Technical Explanations

The Refresher Lift has been compared to the MAC lift because its goals and results are similar, however, that's where the similarity ends. Below, you will find a very short technical explanation of two key components of the Refresher Lift.

Key points of the Refresher Lift:

The mechanism creating the strong vertical uplift of the Refresher Lift is based on an obliquely directed (lateral canthus to base of earlobe) inverted C, elliptically shaped smasectomy, starting with a pie shaped excision of the lateral periorbital orbicularis and finishing with a similar excisional wedge of the superolateral platysma in the sub-tragal area. The strong quasi vertical uplift of the malar pad is achieved with a near/far slipped auto-locking knot running suture. Prior to this step, a gathering auto-locking purse string suture is used to elevate the superolateral platysma and the lower smas in a fanlike fashion, and secure them to the rigid pretragal smas (this suture may extend in the neck when needed, toward the supraglottic area tightening the mid platysma).

In some cases, when a substantial superolateral malar uplift is needed, and only a minimal fat pad laxity is present, a subperiosteal malar undermining accompanied by a strong transfixing suspension suture anchored to the temporal fascia is added to the smasectomy.

Closure of the orbicularis resection consistently improves lower lid posture. The small lateral canthal dog ear created by the vertical uplift is reduced by syringe liposuction of the subcutaneous malar pad. Squinting lines are reduced by a punch avulsion of the lateral periorbital orbicularis. Enhancement of the medial sub orbital fill hollow is achieved at the end of the procedure with 4 to 5 cc micro fat grafting placed below orbital rim and under the periorbital orbicularis.

A receding hairline belies all rejuvenating efforts. The Refresher Lift maintains a youthful temporal hairline because the hairs are never displaced behind or above the superior ear sulcus. This is achieved by using a sharply beveled, wavy, intra, or retro trichial incision, designed to minimize the displacement of the temporal hairline or sideburns. The post-tragal incision is refined by a one sided Z-plasty.

When no anteroposterior neck tightening is needed, the post auricular sulcus absorbs the dog ear resulting from the superolateral cheek skin transfer. When a more substantial lateral neck skin redraping is needed, a beveled, wavy intra and/or retro trichial incision is designed following obliquely, the nape of the neck.

The most common ancillary procedures performed in conjunction with the Refresher Lift are intraconjunctival lower blepharoplasties with a 35% TCA peel, corset platysmaraphy to correct prominent band, pre or sub platysmal fat excision, and repair the platysmal sling with a strong slipped knot, auto locking suture. Our dual plane brow lift is commonly performed to restore an elegant and dynamic framing of the eyes.

Key points of the Dual Plane Brow Lift:

A wavy sharply beveled intra or retro trichial or combination gull wing incision is performed according to the desired height of the frontal hairline, its individual shape, and the quality of the temporal hair implantation.

After an extensive dissector undermining, the forehead skin is detached from the frontalis muscle for a distance of 4 to 5 cm. Two parallel vertical incisions at about the mid papillary line are performed with the back of a 10 blade into the upper frontalis muscle. The underlying frontal periosteum is reflected with elevators and a single suspension tunnel is done on each side with a high speed Microaire drill. The muscle is then elevated bluntly with scissors at the subgaleal level and the periorbitum is reached under direct vision. A careful detachment is done with scissors and punch, preserving the medial retaining ligaments, nerves, and vessels.

The corrugators and procerus are avulsed with the punch. The periorbitum, now mobile, will be uplifted with 2 or 3 retaining 3.0 Mersilene loops passed thru each cortical tunnel. Location of the suspension points is done by a manual uplifting of the mobile brow to determine optimal soft tissue placement and percutaneous transfixion with Keith needles, perpendicular to the brow, to allow easy location of the suspension sites. The most medial sutures grasp the thick subcutaneous padding of the medial brow. The lateral suture(s) grasp the soft tissue of the frontalis/brow pad junction, often accessed by a tunneling dissection in the subcutaneous plane and demonstrated by grasping the lower frontalis with forceps to assess its mechanical effect on the lateral brow elevation. A transfixing suspension suture is placed into that junction. A constant assessment of possible brow puckering is done after each suture placement, and the suture is replaced until no more than a minimal depression is observed.

The sutures are tied snug enough to produce the desired brow uplift. The vertical muscle incisions are closed with 4.0 Monocryl. The undermined skin and scalp are advanced with a single 40 Monocryl suture attached to the medial temporalis fascia. A wavy beveled strip of skin and scalp is excised. The scalp is closed with a running interlocked 50 nylon, the skin with a near/far running 50 Chromic. A small drain is sometime used. A compressive head band is applied.

Results

From more than 200 cases performed over more than 10 years, no permanent motor deficit has occurred, no infection, no skin loss, no hair loss, and rare limited touch ups to address unsatisfactory scars or minimal asymmetry. Recovery occurs in 5 or 6 days. Maturation of the hairline scar occurs within 6 months. Less itching and hypoesthesia has been observed due to the preservation of most of the vertical sensory fascicles. Touch-ups have been very rare and limited. Satisfaction has been impressive whether it regards the improved facial aura, the permanency of the repair, the more youthful expression, or the virtual undetectability of the scars.