Rhytidectomy with a Blepharoplasty and Rhinoplasty – Surgery&Rehabilitation Example

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"Rhytidectomy with a Blepharoplasty and Rhinoplasty" is an impressive example of a paper on surgery and rehabilitation. A rhytidectomy is common plastic surgery and is suggested to be the sixth most common cosmetic surgical procedure in the United States. A rhytidectomy, or facelift, is the surgical removal of wrinkles and usually requires the removal of excess facial skin (Nahai, 2005). In many cases, a rhytidectomy can be performed in the same session as other cosmetic surgeries, commonly a blepharoplasty and a rhinoplasty. These three elements all have interlinking anatomies and physiologies and often patients will request alteration of the facial skin, eyelids and nasal area (Nahai, 2005).

Blepharoplasty refers to the surgical alteration of the eyelid and again relies mainly on the removal of excess skin in this area (Nahai, 2005). Rhinoplasty is another common operation and involves the reshaping of the nose to restore form and function and to aesthetically refine the nasal area (Nahai, 2005). Related Anatomy & Physiology The face has very complex anatomy that needs to be carefully considered in the process of surgeries such as rhytidectomy, blepharoplasty and rhinoplasty.

The face is considered a sense organ complex, two of which may be directly affected by the procedures outlined above (eyes and nose). The areas that most benefit from the facelift procedure are the jowl, submentum, anterior neck and the nasolabial fold (Barton Jr & Gyimesi, 1997). When a rhytidectomy is combined with a blepharoplasty and rhinoplasty, the eyelid and nasal area are also included. A common area affected by ageing that can be improved with a rhytidectomy is the jowl. Many problems with the jowl stem from the platysma, a thin, paired muscle stretching from the lower end of the cheek to the second rib.

The platysma has fused anterior borders which have a strong attachment to the thyroid cartilage. It is this that defines the angle of the mandible. Laxity in this muscle, especially in the anterior neck region, can cause the jowls to have a drooping appearance (Yee, Volshteyn & Puckett, 2003). The superficial muscular aponeurotic system (SMAS) is a fibromuscular layer which extends from the malar region and becomes continuous with the galea from the superior aspect and is becomes continuous with the platysma inferiorly.

In the temporal region, the SMAS has two layers under which lie the superficial temporal artery and a frontal branch of the facial nerve (Yee, Volshteyn & Puckett, 2003). Additionally, “ The SMAS invests the superficial mimetic muscles, including the platysma muscle, orbicularis oculi muscle, occipitofrontalis muscle, zygomatici muscles, and levator labii superioris muscle” (de la Torre & Narayan, 2011). The malar fat pad is a triangular area of the face which is typically found over the zygomatic bone in youth. It covers the orbital rim and the orbital part of the orbicularis oculi (de la Torre & Narayan, 2011).

The malar fat pad is located beneath the skin, like the SMAS, but has very little structural attachment to this area. With age, this malar fat pad generally tends to move downwards over the SMAS (de la Torre & Narayan, 2011). This causes a sagging appearance on the skin because the malar fat pad has a strong association with the skin, but very little structural attachment to the SMAS, allowing it to slide over the SMAS and become a problem area (Yee, Volshteyn & Puckett, 2003). The eyelid is formed of skin, subcutaneous tissue, orbicularis oculi, orbital septum and palpebral conjunctiva.

Additionally, the eyelid is home to the meibomian glands, which secrete the lipid found in tear film (de la Torre & Narayan, 2011). The upper eyelid has a sensory nerve supply from the infratrochlear, supratrochlear, supraorbital and the lacrimal nerves (Baker et al, 1979), all of which stem from the ophthalmic branch of the trigeminal nerve. In the lower eyelid, the nerve supply comes from the infratrochlear and infraorbital nerves (Baker et al, 1979).

The eyelid has two main muscles, the levator and Mü ller muscle (Stuzin et al, 1992), laxity of which can cause eyelid drooping which may cause the patient to seek corrective surgeries. Diagnosis The diagnosis for a rhytidectomy with blepharoplasty and rhinoplasty relates to the above aspects of anatomy and physiology. For a diagnosis as to whether a rhytidectomy with blepharoplasty and rhinoplasty is required, a full examination of the facial structure is required. It is important to note the position of the malar fat pad, as this is one of the most common reasons for excess facial skin and an aged appearance (de la Torre & Narayan, 2011).

If the malar fat pad has slipped from the youthful position above the zygomatic arch, the patient can be considered for a rhytidectomy. Additionally, the patient may complain of problems with the jowl and thus it is important to note if there is laxity in the platysma muscle (Yee, Volshteyn & Puckett, 2003). Pre-Post-Operative Activity Pre-operation, it is important that the patient refrains from taking aspirin, as its blood-thinning mechanisms can cause problems during the surgery.

Additionally, the patient should be advised to refrain from smoking, as this reduces vascularity and circulation within the body (Nahai, 2005). This could cause problems in the operating room and also increase healing time as the flow of oxygen to the affected areas is reduced. Patients should also be advised to buy anything that may be needed for healing, such as anti-bacterial soap to prevent Staphylococcus or other surface infection (Yee, Volshteyn & Puckett, 2003). Post-operation, it is requested for rhytidectomy, blepharoplasty and rhinoplasty that ice be available at all times to help prevent swelling.

This is particularly important for facial surgery, even when bandages have been applied to the area (Nahai, 2005). Refraining from smoking is also important, as has been previously mentioned. It is also important to take the pain medication prescribed as told and to not use any other medications that may have contra-indications with these medications (Nahai, 2005). The patient should also keep the head elevated to hasten the healing process.                       Surgical Procedure This surgery is generally undertaken when the patient is under general anaesthesia, and all three areas can be undertaken under the same anaesthesia session.

The most common method of rhytidectomy is the SMAS lift. The incision generally begins at the temporal lobe, extending above the auricle into the hair, and runs around 1-2cm above the eyebrow level (de la Torre & Narayan, 2011). From here, the incision follows the preauricular crease inferiorly. It then curves around the earlobe, generally leaving 2mm of facial skin adjacent to the earlobe (de la Torre & Narayan, 2011).

Any other incisions depend on the style of rhinoplasty given to the patient (de la Torre & Narayan, 2011). Generally, the incisions on the eyelid wait until a later stage in the surgery to help prevent sagging (de la Torre & Narayan, 2011). The flap elevation from this incision generally begins from the peri-auricular area. A ‘ subcutaneous plane is used in all areas except above the zygoma. In this area, a subfollicular plane is necessary to avoid the superficially located frontal branch’ (de la Torre & Narayan, 2011). The flap elevation then extends around to the ear area, where the subcutaneous tissues are most adherent (Yee, Volshteyn & Puckett, 2003).

When the flap is completely elevated, the SMAS is suspended with plication or imbrication. This method leaves a skin excess which will require trimming. This may leave a scar unless pains are taken to ensure that there is no tension on the skin closure. After stitches have been placed along the incision line, dressings should be applied along the hairline, past the ear and under the jowl to ensure that the entire incision line is completely covered by bandages (de la Torre & Narayan, 2011).

The patient can then begin to recover from the general anaesthetic.

References

Baker, D.C., Conley, J. & others, 1979. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plastic and reconstructive surgery, 64(6), p.781.

Barton Jr, F.E. & Gyimesi, I.M., 1997. Anatomy of the nasolabial fold. Plastic and reconstructive surgery, 100(5), p.1276.

Nahai, F., 2005. The art of aesthetic surgery: principles & techniques, Quality Medical Pub.

Stuzin, J.M. et al., 1992. The relationship of the superficial and deep facial fascias: Relevance to rhytidectomy and aging. Plast Reconstr Surg, 89(3), pp.441–449.

de la Torre, J. & Narayan, D., 2011. Facelift Anatomy. Available at: http://emedicine.medscape.com/article/1294682-overview [Accessed January 6, 2012].

Yee, G.J., Volshteyn, B. & Puckett, C.L., 2003. Intraoperative tissue expansion in rhytidectomy revisited. Plastic and Reconstructive Surgery, 111(1), pp.432-436; discussion 437-440.

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