Placement
      • Men versus Women 
      • importance of temporal hairline 
    • Skin Elevation and Undermining 
    • Treatment of the submentum, jowl, and neck 
      • Platysmaplasty 
      • Liposuction 
    • Elevation of the Superficial Musculoaponeurotic System 
    • Skin Flap Advancement
  • Review the role of autologous fat grafting 
  • Review postoperative management
    • dressing 
    • antibiotics 

 

References 
  1. Tzikas T. Autologous Fat Grafting Combined with Facelifting. Facial Plast Surg. 2017 Jun;33(3):285-298.
  2. Perkins SW, Waters HH. Rhytidectomy. In: Papel ID, editor. Facial Plastic and Reconstructive Surgery. 4th ed. New York. Thieme; 2016. p 139-158.
  3. Griffin G, Azizzadeh B. Rhytidectomy. In: Cheney ML, Hadlock TA, editor. Facial Surgery. 2nd ed. Boca Raton, FL. CRC Press;2015. p 857-879.
  4. Derby BM, Codner MA. Evidence-Based Medicine: Face Lift. Plast Reconstr Surg. 2017 Jan;139(1)151e-167e.

 

Case Studies

  1. A 56-year-old female presents to your clinic seeking rejuvenation of her face. She is concerned about jowling as well as some “wrinkles” around her mouth and face. She states she does not like the bands near her neck and feels she no longer has a side profile.  She is recently divorced but has been thinking about facial rejuvenation for the past several years.  What further questions would you elicit with respect to the patient's past medical history?  What social factors may be concerning in this patient?  How would you examine this patient? What areas of the face would need to be addressed with a surgical procedure? How would you counsel this patient on risks, benefits, and alternatives?
  2. A 58-year-old female has undergone a rhytidectomy procedure earlier today. She has been home for six hours and overall had been doing well. She denies any postoperative nausea and her pain had been well controlled with oral medications. She is calling you because 30 minutes ago she had an aggressive cough and noticed increased pain on her right side of her face and behind her ear compared to the left side. Give this you are concerned that the patient may have a hematoma. Does this patient need to be evaluated now or tomorrow morning? On exam, what findings do you expect to see? What are your treatment options? What are some sequelae you can expect if the hematoma is not treated?

 

Complications

Learning Objectives 
  • Explain Intraoperative Complications and Management
    • Facial Nerve injury 
    • Parotid gland/duct injury 
    • Auricular nerve and jugular vein injury 
  • Explain postoperative complications and Management 
    • Hematoma
    • Flap necrosis
      • Predisposing conditions include poor flap design, extended subcutaneous flap elevation, injury to the subdermal plexus, extensive closing tension, certain systemic conditions (i.e. autoimmune), large hematomas, smoking 
    • Infection 
    • Nerve injury: facial nerve, great auricular nerve
    • Hypertrophic scar
    • Earlobe distortion “Pixie ear deformity”
    • Alopecia
    • Contour deformities (submental deformity- “cobra deformity”)
References 
  1. Chaffoo RA. Complications in facelift surgery: avoidance and management. Facial Plast Surg Clin North Am. 2013 Nov;21(4):551-8.
  2. Batniji RK. Complications/sequelae of neck rejuvenation. Facial Plast Surg Clin North Am. 2014 May;22(2):317-20.

 

Review

Review Questions 
  1. What is the most common postoperative complication?
  2. What are the conditions or factors that predispose to a postoperative hematoma?
  3. Discuss several characteristics of an ideal facelift candidate.
  4. Why are men more likely to experience hematoma compared to women?
  5. What is the most common injured nerve during rhytidectomy?
  6. Why do deep plane and SMAS Rhytidectomy have a decreased risk of flap necrosis?

 

References 
  1. Perkins SW, Waters HH. Rhytidectomy. In: Papel ID, editor. Facial Plastic and Reconstructive Surgery. 4th ed. New York. Thieme; 2016. p 139-158.
  2. Chaffoo, R. Complications in facelift surgery: avoidance and management. Facial Plast Surg Clin North Am. 2013 Nov;21(4):551-8.
  3. Batniji RK. Complications/sequelae of neck rejuvenation. Facial Plast Surg Clin North Am. 2014 May;22(2):317-20.

 

Resources 

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