The American Journal of Cosmetic Surgery Vol. 28, No. 1,2011
ORIGINAL ARTICLE
The Double "C" Plication Technique: A Reliable Technique for Lower Facial Rejuvenation: Review of 1500 Cases
Kevin Sadati, DO, FAACS; Anthony C Corrado, DO
Introduction: Facial rejuvenation procedures have evolved significantly since they were first performed at the beginning of the 20th century. Modern SMAS lifting techniques focus on providing natural facial rejuvenation, durable results, fewer complications, and reduced morbidity. Many techniques exist, each proposing different methods to attain a common goal, resuspension of the SMAS. A simple new technique for SMAS plication of lower face and neck is introduced, called double "C" plication. This technique is reproducible and simple, creating lasting results for a natural look with a low complication rate.
Materials and Methods: In over J500 face-lifts in the last 4 years, the author has evolved a simple technique with a natural look. All cases were done with oral sedation and local anesthesia. Patients were ambulatory immediately following surgery and had a rapid recovery with little edema or ecchymosis. Nerve injuries were avoided, and the temple hairline and earlobe clefts were preserved. There are no ridges, dimples, or "joker lines." Revision rate was less than 0.7%. This technique utilizes double running plication sutures in a "C" shape pattern for SMAS suspension, which can be placed via traditional or short-scar face-lift incisions. This technique provides an evenly distributed multi vector radial traction on the SMAS and lateral platysma, allowing for a more uniform suspension compared to traditional single plication and purse string sutures, which provide point specific tension. This SMAS plication technique tightens up the face just like lacing a shoe, making the entire lower face firm and youthful. The neck plication pulls the platysma up behind the ear to maintain the earlobe up in its normal anatomical position.
Results: Over a 4-year period, 1532 procedures were performed utilizing the aforementioned double "C" lift technique with average follow-up of 18 months. This is a retrospective chart review of a single surgeon's rhyti-dectomy practice. Of the 1532 patients, 110 had undergone previous rhytidectomy by a different surgeon. Complications included in the evaluation process were major hematoma 1.3%, minor hematoma 5%, infection 0.5%, facial nerve injury 0%, greater auricular nerve injury 0.1%, post auricular skin necrosis (>2 cm) 0.8%, and revision rate 0.7%.
Conclusions: The double "C" plication technique is a reliable, simple, and reproducible technique with natural results and low complications. This technique involves a double running plication suturing of SMAS and lateral platysma in a "C" shape pattern.
Lower facial rejuvenation procedures have evolved significantly since they were first performed at the beginning of the 20th century. Early facial rejuvenation techniques were based on skin excision and limited superficial skin flaps. The first major breakthrough was provided by Tord Skoog when he described his technique of dissecting beneath the superficial fascia of the face and neck in 1974.' Over the following 30 years considerable attention has been given to the superficial musculoaponeurotic system (SMAS) in the literature. Modern SMAS lifting techniques focus on providing natural facial rejuvenation, durable results, fewer complications, and reduced morbidity. These goals have been addressed using multiple methods with varying results. Many techniques exist, each proposing different methods to attain a common goal, resuspension of the SMAS.
In regard to SMAS plication, a wide array of techniques are currently available to surgeons, creating significant debate among surgeons as to the optimal technique for each patient. After considering all the novel SMAS plication techniques, the senior author (K.S.) has formulated a technique for lower facial rejuvenation which incorporates many of the superior modalities discussed in prior publications. The technique has been performed on 1532 patients over a 4-year period between 2005 and 2009 with an average of 18 months of follow-up. Due to the large patient population, the authors have been able to carefully study many aspects of the procedure with great scrutiny. After reviewing the data from this large patient cohort, the authors feel this technique provides an extremely reliable means of facial rejuvenation with limited complications. The authors present the double "C" plication technique for lower facial rejuvenation. This technique utilizes running mattress and running interlocking suturing in a double "C" shape pattern for SMAS plication, which can be placed via traditional or short-scar face-lift incisions. This technique provides an evenly distributed radial traction on the SMAS and lateral platysma, allowing for a more uniform suspension compared to traditional single interrupted plication sutures, which only provide point-specific tension. This technique has afforded the authors a strong, reliable technique that produces natural-appearing results for lower facial rejuvenation with 0.7% revision rate.
Methods
Indications for a Double "C" Plication Technique This technique can be utilized in any patient seeking correction of generalized lower face and neck laxity (Baker type I-IV).2 The Baker types are described as follows:
• Baker type I: Patients in their early to late 40s with aging primarily in the face, early jowls, and often submental fat, slight cervical skin laxity but good elasticity.
• Baker type II: Patients in their late 40s to late 50s with moderate jowls and moderate cervical skin laxity. Submental and submandibular fat are usually present, and they may have microgenia.
• Baker type III: Patients usually in their late 50s, 60s, or early 70s. They have significant jowls, moderate cervical laxity, and submental and submandibular fat. They may have significant medial platysma bands active on natural animation.
• Baker type IV: Patients usually in their 60s and 70s with significant jowls and active lax platysma bands. Cervical skin elasticity is poor, and skin folds and deep creases below the cricoid are often present.
Technique
After obtaining consent, diazepam, 15 mg, and diphenhydramine, 25 mg, are administered orally. Then the incision lines, extent of flap undermining, level of the mandible, pertinent neck anatomy, areas of lipodystrophy, and platysmal bands (if present) are all marked in the upright position. In the operative suite the marked area for flap elevation and liposuction is injected with warmed dilute local anesthesia (70 mL of 0.3% Xylocaine with 1:300000 epinephrine mixed with 7 mL of sodium bicarbonate) using a 27-gauge needle. In addition, 30 mL of bupivacaine hydrochloride tumescent solution (9 mL of 0.25% bupivacaine hydrochloride with epinephrine 1:200000 mixed with 21 mL of normal saline) was infiltrated to the marked area using a 22-gauge spinal needle. This allows a superior intraoperative hemostasis, quick flap elevation with prolonged postoperative anesthesia, and comfort.
The patient is then prepped and draped in a usual sterile fashion. Rejuvenation of the neck is completed first, if indicated. Lipocontouring of the submental area is performed with 2.0-mm and 3.7-mm single hole fiat cannulae. If indicated, platysmaplasty is performed using 3.0 Vicryl in a running locking mattress suturing.
A traditional face-lift incision or short-scar incision may be utilized by the operating surgeon. The authors utilize an infratemporal hair-sparing incision which can be extended into the pre or post tragal areas. The incision is then carried around the lobule up the post-auricular sulcus just slightly on the posterior skin of the conchal bowl, to a point just even with the root of the auricular helix. The incision is then carried horizontally to the occipital hair-bearing scalp where it can be carried down along the occipital hair line. The authors feel that this incision camouflages well at the occipital hairline and prevents step-off deformities, while allowing satisfactory access to the lateral platysma.
Skin flaps are then elevated in the subcutaneous plane with a scalpel and Gorney face-lift scissors. The anterior undermining is carried out to a vertical line dropped down from the lateral canthus. Inferior undermining extends along the jowl.
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