Introduction to the Opportunistic Biplane Facelift

The biplane facelift described in this chapter is based on principles that increase aesthetics and longevity with limited morbidity. Facial aging is most pronounced from changes occurring in the deeper musculofascial plane that result in ptosis of the malar fat pad, jowl region, nasolabial folds, and neck. Precise elevation and rotation of this plane is accomplished using this biplane facelift technique. We call the operation "opportunistic," because there is no set anatomic limit to the deep-plane dissection. Rather, it is based on the concept of elevating tissue to the point where the flap can be easily advanced with the effect of providing adequate lift in the mid- and lower midface regions. Generally, this point is quite obvious. A rather sharp release is effected when sufficient elevation is accomplished, and the surgeon observes a marked lifting effect around the anterior cheek and the corner of the mouth.

Lifting the musculofascial flap anteriorly until adequate release is obtained allows the surgeon to obtain an improved lift with better control of the multivector pull necessary in this deeper plane of musculofascial tissue. We have not had any incidence of periauricular wound margin necrosis since adopting this technique. A natural appearance is achieved as a result of the deep multivector lift, with minimal skin tension after redraping.

The term opportunistic also applies to the concept of recognizing that, in some patients, the musculofascial layer becomes so attenuated as the dissection proceeds anteriorly that the resulting biplane flap would lack sufficient strength to provide adequate pull. In these cases, the surgeon wisely retreats and depends on plication for deeper support.

Tumescent anesthesia and fine cannula lipodissection, combined with electrocautery and laser dissection, all help minimize operative time (which averages 1 2 hours) and postoperative morbidity. Because the primary lift is in the deeper plane, we have essentially eliminated skin excision in the temple and occipital regions. Skin bunching in the mastoid area subsides after a few weeks, resulting in a completely hidden scar within the hair and a decreased incidence of skin injury behind the ear. We depend entirely on the deeper pull for the effectiveness of the lift. Skin excision in front of the ear is very conservative. This has produced much better healing and finer scars because of the total absence of pull on the skin.

We have long abandoned postoperative drains or extensive head wraps and have seen no increase in postoperative hematomas. Our incidence of hematoma requiring surgical drainage was 2% (4 out of the past 200 cases) after biplanar facelifts without the use of drains or dressings, compared with a prior incidence of 4% when dressings had been routinely used. Part of the difference is attributable to the ability to recognize early small hematomas during recovery that can be treated conservatively by milking the flap, thus avoiding large hematomas when dressings are removed 24 hours after surgery. In addition, it appeared to us that hematomas would sometimes occur on removal of the drain and may have actually been caused by abrasion of the drain removal. Avoidance of dressings promotes patient comfort and may help avoid the swelling that can result from the tourniquet effect of compressive dressings.

Submusculofascial dissection has been reported to increase the risk of facial nerve injury; arguments have been made that plicating the SMAS is safer and as effective as the deeper plane techniques. In our experience, no permanent facial nerve injuries have occurred. There is no question that expert knowledge of the facial anatomic planes and neurovascular distribution is a requirement to avoid this complication with any facelifting techniques. Furthermore, our use of operating loops and laser dissection minimizes the risk of facial nerve injury. We expect to see the buccal nerve fibers during the course of dissection overlying the masseter muscle and, in fact, feel more comfortable when they are in view. Frequently, portions of the ramus mandibularis are seen as we begin dissection of the posterior platysma.

SMAS plication facelifts can improve facial aesthetics,18'19 but limited improvement is often seen in the malar and mandibular border due to the inability of this technique to free the restraining fibers (zygomatic and mandibular ligaments) in these regions. The biplane lift breaks these adhesions during the submusculofascial dissection. As mentioned, the "opportunistic" description given to this lift is based on the concept of only dissecting far enough anteriorly to release the flap. Should poor flap quality (thickness or continuity) exist, the procedure can easily be converted to a simple SMAS plication procedure.

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