CHAPTER 32 FACIAL CONTOURING Aesthetic Plastic Surgery, 2nd Edition Rees and Latrenta Goal: correction of hard tissues

of the face to look aesthetically different by altering patients physiognomy. This is done by two means: 1. Corrective bone surgery osteotomies of underlying skeleton, bone grafts, and rigid fixation techniques. 2. Camouflage techniques alloplastic implants combined with liposculpture; less timeconsuming, less risky and less expensive. Nose = Nasion - Anterior Nasal Spine (n-sn) Jaw = Anterior Nasal Spine Menton (sn-me) * (Farkas and Kolar, 1987) The nasal segment was found to be a mean of 11.6 mm smaller than the jaw segment and a mean of 6.3 mm smaller than the forehead segment in the most attractive women studied. CANON 3 The facial profile can be divided into EQUAL QUARTERS. The most superior quarter, or calvarial segment, extends from the hairline, or trichion, to the top of the head or the vertex. The superior quarter, or forehead segment, extends from the hairline (trichion) to the glabella. The inferior quarter, or nasal segment, extends from the glabella to the junction of the columella and the philtrum of the lip, or subnasale. The most inferior quarter, or jaw segment, extends from the subnasale to the most inferior point on the chin, or menton. Calvaria = Vertex Trichion (v-tr) Forehead = Trichion Glabella (tr-g) Nose = Glabella Subnasale (g-sn) Jaw = Subnasale Menton (sn-me) * (Farkas and Kolar, 1987) The general population measurements were (21.1% - 23.6% - 26.5 % - 28.9 %). For facially attractive women, this changed to (20% - 23% - 28% - 29%). CANON 4 (The Nasoaural Canon) The height of the middle third of the face, or nose, is roughly equal to the height of the ear. * (Farkas and Kolar, 1987) The height of the ear was was always greater than the nasal height in the facially attractive and most attractive patients. Horizontal Proportions CANON 5 (The Nasoorbital Canon) The width of the space between the eyes equals the width of the nose at the alar base level. * (Farkas and Kolar, 1987) The intercanthal width was found to be a maximum of 4 to 5 mm greater than the nasal base in the most attractive patients.

FACIAL AESTHETIC RELATIONSHIPS Neoclassical Canons and Anthropometric Studies - divide the face into vertical and horizontal proportions. Farkas and Kolar (1987) - established that the healthy face exists within a wide range of anthropometric values of facial linear measurements and proportions (mean +/- 2 SD). In the attractive face: (mean +/- 1 SD). Vertical Proportions CANON 1 The combined total vertical facial and head height is divided into EQUAL HALVES at the midcanthal point or endocanthion. Upper Face and Head Height = Vertex Endocanthion (V En) Lower Face Height = Endocanthion Menton (En-Me) * (Farkas and Kolar, 1987) Attractiveness increased as the total vertical facial and head height decreased. The lower half of the vertical facial and head height was found to be greater than the upper half by a mean of 17.6 mm. CANON 2 The facial profile can be divided into equal anatomic THIRDS. The upper third, or forehead segment, extends from the hairline to the nasofrontal junction, or nasion. The middle third, or nasal segment, extends from the nasofrontal junction to the anterior nasal spine. The lower third, or jaw segment, extends from the anterior nasal spine to the most inferior point of the chin, or menton. Forehead = Trichion Nasion (Trn)

Prepared By: F. Amalik P. Espinosa III, MD

CANON 6 The width of the space between the eyes equals the width of each individual eye. * (Farkas and Kolar, 1987) The intercanthal width was found to be a maximum of 2 to 3 mm greater tha the width of each eye in the most attractive patients. CANON 7 (The Nasooral Canon) The width of the lips equals 1.5 times the width of the nose at the alar bases. * (Farkas and Kolar, 1987) In the most attractive patients, the width of the lips was found to be at least 11 mm greater than the 1.5 times the nasal alar base width. CANON 8 (The Nasofacial Canon) The width of the face equals four times the alar base width of the nose. * (Farkas and Kolar, 1987) In the most attractive patients, the facial width was found to be 3 to 4 mm greater than 4 times the alar base width of the nose. The widest portion of the face was found to be between the malar bones, with the width between the temporal bones of the forehead and that between the gonial angles of the mandible equal and 10% less, respectively. Angular Proportions CANON 9 The inclination of the nose is equal to the inclination of the ear.

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Lateral orbital rim Posterior to the most anterior contour of the cornea by 12 to 16 mm. Used as landmark for assessment of globe position in relation with the cornea. Eye fissures slant upwards from medial to lateral , 4.1 mm in females and 2.1 mm in males. Inferior Orbital rim Junction of the malar complex and the lower eyelid marks the lowest point on the orbital rim and is a key landmark for the Frankfort Horizontal Posterior to the anterior contour of the cornea by 2 to 3 mm rapid check for malar hypoplasia.

II. Nose (Farkas and Kolar, 1987) In the most attractive patients, the nasal root and tip were found to be in high relation to the soft tissue alar widths. The nasal quarter was the most proportionately large component of the facial vertical height. The nose was found to be narrow in proportion to the wider facial width. III. Lips and Mouth (Farkas and Kolar, 1987) Upper lip was found to be higher Both upper and lower lips were vertically short in relation to width Mouth was much wider and fuller in relation to facial width Vermillon arc of upper lip was found to have greatest convex curvature in attractive people Lips at rest slightly touch to 3 or 4 mm apart maxillary incisor show at rest, 4 m in males and 6 mm in female Lip edge should parallel the gingival margin with smiling, with minimal amounts of gingiva showing a full smile.

ANATOMICALLY SENSITIVE REGIONS OF THE FACE

I. Orbits The eyes are bounded by the orbital rims. a. Superior orbital rim 8 to 10 mm anterior to the most anterior contour of the cornea Eyebrow marks the surface of the superior orbital rim Eyebrow arcs upward the superior orbital rim to a peak at the junction of the medial two thirds and lateral third of the orbital rim Lateral limbus corresponds to peak of eyebrow arc

Prepared By: F. Amalik P. Espinosa III, MD

IV. Summary The attractive face: Smaller in vertical dimension, with a broad width between malar bones Forehead and angles of the jaw are very broad as well but taper slightly from strong malar bones Forehead is proportionately very short for its broad width crowned by a short calvaria Midface is the largest component. Wide-set eyes, appearing full because of broad malar bones and nose which is narrow for height. Nasal root and tip are high in relation to the nasal width Narrowness of nose is emphasized by a wide, full mouth set against a jaw that proportionately dominates the lower face. Lips are long , arcing, and high in the upper lip and a lower lip that is sharply separated from the chin

Merrifield and Ricketts Approached the profile from an orthodontic perspective Emphasized the strengthe of the face Used the Z-angle (Merrifield)- line that intersects the upper lip and soft tissue pogonion of the chin Average angle: 82.2 degrees in men and 80.2 in women Facial Profile Line (Ricketts) If the mandible is orthognatic to the upper jaw, the upper lip should fall 4 mm posterior to a line drawn from the tip of the nose to the soft tissue pogonion of the chin, and the lower lip should fall 2 mm posterior to this line. If the mandible was retrognathic, the lips, especially the lower lip should almost abut this line. Forehead Inclination (Farkas) Average Caucasian Male -10.5 degrees Average Caucasian Female - 5.5 degrees Males have a more acute angle because of marked frontal sinus development Ousterhout (1987) Male forehead has a characteristic morphologic appearance with supraorbital bossing at the glabella and flatness above the bossing.

CONTEMPORARY GUIDELINES Medical Photography must be standardized according to the Frankfort Horizontal Plane. Frankfort Horizontal Plane connects the lowest orbital rim point with the highest point of the ear canal meatus. Gonzalez-Ulloa and Stevens (1968) The ideal lower jaw position in a patients profile photograph, a line is dropped perpendicular to the Frankfort horizontal from the soft tissue nasion. Aka Aesthetic Profile Line Intercept the pogonion of the chin. (Farkas, et. al., 1985) found that the aesthetic profile line was found to deviate from the ideal 0-degree position an average of -5.5 degrees. General Profile Line Line that drops from the soft tissue glabella to the soft tissue pogonion of the chin Deviates -3 to -2.7 degrees in most attractive women.

CLINICAL ASSESSMENT Three key prominences of the face: Nose Malar Jaws Assess for: Thorough medical history Potential medical problems History of orthodontic therapy Temporomandibular joint disfunction painful clicking of the jaw on both opening and closing General configuration of the head and face, vertical and transverse dimensions Prognathic patients downward posture Retrognathic patients upward-tilting posture

Prepared By: F. Amalik P. Espinosa III, MD

Forehead and Brows: Excessive forehead recession Bossing Ptosis Excessive transverse creasing Orbital regions, malar prominences, nose and jaws Upper/lower scleral show Malar Prominences: Area of greatest transverse dimension (Malar >temporal or gonial) Lower eyelid scleral show Nose: Jaws: Various dimensions of nose in relation to intercanthal width, width of mouth, vertical dimensions of the face. Nasal dorsum Middle vault Tip and columella Alar bases Septum Posture and competence of lips Musculus mentalis hypertrophy excessive strin to maintain lip competence Interlabial gap (>4mm) Maxillary incisor show at rest (M 4mm ; F 6mm) Malocclusion Chin and lower jaw profile Gonial angles and musculi masseter hypertrophy (bruxism) Traditional signs of aging

Importance: Identifying features of skeletal bone Diagnosis for complicated cases Planning for surgical correction Four Parts Of Cephalometry: 1. Vertical facial measurements 2. Horizontal midface measurements 3. Horizontal lower face measurements 4. Dental measurements23 1. Vertical Facial Measurements a. Nasion-Menton (N-Me) or total anterior face height b. Nasion Anterior Nasal Spine (NAns) or anterior upper facial height c. Anterior Nasal Spine Upper Incisor Edge (ANS-UIE) or subpiriform maxilliary height plus height of the upper incisor d. Anterior Nasal Spine Supradentale (ANS-SD) or subpiriform maxillary height e. Lower Incisor Edge Menton (LIEMe) or anterior mandibular height plus height of lower incisor f. Infradentale Menton (ID-Me) or Anterior mandibular height g. Articulare Gonion (Ar-Go) or Posterior lower facial height Horizontal Facial Measurements a. Sella Nasion (SN) or anterior cranial base length b. Anterior Nasal Spine Posterior Nasal Spine (ANS PNS) or maxillary length increased in maxillary hyperplasia and decreased in maxillary hypoplasia c. Gonion Pogonion (Go-Pg) or Mandibular length increased in prognathism and decreased in micrognathism. Angular Facial Measurements a. (SN-MP) angular relationship between the inferior border of the mandible and the anterior cranial base; increased in long face syndrome ad micrognathia and decreased in short face syndrome and prognathism. b. Sella Nasion Point A (SNA) angular measurement between the upper jaw defined by the point A and

2.

CEPHALOMETRICS Converse and Shapiro (1954) Proposed cephalometry to assist in the diagnosis and planning for surgicalorthodontic treatment of facial malformations Cephalometry Uses a cephalostat and lateral radiographs to take pictures of the teeth in occlusion and lips in repose. The composite of both sides is taken and median is used. Exception: those with facial asymmetry.

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Prepared By: F. Amalik P. Espinosa III, MD

c.

d.

the anterior cranial base; increased in maxillary hyperplasia and decreased in maxillary hypoplasia Sella Nasion Point B (SNB) or the angular relationship between the lower jaw defined by the B point and the anterior cranial base; this angle is increased in prognathism and decreased in micrognathia. Point A Nasion Point B (ANB) or angular measurement between the upper jaw defined by the B point; increased in maxillary protrusion and mandibular retrusion and decreased in maxillary retrusion and mandibular protrusion.

Generally, have the typical protruding or prognathic lower jaw appearance. The nose appears relatively flat with minimal projection.

ALLOPLASTIC AUGMENTATION I. History Aufricht, 1934 Shaped the osteocartilaginous vault of a large hump nose stripped of mucoperiosteum and mucoperichondrium and introduced this autogenous graft over the mental symphisis as a method of increasing chin projection. Dupertuis, 1959; Gibson, 1977 Cartilage grafts were unfortunately found to suffer an insidious tendency towards warping and absorption. Gillies and Millard, 1957 Cartilage grafts, even when stripped of perichondrium, was found to be mobile within the soft tissues. Converse, 1950 Bone grafts, even if well positioned and fixed, were found to adhere, be immobile, and incorporate extremely well into the patients body image, they were found to suffer a marked tendency towards resorption. Most common used donor sites, were the rib cage or iliac crest. Often, secondary or tertiary augmentations were needed due to resorption of the bone. Prosthetic Materials: 1. Polyethylene (Rubin, et. al, 1948) 2. Methylmethacrylates (Gonzales- Ulloa, 1957; Rish 1960; Pitanguy, 1968) 3. Polytetrafluoroethylene (Brown, et. al, 1960) All were found to be very hard and brittle. Significant tissue reactions and scarring were found to develop around the implant.

SURGICAL PLANNING Appearance is the patients primary motivation, and occasionally, the only concern. Angle Classification of Malocclusion (1899): 1. Class I or Neutroclusion The mesiobuccal cusp of the maxillary first molar aligns with the mesiobuccl groove of the mandibular first molar. o Generally have a satisfactory facial profile. o Soft tissue of the chin abuts the aesthetic profile line. o Upper lip is 4 mm from general profile line and lower lip is 2 mm from the general profile line. Class II or Distoclusion The mesiobuccal groove of the mandibular first molar is distal (posterior) to the mesiobuccal cusp of the maxillary first molar. Division 1 involves a narrow upper arch with a labial tilt of the incisors. Division 2 involves crowded upper arch with lingual tilt of the incisors in addition to distocclusion of the posterior teeth. o Typically have a receding facial profile, with convex nasal dorsum and small lower jaw. Class III or Mesioclusion The mesiobuccal groove of the mandibular first molar is mesial (anterior) to the mesiobuccal cusp of the maxillary first molar. The majority of the mandibular teeth are anterior to the corresponding maxillary teeth.

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Silicone (polydimethylsiloxilane) Noncarbon chain polymer introduced in the 1960s for use as an alloplastic material for facial contour augmentation (Rish, 1960; Safian, 1965; Bayne, 1966, Junghans, 1967)

Prepared By: F. Amalik P. Espinosa III, MD

Only noncarbon chain polymers used for alloplastic implants. Long chain molecules with molecular weights in the millions were found to exist as hard silicone blocks (Silastic), whereas short-chain molecules were found to exist in fluid form.

Traditional transverse intraoral incisions, which cut through muscles with traumatic dissection, result in transient, and occasionally, permanent weakness of the perioral musculature.

Vulcanization (Cross-linkage) Process by which molecules of silicone of various lengths were linked to form the rubbery, soft yet hard substance Silastic Advantages Biocompatible within the existing soft tissue bed, inducing a fibrous connective tissue capsule that abuts the implant surface Insertable through cosmetic incisions, offering a good margin of safety from tissue contamination (Terrino, 1991) Modifiable and can be shaped further Conformable to the dimensions of the face Exchangeable Nonpalpable Malleable Compressible II. Caveats 1. Alloplastic augmentation is ideal for patients whose only requirement is less than 0.5 cm of projection. The projection of available chin implants does not exceed 0.8 cm with length from 3.6 to 7.5 cm. Alloplastic augmentation provides a soft tissue to facial skeletal change ratio of 0.66:1, large chin implants will provide roughly 0.5 cm of projection. If one uses a bigger implant, settling and erosion may occur . 2. Alloplastic augmentation does not correct the soft tissue in a 1:1 ratio. Wilmot (1960) revealed that facial soft tissues change in a 0.66:1 ratio when alloplasts are used for augmentation. 3. Avoidance of superficial muscle dissection in the placement of prosthesis avoids transient and occasionally, permanent muscular weakness dysfunction. Incisions should be mucosal only using blunt dissection to the periosteum after elevating small mucosal flaps.

4. A careful, precise subperiosteal pocket dissection is the best method for preventing postoperative sensory dysfunction and prosthesis malposition-extrusion. Palpation of the infraorbital and the mental foramen, allows the surgeon ample warning when dissection will be close to the nerves. A good location for palpating the infraorbital foramen is opposite the medial limbus of the eye 5 to 10 mm inferior to the infraorbital rim. The four major branches are: lower eyelid, nasal upper labial and upper cheek. A good location for palpating the mental foramen is opposite the second premolar approximately halfway down the mandible from the singulum of the second premolar to the mandibular border. o Three branches: mental, lower labial, lower cheek. Placement of implant directly on bone makes sure that the implant is immobile. 5. The pocket for the alloplastic implant should accommodate the prosthesis comfortably. 6. When a vertical discrepancy exists in the chin or maxilla, such as excessive length or shortness, or when severe retrusion in these regions is noted, osteotomy procedures offer a better option for correction.

AUGMENTATION GENIOPLASTY Local anesthesia with light sedation or under general anesthesia Bilateral mental nerve block is provided (provides anesthesia with minimal premandibular swelling) Mental foramen is at the level of the labiomental groove opposite the second premandibular molar. I. Intraoral Approach Preferred route for chin augmentation. Inconspicuous scar, ease of placement with accuracy, surprisingly low complication rate. Technique chosen with conventional sized prosthesis

Prepared By: F. Amalik P. Espinosa III, MD

The buccal sulcus is lightly infiltrated with 0.5% lidocaine with 1:200, 000 epinephrine solution. A longitudinal mucosa only incision, no greater than 1.5 cm, is made opposite either mandibular canine, avoiding injury to the labial branch of the mental nerve. Fine Stevens scissors are used to spread the tissues transversely until the periosteum is reached. Subperiosteal dissection of the pocket is gently performed with a round-ended Kleinert-Kutz elevator below the level of the labiomental groove, medial to the second mandibular premolars to avoid the main branch of the mental nerve. A portion of the origin of the mentalis muscle directly over the pogonion is subperiosteally disinserted from the chin, bu this technique does not reach the median raphe of the muscle fibres over the labiomental groove. With the pocket, the appropriately-sized prosthesis can be inserted. Symmetry is noted by checking that the midpoint of the prosthesis is well aligned with the midpoint of the soft tissues of the chin. The incision is closed with a carefully placed deep 4-0 chromic suture and several 4-0 chromic vertical mattress sutures. When using Anatomic prosthesis, rather than using one longitudinal incision, bilateral symmetric incisions are used so that subperiosteal dissection hugging the inferior border of the mandible only can be extended well lateral to the mental foramina.

An incision is made through the subcutaneous tissue and the platysma is exposed. The platysma incision follows the fibers of the muscle in a muscle-splitting method. A retractor is introduced, and subperiosteal dissection of the chin below the labiomental groove is performed with a round-ended Kleinert-Kutz elevator. A portion of the origin of the mentalis muscle directly over the pogonion is subperiosteally disinserted from the chin by this technique, this approach does not disrupt the median raphe of the mentalis muscle above the labiomental groove. A subperiosteal pocket that comfortably accommodates the prosthesis is created. The prosthesis is inserted with the retractor in place. Pocket for the implant should be made so that the implant can be seated comfortably over the chin prominence and does not extend higher than the natural labiomental groove. The implant should be seated comfortably and squarely over the chin prominence. A two-layer closure is necessary when using the submental approach. o The deep closure brings the muscles together and is helpful in fixing the implants and preventing malposition and extrusion. The skin is closed with several dermal sutures of 5-0 polyglactin mesh (Vicryl) and several vertical mattress sutures of 6-0 nylon.

III. Adjunctive Techniques Chin Augmentation is easily combines with Suction Assisted Lipectomy of the submental region. Patients with small lower jaws often have excess fat collection in the submental region. (Pre/subplatysmal) Patients with subplatysmal fat collections have difficult necks with oblique cervicomental angles and microgenia. Direct submental fat excision and medial platysmaplasty are done. The chin augmentation is always done first to avoid the propensity for a submental hollow.

II. Submental Approach Has the advantage that the surgeon can accurately and precisely perform the subperiosteal pocket dissection only as high as required for the prosthesis. The integrity of the buccal sulcus is preserved, allows for larger anatomic implants, prevents the worry of excessive tension on an intraoral wound, which can lead to wound breakdown and implant extrusion. Incision should be curved and placed in an existing submental crease. The area is lightly infiltrated with 0.5% lidocaine with 1:200, 000 epinephrine solution.

Prepared By: F. Amalik P. Espinosa III, MD

Cervical SAL Performed in the usual radial fashion via a submental incision, with the greatest number of passes of the cannula in the area of the neck with densest fat. Direct Subdermal Fat Excision If the patient has an extensive subplatysmal fat collection with an oblique cervicomental angle and microgenia, the chin augmentation is performed first via an external approach. Medial Platysmaplasty The medial borders of the platysma are then plicated to the hyoid bone with 4-0 polyglactin mesh sutures. The knots are buried on the deep surface of the muscle. The submental incision is then closed in the usual fashion. IV. Dressings/Postoperative Care Elastoplast in basket weave pattern for 2 to 4 days to discourage hematoma formation and facilitate fixation of the prosthesis. Perioperative antibiotics are continued for 3 to 5 days. Intraoral: liquid/soft diet until dressings are removed, with no hard foods for first week. If SAL was done, the patient is placed in a Jobst compression head and neck garment, to be used 2 to 4 days after surgery.

MALAR AUGMENTATION Bilateral infraorbital nerve block is provided since it provides anesthesia with minimal malar and midfacial swelling. The infraorbital foramen can be palpated 6 mm inferior to the inferior orbital rim along a sagittal plane defined by the limbus of each eye.

Hinderer (1975) First to describe the procedure whereby alloplastic silicone rubber implants were placed over the zygomatic complexes Used two reference lines: o Lateral canthus to oral commissure. o Alar base to tragus.

I. INTRAORAL APPROACH Preferred route for malar augmentation. Technique chosen with conventional and anatomic-sized prostheses. The region of the upper buccal sulcus is lightly infiltrated with 0.5% lidocaine with 1:200, 000 epinephrine solution. A transverse mucosa-only incision is made no greater than 2 cm, from canine to premolar on the labial side of the upper buccal sulcus, made with either cautery or scalpel. A fine scissors is used to raise a small buccal vestibular flap down to the maxilla. No muscle dissection is necessary. While a blunt alar retractor is placed to retract the midfacial musculature and the lip, the periosteum of the maxilla is incised and a round-ended Kleinert-Kutz elevator is used for the subperiosteal dissection of the pocket. Subperiosteal dissection should be lateral to the maxillary canine bilaterally to avoid the main branch of the infraorbital nerve. The position of the subperiosteal pocket should be exactly where the surgeon desires to place the implant. The size of the subperiosteal pocket should be larger than the size of the implant. After the pocket has been created, it should be easy to insert the prosthesis, which should accommodate to the malar complex without impinging on the infraorbital nerve. The position of the prosthesis over the most prominent point of the malar complex is manually assessed and visually doublechecked before closure. If a properly sized and positioned pocket is created and a prosthesis of a proper style and size is inserted, no fixation. The prostheses are checked for symmetry and correct position. Symmetry is easily noted by checking that the borders of the prostheses roughly correlate with the borders of the zygomatic arch, lateral orbital rim, and alar base. Hemostasis is obtained with a fiberoptic Aufricht retractor and electrocautery. A thrombin-soaked absorbable gelatin sponge is used. Liberal irrigation with bacitracin (50, 000 units/Liter of normal saline) solution is used. The incision is then closed with several 4-0 chromic vertical mattress sutures.

Prepared By: F. Amalik P. Espinosa III, MD

II. EXTRAORAL APPROACH 1. Subciliary Approach Used when malar augmentation is combined with periorbital cosmetic surgery, especially blepharoplasty. Accurate, visually verifiable positionin of the implants and minimal risk of postoperative infection. Disadvantage: bleeding, fibrosis, eyelid contracture. When combined with subciliary malar augmentation, blepharoplasty should be conservative using skinmuscle flap technique. After hemostasis is obtained, an incision is made in the periosteum at least 5 to 10 mm inferior to the lower orbital rim. Once the bone is reached, a standard subperiosteal dissection is carried out. No fixation is usually required, and if needed, usually signifies inadequate pocket dissection rather an oversized implant. Resection of skin and muscle should be conservative because of the addition traction on the lower eyelid through the volumetric expansion of the cheek. Preauricular Approach Mainly used when malar augmentation is combined with rhytidectomy or composite rhytidectomy Reasonably minimal risk of postoperative malposition. Tedious technique nature of the dissection and the propensity for sensory and motor nerve dysfunction. After the rhytidectomy flap has been raised below the malar complex, the superficial musculoaponeurotic system can be penetrated by blunt transverse dissection in the direction of the facial nerve branches, either medial or lateral to the origin of the zygomaticus.

Once the bone is reached, a standard subperiosteal dissection is carried out.

3.

Transcoronal Approach Used mainly when malar augmentation is combined with subperiosteal rhytidectomy or browlift Chief advantages are also cited for patients who smoke and patients with thin atrophic skin because the tension of the lift is placed deeper on the fascia and not on the skin edges. Chief disadvantage of the technique is the poor quality neck lift achieved by the procedure. Easy to combine with lateral canthopexy and browlift, as well as transcoronal blepharoplasty High propensity for sensory and motor nerve dysfunction.

ADJUNCTIVE TECHNIQUES Buccal Fat Pad (Gaughran, 1957) Deep facial fat responsible for midfacial fullness Heister (1732) Believed that this midfacial fullness was a gland Bichat (1802) Recognized the true fatty nature of the tissue and therefore, the designation fat pad of Bichat is synonymous. Buccal Fat Pad Intimately associated with the muscles, serving as an aid for suckling in the infant and allowing for the smooth, gliding, pistonlike action of the lower jaw against the upper jaw for mastication in the adult. Specialized type of fat termed as syssarcosis, a fat that enhances muscular action Resembles orbital fat Has four extensions: o Buccal, pterygoid, superficial, and deep temporal Body is centrally located, the buccal extension lies superficially within cheek, and the pterygoid and temporal extensions are deep.

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Prepared By: F. Amalik P. Espinosa III, MD

Buccal Extension Most clinically significant portion of the buccal fat pad is also the largest component and most superficial Imparts the cheek fullness (30 to 40%) Below the parotid duct and wraps superficially around the main body on its way to the parotid duct Deep, or lateral, to the main body of the masseter, superficial or medial to the buccinators, and buccopharyngeal fascia. Anterior limit: facial vessels Posterior limit: main body of fat pad. Main Body 25 to 30% of weight begins above the parotid duct and extends along the deep upper portion of the masseter lateral surface of the main body is crossed by large buccal branch of the facial nerve and several smaller zygomatic branches stretches along the posterior border of the maxilla, overlying the buccinators and buccopharyngeal fascia, and along the vestibule of the mouth to the maxillary second molar Posteriorly, it wraps around the maxilla along the ptertygomaxillary fissure, where intimate contact with the second division of the trigeminal nerve and internal maxillary artery is established. Pterygoid Extension Wraps around the coronoid and ramus of the mandible to lie on the lateral surface of the pterygoid. Intimately related to the inferior alveolar bundle and lingual nerve. Temporal Extension A. Deep Temporal Passes beneath the zygomatic arch, separating the temporalis and extends into the temporal fossa adjacent to the greater wing of the sphenoid. Continuous with the main body of the buccal fat pad. B. Superficial Temporal Differs in appearance, different vascular supply, and is anatomically distinct Completely covered by two layers of deep temporal fascia and lies between them from the superior orbital rim to their respective

insertions along the lateral and medial surfaces of the zygomatic arch BUCCAL FAT PAD EXCISION Intraoral approach Buccal extension is rather free and unfixed, whereas the main body of the fat pad us tethered above the parotid duct. If combined with malar augmentation, the incision should be high in the maxillary vestibule, lingual to the parotid duct orifice, beginning above the second molar and extending posteriorly for about 2 cm. Buccopharyngeal fascia and buccinators muscle fibers are easily exposed by blunt dissection with a fine clamp. As external pressure is applied below the zygomatic arch, the herniated fat protrudes. The herniated fat is clamped, excised, and electrocoagulated. Only the fat that can be easily extracted is removed. The opposite side is resected. Closure is done with multiple 4-0 chromic interrupted vertical mattress sutures. Dressings And Post-Operative Care A large protective bulky dressing is worn for 2 to 4 days Perioperative antibiotics are continued for 3 to 5 days Liguid and soft diet until dressings are removed If with buccal lipectomy, place in Jobst compression head and neck garment for 2 to 4 days and then nightly for several weeks.

End

Prepared By: F. Amalik P. Espinosa III, MD