HARMONIC LIFTING (ULTRASONICALLY ASSISTED FACE LIFT) By GLAUCO MENNA, M.D. * ALBERTO DI GIUSEPPE, M.D. ** - GLAUCO MENNA, M.D. * Aesthetic Plastic Surgicenter ORLANDO FLORIDA ALBERTO DI GIUSEPPE, M.D. ** Assistant Clinical Professor Plastic and Reconstructive Surgery University of ANCONA ITALY KEY WORDS: HARMONIC LIFT ULTRASONICALLY ASSISTED FACE LIFT 1
ABSTRACT The utilization of ultrasonically assisted liposculpturing (U.A.L.) has now been extended to face rejuvenation, in combination with rhytidectomy of the entire face and neck. The Authors present a superficial plane rhytidectomy performed with the auxilium of titanium solid probe, following tumescent preparation of the entire area, to provide anesthesia and planes distensions, together with emosthasis and the right medium of working of the ultrasound energy. The utilization of wath we called the harmonic probe limits the need for resection of skin excess, at the deep dermal contracture achieved after dermal stimulation with ultrasound allows redrapings of the skin by directional cantraction of the collagen fibers. The harmonic lifting can be effectively used in young persons with fatty necks and cheeks and older patients with loose skin and wrinkles. The autcome of patients who underwent the procedure during a one year period are reviewed. The results obtained were comparable with those with longer, technically more difficult procedures; the technique is safe, quick, and can be performed on an ambulatory basis. Complications encontoured included minimal skin necrosis, hematoma. No hair loos or facial nerve paresis was seen in a 50 patient sery. THE HARMONIG FACE LIFT: PATIENT EVALUATION AND SELECTION Every patient requesting consultation for facelift should be examined and evaluated and surgical recommendation customized to that individual s needs. To arrive at the rational operation, it is necessary to define the aims of the surgery. These are to improve crow 1 s feet, nasolabial and commissural folds, jowl of the slack jouwline, and the waddle neck. To avoid complications in healthy persons who seek improvement in appearance and to minimize the stigmate of the surgery, keeping the time of work and costs to a minimum. 2
In order to accomplish many of these requirements we present a technique which could be applied, easily, in the following conditions: 1) Face and neck lift in Fitzpatrick type 4 6 to avoid cheloid furmation and post inflammatory hyperpigmentation. 2) Young individuals that do not require a face lift but would benefit from treatment of chubby cheeks and double chin. 3) To enhance the definition of the neck during chin augmentation. 4) To substitute far endoscopic forehead plasty in balding scalps. 5) To achieve dermal stimulation and retraction in the neck beyond areas amenable to caser resurfacing. 6) To release acne scarring of the cheeks. 7) In secondary and tertiary face lifts when partial removal of skin is questionable but the central face need further tightening. ULTRASONICALLY ASSISTED FACE LIFT After the initial work developed by Dr. Michele Zocchi (1) on ultrasonically assisted lipoplasty, many Authors have published an this new subject. Scheflan, M. and Tazi, H., in 1996, in Aesthetic Surgery (2) published a very interesting paper on which they stated that an exceptional degree of skin retraction occurs after U.A.L. They concluded it was mainly due by a combination of factors, including the large amount of fat removed, the specific removal of subcutaneous fat, the skeletomization on the superficial fascial system, and the thermal effects on the subdermal surface and collagenous structures of the superficial fascial system. We varried an a similar study on patients who underwent U.A.L., with an endoscopic study of the tissues alternations which followed subdermal passage of an ultrasound solide titanium probe, close to the skin. 3
We observed: 1) Thickened dermal undersurface. 2) Markedly thickened vertical, collagenous fibers. 3) Intact lymphatic vessels. 4) Intact blood vessels. Probably, this remarkable skin tightening is due to the horizontal and vertical thickening and shortening of the collagen in the dermis and ligamentous fibers. Similarly to what stated by Scheflan and Tazi, we observed clinically and endoscopically that the closer we stay to the skin, the more accurate is fat removal from the subdermal layer, the greater the skin tightening effect results. In order to get the best skin retraction, we should be able to work close to the skin undersurface, by utilizing a safe and simple, repeateble technique. That is why we utilized a solid titanium probe, after proper tumescence of the target areas, which develops a strong cavitation, in order to emulsify just the fat cells and preserve all the surrounding structures of the subcutaneous layer (vessels, nerves, collagen, elastic fibers). As previously described by Zocchi, the cavitation is the phenomenon which is connected with the utilization of U.A.L. The highest cavitation, which means the highest specificity of the system with the target cells, is obtained with a solid titanium probe, without simultaneous aspiration of the emulsified fat. We concluded that, after 4 years of experience with U.A.L. for treatment of primary and secondary lypodistrophies, for breast reduction and pexy, we could utilize U.A.L. subdermal stimulation in order to obtain skin tightening in face lift surgery. PATIENT SELECTION Horizontal frontal creasing and glabellar creasing. Ptosis of lateral eyebrows with or without concomitant laxity of the upper eyelids. Lateral canthal creases (crow s feet), trasverse crease at the roof of the nose, malar crescent, descent 4
of the cheek fat, deep nasolabial grooves, diffuse acne scarring of the cheeks and neck, jowl with a hoten jawline, and neck relaxation and creasing, and secondary and tertiary lifting. Such widespread dissection does much to efface abuse acne scarring, platysmal bands, and nasolabial folds. Redundant skin removal is achieved by the minilift and upper blepharoplasty. The limited draping of the flaps required, allays most patients greatest fear, to look unatural after surgery they elected to have in order to look better. The titanium solide probe utilized ** are straight; this limits the possibility of operating in roundly shaped areas as forehead, mainly, that is why, so often, more incisions are required to reach and undermine and stimulate all the target surface. OPERATIVE TECHNIQUE Consists of the following steps. 1) Patient evaluation Pre.op planning drawnings. 2) Tumescent infiltration. 3) U.A.L. dissection. 4) SMAS suspension (if required). 4) Minimal skin excision (if required). ** 15 cm. long, titanium solid probe, by SMEI, ITAIY. 5
INCISIONS Skin incisions are placed on different sites, depending on the target areas of the ultrasonically assisted harmonic face lift. Forehead: skin incisions at the forehead may be placed at the hairline, midline, or frontal recess. The incisions are made vertically, in order to minimize nerve damage. Temporal region: temporal incisions have to be parallel to the hairline. Submental: submental incisions are made at the submental crease. Pre.auricolar: pre.auricolar incisions is rnade at the earlobe. Upper lowerlids: incisions are made at the blepharoplasty sites. The choice of incision is dictated by the ease of access for infiltration and dissection and the planned skin resections (when indicated). In the frontal recess, the resection is planned as a triangle pointing to the lateral brow and removing part of the glabrous skin as described by Spadafora. In the temporal and preauricolar skin, the resection of a minilift effords access for plication of the SMAS if required and release of the zygomatico dermal retaining ligaments of Furnas. The forehead lift, when indicated, is performed in a subcutaneous plane, through a pretrichial incision, as popularized by Dr. Guyuron. It gives a superior elevation of the lateral eyebrow and the temporal regions have been to correct crow s feet and frontal recess. Alopecia is avoided by pretrichial location of the incisions. The undermining is extensive to the lateral orbital rim, side wall of the nose, nasolabial fold, and completely across the neck from surfaces to suprasternal notch within the two anterior triangles of the neck. 6
PLANNING DRAWNINGS We already gave the indications for the ultrasonically assisted harmonic face lift. Drawnings are made indicating the full extension of the areas of undermining, the lines indicating the vector forces of muscolar tension, the relaxation creases and folds. Besides, criss cross lines of tuneling for undrmining and dermal stimulation are drawn. TUMESCENT INFILTRATION The superwet or tumescent technique has been reported procedure with negligible bleeding, diminution of edema, and bruising, and decreased surgical time (Brody, Shoen, Smith). The solution utilized has the following composition: 1000 cc. Ringer lactated. 10 mg. Kenalog. 1 ml. Epinephrine. 500 mg. Lidocaine (0,05 solution). 12,5 Meq. Sodium bicarbonate. This local infiltration is generally accomplished with I.V. sedation. When performed under general anestesia, lidocaine is diminuished to 200 rng., and sodium bicarbonate is eliminated. Regular blunt tipped 14 pouge gardenhose cannulas are utilized for infiltrate the subcutaneous tissue of the neck, jowls, cheeks, temple and brow. On each side, approximately 500 ml. of solution is infiltrated achieving vasocostriction and hydrotomy, which helps to magnify the target area and better define the tissue planes. The time spent to infiltrate the controlateral side with the rest of the solution allows the vasocostriction to occur. The central forehead requires a separate incisions at the hairline or through the upper eyelid to reach over the convexity of the frontal bone. Digital pressure helps to direct and expand the fluid evenly. The skin is adherent to creased lines and laterally at the temporal crest. When the skin resection is planned, the incision lines are injected with 1% lidocaine with epinefrine 1:200.000 (2 ml. are normally sufficient for each incision). 7
U.A.L. DISSECTION Extent of the dissection: the dissection with the probe includes the frontal area from the hairline to brow, glabella, dorsum of the nose, temple, crow s feet, cheeks to nasolabial grooves, chin, jowls, and anterior neck from chin to sternal notch, and between the anterior triangles of the neck. Level of dissection: the probe is advanced subdermally with the tip of the probe tenting while it is with drawn. Sequence of dissection: from the submental crease incision, the submental area is first released and according to the cervical mobility, the inferior neck may be reached. From the earlobe crease incision the neck is released to join the precious dissection of the submental area. The areas treated will be recognized by complete blanching, more noticeable in the skin with ruddy complexion and smoothness and softness that goes beyond what is achieved by tumescent infiltration of the area. From the earlobe crease, the probe will raise to the level of the mandible and the skin is ballooned up by the infiltration and the probe can slide over the cheek and temple, reaching the nasolabial groove, the side of the fase, and the crow s feet in a radiated fashion. Using the upper eyelid incision, the probe will slide in the glabellar area and central part of the forehead, releasing the cutaneous insertion of the corrugator and procerus without altering the sensibility of the skin. Through a reparate hairline incision, the rest of the forehead is dissected in order to circumvent the convexity of the frontal bone. The evacuation of the emulsion and the tumescent fluid is achieved by gently massaging the area and the fluid will drain from behind the ear due to the dependent position. One suture is utilized to close the incision and a restom foam is applied directly to the skin and a chin strap applied. Ice packs are used in the face and orbital region to avoid bruising and swelling in those areas that are not covred by the restom and the compression bandage. The pain and discomfort is minimal and most of the patients obviate the need for narcotic medication after the surgery. Time of application of U.A.L. is variable; with the power of the machine set up at 35 40% of the total. 8
5 minutes of dermis stimulation are necessary for forehead, and up to 20 minutes more to undermine full face and neck. SKIN EXCISION SMAS SUSPENSION If required, smas can be duplicated or dissected as the usual anatomical plane. Skin excess, if required, can be performed at the same stage. As most of the cases operated in our sery were secondary face lift, skin excision was a rare occurrence. RESULTS We operated a sery of 50 patients with the ultrasonically assisted harmonic face lift, with a follow.up of one year. Beeing a still recent technique, results of a limited sery of patients are still under investigations. More research is needed to evaluate limitation of the technique and permanence of its results. We have widened the indications for lifting procedure to younger persons with acne problems to older persons with lax skin and the results have been comparable to the results obtained through a more extensive, difficult surgery, that recently involved hospitalization and higher risks and costs, and amount of time out of work. What we called the harmonic probe (the solid titanium probe 15 cm. long) an excellent tool for office surgery, simplifying the surgical procedure and maximiting results with a minimum of time off work, making this procedure ideal for a weekend rejuvenation. What is really amazing, is the amount of skin retraction we observed clinically after U.A.L. subdermal stimulation, clse to the skin surface. What already observed and described by Scheflan and Tazi was enhanced by these clinical results; the skin retraction observed by these Authors mostly in lax abdominal skin, and that we already experienced in breast reduction and pexy with U.A.L., was more and more evident in loose neck and face and forehead skin. 9
Results obtained were costant after 1 year follow.up; we had to reoperate only one case, a patient who lost 20 kg. in six months time, and came to the office with loose neck skin. A new U.A.L. stimulation was performed, as easy as the previous stimulation, in a one hour office surgery. Acne scarring was improved in 2 cases. Complications included one hematoma, which required evacuation, and minimal skin necrosis, in 2 cases, which healed spontaneously, not compromizing the cosmetic final appearance. 10
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