Invited commentary

Invited commentary 4. Dubin B, Jackson IT, Halim A, Triplett WW, Ferreira M (1989) could cause injury to this structure and should be avoid- Anatomy of the buccal fat pad and its clinical significance. ed. Plast Reconstr Surg 83:257 The position of the next incisions, in the earlobe re- 5. Stuzin JM, Wagstrom L, Kawamoto HK, Baker TJ, Wolfe SA gion, are variable but generally involve a lower temporal (1990) The anatomy and clinical applications of the buccal fat incision directly superior to the pinna and a small (3 pad. Plast Reconstr Surg 85:29 mm) incision behind the earlobe. The surgeon pretunnels 6. Duffy MJ, Friedland JA (1994) The superficial plane rhytidec- tomy revisited. Plast Reconstr Surg 93:1392 the cheek, mental region and the lateral surface of the neck through these incisions. After pretunneling with a small blunt liposuction cannula, skin undermining is completed by scissor dissection in the supra-SMAS plane, which is safe because the main branches of the fa- cial nerve are located deep to the SMAS plante (Fig. 8). The dissection is performed at a deeper level in the area G.F. Maillard of the malar fat pad, this structure can be repositioned to improve the midface appearance [3]. This technique 17. Avenue de la D61e, CH-1005 Lausanne, Switzerland maintains the fat pad attachment to the overlying skin and the tension on the skin elevates the cheek. The buc- cal fat pad is clinically significant and contributes to The endo-assisted face-lift (EAFL) is now a new way to cheek contour [4, 5]. Because of its intimate relationship perform facial rejuvenation. I participated actively, as a to the facial vessels, parotid duct, and branches of the fa- member of the faculty, in the three first Deep Plane cial nerve the fat should be gently teased and removed. Face-Lift Symposia in Baltimore (1992, 1993, and If the endoscopic procedure is chosen, the fat pad should 1994), very well organized by Oscar Ramirez from be approached from the anterior border of the masseter Johns Hopkins Faculty of Medicine. This was three his- with a gentle spreading motion. This supra-SMAS dis- toric opportunities to learn and practice anatomical dis- section allows the surgeon to individualize the contour- section at the Maryland University Institute of Anatomy. ing needs in these areas [6]. The second year, Nicanor Isse from California was invit- The next step in the procedure begins with the short ed to present his first steps in the EAFL. Impressed by horizontal incision in the submental area through which this new approach, Oscar Ramirez jumped very quickly the surgeon may suction the subcutaneous fat from the on the boat. He rapidly mastered the new technology and submental and cervical regions. Fatty tissue localized gave the proof of the quality of his results at the third between the anterior edges of the platysma muscle is meeting, one year later. sharply excised with the scissors (Fig. 9). These edges of Under commercial pressure from the instrument and the platysma are sutured together in the midline for sev- video camera manufacturers and also under the impres- eral centimetres (Fig. 10). sion that a new dimension in face-lift surgery was begin- The endoscopically-assisted SMAS procedure is per- ning, some brilliant surgeons like Rollin Daniel in Cali- formed through the lower temporal incisions. The fornia, Foad Nahai in Atlanta, Antonio Fuente del Cam- SMAS system visible in the cadaveric dissection (Fig. po in Mexico, Daniel Marchac and Pierre De-Taddeo in 11), is pulled superiorly and posteriorly by an anchoring Paris, Henry Delmare in Antibes, Frank Trepsat in Lyon, absorbable suture placed between the lateral border of and Barry Jones in London also switched progressively the platysma muscle and the mastoid or sternocleido- to the EAFL. mastoid fascia (Fig. 12). Many others, like myself, even although they have With the development of endoscopic techniques, mastered the anatomy and the instrumentation, are not knowledge of the facial anatomy becomes even more yet completely convinced; although some results in good important. The magnification, clarity and reduced intra- hands are satisfactory, I have been upset by seeing poor operative bleeding permits better visualization and more results. I feel more comfortable using the open technique precise correction. The knowledge and familiarity of fa- if I really want a sure lift effect. In the preoperative dis- cial anatomy allows the endoscopic facial surgeon to cussion with the patient, I make both proposals: open or perform extensive dissections with confidence and en- endo-lift. If the patient is reluctant to have the big coro- sures that the safety of important nerves and vessels will nal scar, then I feel that he or she should have an endo- not be compromised. lift. Thus, my feeling is that there are, in fact, two differ~ ent ways and also different results: the endo is probably better for more minor ptosis. Thus, the problem today is References mainly one of indications. Because the subject is still very young and not very 1. Bostwick J, Eaves F, Nahai F (1994) Endoscopic plastic sur- well accepted by everyone, I think that a real "basic" pa- gery. Quality Medical Publishing, St Louis per on the anatomy merits publication. These open dis- 2. Mitz V, Peyronie M (1976) The superficial musculo-aponeurot- sections are presented with an "endo-thinking" and this ic system (SMAS) in the parotid and cheek area. Plast Reconstr concept can be very useful. Surg 58:80 3. Owsley JQ (1993) Lifting the malar fat pad for correction of We can be grateful to Doctor Shilov and associates prominent nasolabial fold. Plast Reconstr Surg 91:463 for the high quality of the illustrations. European Journal of Plastic Surgery Springer Journals

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Copyright © 1997 by Springer-Verlag
Medicine & Public Health; Plastic Surgery
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