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Comprehensive Facial Rejuvenation: CHAPTER FIVE: LOWER FACIAL REJUVENATION
The rhytidectomy, or facelift, procedure has remained synonymous with facial rejuvenation in the lay public's mind. The term "facelift" has entered the lexicon to signify any reparative endeavor, e.g., the dilapidated edifice underwent a much-needed facelift. In the past, a cervico-facial rhytidectomy represented the principal, if not sole, method by which the facial plastic surgeon could achieve global restoration for the aging face. The midface was uncharted terrain; and traditional options for brow rejuvenation were often judged too invasive to merit routine implementation. Because of these reasons, the facelift was, and still often is, undertaken to lift the midface and temporal brow region in an effort to provide a complete full facial rejuvenation through one procedure. This ambitious surgical enterprise may not always bear the best aesthetic result due to unnatural vectors of suspension and violation of the temporal hair tuft, a stigma of aging and surgical manipulation. Furthermore, the overly pulled, so-called "windswept" look, of a poorly executed facelift has traumatized the public psyche and dispirited many a prospective patient from venturing any further into the realm of cosmetic surgery.
Another obstacle that has potentially hampered public enthusiasm concerns the confusing array of facelift types that are advocated, including the tri-plane facelift, the deep-plane facelift, the composite facelift, the SMAS lift, the subperiosteal lift, the endoscopic facelift, the S-lift, the vertical facelift, the "weekend" facelift, the "lunch-time" facelift, etc., and endless thematic permutations. Clearly, some of the aforementioned surgical techniques reflect ensconced ideologies based on empiricism and scientific inquiry, whereas others testify to unrepentant marketing strategies. Unfortunately, the public is often at the mercy of the Internet and other prejudicial mass-media resources and unable to distinguish between sham and untrammeled science.
This monograph does not purport to offer a wholly impartial perspective on lower-facial rejuvenation but rather espouses a philosophy and strategy that have emerged from a significant clinical experience. Although deeper-tissue (sub-SMAS, extended sub-SMAS, deep-plane, and composite) rhytidectomy procedures have been to some degree in vogue for the past two decades, the authors have noted a trend toward more conservative restorative modalities in the nation. The protracted healing time and potential for higher morbidity may not always translate into a notable clinical improvement according to the authors' opinions, a finding that has also been borne out by the authors' clinical experience. , Further, the authors contend that this return to a more conservative operative technique represents a paradigm shift that matches the present minimal-invasive Zeitgeist. Nevertheless, this controversy will undoubtedly be sustained for quite some time, as proponents of deep-plane and SMAS techniques continue to wage intellectual warfare.
This chapter will endeavor to offer the reader a systematic appraisal of the aging lower face and how to select and implement a host of therapeutic options. For instance, the younger patient who presents with exclusive submental adipose accumulation without notable platysmal diastasis would require only a localized liposuction/lipectomy. These diagnostic deliberations will be explored more in-depth in the following section on preoperative considerations. The reader is further reminded that not all techniques for lower facial rejuvenation are reviewed in this chapter, e.g., collagen injection and alloplast implantation, for which a chapter dedicated to adjunctive procedures has been allocated. These less invasive procedures may be used in conjunction with or independent of the procedures described henceforth in this chapter in a strategy for global facial rejuvenation. Accordingly, these adjunctive procedures will be reviewed in the section on preoperative considerations so that the surgeon can determine when and how these procedures can be implemented and/or combined. However, operative detail may be found in the respective chapter on Adjunctive Procedures for Rejuvenation (Chapter 8). Thoughtful reflection and open dialogue will ensure that the surgeon and patient arrive at the optimal tactical treatment plan.
Preoperative Considerations: Patient Selection & Relevant Anatomy
As stressed above and elsewhere, the surgeon must venture to grasp the aesthetic flaw that concerns the patient before the surgeon proffers his or her own independent management agenda. After the patient has declared the specific locus or loci of concern, the surgeon must then determine whether the patient desires a more limited, targeted approach (adjunctive procedures, e.g., collagen, Botox, etc.) or a more extensive rejuvenative protocol (e.g., submentoplasty, chin augmentation, rhytidectomy, etc.) However, patients often look toward the surgeon for his or her informed and educated opinion, and the surgeon should help strategize for the patient the procedures that would offer the most return on investment. For example, the surgeon can proclaim, "If you could only do one thing, this would give you the most bang for your buck (pardon the colloquialism); and two things, I would recommend, etc." Obviously, the surgeon should recommend only those procedures that are in alignment with the patient's declared interest, e.g., the surgeon should not dwell on a perceived correctable nasal flaw if the patient presents for neck rejuvenation. The reader is advised to review the section on "The Dynamics of an Effective Consultation" (Chapter 3) for more cogent remarks. The remainder of this section will outline a systematic approach that the surgeon can apply when contemplating the optimal treatment strategy for the patient. The two principal areas that will be discussed are the lower face (dependent jowl as well as prominent labiomandibular and nasolabial folds) and the neck region (platysmal banding, excessive submental adipose, redundant skin, and underprojected chin). As these two regions are confluent and overlap, certain topics will be, by necessity, covered in both sections. In addition, the revision or tuck-up rhytidectomy patient deserves special consideration during the preoperative evaluation. Although the lip constitutes part of the lower face, this particular specialized anatomic region will be thoroughly investigated in Chapter 8 (Adjunctive Procedures for Rejuvenation) and Chapter 9 (Cutaneous Rejuvenation) and will not be repeated herein.
The Neck and Chin Region
The central neck region is the area of principal concern for most patients. In this area, platysmal banding, submental adipose, and redundant skin can all be readily apparent. A hypoplastic mentum can exacerbate these conditions and make surgical intervention less than successful. As mentioned before, submental adipose tissue may be an unsightly feature that appears even in early age, particularly in the Caucasian race. Submental fullness is usually more of a problem only in the more mature Asian patient. Conversely, platysmal diastasis is twice as prevalent in the Caucasian than the Asian race (60% vs. 30%). Nevertheless, individual variations mandate that the surgeon tailor the specific surgical plan according to that patient's anatomy.
The younger patient (in the 30's) will often present with submental fullness due to adipose accumulation at times disproportionately greater than the corporal distribution (e.g., thighs and abdomen). Fortunately, a full rhytidectomy would be a premature and unwarranted procedure, as redundant skin and platysmal definition have yet to occur. In addition, the favorable fibrosis induced by cervical dissection permits contraction of the overlying skin sleeve, which is still relatively elastic in the younger patient. An augmentation mentoplasty may also enhance the surgical outcome by better defining the cervico-mental angle. A profile view taken in the correct Frankfort horizontal plane with appropriate pre- and postoperative digital manipulation will often be a helpful adjunct in convincing the patient of the projected improvement. Satisfaction among younger patients with confined submental adipose tissue who have undergone targeted liposuction has been uniformly high.
Augmentation mentoplasty is a marvelous adjunct to lower facial rejuvenation for several reasons. First, as mentioned, when combined with submental liposuction, cervico-mental definition is increased. Second, an extended alloplast that traverses the prejowl region can diminish a heavy jowl appearance, especially when combined with a rhytidectomy. Accordingly, success of a rhytidectomy is partly contingent on the presence of a bony, angular face: the more projected mentum serves as a focal point over which the SMAS may be suspended and the skin, redraped. Fourth, as a patient matures, some bony resorption of the mentum occurs, which contributes in part to the loss of structural support and consequent platysmal separation. Alloplastic augmentation restores the more youthful prominence of the chin. Fortunately, added dissection time is minimized when combined with a submental liposuction and/or platysmal approximation, as the same incision is used for all the above procedures. A sliding-type osseous genioplasty is a viable alternative for augmentation mentoplasty and is particularly versatile in that the chin may be augmented, reduced, vertically shortened, or laterally repositioned. However, the authors have less extensive experience with this technique and will not endeavor to elaborate on the technical specificities entailed with this procedure.
Dedo's renowned thesis on neck classification is worthy of review, as distinctive anatomic configurations and dispositions will dictate surgical intervention and potentially limit surgical success a fact that must be conveyed to the patient during the preoperative phase (Figure 5-1 A, B, C, D, E, F) A Class I deformity exhibits only minimal cosmetic deformity that may or may not warrant surgical intervention. A Class II deformity presents with only skin laxity. This condition is usually quite rare, as concomitant submental fat accumulation and/or platysmal diastasis are usually present to a varying extent. If minimal skin laxity is present, submental liposuction alone may induce sufficient favorable skin contraction. Alternatively, a limited rhytidectomy incision that only extends under the ear lobule in a lazy-S configuration may provide enough exposure for dissection and adequate skin excision. However, cervical skin redundancy usually requires the standard postauricular incision for proper adjustment (vide infra). A Class III deformity refers to excessive submandibular and submental adipose, surgical correction of which has been described above. A Class IV deformity refers to anterior banding of the platysma, which will be addressed further in the following paragraph. Class V deformity describes the condition of retrognathia or microgenia? that can be improved with alloplastic implantation, as outlined above. Finally, a Class VI deformity describes a low-residing hyoid bone that can interfere with optimal cervical rejuvenation. Ideally, the hyoid should be situated at the fourth vertebra, near the cervical-mental interface. Although not included in the original classification schema, a ptotic submandibular gland should also be carefully observed in the preoperative evaluation, as this condition may limit improvement with a rhytidectomy and further correction of which should never be indicated for an aesthetic objective alone.
The anterior platysmal border becomes more accentuated over time due to loss of skeletal support and atrophy of the muscle. The anterior platysmal fibers insert into the mandibular periosteum and demonstrate the greatest variability in distribution. Posteriorly, the muscle fibers blend with the risorius muscle and the SMAS. Therefore, the combination of suturing the anterior platysmal bands with suspension of the posterior platysma/SMAS effects a hammock-like sling that restores definition to the neck. At times, men will seek the most expedient remedy for anterior platysmal banding while refusing a rhytidectomy at all costs due to societal stigma and desire for limited surgery. Jowling and lower facial descent are of secondary concern to many men. If the male patient cannot be convinced that a rhytidectomy is the preferred route, the alternative of direct skin excision, open lipectomy and platysma suturing can be entertained. The major drawback, of course with this approach is a noticeable incision in the midline of the neck, which can be camouflaged with multiple cutaneous z-plasties or geometric broken-line repair the former type of repair is favored due to alacrity of this closure and minimization of scar contracture. If the patient understands this potential, but low, risk, then a direct excision can be undertaken.
In most cases, skin redundancy of the neck can be effectively eliminated by a standard rhytidectomy. The above-described technique of direct excision is an alternative method in the select patient. In rare circumstances, the severity of cervical skin excess may mandate an adjunctive posterior neck lift. This procedure employs a T-shaped incision in which the horizontal limb resides just within the hair-bearing area near the hair-hairless interface and in which the vertical limb falls principally in the non-hair-bearing area (Figure 5-2). Therefore, the patient must be aware that a vertical scar in the occipital midline may be evident postoperatively. Dissection is carried in the subcutaneous, supramuscular plane until adequate elevation permits sufficient skin redrapage. Oftentimes dissection must be carried out near toward the cervical rhytids to achieve enough skin mobility for complete effacement of the rhytidosis. Redundant skin is excised and the wound edges approximated to each other and tacked to the underlying occipital musculature. A posterior neck lift should be undertaken several months, at a minimum, after initial rhytidectomy to determine accurately whether this procedure is needed, how much skin excision is required, and to minimize risk of flap necrosis. It should be emphasized again that this procedure is only rarely indicated. Of note, any skin resurfacing in the neck region should be undertaken with great caution, as the pilosebaceous density is markedly attenuated compared with that of the face (Refer to Chapter 9 for further details). Clearly, cervical flap elevation should delay any resurfacing for a minimum of 6 months, at which time resurfacing should be carried out with even greater conservatism.
The Lower Facial Region
The component regions of the lower face embrace the jowl, which continues upward as the labiomandibular fold (or marionette line), and the nasolabial fold (or smile line). The lower face can only be partly, and somewhat arbitrarily, delineated from the neck region, but is done so herein in order to provide a rational framework for the reader's preoperative assessment. Although the jowl may be conceived of as an extension of the labiomandibular fold, this structure represents a unique surgical entity. Unlike the upper aspect of the labiomandibular fold that requires a soft-tissue filler, the jowl region can only be effectively effaced with a cervico-facial rhytidectomy. In fact, if the patient is principally concerned with the labiomandibular and nasolabial depressions, then the patient should be dissuaded from rhytidectomy. Instead, soft-tissue augmentation may provide the best solution to address the patient's concerns.
The labiomandibular fold is defined superiorly by the cutaneous insertion of the depressor anguli oris muscle. At rest, the labiomandibular fold is only visible along the upper 1/3 to 1/2 of its distance by virtue of the action of the depressor anguli oris muscle on the overlying skin. The fold is tethered specifically at two points: the aforementioned depressor muscle superiorly and the mandibular ligament along its entire length (Figure 5-3). During animation, the zygomaticus and platysma muscles exert their pull at these two points of fixation, thereby causing a bowstring effect and forming a continuous fold. These unique properties of the labiomandibular fold inform the most suitable course of labiomandibular effacement. As the inferior aspect of the crease is absent at rest, the surgeon is advised to concentrate his or her efforts at soft-tissue augmentation only along the superior aspect of the fold. Soft-tissue injectables (temporary) or solid implants (permanent) are both acceptable methods of augmenting the superior labiomandibular fold. For a more detailed description of preoperative, intraoperative, and postoperative management of the nasolabial and labiomandibular folds, the reader is directed to Chapter 8 on adjunctive procedures. As mentioned, the inferior portion of the labiomandibular fold that is accentuated by the jowl should be addressed with a rhytidectomy rather than with augmentation materials.
The nasolabial fold is defined by the cutaneous insertion of four principal muscles: the two levator muscles (anguli oris and alaeque nasi) as well as the paired zygomaticus muscles (major and minor).? Unlike the labiomandibular fold, the nasolabial fold may be apparent along its entire length at rest and during animation. The nasolabial fold may be thought of as a lateral mountain and a medial valley, the latter of which should be elevated with augmentation materials to soften the transition between the two areas. Some authors have also advocated direct, transcutaneous micro-liposuction of the lateral raised aspect to soften the transition further. However, liposuction in this area may be less forgiving than the cervical region. If a concomitant rhytidectomy is planned, the SMAS may be excised before imbrication and used as soft-tissue filler. Unfortunately, the nasolabial and labiomandibular folds are recalcitrant to effacement via traditional rhytidectomy, regardless of whether a deep-plane or SMAS technique is undertaken.2
Revision Rhytidectomy Patient
When a patient inquires in the preoperative period whether a facelift will endure for perpetuity, the surgeon can respond affirmatively. The surgical result will persist; however, the patient will continue to be subjected to both extrinsic (smoking and sun exposure) and intrinsic (genetic predisposition) forces that will slowly erode the once stellar outcome. An example often illuminates the situation in a more concrete fashion for the patient: if the patient had a twin sibling, the patient would always appear younger than his or her twin if all extrinsic factors were negated. Based on these multiple variables, the patient may return as soon as 3 years after the initial surgery for a tuck-up procedure or even a decade or more later. It may be worthwhile to introduce to the patient that a tuck-up facelift may be needed at some later interval, even as short as 2 years, so that the patient will be more accepting of this need when the time comes.
What constitutes the difference between a tuck-up and a revision facelift? A tuck-up procedure is one in which the surgeon is revisiting his or her own work, and revision surgery entails that the surgeon is operating on his or her colleague's previous surgery. Although this distinction is meant to be facetious to a certain extent, it accurately encapsulates a notable truism. When a surgeon must reoperate on another surgeon's facelift, he or she encounters a host of problems. First and foremost, the type of incisions that the other surgeon elected to undertake often does not parallel one's own choices. Therefore, when very little redundant skin is already present (a fact that will be discussed in greater detail in the intraoperative section), the surgeon must make deliberate choices as to where he or she should create the new incisions. These incisions that are often less than ideal, both in terms of exuberant scarring and location, mandate excision of the existing incision and relocation (if possible) to a more favorable site. In addition, if the facelift result is suboptimal, the surgeon must aim to correct his or her colleague's work. All of these factors make "revision" surgery oftentimes more arduous than a "tuck-up" of one's own work. Furthermore, this semantic distinction offers the surgeon a favorable language in which to couch the new surgical enterprise.
At times, a secondary rhytidectomy may prove difficult for another reason: the patient may have unrealistic expectations of the rejuvenative potential, as the degree of improvement may be more limited than in the primary setting. In the rare circumstance in which the patient demands further neck tightening than the surgeon can realistically achieve with a conventional tuck-up procedure, a rhytidectomy with a Gore-Tex sling may be indicated. However, the authors tend to be reluctant to use alloplasts on a frequent basis for the attendant problems that may arise with foreign materials. In addition, the patient should be counseled that the implant may be palpable and require adjustment if it feels too constrictive. Only in the most fastidious patient who already has an established rapport with the surgeon should the Gore-Tex sling be offered as a surgical option. Therefore, the Gore-Tex sling should almost never be performed in the primary setting according to the authors' experience.? It should be reiterated that only a very select patient qualifies for placement of a Gore-Tex sling.
Psychological Aspects of the Facelift Patient
Apart from the anatomic considerations elaborated above, the surgeon should always be mindful of the psychological dynamics that inform the patient's motivation for facelift surgery. Edgerton classified four subtypes of patients who seek facial rejuvenation by age and sex. , The first three categories refer to women, and the remaining fourth category is reserved for men. The first category concerns the woman aged 29 to 39 who desires surgical rejuvenation: she is viewed as an emotionally dependent personality, who seeks constant approbation from her spouse and may not have fully transitioned from adolescence to adulthood in terms of psychological maturity. Given the little adjunctive procedures (e.g., collagen, Botox, chemical peels, etc.) that are available today, this categorization may be a bit outdated. The second category is defined by the woman aged 40 to 50 ("the worker group") who desires to maintain her productivity in the workplace and wishes a countenance to match her energetic lifestyle. Oftentimes, these patients only seek one to two procedures that can improve their look. The third category refers to the woman over 50 years old ("the grief group") who has lost support from her spouse either through divorce or death and is looking for a major lifestyle change through cosmetic surgery. These patients tend to pursue plastic surgical intervention with sustained fervor, demanding additional procedures but infrequently being fully satisfied with the outcome. The final, and fourth, group describes the male facelift patient and is further subdivided into two types. One subcategory refers to the male patient over 50 who is secure in his occupation and is happily married but desires to remain competitive at work: he believes that a facelift may offer him the competitive advantage in a work environment increasingly populated by younger faces. The second type of male facelift patient is the man who is recently widowed or divorced and maintains a relationship with a much younger partner: he desperately wants to retain approbation from his more junior companion and believes that a facelift may narrow the age difference. Clearly, these broad categories are not universally applicable to all patients but are only intended to serve as a framework by which the surgeon may evaluate the prospective rhytidectomy patient in a systematic fashion.
Intraoperative Considerations: Technique & Salient Technical Points
Instrumentation/Equipment for Submentoplasty/Rhytidectomy
Prep Stand:
Non-sterile gloves
10 cc syringe (2), 27-gauge (1 1/4 inch long) needle (2) with
lidocaine 1% and 1:100,000 epinephrine
Surgical marking pen
Basic soft-tissue instrument set (see Chapter 4)
Bovie handpiece and tip
2-0 Silk FS (C-15, CE-6) [C8] <ED-3>needle (to retract the ear)
CV-3 Gore-Tex Th-26 needle (for SMAS suspension)
5-0 chromic P-3 (P-13, PRE-2) <RE-3> needle (2) (for postauricular
skin closure)
6-0 polypropylene P-3 (PRE-2, P-13) <RE-3>needle (2) (for
preauricular and submental skin closure)
5-0 nylon P-3 (PRE-2, P-13) <RE-3>needle (for closure of temporal skin
4-0 polydioxanone PS-3 (P-11, PRE-3) [PC-34] <RE-6>?
(for approximation of platysmal bands)
CV-4 Gore-Tex, PT-17 needle (only to suture a Gore-Tex sling into place
for revision cases)
Other Supplies:
Skin stapler
Laparotomy pads
Ear plugs
2 red rubber catheters (as postauricular drains)
Wall suction, suction tubing, liposuction cannula (for submentoplasty)
10 cc syringe (2), 27-gauge (1 1/4 inch long) needle (2) with
lidocaine 1% and 1:100,000 epinephrine
2 x 30 cm Gore-Tex sling (only for revision cases that require a Gore-Tex sling)
4 x 4 gauze
3″ Kling (3)
Cotton padding
Bacitracin ointment in 5 cc syringe
1″ clear tape
A. Submentoplasty with Liposuction
A submentoplasty may be effectively combined with a rhytidectomy and/or chin augmentation for the optimal aesthetic result. It consists of two principal components: submental liposuction and anterior platysmaplasty. The former may be all that is required for a younger patient, whereas both elements may be necessary for the more mature patient, as part of a rhytidectomy. The submentoplasty is always performed at the outset prior to a rhytidectomy, because the approximated anterior border of the platysma is difficult to unite after the lateral pull of the rhytidectomy has been completed. Similarly, submental liposuction always precedes anterior platysmaplasty, as the removal of adipose and concomitant undermining permit visualization of the skeletonized platysma. Chin augmentation should always follow a submentoplasty but precede a facelift, as the submentoplasty incision is used as the point of entry for chin implantation. Further, vigorous submentoplasty may disturb the position of the implant if performed after implant positioning.
Submentoplasty should practically be considered part of a complete rhytidectomy but is discussed herein as a separate procedure for the sake of clarity and to emphasize the versatility of it as an independent procedure. Submental dissection should precede a rhytidectomy in most circumstances, even in the leanest necks that may not otherwise appear by intuition to warrant this intervention. Uniform submental/submandibular flap undermining promotes favorable skin contraction that by and large enhances a rhytidectomy result. Undoubtedly, aggressive liposuction should be avoided in a very thin neck for risk of producing an over-skeletonized appearance. Instead, sharp scissor dissection only, i.e., undermining alone, may be sufficient in these circumstances. Similarly, a platysmaplasty is justified in most cases when a rhytidectomy is also planned, as the combined effect can be beneficial for the neck contour. However, if a patient presents with only minimal jowl formation correctable with an S-lift, or short-incision, rhytidectomy, then a submentoplasty of any kind may not be a requisite step.
The submentoplasty begins with a straight incision about 1 mm posterior to the submental crease that extends typically about 2 cm in breadth. The incision should always fall slightly posterior to the submental crease because placement of the incision directly in the crease will deepen over time so that the line will become lamentably conspicuous. After the initial incision through the skin to the underlying subcutaneous adipose is accomplished, wide double-hooked retractors are placed into the inferior aspect of the wound by the assistant for proper tension and retraction. The surgeon then performs wide undermining of the flap from just inferior to the jawline (1 to 2 cm below) across the submental region to the contralateral jawline using a pair of Metzenbaum scissors in the subcutaneous plane (Figure 5-4). Dissection should not pass directly over the jawline in order to minimize risk of marginal-mandibular nerve injury. Although the nerve should be protected under the platysma in most cases, an attenuated or dehiscent platysmal layer may predispose the nerve to inadvertent harm. Furthermore, dissection with a pair of Metzenbaum scissors is preferred to blunt tunneling dissection with the liposuction cannula because the former permits a more uniform undermining and thereby reduces the chance of uneven contour to the skin.
After the submental region has been widely undermined, a liposuction cannula can be introduced with the aperture always facing deep, away from the flap (Figure 5-5). The aperture of the cannula should be directed away from the flap in order to avoid the development of an irregular skin contour from suctioning the overlying flap. Furthermore, the vascular supply of the flap emanates from its deep surface, and liposuction under the flap may lead to vascular compromise. The liposuction canister pressure should match the ideal setting of 29″ Hg before beginning the procedure. The surgeon should ensure that the instrument is evenly passed over the entire expanse of the undermined submental region, with perhaps additional treatment centrally where a greater adipose deposit may be observed. The authors discourage routine use of open lipectomy only, as direct excision alone tends to be limited to the midline of the neck, leading to an uneven cervical contour, or worse yet a "cobra" deformity. Certainly, a cobra deformity may arise after liposuction (like lipectomy) of the neck if it is conducted in an aggressive fashion only in the central cervical compartment. A cobra-like deformity may be further accentuated if the anterior platysmal bands are not united after a central lipectomy. However, a central lipectomy may be a useful adjunct in select cases. First, a central lipectomy may be conducted to remove discrete adipose pockets that remain in the midline after a broad liposuction has been carried out. Second, a central lipectomy may be required in order to visualize the anterior platysmal bands obscured by exuberant fat deposition. In select cases, a central lipectomy alone is justified, e.g., a patient who exhibits a discrete submental fat pad, but this task should be carried out in a conservative fashion.
The authors would like to stress a few more remarkable operative considerations concerning liposuction technique. As the submental incision has already been made and the submental/cervical region undermined before liposuction is begun, it should be noted that "open" versus "closed" liposuction is a superfluous technical distinction. The liposuction aperture is in direct apposition to the adipose bed, thereby forming a sealed, or closed, environment despite the open nature of the wound at the time of liposuction. Recent reports have suggested that other liposuction techniques, e.g., tumescent, liposhaving, ultrasound assisted, may be superior to traditional liposuction. Tumescent technique, which has been applied with success for body liposuction, is less than ideal for the cervico-facial region, as the distortion engendered renders assessment difficult and the persistent edema that arises an unwarranted drawback. The risk of third-space volume shifts further compounds the problem with the tumescent method. Although safety with the liposhaver has been documented in a multi-institutional review the hazard of higher seroma and hematoma rate has not been entirely disproved. The ultrasound method suffers from the attendant risk of increased thermal injury (if internally applied) and neural and cutaneous flap injury. These adverse outcomes are not definitively established, as no controlled studies exist, but remain a concern nevertheless. In all surgical endeavors, the authors advocate that the surgeon strive to undertake the procedure with the most straightforward, yet safest, technique without the crutch of unneeded gadgetry that may in fact encumber the surgeon and unnecessarily add to overhead cost.
After the liposuction has exposed the anterior platysmal border, the platysmaplasty may be undertaken (Figure 5-6). With headlight illumination and a Converse retractor, the surgeon should properly visualize the anterior terminal fibers of the platysma. If the platysma appears obscured by a wealth of overlying adipose, the surgeon can perform a selective lipectomy with scissor dissection or with the liposuction cannula, as mentioned before. The surgeon may elect to resect a narrow strip along the anterior border of the platysma to promote better adherence. Although the efficacy of this step has not been rigorously validated, the authors routinely undertake this step unless the platysma is determined to be minimally redundant and the consequent tension of closure would be too great if additional platysmal resection is performed. If the platysmal borders appear widely separated that would preclude a relaxed closure, then sufficient undermining is carried out to facilitate closure. However, significant subplatysmal dissection increases both the likelihood of poorly controlled and visualized hemorrhage and the risk to the marginal mandibular branch of the facial nerve. Before the platysma may be approximated, the inferior extent of the platysmal closure should be identified, viz., the cervico-mental angle, typically located at the thyroid notch. Small (1 to 2 cm) backcuts with Metzenbaum scissors into each side of the platysma at this level are executed for two reasons: (1) tension of the closure may effectively be reduced (2) the neck profile appears more natural with a graduated break at the cervico-mental angle. The reader is reminded that any platysmal dissection, resection, or transection will lead to some hemorrhage, which should be managed with bipolar cautery at the time that the bleeding is encountered. If several areas of hemorrhage are allowed to propagate unabated before electrocautery control, the surgeon will encounter the dubious task of extinguishing these bleeding sites under limited visualization in the confined cervical space illuminated only by headlight. After the platysmal borders have been properly exposed and dissected, the task is then to approximate the anterior free edges with 4-0 polydioxanone (PDS [Ethicon], Maxon [Davis & Geck]), or equivalent, suture in a running, non-locking fashion. To reiterate, the suture should be started approximately at the thyroid notch, or cervico-mental angle, immediately superior to the backcuts that were executed in that region. If a chin implant is not planned, then the submental skin incision is closed with a 6-0 running, locking polypropylene suture.
B. Chin Augmentation
As mentioned, chin augmentation should be carried out after submentoplasty and prior to rhytidectomy. The intended objective for mentoplasty should be kept in mind when deciding on the type of implant to be used. If a hypoplastic mentum requires projection, then a standard implant that is thicker in the middle should be employed. However, if the labiomandibular fold, or prejowl region, requires correction, then a longer implant that extends over the jowl with less central projection should be implemented. A Gore-Tex or silicone implant can be shaved in the central aspect in order to achieve this desired profile for the prejowl implant, whereas a proper Mersilene mesh implant (Ethicon, Sommerville, NJ) may be fashioned with a longer base segment and fewer shorter central segments (vide infra). Although many types of implants have been successfully used for augmentation mentoplasty, the authors have relied on either Gore-Tex or Mersilene mesh as the two major methods for alloplastic insertion. Both materials offer long-term stability, low morbidity, and a natural appearance. Decision as to which implant to employ is a matter of surgical preference. Gore-Tex exhibits the favorable qualities of good biocompatibility, especially in the chin region, ease of insertion and removal, and limited postoperative edema. Mersilene mesh is also very well tolerated, costs considerably less than Gore-Tex, and may be deemed more versatile as the surgeon can create different sizes of the implant at the time of surgery. However, Mersilene mesh requires additional preparatory time for creation of the implant both preoperatively and intraoperatively (vide infra), is more difficult to insert and remove, and shows more exuberant postoperative edema that resolves over a 1-to-2 week period. Because of these reasons, the authors have shifted away from Mersilene somewhat despite the added expense of Gore-Tex.
If a Gore-Tex, or silicone, implant will be used, then no preliminary work need be done during the preoperative phase. On the other hand, a Mersilene mesh sheet must be rolled and sutured into precise, prescribed shapes before use. Dr. Perkin's article provides an excellent defense and review of technique for Mersilene mesh chin augmentation, and the reader is referred there for more details about the background, rationale, safety, and surgical implementation. However, this book will provide a summary of the major technical points in fabrication of a Mersilene mesh implant (Figure 5-7, 5-8, 5-9). All the implants are derived from a single 30 x 30 cm sheet of Mersilene mesh, as prescribed by Dr. Perkin's article. A 5 x 2 cm cardboard template is used to guide construction of the Mersilene mesh implant: the sheet is rolled over the cardboard template 9 times in order to obtain an implant that is 10 layers thick. A smaller-size implant is created that measures 5 x 1 cm in dimensions using another cardboard template in the same fashion as above. The smaller 5 x 1 cm segment will be suture fixated to the anterior, central aspect of the larger implant (5 x 2 cm) during surgery. Prior to surgery, all of these individual rolls are packaged and sterilized for intraoperative use. During surgery, the size of augmentation is determined, and the number of tiers that are required to achieve proper chin projection is assessed. A series of smaller 5 x 1 cm segments are then suture fixated to the larger 5 x 2 cm segment to achieve the desired degree of augmentation. Generally speaking, a medium-sized implant requires one 5 x 1 cm implant sutured atop a 5 x 2 cm segment. A larger implant can be made using two 5 x 1 cm segments on top of a single 5 x 2 cm segment. As mentioned, at the time of surgery, the segments are sutured together as a stack to achieve the desired height (Figure 5-7,5-8: and the edges are tapered for ease of insertion (Figure 5-9). As far as the Gore-Tex implant is concerned, the implant is typically manufactured in three extended sizes: small, medium, and large. In the great majority of cases (approximately 80%), a medium-size implant is sufficient for adequate projection or to soften the prejowl fullness, while the remaining 20% of the time is equally divided between use of a small and large implant. The small implant is really designed for the minority of patients who only want very subtle augmentation. As most patients who elect to undergo chin augmentation are willing to incur the extra expense, they typically desire a little more noticeable augmentation than can be afforded by a small-size implant. In addition, the medium-size implant is more versatile, as it can be sculpted to be smaller in size. With the large implant, the reader is reminded to assess the patient's occlusion before electing to place this implant. Oftentimes, the patient who has a significant recession of the chin exhibits concomitant occlusal disharmony, usually a Class II occlusion, or "overbite". Obviously, placement of a large implant will do nothing for the occlusal problem, and the patient should be counseled about that fact.
Appropriate local anesthesia of 1% lidocaine with 1:100,000 epinephrine is infiltrated directly into the submental incision as well as transorally for a mental-nerve block (Figure 5-10). The procedure is begun with a submental incision, as described in detail in the preceding section on submentoplasty. With proper headlight illumination and retraction on the superior wound edge, dissection is carried out over the anterior aspect of the chin in the plane below the mentalis muscle but above the periosteum. The implant will be seated in a supraperiosteal plane centrally and in a subperiosteal plane laterally in order to ensure maximal fixation (Figure 5-11). A Converse retractor should be used to inspect the pocket laterally, as the surgeon prepares to enter the subperiosteal plane. A monopolar cautery is used to score the periosteum in a vertical direction in a parasagittal line running through the canine teeth (Figure 5-12), and a Joseph elevator is then inserted into this subperiosteal plane to dissect the pocket laterally (Figure 5-13). The Gore-Tex implant tends to be easier to insert, and a tighter lateral, subperiosteal pocket can be fashioned. A slightly more generous pocket is often necessary for the Mersilene mesh implant, which tends to resist easy insertion into the subperiosteal pocket. The midline of the implant itself should be marked before placement by excising a small, vertical wedge in the presumed midline, if not already inscribed in some fashion by the manufacturer. Any further trimming of the implant should then be completed prior to insertion. A tonsil, or equivalently large and curved, hemostat is used to grasp one end of the implant with the tines extending to the end of the implant to ensure that the implant does not fold back onto itself and to facilitate ease of placement (Figure 5-14). With a Converse retractor and headlight, the implant is gently delivered into the subperiosteal pocket (Figure 5-15), and the same maneuver is conducted on the contralateral side (Figure 5-16A, B). Before the incision is closed, the implant should be noted to be in the midline (according to the designated mark) and completely residing over the anterior aspect of the mentum. At times, the distal end of the implant may buckle, particularly with the Mersilene mesh implant; and the surgeon is advised to palpate the distal aspect carefully before closure of the incision. Unlike in a straightforward submentoplasty, a single subcuticular closure with a 4-0 polydioxanone suture is warranted: the violated mentalis muscle can be reapproximated to secure the implant and to prevent a "witch's chin" deformity (Figure 5-17). The skin incision is then closed with a running, locking 6-0 polypropylene suture, as described for a standard submentoplasty (Figure 5-18).
C. Primary Rhytidectomy
Like in all facial plastic procedures, infiltration of sufficient and well-timed local anesthesia containing epinephrine is a critical first step for success. 1% lidocaine mixed with 1:100,000 epinephrine should be placed into the postauricular, preauricular, and cheek areas on the right side of the face toward the close of the submentoplasty. Similarly, the left side of the face should be injected toward the completion of the right side of the face. Judicious timing with a ten-minute delay will ensure maximal hemostasis and adequate anesthesia for the intended operative time. Of note, after a one and a half hour period of time, the effects of the lidocaine and epinephrine markedly diminish, making diligent and expeditious surgery mandatory for an optimal result. Before actual surgery commences, a cotton tampon consisting of either a Kitner sponge or the cottony central portion of an eyepad should be inserted into the entrance of the external ear canal to absorb any blood. In addition, a liberally moistened laparotomy sponge is opened lengthwise to circumscribe the hair-bearing scalp, and a surgical towel is then applied exterior to this laparotomy pad both are held in place with a towel clamp. This dressing serves to absorb the majority of any excessive blood during the operation and thereby minimize the need for any labor-intensive cleaning of the hair at the end of the case.
Although many variations of skin incisions have been proposed for a rhytidectomy, the authors advocate the formula described herein for the best aesthetic outcome. The following guidelines stress the philosophical underpinnings that have informed the authors' chosen pattern of incisions. Beginning postauricularly, the surgeon should strive to follow the incision along the hairline rather than traverse the naked skin into the hairline at the mid-auricular level (Figure 5-19). Many mature women who desire rhytidectomy prefer a shorter hairstyle that precludes the more readily visible lower postauricular incision. In the preauricular region, the surgeon should strive to follow the natural curvature around the lobule, behind the tragus, and again around the helical crus superiorly: straight and/or pre-tragal incisions may be more conspicuous, particularly in darker complected individuals and in those patients prone to exuberant scar formation. Whether to use a pre- or post-tragal incision remains a controversial subject. However, the authors strongly contend that the latter serves to camouflage the incision more discreetly and has unequivocally resulted in a natural appearance. Finally, the temporal hair tuft should not be violated, as the recessed position after surgery is a glaring stigma of advanced aging. After repeated rhytidectomy in this manner, the alopecia may be serious enough to justify a tedious, and often unsatisfactory, hair transplantation to correct this problem.
To begin the rhytidectomy, the posterior aspect of the auricle is pierced with a 2-0 silk suture toward the base of the ear and further superiorly so that the entire length of the ear may be retracted with the suture pulled anteriorly to expose the postauricular skin. A hemostat should be clamped to the suture to facilitate the assistant's retraction of the ear. The second maneuver in a rhytidectomy is a directed, stab incision at the base of the lobule and insertion of a single-pronged hook for proper retraction inferiorly (Figure 5-20). The postauricular region is always initially incised in a complete rhytidectomy for the simple, perhaps obvious, fact that any prior preauricular incisions will trickle blood into the postauricular site obscuring ease of dissection. The postauricular incision should be begun along the inferior hairline using a No.15 Bard-Parker blade and carried superiorly until the hairline meets the posterior surface of the ear but should be notched in a V-configuration immediately prior to this junction to avoid unfavorable scar contracture (Figure 5-21). The incision is continued onto the actual postauricular surface of the ear (about 1 to 2 mm anterior to the auricular-postauricular interface and situated on the cartilaginous portion of the ear) in order to facilitate ease of closure and to resist the tendency toward deepening of the postauricular sulcus over time. The postauricular incision terminates at the aforementioned lobular stab incision.
A tiny double-hooked retractor is inserted into the superior aspect of the postauricular incision (near the hairline-auricular junction), and sharp dissection is undertaken of the postauricular flap with a No.15 Bard-Parker blade (Figure 5-22). Transillumination of the flap with one overhead operative light directed through the flap from above and the other over the surgeon's right shoulder aimed under the flap provides the best visualization of the dissection plane. A headlight, on the other hand, may interfere with this type of illumination technique. All postauricular dissection is conducted sharply with the No.15 blade, as the plane of dissection over the sternocleidomastoid muscle is somewhat ill defined. The surgeon should strive to elevate the flap leaving the glistening sternocleidomastoid fascia intact on the muscle surface: this surgical plane prevents inadvertent injury to the major branch of the great auricular nerve and undue hemorrhage from muscle transection. As the cervical pocket is approached, the surgeon may elect to continue the dissection with sharp Metzenbaum scissors to expedite completion of postauricular flap elevation (Figure 5-23).
After the postauricular flap has been successfully completed, the surgeon should turn his or her attention to the preauricular region. The above-described curvilinear, post-tragal incision should be initiated with the No.15 blade. The exception to this rule would be a1 patient who requires a preauricular incision to avoid translocation of hair-bearing skin onto the tragus, making daily shaving a treacherous exercise (Figure 5-24). The incision is carried around, i.e., inferior, to the temporal tuft of hair, or sideburn, with the knife blade beveled slightly away from the hair to prevent follicular transection. Two tiny double-pronged hooks should then be placed on either side of the tragus to retract the skin forward and to assist in initial flap elevation (Figure 5-25). As the flap is developed, larger double-pronged retractors may be substituted for the smaller versions to facilitate flap elevation (Figures 5-26A, B). The same orientation of the two overhead lights, as described for the postauricular dissection, should be used for the preauricular region. Sharp Metzenbaum or dedicated facelift scissors are used to elevate the preauricular flap: the flap should be elevated by advancing the scissors forward under the flap with tines held slightly ajar rather than opening and closing them in a traditional manner: this method helps to establish the proper plane of dissection to lessen the chance of flap transection ("button-holing") (Figures 5-27A, B). After several of these passes have been made and the dissection plane, identified, the surgeon can elect to connect these pockets by gentle spreading of the scissor tines or by opening and closing the tines as usual.
The length of the cutaneous flap is dictated by several factors. Most importantly, the distance of flap elevation should depend on the ease with which the SMAS can be retracted and suspended, which can be assessed by tugging on the SMAS with a pair of Brown-Adson forceps (Figure 5-28). If any resistance is met or if the skin appears to drape poorly, then additional undermining of the skin flap is recommended. Generally, a "medium"-length flap that terminates near the midcheek, just medial to the lateral canthus, is a reasonable first attempt. Another factor that may inhibit the surgeon from extensive flap elevation is the fear of flap necrosis secondary to tobacco usage, diabetes mellitus, or other impediments of a vascular or healing nature. The authors have not made it a strict policy to abstain from surgery in chronic, habitual smokers because they almost never obey instructions and more conservative flap elevation generally protects against any flap compromise. However, the patient is asked to cease all forms of tobacco for a two-week period before and after surgery (total of one month), knowing well that this request will most likely be breached despite stern admonition to refrain.
SMAS suspension is accomplished with either imbrication (SMAS-ectomy, or SMAS excision, followed by suture fixation of the exposed edges) or plication (folding the SMAS onto itself without excision). Imbrication is the favored technique, as it typically permits a more even, less buckled, contour of the lateral cheek. Furthermore, the excised strip of SMAS tissue can be harvested for nasolabial, labiomandibular, or labial soft-tissue augmentation.? Approximately a 2-cm width of SMAS adjacent to the anterior border of the ear extending inferiorly to just around the lobule but terminating superiorly before the temporal region (to avoid temporal-branch neuropraxia) should be excised as part of a SMAS imbrication (Figure 5-29). However, in a very gaunt patient, the surgeon may prefer to undertake a SMAS plication instead to restore some youthful fullness to the face.
A very important principle should be stated at this point: the SMAS provides all suspension of descended tissue, whereas the skin is simply redraped after SMAS suspension. The skin should support no tension for two reasons: (1) a widened scar may develop and (2) a "windswept" appearance of a poorly executed facelift will often result. Conversely, the SMAS may be tightened with as much tension as possible without an untoward aesthetic outcome. Furthermore, the vector of pull for the SMAS should be primarily in a vertical direction to counteract the forces of gravitational descent rather than simply posteriorly which will be more precisely delineated. Three or more sutures of CV-3 Gore-Tex, or equivalent, suture should be used for SMAS suspension (Figures 5-30A, B, C). (If Gore-Tex suture is used, then a minimum of 7 knots should be thrown per suture knot: the first 3 to 4 knots are not tied down extremely tightly because of the tendency for the suture to continue to slide when tightened down.) Only the last 2 to 3 knots should be cinched very tightly to avoid unraveling. Despite additional expense, Gore-Tex offers the unique ability to fasten a square knot in the air and to slide that knot down to the desired position and to adjust the degree of tightness without slippage. The first suture should be placed at the jawline and the vector of suspension should follow the jawline posteriorly. However, the next two suspension sutures should follow the prescribed formula of 1/2 vertical and 1/2 posterior pull. The second suture should be placed approximately at the level of the inferior third of the face, and the remaining suture positioned somewhat higher at the level of the tragus (Figure 5-31). The precise location of these sutures and the need for additional sutures are dictated by circumstance. Generally, however, the above method should suit the novice surgeon well until greater clinical experience is accumulated.
The next task at hand is to redrape the skin and excise any excess. As stated, if the skin is noted to drape poorly at this point, additional undermining may be needed. However, some contour irregularity at the site of the SMAS suspension suture is commonly present and does not warrant any concern, as time tends to remove these apparent imperfections. The proper sequence for skin excision and redrapage should be as follows: temporal region, then hairline region, finally the ear lobule. This point deserves reiteration: the pre- and postauricular areas are always suture fixated prior to lobule adjustment so as to prevent undue traction on the lobule with resultant pixie, or devil's ear, deformity (Figure 5-32). First, a single hook retractor is positioned into the anterior aspect of the temporal incision and gently retracted anteriorly by the assistant, with almost no significant traction. The surgeon then redrapes the skin supero-posteriorly, again following the 1/2 superior, 1/2 posterior rule, outlined previously for SMAS suspension. The excess of skin in the temporal region is excised, and the temporal incision closed with a 5-0 nylon suture in a running, locking fashion (Figure 5-33). The skin along the hairline is then carefully redraped according to the prescribed postero-superior vector with no tension, and the excess skin, trimmed along the hairline and tacked in place with 5-0 chromic sutures and surgical staples further posteriorly along the hairline (Figures 5-34A, B, C, D, E). At this point, the skin has been redraped and secured anteriorly and posteriorly to the ear with the remaining excess of skin obscuring the inferior aspect of the ear (Figure 5-35). The surgeon can now safely trim the redundant skin covering the lower auricle with a pair of serrated Metzenbaum scissors down to expose the lobule (Figure 5-36A). The surgeon should always aim toward a conservative trimming, especially during the initial pass of the scissors, to avoid tension on closure of the lobule (Figure 5-36B). If the surgeon believes that he or she has trimmed too far past the lobule, then he or she can reapproximate the transected skin to the desired point. Similarly, if a patient presents with a pixie-ear deformity, the surgeon can correct this problem with a V to Y advancement.
Postauricularly, the V-shaped notch that was created at the time of initial skin incision between the postauricular sulcus and hairline (to prevent scar contracture) is recreated in the newly redraped flap and suture fixated with several interrupted 5-0 chromic sutures. Remaining excessive skin along the postauricular sulcus is trimmed and closed with a running 5-0 chromic suture (Figure 5-37A). Prior to complete closure with the 5-0 chromic suture postauricularly, a red rubber catheter should be inserted at the midpoint of the incision to provide drainage (Figure 5-37B). The excess skin that now remains anteriorly should be trimmed to match the curvilinear preauricular incision with careful attention to thin the tragal region appropriately (Figures 5-38A, B, C). The preauricular skin is then closed with a 6-0 polypropylene suture in a running, non-locking fashion: the suture is not locked for ease of closure and to permit cutting every other suture at 7 days postoperatively, as described in the postoperative section.
The contralateral side of the face is completed in the same manner as described above. By convention, the authors complete the right side of the face prior to the left side: whatever order the reader ultimately decides to follow, he or she is encouraged to remain consistent in that order. Also, the reader is reminded that local anesthesia for the contralateral face should always be infiltrated 10 to 15 minutes prior to actual incision on that side for ideal anesthesia and hemostasis. The hair should not be cleaned with peroxide unless the hair color is already white for risk of unintended bleaching. Placement of a heavily moistened laparotomy pad around the hair-bearing head absorbs most of the blood during the operation and usually eliminates the need for any painstaking cleaning. At the end of the case, a pressure dressing is fashioned in the following manner. Bacitracin ointment is applied to all incision sites prior to the placement of the dressing. A 4 x 4 gauze with a curvilinear incision to accommodate the shape of the ear is placed over each ear, followed by several uncut 4 x 4 gauze sponges on top (Figure 5-39A). Additional 4 x 4 gauze dressings are placed in the postauricular area. A folded 4 x 4 gauze is placed immediately over the submental incision site. Thick cotton dressing is applied over the 4 x 4 gauze along the jawline and over the postauricular site for additional reinforcement (Figure 5-39B). The cotton dressing should always rest superficially to the 4 x 4 gauze and not make direct contact with the skin or hair, as it tends to adhere tenaciously, making removal of it a tedious exercise. Finally, a 3″ Kling is secured over the above dressing in two vectors: (1) from the submental area to the superior aspect of the head, like a Barton's bandage and (2) from occiput to forehead (Figure 5-39C, D). The reader is also advised not to over tighten the Kling wrap but to exert only enough force to circumscribe the head. Although the above text appears to be self-explanatory, proper application of dressing is not always intuitive and can avoid needless headaches.
D. SMAS Insertion for Augmentation of the Nasolabial & Labiomandibular Folds
For the sake of clarity, insertion of SMAS tissue to augment the nasolabial and labiomandibular folds is separately presented from primary rhytidectomy. Clearly, this adjunctive procedure can only be performed during a rhytidectomy when the tissue is harvested during resection of SMAS for imbrication. Rather than discarding this extra tissue, it can be used to augment the nasolabial and labiomandibular folds. The technique is the same as that will be described for Alloderm and Gore-Tex in Chapter 8.
This section will present precisely how to insert the SMAS tissue to augment the labiomandibular folds. As would be expected, the same technique applies to augmentation of the nasolabial folds and the lips. Generally speaking however, there is usually insufficient amount of removed SMAS to augment all three areas.For more detail about nasolabial fold or lip augmentation, the reader is referred again to Chapter 8.
The SMAS is harvested in the manner prescribed in the previous section, under "Primary Rhytidectomy" (Figure 5-40). The excised SMAS tissue is then measured to determine the proper length needed to augment the desired fold, and an 0 silk suture is tied to one end of the implant while the other end of the suture is affixed to a long Keith needle? (Figure 5-41). A stab incision is placed at both ends of the labiomandibular fold, and the introducer that resembles a Freer elevator with a central groove is used to create a subcutaneous pocket to receive the implant (Figure 5-42). The aforementioned needle is then passed into the central groove of the introducer device (Figure 5-43), and the introducer is then removed with the needle still in position. Tiny, double hooks are used to retract the wound edges while the needle is pulled through in order to draw the implant into the recipient pocket (Figure 5-44). The excess tissue is trimmed to leave an excess of 1 cm on either end (Figure 5-45), and fine-toothed forceps are used to tuck the excess 1 cm of both ends distal to the incision by this length (Figure 5-46). (The rationale for this technique is further elaborated in Chapter 8). The stab incisions are closed with interrupted 6-0 polypropylene sutures (Figure 5-47). Usually two sutures per incision should suffice.
E. Secondary Rhytidectomy
A secondary rhytidectomy is an inevitable necessity, as all individuals continue to mature and will require additional surgery at a later date to maintain their rejuvenative appearance. The timing and extent of surgery is predicated on the combined extrinsic and intrinsic factors that lead to further aging. The procedure can be a straightforward or complicated affair, oftentimes depending if the surgeon is operating on his or her own handiwork or someone else's. This practical distinction has already been addressed in the preoperative section of this chapter. However, it is worthwhile to reiterate two important principles: (1) very little to no skin need usually be excised in a secondary rhytidectomy and (2) decision to revise the placement of unfavorable incisions is determined in part by the laxity of skin that will permit translocation of the incision, e.g., movement of an incision from a pre- to a post-tragal position.
The next factor that should be determined, just as in a primary rhytidectomy, concerns the intended area for rejuvenation, viz., submental, jowl, etc. If the anterior platysmal bands were already sutured together during primary rhytidectomy and no visible platysmal cords are evident, then this procedure need not be repeated. However, even in the most assured past platysmal closure, the returning patient may exhibit platysmal diastasis that mandates repeat muscular approximation.
*Patient Results May Vary
Filed Under: Publications


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Mermaid Bay // 4oz Mini Tin Soy Candle
Mermaid Bay // 4oz Mini Tin Soy Candle
-Mermaid Bay-
Notes of cucumber, oak moss, sandalwood, fig, jasmine, grapefruit and cedar. Inspired by the beauty of the sea and the mythic mermaid, this fragrance is fresh, herbaceous and aquatic.
and poured into a 4oz size tin.
Approx. 20 hours burn time.
Astatula candles are created in small batches in the heart of Old Seminole Heights, Tampa, FL.
I use 100% USA soy wax, cotton wicks, essential oils, and fine fragrances free of harmful pthalates.
Free of dyes and additives, my goal is to get as pure as possible with these little lights.
** PLEASE TAKE CARE when you burn a candle and make sure it's not left unattended in a room. For best results I would burn a new candle 3-4 hours in order to get an even melt pool of wax to the edges of the jar. I would also advise that you keep the wick trimmed to 1/4" in order to get the most out of it and prevent any smoking.
**SHIPPING - Domestic orders will ship via USPS priority mail. International orders ship USPS First Class International.
These small tins are so cute and perfect for travel or gifts. They are also great if you want to test out the scent before purchasing the larger sized jar.
Containers are reusable and recyclable!


text: 12. October 2012 13:09 by m 0 Comments The James Bond Archives 12. October 2012 13:09 by m | 0 Comments Here is an item all James Bond Fans will be wanting to add to their Christmas Wish List: Author Paul Duncan has done a tremendous job: this enormous book is packed with interviews and a most impressive collection of archival photos taken on set and behind the scenes. The photos and diagrams from the Connery Bond films are particularly impressive. This is simply a must have book for any devoted fan of the James Bond films and is an indispensible addition to any 007 collection. Fifty years of Bond, James Bond The James Bond Archives Fifty years of Bond, James Bond "Bond, James Bond." Since Sean Connery uttered those immortal words in 1962, the most dashing secret agent in the history of cinema has been charming and thrilling audiences worldwide. This impeccably British character created by author Ian Fleming has starred in 23 EON-produced films, played by 6 different actors over five decades. To celebrate 50 years of this innovative franchise, EON Productions opened their archives of photos, designs, storyboards, and production materials to editor Paul Duncan, who spent two years researching over one million images and 100 filing cabinets of documentation. The result is the most complete account of the making of the series, covering every James Bond film ever made, beginning with Dr. No (1962) and ending with the upcoming Skyfall (2012), including the spoof Casino Royale (1967) and Never Say Never Again (1983). The stunning imagery is accompanied by an oral history recounted by over 150 cast and crew members, relating the true inside story of how the Bond films were made. Containing previously unpublished photography and artwork, as well as production memos from filming, this book is a comprehensive tribute to the legend of James Bond. * Celebrating the 50th anniversary of the most successful and longest-running film franchise in cinema history! * Made with unrestricted access to the Bond archives, this XL tome recounts the entire history of James Bond in words and pictures * Among the 1,100 images are many previously unseen stills, on-set photos, memos, documents, storyboards, posters, and designs, plus unused concepts, and alternative designs * Behind-the-scenes stories from the people who were there: producers, directors, actors, screenwriters, production designers, special effects technicians, stuntmen, and other crew members * Includes every Bond film ever made, from Dr. No (1962) to Skyfall (2012) * Special bonus included with the first print run of the book only: an original strip of film from Dr. No Written by: Paul Duncan Published by: Taschen America, LLC Date published: 11/09/2012 ISBN: 9783836521055 Available in Hardcover Order your copy of The James Bond Archives today James Bond films © 1962–2012 Danjaq, LLC and United Artists Corporation.All rights reserved. Also available in 2 Art Editions, each limited to 250 copies. Tweet


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Published 15/08/12
EISA selected Sigma's large aperture medium telephoto macro lens because of its build and image quality. This upgraded lens features Sigma's proprietary Optical Stabilization OS technology and provides extremely high optical performance from infinity to 11 macro. It is sold by authorized Sigma dealers for the MSRP of $1,600.
According to a citation provided by EISA, ''The Sigma 150mm F2.8 EX DG OS HSM APO Macro lens is one of the best performing macro lenses available on the market. The combination of a long focal length and thereby good working distance between lens and subject, high sharpness even at full aperture and optical image stabilization makes it perfect for catching dragonflies, butterflies and other elusive insects handheld. But the lens is also excellent for photographing plants or portraits when you want to achieve a really soft and pleasant blurry background. If you also consider how solidly this lens is made, its price makes it a real bargain''
EISA is comprised of 50 special interest magazines from 19 European countries and it started in 1982 when the editors from five European photo magazines came together to select The Camera of the Year Since then, EISA member magazine editors have broadened the scope of the annual awards and they convene each year to decide which products are worthy of EISA Awards.
''Our 150mm F2.8 EX DG OS HSM APO Macro lensallows for the flexibility of handheld photography when photographers want to get close-up shots that are difficult to capture,'' said Mark Amir-Hamzeh, president of Sigma Corporation of America. ''EISA's recognition of this versatile lens highlights our dedication to developing products that expand our unique lens lineup and help produce outstanding image quality for photographers of all types and levels.''
This year, Sigma also took home two awards from the Technical Image Press Association TIPA. The company's18-200mm F3.5-6.3 II DC OS HSM and APO Macro 180mm F2.8 EX DG OS HSM lenses won for the Best Entry Level DSLR Lens and Best Expert DSLR Lens awards, respectively.
To locate an authorized Sigma dealer nearest to you, visit www.sigmaphoto.com/where/where.asp. For information about Sigma Corporation of America, visit www.sigmaphoto.com.
The Societies of Photographers Convention and Trade Show at The Novotel London West, Hammersmith ...
You have 121 days until The Societies of Photographers Convention starting on Wednesday 22nd January 2020


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Get Started with Health & Care: First Aid
Event Details
First aid is a useful and essential piece of training to have, especially if you are looking to work in the health industry.
Our 'Get Started with Health & Care: First Aid' event puts you in a role play scenario where someone requires first aid. Airways, breathing and chest compression will be explored as the initial assessment of a first aid scene. You will also take part in a bandaging activity and discover what the normal rate of breathing, pulse and pressure is for individuals.
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Jim Babka leaves an excellent comment criticizing Walter Berns' position that traditional Christianity is incompatible with the natural rights philosophy of the American Founding. In particular Babka writes:
First, Locke pretty much starts with a man named Adam, living in a garden — THE BIBLICAL NARRATIVE. And whether or not Rousseau had influence on our Founders, particularly Jefferson, no one doubts Locke had anything short of tremendous influence.
Second, whether or not our Founders were predominantly Theistic Rationalists, as Jon Rowe keeps illustrating, they still had to sell their idea in an orthodox, Christian milieu. If Natural Rights was so explicitly counter-Biblical, please tell me how a culture that actually owned and read Bibles, stood for rights? …and why Christians, even the most fundamentalist of them, endorse the notion of rights as found in the Declaration of Independence?
The Straussians explain at great length this interesting dynamic of traditional Christians going along with ideas that were not authentically Christian, perhaps anti-biblical. They also explain why Locke, although he dresses his arguments up in biblical language, was not a Christian. They go too far in my opinion. I would agree that Locke was not an orthodox Trinitarian Christian and his "state of nature" philosophy was a moderated version of Hobbes' original concept. But, I think that Locke's teachings were compatible with traditional Christianity, even though they clearly do not derive from that system.
I will take Locke at his word: He claimed to be a "Christian" but seemed to disbelieve in original sin and never affirmed the doctrine of the Trinity. His "Reasonableness of Christianity" was accused of peddling Socinian Unitarianism. And this is because in that book Locke sets forth what he sees as the fundamental doctrines of Christianity but leaves out original sin and the Trinity! Scholarly consensus concludes that Locke was a Unitarian most likely of the Arian variety, like his friend Isaac Newton whom Locke encouraged to publish unitarian arguments.
But in any event many Founding era ministers, some of them orthodox Trinitarian like John Witherspoon, and some of them Unitarian like Jonathan Mayhew turned to Locke's ideas to justify rebellion and otherwise explicate what they saw as the purpose of government. The Straussians argue that these ministers were key to getting a Christian populace to go along with ideas that were either a-biblical or anti-biblical. There is also disagreement over whether these "Christian" figures consciously understood that Locke's ideas were not authentically biblical and otherwise broke with the traditional Christian view of man and government.
Way back when I was just a "reader" of Sandefur's Freespace, I wrote him with Walter Berns's theory on the matter. Here is what I wrote:
Although [Walter] Berns is generally a social conservative and anti-libertarian, he actually has quite a strong understanding of this nation's secular foundation. Chapter 2 — "God Before Country" — in Making Patriots provided me with some pretty valuable insights regarding America's secular founding.
That book also notes that John Witherspoon...was as much of a Lockean as he was a Calvinist.... From Berns: "Like Jefferson and Madison, [Witherspoon] had obviously read Locke with care and was persuaded by him of the importance of liberty of conscience — which put him at odds with the founder of Presbyterianism, John Calvin. (For Calvin, liberty of conscience meant just that, and no more than that. If someone gave voice to his conscience, thus being heard or read by others, he might rightly be punished. So it was that, as the effective governor of his city of Geneva, Calvin had one of his anti-Trinitarian critics put to death.)" Making Patriots, p. 42.
Witherspoon's importance to our founding seems to be that he acted as sort of a "mediator" between the Enlightenment philosophers and Christian theology, and led Christians to believe that Enlightenment philosophy was perhaps more compatible with their orthodox Christianity than perhaps it really was. The philosophers who articulated "Natural Right" were either non-Christians or non-Trinitarian heretic Christians. "Nature's God" who, according to the philosophers, grants us inalienable rights certainly wasn't the God of orthodox Christianity. And the notion that Jehovah or Jesus grants us inalienable rights is "wrong as a matter of doctrine — where does the Bible speak of unalienable natural rights, or the liberty to worship or not to worship as one pleases?" Id.
However, it made very good political sense for a nation founded on Enlightenment principles, yet populated by many orthodox Christians, to get such Christians to believe in this. And Witherspoon greatly helped in making this a reality (too successful–how many times do we hear today the religious right claim that this nation was founded on Christianity because the Declaration states that our rights come from the "Creator" which they interpret as the God of Biblical Christianity?). "Witherspoon could speak unreservedly of 'natural liberty' and 'natural rights'; and of the 'state of nature' and like Locke…of its 'inconveniences,' inconveniences that caused men to leave it for the 'social state.' But in the same lecture he could admonish his listeners and readers to accept 'Christ Jesus as he is offered in the gospel,' for 'except that a man be born again, he cannot see the kingdom of God.' In a word, Witherspoon saw no conflict between the new political philosophy and the old religion, which is to say between the principles set down in the Declaration of Independence and what he understood as orthodox Christianity." Id.


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When things get easy, people get weak. The only way to win is to get mad, get hungry . . . get the Eye of the Tiger.
In a recent interview, Columbia's Mark Lilla argues that conservatives lost their Eye. Why?
Just like Rocky, conservatives in the 1970s and 1980s scored major successes. Not by beating up Mr. T, in conservatives' case, but by establishing dedicated intellectual institutions. Those institutions could and did fund conservative research and thinking.
So what's the problem? According to Lilla, those plans worked only too well. Conservatives, he argues,
created institutions that have easy sources of funding and never have to go out and argue with people who disagree with them. It's made their world inbred, lazy, and self-satisfied. It gets harder and harder to find serious conservative books on the major issues of the day.
Following that Rocky logic, it seems the best tonic for conservative anomie would be a long winter stint out in the woods, working out with cinder blocks and being uncomfortable.


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Amy | New Albany IN Maternity Photographer | Photography & Design By Lauren
Meet one of my best buds Amy!We have quite a photography history together. She was one of my first engagement sessions my very FIRST wedding and in a few short weeks I will be taking newborn pictures for baby Nathan. After I did her engagement pictures we quickly became friends. Amy has always been one of my biggest photography supporters and I am sooo greatful for her friendship! You looked beautiful during your pictures and I know you'll be an awesome mom ;)


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Types of Server Clustering
Erik Rodriguez
This article is part 2 of
server clustering
Types of clusters
Clusters can be custom designed to fit the needs of a specific task or an organization. Several types of popular clusters and their uses are discussed below:
Load-Balancing Clusters
Grid Clusters
Render Clusters
Each type of cluster unique method of operation. For instance, a load-balancing cluster operates differently from a render cluster. Load-balancing clusters are commonly used with high-traffic websites. Load-balanced clusters are usually run in an
active-active configuration
. However, in a different type of operation usually referred to as a redundant cluster or failover cluster, they can operate in an
active-passive configuration
. See the diagram below:
Shown above, is an active-active cluster operating with a load balancer. The load balancer as mentioned in
part 1
of this article is making decisions based on each cluster memebers' load. By monitoring all requests to and from the cluster, it will pass new requests to the "least busy" server in the cluster.
Grid clusters and render clusters are very similar. Rendering clusters are used by motion picture studios like Pixar to "render" 3D graphics. Grid computing is used for other applications like
folding at home
. Grid clustering is largely used in the medical and research fields. Why is it called "grid" computing? These systems are usually computing data through the use of linear algebra. This involves the the use of matrices or grids. Grid computing clusters can contain 100's or even 1000's of members. Software like folding at home, allows different job details to be downloaded by a member or members. Once the job is done being processed, the results are then uploaded to a central repository for further processing. See the diagram below:
Clusters in Action...
The images below are actual clusters. Remember that if you build a cluster, be aware of potential fire hazards posed by powering large amounts of equipment. Clusters can consume are large amount of electricity and also produce a massive amount of heat. Think carefully when installing or planning a cluster of servers. The image below shows a render farm using infiniband connectivity:
The image below shows a Linux cluster. Notice the dual 30 amp power feeds to each cabinet to accomidate the server density.
Remember that each type of cluster has a specific purpose and/or goal. The web cluster's main goal is load-balancing. It achieves performance and uptime because of the load-balancing performed by the cluster manager (load balancer). The grid and render cluster's main goals are power. Through the use of many servers, power is used efficiently to complete jobs. Clusters can vary is size. Web clusters are generally smaller, unless they are used very large sites. Grid clusters or "server farms" can contain 100's or even 1000's of servers.
There are many options for cluster operating systems. Windows Server, FreeBSD, and Linux all have various tools available for cluster configuration. Skullbox.Net recommends the use of
Red Hat Enterprise Linux
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European Feed Materials Register
Regulation (EC) No 767/2009 on the placing on the market and use of feed states in article 24(6): "the person who, for the first time, places on the market a feed material that is not listed in the Catalogue shall immediately notify its use to the representatives of the European feed business sectors referred to in Article 26(1). The representatives of the European feed business sectors shall publish a Register of such notifications on the Internet and update the Register on a regular basis".
All information provided on this website is provided "as-is" without warranty of any kind. Your access to and use of the information related to feed materials notified by feed business operators is at your sole risk. No warranty or representation is made, express or implied, that the information contained or referenced herein is accurate, current, or complete. Furthermore, the developers and owners of this website shall not be liable in any manner whatsoever for direct, incidental, special, consequential or punitive damage resulting from the use of, or inability to use, any of the information contained or referenced in this website or any information that is provided through linked websites. The developers and owners of this website reserve their rights to remove illegal or abusive notifications.
23 June 2017: The third update of the EU Catalogue of feed material was published in the Official Journal od the Union (Regulation (EU) 2017/1017). All new entries in the catalogue will be withdrawn from the present register without prenotification to applicants in January 2018, where the new Catalogue will be fully enforced.
4 January 2017: The Standing Committee on Plants, Animals, Food and Feed - Section Animal Nutrition voted in favour of the third upgrade of the EU Catalogue of Feed Materials, based on the submission from the EU Feed Chain task Force on the Catalogue of Feed Materials. The updated version (still not official) can be found among the list of available documents below and is expected to be published in the Official Journal in April / May 2017. All new entries in the catalogue will be withdrawn from the present register without prenotification to applicants.
4 February 2014: Applicants are invited to check carefully the feed materials status of their products before notifying them to the present register. To this end, the representatives of the EU feed business sectors encourage applicants to use, among others, the Classification tool developed and made available by FEFANA at http://www.fefana.org/ClassTool/.
The classification tool is intended to help the feed business operators to determine the legal feed status of products. The representatives of the EU feed business sectors do not take any responsibility in the use of the classification tool and in the further decision made by the operators. The placing of products and substances on the market and notification to the register of feed materials stays under the sole responsibility of the operator.
4 February 2014: The call for proposals for the third update of the EU Catalogue of feed materials is closed. The submissions will now be assessed by the representatives of the EU feed business sectors who will decide whether to take them on board or not. Due to the length of the procedure, the publication of the third update of the EU Catalogue of feed materials will take place at the end of 2014 at the earliest.
15 November 2013: The representatives of the EU feed business sectors started working on the third update of the EU Feed Materials Catalogue. Feed business operators are invited to use the contact button of the present website to propose suggestions for further amendments to the catalogue (new entries or amendments to description, including maximum contents for chemical impurities from the manufacturing process and from processing aids) before 15 January 2014.
- This call does not concern amendments related to the translation from the English version of the catalogue into national languages. Requests for amendments due to inappropriate translation shall be addressed with national authorities.
- As a matter of principle, only feed materials listed in the register of feed materials are eligible for "transfer" into the catalogue.
- For proposals for new entries, requests for inclusion in the Catalogue should specify the name of the feed material, its category, a proper description as well as proposed labelling particulars. In addition, the applicant shall specify the present registration number of the product as delivered by the Register of Feed materials.
- The purpose of the ongoing update of the Catalogue of Feed materials is to focus on essential amendments of existing entries and essential new entries.
This message does not guarantee that proposals for amendments / new entries of the Catalogue of Feed Materials that would be submitted to Organisations of the EU feed business sectors will be endorsed by them, forwarded in all or partial form to EU authorities and included in the next version of the EU Catalogue of Feed Materials as published in the Official Journal of the European Union.
30 January 2013: Further to the publication of Regulation (EU) No 68/2013 updating the EU Catalogue of Feed Materials, entries corresponding to feed material names now included in the Catalogue will be progressively removed from the Register. We recommend operators to regularly check that their feed materials comply with the requirements set for the EU Catalogue of Feed Materials and the Register, as applicable.
To assist feed business operators in registering their feed materials as required, the EU organisations representing the European feed business sectors listed hereafter have developed a registration tool that enables the publication and regular update of a "user-friendly" Register within the mandate of Regulation (EC) No 767/2009. Any notification submitted by other means (letter, email, fax, etc.) will not be accepted.
This website is composed of two main sections:
- a registration tool for feed business operators and
- the Register itself.
We invite feed business operators to read carefully the two following documents before starting notification:
- A Q&A (updated 04 02_2014) addressing questions related to the legal provisions with recommendations: this is for guidance only (see disclaimer). Questions related to legal obligations must be submitted to the competent authorities and not to the representatives of the European feed business sectors.
- A guide to the notifying feed business operators (updated 04 02 2014) addressing in particular issues related to the registration procedure. Any question regarding this guide and in general the practical aspects of the registration procedure can be communicated to us via the contact section.
- Feed business operators may not notify to the register a feed material under a name listed in the EU Catalogue of feed materials (Regulation (EU) No 68/2013)
List of representatives of the European feed business sectors:
APAG, CEFS, COCERAL, COFALEC, Copa-Cogeca, EABA, EAPA, EDA, EFPRA, EFFPA, EMFEMA, EUCOLAIT, EUROMALT, European Flour Millers, EUSALT, FEDIAF, FEDIOL, FEFAC, FEFANA, FERM, FoodDrinkEurope, IFFO, IMA-Europe, spiritsEUROPE, Starch Europe and The Brewers of Europe.
Notifying feed business operators should in addition note that:
- The legal purpose of this Register is to increase market transparency as referred to in (whereas (30)) of Regulation (EC) No 767/2009.
- Feed business operators having notified a feed material in accordance with the present procedure shall be considered as having met the obligation provided for in article 24(6) of Regulation (EC) No 767/2009.
- The presence of a feed material in the Register does not provide any information in relation to its safety for use as a feed material. It therefore does not exempt individual feed business operators from their responsibility as regards the safety of feed as provided for in Article 4 of Regulation (EC) No 767/2009 and in accordance with the General Food Law (Regulation (EC) No 178/2002) and the Feed Hygiene legislation (Regulation (EC) No 183/2005).
- The current website, including the notification procedure, is provisional and possibly subject to further modifications.
- For practical reasons, only notifications containing all the information required and submitted via the online registration tool will be accepted as complete. Any notification submitted by any other means (letter, email, fax, etc.) cannot be accepted.
- A notification to this Register is not an application for listing of the feed material in the EU Catalogue of feed materials (article 24 of Regulation (EC) No 767/2009).
- The information listed in the Register is the sole responsibility of the notifying feed business operator, as we as representatives of the European feed business sectors have no mandate to "pre-check" the validity of the information provided in the notification.
- The presence of a product in the Register does not provide any legal guarantee as to its feed material status. The developers and owners of this website reserve their rights to remove illegal or abusive notifications. Feed business operators are advised to check regularly for the legal status of the product they place on the market as feed material.
NB: the content of this website and the documents contained in it may be updated. You are invited to check them regularly.
Press release on 6 July 2011 (Fichier .pdf)
Press release on 30 January 2013 (Fichier .pdf)
Q&A Legal Requirements (Fichier .doc)
Guide to applicants (Fichier .doc)