Rhytidolipoplasty: Improvement by Tunnelization Through New Concepts of Abdominolipoplasty

Abstract

Introduction

Rhytidoplasty is a very important field in plastic surgery since everybody will need and consequently some people may look for some improvement on the facial contour. For this reason, it is one of the most frequent operations and the whole population potentially may think about self-image. The aim of the operation is not to provide eternal youth but to improve the physical appearance to an image which is more pleasant and better accepted. Vanity is a necessity for each person to value himself/herself as an individual but not as a product of social competition.

Since my publications concerning anatomical studies and research which result in new concepts for abdominoplasty, it was evident that those surgical principles would be employed to improve rhytidoplasty procedures avoiding complications. In fact, skin slough and necrosis, infection, nerve injuries, and other peri- and postoperative problems were related to traumatic operations. Therefore, similar procedure of basic fundaments with preservation of perforator vessels due to the combination of liposuction with minimal cutaneous undermining was useful also in facial rejuvenation.

Technique

The operation may be performed under general anesthesia or with local anesthesia combined with intravenous sedation both under the care of an anesthesiologist. Local infiltration is a mandatory step even when the procedure is carried out under general anesthesia. Initially, one side of the face and neck following the sequential steps: local infiltration, liposuction, tunnelization following cutaneous incisions with reduced area of cutaneous undermining, and suture of the SMAS if it is necessary, and the final step traction of the cutaneous facial and neck flap is pulled, resected, and sutured.

Local Infiltration, Tunnelization, and Liposuction

Two types of local infiltrations must be done: (1) local anesthesia and (2) hyperinfiltration or tumescent infiltration with 40 ml 2 % lidocaine, 1 mL (1:1000) epinephrine, and 160 ml water, giving a total volume of 201 ml. Afterward, hyperinfiltration or tumescent one is done with serum underneath the skin all over of one side of the face and neck using a special to separate the skin from the subcutaneous fatty layers and soft deeper tissues as well. The operation must start immediately afterward by subcutaneous tunnelization using a very thin cannula, which preserves all anatomical structures below the cutaneous flap. Some cutaneous incisions of 0.5 cm in length are done just to introduce instrument: on temporal region, on preauricular region, on the earlobe and another on the posterior sulcus of the ear, and on the submental region. Back and forth movements are done just below the overlying skin all over the face and neck. Liposuction is performed in selected patients. At the end, the thickness of the skin flap is appropriate with all anatomical structures which provide normal vascularization avoiding any damage postoperatively.

Afterward, a nontraumatic surgical instrument with different width I have developed for this purpose is similar to a cannula but without openers. The first one is thinner and then progressively a wider one is employed until the widest one always doing back and forth movements. All these procedures are done in a closed-pocket system since the cutaneous incisions have not yet been performed. In addition, using extensive supraplatysmal tunnelization undermining communicates in the midline, from one side to the other, which makes the skin flap slide over the muscle. This is the fundamental difference between my procedure and the traditional techniques using scissors for cutaneous undermining which cut all vessels from the depth to the skin flap with abundant bleeding during and after.

After tunnelization, cutaneous incisions with a knife are done. Although there is no bleeding during the operation, careful hemostasis must be done. SMAS treatment may be performed according to the surgical planning by pulling with minimal undermining.

In fact, performing only the lateral suture with suspension of the platysma improves the whole area on each side of the neck with a natural and smooth result.

The next step of the operation is done by pulling the cutaneous flap posteriorly and superiorly following the direction and traction of the cutaneous facial and neck. Once the cutaneous flap has been pulled, the redundant skin is excised with a knife all around the ear. The amount of traction which is applied depends on the state of the skin and the nature and degree of correction required.

After performing completely the operation described on one side, the same procedure is carried out on the other side of the face and neck.

Afterward, a gentle dressing is done on the area of the head and neck, leaving the eyes, mouth, and nostrils free. I do not use any kind of drain, since there is no bleeding during and after face-lifting procedure. The bandage is changed on the day after the operation and a new one is placed over the face and neck, and this is completely removed 2 days later.