When performing a secondary cervicofacial rhytidectomy, it is advisable to execute each surgical manoeuvre as you would with a primary procedure, only modify the direction and tension of tissue repositioning and the amount of tissue to be excised. However, it is also important to have a surgical fall back position. That is, if things are not going well, for example during submuscular aponeurotic system (SMAS) elevation, the tissue plane may be scarred from previous surgery or atrophic owing to the patient’s age and you may need to convert to a SMASectomy plication technique rather than a SMAS flap and imbrication procedure.
Secondary cervicofacial rhytidectomy
For patients who are focused on recurrence of skin laxity of the lateral cheek and jowl only, a lateral cheek lift using a SMAS flap and imbrication technique is routinely carried out. If the SMAS is atrophic or significantly adherent owing to previous surgery, a plication technique with or without a SMASectomy is recommended. However, for patients who present with some degree of recurrent cervical laxity with or without cervical fat excess, a complete secondary cervicofacial rhytidectomy is indicated.
The operation begins by marking the patient in the upright position, which allows you to determine the effects of gravity on the facial tissues. The incision is marked to begin about 3 cm above the ear in the temple hairline and curve inferiorly to the helical root. It follows the contours of the ear in a retro-tragal fashion, falls into the facial-lobule junction and then onto the conchal bowl, not in the postauricular sulcus as the scar tends to migrate onto the mastoid over time. It makes a right angle turn at the level of the common crus and then follows the posterior hairline for a distance determined by cervical laxity, typically between 3 and 6 cm. When actually making the incision in this area, a trichophytic technique is used; that is, the skin is incised at an extreme bevel just inside the hairline to preserve hair follicles and encourage hair growth through the scar. It is rarely recommended or desirable to create a pre-tragal incision or follow the temple tuft to preserve the sideburn, as the scar can often be seen, even with the most careful closure. The temple hairline can be kept at the same level by redirecting the temple flap more posteriorly and less vertically. If a sideburn incision is used, a trichophytic incision is performed. If the scar is visible post-operatively, micro-follicular hair unit transfer can be used to camouflage the scar. To correct an excessively high temporal hairline, or to repair an area of alopecia from previous surgery, hair grafts can be harvested, divided and placed at the time of secondary facelift surgery or as a separate procedure.
During surgery, the patient is intubated and an intravenous antibiotic administered. To eliminate the risk of bladder distension, the patient is catheterised for any procedure lasting more than 3 hours, which should make the patient more comfortable, resulting in lower peri-operative blood pressure. This will reduce the risk of post-operative haematoma, which appears to be most closely linked to peri-operative hypertension11.
Approximately 20 cc of lidocaine 0.75% with adrenaline 1 : 150000 is routinely injected in the neck, and then the face and neck are prepped and draped in a sterile fashion. As an alternative, one may choose to use plain 0.5% lidocaine. This is supported by Jones and Grover8 who reviewed more than 900 patients undergoing cervicofacial rhytidectomies, and concluded that the elimination of adrenaline from the injection fluid is the only factor that correlates in a statistically significant manner with haematoma reduction. It is felt that one avoids the rebound effect after the adrenaline effect wears off, which can lead to delayed bleeding that was not detected and controlled during surgery.
Procedure
An incision is made in the submental crease and a subcutaneous plane developed. Wide pre-tunneling using a 2.7 mm blunt-tipped liposuction cannula, without suction, between the anterior borders of the sternocleidomastoid (SCM) muscles is performed and the dissection carried inferiorly to the level of the thyroid cartilage. If indicated, liposuction is then performed with the same cannula. A thin layer of fat must be left on the skin flap to maintain a natural appearance of the neck. Wide subcutaneous undermining is then accomplished using scissor dissection with care taken to preserve the marginal mandibular nerve. Patients undergoing secondary facelifts may be at particular risk for marginal mandibular nerve injury owing to fibrosis and adherence of the subcutaneous tissues to the platysma. Furthermore, older individuals may have a very thin, atrophic platysma, which will afford little protection to the nerve. The ‘danger zone’ for injury to this nerve is from the angle of the mandible to its crossing by the facial artery and extends from the inferior border of the mandible to a parallel line 3 cm below15.
After the cervical skin is elevated, additional fat contouring may be carried out under direct vision. The interplatysmal fat is then grasped, clamped with a Kelly clamp, bipolar cauterised and excised. This helps to clearly identify the medial borders of the platysma and debulks sub-platysmal soft tissue centrally, which facilitates the creation of a pleasing cervicomental angle. Transverse cutting of the platysma is non-anatomic and unnecessary. The medial platysmal borders are then plicated with multiple, buried 3–0 PDS sutures. Haemostasis is confirmed using a lighted retractor and the submental incision closed with interrupted, 5–0 plain gut sutures in a vertical mattress fashion to prevent depression of the scar, which can accentuate chin ptosis.
If the chin appears ptotic as a consequence of previous facelift surgery or advanced age, a fat flip-flop-flap may be an appropriate remedy. To execute this flap, there must be adequate subcutaneous fat in the central neck, otherwise free fat transfer may be indicated. If there is sufficient fat present, once the submental incision is made, the neck skin and fat are separated in the subcutaneous plane, with most of the fat left attached to the platysma. The fat is then incised transversely, approximately 3–4 cm inferior to the initial submental incision. The width of the cut is approximately 3–4 cm. Vertical incisions are then made on either side of the transverse incision back towards the submental incision. The fat is then retro-dissected off and between the platysma muscles and left pedicled just inferior to the submental incision. The soft tissues of the chin are then elevated for approximately 2 cm and the fat flap tucked under the elevated chin tissues and sutured into position. The submental skin incision is then closed in an interrupted vertical mattress fashion. This provides vascularised soft tissue bulk and corrects the ptotic or witch’s chin deformity. If the chin has insufficient anterior projection leading to a short cervical–mental distance, an anatomic chin implant is recommended. It should be placed in the subperiosteal plane at the time of rhytidectomy.
