Li-na ZHAO,Meng-tong GONG,Xiao-feng LIU,Song-mei XIE,Tong-kui ZHOU

Department of plastic surgery,Xuzhou Central Hospital,Xuzhou city,Jiangsu Province,221009,China

ABSTRACT Objective To investigate the effect of frontotemporal rhytidectomy combined with botulinum toxin A type injection on lifting upper facial skin,improving upper facial skin aging,removing peri-orbital,glabellar and forehead wrinkles and strengthening the effect of rhytidectomy.Methods 20 patients with upper facial wrinkle plastic surgery,female,were designed with incision marking line along forehead and temporal hairline for dissection.The forehead was stripped along the superficial layer of periosteum,and the temporal part was stripped against the superficial surface of superficial temporal fascia.Then the suspension was used to tight the skin,the redundant skin tissue was removed,the cosmetic incision was sutured,the drainage device was placed routinely after the operation,and the pressure dressing is applied for 72 hours.The stitches were removed 7 days after the operation,at the same time ,the appropriate dose of botulinum toxin type A was injected into the glabella,the outer corner of both eyes and the forehead to remove wrinkles and to rejuvenate the upper facial skin.Results 20 patients were followed up for 1-12 months,the results were all satisfactory.The upper skin relaxation was obviously improved,the forehead,glabellar and periorbital wrinkles were significantly reduced,the skin was plump and lustrous,the scar was hidden ,not obvious and without complications after the incision was healed,and the upper facial skin showed obvious rejuvenation effect.Conclusion Frontotemporal rhytidectomy combined with botulinum toxin type A injection facial rejuvenation treatment is safe,effective,and has less complications as well as quick recovery,which is a feasible and good treatment.

KEY WORDS Frontotemporal rhytidectomy;botulinum toxin type A;combined with;facial rejuvenation

Facial aging is mainly reflected in the the appearance of sagging skin and wrinkles,especially in the upper face,which is obvious around the orbit,between the eyebrows and the forehead.There are various methods for wrinkles at these sites.At present,surgical treatment and minimally invasive treatment are widely used.In clinical practice,they are all single application,and the effect is not ideal for some patients.From Feb.2016 to Feb.2018,our department applied frontotemporal rhytidectomy combined with botulinum toxin type A injection for upper facial rejuvenation.The effect of the two methods were superimposed and complementary after combination,and good clinical results were obtained.

MATERIALS AND METHODS

Clinical materials

The 20 cases in this group were all female,aged 48-62 years,with an average age of 53 years.The upper facial skin aging was found in all 20 cases,mainly manifested as forehead wrinkles,glabellar wrinkles and crow’s feet.And their skin was loose with obviously visible wrinkles in static state and even deeper wrinkles when making expression.There were no abnormalities in blood routine examination,coagulation function examination and ECG examination before surgery,and the patients with botulinum toxin type A allergy,major disease,local infection and hemorrhagic disease were excluded.

Methods

Incision design:a coronal incision was selected on the forehead 3-5cm from the forehead hairline,and an incision was selected on the temporal part 3-5cm from the hairline extending upward along the upper pole of the auricle.

Surgical procedure

Before surgery,0.5% iodophor was used to wash the hair and normal iodophor was used to disinfect the surgical drape ,the forehead surgery was performed first,and then the temporal surgery was conducted.

Forehead surgery

1% lidocaine with 1:100000 adrenaline hydrochloride was used for incision infiltrating anesthesia.The scalp was cut along the direction of hair growth to the loose tissue under the galea aponeurosis,a scalp clip is used to stop the bleeding at the incisal edge of the scalp.Then it is stripped along the superficial layer of the periosteum to 2cm above the orbital margin,and separated to the surface of the orbital margin above the nasal bone under the periosteum ,and the attention should be paid to protect the supraorbital nerve.After successful hemostasis,the scalp flap was pulled up to an appropriate height and fixed at a specific point,the height of the eyebrows on both sides was adjusted to achieve bilateral symmetry,the redundant scalp was removed,the drainage tube was placed,and the wound was sutured.

Temporal surgery

After successful anesthesia,the skin was cut along the incision line,stripped on the superficial surface against the superficial temporal fascia and separated to the outer edge of the orbicularis oculi muscle.The superficial temporal fascia was folded up and outwards,sutured and fixed for 3 stitches.Then the skin was pulled up and backward,and fixed at a specific point,the redundant scalp was removed,the drainage tube was placed,the wound was sutured in layers and the attention was paid to the adjustment of both sides to keep the symmetry of both eyebrows tails and outer canthus.

Postoperative management

The surgical site was placed with a silica gel drainage tube for 3 days and pressure bandaged with a cotton padded head cover for 3 days,antibiotics were given intravenously for 5 days,and the stitches were removed 7 days after surgery.

Botulinum toxin type A injection

The type A botulinum toxin used in our department was an alyophilized product (Hengli) produced by Lanzhou Institute of Biological Products with batch number C3304C3,each bottle is 100u.After the removal of stitches 7 days after surgery,the patients were injected 3 points each at 1cm outside the bilateral orbit with fanshaped injection and 5 units at each point,2 points at each side of the corrugator supercilii and the depressor supercilii between the eyebrows and 1cm from the beginning of the eyebrows with 2 units at each point,4-5 points in two rows at 2cm above the brow with 2.5 units at each point,the interval between each point was 2cm,and the interval between the two rows was 1-1.5cm.

Observation index

The postoperative complications and recovery were observed,and the clinical efficacy and treatment satisfaction were followed up for 1-12 months.The main facial manifestations were observed.

RESULTS

There was no hematoma and other complications ,no obvious incision scar and no facial nerve injury in the 20 patients after the surgery.The clinical effect was good.The patients were followed up for 1-12 months.The effective rate and satisfactory rate of the 20 patients were 100% when they were followed up for 1-5 months,the upper facial skin was tight and plump,the wrinkles were obviously reduced or disappeared,and the effect of rejuvenation was significant.The effective rate was 100%and the satisfactory rate was 90% at 6-12 months,which was mainly reflected in slight wrinkles in the eye tail,glabella and forehead when making facial expression,but it was significantly improved compared with that before the surgery.15 of them were injected with botulinum toxin type A again 6-12 months after the surgery to consolidate the effect,the results were all satisfactory.

Typical case

Fig.1 Typical case Note:a Before surgery,b 7days after surgery,c 5 months after surgery

The patient,female,54 years old,complained that the upper facial skin was loose with obvious wrinkles,especially the forehead,glabella and outer canthus of both eyes,showing aging,hoping to improve.Through the detailed communication with the patients,a plan was made:frontotemporal rhytidectomy combined with botulinum toxin A injection was conducted,the postoperative effect was good and the patients were satisfied(Fig.1).

DISCUSSION

With the improvement of living standards and social recognition,plastic surgery has been accepted by more and more people,and the facial rejuvenation treatment is the demand of all ages.Young patients often ask to remove crow’s feet from the corner of the eye,while older patients pay more attention to forehead wrinkles and glabellar wrinkles[1-2].

According to the degree of skin histological changes and the depth of wrinkles,some scholars divide skin aging into three degrees.Mild:fine and shallow wrinkles can be seen when facial muscles are active,and disappear when the activities stop.Moderate:wrinkles can be seen in static state,but disappear when the skin on both sides of the wrinkles is pulled and stretched,and deepen when the expression is made.Severe:the thick and deep wrinkles do not disappear completely when pulling the skin on both sides[3].

For mild patients,in general,botulinum toxin type A injection alone is enough to achieve good results.For moderate and severe patients,rhytidectomy combined with botulinum toxin type A injection is often needed to achieve satisfactory results.Our department is aimed at the treatment for the latter two kinds of patients.

Due to the full range of dissection and fine anatomical operation,the traditional frontotemporal rhytidectomy can achieve multi-level and multi-vector lifting,can purposefully perform SMAS suspension and folding,can remove redundant skin to avoid skin accumulation and facial irregularities,and can achieve a long-lasting and reliable facial lifting effect[4].The scars left after the surgery are also more concealed and can be accepted by most patients.Botulinum toxin type A is a popular micro-plastic method,which is favored by the majority of beauty seekers for its advantages such as small trauma,fast recovery,no scar and no need to rest.It acts on the terminals of cholinergic motor nerve,and then interferes with the release of acetylcholine by antagonizing calcium ion to make muscle fiber unable to contract,resulting in muscle relaxation to achieve the purpose of wrinkle removal and beauty[5].Because of the repair and regeneration of nerve endings,the average action time of botulinum toxin type A is 4-6 months,and the injection should be repeated after the effect disappears.

Frontotemporal rhytidectomy can improve the wrinkles obviously,but it can not correct the fine lines formed in the skin for a long time,which will deepen when the expression is made.And botulinum toxin type A is mainly aimed at the dynamic wrinkles of the face and has poor effect on the static wrinkles,which can improve the skin fine lines by inhibiting muscle contraction[6-7].Therefore,frontotemporal rhytidectomy combined with botulinum toxin A injection can play a synergistic role.It can not only achieve the purpose of facial wrinkle removal,improve the postoperative experience of patients,but also retain the advantage of prolonging the retention time of wrinkle disappearance brought by surgery[8-10].At the same time,we believe that[11-14],(1) the drug absorption of botulinum toxin type A injected after the removal of stitches 7 days after surgery is better better than that of the injection immediately after the operation,because the swelling of the tissue basically disappears at that time.(2) Botulinum toxin A inhibits muscle contraction and thus reduces the tension of the incision,which has a good effect on scar healing.(3) According to clinical experience,after the injection of botulinum toxin A,not only the wrinkles disappear,but also the skin condition of corresponding parts is improved,the skin is plump and lustrous,and the patient is satisfied.A few months later,after the effect of botulinum toxin A disappears,the injection can be repeated if the patient requires it.

To sum up,frontotemporal rhytidectomy combined with botulinum toxin A injection facial rejuvenation treatment is safe,effective,and has less complications,fast recovery as well as high satisfaction,which is a practical and good treatment method,and worthy of clinical application and promotion.