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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz:
Welcome back to the channel, everyone. I hope you enjoyed today's video. It's
very interesting. This is a facelift and neck lift. The procedure involves
making an incision from the temple, either inside the ear or outside the ear,
here around the earlobe, and back, so that I can gain access to the soft
tissues of the face, re-sculpt them, elevate, then re-drape and elevate the
skin. The same thing in the neck, and we'll see the direction of pull going up
and back when we get finished.
I hope you enjoyed this video. It's very
surgical, so if you have any questions about this surgery, or indications, or
post-op care, or all that, please leave them in the comments below, and I'll do
my best to get them answered as soon as possible. Today we're going to do a
face and neck lift and also take a little extra. And we have a very pretty
woman, and over time, she's accumulated fat here in the jowls and in the neck
here, and she's lost a little bit of the fullness in her cheeks. And when we
lose fat in the lower eyelids, what happens is we get this tear trough right
here, this depression where when we're younger, we don't see the border or the
boundary between the eyelid skin and the cheek skin, but as we age, because we
lose fat here, we see the difference between the cheek below and the eyelid
above, and that trough is called the tear trough. So we're going to remove some
of the excess fat there. We're going to remove some of this excess skin without
making it too tight, and then on the face, we're going to remove some of the
excess fat here in the parentheses, in these jowls, the excess fat in the neck,
lift that tissue underneath, and then lift the skin and do that without
changing the basic facial features so that she looks like her, which is a very
pretty woman but a little refreshed from the aging changes. So, stick around,
and we'll show you how we do that.
What we're doing now is putting in tumescent
solution into the face because we're going to thin out this fat initially with
liposuction to minimize the trauma and also this will help dissect the area of
the face we need so that so that we can do the face lift and the neck lift with
minimal bleeding. So, this solution consists of a drug that helps the swelling
and bruising to go away faster.
So, when we mark the eyes here, we want to
notice where is the tarsal fold, and that's going to be right here. You can see
that's where that eyelid folds. There's a little plate in the upper eyelid made
out of cartilage, and this angle we want it to follow the curve of the lower
eyelid, and then we'll come up and over, sort of a crescent shape, so that when
we remove this skin, it becomes like that, and we want to take just enough that
it removes that excess skin but not so much that she has trouble closing her
eyelid, and I know from looking at her before that we're going to need to take
a little bit extra from this side because she's got a little bit more redundant
upper eyelid skin on this side.
Could we have a paper cup in that way?
This fat is a yellower color than the fat
medially. So, there's what that looks like.
Why is it different? It's got different
chemistry. It's got different mitochondria. And the lipid is a little
different.
And it's going to create, if I did this
properly, a little pexy which will lift the brow up. So that will elevate the
brow a little bit if she has a very heavy brow, especially on the opposite
side. Just with a little pressure on the globe, that fat pad, when we find it,
it will come out readily. And it's going this way, and it's going this way. So
if I dissect it carefully, each arm, I can take it out without opening up
everything. Although it is possible to open everything, the septum all the way
across here is usually not necessary. Take a minute to appreciate how different
this fat is from this fat, even though they're very close together and they're
really serving the same purpose, which is to pad the globe within the bony eye
socket so it's cushioned.
So, what we're doing now is reducing the fat
in the neck. Here you can see the fat.
So, if you want to have a look here, over on
this side, the jawline developing here, as opposed to the side that I haven't
done, on the patient's left side here, you see how this is all still very puffy
and full, versus this side that I have created a better jawline for, simply by
removing the fat from below the jawline and from this jowl area here. So, she
still has the jowl, she still has this very full area of the neck on the side
that I haven't done yet. So, as I remove this fat, we'll see the same nice
jawline develop that we did over here. We'll see it over on the opposite right
side. So, here you can see the fat that is coming out, and that's all fat mixed
with a little of the fluid that we injected, coming out from the jawline area
here. So, this vessel that I just tied off, a branch of, you can see it here
coming up, is the superficial temporal vein. And it's called that because it's
superficial; it's in the temporal area, and it's a vein. And with every vein,
there's going to be a blood-hining artery, and in this case, the artery is
anterior, toward the face. And we're dissecting this over this little cartilage
in front of the ear called the tragus. So, as we dissect, obviously, we want to
be aware of the anatomy, and the anatomy in the pre-auricular area is going to
be like everywhere, a layered situation. And so, we have the skin, we have the
subcutaneous tissue. Below the subcutaneous tissue, we have fibroadipose tissue
that is a condensation of connective tissue with adipose tissue, or fibro-fatty.
And that condensation is part of a whole system that you can think of as a, if
you think about taking a giant sock and pulling it over the whole head and neck
area, that layer is in some places muscle, and in some places, fibro-fatty
tissue. Here in the temple, it's this layer that contains this big blood
vessel, this fibro-fatty layer that we call the superficial muscular, or sorry,
superficial temporal fascia, and that contains these two big blood vessels, the
vein and the artery, that you can't see the artery. And that can be used as a
flap, and then in the forehead, it's the frontalis muscle. Back here in the
scalp, it's what's called the gallia, named after Dr. Galen, a famous Roman
physician. And in the front of the ear here, it's a fibro-fatty layer called
the SMAS, or superficial muscular aponeurotic system. In the neck, it's the
platysma, and in the back of the neck, it becomes the occipitalis muscle. So,
it's all part of one layer system, but it's expressed in different ways in
different places. Some places, it's just fibro-fatty, some places, it's muscle.
But as long as you understand what layer you're at and where you are, then you
can predict what you should be finding, because certain things are above that
layer, certain things are on that layer, certain things are going to be
underneath that layer. So, it's helpful in keeping ourselves oriented
anatomically as we go along to understand those basic concepts. And if you're a
little confused, don't worry about it. If you just think of things in a layered
fashion as you approach anatomy, it's really not as difficult as you think.
Everything is named very logically, and the organization anatomically is not
random at all. It actually makes a lot of sense and follows certain patterns.
So, let's do a little anatomy review. There are basically two kinds of
earlobes: one earlobe is attached, and the other type of earlobe is not
attached. So, an earlobe that hangs is unattached, and it's something that is
genetically determined. The attached earlobe is an autosomal recessive trait.
In other words, you've got to have the detached earlobe gene on both of your
maternal and paternal chromosomes. Perfect. Perfect. This side we've done, and
you can see she has a better jawline here. She's a little puffy, but there's no
hematoma or fluid collection, and the cheek is elevated here. On this side, we
can see more of the jawline. So, on this side, we've taken out a lot of the
excess fat, but the face still needs to be lifted so that it matches the other
side. And that's what we'll concentrate on doing in this next part of the
operation.
So, one little technical part here is that the
facelift scissor has a blade here on the inside, but it also has a blade on the
outside. You can see how this is, of this blade, there's a dull blade here on
the outside of the scissor. So, when I spread, it cuts a little bit. And if I
spread up and down like this, instead of like this, there's less chance of me
causing an injury to an important structure that's running in this direction,
which would be the facial nerve or the salivary gland duct. Of course, both of
those structures are significantly deeper than where we are right now, but we
always want to be prudent in our dissection. I can track where my scissor is at
just by this hand palpating. And Jaime is watching for evidence that I may be
deeper than where I think I am. And he's looking for stimulation of the facial
nerve, which would be a sign that I'm too deep. And he's a good tech, so he's
constantly assessing where I am and keeping up with what I'm doing and also
double-checking everything I'm doing so that if he feels like I'm not aware of
something or I'm making a surgical error, he's going to tell me because he's
not afraid to point out a potential problem. It's always appreciated. Let's
take a look at the facelift flap now. So, this is the typical facelift
incision. The other way to go is to go across the sideburn area here instead of
up into the hairline. And then the other way to go back here is instead of
going into the hairline, go along the hairline at the nape of the neck. And
we've undermined into the cheek, well into the cheek, so that this fibro-fatty
tissue can be elevated.
We've undermined well into the neck so that we
can de-fat that and so that as we do our pull, our pull is even and we're not
creating folds or billowing. Let's take a look at that first fixation suture.
So, we've helped support everything by bringing the SMAS, or superficial
musculoaponeurotic system layer, tighter, brought it up and held it. And now
we're going to put our fixation sutures in to hold this skin up in this
elevated position that we want. And we're not going to put those sutures into
the ear because we don't want the ear to be coming down. We want the face to be
held independent of the ear. Otherwise, it produces that sort of pixie ear look
where the earlobe is pulled down and the scar then widens.
So, it's important that the ear be left out of
the whole equation. So, some people need just a skin tightening kind of
operation. Some people need the face to be de-fatted and the skin tightened.
Some people will do with de-fatting the face and injecting fat to replace
volume in places that's been lost. Other people need a deep, plain face. It
just depends on the individual. In general, I think it's a mistake to produce a
look that is not in keeping with how that individual looked at an earlier point
in their life.
We are finished here. And we've done a
blepharoplasty in the upper lids and the lower lids. We've raised the brow a
little bit to hold that up out of our way. We've taken the extra fat from the
neck and from the jowl area and then we've elevated the SMAS layer, that
fibro-fatty layer of the cheeks. And then we've raised the skin and taken out
the excess skin and sewn everything up. And we're ready to now put on the
bandage and get her to the recovery room.
Well, I hope you enjoyed that video of a
facelift. This is a wonderful patient, and I appreciate her sharing her story
with us. Just to review, a facelift involves an incision either just up in the
temple or usually more traditionally needing to go all the way down and around
the ear back into the scalp. This will elevate the sideburn a little bit. This
will elevate the skin behind the ear a little bit. And the whole idea of the
operation is to elevate the face, tighten the facial skin and the neck skin, but
not support it by the ear. Otherwise, the ear gets pulled down, and we get that
very pulled look on the ear. So we don't want to see that. We want to see the
face being held up by itself, just like it naturally is.
So, facelift is a wonderful operation for the
right person. If you have any questions about it, please leave them in the
comments below. If you want to see some other type of particular surgery,
please let me know, and I'll do my best to get that posted up onto YouTube for
you. Until then, we will be doing our thing in Aronowitzland, and you do your
thing.
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