RU2742455C1 - Method for correcting age-related changes of gravitational nature of soft tissues of lower third of face and neck - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to plastic surgery. Performing cuts in paraauricular areas, mobilizing skin flaps of face and neck, superficial musculo-aponeurotic system dissection, dissection in the layer under the superficial musculo-aponeurotic system, mobilization of the superficial muscle of the neck, movement, re-fixation of the cut out flaps of the superficial musculo-aponeurotic system of the face, excision of excess skin flaps and wound closure. Incisions in paraauricular regions are made by enclosing the hair growth line on the temple from the level of the upper edge of the auricle. Then tragus surface is passed into bovine and occipital areas, edging earlobes and auricle. Mobilization of skin flaps of the face and neck is performed to a vertical line that passes from the point of bilge arc intersection with the periphery of the circular muscle of the eye through anterior border of the masseter to the lower edge of the thyroid cartilage. Incision of the superficial muscular-aponeurotic system of the face is performed at distance of 2.5 cm from the tragus of the ear, parallel to the front edge of the masseter, from the level of the zygomatic bone to the upper edge of the thyroid cartilage, preserving the peripheral branch of the lower jaw of the facial nerve; horizontal skin incision 2 cm long in the sub-chin region at 1 cm from the chin protrusion, and Furnas's mandibular ligaments are transected. Cut out flaps of superficial musculo-aponeurotic system are moved in three vectors: first - in cranial direction and laterally at angle of 45 degrees in parotid-chewing area with fixation to front edges of lateral segments of superficial musculo-aponeurotic system. Second one is medial when interplatismal space in the sub-chin area is closed. Third one is lateral - when the subcutaneous muscle of the neck is sutured to the Laura fascia.

EFFECT: method enables excluding skin incisions in the temporal region in the scalp, reducing the volume of mobilized facial skin, optimizing the stability and quality of the aesthetic result, avoiding flattening of tissues in operated areas and stigma formation of "operated face".

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Description

The proposed invention relates to medicine and is intended for use in plastic surgery when performing surgical correction of age-related changes in the face. Age-related changes in the face are a consequence of gravitational ptosis of soft tissues as a result of collagen atrophy, weakening of the ligamentous apparatus and changes in the configuration of the bones of the facial skull, especially the upper and lower jaw, including as a result of tooth loss. To date, in the medicine of facial rejuvenation, the most effective are surgical methods that involve changing the topographic and anatomical characteristics of soft tissues by mobilizing and moving ptosized tissues to a position that corresponds to the geometry of the face at a young age. These operations, undoubtedly, require careful planning, the technology of execution should result in the effectiveness and durability of the effect.

There is a significant number of surgical techniques described in the literature, including various access methods, volumes of mobilization and methods of tissue fixation [1 - 3]. One of the methods described [2] involves performing an operative access by means of skin incisions, which are made vertically downward from the scalp in the temporal region to the tragus in the preauricular region and, bordering the earlobe, continue to the occipital region. Then an incision of the superficial musculo-aponeurotic system is performed along the zygomatic arch from the lower edge of the orbit to the upper edge of the thyroid cartilage at a right angle. Dissection is performed in the layer under the superficial musculo-aponeurotic system of the face, refixation of cut out flaps of the superficial musculo-aponeurotic system. Then the skin is sutured.

As the closest analogue, the "Method of surgical correction of age-related changes in the face in patients of the older age group" is adopted, in which incisions are made in the paraauricular areas, skin flaps on the face and neck are mobilized to the level of the nasolabial fold, the superficial musculo-aponeurotic system is dissected from the apex of the zygomatic bone along a straight line to the lower border of the earlobe and further along the sternocleidomastoid muscle 3-4 cm down, dissection is performed in the layer under the superficial musculo-aponeurotic system of the face. The excess of the superficial musculo-aponeurotic system is moved and fixed in the form of a duplication to an unmobilized flap of the superficial musculo-aponeurotic system, parotid-chewing fascia and mastoid process. Excess cut skin flaps are excised and the wound is sutured (patent RU 2563227).

The disadvantage of this method is that the line of skin incisions in the temporal region enters the zone of the scalp, resulting in damage to the hair follicles lying at an angle and the formation of visualized alopecia along the lines of the incisions, a wide mobilization of the skin and fat flap of the face to the nasolabial fold is performed, which increases the risk of developing marginal skin necrosis in the paraauricular areas due to a decrease in blood flow due to the intersection of perforating vessels, the incision of the superficial musculo-aponeurotic system of the face is carried out in the vertical plane, which implies only one vector of tissue movement - laterally, which results in flattening of the face in its lateral sections and the formation of the stigma of the "operated person". They do not cross the Furnas mandibular ligament, which, being a fulcrum, creates a moment of rotation of the soft tissues of this zone and reduces the effectiveness of the wing correction.

Objectives: To exclude skin incisions in the temporal region in the scalp area, to reduce the volume of mobilized facial skin, to optimize the stability and quality of the aesthetic result, to exclude tissue flattening in the operated areas and the formation of the stigma of the “operated face”.

The essence of the invention is that the incisions in the paraauricular areas are made, bordering the hairline at the temple from the level of the upper edge of the auricle, then they are passed through the surface of the tragus into the behind the ear and occipital regions, bordering the earlobe and the auricle; mobilization of skin flaps of the face and neck is performed up to a vertical line that runs from the point of intersection of the zygomatic arch with the edge of the circular muscle of the eye through the anterior edge of the masseter muscle to the lower edge of the thyroid cartilage; the incision of the superficial muscular-aponeurotic system of the face is made at a distance of 2.5 cm from the ear tragus parallel to the anterior edge of the masseter muscle from the level of the zygomatic bone to the upper edge of the thyroid cartilage, preserving the marginal branch of the lower jaw of the facial nerve; perform a horizontal skin incision 2 cm long in the submental region at a distance of 1 cm from the chin ridge and cut the Furnas mandibular ligaments; cut out flaps of the superficial musculo-aponeurotic system are moved in three vectors: the first - in the cranial direction and laterally at an angle of 45 degrees in the parotid-masticatory region when fixing to the anterior edges of the lateral segments of the superficial musculo-aponeurotic system; the second - medially when suturing the interplatysmal space in the submental region; the third - laterally when suturing the subcutaneous muscle of the neck to the fascia of Laura.

EFFECT: method makes it possible to exclude the formation of alopecia along the line of skin incisions in the temporal region by performing skin incisions in the temporal region, bordering the hair growth line, to minimize the risks of developing marginal skin necrosis in the paraauricular regions by mobilizing skin flaps of the face and neck to the vertical line, which runs from the point of intersection of the zygomatic arch with the edge of the circular muscle of the eye through the anterior edge of the masseter muscle to the lower edge of the thyroid cartilage, to achieve a more stable result of eliminating age-related changes in the face by crossing the Furnas mandibular ligament, to form a clear contour of the lower jaw and cervico-chin angle due to suturing the interplatysmal space and suturing the subcutaneous muscle of the neck to Laura's fascia, eliminate the presence of flaps, reduce the depth of the nasolabial fold in its lateral part and exclude flattening in the parotid-masticatory region, regardless of the thickness of the superficial musculoaponeurotic 1st system of the face, the patient's age due to the movement of the superficial musculo-aponeurotic system of the face in the cranial direction and laterally at an angle of 45 degrees while fixing the superficial musculo-aponeurotic system of the face to the anterior edges of the lateral segments of this system. The terms of applying a pressure bandage have been reduced by half.

The method has been tested on fifty-two patients in combination with periorbital rejuvenation (thirty-one patients) and in isolation (sixteen patients) for two years.

The method is carried out as follows. Before the operation, the planned incisions are marked in the temporal, parotid-chewing and behind the ear areas. The intervention is carried out in the operating room, under general anesthesia. According to the preoperative marking, incisions are made in the paraauricular areas, bordering the hairline at the temple from the level of the upper edge of the auricle, then they are passed through the surface of the tragus into the behind the ear and occipital regions, bordering the earlobe and the auricle. Mobilization of skin flaps is performed up to a vertical line drawn from the point of intersection of the zygomatic arch with the edge of the circular muscle of the eye through the anterior edge of the masseter muscle to the lower edge of the thyroid cartilage. At a distance of 2.5 cm from the ear tragus, parallel to the anterior edge of the masseter muscle, a vertical incision from the level of the zygomatic bone to the upper edge of the thyroid cartilage, preserving the marginal branch of the lower jaw of the facial nerve, dissect the superficial musculo-aponeurotic system of the face, enter the pre-chewing cellular space by mobilizing a flap of the superficial musculo-aponeurotic system of the face from the underlying parotid-masticatory fascia. Dissection is performed in the layer under the superficial musculo-aponeurotic system with the intersection of the chewing ligaments [4] and combining into a single space of the pre-zygomatic, upper and lower pre-chewing cellular spaces [5], while identifying, isolating and keeping intact marginal, buccal, zygomatic branches of the facial nerve on both sides. In the submental region at a distance of 1 cm from the chin ridge, a horizontal incision 2 cm long is made, the skin, subcutaneous tissue are dissected, the anterior edges of the subcutaneous muscle of the neck are exposed, the interplatysmal fat is excised, the body of the lower jaw is skeletonized, and the mandibular ligaments of Furnas are crossed [6]. The front edges of the subcutaneous muscle of the neck are sutured with a purse-string suture. With interrupted sutures, the flaps of the superficial musculo-aponeurotic system of the face are moved in the cranial direction and laterally at an angle of 45 degrees, fixed with corset sutures to the anterior edges of the flaps of the lateral segments of the same system at the level of the anterior edges of the parotid salivary glands, the direction vector of the superimposed sutures is upper-lateral. Along the posterior edge of the subcutaneous muscle of the neck, the latter is mobilized from the level of the mastoid process to the middle third of the sternocleidomastoid muscle, the preplatysmal skin-chewing ligaments are cut, the trunks of the external jugular veins and the large ear nerves are identified, isolated and preserved. In the plane of the layer under the superficial musculo-aponeurotic system, the neck is dissected to the midline, the subcutaneous muscle of the neck is dissected horizontally from both sides to the lateral edges of the thyroid cartilage, at the level of the middle of its length. The cut out flaps are moved, fixed in the upper-lateral direction with interrupted matching sutures to Laura's fascia [7]. The wound is drained through counterpertures with Redon drains. Skin flaps are redraped, determining the true excess of the latter. Resection is performed with the removal of excess, without tension, reference sutures are applied, and pre-gross depressions are formed. The skin is closed with continuous intradermal matching sutures. Apply Omnistrip tapes and aseptic pressure bandage with Peha-haft self-fixing bandage (Paul Hartmann, Germany)

Example 1

For a better understanding of the general principles of the course of the operation, Figures 1-26 are shown for example 1.

FIG. 1: Marking of incisions in the paraauricular areas

FIG. 2: Marking of the incisions in the paraauricular regions behind the ear

FIG. 3: Access to the subcutaneous layer with dissection within the preoperative marked area

FIG. 4: Mobilization of the skin flap

FIG. 5: Border mobilization of skin flaps of the face and neck

FIG. 6: Dissection of the superficial musculoaponeurotic system of the face

FIG. 7: Entrance to the pre-chewing checkered space

FIG. 8: Pre-chewing and pre-zygomatic spaces

FIG. 9: Interplatysmal fat excised, visualizing the medial edges of the platysma muscle

FIG. 10: Chin protrusion skeletonized, Furnas ligaments supersaturated

Fig. 11: Displacement of the superficial musculoaponeurotic system of the neck medially during suturing of the interplatysmal space in the submental region

FIG. 12 Dotted lines: The direction of movement of the cut flaps of the superficial musculo-aponeurotic system in the parotid-masticatory region when fixed to the anterior edges of the lateral segments of this system

FIG. 12 Solid lines: Lateral displacement of the superficial musculo-aponeurotic system of the neck while suturing the subcutaneous muscle of the neck to Lore's fascia

FIG. 13: Suturing of the flaps of the superficial musculoaponeurotic system of the face with corset sutures

FIG. 14: Fixation of the posterior edges of the platysma muscle to Lore's fascia

FIG. 15: Determination of excess skin flaps

FIG. 16: Skin flaps are redraped, the wound is sutured

FIG. 17: Right side profile view before surgery

FIG. 18: Right half-profile view before surgery

FIG. 19: Front view before surgery

FIG. 20: Semi-profile left before surgery

FIG. 21: Left side profile view before surgery

FIG. 22: Right side profile view after surgery

FIG. 23: Right half-profile view after surgery

FIG. 24: Front view after surgery

FIG. 25: Left half-profile view before surgery

FIG. 26: Left side profile view after surgery

Patient E., 46 years old, was admitted to the Center for Plastic and Reconstructive Surgery with a diagnosis of age-related gravitational changes in the soft tissues of the lower third of the face, upper half of the neck.

Examined.

On November 19, 2018, surgical treatment was performed in a planned manner: Three-plane multi-directional movement and refixation of soft tissues of the lower third of the face and neck.

The intervention was carried out in the operating room under general anesthesia. Before the operation, the planned incisions were marked in the temporal, parotid-masticatory and behind the ear regions (Figs. 1-2). According to the preoperative markings, incisions were made in the paraauricular areas, bordering the hairline at the temple from the level of the upper edge of the auricle, then passed through the surface of the tragus into the behind the ear and occipital regions, bordering the earlobe and auricle (Fig. 3). The mobilization of skin flaps was carried out to a vertical line drawn from the point of intersection of the zygomatic arch with the edge of the circular muscle of the eye through the anterior edge of the masseter muscle to the lower edge of the thyroid cartilage (Fig. 4-5). At a distance of 2.5 cm from the ear tragus, parallel to the anterior edge of the masseter muscle, a vertical incision from the level of the zygomatic bone to the upper edge of the thyroid cartilage, preserving the marginal branch of the lower jaw of the facial nerve, dissected the superficial muscular-aponeurotic system of the face (Fig. 6), carried out entrance into the pre-chewing cellular space by mobilizing a flap of the superficial musculo-aponeurotic system of the face from the underlying parotid-masticatory fascia (Fig. 7). Dissection was performed in the layer under the superficial musculo-aponeurotic system with the intersection of the dermal-masticatory ligaments and the integration into a single space of the pre-zygomatic, superior and inferior pre-chewing cellular spaces, while the marginal, buccal, zygomatic branches of the facial nerve were identified, isolated and preserved intact on both sides (Fig. 8). In the submental region, at a distance of 1 cm from the chin protrusion, a horizontal incision 2 cm long was made, the skin, subcutaneous tissue were dissected, the anterior edges of the subcutaneous muscle of the neck were exposed, the interplatysmal fat was excised (Fig. 9), the body of the lower jaw was skeletonized, the mandibular ligaments of Furnas were cut ( Fig. 10). The anterior edges of the subcutaneous muscle of the neck were sutured with a kissset suture (Fig. 11). With interrupted sutures, the flaps of the superficial musculo-aponeurotic system of the face were moved in the cranial direction and laterally at an angle of 45 degrees, fixed with corset sutures to the anterior edges of the flaps of the lateral segments of the same system at the level of the anterior edges of the parotid salivary glands, the direction vector of the sutures superimposed is upper lateral (Fig. 12- thirteen). Along the posterior edge of the subcutaneous muscle of the neck, the latter was mobilized from the level of the mastoid process to the middle third of the sternocleidomastoid muscle, the preplatysmal skin-masticatory ligaments were cut, identified, isolated and preserved intact the trunks of the external jugular veins and large ear nerves. In the plane of the layer under the superficial musculo-aponeurotic system, the neck was dissected to the midline, the subcutaneous muscle of the neck was dissected horizontally from both sides to the lateral edges of the thyroid cartilage, at the level of the middle of its length. The cut out flaps were moved, fixed in the upper lateral direction with interrupted matching sutures to Laura's fascia (Fig. 14). The wound was drained through counterpertures with Redon drains. Skin flaps were redraped, and the true excess of the latter was determined (Fig. 15). Resection was performed with removal of excess, without tension, reference sutures were imposed, and precalculous impressions were formed (Fig. 16). The skin was sutured with continuous intradermal matching sutures. Omnistrip tapes and an aseptic pressure bandage were applied with a Peha-haft self-fixing bandage (Paul Hartmann, Germany).

The postoperative period was standard, without complications, the edges of the wound were correlated without bleeding and complications, the function of the facial muscles was preserved, the drainage was removed on day 1. Discharged for 2 days. Skin incisions in the temporal region in the area of the scalp are excluded, the volume of mobilized facial skin is reduced, the stability and quality of the aesthetic result are optimized, flattening of tissues in the operated areas and the formation of the stigma of the “operated face” are excluded

The result of the operation after 1 month is presented (Figs. 22-26).

Example 2

For better understanding, figures 27-36 are shown.

FIG. 27: Right side profile view before surgery

FIG. 28: Right half-profile view before surgery

FIG. 29: Front view before surgery

FIG. 30: Left half-profile view before surgery

FIG. 31: Left side profile view before surgery

FIG. 32: Right side profile view after surgery

FIG. 33: Right half-profile view after surgery

FIG. 34: Front view after surgery

FIG. 35: Semi-profile view on the left before surgery

FIG. 36: Left side profile view after surgery

Patient X., 52 years old, was admitted to the center of plastic and reconstructive surgery with a diagnosis of Gravitational changes in the lower third of the face, upper half of the neck.

Examined.

On June 17, 2018, surgical treatment was performed in a planned manner in the amount of: Three-plane multi-vector movement and refixation of soft tissues of the lower third of the face and neck.

The operation was carried out in the manner described in example 1.

The postoperative period was standard, without complications, the edges of the wound were correlated without bleeding and complications, the function of the facial muscles was preserved, the drainage was removed on day 1. The patient was discharged from the clinic on the 2nd day. Skin incisions in the temporal region in the area of the scalp are excluded, the volume of mobilized facial skin is reduced, the stability and quality of the aesthetic result are optimized, flattening of tissues in the operated areas and the formation of the stigma of the “operated face” are excluded

Bibliography

1. Belousov, A.E. Plastic reconstructive and plastic surgery. - SPb .: Hippocrates, 1998 .-- 744 p.

2. Pshenisnov K.P. Plastic Surgery Course: A Guide for Physicians. In 2 volumes - Yaroslavl: Rybinsk Printing House, 2010 .-- 1419 p.

3. Paper A. D. Facial plastic and reconstructive surgery. - M .: Binom, 2007 .-- 935 p.

4. Stuzin JM, Baker TJ, Gordon HL Plast Reconstr Surg. 1992 Mar; 89 (3): 441-9; discussion 450-1.

5. Mendelson BC, Freeman ME, Wu W, et al. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthetic Plast Surg 2008; 32: 18595

6. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989; 83: 11-16.

7. O'Brien JX, Rozen WM, Whitaker IS, et al. Lore's fascia and the platysma-auricular ligament are distinct structures. J Plast Reconstr Aesthet Surg 2012; 65: e241-5.

Claims (1)

A method for correcting age-related changes in the gravitational nature of the soft tissues of the lower third of the face and neck, including making incisions in the paraauricular areas, mobilizing skin flaps of the face and neck, dissecting the superficial musculo-aponeurotic system, dissecting in the layer under the superficial musculo-aponeurotic system, mobilizing the superficial neck muscle, movement, refixation of cut flaps of the superficial musculo-aponeurotic system of the face, excision of excess skin flaps and completion of the operation by suturing the wound, characterized in that the incisions in the paraauricular areas are performed bordering the hairline on the temple from the level of the upper edge of the auricle, then they are carried out through the surface of the tragus in the behind the ear and occipital region, bordering the earlobe and auricle; mobilization of skin flaps of the face and neck is performed up to a vertical line that runs from the point of intersection of the zygomatic arch with the edge of the circular muscle of the eye through the anterior edge of the masseter muscle to the lower edge of the thyroid cartilage; the incision of the superficial musculo-aponeurotic system of the face is made at a distance of 2.5 cm from the ear tragus, parallel to the anterior edge of the masseter muscle, from the level of the zygomatic bone to the upper edge of the thyroid cartilage, preserving the marginal branch of the lower jaw of the facial nerve; perform a horizontal skin incision 2 cm long in the submental region at a distance of 1 cm from the chin ridge and cut the Furnas mandibular ligaments; cut out flaps of the superficial musculo-aponeurotic system are moved in three vectors: the first - in the cranial direction and laterally at an angle of 45 degrees in the parotid-masticatory region when fixing to the anterior edges of the lateral segments of the superficial musculo-aponeurotic system; the second - medially when suturing the interplatysmal space in the submental region; the third - laterally when suturing the subcutaneous muscle of the neck to the fascia of Laura.

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