Keywords revision - facelift - neck lift - secondary facelift - deep plane facelift
The patient requesting revision facelift presents a potentially complex surgical and psychological challenge.[1 ] Contemporary society has become increasingly critical of facial appearance, the explosion of digital photography, online avatars, video conferencing, carefully curated lighting, postproduction editing, photographic filters, and makeup have seen the aesthetically aware public increasingly seek facial plastic surgery to correct all perceived flaws and optimize their facial appearance.[2 ] Recent technical advances, focused expertise in niche facelift practices, and online before and after galleries have rightly set expectations high. Facial plastic surgery and specifically rhytidectomy has a high satisfaction rate leading to previously happy patients requesting secondary rhytidectomy years later for continued natural facial aging.[3 ] However, if prior expectations of primary facelift surgery are not met or there are visible stigmata of surgery, revision surgery is sought by a patient who is not only a more challenging surgical case but might have diminished trust in the process of surgery as a whole. It is common for both secondary and revision facelift patients to present having already tried less invasive nonsurgical treatments such as radiofrequency and ultrasound skin tightening, thread lifting, and/or injectable volumizers and biostimulators.[4 ] These interventions might compound the challenge facing the facial plastic surgeon with tissue scarring, tethering, plane adhesion, and deformity making revision rhytidectomy a more technically demanding complex and riskier procedure.[5 ]
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[8 ] Despite this, satisfaction rates remain high in revision rhytidectomy.[9 ] In this article, the author describes the assessment, management, challenges, and principles of secondary and revision rhytidectomy using a modified extended deep plane approach.
Revision Facelift Assessment and Challenges
Revision Facelift Assessment and Challenges
A wealth of information online has led to an increasingly discerning and educated patient demographic. The patient presenting for revision facelift will often be aware of technical lift failure or specific deformities of tension and vector, equally patients might present requesting revision rhytidectomy after an expertly performed and well-healed outcome that has not met their expectation or specific aesthetic taste. The revision facelift surgeon must be aware of tissue limitations, their own technical ability and mutual aesthetic preferences, previous interventions, and often masked psychosocial aspects of patient dissatisfaction.[10 ]
Patient Assessment
In an increasingly global marketplace, patients will often seek international secondary opinion precluding easy in-person consultation and examination. Detailed knowledge of medical history, previous surgical technique, challenges in previous surgery and/or recovery, and intervening nonsurgical intervention are essential in revision surgical planning. While a thorough history and photographic analysis can be undertaken and comprehensively documented remotely, a detailed physical examination is essential prior to revision rhytidectomy. The face and neck should be methodically examined[11 ] paying attention to glide plane adhesion, contour irregularity, skin and soft tissue laxity and/or tension, skin quality, preauricular skin reserve, and surgically created deformity.
Common Examination Findings
Even in a perfectly performed previous rhytidectomy without skin tension at closure, any tension-based facelift without full ligament release will inevitably lead to tension transfer to the skin incision[12 ]
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[14 ] ([Fig. 1 ]).
Fig. 1 (A ) Hypertrophic, preauricular scar due to skin tension and (B ) hairline step deformity due to poor incision planning.
Preauricular skin tension, reserve, quality, vascularity, and telangiectasia should be assessed.[15 ] Scar atrophy, migration, and hypertrophy, tragal blunting or amputation, hairline disruption,[16 ] ear pole rotation and pixie ear deformity,[17 ] contour irregularity, and altered rhytid direction might suggest inappropriate tension that will need to be released and revectored ([Fig. 2 ]).
Fig. 2 Atrophic scarring and lift failure 2 years after a superficial musculoaponeurotic system (SMAS) minilift and following revision deep plane face and necklift and deep neck reduction.
The midface should be assessed for mobility, smile block,[18 ] volume, and descent.[19 ] Lateral vector superficial musculoaponeurotic system (SMAS) lifts might over time create the juxtaposition of preauricular lateral tension and pendular medial midface descent leading to suborbicularis oculi fat (SOOF) herniation, lagophthalmos, lateral lid bowing and scleral show in the upper midface, and lateral sweep, malar descent, and/or buccal fat pseudojowl herniation in the lower midface.[14 ] All facial nerve movements should be examined for movement and synkinesis.[20 ]
[21 ] The neck should be carefully evaluated for superficial fat loss from liposuction, cryolipolysis, and/or deoxycholic acid injections with adherence of skin to underlying platysma. The platysma is assessed for integrity, banding, strength, and hypertonicity. Cobra neck deformity is a submental concavity from prior central interdigastric fat reduction, with visible paramedian submandibular gland and/or digastric muscle convexity.[15 ]
[22 ]
[23 ] Previous scars and hairline should be examined for temporal tuft amputation or postauricular step.[16 ] Errors of omission are common. The face and neck are one anatomical unit and a facelift should always include a neck lift and vice versa.[24 ] Other body scars should be assessed for healing and a detailed history to exclude collagen connective tissue disorders if poor scarring is the presenting complaint. All findings should be carefully documented with preoperative photography and/or videography if necessary ([Fig. 3 ]).
Fig. 3 Superficial musculoaponeurotic system (SMAS) lift earlobe pole rotation, pixie ear deformity, and atrophic scarring and after revision deep plane face and neck lift.
Previous Interventions
It is almost ubiquitous in the modern paradigm that patients have already sought a nonsurgical alternative to improve their facial appearance. These add a degree of complexity and risk to any revision procedure.[5 ]
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[8 ] While previous surgical scarring is expected it is usually predictable and easily dissected. In the author's experience, energy devices using plasma and ultrasound can create unpredictable dense scarring across several planes complicating tissue dissection and significantly increasing the degree of tissue trauma increasing the risk of poor flap integrity, tissue tearing, and nerve injury. Injectable biostimulators occasionally act like tissue glue fusing glide planes with dense scar. Nonabsorbable thread lifts impede dissection and resist tensionless repositioning of released glide planes. They require removal and are often barbed or entwined in facial nerve branches ([Fig. 4 ]).
Fig. 4 Nonabsorbable barbed monofilament threads under composite deep plane flap entwined in buccal and zygomatic facial nerve branches.
Injectable fillers do not hinder surgical dissection but might increase recovery due to edema and water retention[25 ] ([Fig. 5 ]).
Fig. 5 Hyaluronic acid filler persisting over a decade after injection might prolong surgical edema.
Expectation Management
Patients seeking a secondary rhytidectomy years after their successful primary have trust in the procedure and recovery and have firsthand experience. Conversely, patients seeking a revision facelift due to dissatisfaction present a more complex problem. In both, an open and frank discussion regarding their goals and expectations is key. The former group will by definition have tissue quality a decade older and the latter previously operated scarred tissue. Both are higher complexity and risk compared with primary surgery, but the revision facelift group has also lost trust in the procedure and/or their previous facial plastic surgeon. This should be compassionately addressed with impartiality. These patients might be seeking redress and/or looking for confirmation of assumed previous malpractice. It is always best to encourage them to look forward not backward, remain an impartial advocate, identify the concern, and how it might be addressed.[18 ] The threshold for satisfaction in this group is lower. Realistic expectations should be set, natural asymmetries discussed, a full discussion of heightened risks, no guarantees made, and everything documented meticulously. The author has a low threshold for declining to undertake revision surgery if prior resentment persists and will offer counseling before considering surgery.
Revision Rhytidectomy Principles
Revision Rhytidectomy Principles
The goal of any facelift surgery is a happy patient. Patients are happy when they look naturally rejuvenated without signs of surgery. The best way to achieve this is to restore tension-free anatomy, unrestricted glide planes, and ensure balance and harmony across all facial subunits. The face and neck should always be addressed as one unit. Concomitant brow lift, blepharoplasty, and skin rejuvenation are often required. Deeper tissue contouring and angles can be customized to patient preference. A secondary rhytidectomy requires meticulous identification of issues, their cause, and surgical planning. It is often possible to plan incisions around naturally concealed contours even if previous scar excision is planned. Suboptimal scars are usually due to immediate or delayed skin tension and migrate allowing new trichophytic incisions to be made optimally. Hairline shift or temporal tuft amputation is best addressed secondarily with follicular unit transplantation.[26 ]
The SMAS and platysma are weaker in secondary and revision facelift patients. The facial plastic surgeon should be aware that careful dissection of a thick composite flap is needed to prevent tearing of the weaker thinner SMAS during elevation,[9 ] which is why the author uses a preservation approach to limited skin delamination.[27 ]
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Tension Release and Revector
Tension Release and Revector
Faces and necks age in a pendular fashion. Gravitational inertia causes the skin and soft tissue envelope to descend along the sub-SMAS glide plane. Patients commonly seek revision rhytidectomy when these principles have not been followed. Most signs of facial aging present in the central three-fifths, yet most SMAS level facelifts tighten the lateral fifths with SMAS plication, resection, or imbrication. Between the tightened lateral fifth and central three-fifths sit the retaining ligaments of the face which resist lateral tightening. Over time, this resistance transfers tension to the incision line causing scar migration, atrophy, ear pole shift, and pixie ear deformity. Lack of lift anterior to the retaining ligaments leads to juxtaposition of preauricular tension and midface failure, lateral sweep deformity, and jowl recurrence[29 ] ([Fig. 6 ]).
Fig. 6 Juxtaposition of preauricular tension and central face pendular descent with atrophic migrated scarring and lateral sweep in a patient having undergone superficial musculoaponeurotic system (SMAS) lift and after 6 months deep plane revision rhytidectomy with full ligamentous release and redrape.
Similarly, in the neck insufficient release leads to recurrent platysma banding and/or pseudo-cobra neck deformity due to failure of the submental muscular sling ([Fig. 7 ]).
Fig. 7 Three-dimensional (3D) Vectra (Canfield Scientific) before and after revision deep plane repair of pseudo-cobra neck deformity caused by failure of the submental platysma sling effect without retaining ligament release.
In almost every revision rhytidectomy case in the author's practice, the patient has presented with dissatisfaction due to tension and vector. The goal of revision surgery is to restore natural anatomy by releasing all tension, and repositioning the skin and soft tissue envelope. This is achieved with a modified extended deep plane approach which respects normal anatomy and guide planes with deeper structural tissue contouring where appropriate ([Figs. 8 ] and [9 ]).
Fig. 8 Juxtaposition of preauricular tension and central face pendular descent in a patient 10 years after successful superficial musculoaponeurotic system (SMAS) lift without ligament release and reposition. Six months after secondary deep plane facelift with full ligament release and tension-free redrape. Homogeneity of tension restored across facial fifths.
Fig. 9 Juxtaposition of preauricular superficial skin tension and central face pendular descent causing skin pleating and contour deformity and 6 months after secondary deep plane facelift with full ligament release and tension-free redrape restoring contour homogeneity.
Deep Structural Contouring
Deep Structural Contouring
Deep Neck Reduction
Blunting of the cervicomental angle is rarely due to superficial fat excess and is more commonly due to platysmal laxity with or without deep neck glandular and/or muscular ptosis. The latter can be assessed preoperatively but having the patient apply lingual pressure to their hard palate while seated and palpating the gland, deep fat, and digastric muscles with and without platysma contraction. The creation of dead space in the submandibular triangle and submentum may provide less resistance to central plication and improve lateral lifting in many cases ([Fig. 10 ]).
Fig. 10 Six months after deep plane facelift with deep neck, parotid, and buccal fat reduction.
The revision facelift surgeon must remain judicious however in volumetric reduction to avoid the appearance of excavation. Overresection centrally while attractive supine intraoperatively will lead to cobra neck deformity later while upright and global overresection might lead to a gunshot neck appearance[22 ]
[23 ] ([Fig. 11 ]).
Fig. 11 Overresection of central interdigastric fat might lead to cobra neck deformity.
Buccal Fat Reduction
Buccal fat prominence is best assessed intraoperatively after full release in the deep plane. Only recently as deep plane facelift surgery becomes popularized are surgeons routinely considering the contribution buccal fat makes to an attractive ogee curve in facelifting.[30 ] Ptotic or prominent buccal fat pads might be genetic, or become apparent due to disruption of SMAS integrity. They can be reduced or suspended[31 ] easily under a composite deep plane flap ([Fig. 12 ]).
Fig. 12 The buccal fat pad is easily accessed, reduced, or suspended under a composite deep plane flap.
Parotid Reduction
Where lower facial third slimming is required and/or there is parotid hypertrophy, a superficial parotid lobe reduction can be performed within the mastoid crevasse. Wedge removal provides increased collapsibility of the parotid and provides less resistance to platysmal lifting and inset of the parotid tail into the deep pharyngeal space. It is essential to close the capsule meticulously and inject botulinum toxin into the exposed gland to avoid sialoma in these cases ([Figs. 13 ] and [14 ]).
Fig. 13 Excavation and reduction of superficial parotid lobe via the mastoid crevasse approach.
Fig. 14 Before and 6 months after deep plane facelift with deep neck, parotid, and buccal fat reduction.
Midface Correction/Orbicularis Revectoring
Midface Correction/Orbicularis Revectoring
Prior lateral vector tension with or without ligament release might devolumize the midface and reduce lower lid support.[14 ] The midface dissection can be extended in selective cases with lagophthalmos, lateral lid bowing, postblepharoplasty ectropion, or aging scleral show to incorporate a cuff of orbicularis in the SMAS composite flap by bluntly releasing the outer and inner lamellae of the orbicularis retaining ligament in the suborbicularis space after prezygomatic space entry and zygomatic cutaneous ligament release. Care should be taken to tangentially transect orbicularis for 0.5 to 1 cm and only between 4 and 5 o'clock on the left side and 7 and 8 o'clock on the right side to avoid damage to surrounding facial nerve branches, temporal above and buccal, zygomatic below[32 ] ([Fig. 15 ]).
Fig. 15 Orbicularis retaining ligament is a bilaminar structure that can be released as an extension of the superficial musculoaponeurotic system (SMAS) composite flap to revector transected orbicularis between facial nerve branches.
Finger palpation of the suborbicularis space confirms full release to the arcus and gentle retraction on a pitanguy flap clamp applied to the orbicularis-SMAS cuff confirms capture of the lower lid complex and cranial mobility of the lower lid margin to a more aesthetically pleasing and youthful position, as well as deherniation of the SOOF and softening of the palpebromalar sulcus ([Figs. 16 ] and [17 ]).
Fig. 16 Before and 6 months after revision deep plane facelift with orbicularis revectoring to restore midface and lower lid support following previous lateral vector superficial musculoaponeurotic system (SMAS) lift.
Fig. 17 Before and 6 months after deep plane facelift with orbicularis revectoring. Previous transcutaneous lower blepharoplasty with ectropion and lid retraction. Restoration of attractive lower lid position without secondary lower blepharoplasty.
Skin Preservation Deep Plane Facelift
Skin Preservation Deep Plane Facelift
The preauricular skin quality in secondary and revision rhytidectomy is often poor, thin, and marked with telangiectasia. The SMAS is also weaker and thinner.[9 ] This might be due to older age at time of secondary surgery or tissue integrity change following prior elevation and subsequent scarring. Preoperative measures such as nicotine cessation, hyperbaric oxygen, and lymphatic drainage are useful adjuncts. Tranexamic acid should be avoided in the tumescent solution but is given intravenously.[33 ] Reelevating a wide preauricular skin flap before the deep plane transition anterior to Pitanguy's line, risks further vascular compromise, skin quality detriment, and leaves a temporary dead space for fluid accumulation. For this reason, the author uses a modified deep plane entry incorporating the sailboat modification and limits cervical skin undermining—the preservation deep plane facelift.[27 ]
[28 ] This maximizes the composite area of the flap by reducing the delaminated skin at closure assuming the deep entry line will inset the temporal tuft incision angle ([Figs. 18 ] and [19 ]).
Fig. 18 A modified sailboat modification of the deep plane entry enables composite flap inset into the temporal tuft incision. Areas of skin elevation marked in green (with permission Dr. Alessandro Gualdi).
Fig. 19 Preservation deep plane facelift. (A ) A standard extended deep plane composite flap inset. (B ) Limited skin delamination with the preservation deep plane facelift.
Limiting the amount of skin delamination may decrease ischemic effects on the distal flap including discoloration and telangiectasias and reduces the dead space for fluid accumulation. It also improves volume along the zygomatic arch and lateral flap, lowers the chance of damaging the zygomaticus muscle complex and resulting smile block, and the SMAS is thicker laterally providing easier entry and a better cuff for suspension. The reduced preauricular skin delamination hastens visible recovery ([Fig. 20 ]).
Fig. 20 Preservation deep plane facelift recovery.
Extended Deep Plane Face and Neck Lift Technique
Extended Deep Plane Face and Neck Lift Technique
Deep Neck Reduction
Submental surgery is always performed first. Following submental incision, the supraplatysmal plane is bluntly dissected inferiorly to the top of the thyroid cartilage then laterally to the extent of the Aufricht retractor. The medial platysma are elevated by blunt dissection on their immediate undersurface. The dissection continues toward the lateral hyoid at the level of the lateral fascial sling of the digastric muscles where the submental and submandibular triangle fullness is then evaluated, assessing anterior digastric muscles, submandibular glands, and fatty lymphoid tissue. When lying supine, the lateral compartment in the submandibular triangle may appear much less ptotic than when sitting the patient upright. For this reason, the lateral tissues are reduced first and more judicious with the medial or central tissues. The central submental compartment should always remain slightly fuller than the anterior digastric and lateral triangles to avoid later midline defects such as cobra neck or pseudo-cobra neck deformity. To perform gland reduction, the medial and inferior portions of the gland are delivered from the capsule, and injected with local anesthesia. The gland is then released from the capsule circumferentially until only the stalk from the mylohyoid remains. This area is then transversely transected using needle tip electrocautery for cutting and bipolar electrocautery for ligation of ducts and vessels ([Fig. 21 ]).
Fig. 21 Submandibular gland access. Intracapsular dissection of submandibular gland. Note inferior “vessel of Sullivan” seen in 30% of glands.
Reduction is performed until the inferior gland is at level with the mylohyoid. Risk of bleeding increases with more posterosuperior dissection as the vessel caliber increases.[34 ]
Fullness of the anterior digastric muscles might also be present. Plication of the digastrics is avoided in almost all cases to avoid medialization of the submental contents, although this is a valid option to infill previous midline reduction when needed or temporarily medialize glands to improve access. Anterior digastric reduction is performed by strip excision of the outer half of muscle using bipolar electrocautery and/or scissors. Platysmaplasty is then performed using a classic platysmal plication technique.[35 ] Cadaveric studies have demonstrated that full plication platysmaplasty may limit the extent of vertical lifting in the face.[36 ] This effect is neutralized by limiting plication to submental platysmaplasty alone without infrahyoid extension. To perform the plication, the platysmal edges are approximated in the midline using buried 2/0 vicryl sutures beginning in front of the hyoid advancing toward the incision with a running vertical mattress.
Marking and Skin Elevation
Incisions are made with a 10-blade scalpel around the temporal tuft following the prehelical crease. The incision follows around the earlobe up postauricular sulcus and crosses to the hairline as the mastoid flattens. The posterior limb incision follows the occipital hairline around 2.5 to 3.5 cm in most patients but can be omitted in some. Elevation of skin is performed with a 10-blade scalpel in the subdermal plane leaving hypodermal fat on the reticular dermis followed by scissor dissection and assistant countertension. The post-auricular skin is then elevated and connected to the facial skin dissection around the earlobe. The subcutaneous blunt scissor spreading dissection of the supraplatysmal plane continues to the midline. If a submental procedure was performed first, the two cavities may be connected at this point. In a preservation approach an undissected skin island remains.
Deep Plane Transition
The sailboat line is marked on the SMAS deep plane entry point and incised with a monopolar needle ([Fig. 22 ]).
Fig. 22 Sailboat modification of deep plane transition line.
The deep plane is then entered and elevated beginning at the lateral border of the facial platysma where risk is low.[37 ] Blunt dissection continues anteriorly over the masseter as the mobile glide plane is entered and continues inferiorly into the neck ([Fig. 23 ]).
Fig. 23 Premasseteric space dissection in the deep “glide” plane.
The underside of the platysma is elevated off the tail of the parotid fascia inferior to the mandible and continues to the sternocleidomastoid muscle (SCM) and external jugular vein. The decussation plane of fibers that exist between the lateral platysma over the parotid tail fascia are referred to as the cervical retaining ligaments. Blunt scissor dissection from top-down releases the cervical retaining ligaments off the parotid tail. Great care is taken to avoid cervical facial nerve branch dissection and the small branches to the depressor labii inferioris under the platysma.
Midface Release
The midface dissection is performed next using blunt dissection to enter the sub-SMAS plane on top of the zygomaticus and orbicularis musculature. A supramuscular dissection is performed to allow mobilization of the facial soft tissues without affecting mimetic muscle function. Dissection continues over zygomaticus using blunt vertical scissor spreading or a Trepsat dissector pointing toward the nasal alar base angled 10 degrees deep. Tactile percutaneous feedback helps maintain the proper plane of dissection as the SMAS release continues toward the nasolabial fold inferiorly and nasal bridge medially. At this point, the buccal decussation zone is the only remaining area connecting the sub-SMAS pockets of the neck and midface ([Fig. 24 ]).
Fig. 24 Dissection through zygomatic cutaneous ligaments and buccal decussation zone.
The lateral extent of the zone has been referred to as McGregor's patch or the zygomatic cutaneous ligaments.[38 ] Sharp dissection under vertical countertension palpably releases the reticular fibers. The transverse facial artery perforator exits here and is easily bipolar cauterized. Elevation then continues anteriorly along the line of the parotid duct, through the buccal decussation plane which contains the junctional interweaving fibers of fascial SMAS and platysma, dissection terminates at the anterior extent of the buccal capsule. A small shelf is then made along the sailboat entry line to provide a composite cuff for suspension. The facial flap is then repositioned and cuff fixed to the temporal parotid and tympanoparotid fascia (Lore's fascia).[12 ] Nonabsorbable or absorbable sutures can be used for the deep plane suspension, as long as the sutures are positioned under no tension toward the individual patient's vector of greatest elevation. Confirmation of the greatest vector and position for suspension is achieved with palpatory feedback. The vector of aging for that particular patient is confirmed by passing a suture through the apex of the composite sail pulling the cranial end cranially, the lateral posteriorly with equal tension to lift the midface, jowl, and neck in vector of maximum correction. This demarcates the fixation point and if correctly designed should inset in to the 90-degree perihelical-temporal tuft skin incision leaving minimal skin delaminated ([Fig. 25A, B ]).
Fig. 25 Sailboat flap tensioning and inset. (A ) The vector of aging for the hemiface is confirmed by passing a suture through the apex of the composite sail and (B ) pulling the cranial end cranially, the lateral posteriorly with equal tension to lift the midface, jowl and neck in vector of maximum correction but without significant tension.
Mastoid Crevasse
Once the facial flap has been suspended, the cervical retaining ligament patch is mobilized vertically, posteriorly, and deep with the mastoid crevasse.[39 ] The mastoid crevasse is opened by vertical incision using needle tip monopolar electrocautery along the anterior mastoid line to expose the anterior wall of the mastoid tip. Anteriorly, this dissection frees the parotid tail from the mastoid allowing the parotid and surrounding tissues to be compressed back into the deep pharyngeal space. Superiorly, the conchal bowl can be elevated to allow a more vertical repositioning of the platysmal cervical retaining ligaments, allowing a more substantial correction of the inferior neck and submandibular triangle. Inferiorly, the dissection stops at the SCM to avoid the greater auricular nerve damage. Exposure of the anterior mastoid line allows inset of the platysma into the anterior mastoid rather than onlay over the mastoid ([Fig. 26A–D ]).
Fig. 26 (A ) Incision along the mastoid line reflecting fascia containing the greater auricular nerve forward, (B ) fascial release enables collapse of parotid tail into the pharyngeal space, (C ) condensation of cervical retaining ligaments and platysma fixed deep on anterior mastoid periosteum, and (D ) full closure of capsule up to conchal bowl to prevent sialoma.
This provides a better position of fixation with substantially improved gonial angle depth and vertical platysma movement. It is important to maintain continuity and integrity of the inframandibular platysma, which directly elevates the hyoid and submental contents. This also aids better encapsulation of the parotid gland and tail, slimming the lateral facial fifths, especially in patients with parotid hypertrophy. The divided cervical retaining ligament condensation of the lateral platysma is sutured on the anterior mastoid wall ([Fig. 27 ]).
Fig. 27 The mastoid crevasse. Lateral platysma inset deep on to the anterior mastoid process enables true vertical platysma elevation, inframandibular border depth and definition, and contour creation of the mandibular ramus (with permission Dr. Ben Talei).
Parotid Reduction
If parotid hypertrophy is present, a minor tail of parotid reduction may be performed to reduce the tail of the parotid. The fascia overlying the parotid tail is elevated reflecting the great auricular nerve within the fascia. A wedge of parotid can safely be excavated from underneath the retracted fascia. Parotid excision is limited to the anterior border of the great auricular nerve while avoiding any excision deep to the mastoid tip to avoid any heat dispersion to the facial nerve as it exits the stylomastoid foramen. The fascia should be closed to lessen risk of parotid gland exposure and potential sialoma. If sialoma occurs treatment with a combination of bland diet, anticholinergic patches, botulinum injections,[40 ]
[41 ] serial aspiration,[41 ] suction drainage, or compression with a bolstered gauze and silk net[28 ] provides the compressive surface area to provide sialostasis far better than a net alone.
Closure
There should be no tension on or around the soft tissues of the ear, assuring prevention of pixie ear or tell-tale rotation of the ear. The facial and neck insets and minimal skin delamination prior to closure ([Fig. 28 ]).
Fig. 28 Limited skin delamination at closure. Note sailboat composite flap inset to temporal tuft incision and lateral platysma in mastoid crevasse. Cervical skin undermining extends two finger widths along the inferomandibular border.
Excess skin is trimmed. A tension-free closure at all points helps ensure minimization of scarring. A 7-French round drain may be placed in the neck bilaterally overnight. The suction tubing is mainly used to aid in redistribution of skin and drain off blood-tinged seromatous exudate rather than for prevention of hematoma. Netting sutures are not routinely placed but saved for noncomposite areas of the neck skin delamination, in hypertensive patients at risk, or excessive bleeders and they are removed after 72 hours. A soft headwrap is placed overnight with great care to avoid compression ischemia at the cervicomental angle.
Conclusion
Revision deep plane rhytidectomy is a technically challenging procedure in a patient population who has lost further confidence not only in their appearance but in surgery as well. If the principles discussed in this article are followed and natural anatomy is restored, the facial plastic surgeon has the opportunity to not just restore a patient's confidence in their appearance but their confidence in our specialty as well. It is a technically demanding surgery that might require the advanced techniques discussed but if done well and sufficient time given to preoperative assessment and discussion and clear documented expectations, can be highly rewarding for both patient and surgeon.
