During the period between and , the superficial musculoaponeurotic system SMAS traction for correction of the nasolabial fold was associated with the round-lifting technique in patients. Since , the treatment of facial fat, mainly the malar fat pad, has been included in 85 rhytidectomy cases.
Rhytidectomy has undergone constant evolution in our clinic. Simple skin undermining and traction were followed by large undermining of the facial flaps. Subsequently, the SMAS was addressed, with variable undermining of this structure.
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Later, this technique was replaced by SMAS traction and plication, which produced similar results and lower morbidity. Experience then showed that, in selected cases, the isolated treatment of the SMAS was not effective in treating the nasolabial fold.
Consideration of facial fat became necessary, and the surgical treatment of the fascial fatty layer has recently been adopted, with gratifying results. After appropriate undermining of skin, the SMAS and the fascial fatty layer are identified.
The fascial fatty layer, specifically the malar fat pad, is identified, and the retaining ligaments that join this layer to the deep dermis are incised, allowing it to be repositioned in a more superior and lateral direction and removing the weight from the nasolabial fold. The traction is executed, and the fascial fatty layer is plicated superiorly, following the direction described above, with the same absorbable suture.
This surgical step corrects the ptosis of the malar fat pad over the nasolabial fold Figure 1. Following the proper treatment of these deeper structures, the skin flaps are rotated, rather than simply pulled, in well-defined directions. The anterior flap follows a vector that connects the tragus to Darwin's tubercle of the ear.
Two traction forceps position the flap, and a Pitanguy flap demarcator is used to define excess skin at point A. The posterior flap is rotated in a superior and slightly anterior direction to avoid a visible step-off in the hairline; this defines point B.
Face-neck lifting and ancillary procedures
The direction of traction of the anterior facial flap follows a vector that connects the tragus to Darwin's tubercle. Complementary procedures are appropriate when the nasolabial fold continues to be troublesome. These are discussed below. Direct excision of the nasolabial fold was performed in 11 male patients.
The excision included the whole extension of the fold, with deepithelialization of skin, bringing the dermal borders together bilaterally. Suturing, done by planes, ensures the eversion of the fold Figure 5. A single intradermal test, performed in all patients, was negative. The injection was executed with a fine gauge needle and followed the line of the nasolabial fold. The immediate result of collagen injection, as well as its durability, was evaluated. Long-term follow-up included identification of any adverse reactions.
A, Preoperative view of a year-old man with severe acne sequela and pronounced nasolabial folds. B, Postoperative view at 2 weeks after direct excision shows good quality scarring. C, Postoperative view at 1 year. Fat grafting was performed in 90 patients. The donor areas were the inner knees, the submental region, and, in some cases, the abdominal region. The fat was harvested by use of liposuction and kept in the syringe in a vertical position, allowing for decantation. Excess liquid was removed so that only fat remained. With a large-bore needle, the fat was injected below the deep dermis of the nasolabial fold.
Grafting began in the furthest extremity of the nasolabial fold and was done as the needle was pulled back. Local massage was helpful in spreading the fat graft. In all cases, a slight overcorrection was performed, foreseeing a variable postoperative absorption. Because collagen injection is considered more expedient, it was our complementary procedure of choice. However, when the intradermal collagen test result was positive or when the patient did not want to undergo collagen injections, fat grafting was performed.
Traction of the SMAS was noted to soften the appearance of the nasolabial fold, but other complementary procedures, such as collagen injection or fat grafting, were often necessary to achieve more satisfactory correction. Durability of nasolabial fold correction with simple SMAS traction varies with each individual and his or her unique aging process. Simple traction of the SMAS does not include treatment of the fascial fatty layer. The senior author has included the treatment of the fascial fatty layer in his standard rhytidectomy over the last 2 years, with improved aesthetic results Figures 6 and 7.
Again, the durability of this maneuver is related to the aging process, but the final result was deemed superior to treatment of the SMAS alone. A, Preoperative view of a year-old woman.
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A, Preoperative view of a year-old woman who requested correction of early signs of aging. In these select cases, the results were considered satisfactory to both the surgeon and patient, with complete correction of the fold and acceptable scars. Complementary procedures ie, collagen injection or fat grafting were indicated in patients who underwent a face lift without the direct approach to the fascial fatty layer.
Immediate results of collagen injection were considered satisfactory. There was no sequela. Interestingly, in both cases the intradermal test result was negative. Only a single test was done routinely; however, it was repeated a second time if the result was questionable. The initial results of fat grafting were considered satisfactory. There was one case of infection that was treated with clinical measures and local excision. Complementary procedures to face lifting are summarized in the Table. Surgical treatment of the aging face in the Ivo Pitanguy Clinic to A smooth nasolabial fold is the ideal and should not be removed completely or distorted.
However, a fold that is too prominent is a significant sign of facial aging. Several procedures are available for the correction of the nasolabial fold, and each method has advantages and disadvantages. Factors such as the type of procedure used, the geographic location, and the surgeon's experience can change this price.
Material and Methods
Always check in with potential surgeons to see what the cost of the procedure will be. The American Society of Plastic Surgeon's average estimates only the cost of the procedure. This means that expenses such as anaesthesia, operating room facilities, follow up care or other costs. As a patient, you may also incur other expenses related to the facelift such as medications after the procedure, medical tests, post-surgery garments, and facility costs.
Since cosmetic surgery is not considered medically necessary by most insurance companies, it is unlikely that the cost of the facelift will be covered under your normal insurance. To help accommodate their patients, many surgeons will offer financing plans or other repayment options.
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Once the graft is in place and released by the forceps, gentle manual retraction of the lip away from the teeth in the midline will tend to pull the SMAS graft into the central portion of the lip and away from the incisions. Palpation of the lip will allow for slight manipulation of the graft as needed. Any excess graft that extends into or beyond the oral commissure incisions can then be carefully trimmed and excised. The procedure is repeated for the second lip, and the oral commissure incisions are then closed with 2 interrupted plain gut sutures on each side.
The surgeon should ensure that the SMAS graft is not caught by the sutures while closing the oral commissure incisions because this could potentially tether the graft and cause asymmetry or restrict the movement of the lip.