Rhytidectomy - Surgical Anatomy

Surgical Anatomy

• SMAS
• Facial musculature
• Facial nerve

A dissection in the deep plane can mostly be performed safely, because the facial nerve innervates the facial muscles on the deep surface of these muscles (except for the muscles which are lying deep to the facial nerve, the mental nerve, the levator anguli oris and the buccinator). The fibres of the nerve are becoming more superficially medially. Therefore, the dissection of a deep plane begins further away of the surface then it ends. This allows the undermining to be carried out towards the nasolabial fold without harming the branches of the facial nerve.

• Retaining ligaments

The retaining ligaments in the face provide an anchorage of superficial structures to underlying bone. Four retaining ligaments exist. The platysma-cutaneous ligaments and the platysma-auricular ligament are aponeurotic condensations which connect the platysma to the dermis. The osteocutaneous ligaments, the zygomatic ligament and the mandibular ligament, are more important. They attach to the skin and bone, leading to a counteraction of gravitational forces. These ligaments should be released surgically to obtain a fully mobile facelift flap.

• Nasolabial folds
• Melolabial folds (marionette lines)
• Greater auricular nerve

Injury to the greater auricular nerve is the most seen nerve injury after rhytidectomy. Care should be taken in elevation over the sternocleidomastoid muscle, because of the terminal branches of the nerve that pass superficially to innervate the earlobe.

• Vascularisation

The composite flap is vascularised by facial, angular and/or inferior orbital arteries. The facial artery supplies the platysma and goes on as the angular artery, which connects with the branches of the arteria supratrochlearis and arteria infraorbitalis. The parts of the face elevated are in continuity in the deep-plane and the composite rhytidectomy include the SMAS layer in the lower face, subcutaneous tissue and the skin as the arteries to these parts are preserved. With this option you can create a well vascularized tissue flap, which can be used to tighten the skin without loss of vascularization, this will result in fewer complications like skin slough and necrosis.