RU2732098C1 - Method for double-plane harmonic face lifting - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to surgical and plastic surgery. At the first stage, a skin, subcutaneous fat and superficial temporal fascia are incised along a line connecting an external edge of the nose and an external edge of the eye extended to a scalp of the temple at distance of 2 cm from the hair growth line, tissue separation is performed to form a tunnel above a deep temporal fascia to an external eye angle. Further, at the level of upper canine 5–8 mm from the vestibular fold, a mucosal and periosteum incision is made, followed by subperiosteal dissection of tissues in an anterior surface of the upper jaw to a lower-vertebral edge and an external angle of the eye, limited by a medial line drawn from the point of output of the second branch of the trigeminal nerve to the canine, and laterally – by a line extending from outer angle of eye to second minor molar tooth, wherein finger is pressed on point of output of second branch of trigeminal nerve, maxillary nerve with periosteum and adjacent tissues, chewing muscle is not detached, and the circumferential muscle is peeled apart from the attachment point along the lower-vertebral edge. Further, in the area of the external angle of the eye, the subperiosteal space of the middle one-third of the face is interconnected with a tunneled space formed through the temporal approach. At the second stage, two U- or Z-shaped sutures are applied in intra-oral approach in the area of the fatty jaw and in the area of the modiolus; ligatures are brought out through the tunnel into the temporal incision and fixed to a deep temporal fascia. At the suturing points, duplication of the periosteum, subcutaneous fat, superficial fascia to the deep temporal fascia is created, after which through 5 mm-long incision made on the side of the conjunctiva of the lower eyelid, needle with ligature is applied with grasping eye circular muscle in formed subperiosteal space, and then, having captured periosteum of lower edge of circular muscle of eye, needle is again removed into conjunctival incision. At the third stage, the skin, subcutaneous fat in the preauricular and postaural-occipital areas are incised and their limited detachment by 2 cm in the subcutaneous layer, wherein the medial dissection boundary is limited by a line drawn through the outer edge of the iris – the outer corner of the mouth, the lower dissection limit passes at 3 cm below the ramus of mandible, after which a superficial musculo-aponeurotic system in the region of parotid fascia is incised, crossing preauricular, bilge, Macgregor, auricle-platysmal, chewing and mandibular ligaments, subcutaneous space is used to pierce the superficial musculo-aponeurotic system in the region of Modiolus and the Bichat's fat pad and the ligature are fixed laterally to the arcus zygomaticus, sutures are then superimposed on a superficial musculo-aponeurotic system along a line from the outer angle of the eye to the ear lobe. At the fourth stage, the platysma is cut off from the superficial musculo-aponeurotic system within the angle of the lower jaw and fixed with U-sutures to the mastoid and posterior edges of the sternocleidomastoid muscle. At the fifth stage, excess skin is excised, the wound is closed with a two-row suture.

EFFECT: method provides higher safety, radicality and stability of correction of age-related face changes with preservation of individual traits and facial expression.

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Description

The invention relates to medicine, in particular to operative surgery and plastic surgery, and can be used in clinical practice of practical health care.

In recent years, face lifting (Face Lifting) has become a kind of "gold standard" in the field of correcting age-related changes in the face. Most often, face lifting uses only one plane of tissue mobilization and one vector of tissue displacement. In this regard, the operation is not radical, its result is less stable, and the patient's individual features and facial expressions are not preserved.

There is a variety of methods used to correct age-related changes in the face, facelift: with mobilization of the superficial musculo-aponeurotic system (SMAS), lifting of the superficial skin and fat system (subcutaneous dissection), subperiosteal lifting (subperiosteal dissection), combined lifting (using several planes of detachment ) and composite (a flap consisting of different deep tissues). These techniques are usually used in isolation. They have both positive and negative sides.

A known method of surgical correction of age-related changes in the soft tissues of the lateral surfaces of the face and neck by dissecting tissues in the temporal, parotid-chewing and behind the ear regions, peeling off the skin and fat flap to the projection of the nasolabial fold. Then, the superficial musculoaponeurotic system (SMAS) is dissected along the anterior edge of the auricle and zygomatic arch, separating the fascial flap from it in the medial direction from the outer surface of the adjacent facial muscles. Further, the SMAS flap is pulled laterally and upward, the excess is excised and fixed with interrupted sutures to the periosteum of the zygomatic arch, the posterior edge of the SMAS incision, and also to the mastoid process in the ear region. The fatty skin flap is also pulled laterally and upward, the excess tissue is excised, the flap is fixed to the posterior part of the incision in the temporal, parotid-chewing and behind the ear regions. [Belousov A.E. et al. "Plastic, reconstructive and aesthetic surgery" - SPb .: Hippocrates, 1998. - p. 588-589].

However, the known method has significant drawbacks: incomplete correction of the medial parts of the face (drooping of the soft tissues of the cheek with the preservation of a noticeable nasolabial fold), which is associated with dissection under the SMAS only in the “safe zone”, without separating fascial adhesions and crossing the retaining ligaments of the face; lack of stability of the result due to the teething of the seams, because in most patients, SMAS is loose and poorly differentiated. With this method of face lifting, only one displacement vector is used - oblique-vertical, and the skin displacement vector and SMAS coincide. It is believed that the direction of movement of the SMAS and skin flaps should not coincide. Typically, the skin is moved more laterally to the deep layer ascent vector (SMAS). Failure to comply with this rule leads to visible postoperative distortions: with excessive verticalization in the lower-lateral parts of the face and neck - to the manifestation of the so-called strangulation groove, especially when the head is tilted down. Ideally, the direction of lifting the tissues of each anatomical region should be directly opposite to the vector of gravitational ptosis, which we also took into account in our method. A large trauma and a high percentage of postoperative alopecia are associated with a wide dissection in the temporal region.

In plastic and reconstructive surgery, there is a known method for correcting age-related changes in the soft tissues of the face, subperiosteal lifting according to O.M. Ramirez. According to the author's method, the dissection here is either subperiosteal, if there is a periosteum, or axillary at the level of muscle fixation and subfascial in the temporal region at various distances above the masseter muscle. By vestibular access, the zygomatic arch is separated in the sub-periosteal layer and the entire edge of the orbit, with the exception of the medial canthus ligament. Front-glabello-nasal dissection is combined with zygomatic-maxillary [Ashrafov RA "Facial and cervical lifting" - Moscow 2001. - S. 68-79].

The main disadvantage of this technique is a slight displacement of facial tissues, because The periosteum is not an elastic structure, there is no tension in the tissues, but their movement, plus there is a shift in the fixation points of the muscles, which radically changes the patient's face (the patient ceases to be recognized). Also, the displacement of tissues occurs along one vector - vertically, which is not sufficient to straighten the tissues in the periorbital region (there is no harmonization of the face), with excessive verticalization in the lower-lateral parts of the face and neck, a so-called strangulation groove appears, especially when the head is tilted down. To consolidate the tightening effect, tissue immobilization for at least 3-4 weeks, which is practically impossible to ensure, therefore, muscle contraction in the postoperative period leads to the loss of correction and to the convergence of the muscle attachment points in comparison with the initial state. This surgery is suitable for young patients 30-45 years old.

The closest to the claimed method - the prototype is a method of face lifting using a composite flap (consists of different deep tissues) [Hamra S.T. Surgical anatomy of the midface and molar mounds // Plastic and reconstructive surgery. - 2002. - Vol. 110 (3). - P. 876]. The point of this method is to move only that part of the tissues that are involved in aging. The incisions are located in the temporal region, anterior and posterior regions. In the preauricular region, dissection is performed subcutaneously, then the “safe zone” is advanced under the SMAS in the region of the fascia of the parotid gland, the ligaments are cut off, and again into the subcutaneous layer. The formed flap is moved by applying different vectors and pulling force. Fixation in 3 places: to the deep temporal fascia with a flap cut from the circular muscle of the eye "suspension" for the mid-medial part of the face and in the areas of the temporal and mandibular mesentery. Thus, S. Hamra formulated a concept that is close to us, the idea of the rationality of multi-directional tightening of tissue blocks throughout the face. This makes it possible to avoid the problems of flattening the face and insufficient influence on the middle zone, characteristic of the traditional "skin" lifting [Pshenisnov K.P. Plastic Surgery Course: A Guide for Physicians. Rybinsk Printing House. T. 1, 2010, p. 729-742].

The main disadvantages of this technique are:

• low anti-aging result, since the mobilization of tissues is only in one plane;

• minimal stability, because the fixation of the flap is carried out only in three places, therefore, there is a large load on the sutures;

• lack of rejuvenation of the periorbital region with preservation of the eyelid-buccal groove, due to the inclusion of the circular muscle of the eye in the composite flap;

• low safety, as they perform a wide dissection in the temporal region;

• lack of improvement of the contour of the lower jaw and cervico-chin angle, again due to the movement of tissues in a single complex.

The technical result of the present invention: increased safety, radicality and stability of the correction of age-related changes in the face while maintaining individual features and facial expressions.

Facial rejuvenation consists of two main components - lifting and volume rejuvenation. Surgery should meet the following philosophy: preservation of a natural, natural appearance after surgery; the use of methods adequate to the occurred age-related changes; harmonization of the rejuvenation of the upper and lower areas of the face.

The technical result is achieved by the fact that the method of two-plane harmonic face lifting is performed, which is characterized by the use of two planes of tissue mobilization (composite SMAS and subperiosteal), multi-vector tissue displacement (vertical vector in subperiosteal dissection, oblique-vertical vector of SMAS displacement, lateral platysma) in the new boundaries of the detachment the middle zone of the face, replacing the wide area of the temporal dissection with tunneling, performing duplication of tissues at the site of suspension sutures, imposing a transconjunctival-subperiosteal suture with plication of the lateral portion of the circular muscle of the eye and fixing it to the infraorbital edge, limiting the formation of a composite flap to a "safe zone the circular muscle of the eye with an inferior orbital edge without its inclusion in the composite flap, limiting the formation of the composite flap to the branch of the lower jaw by cutting off the platysma from the SMAS of the lower third of the face, performing lateral ny platysmoplasty with periosteal fixation with a lateral tension vector located below the angle of the mandible.

Implementation of the invention

Under endotracheal anesthesia, in the supine position of the patient with arms retracted at 90 °, an antiseptic treatment of the operating field (alcohol solution of chlorhexidine) is carried out, the boundaries of detachment and the lines of future skin incisions are marked with a medical pencil.

In the planned zone of detachment of the composite SMAS, tissue infiltration is made with an adrenaline solution and saline in a ratio of 0.15 ml: 300 ml.

At the first stage, in the temporal region, we make an incision in the skin, subcutaneous fat and superficial temporal fascia along the line connecting the outer edge of the nose and the outer edge of the eye, continued into the scalp of the temple, 2 cm away from the hairline. Tissue detachment is carried out using a dissector, we form a tunnel over the deep temporal fascia to the outer corner of the eye, so as not to damage the frontal branch of the facial nerve.

After processing the oral cavity at the level of the orbital incisor, 5-8 mm from the vestibular fold, we make an incision in the mucous membrane and periosteum to form the first lifting plane. Then, with the help of a raspator, the tissues in the region of the anterior surface of the upper jaw are exfoliated subperiosteally (the formation of the subperiosteal space of the middle third of the face). In the proposed method, in contrast to the classical, subperiosteal tissue dissection is limited medially by a line drawn from the exit point of the second branch of the trigeminal nerve (fossa canina) to the canine. During the dissection, the surgeon puts a finger on the outside of the fossa canina, thereby protecting the second branch of the trigeminal nerve from damage (both direct and from tension). The proposed limitation of dissection by this medial line makes it impossible to damage the incisal nerves, often tightly adjacent to the periosteum, thereby preventing painful paresthesia in the medial zone of the upper jaw, and the use of a compression technique makes it almost impossible to damage the maxillary nerve.

Holding the finger at the site of the exit of the maxillary nerve, we continue the dissection along the anterior surface of the upper jaw to the lower orbital edge and the outer corner of the eye. Unlike all other methods, the proposed method does not exfoliate the maxillary nerve, and the periosteum is preserved around it along with the adjacent tissues. In addition, at this stage, the circular muscle of the eye is exfoliated subperiosteally without being cut off from the attachment site along the inferior orbital edge. The lateral zone of periosteal dissection is limited by a line running from the outer corner of the eye to the second minor molar. Since the chewing muscle does not exfoliate in this method, the fact of possible bleeding and pain syndrome associated with the functioning of this muscle is excluded. The lack of mobilization along the zygomatic arch makes it impossible to damage the frontal branch of the facial nerve.

In the area of the outer corner of the eye, the subperiosteal space of the middle third of the face is connected to the tunnelled space formed through the temporal approach. In this method, there is no wide mobilization of the tissues of the temple area, thereby there is no risk of injury to the temporal vein, frontal branch of the facial nerve and postoperative alopecia.

At the second stage, the detached tissues of the midface zone are fixed to the deep temporal fascia. There is a vertical vector of tissue displacement. To do this, two U- or Z-shaped sutures (PDS 2-0 suture material) are applied through the intraoral access: one in the cheek fat pad, the other in the modiolus, the ligatures are brought out through the tunnel into the temporal incision, where they are fixed to the deep temporal fascia. When these sutures are applied, we create a duplication of tissues (periosteum, subcutaneous fatty tissue, superficial fascia to the deep temporal fascia) at these two points at which sutures were applied, which leads to an additional lifting effect and the creation of a more reliable fixation point. This technique (tissue plication at the site of the suspension sutures) is not described in any of the previously presented methods.

Through a 5 mm incision made on the side of the conjunctiva of the lower eyelid, a needle with a ligature is inserted with the capture of the circular muscle of the eye into the formed subperiosteal space, and then, capturing the periosteum of the lower edge of the circular muscle of the eye, the needle is again withdrawn into the conjunctival incision (suture material PDS 4- 0). Thus, this U-shaped suture lifts and plicates the lateral portion of the circular muscle of the eye and creates an additional fixation point for the detached tissues of the midface zone. This point (transconjunctival-subperiosteal plication and lifting of the circular muscle of the eye with fixation to the lower orbital edge) was applied by us for the first time and was not described in any previously known lifting methods.

At the third stage, an incision is made in the skin, subcutaneous fatty tissue in the preauricular and behind the ear-occipital region and their limited detachment by 2 cm in the subcutaneous layer, then an incision is made in the superficial musculoaponeurotic system (SMAS) in the region of the fascia of the parotid gland ("safe zone") , then cross the ligaments (preauricular, zygomatic, McGregor, ear-platysmal, chewing and mandibular), penetrating into the subcutaneous layer. We make a thorough hemostasis using gauze pads and electrocoagulation. The medial border of the dissection is limited by a line drawn through the outer edge of the iris - the outer corner of the mouth, the lower border of the dissection is 3 cm below the ramus of the mandible. From the subcutaneous space, PDS 2-0 (U- or Z-shaped sutures) of SMAS are stitched in the area of the modiolus and Bishat's fat lump and the ligatures are fixed laterally to the zygomatic arch. Thus, unlike all other methods, the suspension seams are duplicated. Due to tissue lifting, SMAS folding is formed, which is eliminated by applying a number of sutures to SMAS (Nurolon 1-0) along the line: from the outer corner of the eye to the earlobe, due to this we achieve an oblique-vertical vector of SMAS tissue displacement. The two SMAS plication lines are also used by us for the first time.

Thus, overlapping sutures reliably stabilize the tissue in the new position. The use of double-row plication SMAS eliminates tissue relaxation in both the middle zone and the flaps, in addition, creates the necessary volume in the middle zone of the face.

At the fourth stage, in the area of the lower jaw angle, we cut off the platysma from the SMAS and fix it with U-shaped sutures (Nurolon 1-0) in the behind-ear region to the mastoid process and to the posterior edge of the sternocleidomastoid muscle. Due to this, there is a lateral displacement of tissues and a clear drawing of the contour of the lower jaw and neck.

At the fifth stage, excess skin is excised, the wound is sutured with a two-row suture: adaptive sutures - Vycryl 3-0 and intradermal sutures - Resopren 4-0.

In the proposed method, the zones forming the “aging face” are corrected, with the corresponding rise of tissues, and the reconstruction of volume. At the same time, when performing tissue dissection, there is no direct contact with neural structures and reliable tissue stabilization is achieved.

Thus, the use of the listed surgical techniques leads to an increase in the safety, radicality of the surgical intervention and the stability of the correction of age-related changes in the face while maintaining individual features and facial expressions.

Clinical example.

Patient A., 50 years old, was admitted to the surgical department No. 2 with a diagnosis of age-related changes in the skin of the face. The formation of the lacrimal and nasolabial grooves, depletion and skeletonization of the infraorbital region, ptosis of the tissues of the molar region, ptosis of the mouth angle, and formation of flews are noted (Fig. 1).

Surgery was performed according to the above method. The postoperative period was unremarkable.

Examined after 1, 6 months, 1, 3 years. The stability of the aesthetic results was noted: correction of the lacrimal, nasolabial grooves, flews, filling the painter's and infraorbital areas, lifting the angle of the mouth (Fig. 2).

Claims (1)

The method of two-plane harmonic face lifting, which includes five stages, characterized in that at the first stage, an incision is made in the skin, subcutaneous fatty tissue and superficial temporal fascia along the line connecting the outer edge of the nose and the outer edge of the eye, continued into the hairy part of the temple, 2 cm away from hairline, tissue detachment is carried out with the formation of a tunnel above the deep temporal fascia to the outer corner of the eye, then at the level of the upper canine, 5-8 mm from the vestibular fold, an incision of the mucosa and periosteum is made, after which a subosteal tissue dissection is performed in the region of the anterior surface of the upper jaw to the inferior orbital edge and the outer corner of the eye, bounded medially by a line drawn from the point of exit of the second branch of the trigeminal nerve to the canine, and laterally - by a line passing from the outer corner of the eye to the second minor molar, while pressing with a finger on the point of exit of the second branch of the trigeminal nerve, upper jaw the stalny nerve with the periosteum and adjacent tissues, the masseter muscle does not exfoliate, and the circular muscle exfoliates without being cut off from the attachment site along the inferior orbital edge, then in the area of the outer corner of the eye, the subperiosteal space of the middle third of the face is connected with the tunnelled space formed through the temporal access; at the second stage, two U- or Z-shaped sutures are applied through the intraoral access in the area of the fatty lump of the cheek and in the area of the modiolus, the ligatures are brought out through the tunnel into the temporal incision and fixed to the deep temporal fascia, while at the suture points a duplication of the periosteum, subcutaneous adipose tissue, superficial fascia to the deep temporal fascia, after which a needle with a ligature is inserted through a 5 mm long incision made from the conjunctiva of the lower eyelid with the capture of the circular muscle of the eye into the formed subperiosteal space, and then, capturing the periosteum of the lower edge of the circular muscle of the eye, the needle is again withdrawn into the conjunctival incision; at the third stage, an incision is made in the skin, subcutaneous fatty tissue in the preauricular and behind the ear-occipital region and their limited detachment by 2 cm in the subcutaneous layer, while the medial border of dissection is limited by a line drawn through the outer edge of the iris - the outer corner of the mouth, the lower border of dissection passes 3 cm below the branch of the lower jaw, after which an incision is made in the superficial musculo-aponeurotic system in the region of the fascia of the parotid gland, the preauricular, zygomatic, MacGregor, auricular, platysmal, chewing and mandibular ligaments are intersected, the superficial musculoaponeurotic system is stitched from the subcutaneous space in the area modiolus and Bish's fat lump and ligatures are fixed laterally to the zygomatic arch, then sutures are applied to the superficial musculo-aponeurotic system along the line from the outer corner of the eye to the earlobe; at the fourth stage, in the area of the angle of the lower jaw, platysma is cut off from the superficial musculo-aponeurotic system and fixed with U-shaped sutures to the mastoid process and to the posterior edge of the sternocleidomastoid muscle; at the fifth stage, excess skin is excised, the wound is sutured with a two-row suture.

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