RU2766524C1 - Method for surgical correction of age-related changes of facial soft tissues - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to aesthetic plastic surgery. Skin is marked for identification of facial spaces by marking three horizontal lines: first line starts from the place of attachment of the earlobe to the cheek, then goes 1 cm above the edge of the lower jaw and continues to the chin, second line starts from the lower point of the tragus and continues to the angle of the mouth, third line starts from upper point of tragus and extends to wing of nose. Pre-chewing space is located between the first and second lines, the free cheek space is located between the second and third lines, the pre-malar space is located above the third line. Then, facial soft tissues are hydraulically dissected; skin is incised within a temple length of 2 cm along a hairline, then along an auricle, along an inner surface of a tragus, around a lobe and in a postaural fold by 4 cm. Further, the skin is detached along 5 cm from the skin incision with the obligatory dissection of masseteric cutaneous ligaments. Then, on the SMAS layer exposed after the cutaneous detachment, to facilitate identification of facial spaces, three extended horizontal lines are marked, similar to lines on the skin: first line from the point of attachment of the earlobe to the cheek, then 1 cm above the edge of the lower jaw to the border of the skin detachment in the direction of the chin, second line from lower point of tragus, then to border of skin detachment in direction of mouth angle, third line from upper point of tragus, then to border of skin detachment in direction of wing of nose. Additionally, an oblique line is marked on the open after the skin detachment layer SMAS, which starts at the top from point located 1 cm outwards from the outer corner of eye and 1.5 cm vertically downwards, at the bottom the oblique line continues to the projection of the angle of the lower jaw. From the beginning and from the end of this oblique line, two horizontal lines 1 cm long are additionally marked in the medial direction on the SMAS layer exposed after the cutaneous detachment. Layer of SMAS is dissected along the oblique line and two horizontal lines each 1 cm long. Two SMAS flaps are formed — fixed proximal and rectangular movable distal. Then the rectangular movable distal flap SMAS is exfoliated for 2 cm by entering the face spaces: pre-chewing space, space of free cheek and pre-malar space, guided by three previously marked, on open after cutaneous detachment layer SMAS, extended horizontal lines. After entering these three face spaces, all vertical ligaments between these spaces are transected. Rectangle is then cut from the edge of the rectangular movable distal flap SMAS so that the top and bottom are 1 cm², protruding sections of the movable distal flap SMAS. As a result, a movable U-shaped distal flap of SMAS is formed. Further, 0.5*0.5 cm windows are formed in the preauricular region at distance of 1 cm medially from the skin incision line in the fixed proximal flap: at the tragus, in the projection of the zygomatic arch and in the temporal region above the projection of the zygomatic arch by 1 cm. Nylon 3.0 fixation sutures are delivered through these windows so that the knots turn out to be screwed in. Nylon 3.0 fixation suture is delivered as follows: 0.5*0.5 cm SMAS proximal flap is punctured through each formed window, from the inside to the outside, in the lateral direction, then the movable distal U-shaped flap of the SMAS is stitched from the inside to the outside at distance of 1.5 cm from its free edge, then the movable distal U-shaped flap of the SMAS is stitched from the outside to the inside at distance of 1.5 cm from its free edge, distance between these pricks on the movable distal U-shaped flap of SMAS is 0.5 cm and then stuck into the formed window in the fixed proximal flap of SMAS 0.5*0.5 cm, stitching from the outside to the inside in the medial direction. Distance between the pricks on the fixed proximal flap of SMAS is 0.5 cm. All three nylon 3.0 fixation sutures are thus delivered through the movable distal U-shaped flap of the SMAS in the pre-chewing, pre-malar and free cheek space. Pre-chewing area is fixed with nylon 3.0 suture in the area of the formed window with size of 0.5*0.5 in the fixed proximal flap of the SMAS at the tragus, free cheek area is fixed with nylon 3.0 thread in the area of the formed window with size of 0.5*0.5 in the fixed proximal flap of the SMAS at the zygomatic arch, pre-malar region is fixed with nylon 3.0 suture in the area of the formed window sized 0.5*0.5 in the fixed proximal flap SMAS at temporal fascia 1 cm above the zygomatic arch. After pulling up the movable distal U-shaped flap SMAS, nylon 3.0 fixation sutures are tightened and tied. Then, to close formed nylon 3.0 fixation suture knots, three formed windows are interrupted sutured with vicryl 4.0 suture in the fixed proximal flap SMAS above nylon 3.0 fixation suture knots. Further, the free edge of the movable distal U-shaped flap of the SMAS is sutured with the fixed proximal flap SMAS with a continuous blanket suture of PDS 3.0 suture, in such a way that in the zygomatic region and in the region of the angle of the lower jaw, an overlap is formed, by the type of duplication, protruding by 1 cm² sections of movable distal U-shaped flap SMAS, on the fixed proximal flap SMAS, and in the cheek area the movable distal U-shaped flap of SMAS is sutured with the fixed proximal flap SMAS "edge to edge". Similar manipulations are performed on the other side of the face. That is followed by distributing, tightening and excising the excess skin-fat flap on both sides of the face, draining with rubber graduates in postaural zones and applying intradermal sutures on the incisions.

EFFECT: method makes it possible to effectively eliminate "flews", to correct facial contours, to smooth labial-chin and nasolabial folds, as well as to correct a zygomatic zone; to obtain a stable result of the operation and inconspicuousness of the formed skin scars; to form a natural young face relief with volume in the area of cheekbones and jaw angles.

1 cl, 18 dwg, 1 ex

Description

The invention relates to the field of medicine, namely aesthetic plastic surgery during surgical correction of age-related changes in the face.

Facial rejuvenation surgery is one of the most sought-after areas of aesthetic plastic surgery (see Course of Plastic Surgery in two volumes: a guide for doctors. In 2 volumes / Edited by K.P. Pshenisnov. Yaroslavl; Rybinsk: Rybinsk Printing House Publishing House , 2010. - S. 686).

A qualitative leap in this area occurred when the role of deep tissue structures in the occurrence of age-related changes in the face was studied in detail. The proposed interventions on the superficial musculoaponeurotic system (SMAS) made it possible to eliminate even extremely pronounced age-related changes. The superficial muscular-aponeurotic system of a person is currently defined as an anatomical complex of interconnected muscles and aponeuroses, lying in a separate layer under the skin (see Belousov A.E. Plastic, reconstructive and aesthetic surgery. - St. Petersburg: Hippocrates, 1998 - S. 582).

The entire face is represented by five main layers: skin, subcutaneous layer, SMAS layer, loose spaces or spaces with retaining ligaments, as well as periosteum and deep fascia. Between the ligaments of the face there are spaces where there is no tight connection with the higher and underlying tissues. Such spaces are sliding planes, and it is through these spaces that the soft tissues of the face slip with age. The facial nerves and vessels do not pass through the spaces themselves, but through the ligaments around them. From the point of view of surgery for the surgical correction of age-related changes in the face, the following spaces are important:

- the pre-zygomatic space is located above the zygomatic bone (at the top it is limited by the retaining ligament of the circular muscle of the eye, at the bottom it is limited by the zygomatic ligament;

- the pre-masticatory space covers the lower half of the masticatory muscle, is limited from above by the masticatory-cutaneous ligaments, and anteriorly - downwards by the mandibular ligament;

- the space of the free cheek is located in the middle between the pre-zygomatic and pre-masticatory spaces medial to the anterior edge of the masticatory muscle and above the level of the oral commissure. The entrance to this space is limited by vertically located superior masseternocutaneous ligaments (see Mendelson BC, Jacobson SR Surgical anatomy of the midcheek. Facial layers, spaces, and the Midcheek Segments. Clin. Plast. Surg. 35:395-404, 2008. and Mendelson BC Anatomic Study of the Retaining Ligaments of the Face and Applications for Facial Rejuvenation Article in Aesthetic Plastic Surgery, March 2013, 513-515).

Facial spaces facilitate the process of detachment and allow them to be used to move and fix relaxed and toneless tissues to the position in which they were at a young age (see RF patent RU 2707063 C1).

Many methods have been proposed for the surgical correction of age-related changes in the soft tissues of the face. A known method of circular lifting of the soft tissues of the face, including the application of a figured incision on the skin along a pre-drawn marker line, starting from the temporal region, further in front of the auricle, bordering the earlobe and rising along the behind-the-ear groove, and ending on the hairy surface of the occipital region, separating the skin to the required limits, stretching the skin upwards and backwards, followed by excision of excess skin in front of the auricle, in the temporal region and on the neck (see Andreeva D.N. Handbook of medical cosmetics. L .: Medicine, 1978, p. 92-93) .

The reasons preventing the achievement of the technical result indicated below when using the known method include the fact that with this method, only the skin is detached without detachment of the CMAS layer. The skin after such an operation again quickly stretches, under the influence of deeper, not tightened tissues, as a result, the duration of the result is short-term. The consequence of a wide detachment of the skin is a violation and a long-term restoration of its sensitivity. Strong skin tension increases the load on the skin scars, which hypertrophy and stretch. Wide detachment of the skin, subsequently leads to extensive subcutaneous scarring and distortion of facial expressions. A simple skin tension flattens the relief of the face, in particular the zygomatic region and the region of the angle of the lower jaw. The result of such an operation creates the appearance of a "tight", "operated" face.

Also known is a method of face tissue tightening, in which after dissection of the skin in the temporal, anterior, posterior and mastoid regions, a skin-fat flap of the lower two-thirds of the face is formed in an acute way. The CMAS layer is dissected along the zygomatic arch. The CMAS layer is then mobilized from the underlying tissues and stretched backwards and upwards. The excess CMAS flap is excised and sutured along the incision line. The skin-fat flap is stretched, the excess is excised and the wound is sutured (see Belousov A.E. Plastic, reconstructive and aesthetic surgery. - St. Petersburg: Hippocrates, 1998 - p. 588-590).

The reasons preventing the achievement of the technical result indicated below when using the known method include the fact that with this method, detaching the SMAS layer in the area above the gland saliva capsule does not make much practical sense, since this SMAS area is inactive. At the same time, such a detachment additionally injures the vessels, increases the risk of damage to the parotid salivary gland, and lengthens the operation time. A widely detached CMAS flap is obtained with uneven thickness and strength, which subsequently affects the stability and duration of the result of the operation. Pulling and fixing the CMAS flap at a considerable distance from the central zone of the face loses its tension and reduces the effect of the correction. The closure of the CMAS flap is only edge-to-edge, not strong enough, since a strong load is created on this seam. The resulting scars of the CMAS layer quickly weaken, the effect of the operation becomes short-lived and is due only to the strength of the resulting scars of the CMAS layer. Continuous tension of the CMAS flap flattens the relief zones of the face - the zygomatic region and the angle of the lower jaw.

The closest technical solution in relation to the proposed set of essential features is a method (see RF patent RU 2707063 C1), including hydropreparation of facial soft tissues, skin incision, detachment of the skin-fat flap, dissection of the SMAS, detachment of the SMAS, fixation of the SMAS flap, removal excess skin, visualization of SMAS, hydropreparation of the soft tissues of the face is performed using an injection pump in a volume of up to 400 ml per side, the skin incision is made, limiting it to 2 cm in the temple and occiput, along the auricle and along the inner surface of the tragus, detachment of the skin-fat flap carried out at a distance of 3-4 cm from the skin incision line, 4-5 cm CMAS dissection is carried out vertically in the anterior zone, CMAS detachment is carried out in the space of the zygomatic region, in the space of the free cheek and in the space of the pre-masticatory region, fixation (of tissues) - the CMAS flap is carried out non-absorbable material Etibond 3-0, removal of excess skin is carried out without disturbing I hairline in the temporal and occipital region, visualization of SMAS is carried out only in the area of skin detachment - 3-4 cm from the skin incision line, in addition, the zygomatic block is lifted and fixed to the edge of the orbit, suturing and lifting the space of the fatty body of the cheek to anterior fascia, as well as lifting, moving and fixing the pre-masticatory space to the posterior fascia.

The reasons preventing the achievement of the technical result indicated below when using the known method adopted as a prototype include the fact that the implementation of detachment of the skin-fat flap at a distance of only 3-4 cm from the skin incision line is insufficient, since the subsequent significant tightening of the SMAS flap leaves irregularities and retractions on the skin due to the preservation of the masseter-skin ligaments between the skin and the SMAS layer. The non-absorbable Etibond 3-0 thread used to fix the SMAS flap is a braided thread and has a wick effect, so it absorbs infection in case of inflammation and becomes an additional source of infection. To eliminate the developed infection, the infected thread Etibond 3-0 requires removal, with consequences in the form of loss of the result of the operation. In addition, knots from non-absorbable Ethibond 3-0 threads remain under the skin, resulting in the formation of scar tissue around them and patients may feel them in the form of "bumps". The movement and fixation of the pre-masticatory space to the posterior fascia has a horizontal vector and corrects the oval of the face insufficiently, since the rational vector for correcting the area of the oval and the "brilli" is oblique-vertical. Pulling and continuous fixation of the CMAS flap flattens such volumetric areas of the face as the zone of the cheekbones and the zone of the angles of the lower jaw and expands the transverse dimension of the face in the buccal zone due to the layering of the tightened CMAS flap.

The objective of the invention is to overcome the above disadvantages of analogues and create a method for surgical correction of age-related changes in the face, providing a technical result consisting in the permanent elimination of age-related changes in the soft tissues of the face and in replenishing the volume of the zygomatic regions and angles of the lower jaw.

This technical result is achieved by expanding the subcutaneous detachment by 5 cm from the line of the skin incision, with the obligatory dissection of the masseter-dermal ligaments, the formation of a movable distal U-shaped flap of the SMAS, the creation of a duplication in the area of the angle of the lower jaw and in the area of the cheekbone by the type of overlay of protruding 1 sq. see sections of the movable distal U-shaped CMAS flap on the immovable proximal CMAS flap, suturing the CMAS flaps “punched to the edge” in the cheek area to eliminate excess tissue volume in the cheek area, using non-absorbable nylon 3.0 threads to fix the detached movable distal U-shaped CMAS flap , forming windows in the fixed proximal CMAS flap for immersing nodes from the nylon 3.0 thread that fixes the movable distal U-shaped CMAS flap, forming nylon 3.0 submersible screw-in sutures, suturing the windows in the fixed proximal CMAS flap with vicryl 4.0 thread, suturing the edges of the CMAS flaps with a twisting continuous suture thread PDS 3.0.

The specified technical result in the method of surgical correction of age-related changes in the soft tissues of the face is achieved by performing a hydropreparation of the soft tissues of the face, making a skin incision in the temple area 2 cm long along the hairline, then along the auricle, along the inner surface of the tragus, around the lobe and in the postauricular fold by 4 cm, the skin-fat flap is detached, the SMAS is dissected, the SMAS is detached in the space of the zygomatic region, in the space of the free cheek and in the space of the pre-masticatory region, the SMAS flap is tightened and fixed, excess skin is removed, drained and impose intradermal sutures on the incisions.

The peculiarity lies in the fact that at first markings are applied to the skin to facilitate the identification of facial spaces, marking three horizontal lines: the first line starts from the place where the earlobe is attached to the cheek, then it goes 1 cm above the edge of the lower jaw and continues to the chin, the second line starts from the lower point of the tragus and continues to the corner of the mouth, the third line starts from the upper point of the tragus and continues to the wing of the nose. The chewing space is between the first and second lines, the free cheek space is between the second and third lines, the pre-zygomatic space is above the third line. Detachment of the skin is performed for 5 cm from the skin incision, with a mandatory dissection of the masseter-cutaneous ligaments. Then, on the CMAS layer opened after the skin detachment, to facilitate the identification of facial spaces, three extended horizontal lines are also marked, focusing on similar lines on the skin: the first line from the place where the earlobe is attached to the cheek, then 1 cm above the edge of the lower jaw to the border skin detachment in the direction of the chin, the second line from the lower point of the tragus, further to the border of the skin detachment in the direction of the corner of the mouth, the third line from the upper point of the tragus, further to the border of the skin detachment in the direction of the wing of the nose. Additionally, on the CMAS layer opened after skin detachment, an oblique line is marked, which starts at the top from a point located 1 cm outward from the outer corner of the eye and 1.5 cm vertically down, below the oblique line continues to the projection of the angle of the lower jaw. From the beginning and from the end of this oblique line in the medial direction, on the SMAS layer that is open after skin detachment, two short horizontal lines 1 cm long each are marked. The CMAS layer is dissected along the oblique line and these two short horizontal lines. In this case, two SMAS flaps are formed - a fixed proximal and a rectangular movable distal one. Then detachment of a rectangular movable distal SMAS flap is carried out for 2 cm, by entering the facial spaces: pre-masticatory space, free cheek space and pre-zygomatic space, focusing on three previously marked, on the CMAS layer open after skin detachment, extended horizontal lines. After entering the three spaces of the face, the intersection of all vertical ligaments between these spaces is performed. Then, a rectangle is cut out from the edge of the rectangular movable distal CMAS flap, so that protruding sections of the rectangular movable distal CMAS flap of 1 sq. see As a result, a mobile distal U-shaped SMAS flap is formed. Further, in the anterior region at a distance of 1 cm medially from the line of the skin incision in the fixed proximal SMAS flap, windows sized 0.5 * 0.5 cm are formed: at the tragus, in the projection of the zygomatic arch and in the temporal region 1 cm above the projection of the zygomatic arch. Nylon 3.0 fixation threads are passed through these windows, so that the knots turn out to be screwed. The thread is carried out as follows: they are punctured through each formed window in the fixed proximal SMAS flap 0.5 * 0.5 cm, from the inside to the outside, in the direction laterally, then the movable distal U-shaped SMAS flap is stitched with this thread from the inside to the outside, retreating from its free edges 1.5 cm, then the movable distal U-shaped SMAS flap is sutured from the outside inward, departing from its free edge 1.5 cm, the distance between these injections on the movable distal U-shaped SMAS flap is 0.5 cm and then injected into the formed a window in a fixed proximal CMAS flap 0.5 * 0.5 cm, stitching from the outside inward in the medial direction. The distance between the injections on the immovable proximal CMAS flap is 0.5 cm. All three nylon 3.0 fixation threads are thus passed through the movable distal U-shaped CMAS flap in the area of the pre-masticatory, pre-zygomatic and in the area of the free cheek space. The pre-masticatory area is fixed with nylon 3.0 thread in the area of the formed window in the fixed proximal CMAS flap 0.5*0.5 cm in size near the tragus, the free cheek area is fixed with nylon 3.0 thread in the area of the formed window in the fixed proximal CMAS flap 0.5*0 in size, 5 cm at the zygomatic arch, the pre-zygomatic region is fixed with nylon 3.0 thread in the area of the formed window in the fixed proximal CMAS flap measuring 0.5 * 0.5 cm near the temporal fascia 1 cm above the zygomatic arch. After pulling up the movable distal U-shaped CMAS flap, tighten and tie nylon 3.0 fixation threads. Then, to close the formed knots of the nylon 3.0 fixation thread, the formed windows in the immobile proximal CMAS flap above the knots of the nylon 3.0 fixation thread are sutured with an interrupted suture with a Vicryl 4.0 thread. Next, the free edge of the movable distal U-shaped SMAS flap is sutured with a fixed proximal CMAS flap with a continuous twisting suture with a PDS 3.0 thread, so that in the zygomatic region and in the region of the angle of the lower jaw, an overlap is formed, according to the type of duplication, protruding by 1 sq. . see sections of the movable distal U-shaped CMAS flap onto the immovable proximal CMAS flap, and in the cheek area, the movable distal U-shaped CMAS flap is sutured with the immovable proximal CMAS flap "edge to edge". Similar manipulations are performed on the other side of the face.

The essence of the invention is illustrated by drawings.

Fig. 1. Marking on the skin in the form of three horizontal lines to identify facial spaces. Marking the skin incision line in the temple area 2 cm long along the hairline, then along the auricle, along the inner surface of the tragus, around the lobe and in the posterior fold by 4 cm.

Fig. 2. Making a skin incision and detaching the skin for 5 cm.

Fig. 3. Marking, on the SMAS layer opened after skin detachment, of three extended horizontal lines similar to lines on the skin to identify facial spaces.

Fig. 4. Marking on the open CMAS layer after skin detachment, an oblique line and two horizontal lines.

Fig. 5. Dissection of the CMAS layer along an oblique line and two horizontal lines, and detachment of the movable distal CMAS flap for 2 cm.

Fig. 6. Cutting out a rectangle from the edge of a rectangular movable distal CMAS flap with the formation of protruding sections of 1 sq. see each.

Fig. 7. Formation of a movable distal U-shaped SMAS flap.

Fig. 8. Formation of windows 0.5 * 0.5 cm in size in the anterior region at a distance of 1 cm medially from the line of the skin incision in the fixed proximal CMAS flap: at the tragus, in the projection of the zygomatic arch and in the temporal region 1 cm above the projection of the zygomatic arch.

Fig. 9. Insertion of the nylon 3.0 fixation thread: puncturing through the formed window in the immovable proximal CMAS flap 0.5*0.5 cm, from the inside outwards, in the direction laterally.

Fig. 10. Placement of the nylon 3.0 fixation thread: suturing of the movable distal U-shaped CMAS flap from the inside outwards, 1.5 cm away from its free edge.

Fig. 11. Placement of the nylon 3.0 fixation thread: suturing of the movable distal U-shaped SMAS flap from the outside to the inside, 1.5 cm away from its free edge.

Fig. 12. Placement of the nylon 3.0 fixation thread: injecting into the formed window in the fixed proximal CMAS flap 0.5 * 0.5 cm, stitching from the outside inward in the medial direction.

Fig. 13. Tying the nylon 3.0 fixation thread with the formation of a screw-in knot.

Fig. 14. Placement of the nylon 3.0 fixation thread: the distance between the injections on the movable distal U-shaped SMAS flap and on the fixed proximal CMAS flap is 0.5 cm. Tying the nylon 3.0 fixation thread with the formation of a screw-in knot.

Fig. 15. Passing all three nylon 3.0 fixation threads through the movable distal U-shaped SMAS flap in the area of the pre-cheek, pre-zygomatic and in the area of the free cheek space. Fixation of the pre-masticatory area in the area of the formed window near the tragus. Fixation of the area of the free cheek in the area of the formed window near the zygomatic arch. Fixation of the pre-zygomatic region in the area of the formed window near the temporal fascia 1 cm above the zygomatic arch.

Fig. 16. Pulling up the movable distal U-shaped CMAS flap, tightening and tying the nylon 3.0 fixation threads. Closure of the resulting knots of nylon 3.0 fixation threads by suturing three formed windows in the fixed proximal SMAS flap with an interrupted suture with a Vicryl 4.0 thread.

Fig. 17. Stitching the free edge of the exfoliated movable distal U-shaped SMAS flap with a fixed proximal SMAS flap with a continuous twisting suture with a PDS 3.0 thread, in such a way that in the zygomatic region and in the region of the angle of the lower jaw, an overlap of protruding 1 sq. see sections of the movable distal U-shaped CMAS flap, onto the immovable proximal CMAS flap, and in the cheek area, the suturing of the movable distal U-shaped CMAS flap with the immovable proximal CMAS flap is carried out "edge to edge".

Fig. 18. Closure of the formed knots of the nylon 3.0 fixation threads by suturing the formed window in the fixed proximal SMAS flap with an interrupted suture with a Vicryl 4.0 thread.

The method of surgical correction of age-related changes in the soft tissues of the face according to the invention is carried out as follows. First, markings are made on the skin to identify facial spaces, marking three horizontal lines: the first line 1 (Fig. 1, 2) starts from the place where the earlobe is attached to the cheek, then goes 1 cm above the edge of the lower jaw and continues to the chin, the second line 2 (Fig. 1, 2) starts from the lower point of the tragus and continues to the corner of the mouth, the third line 3 (Fig. 1, 2) starts from the upper point of the tragus and continues to the wing of the nose. The chewing space is between the first and second lines, the free cheek space is between the second and third lines, the pre-zygomatic space is above the third line. Next, a hydropreparation of the soft tissues of the face is performed, a skin incision 4 (Fig. 1, 2) is made, in the temple area 2 cm long along the hairline, then along the auricle, along the inner surface of the tragus, around the lobe and in the posterior fold by 4 cm. Detachment of the skin 5 (Fig. 2, 3) is performed for 5 cm from the skin incision, with the obligatory dissection of the masseter-cutaneous ligaments. Then, on the CMAC layer 26 opened after skin detachment (Fig. 2, 3, 4), to facilitate the identification of facial spaces, three extended horizontal lines similar to lines on the skin are also marked: the first line 6 (Fig. 3, 4, 5) from the places of attachment of the earlobe to the cheek along the line 1 cm above the edge of the lower jaw to the border of the skin detachment in the direction of the chin, the second line 7 (Fig. 3, 4, 5) from the lower point of the tragus to the border of the skin detachment in the direction of the corner of the mouth, the third line 8 (Fig. 3, 4, 5) from the upper point of the tragus to the border of the skin detachment in the direction of the ala of the nose. Additionally mark on the open, after skin detachment layer CMAS 26 (Fig. 2, 3, 4), an oblique line 9 (Fig. 4), which starts at the top from point 10 (Fig. 4) located 1 cm outward from the outer corner eyes and 1.5 cm vertically down, at the bottom, the oblique line continues to the projection of the angle of the lower jaw 11 (Fig. 4). From the beginning 10 (Fig. 4) and from the end 11 (Fig. 4) of this oblique line 9 (Fig. 4), additionally in the medial direction, on the CMAC layer 26 (Fig. 4) open after skin detachment, two horizontal lines 12 are marked (Fig. 4) 1 cm long each. Along an oblique line 9 (Fig. 4) and two horizontal lines 12 (Fig. 4) 1 cm long, a dissection 13 (Fig. 5) of the CMAS layer 26 (Fig. 4) is performed. In this case, two CMAS flaps are formed - a fixed proximal 18 (Fig. 5) and a rectangular movable distal 15 (Fig. 5). Then, a detachment 14 (Fig. 5) of a rectangular movable distal CMAS flap 15 (Fig. 5) is carried out for 2 cm, by entering the facial spaces: pre-masticatory space, free cheek space and pre-zygomatic space, focusing on the three previously noted, on the open after skin detachment of the CMAS layer, extended horizontal lines 6, 7, 8 (Fig. 4, 5). After entering these three facial spaces, the intersection of all vertical ligaments between these facial spaces is performed. Then, a rectangle 16 (Fig. 6) is cut out from the edge of the rectangular movable distal CMAS flap 15 (Fig. 5, 6), so that 1 sq. see protruding sections 27 (Fig. 6) of the movable distal CMAC flap 15 (Fig. 5, 6). As a result, a movable distal U-shaped CMAS flap 17 is formed (Fig. 7). Further, in the anterior region at a distance of 1 cm medially from the skin incision line 4 (Fig. 1, 2, 8) in the fixed proximal CMAS flap 18 (Fig. 8) windows 0.5 * 0.5 cm in size are formed: at the tragus 19 (Fig. 8), in the projection of the zygomatic arch 20 (Fig. 8) and in the temporal region 21 (Fig. 8) above the projection of the zygomatic arch by 1 cm. so that the nodes turn out to be screwed. The fixation thread 22 (Fig. 9) nylon 3.0 is carried out as follows: they are punctured through each formed window 19,20,21 (Fig. 8) in the fixed proximal CMAS flap 18 (Fig. 8) 0.5 * 0.5 cm , from the inside to the outside, in the direction laterally (Fig. 9), then with this thread 22 (Fig. 10) the movable distal U-shaped CMAS flap 17 (Fig. 10) is sutured from the inside outwards, departing from its free edge 1.5 cm, then sutured movable distal U-shaped flap SMAS 17 (Fig. 11) from outside to inside, departing from its free edge 1.5 cm, the distance between these injections on the movable distal U-shaped flap SMAS 17 (Fig. 11, 14) 0.5 cm and then they are injected into the formed window 19 (Fig. 12) in the fixed proximal CMAS flap 18 (Fig. 12, 14) 0.5 * 0.5 cm, stitching from the outside inward in the medial direction (Fig. 12, 14). The distance between the injections on the fixed proximal CMAS flap 18 (Fig. 14) is 0.5 cm. , 15) in the area of the pre-cheek, pre-zygomatic and in the area of the space of the free cheek. The chewing area is fixed with thread 22 (Fig. 15) nylon 3.0 in the area of the formed window with a size of 0.5 * 0.5 in the fixed proximal CMAS flap 18 (Fig. 15) at the tragus 19 (Fig. 15), the area of the free cheek is fixed with thread 22 (Fig. 15) nylon 3.0 in the area of the formed window with a size of 0.5 * 0.5 in the fixed proximal CMAS flap 18 (Fig. 15) at the zygomatic arch 20 (Fig. 15), the pre-zygomatic region is fixed with thread 22 (Fig. 15) nylon 3.0 in the area of the formed window with a size of 0.5 * 0.5 in the fixed proximal CMAS flap 18 (Fig. 15) near the temporal fascia 21 (Fig. 15) 1 cm above the zygomatic arch. After pulling up the movable distal U-shaped CMAC flap 17 (Fig. 16), fixation threads 22 (Fig. 13, 16) nylon 3.0 are tightened and tied. Then, to close the formed knots 23 (Fig. 13, 14, 18) of the fixation thread 22 (Fig. 18) nylon 3.0, the formed windows 19.20 are sutured with an interrupted suture 24 (Fig. 16, 17, 18) with a Vicryl 4.0 thread. 21 (Fig. 16, 17) in a fixed proximal CMAS flap 18 (Fig. 16, 17,18) above the nodes 23 (Fig. 18) of the fixation thread 22 (Fig. 16, 18) nylon 3.0. Next, the free edge of the movable distal U-shaped CMAS flap 17 (Fig. 17) is sutured with a fixed proximal CMAS flap 18 (Fig. 17) with a continuous twist suture 28 (Fig. 17) with a PDS 3.0 thread, so that in the zygomatic region and in the region of the angle of the lower jaw, an overlap is formed, according to the type of duplication 25 (Fig. 17), protruding by 1 square. see sections 27 (Fig. 17) of the movable distal U-shaped CMAS flap 17 (Fig. 17), onto the fixed proximal CMAS flap 18 (Fig. 17), and in the cheek area, the movable distal U-shaped CMAS flap 17 is sutured (Fig. . 17) with a fixed proximal CMAS flap 18 (Fig. 17) "edge to edge". Similar manipulations are performed on the other side of the face.

Moving the pre-masticatory space along the oblique-vertical vector eliminates the “flies” and corrects the oval, moving the space of the free cheek smoothes the labio-chin and lower half of the nasolabial fold, moving the pre-zygomatic space corrects the upper part of the nasolabial fold and the zygomatic area.

Expansion of the subcutaneous detachment by 5 cm from the line of the skin incision, with the obligatory cutting off of the masseterocutaneous ligaments, eliminates irregularities and retraction of the facial skin after tightening and fixing the detached SMAS flap.

The use of non-absorbable nylon 3.0 threads, which fix the detached CMAS flap, provides a stable and durable result of the operation.

The formation of windows in the SMAS layer to sink knots from the fixing nylon 3.0 thread, the use of screw-in sutures fixing the detached SMAS flap, suturing the windows of the CMAS layer with Vicryl 4.0 thread eliminates the possibility of probing the knots of the non-absorbable nylon 3.0 thread.

Suturing of the SMAS flap with continuous continuous suture with PDS 3.0 thread. forms a stable, durable suture of the entire CMAS flap

The use of non-absorbable nylon 3.0 monofilament thread eliminates the possibility of microbial absorption by the thread in the event of an infection.

The operation is completed by distributing, tightening and excising excess skin-fat flap on both sides, draining rubber graduates in the behind-the-ear zone and applying intradermal sutures to the incisions.

Clinical example

Patient V., aged 51, came with a diagnosis of atrophic changes in the soft tissues of the face. From the anamnesis, it was established that for a long time she performed various facial rejuvenation procedures and performed various injections and hardware effects with a temporary effect. Appealed to eliminate age-related changes in the face.

The patient was operated on by the proposed method.

Under general anesthesia, after treating the surgical field with antiseptic solutions three times, markings were applied to the skin to facilitate the identification of facial spaces, three horizontal lines were marked: the first line from the place of attachment of the earlobe to the cheek, then 1 cm above the edge of the lower jaw to the chin, the second line from the lower point of the tragus to the corner of the mouth, the third line from the upper point of the tragus to the wing of the nose. The skin was exfoliated for 5 cm from the skin incision, the masseter-cutaneous ligaments were dissected. Then, on the CMAS layer opened after the skin detachment, three long horizontal lines were marked, focusing on similar lines on the skin: the first line from the place where the earlobe was attached to the cheek, then 1 cm above the edge of the lower jaw to the border of the skin detachment in the direction of the chin, the second line from the lower point of the tragus, further to the border of the skin detachment in the direction of the corner of the mouth, the third line from the upper point of the tragus, further to the border of the skin detachment in the direction of the nose wing. Additionally, on the CMAS layer opened after skin detachment, an oblique line was marked, which started at the top from a point located 1 cm outward from the outer corner of the eye and 1.5 cm vertically downwards, at the bottom the oblique line continued to the projection of the angle of the lower jaw. From the beginning and from the end of this oblique line in the medial direction, on the CMAS layer that was open after skin detachment, two short horizontal lines 1 cm long each were marked. The CMAS layer was cut along the oblique line and these two short horizontal lines. At the same time, two SMAS flaps were formed - a fixed proximal and a rectangular movable distal one. Then, a rectangular movable distal SMAS flap was peeled off for 2 cm by entering the facial spaces: the pre-masticatory space, the free cheek space and the pre-zygomatic space, focusing on the three previously noted long horizontal lines on the CMAS layer open after skin detachment. After entering the three spaces, the faces crossed all the vertical ligaments between these spaces. Then, a rectangle was cut out from the edge of the rectangular movable distal CMAS flap, so that protruding sections of the rectangular movable distal CMAS flap of 1 sq. see As a result, a mobile distal U-shaped CMAS flap was formed. Further, in the anterior region at a distance of 1 cm medially from the line of the skin incision, windows sized 0.5 * 0.5 cm were formed in the fixed proximal CMAS flap: at the tragus, in the projection of the zygomatic arch and in the temporal region 1 cm above the projection of the zygomatic arch Nylon 3.0 fixation threads were passed through these windows, so that the knots turned out to be screwed. The threads were carried out as follows: they were punctured through each formed window in the immovable proximal SMAS flap 0.5 * 0.5 cm, from the inside to the outside, in the direction laterally, then the mobile distal U-shaped SMAS flap was stitched with this thread from the inside to the outside, stepping back from its free edge 1.5 cm, then the movable distal U-shaped CMAS flap was sutured from the outside inward, departing from its free edge 1.5 cm, the distance between these injections on the movable distal U-shaped SMAS flap was 0.5 cm, and then they were injected into the formed window in a fixed proximal CMAS flap 0.5 * 0.5 cm stitched from the outside inward in the medial direction. The distance between the injections on the immovable proximal CMAS flap was 0.5 cm. All three nylon 3.0 fixation threads were thus passed through the movable distal U-shaped CMAS flap in the region of the pre-masticatory, pre-zygomatic and in the region of the space of the free cheek. The pre-masticatory area was fixed with nylon 3.0 suture in the area of the window formed in the immovable proximal CMAS flap 0.5*0.5 cm in size near the tragus; 5 cm near the zygomatic arch, the pre-zygomatic region was fixed with a nylon 3.0 thread in the area of the formed window in the fixed proximal CMAS flap with an exchange of 0.5 * 0.5 cm at the temporal fascia 1 cm above the zygomatic arch. Then, the movable distal U-shaped CMAS flap was pulled up, tightened, and nylon 3.0 fixation threads were tied. Then, to close the formed knots of the nylon 3.0 fixation thread, the formed windows in the fixed proximal SMAS flap were sutured with an interrupted suture with a Vicryl 4.0 thread. Next, the free edges of the movable distal U-shaped SMAS flap were sutured with a fixed proximal CMAS flap with a continuous twist suture with a PDS 3.0 thread, so that in the zygomatic region and in the region of the angle of the lower jaw, an overlay of protruding 1 sq. see sections of the movable distal U-shaped SMAS flap, onto the immovable proximal CMAS flap, and in the cheek area, the movable distal U-shaped CMAS flap was sutured to the immovable proximal CMAS flap "edge to edge". Similar manipulations were performed on the other side of the face. Distributed, tightened and excised excess skin-fat flap on both sides of the face, put intradermal sutures on the incisions, removed drainage rubber graduates in the behind-the-ear areas. An aseptic pressure bandage was applied.

The postoperative period was uneventful, the drainage rubber graduates were removed on the 2nd day.

The patient was examined after 3, 6, 9 months. Complaints does not show, feels satisfactory. Aesthetic results are assessed well.

According to this method, 4 patients were operated on, no complications were observed in them. All patients were discharged in a satisfactory condition. Examined after 3, 6, 9 months - no complaints, feel satisfactory. The aesthetic result is well appreciated.

Thus, the use of the proposed method allows:

- effectively eliminate "flies", correct the oval of the face, smooth out the labio-chin and nasolabial folds, as well as correct the zygomatic zone;

- to obtain a stable result of the operation and low visibility of the emerging skin scars;

- to form a natural young facial relief with volume in the cheekbones and jaw angles.

The method is simple to perform, maximally anatomical and physiological, which expands the indications for surgical correction of age-related changes in the soft tissues of the face. Based on the foregoing, the method can be used in clinical practice when performing surgical correction of age-related changes in the soft tissues of the face.

Claims (1)

A method for surgical correction of age-related changes in the soft tissues of the face, including marking on the skin to identify facial spaces, three horizontal lines: the first line starts from the place where the earlobe is attached to the cheek, then goes 1 cm above the edge of the lower jaw and continues to the chin, the second line starts from the lower point of the tragus and continues to the corner of the mouth, the third line starts from the upper point of the tragus and continues to the wing of the nose, hydropreparation of the soft tissues of the face, skin incision, in the temple area 2 cm long along the hairline, then along the auricle, along inner surface of the tragus, around the lobe and in the postauricular fold by 4 cm, skin detachment for 5 cm from the skin incision, obligatory dissection of the masseterocutaneous ligaments, marking, on the SMAS layer open after skin detachment, three long horizontal lines similar to lines on the skin : the first line from the place of attachment of the earlobe to the cheek, then 1 cm above the edge of the lower jaw to the border skin detachment in the direction of the chin, the second line from the lower point of the tragus, further to the border of the skin detachment in the direction of the corner of the mouth, the third line from the upper point of the tragus, further to the border of the skin detachment in the direction of the wing of the nose, additional marking, on the CMAS layer open after skin detachment , an oblique line starting at the top from a point located 1 cm outward from the outer corner of the eye and 1.5 cm vertically down, below the oblique line continues to the projection of the angle of the lower jaw, marking, from the beginning and from the end of this oblique line, in the direction medially, two horizontal lines 1 cm long each, dissection of the CMAS layer along an oblique line and two horizontal lines 1 cm long, formation of two CMAS flaps - a fixed proximal and a rectangular movable distal flap, exfoliation of a rectangular movable distal CMAS flap for 2 cm, by entrance to the spaces of the face: pre-masticatory space, space of the free cheek and pre-zygomatic space, orientation, at the same time, to three previously marked, on the CMAS layer open after skin detachment, extended horizontal lines, the intersection of all vertical ligaments between these facial spaces, cutting out a rectangle from the edge of a rectangular movable distal CMAS flap, so that the top and bottom remain, 1 sq. cm, protruding sections of the movable distal CMAS flap, the formation, as a result, of a movable distal CMAS flap of a U-shaped shape, the formation in the anterior region at a distance of 1 cm medially from the line of the skin incision in the fixed proximal CMAS flap of windows 0.5 * 0.5 in size cm: at the tragus, in the projection of the zygomatic arch and in the temporal region above the projection of the zygomatic arch by 1 cm, passing nylon 3.0 fixation threads through these windows, so that the knots turn out to be screwed in, inserting nylon 3.0 fixation threads as follows: punching out, through each the formed window in the fixed proximal SMAS flap 0.5 * 0.5 cm, from the inside outwards, in the direction laterally, then suturing the movable distal U-shaped CMAS flap from the inside outwards with this thread, departing from its free edge 1.5 cm, then suturing the movable distal U-shaped SMAS flap, from outside to inside, departing from its free edge 1.5 cm, the distance between these injections on the movable distal 0.5 cm U-shaped CMAS flap, and then injecting into the formed window in the immovable proximal CMAS flap 0.5 * 0.5 cm, stitching from the outside inward in the medial direction, the distance between the injections on the immovable proximal CMAS flap 0.5 cm , passing all three nylon 3.0 fixation threads through the movable distal U-shaped SMAS flap in the area of the pre-cheek, pre-zygomatic and in the area of the free cheek space, fixing the pre-masticatory area with nylon 3.0 thread in the area of the formed window with a size of 0.5 * 0.5 in the fixed proximal flap SMAS at the tragus, fixation of the free cheek area with nylon 3.0 thread in the area of the formed window with a size of 0.5 * 0.5 in a fixed proximal SMAS flap near the zygomatic arch, fixation of the premallar region with nylon 3.0 thread in the area of the formed window with a size of 0.5 * 0.5 in the fixed proximal CMAS flap near the temporal fascia 1 cm above the zygomatic arch, pulling up the mobile distal U-shaped CMAS flap, tightening and tying the nylon 3.0 fixation threads, then suturing with an interrupted suture with a vicryl 4.0 thread, over the knots of the nylon 3.0 fixation thread, three formed windows in the immovable proximal CMAS flap, to close the formed knots of the nylon 3.0 fixation thread, suturing the free edge of the movable distal U-shaped flap SMAS with a fixed proximal SMAS flap with a continuous twisting suture with a PDS 3.0 thread, so that in the zygomatic region and in the region of the angle of the lower jaw, an overlap of protruding 1 sq. see sections of the movable distal U-shaped CMAS flap on the immovable proximal CMAS flap, and in the cheek area, the suturing of the movable distal U-shaped CMAS flap with the immovable proximal CMAS flap takes place “edge to edge”, similar manipulations are performed on the other side of the face, distribution, tightening and excision of excess skin-fat flap on both sides of the face, drainage with rubber graduates in the behind-the-ear areas and intradermal sutures on the incisions.

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