"Literature has shown that smokers have a 12 times higher incidence of skin sloughs than patients who don't smoke," Douglas Dedo, M.D., of the Palm Beach Institute of Cosmetic Surgery and Dermatology, Palm Beach, Fla., tells Cosmetic Surgery Times. "The incidence of skin slough to date in smokers is zero with this (facelift) technique. In addition, the complication rate has been greatly reduced, and the overall recovery time is cut in half."
He has performed the procedure on six patients during the past three years.Dr. Dedo outlined the technique at the 22nd Annual Scientific Meeting of the AACS here in January.
To begin, Dr. Dedo creates a myocutaneous flap of facial skin that is accomplished with the deep plane facelift. The facial skin is undermined a very short distance and the SMAS is incised. The dissection is then carried forward under the SMAS, preserving the vasculature from the SMAS up to the facial skin.
As the skin flap dissection is extended down into the neck, gentle undermining is done, and care is taken not to damage dermal plexus. Along the anterior border of the sternocleidomastoid muscle (beneath the angle of the mandible), an island of tissue is preserved which extends from the platysma muscle to the cervical skin.
In the submental area, underneath the chin, the skin dissection is done without communicating the undermining to the occipital skin flaps laterally.
"This is in direct contrast to my normal facelift," Dr. Dedo explains, "in which the skin is undermined from angle to angle and entirely elevated, allowing the physician to adequately sculpt the fat and redrape the skin. But if you do this in a smoker, you're going to get a skin slough."
Once the skin flaps are elevated, the SMAS dissection from the face is continued down along the anterior border of the sternocleidomastoid muscle to incise the posterior border of the platysma muscle. As the dissection is carried anteriorly under the platysma muscle, a second myocutaneous flap is thus created which preserves the blood supply to the cervical skin. The platysma myocutaneous flap is advanced posteriorly and secured to the fascia of the sternocleidomastoid muscle.
To correct the turkey waddle deformity, fat liposuction is done followed by a submental tuck. The latter is an excision of the midline soft tissue lying between the anterior borders of the platysma muscle. The cut edges are subsequently reapproximated with 4-0 PDS suture.
Two final steps are taken to preserve and improve the metabolism of the skin. The first involves use of platelet gel. At the beginning of the procedure, the patient's own blood is drawn and about 66 cc of platelet-rich plasma is harvested. The platelet gel and fibrin-enhanced concentrate are then mixed with calcium/thrombin. As this mixture is sprayed on the raw surface of the undermined skin (under the SMAS and platysma myocutaneous flaps), the tissues are provided with a nutrient-rich mixture which will enhance healing. The wound is then closed sequentially. In the preauricular area, the amount of undermined skin not attached to the SMAS flap is about a centimeter.
"There is hardly any undermined skin — it's all done deep plane," Dr. Dedo says. "In the occipital or postauricular area, the skin is redraped and the tension is modified, but it isn't made as tight as you would in a person who doesn't smoke."
Because of the presence of the platelet gel, no drains are used. A dressing is applied which will be removed when the patient comes back the next day.