Face and neck lift Endoscopic brow lift Upper and lower lid blepharoplasty Fat injections of the face.

PREOPERATIVE DIAGNOSIS:                Senile elastosis.

POSTOPERATIVE DIAGNOSIS:                         Senile elastosis.

OPERATION PERFORMED:                    1.         Face and neck lift.

2.                  Endoscopic brow lift.

3.                  Upper and lower lid blepharoplasty.

4.                  Fat injections of the face.

anesthesia:                                             General.

PROCEDURE IN DETAIL:                        The patient was brought to the operating room and placed supine on the operating table.  General anesthesia was administered and the patient was then prepped and draped. 

Next, corneal protectors were placed in the eyelids and ophthalmic ointment.  Tumescent fluid was then infiltrated.  First, 30 mL of 1% lidocaine with epinephrine was injected into the incisions on the scalp region.  Tumescent fluid consisted of 200 mL of lactated Ringer mixed with 30 mL of 1% lidocaine and 1 amp of epinephrine was then injected into the forehead and the face.  Radial incisions were made in the scalp as well as 2 incisions were made in the temporal region.  Under endoscopic visualization, the subperiosteal dissection was created.  Under direct vision, the periosteum was elevated off the anterior skull.  Laterally, the plane was divided just above the deep temporal fascia.  This was brought down inferiorly to the lateral orbital rim.  Next, the periosteum was divided with Bovie cautery at the margin of the orbital rim.  The corrugator muscles were then divided. 

Before the rest of the brow lift was performed, the upper lid blepharoplasty was performed.  The preoperative marks were confirmed with a caliper and the skin was excised.  Next, medial and middle fat pads were removed conservatively.  This was performed on the contralateral side as well.  The medial portion of the incisions were then closed with 6-0 nylon.

Next, a subciliary incision was made.  A skin flap was elevated.  Next, the orbicularis oculi muscle was divided and the orbital septum was identified.  The orbital septum was then divided from the medial to lateral portions.  Excess fat was noted which was then excised laterally medial and in the middle.  The fat that remained was then brought out over the orbital rim and sutured in place with 5-0 Vicryl.  Subcutaneous suture was then also used medially to further use the fat to fill in the trough.  The same procedure was performed on the contralateral side.  Next, 4-0 Vicryl was used to perform a lateral canthoplasty.  The rest of the upper eyelid incision was closed with 6-0 nylon suture.  Excess skin was then excised from the lower eyelid and then closed with 5-0 fast-absorbing plain gut.

Attention was then drawn to the neck and face where more tumescent fluid was then infiltrated.  Two mL of lactated Ringer mixed with 30 mL of 1% lidocaine with epinephrine was injected.  A chin incision was then made.  Undermining was then performed.  Approximately 0.5 mL was liposuctioned from each cheek region. 

Next, the neck dissection was performed.  Care was taken to undermine carefully to leave a small thin flap on the undersurface of the skin.  Defatting was then performed medially.  Dissection was then performed laterally on top of the platysmal muscle.  Next, the periauricular incisions were made.  A very thin flap was created for the first 2 cm.  In the neck, undermining was performed widely.  Next, dissection was then brought down to the platysmal muscle in the neck and then it was dissected medially until this connected with the previous dissection.  Dissection was brought all the way down to the masseteric tendons. 

In the cheek region, dissection was performed and just over the zygomaticus muscle, dissection was performed down to the nasolabial folds.  Complete elevation and release of the cheek was performed.  The same procedure was performed on the contralateral side.

Next, 2 Endotine ribbons were opened with a lot #02105.  The distal tines were excised and the device was then placed into the cheek, deployed, used to elevate the cheeks, and then sutured to the deep temporal fascia with 3-0 Vicryl suture.  In the cheek, 3-0 Vicryl suture was used to further close the skin.  The same procedure was performed with the ribbon on the contralateral side.

Once the cheeks are adequately elevated, attention was then drawn to the neck where in the midline, fat was excised.  Fat was excised above and below the platysmal muscle.  Midline plication was performed with 3-0 Vicryl suture.  The pockets were then irrigated, hemostasis was obtained, and the flaps were advanced and the excess skin was excised.  Multiple-layer closure was performed with 3-0 Monocryl, 5-0 Monocryl, and 5-0 fast-absorbing plain gut.  A drain was placed in the neck, which was sutured in place with 2-0 silk suture.

Attention was then brought back up to the forehead where the forehead wound was irrigated.  It was then examined and the Ultratine Endotines were then used.  First, the drill bit was used to drill a hole into the skull.  The Ultratine forehead 3.5 were then used to elevate the forehead.  Lot # was 02045.  After adequate elevation, the incisions were closed with skin staples.  

After this, attention was drawn to the abdomen where tumescent fluid was infiltrated.  Once again, 200 mL of tumescent fluid was infiltrated.  After this, syringe liposuction was performed.  The fat was then separated and then injected into the face.  The preauricular sulcus was injected with 1 mL each.  Approximately 3 mL was injected into each cheek and 1 mL in the tear trough. 

After this, the patient was awakened and taken to the recovery room in stable condition.