Asian Face Lifting Technique: Composite Facelift Technique
The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors’ technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure.
The face lift in Asian patients is a unique procedure because of the differences in the skeletal structure and soft-tissue quality of Asian patients compared to white patients. Accordingly, the performance of face lift techniques developed primarily for white patients may be different in Asian patients. These techniques have to be modified and adapted for the Asian anatomy and tissue characteristics. Many techniques have been used in Asian face lifts.
In general, these techniques may be divided into two broad categories: (1) superficial techniques that dissect only above the superficial musculoaponeurotic system (SMAS) and (2) deep plane techniques that require sub-SMAS dissection. The composite face lift belongs to the latter group of procedures that involve juxtafacial nerve dissection. Understandably, while a profoundly powerful technique, the potential risks of nerve injury remain a significant deterrent to surgeons in adopting this approach. However, the composite face lift technique has experienced a resurgence in popularity recently because of improved understanding of the surgical anatomy, which allows for greater safety in performing the procedure. The composite face lift has certain inherent characteristics and technical features that make it ideal for Asian patients. This article reports our experience with the composite face lift for Asian patients. Applied Anatomy of the Face for Composite Face Lift
The soft tissues of the face and neck are constructed in five concentric layers: (1) skin, (2) subcutaneous fat, (3) the musculoaponeurotic layer, (4) the loose areolar layer, and (5) deep fascia or periosteum. These five layers, as summarized by the mnemonic SCALP, are bound together and supported by a system of facial retaining ligaments
Functionally, however, the face is divided into two fascial layers, the superficial and deep fascia, with the muscle of facial expression located in the superficial fascia, while the muscles of mastication and the associated glandular structures (e.g., the parotid gland) are located under the deep fascia. The superficial fascia is made up of the outer three layers: skin, subcutaneous layer, and the musculoaponeurotic layer bounded together by the retaining ligaments. The musculoaponeurotic layer (layer 3) is the SMAS in the lateral cheeks, orbicularis oculi in the periorbital area, and platysma in the anteromedial lower face and neck. The deep fascia (layer 5) is the periosteum and deep facial layers covering the muscle of mastication, the temporalis, and masseter. The loose areolar layer (layer 4) is for the most part a gliding plane that allows the superficial fascia to glide and hence move freely over the deep fascia. A series of facial soft-tissue spaces, from the lateral cheek to the neck (i.e., prezygomatic, upper and lower premasseter, and subplatysmal spaces) located within layer 4, are designed for this purpose. Because of the inherent mobility of this plane, it is the anatomical location most predisposed to laxity and
sagging with aging. Accordingly, it is also the location that, when directly tightened, results in the most natural restoration of the contours of youth. The composite face lift is an approach that dissects in layer 4, through the facial soft-tissue spaces (the gliding plane), with precise release of the retaining ligaments in layer 4 to allow for tightening of the superficial fascia as a single composite from the underside of the composite flap.
Results of Composite Face Lift
Below shows the long-term results of our patients treated with this technique. Most patients had facial fat grafting performed together with their face lift. The mean volume of structural fat grafted was 29 cc (range, 14 to 46 cc of fat). Ninety-six percent of patients were satisfied or highly satisfied with their result. The scars healed well and were discrete. Only three patients, with strong tendency toward scarring, developed prominent hypertrophic scars after surgery. These were successfully treated in all three with intralesional steroid injections and laser treatments.
(Above, left and below, left) This 63-year-old Chinese woman underwent a composite face lift with full face fat grafting. Twenty milliliters of fat were injected for her. At the same time, upper blepharoplasty with levator advancement for upper eyelid ptosis correction was performed. Additional procedures performed included an extended transconjunctival lower blepharoplasty, an upper lip lift, and a chin implant via an intraoral approach. No submental incision was performed. The patient is shown at one year after surgery. The composite face lift delivers a natural rejuvenation. (Above, center, and below, center) Three-quarter view of our patient. Note the restoration of the Ogee curve of youth and long-term correction of the jowl and jawline. (Above, right and below, right) Lateral views of our patient with good long-term results. The temporal hairline and retrotragal incisions healed well, being imperceptible when closed in a tension-free manner.
(Left) This 57-year-old Chinese woman underwent a composite face lift with facial fat grafting A chin implant was placed via the intraopral approach. No submental incision was performed. Fourteen cc of fat were injected into her centrofacial areas. (Right) She is shown here at 2 years postoperatively. Note the restoration of the Ogee curve of youth and long-term correction of the jowl and jawline.
The complication rates were low, compared to usual reported rates. There were no hematomas requiring surgical drainage, nor was there any case of skin flap necrosis. Our nerve injury rate was low with a 1.5 percent temporary nerve injury rate. One patient developed a temporary buccal branch neuropraxia, and one developed a temporal branch neurapraxia. Both recovered fully in within 4 weeks. No patient developed a permanent nerve injury.
Reasons to apply Composite Face Lift with Asian Patients
Asian patients seeking face lifts want natural results with no tell-tale signs of surgery. They are also most concerned about scarring and minimizing their down time. Face lift techniques used for Asian patients should deliver on these objectives. The anatomy of the Asian face is unique, with wider bizygomatic distance with a more abrupt or acute transition from the lateral to the anterior face over the body of the zygoma and a flatter or more retruded central face. This characteristic of the Asian face results in loss of effective mechanical lifting force in the anterior face for forces applied from the preauricular or temporal areas of the lateral face. It is, therefore, mechanically necessary for the lifting and fixation to be applied more anteriorly in Asian patients.
To optimally fulfill these requirements and circumvent the challenges peculiar to the Asian anatomy, our technique of composite face lift has been adapted to address these specific considerations. The advantages include the following: (1) the composite face lift restores the superficial fascia to its youthful location as tension is placed on the support layer of the face (i.e., the SMAS). (2) The results are profoundly rejuvenating and yet completely natural. (3) The unnatural stretched and taut appearance that may be seen with more superficial procedures that rely on directly tightening the skin to achieve the desired lift is not seen with this technique. (4) With the composite face lift, because of the anatomical advantage of keeping the skin, subcutaneous tissue, and SMAS intact as a single composite flap, the thickness and effective strength of the SMAS may be completely preserved. The vascular supply of the composite flap is, therefore, more robust. This allows for greater tension on the skin flaps to lift the thicker and heavier tissues in Asian patients.
This is in contrast to face lift techniques that either elevate the SMAS as an isolated flap or dissect on the surface of the SMAS, which may thin the flap and hence reduce its ability to hold tension placed on it. Lifting and fixation of the composite flap—independent of skin closure—enable the skin to be closed in a tension-free manner. This provides the required tension-free condition for optimal skin healing and minimizes scarring.Composite face lift dissection is performed in layer 4, the loose areolar plane that is the interface between the superficial and deep fascia. Adequate release of the retaining ligaments is important to give the required mobility to the superficial fascia to achieve effective, long-lasting lifting of the flaps.
Facial fat grafting is an integral part of our procedure. Fat grafting in Asian patients differs in quantity and locations of priority compared with white patients. Asian patients, because of their fuller faces, generally require less volume of fat. However, as with white patients, with aging, certain areas of the face lose projection and facial fullness. On average, we grafted 29 cc of fat in our patients. Considering the areas that we grafted, in the forehead the areas of deficiency are similar to those of white patients, with the temple, supraorbital ridge, the brow, and the forehead in general being the areas that required grafting. In the midface, however, the areas of priority are quite distinct. The areas of deficiency are the medial maxilla, piriform aperture, and nasolabial folds. The zygoma is generally much more prominent, so that much less graft volume is required here compared to white patients. That is, Asian patients require much more in the central mid-face and less in the lateral aspect of this area. In the lower face, the chin and pre-jowl areas were commonly grafted. The jawline and, specifically, the angle of the mandible are usually quite prominent and therefore do not commonly require grafting.
Finally, as Asian patients tend to bleed and bruise more, they develop more prolonged swelling. To minimize the down time and recovery following face lift surgery, minimizing bleeding and trauma associated with the surgery is key. From this perspective, the ideal plane of dissection is the gliding plane of level 4 (i.e., through the facial soft-tissue spaces). By limiting the extent of the subcutaneous dissection to only the extent necessary to access these spaces and subsequently excising a significant portion of the undermined skin subsequent to tightening the soft tissues, most of the skin flaps on the face and neck would have been dissected atraumatically in the plane of the facial soft-tissue spaces. With the composite face lift technique, most of our patients are able to gradually return to their social engagements in about 3 weeks after surgery.
Minimizing Nerve Injury
To maximize safety from nerve injury, the release of the retaining ligaments should be performed when they are under tension and at the level of the ligament that is furthest away from the path of the facial nerve. To achieve this, the sub-SMAS dissection is started by bluntly opening the facial soft-tissue spaces, as these spaces are devoid of any vital structures and, therefore, the safest areas to dissect. This is then followed by retraction of the roof of the adjacent spaces to put the target retaining ligament under tension. The ligaments can then be precisely released closer to the roof of the space, while the nerves are protected, running close to the floor of the dissected space. With the three-step dissection approach as described, the surgical release may be performed safely with minimal risks of nerve injury.
The employment of autologous PRP biological therapies is troubled by the heterogenicity in PRP formulations, inconsistencies in nomenclature, and poor standardisation of evidence-based guidelines (i.e., there are multitudes of preparation methods generating a clinical treatment vial). Predictably, the absolute PRP content, purity, and biological properties of PRP and related products vary widely and impact the biological efficacy and clinical trial outcomes. The choice of PRP preparation device introduces the first critical variable.
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