本文術前術後案例照，為手術醫療資訊介紹分享，其治療效果會因個人 體質 與 術後保養 而有異。
Facelift alone for round face patients often yielded an unideal cosmetic outcome, therefore, according to previous experience, it is more desirable that surgeons change bony structure ahead of performing facelifts in those patients with a protruding mala or widened mandible[1, 2, 4]. Reduction malarplasty alone for wide face patients has found an incidence of soft-tissue sagging and cheek descent postoperatively, and in our practice, these patients usually seek for further facelift 6 months after previous bone surgery.
Aging in the middle and low face area is associated not only with soft-tissue drooping but also with the widening of zygoma and mandible, and descent of the malar area[5, 6]. These all provide insufficient facial projection and result in an old-looking and unattractive face. That is why an effective facial rejuvenation cannot be achieved by simply a facelift, especially in Asians with a wide zygoma projection or prominent mandibular angle.
Besides, compared to Caucasian, Asians tend to have congenital lateral hooding of upper eyelid related to downward eyebrow ridge, contributed to an aging and less attractive facial appearance (Fig. 1), and in those severe cases (Fig. 11), the shaving of supraorbital ridges should be applied. Some of these cases were found with no improvement after mistakenly operated with several times of blepharoplasty under illusion to improve lateral hooding.
Facelift and bone contouring are two time-consuming surgeries with different lengthy incisions (external facelift incision v.s. intra-oral bony reduction incision), blood loss in bone reshaping, enhanced swelling, are often performed as two separate procedures.
Few articles mentioned simultaneous facelift and facial bone contouring before[1, 3]. For zygoma reduction and midface lift, Baek and Lee, in 2009, demonstrated malar repositioning through bicoronal approach, dissection under the temporoparietal fascia, osteotomy with bone fixation and a simultaneous periosteal midface lift and forehead lift. In 2016, Zou and Wang further exhibited multiple-incision simultaneous intra-oral reduction malarplasty with transverse temporal incision cheek-lift, and described Baek’s method of having the advantage of wider operative field and easier conduction of a forehead lift, but overly traumatic for those who did not require a forehead lift and had the shortcomings of longer operative time and longer scalp scar. In author's opinion, Baek’s method fails in complete exposure of zygoma, hence results in the inconvenience of hemostasis and precise bone fixation. Zou and Wang’s method of intraoral and external facelift incisions had sustaining problems of long operative time, incomplete vision of the surgical field, increased blood loss and postoperative swelling, intraoral infection, as well as oral intake discomfort.
For solitary zygoma reduction or mandible angle resection, all described operative methods are performed through an intraoral approach[7, 8] because it can avoid the external scar. However, the intraoral-only approach also has some complications because of its limited operative visibility and restricted movement of the oscillating saw, subcondyle fracture, massive hemorrhage and bone asymmetry in particular. Lei and Wang therefore presented a modified intraoral and external approach for the prominent mandibular angle, with the usage of a reciprocating saw through an extraoral incision created in the auriculocephalic sulcus behind the earlobe. However, from author’s point of view, when combined with facelift, the facelift approach can be used with no other access when the supraorbital ridge, zygoma or mandible require contouring. In our practice, supraorbital ridge correction can be performed through forehead coronal incision, whereas zygoma reduction can be performed using middle facelift incision, and mandibular angle resection can be performed using lower facelift incision with extension approximate 3 cm at retroauricular hairline.
By our method, owing to the extensive subcutaneous dissection in facelift, the surgeon can visualize targeted bone directly, protect nearby vessels and nerves, and the difficulty in blood management is lessened. The bone reduction is thus more accurate and safer with shortened operation time and minimal blood loss of less than 30 ml. Hirohi and Yoshimura reported that in their 519 cases of intraoral approach mandibular angle osteotomy, the average operation time for combination of en-bloc mandibular corpus-angle ostectomy and corticectomy was 95 minutes, ranged from 76 to 164 minutes. Yoon, E.S., et al. analyzed the data from 33 surgeons in South Korea conducting summing up to 1251 intraoral approach mandibular angle osteotomy. For bilateral angle osteotomy, it took less than 1 hour in 9% of all cases, about 1 to 2 hours in 36%, and about 2 to 3 hours in 45%. Comparatively, the average operation time of our method for external bilateral mandibular angle resection is about 1 hour, which is relatively shorter than other procedures.
The major advantages of the facelift incision are direct vision, time-saving, precise contouring of the selected bones, especially in wide-jaw patients with prominent posteroinferior projection. However, this procedure was rarely used may because of the following disadvantages. First, the surgeon must be well-experienced in both facial bone reduction and facelift surgeries. Secondly, the anatomic dissection of periorbital and mandible angle area must be familiar to the operator in order to (Fig. ). These all require a long learning curve and practicing experiences.
With regard to facelift surgery, numerous variations in techniques have been described. Though, it remains impossible to define which techniques are best given subjectivity, differences in aesthetic judgement, patient differences, and small sample size.
Dr. Rohrich in 2016 represented that early in his experience, the extended SMAS dissection was performed, however, the deep plane technique has been abandoned for an SMAS plication or SMASectomy. In his hands, the latter technique provides similar results without the extensive dissection of the SMAS. We agreed and carried out this concept for years. It can avoid the threats of facial nerve damage, meanwhile, demand less dissection time. That’s why we can not only save time in performing facelift, but also perform in a safer way, on the other hand, yield good cosmetic outcome.
As a consequence, performing facelift with multiple bone contouring in single incision is a logical approach for those patients who complained of downward eyebrow ridge, prominent zygoma or wide mandible, with or without aging face. Our experience with this technique suggests that this procedure can be performed safely with satisfactory results.