I was pleased to be asked to comment on the article entitled “Modified Composite-Flap Facelift Combined With Finger-Assisted Malar Elevation (FAME): A Cadaver Study” by Cakmak et al.1 In this study the authors examine the integrity of facial nerves after “modified FAME” composite-flap rhytidectomy dissection into 22 cadaver hemifaces. They emphasize the need to thoroughly release the facial retaining ligaments – some of which are intimately associated with facial nerve branches − in order to achieve a more “balanced and harmonious result,” to effectively mobilize the malar fat pad for midface elevation without the need of a separate midface lift, and to avoid lateral sweep phenomena. Having personally found these things to be true and having emphasized it in presentations and writing,2,3 I am happy to see whenever others share and support this concept. In this age of “quick fixes,” fillers, and thread lifts, where the idea of a facelift in general is under public assault, the education of younger surgeons in powerful, natural-appearing, and volumizing composite flap or deep-plane techniques could not be more critical. As a cadaver study the paper has the obvious limitation (which the authors acknowledge) of not being able to assess neuropraxic injuries which are much more common. Even so, the finding of intact nerve branches in all specimens supports the safety of the dissection. The authors describe two modifications to Aston’s original high superficial musculoaponeurotic system (SMAS) with FAME technique.4 The first is that their entry point into the sub-SMAS plane is more inferomedial than the original description so as to avoid injury to the temporal branches innervating the orbicularis oculi muscle (OOM). Since the OOM has been found to have segmental innervation, this may not be as much of a concern.5 However, while the more lateral incision might put these branches to the OOM in jeopardy during dissection, starting the SMAS entry point more inferomedially means that the main temporal branch itself is more vulnerable to injury during flap fixation, particularly in relatively younger patients where the composite may not be able to be advanced superolaterally past Pitanguy’s line (as the authors state they do clinically). Indeed, Ryu and Moon, whose patients were Asian and 50.7 years average in age, reported that their single case of (temporary) temporal branch injury was due to “grabbing periosteum at the mid-zygomatic arch” during a fixation attempt.6 As long as this is recognized and avoided during fixation, the more inferomedial flap origin (with a diagonal incision in the SMAS, as opposed to a vertical one closer to the ear; Figure 1) has the advantage of proximity to the nasolabial fold and hence more power in elevating the cheek. This is the reason I converted from the lateral, right-angled SMAS incision to the diagonal and more medial one about six years ago. (Figure 1A shows the SMAS incision pattern I use and the relevant anatomy, considering the findings of the present authors.) Figure 1. View largeDownload slide (A) Total composite flap (TCF) lift, SMAS incision and deep anatomy relevant to dissection. (This illustration considers the author’s findings with regard to facial nerve branches relative to facial ligaments.) Black dotted line, incision into the SMAS/platysma with back-cuts superiorly and inferiorly. Blue, prezygomatic space (PZS). Purple, subplatysmal space (this space is dissected to the midline). Gray, facial ligaments; from superior to inferior, zygomatic cutaneous (ZCL), four masseteric-cutaneous (MCL), and cervical retaining ligaments. Yellow, facial nerve branches (note the communicating branch anterior to the lower MCLs). Red, facial artery crossing the mandible over the marginal mandibular branch. This is where the marginal branch becomes more superficial. (B) Flap anatomy. Blue dotted line, limits of skin dissection. Black dotted line, incision into the SMAS/platysma. Red shaded area, limits of dissection. Malar fat pad (included in the flap) is shown in yellow. Back-cuts releasing the orbicularis oculi muscle (OOM) superiorly and platysma (PL) inferiorly are shown. The inferolateral OOM is included in the flap. Figure 1. View largeDownload slide (A) Total composite flap (TCF) lift, SMAS incision and deep anatomy relevant to dissection. (This illustration considers the author’s findings with regard to facial nerve branches relative to facial ligaments.) Black dotted line, incision into the SMAS/platysma with back-cuts superiorly and inferiorly. Blue, prezygomatic space (PZS). Purple, subplatysmal space (this space is dissected to the midline). Gray, facial ligaments; from superior to inferior, zygomatic cutaneous (ZCL), four masseteric-cutaneous (MCL), and cervical retaining ligaments. Yellow, facial nerve branches (note the communicating branch anterior to the lower MCLs). Red, facial artery crossing the mandible over the marginal mandibular branch. This is where the marginal branch becomes more superficial. (B) Flap anatomy. Blue dotted line, limits of skin dissection. Black dotted line, incision into the SMAS/platysma. Red shaded area, limits of dissection. Malar fat pad (included in the flap) is shown in yellow. Back-cuts releasing the orbicularis oculi muscle (OOM) superiorly and platysma (PL) inferiorly are shown. The inferolateral OOM is included in the flap. The second modification is that the authors perform the FAME maneuver with the dominant index finger facing the zygoma as opposed to facing away. Exploiting the safety of dissection through the prezygomatic space (PZS) is a very helpful way to safely elevate the malar fat pad. However, the ligamentous attachments deep to the malar fat pad can be strong, particularly in relatively younger patients, and releasing them with a finger is sometimes difficult and traumatic to the tissues. The authors do note that stronger ligaments are released sharply under direct vision. I personally avoid blunt finger dissection in general and have found careful scissor spreading dissection here, with preemptive cauterization of the zygomatic cutaneous vessel at the origin of the zygomaticus minor, to result in less postoperative swelling and bruising. Within the loose areolar premasseteric spaces I use an inverted 15-blade to sweep away the overlying SMAS and have found this to be more precise and atraumatic (Video). Indeed, Ryu and Moon noted prolonged postoperative edema with their blunt finger dissection in the facial spaces.6 Obviously, though, the finger dissection technique if done gently is a safe and time-honored one that perhaps makes this procedure more reproducible. The authors’ supplementary operative video shows the dissection crossing the mandible as far anterior as the facial artery, where the marginal mandibular branch becomes superficial. The paper does not have a description of how this branch is specifically protected. I have found that when the masseteric fascia is followed downward, visualizing buccal branches deep to it, the marginal mandibular branch is often seen next and can be traced distally to ensure it is protected as dissection courses over the mandible. Here again I find gentle scissor-spreading dissection preferable to blunt finger dissection: I would rather see the nerve than push tissues away from where it should be found. Moving into the neck, the authors tellingly describe a preplatysmal neck dissection as “standard.” They do release the anchoring ligaments between the sternocleidomastoid and platysma, but do not extend the subplatysmal dissection into the neck medially since this area “lacks collagenous attachments.” However, having routinely done this subplatysmal (Skoog composite flap) dissection to the midline, I have found that while the platysma is relatively mobile, there are often fairly strong collagenous attachments whose release is necessary for adequate elevation and redraping of the platysma. The technique I reported in this journal of “total composite flap (TCF)” lift requires this since I do not undermine neck skin from the lateral approach (see Figure 1 with the subplatysmal space in purple).1 Residual neck laxity was Hamra’s original reason for abandoning the Skoog neck flap.7 Along with Mustoe, Jacono, and others, though, I have personally found the opposite, and more importantly have found that wide composite-flap subplatysmal release in the neck yields a more smooth, full, and durable neck and jawline with a lower incidence of visible lumps and irregularities in the neck (Figure 2).8,9 This reflects the same volumizing advantage a composite flap has in the face, since the thicker flap is elevated over the mandible. Also, the neck composite flap better suspends ptotic and enlarged submandibular glands, thereby reducing or obviating the need to resect them. Figure 2. View largeDownload slide (A) Preoperative and (B) 20-month postoperative lateral view of a 54-year-old man who underwent a total composite flap (TCF) lift showing the smooth and full jawline that results from extending the composite flap dissection into the midline of the neck. I have found this dissection to be more free of irregularities such as lumps and bands as opposed to preplastysmal dissection, and equally or more durable as demonstrated in this relatively long-term postoperative photograph. This patient has inflammation anterior to the helix from laser hair removal which is sometimes necessary with the tragal crest incision. Figure 2. View largeDownload slide (A) Preoperative and (B) 20-month postoperative lateral view of a 54-year-old man who underwent a total composite flap (TCF) lift showing the smooth and full jawline that results from extending the composite flap dissection into the midline of the neck. I have found this dissection to be more free of irregularities such as lumps and bands as opposed to preplastysmal dissection, and equally or more durable as demonstrated in this relatively long-term postoperative photograph. This patient has inflammation anterior to the helix from laser hair removal which is sometimes necessary with the tragal crest incision. As depicted in Figure 1B, the subplatysmal space is analogous to the PZS in its relative ease of opening and safety of dissection. Cervical branches to the platysma should be isolated and preserved, particularly during dissection in patients (approximately 2% of the population, according to Rubin)10 who exhibit a strong platysmal component in their “full-denture smile.” As more surgeons exploit this tissue plane, the relative advantages of it vs wide skin dissection should provide very interesting discussion. The results section includes analysis of the relative locations of the facial ligaments as well as their relative strength. I found this section with its measurements to be very useful, particularly the authors’ Table 1 which compares the study with six previous cadaveric studies. Their findings regarding the nature of the ligaments echoed my own experience, with the more posterior zygomatic cutaneous (ZCL) and more superior masseteric-cutaneous (MCL) being more dense and likely to require sharp dissection. This is a reflection of facial function, since the more anterio-inferior face has to be more mobile for facial expression and mastication. One caveat relating to cadaver studies is that precise distances and even positions of nerves relative to other structures can vary between cadaver specimens and live patients. An opportunity for future study would be similar measurements taken intraoperatively, and a comparison to the measurements here quite interesting. Figure 1 shows my interpretation of this study’s findings as it relates to composite-flap dissection. Note in Figure 1A the communicating branch between the lower zygomatic and buccal branches, which falls just distal to the lower MCL. This type of communicating branch (which can also be found within zygomatic or buccal branches themselves) tends to arc superficially as it is stretched during dissection and in some cases can help with orientation as it is gently teased away from the overlying SMAS (Supplemental Video). On a point of terminology, the authors appropriately point out that, while Jacono and others have described a “PZS” dissection that is above the OOM, Aston’s original description of the FAME maneuver was in the suborbicularis oculi plane, which equates to a PZS dissection since the roof of the PZS is the OOM.11 Incorporation of the OOM into the flap is what distinguishes a “composite flap” from a “deep-plane” dissection. Further, the authors note both in the Discussion and Conclusion sections that this composite flap can be dissected with the ZCL released under direct vision via the PZS leaving the MFP attached to the skin without a transblepharoplasty approach. I agree with this and believe it is important since (as the authors also note) it therefore avoids violation of the middle lamella and its attendant potential lower eyelid complications. In summary, I congratulate the authors on a detailed and well-documented paper that contains useful, precisely described information to the surgeon interested in composite facelift flap techniques. The knowledge of - and feel for - facial anatomy required to do the procedure well are only outweighed by the beauty of its potential results. Video. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy076 Video. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy076 Close Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Cakmak O , Ozucer B , Aktekin M , Ozkurt FE , Al-Salman R , Emre IE . Modified composite-flap facelift combined with finger-assisted malar elevation (FAME): a cadaver study . Aesthet Surg J . 2018 . doi: 10.1093/asj/sjy062 . [Epub ahead of print] 2. Mani M . The deep-plane transition zone: a critical consideration of SMAS lifting in the midface . Presented at: The Annual Meeting of the American Society for Aesthetic Plastic Surgery , Vancouver, British Columbia ; May 5, 2012 . 3. Mani M . Total composite flap facelift and the deep-plane transition zone: a critical consideration in SMAS-release midface lifting . Aesthet Surg J . 2016 ; 36 ( 5 ): 533 - 545 . Google Scholar Crossref Search ADS PubMed 4. Aston SJ . The FAME procedure . Presented at: the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons , Dallas, TX ; November 9–13, 1996 . 5. McCord CD , Walrath JD , Nahai F . Concepts in eyelid biomechanics with clinical implications . Aesthet Surg J . 2013 ; 33 ( 2 ): 209 - 221 . Google Scholar Crossref Search ADS PubMed 6. Ryu MH , Moon VA . High superficial musculoaponeurotic system facelift with finger-assisted facial spaces dissection for Asian patients . Aesthet Surg J . 2015 ; 35 ( 1 ): 1 - 8 . Google Scholar Crossref Search ADS PubMed 7. Hamra ST . The deep-plane rhytidectomy . Plast Reconstr Surg . 1990 ; 86 ( 1 ): 53 - 61 ; discussion 62. Google Scholar Crossref Search ADS PubMed 8. Jacono AA , Talei B . Vertical neck lifting . Facial Plast Surg Clin North Am . 2014 ; 22 ( 2 ): 285 - 316 . Google Scholar Crossref Search ADS PubMed 9. Mustoe TA , Rawlani V , Zimmerman H . Modified deep plane rhytidectomy with a lateral approach to the neck: an alternative to submental incision and dissection . Plast Reconstr Surg . 2011 ; 127 ( 1 ): 357 - 370 . Google Scholar Crossref Search ADS PubMed 10. Rubin LR . The anatomy of a smile: its importance in the treatment of facial paralysis . Plast Reconstr Surg . 1974 ; 53 ( 4 ): 384 - 387 . Google Scholar Crossref Search ADS PubMed 11. Aston SJ , Walden JL . Facelift with SMAS techniques and FAME . In: Aston SJ , Steinbrech DS , Walden JL , eds. Aesthetic Plastic Surgery . London : Saunders Elsevier ; 2009 : 73 - 86 . © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: firstname.lastname@example.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Aesthetic Surgery Journal – Oxford University Press
Published: Nov 12, 2018
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