Chicago facial plastic surgeron, Dr. Anil Shah, discusses his latest technique for facelift procedures. www.shahmd.com

1. CPMS (Complete Platysmal
Muscular Suspension)
ANIL R. SHAH, MD
CLINICAL INSTRUCTOR, UNIVERSITY OF CHICAGO
DIVISION OF OTOLARYNOGLOGY/ FACIAL PLASTIC SURGERY
845 N MICHIGAN AVENUE

2. Facelift
• Beauty
• Physiology of Aging
• Anatomy
• Application of Knowledge

3. Goals in Face-lift
• More Youthful Appearance
• Beauty- Want to Look Better
• Natural appearance
• Minimal Recovery

4. Science of Beauty
• “I can't define it but I know it when it walks
into the room”. Aaron Spelling

5. Science of Beauty
• Anthropologists Kim Hall Jones
– Compared beauty amongst South American
tribes with urban South Americans, North
Americans and Asians
– Found that delicate chins, delicate jaws, and
smooth skin appeared to be most responsible
for beauty

6. Science of Beauty
• Harvard psychologist Nancy Etcoff
– Found similar findings in delicate jawline,
delicate mouths and jawlines in females

7. Science of Aging- The Ogee
Curve
• Ogee is a shape consisting of a concave
arc flowing into a convex arc

8. The Ogee Curve
• In facelift surgery the goal is to restore the
cheekbone hence the Ogee curve

9. Science of Aging
• Pyramid and Inverted Pyramid

10. Dedo classification of cervical
abnormalities

11. Goal of Facelift
• Emphasize jawline
• Create a delicate neck
• Emphasize cheekbones- Reverse the
pyramid

12. Facelift Anatomy
• Safety
• Restorative

13. Greater Auricular Nerve Anatomy
• Originates from anterior rami
of second and third cervical
nerves
• Bends around posterior aspect
of SCM

14. Greater Auricular Nerve Anatomy

15. Greater Auricular Nerve
• Care must be taken when plicating
platysma

16. Applying local anesthetic to the greater auricular nerve results in
anesthesia of the :
• Entire auricle
• Inferior auricle and skin over the mastoid.
• Superior auricle and preauricular skin.
• Entire posterior surface of the auricle.
• Tragus and preauricular skin.

17. Applying local anesthetic to the greater auricular nerve results in
anesthesia of the :
• Entire auricle
1.Inferior auricle and skin over the mastoid.
• Superior auricle and preauricular skin.
• Entire posterior surface of the auricle.
• Tragus and preauricular skin.

18. Does it matter if you clip a branch of the
great auricular nerve?
• No difference seen in parotidectomy patients in post-
operative sensation at 2 weeks, 2 months, 6 months,
one year when posterior branch clipped verus
preserved
• (Preservation of the great auricular nerve during parotidectomy M.J. PORTER
• & S.J. WOOD ENT Department, St. Michael's Hospital, Bristol, UK)

19. Facial Nerve
• Critical Structure to avoid
• Arborization of nerve makes chances of
nerve damage less likely
• Most commonly injured branch
– Depends on what study is quoted

20. Temporal Branch (CN VII)
• How do you find it preoperatively?
• Quatela
– Tragus to lateral canthus (first line)
– Inferior aspect of ear lobe to forehead through
a point that bissects first line
• Pitanguay
– Inferior ear lobe to lateral eyebrow

24. Zygomatic Branch VII Nerve Anatomy
• Zygomatic branch lies deep to zygomaticus major
• Can be located by utilizing the Zygomaticus
insertion point

25. Zygomaticus major muscle
 Deep plane facelift surgery
 Landmark for depth
 Dissection medially to zygomatic cutaneous
ligament (MacGregor’s patch)
 Plicated or shortened in facial rejuvenation
 Botox
 Avoid ZM injections during periorbital
injections

26. Course of the zygomaticus major
muscle
 Insertion- modiolus
 Origin- not as clear
 Various methods of predicting the course of
the zm muscle

35. Mandibular branch VII Nerve
• Superficial anterior to facial notch
• Avoid dissection medial to facial notch
• Avoid dissection deep to the platysma and
parotidomassetric fascia muscle near mandibular
border

36. Course of Marginal Mandibular
Nerve
• Runs deep to
platysma until
approximately 2 cm
from oral commisure

37. Cervical branch VII Nerve
• Lies underneath platysma muscle 2 cm below
mandible

39. Lymphatics of the face
• Most of persistent
edema is found
medially
• Recent study
regarding lymphatic
drainage confirms
clinical suspicion

40. Anatomy of the Facial
Ligaments
• Facial Ligaments resist pull of deeper
tissues
• Release of ligaments allow for mobilization
of tissue without tension
• Measured in amount of cervical skin
release

41. Anatomy of the Facial
Ligaments
• Zygomatic Cutaneous Ligament
• Mandibular Ligament
• Masseteric Ligaments
• Cervical Elements
– Short versus Long Flap

43. Short versus Long Flap
Release of skin will allow
further redraping of neck/
platysmal cutaneous fibers

44. Anatomy of the Platysma
Muscle

45. Defining the Superior Extent of the Platysma
Muscle: A Review of 72 Consecutive
Facelifts
• MML (Malar
Mandibular Line)
• 3.98 cm from
mandible
• 3.09 cm from ME
• 56% of MML

46. CPMS
• Complete Platysma Muscle Suspension
• Repositioning the Platysma Muscle is
Critical to Rejuvenating the Aging Face

47. CPMS
• Modification of Deep Plane Rhytidectomy
• Purported disadvantages to deep plane:
– Risk of facial nerve injury
– Delayed healing
– Increased swelling

48. CPMS-Advantages
• Risk of facial nerve injury- 0% in over 1250
cases
• Delayed healing- Less hematoma 4 out of
1250 and no facial hematomas
• Infection- 4 out of 1250

49. CPMS-Advantages
• Risk of facial nerve injury- Safer because
you can manipulate plane rather than
placing a blind suture
• Swelling/Hematoma- Less because based
on embryologic glide plane which is
avascular versus subcutaneous. Avoid
drains

50. Isolate platysma muscle
• Cervical- Midline
• Face- Lateral Border
• Cervical- Posterior Border

51. CPMS-Addressing the Neck
• Almost every patient needs cervical
redraping
• Not every patient needs a platysmaplasty
• Release the mandibular ligaments
• Address subplatysmal fat
• Address platysmal bands
• Release platysmal dermal attachements

52. CPMS-Addressing the Neck
• Incision just anterior to the submental
crease
• Even defatting along the submentum
• Locations failure:
– Leave extra fat along the skin flap near
incision
– Failure to address subplatysmal fat

53. Artistic Components
• Neck Sculpting- Volumetric Replacement
• Amount of Skin to be Excised
– Skin laxity, amount of fat removed, etc
• Vector of Pull
• Amount of Cheek Bone Enhancement

55. Skin
mark
incision
Marking
indicates the
position of
platysma cords

56. Submental & Submandibular Liposuction

57. 10 mm fiber optic retractor

58. Separating skin from platysma

59. Suturing anterior bands of platysma in midline

61. CPMS-Addressing the Face
• Mark a line from Zygomatic Insertion Point
to Mandibular Angle
• Identify Platsyma Muscle Within Face First
• Release Masseteric Fibers

62. CPMS-Addressing the Face
• Release Zygomatic Cutaneous Ligaments
(aka) MacGregor's Patch

63. Subcutaneous dissection
Elevation above
the platysma

64. Superficial
Temporalis facsia
& VII nv.
Deep
Temporalis
fascia

65. In the deep
plane
beneath
Platysma
over Masseter

66. Entering the
deep plane Platysma
under platysma
over Masseter
Masseter

67. Dissection over
the Zygomaticus

68. Zygomaticus
Major

69. Zygomaticus
Major

70. Zygomaticus
Major

71. Zygomaticus
Major

73. CPMS-Addressing the Posterior
Neck
• Dissect Along Platysmal Border Inferiorly
Along to Neck
• Place Platysma Along Neck
• Beware of Cervical Branch of Facial Nerve

74. CPMS-Addressing the Posterior
Neck
• Release Platysma From Deeper Elements
• Create a Platysma Flap

76. Posterior border
of Platysma

77. Posterior border
of Platysma

80. Zygomaticus Below the platysma
Platysma attached
along the mandible
Masseter
Above the Platysma

81. CPMS-Suspending the
Platysma Muscle
• Suspend to the Ligament of Earlobe
• Suspend to the Temporalis (Horizontal)
• Suspend to the Mastoid Periosteum

82. Analysis of Anchoring Points in
Rhytidectomy
• Previous authors have determined that a
composite flap resisted tearing more than
skin, smas
• Looked at anchoring points in facelift

85. Anchoring Points Facelift
• Root of zygoma was (7.01kg) versus for temporalis fascia (3.44kg)
(p<.05) .
• Iinfralobular tissue (5.05kg) versus for SMAS (4.09 kg) located 1 cm
anterior to the infralobular tissue (p<.05).
• The fascia of the sternocleidomastoid was (3.89kg) compared to the
fascia of the mastoid (5.557kg) (p<.05).
• There was a statistical difference between vertical bites of the
temporalis fascia 1.90kg versus horizontal bites of the temporalis
5.01kg.

86. Suturing mandibular
angle Platysma to
fascia beneath ear lobe

87. Suturing
Suturing mandibular
angle Platysma to fascia
beneath ear lobe

89. CPMS-Skin Redraping
• Do not put tension on the skin
• Redrape along the direction of the angle of
the mandible
• Place deep sutures irregardless of no
tension

90. Title
• Content

93. Title
• Content

94. Fibrin glue

95. Suturing temporal dermis
to deep temporal fascia

96. Deep dermis to
deep temporalis
suture