53. Elastic canthopexy in elastic MACS and neck lifting
KEYWORDS: Elastic kanthopexy, MACS elastic lifting, blepharoplasty, retinaculum oculi
The preoperative design shows: the incision that crosses the sideburn and stops at the tragus, the pathway of the elastic canthopexy thread, the parallel neck threads, and the vectors of the isosceles triangles that suspend the cheeks and the malar region.
A solution of 2% mepivacaine with 1/2 mg of epinephrine is injected into the areas that are to be dissected in the temporal region and the preauricular regions where the tunnels will be created in order to anchor the elastic neck thread to the fascia of Loré.
The same anesthetic, diluted to 1% or slightly less, is injected along the pathway of the threads. Once local anesthesia is complete, the operating field is further disinfected and the operation begins. First of all, Adipolysis is used to eliminate an excess of submental fat, which has been marked out before the procedure. Adipolysis, which is one of the more than 70 standardized techniques of Timedsurgery (Technique for the Implementation of Measured Electrosurgical Data), reduces the number of adipocytes while maintaining the integrity of the connective stroma. Barrier anesthesia and/or in-depth anesthesia is carried out in the area of excess fat. The partially insulated EM10 Gray electromaniple must enter directly into contact with the adipocytes, and not with the anesthetic solution.
The skin incision that crosses the sideburn and stops at the tragus is now made. This incision is beveled in order to maintain the integrity of the hair follicles of the sideburn.
The subcutaneous tissue is dissected from the superficial temporal fascia with scissors. The dissected area is rectangular in shape and extends slightly beyond the zygomatic arch; it is not extended medially, in order to avoid interfering with the functioning of the frontal branch of the facial nerve. Dissection is normally carried out with large scissors, as my mother, Dr Spolidoro, used to teach.
The operator uses a finger to check whether the dissection has extended beyond the zygomatic arch.
The preauricular tunnel above the fascia of Loré is now dissected. The scissors are in contact with the fascia, to which the neck-lifting thread will be anchored. Maintaining the full thickness of the subcutaneous tissue prevents the knots from becoming palpable or ulcerating.
We now implant the elastic thread that will place the external canthus under traction. The two-tipped Jano needle penetrates the temporal fascia from the dissected area, at a distance from the edge of the skin incision, and emerges from the skin, anchoring the elastic thread. In this way, we create the base of the isosceles triangle that draws the canthus and periorbital tissues laterally.
The elastic thread is pulled through and the Jano needle is extracted until 5 mm of the posterior tip remains in the tissues. The needle is then rotated and passes through the subcutaneous tissue immediately above the superficial fascia in the direction of the canthus, where it will fix the elastic thread to the retinaculum oculi.
The inclination and the shape of the eye is conditioned not only by the direction of the isosceles triangle, but also by the anchorage to the retinaculum. If the eye is to be given a more "oriental" look, the thread can be anchored to the retinaculum at a distance of a few mm from the apex of the canthus or below the canthus, in the inferior lateral retinaculum. In this case, the two-tipped needle partially emerges below the canthus, at a distance of about 5 mm from its lateral extremity.
A hook is used to help the tip of the Jano needle to pass through the skin.
The needle partially emerges. The elastic thread is pulled through. When less than 5 mm of the posterior tip of the needle remains in the tissues, the operator maneuvers the tip in order to pass through the fibrous tissues of the retinaculum, an anatomical structure that is resistant to traction. During this maneuver, the operator uses the tip of the needle to feel for this compact tissue, which is more resistant to penetration. At this point, the operator may decide to insert a 5-0 Quick stitch to fix the elastic thread to the retinaculum, though this is not essential. The stitch will be knotted once the isosceles triangle has been completed.
The operator must be familiar with the anatomy of the palpebral canthus and the location of the retinaculum, which is more extensive in men and less so in women.
The Jano needle passes through the subcutaneous tissue immediately above the superficial fascia and returns to the entry point. Its pathway is not superficial.
Once the elastic thread has been colonized by fibrohistiocytic cells, the result will become permanent. The mini-invasive nature of elastic canthopexy and the absence of scars at the canthus means that, once the result has become stable, a second elastic thread can be implanted if the patient wishes to elongate the eyes further, or if the operator is not completely satisfied with the result.
Elastic canthopexy is a new procedure that is carried out in a region in which traditional techniques often fail or leave artifacts. The possibilities of elastic canthopexy will be more clearly elucidated once larger case-series are available and the operating technique has been perfected. Today, however, we already know that the incision used for elastic MACS lifting can also be used to rejuvenate the patient's look. The traction exerted on the canthus, even if only of a few mm, tightens up the canthal ligaments and rejuvenates aged eyes.
The elastic canthopexy threads are placed under tension and knotted. The 5-0 Quick absorbable thread is also knotted.
We now implant the threads that form the isosceles triangle, which lifts the malar region. The Jano needle is inserted in the dissected area and partially emerges from the skin, with the aid of a hook. The hook is particularly useful in order to ensure that the tip of the needle emerges perpendicularly to the skin.
The depth marks on the needle are counted. The needle is extracted until 5 mm of the posterior tip remains in the tissues. It is then rotated and travels along the preoperatively drawn line; its pathway through the subcutaneous tissue of the malar region must be kept superficial. The operator checks the mobility of the skin. In this region, if the needle is not superficial, the skin will not be mobile and the volumes will not be lifted. If this happens, the thread will have to be extracted and reimplanted more superficially.
The elastic thread is pulled through.
The tip of the needle emerges, aided by the hook. The elastic thread is pulled through. When 5 mm of the posterior tip remains in the tissues, the Jano needle is rotated and travels towards the point of entry on the temporal fascia. The needle emerges from the upper portion of the corner of the dissected flap. The elastic threads are placed under tension and knotted.
The first of the threads that will lift the cheeks is now implanted. The Jano needle penetrates the temporal fascia, from which it then emerges completely. The needle now travels towards the pre-established point in the preoperative design. The tip of the needle enters the subcutaneous tissue from the upper portion of the angle created by the dissection of the skin. The needle is partially extracted and the elastic thread is pulled through. Elastic MACS lifting continues with the creation of the last isosceles triangle that will lift the cheek, and with elastic lifting of the neck. As is known, we have eliminated dissection of the cheeks and neck from face-lifting procedures.
After about three months, the excess lateral tissue of the upper eyelids is removed. This excess frequently arises after canthopexy, owing to the new elongated shape of the eyes.
After about six months, we rejuvenate the patient's face by means of cellular Adipofilling, which uses a suspension of single, living adipocytes and stromal cells. This cellular suspension is created from washed lipoaspirate in about 20-30 seconds, by means of the Adipopimer, an economical disposable device. Adipofilling corrects facial volumes and makes the face symmetrical, in addition to restoring the youthful look of the skin. The suspensions of single cells and small lobular fragments created by the Adipopimer do not freeze. For this reason, they can be conserved in 1 mL or 2.5 mL vials in a normal laboratory freezer.
Timedsurgical de-epithelialisation, application of the saturated solution of resorcin and formation of the crust. Before and after. Shortening of the white portion of the lip shows that the result is permanent.
Capurro S. (2021): Elastic canthopexy in elastic MACS and neck lifting. CRPUB Medical Video Journal. Elastic Plastic Surgery section. www.crpub.org.
Can Adipolysis also be carried out in other areas?
Yes. It can be used on drooping volumes of the cheeks, the nasolabial folds, malar pouches, and on all small excesses of fat. Adipolysis utilizes a specific current generated by the Timed apparatus and a partially insulated, 0.15 mm diameter EM10 Gray electromaniple. Adipolysis must be performed in tissue that has not been infiltrated by local anesthetic.
How many sweeps of the partially insulated EM10 electromaniple do you make? What are the program data?
We normally make 100-150 sweeps per area. The region that is to be reduced in volume is divided into areas according to the dimensions of the electrode. The electrode brushes the skin without leaving scars.
The program data are: Direct Pulsed 0.3/5.3 hundredths of a second – Coag – 38 Watts – partially insulated EM 10 Grey electromaniple.
In elastic canthopexy, no skin incisions in the canthus are needed. What are the advantages of this?
The procedure is simple and can be carried out through a 2 mm incision at the hairline. Elastic canthopexy is often requested by patients who have already undergone blepharoplasty and canthopexy procedures. Elastic canthopexy avoids further scars in this region. In addition, further elastic traction threads can be implanted without any problem. Another advantage is that the isosceles triangle that places traction on the canthus also places traction on the lateral tissues of the eyes, thereby lifting this area.
Which other procedures do you perform in order to rejuvenate the lower eyelids?
Transconjunctival blepharoplasty, in which we remove all the herniated adipose pouches from the septum orbitae; timedsurgical mixed peeling, which eliminates palpebral wrinkles and festoons; cellular Adipofilling, in which the cellular suspension can be injected immediately beneath the thin palpebral skin in order to correct the lacrimal sulci and sunken orbits and to give the skin new life.
Why do you have to remove all the adipose pouches if you then reinsert the fat?
Removing all the adipose pouches allows the skin to retract; in most patients, this avoids the need for mixed peeling. In addition, complete removal of the fat creates the natural concavity under the eyelashes. With regard to fat, adipose pouches must not be confused with the cellular suspension used in Adipofilling. Adipose pouches retain water. If the patient eats pizza or salami in the evening, the eyelids are likely to be swollen the next morning in any areas where the adipose pouches have not been removed. By contrast, the adipocytes and stromal cells used in Adipofilling do not have the same capacity to retain water. Many surgeons say that they do not remove all the fat because, in order to remove all the herniated fat, you need to have a lot of experience and an apparatus like the Timed apparatus, which enables the pouches to be removed selectively through two 8 mm incisions by means of rapid pulsed timedsurgical cutting.
How long is the base of the isosceles triangle in elastic canthopexy?
In this patient, about 2,5 cm. I wouldn't make it any shorter.
Do you often put an absorbable stitch into the retinaculum after fixing the elastic thread?
No, not any more. We have learnt how to fix the elastic thread in depth in the fibrous tissue of the retinaculum.
The two-tipped needle has to penetrate in depth, where it meets with resistance. Fixing the thread to the fibrous tissue
makes canthopexy perfectly stable. No supplementary fixation is needed.
Have you ever had problems of asymmetry?
If the isosceles triangles are identical and correctly positioned), elastic canthopexy cannot cause problems of asymmetry.
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