CASO CLÍNICO

Bone rongeur as nasolabial fold sculptor instrument. A technical note

La gubia ósea como instrumento escultor del pliegue nasolabial. Nota técnica

M.Y. Mommaerts¹, B. Ramos Medina²

¹ Staff surgeon
² Visiting surgeon (Cartagena-Murcia)
Servicio de Cirugía Maxilo-Facial. AZ St. Jan, Brugge, Bélgica

Correspondence

ABSTRACT

Prominent nasolabial folds are of concern to many face lift candidates. Many techniques have been described which tackle this distinct sign of ageing. Crease fillers have inherent limitations. Extended SMAS dissection and suspension has no effect after 24 hours. Malar fat pad suspension has an effect which extends maximally to 2 years. Direct fat excision lateral to the crease must be done cautiously. However, it is the only technique providing permanent results. Fat removal can be done with tweezers and scissors, with liposuction canules, and with curettes. Tactile and visual control over location and depth of the resection is required. Such is possible when using a bone rongeur in one hand to reduce the fat mount which has been dissected off the dermis. The other hand turns over the cheek flap for alternating internal and external control of the sculpturing effect, and for external tactile guidance.

Key words: Rhytidoplasty; Rejuvenation; Surgical Instruments.

RESUMEN

Los pliegues nasolabiales prominentes son uno de los aspectos que más preocupan a los pacientes candidatos a un lifting facial, y han sido descritas muchas técnicas que intentan atenuar este signo distintivo del envejecimiento. Las sustancias de relleno tienen limitaciones inherentes. Las disecciones amplias del SMAS y su posterior suspensión no tienen efecto después de transcurridas 24 horas. La suspensión de la almohadilla grasa malar tiene un efecto que se extiende como máximo a los dos años de duración. La extirpación directa de la grasa lateralmente al surco nasolabial, aunque debe hacerse con mucha cautela, es la única técnica que proporciona resultados permanentes. Técnicamente, esta resección grasa se ha descrito realizada valiéndose de pinzas y tijeras, con cánulas de liposucción o con curetas. Este procedimiento requiere un control muy preciso, táctil y visual, de la localización y profundidad de la extirpación, control que puede mejorarse usando una gubia ósea con una mano para extirpar la grasa a eliminar de la dermis, mientras la otra mano maneja el colgajo cutáneo de la mejilla, para un control alternativo interno y externo del efecto escultural de la extirpación y para permitir una guía táctil externa.

Palabras clave: Ritidoplastia; Rejuvenecimiento; Instrumentos quirúrgicos.

Introduction

The nasolabial crease is absent in newborns and in patients with facial paralysis, indicating that muscular tone and action are determining its presence and location. At the beginning of the fourth decade, the nasolabial fold becomes more prominent and the labiomandibular fold and jowling appear. These first signs of ageing prompt some people to seek advice for rhytidoplasty

The nasolabial crease is determined by the insertion of the SMAS and the mimetic muscles that elevate the lip and the corner of the mouth. Lateral to the crease is the fold, which comprises skin and subcutaneous fat of variable thickness. ¹ Fibrous septae between the SMAS and the overlying fat maintain the fold.^2,3 At the end of the third decase, the cheek skin loses its elasticity and the septae are disrupted by mimetic action. The skin and subcutaneous fat of the fold start to slide forward and down over the underlying SMAS. As the nasolabial crease remains in position with ageing, the posterior skin and fat fold on themselves.

Dermal insertions of the depressor anguli oris form the superior crease of the labiomandibular fold⁴ and the osteocutaneous mandibular ligament the lower part.⁵ Lateral is cheek fat. The labiomandibular fold is accentuated by smiling due to platysma pull.⁴

Since nasolabial and labiomandibular folds are appearing with age, and caused by the action of gravity on fat and skin, it makes sense to lift these two components, whether as a unit or in a separate way. Hamra described repositioning of the cheek fat as part of a deep plane face lift in 1990, and reported remarkable results in the nasolabial fold area.⁶ However; in 2002 the same author admitted that with deep plane face lifts, the nasolabial folds recurr after 1 or 2 years. He stated that only direct excision will produce a permanent correction of the nasolabial fold.⁷

The senior author (Mommaerts) studied the technique of direct fat excision with Millard in 1989. Millard marked out the nasolabial fold with 2 catheters. During the scalpel freeing of the dermis, the dissection was carried moderately deeper at the nasolabial fold, slicing off its fatty crest, which was left attached to the skin.⁸ This dissection was done blindly. The excess fat was removed from the skin’s undersurface with long scissors and long tweezers, under direct vision.

Surgical technique

The problem when using tweezers and scissors is that both hands and the eyes have to join efforts to snip the fat. An assisting surgeon has to retract the skin flap. To correlate the image of the subcutaneous situation with the external facial anatomy is difficult, time consuming and traumatic for the surgeon’s spine.

There are the options to leave the fat on the skin side or on the muscle side, before resecting it with bone rongeurs. Bone rongeurs enable to grasp the fat lobules more easily, to pull on them to verify externally the location for volume reduction; all that with one hand (Fig. 1). The other hand retracts the skin flap and controls also tactically the result of the fat reduction during the procedure. Bone rongeurs remove fat by a pulling and cutting action. By uniform action along the length of the fold, there is less risk for visible depressions in the sculpted areas as is the case with the scissors and tweezers technique. We sometimes use a finebeaked rongeur to dissect in between the skin and the orbicularis oris muscle, beyond the crease. Nearly all action can be done with external visual and tactile control, both in the nasolabial fold, and labiomandibular fold. Only for the sagging jowl we verify more internally the depth of the fat resection.

Discussion

In the last two decades, face lift surgeons have explored many techniques to address midfacial ptosis properly. Indeed, reduction of the nasolabial fold is high on the priority list of rhytidoplasty candidates.

SMAS suspension has a permanent effect on the sagging jowls, but not on the nasolabial folds. Ivy et al. (1996)⁹ compared extended SMAS face lifts with lateral SMASectomies, conventional SMAS face lifts and composite flap lifts. The composite flap pulled with great tension exerted the largest effect on the fold during the surgery. However, after 24 hours the difference between the 4 types of lifts was lost for ever. Youssif et al. (1994)² reported similar intraoperative findings.

Repositioning of the malar fat pad was first undertaken by Hamra (1990).⁶ Owsley (1993, 1995)^1,10 described suture suspension of the advanced fat pad and Stuzin et al. (1993)¹¹ further underlined the importance of permanent suture suspension. Hamra⁷ admitted in 2002 that also this technique was prone to relapse after some years.

Severing the dermal attachments of the mimetic muscles in the crease area is not advocated. The muscular insertions are fixing the crease but they also responsible for individual smile characteristics.¹² Although release of the cutaneous insertion of these muscles would allow the skin to glide more superiorly with traction on the flap, and smooth the crease,³ trauma to the muscle insertions could lead to sagging of the corner of the mouth and a change in the smile pattern. It remains also to be seen if the muscles would not reattach to the dermis!

Judicious subcutaneous lipectomy and posterior traction to the freed facial skin has been proven efficacious.¹³ Canule suction has been proposed to facilitate this.¹⁴ Ellenbogen et al. (1989)¹⁵ claimed that curettes are superior to fat suction. We described a technique using bone rongeurs to sculpt the fat pad.

Correspondence:
Maurice Y. Mommaerts, MD, DMD, PhD, FEBOMFS
AZ St. Jan, Ruddershove 10
B-8000 Brugge. Bélgica
Email: maurice.mommaerts@azbrugge.be

Recibido: 07.12.2005
Aceptado: 16.06.2008

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