Facelift	Advantages	Disadvantages and complications
Skin only	Conceptual and technical simplicity	Secondary facelift deformities caused by skin tension
SMAS plication	No sub-SMAS dissection so technically less demanding and time consuming than procedures in which a flap is raised	Wide skin flap undermining; contour irregularities if sutures are not placed carefully; potential injury to facial nerve branches and parotid gland or duct; little if any midface improvement
SMASectomy	No sub SMAS dissection required; skin and SMAS can be shifted along different vectors so skin tension can be set low, and sideburn displacement and shifting of cervical wrinkles onto the face can be minimized	Wide skin undermining; facial nerve branches at risk when SMAS excised and sutured; may be contour irregularities; minimal improvement in midface
Deep plane	Single-layer dissection so flap elevation is easier and less time consuming than multilayer dissection and flap is thicker with a better blood supply	Potential excessive sideburn displacement, and shifting of cervical rhytids to the face; unnatural appearances caused by extraordinary tension; midface improvement not always as expected; facial nerve branches and other structures at risk
Composite	Similar to those for a deep plane lift, but also allows repositioning of orbicularis oculi and raising of lid-cheek junction	Similar to those of deep plane technique, but also may be prolonged periorbital edema and denervation of orbicularis oculi
Lamellar SMAS dissection and bidirectional	Skin and SMAS advanced bidirectionally in different amounts along separate vectors, and suspended under differential tension so avoiding skin tension, hairline displacement, and wrinkle shifts	Technique dependent and time consuming; flaps more fragile; facial nerve branches at risk
Extended SMAS	Improved effect in the mid face and infraorbital region and increased support of the lower eyelid	More technique dependent and time consuming; flap is more fragile; facial nerve branches at risk
High SMAS	Restoration of youthful upper cheek contour; filling of infraorbital region; increased support of lower eyelid; improved correction of nasolabial fold; readily combined with midface fat injections	Similar to those techniques using a sub-SMAS dissection
Subperiosteal	Dissection is familiar to most plastic surgeons and is largely deep to facial nerves; avoids many problems associated with skin-only procedures; improvement in infraorbital and upper midface areas in some cases	Generally longer recovery and often hard to obtain optimal improvement along jawline; problems of suspension sutures
Endoscopic	Minimal scarring	No means for skin excision; little improvement in lower cheek and along jawline
Midface	To improve midface area	Steep learning curve and fraught with complications, especially when performed through a blepharoplasty incision, including lid retraction, ectropion, canthal displacement and dry eye; disappointing results
Suture suspension	Seeming simplicity; easy marketability; can often be placed quickly under local or light anesthesia by inexperienced surgeons without surgical training; small incision; lower risk of hematoma, flap compromise and related complications	Support of the face cannot be predictably obtained; infection; extrusion; traction dimples; visible bowstringing; nerve injuries; facial dyskinesias; chronic pain syndromes; abnormal appearances during animation; a tight or choking feeling when used in the neck; palpable knots and sutures beneath the skin and occasional erosion of overlying skin
MACS (minimal access cranial suspension)	Seeming simplicity; no formal SMAS dissection; can be performed under local or light anesthesia; a shorter scar; shorter operating time.	Technique dependent and contour irregularities can result; problems associated with the placement of a stiff and rigid suture in the superficial layers of the face; injury to the parotid gland, parotid duct, facial nerves, and other deep facial structures
Short scar	Appeal to patients	Limited access to deep layer structures; redundant skin cannot be shifted along proper vectors; prevent skin from being properly excised
Mini-lift	Appeal to patients	Minimal improvement

Skin only

Although the excision of skin formed the foundation of the facelift procedure for the first 70 years or so after its inception, this has ultimately been shown to be ineffective and conceptually flawed, and there are compelling reasons (Box 9.1) not to rely on skin resection only when surgically rejuvenating the face.

Box 9.1 Reasons why skin-only resection should not be relied on when surgically rejuvenating the face

Skin is intended to serve a covering function, not a structural or supporting one

• Skin evolved to stretch and move as we express ourselves, and was not meant to support sagging deep layer tissues.

• Tightening skin corrupts its natural covering function and results in unnatural appearances and the older and more inelastic the skin, the more this is true.

• Examination of the faces of young persons shows their faces are not tight

Skin tension flattens contour rather than restoring it

• This is not consistent with the goal of enhancing facial contour.

Skin is not capable of providing sustained support of ptotic deep layer tissue

• Although initial outcomes of skin-only procedures may appear good, as an elastic layer, skin will rapidly stretch and any improvement obtained will typically be quickly lost.

Skin tension results in secondary facelift deformities

• Almost all secondary facelift deformities such as poor scars, hairline displacement, tragal distortion, and ear lobe malposition can ultimately be traced back to skin tension.

The fundamental flaw in skin-only facelifts, mini-lifts, and similar procedures is that skin is meant to serve a covering function and not a structural or supporting one. Skin tension flattens contour, rather than restoring it and because skin stretches as tension is applied, objectionable temple, sideburn and occipital hairline displacement is difficult to avoid when skin-only facelift techniques are used.

Despite their inherent drawbacks, well-known weaknesses, and tendency to produce secondary deformities, however, skin-only facelifts remain popular largely because of their conceptual and technical simplicity.

Deep plane

A deep plane facelift consists of a sub-SMAS dissection first described by Skoog and later popularized by Lemon and Hamra in which the cheek skin and SMAS are raised together in one layer as a unified flap (Skoog flap). In the deep plane procedure the SMAS was used to reposition the lower cheek and jowl and the midface was then said to be elevated by ‘extraordinary tension’ on the preauricular portion of the flap.

Advantages of the deep plane technique include:

• single layer dissection and therefore flap elevation is easier and less time consuming than multilayer dissections in which both a skin and SMAS flap are raised;

• the flap is thicker and arguably has a better blood supply then when a layered dissection is made, and therefore may be safer in smokers or other patients with compromised circulation.

Potential disadvantages are:

• skin and SMAS must obligatorily be shifted along the same vector in the same direction and to the same degree, which can result in excessive sideburn displacement, and shifting of cervical rhytids from the neck to the face;

• extraordinary tension on the flap can result in distortion and unnatural appearances;

• the midface improvement expected is not always realized;

• facial nerve branches and other structures are also at risk.

Hamra has abandoned the deep plane technique in favor of the composite technique (see below), and the term deep plane has since come to be used generically by most surgeons for any procedure where there is some kind of modification of the SMAS is performed.

Composite

A composite facelift consists of a deep plane sub SMAS dissection that additionally includes the orbicularis oculi muscle in the upper part of the flap (i.e. the flap is a composite of skin, SMAS and orbicularis oculi).

Advantages of the composite technique are:

• the midface is elevated by a medially vectored flap of orbicularis oculi anchored near the lateral orbit.

Potential disadvantages are:

• prolonged periorbital edema;

• potential denervation of orbicularis oculi resulting in atonic lower lids and eyelid dysfunction.

Because skin and SMAS age at different rates and along somewhat different vectors, optimal treatment of each layer is generally not possible when single layer ‘Skoog’ and ‘composite’ dissections are made.

Lamellar SMAS dissection and bidirectional facelift

Because skin and SMAS age at different rates and along somewhat different vectors, optimal treatment of each layer is generally not possible when Skoog flaps are used and single-layer composite dissections are made.

In a lamellar SMAS facelift the skin and SMAS are dissected as separate and distinct layers and advanced along independent vectors. The advantage of this technique over a single layer Skoog or composite flap technique is that skin and SMAS can be advanced bidirectionally in different amounts along separate vectors, and suspended under differential tension. Skin tension, hairline displacement, and objectionable wrinkle shifts can therefore be minimized or avoided, and in turn results in a more natural appearance, a more comprehensive rejuvenation, and fewer secondary deformities;

Disadvantages of procedures that use lamellar SMAS dissections:

• they are more technique dependent and time consuming;

• the flaps are more fragile than when a Skoog or composite dissection is made;

• facial nerve branches are at risk because a sub-SMAS dissection is performed as part of the technique.

Extended SMAS

The extended SMAS concept was set forth by Stuzin and others, and is the name adopted by Baker, Gordon, and Stuzin to describe their personal facelift technique.

In the extended SMAS technique separate skin and SMAS flap dissections are made in a lamellar fashion and, in addition, a sub-SMAS dissection is performed in the upper cheek and midface to release retaining ligaments and free up the malar fat pad from the superior aspect of the lip elevators.

The advantage of the extended SMAS technique is that a more comprehensive release of SMAS is achieved than in other SMAS dis-sections, resulting in an improved effect in the midface and infraorbital region and increased support of the lower eyelid.

Disadvantages of the extended SMAS procedure compared with a standard dissection include:

• it is more technique dependent and time consuming;

• the flap is more fragile;

• the facial nerve branches are at greater risk.

Using the SMAS to lift sagging facial tissues and to restore facial contour circumvents the problems associated with skin-only lifts because it is an inelastic structural layer intimately associated with sagging facial muscles and fat that is capable of providing effective and sustained support.

High SMAS

The conventional low cheek SMAS flap design in which the superior margin of the flap is planned below the zygomatic arch suffers the fundamental design flaw that it does not exert an effect on the tissues of the midface and infraorbital region. Low designs target the lower cheek and jowl only, and produce little if any improvement in the upper medial cheek area. Planning the flap higher, along the superior border of the zygomatic arch and making an extended dissection medially to mobilize midface tissue overcomes this problem and produces an improved result (Fig. 9.1A-D).

Fig. 9.1 High and low SMAS techniques. A, Plan for low SMAS procedure. The superior margin of the flap lies below the zygomatic arch. B, Low SMAS flap after dissection and suspension. The area of the flap effect (green circle) is limited to the lower cheek and jowl and there is no improvement in the midface or perioral region (black dotted circle). C, Plan for high SMAS procedure. The superior margin of the flap lies along the zygomatic arch. D, High SMAS flap after dissection and suspension. The area of the flap effect (green circle) includes not only both the cheek and jowl, but also the midface and perioral region (black dotted circle).

The high SMAS procedure can be performed using a two-layer lamellar technique with separate skin and SMAS flaps as advocated by Connell, or using a one-layer composite flap as practiced by Barton.

Advantages of a high SMAS plan include:

• restoration of youthful upper cheek contour;

• filling of the infraorbital region;

• increased support of the lower eyelid;

• improved correction of the nasolabial fold;

• readily combined with midface fat injections because midface and infra-orbital tissue planes are not opened or dissected, which averts the need to perform complex and potentially problematic procedures in which orbital fat is transposed, the orbital septum reset or free grafts are placed.

For many patients, the repositioning of midface tissue obtained with a high SMAS flap will be satisfactory in achieving the desired effect, and no additional or separate midface lift procedure will be required (Fig. 9.2A&B).

Fig. 9.2 Before and after high SMAS facelift, necklift, hairline lowering, forehead lift, upper and lower blepharoplasty and partial facial fat injections. A, Preoperative photograph of a 49-year-old woman before surgery. Note the loss of a youthful contour and midface ptosis. B, Postoperative photograph 11 months following the surgery. Ptotic midface tissues have been repositioned, a youthful jawline contour has been restored, and redundant skin has been excised without an unnatural tight or pulled appearance.

Disadvantages of the high SMAS technique are similar to other techniques in which a subSMAS dissection is made although some surgeons have expressed concern that the frontal branch of the facial nerve is at risk when high SMAS procedures are performed, they are chrucally safe and anatomically sound when performed as described.

For many patients, repositioning midface tissue obtained with a high SMAS flap will be satisfactory in achieving the desired effect, and no additional or separate midface lift procedure will be required.

Subperiosteal

Despite its seeming unsuitability, the periosteum has been advocated by Ramirez and others as the layer beneath which facelift dissection should be performed and the layer by which sagging superficial and deep facial tissues should be elevated.

Potential advantages of a subperiosteal facelift include:

• the dissection is familiar to most plastic surgeons and is made in large part deep to facial nerves and other deep layer structures;

• when properly performed sagging facial tissues can be repositioned diverting some tension away from the skin, which averts many of the problems associated with skin-only procedures;

• improvement in the infra-orbital and upper midface areas is obtained in some cases depending on procedure design.

The periosteum is, however, an intuitively and conceptually illogical choice for overall rejuvenation of the face because it is densely adherent to the facial skeleton and does not significantly descend as part of the aging process. It is also not closely associated with the intermediate layers of the face where most of the aging is known to occur.

Potential disadvantages of the subperiosteal technique include the following:

• the dissection is said to result in prolonged swelling and induration and generally portends a longer period of recovery for the patient compared to that in other procedures;

• optimal improvement along the jawline is often hard to obtain;

• because many subperiosteal facelift techniques rely on the concomitant use of suspension sutures these procedures can share related problems.

Endoscopic

Despite the importance of concealing scars in aesthetic surgery, other surgical specialties were the first to introduce and employ endoscopic techniques. The introduction and acceptance of the endoscopic fore-head lift eventually set into motion efforts to design a facelift performed using the same technique. Despite considerable effort, however, no proven or generally accepted technique for the face has emerged. In addition, focus has been diverted away from development of an endoscopic procedure to some extent by the introduction of techniques using percutaneously placed barbed threads and suspension sutures.

The major obstacle to the development and wide application of an endoscopic facelift is that skin redundancy remains a significant component of the aging deformity and although some support of deep layer tissue can be obtained, the endoscopic technique does not provide a means for this to be excised. Alternatives to excision including laser resurfacing are inadequate for all but a younger group of patients with small skin excess, and even these procedures have proven to be skin smoothing and not skin shrinking technologies.

For the most part the improvements obtained in endoscopic facelifts are limited largely to midface elevation, and improvements in appearance obtained from concomitantly performed forehead and neck surgery or the result of other ancillary procedures. Less improvement is obtained in the lower cheek and along the jawline.

Most endoscopic facelifts that have been proposed have been performed in a subperiosteal plane but often also attempt to resuspend the buccal fat pad, malar fat and the SOOF (sub-orbicularis oculi fat).

Midface

The midface is generally defined as an inverted triangular area situated over the anterior upper cheek that is bounded by:

• the zygomaticus major muscle laterally;

• the nasolabial fold medially;

• the infraorbital rim superiorly.

In healthy, youthful appearing men and women this area is full and makes a smooth transition to the adjacent cheek and lower eyelid. As one ages however, there is generally atrophy of, and loss of volume from this area, and over time this results in an ill, haggard, and elderly appearance.

Midface atrophy is considered by some surgeons to be accompanied by descent of midface tissues, and the aging change occurring in the upper cheek area is as a result often, perhaps erroneously, referred to as midface ptosis.

The recognition of midface ptosis as a significant component of the changes occurring in the aging face, combined with the realization that the traditional SMAS facelift produced little or no improvement in the midface region, has led to a variety of procedures designed to specifically target the midface area. Many of these techniques are now being performed as isolated procedures or in conjunction with lower eyelid surgery.

Although there is merit in the idea of rejuvenating the midface, isolated midface lift procedures are still evolving, and have not been perfected. Most procedures have a steep learning curve and have been fraught with complications, especially when performed through a blepharoplasty incision. These complications include lid retraction, ectropion, canthal displacement and dry eye problems. As a result, many midface lift techniques have come to incorporate potentially problematic aggressive adjunctive surgical maneuvers including can thotomies, canthoplasties and orbicularis oculi muscle suspensions to prevent these problems. These maneuvers often result in a changed look that is disturbing to many patients, however, and carry a high risk of significant and troublesome complications of their own.

Many other valid arguments can be made against the use of isolated midface procedures including the fact that attractive rejuvenation of the face is possible without complete effacement of the nasolabial fold. Most patients with nasolabial folds had them when they were young and their presence reflects the individual’s anatomic make-up, and not an age related undesirable change. In such cases complete effacement is neither necessary nor desirable because they are an inherent and appropriate feature of the patient’s face.

As a practical matter, most of the improvement obtained by midface lifts consists only of elevation of the lid-cheek junction, and not correction of the nasolabial fold. Midface lifts also typically produce a subtle improvement that is difficult to document in photographs and not always noticed or appreciated by the patient. Because of this, it can be argued that time in the operating room is better spent on lower risk maneuvers that result in more noticeable improvement of higher priority to patients.

Careful examination of most patients who need or request a midface lift will show that they also need a facelift, and it is rare to encounter a patient with midface aging who does not also have sagging in the cheek and jowl. Because of this midface lifts are arguably more logically performed in conjunction with a formal facelift procedure. When this is done improvement is more balanced and comprehensive, and a more harmonious and natural appearing result is usually obtained. Healing is also generally faster and complications are less likely if midface improvement can be obtained through the facelift incision, rather than through a blepharoplasty or intraoral approach.

Most midface lifts are also generally conceptually flawed in that they mistakenly assume the problem seen in the anterior upper cheek is solely one of tissue sagging. Failure to acknowledge that significant atrophy is usually present has led to general disappointment following many procedures for both patients and surgeons, and has resulted in the addition of dermis fat grafts, orbital fat transposition and septal resets to midface lift procedures. It is questionable and remains to be answered however, whether these procedures can produce a restoration of lost volume as simply, naturally and effectively as obtained with fat injections.

Suture suspension

A variety of suture-lift procedures have been devised in which attempts are made to suspend deep facial tissues with sutures, including those in which:

• long cable sutures are placed through small temporal incisions;

• barbed sutures and threads are placed percutaneously.

Advantages of suture-lift procedures include:

• seeming simplicity;

• easy marketability;

• can often be placed relatively quickly under local anesthesia or light anesthesia by inexperienced surgeons and physicians without surgical training;

• small incision;

• less risk of hematoma, flap compromise and related complications because skin is typically not excised or undermined.

Disadvantages of suture-lift procedures include:

• sustained and attractive support of the face cannot be predictably obtained;

• infection;

• extrusion;

• traction dimples;

• visible bowstringing;

• nerve injuries;

• facial dyskinesias;

• chronic pain syndromes;

• abnormal appearances during animation;

• a tight or choking feeling that is disturbing to patients, and can result in difficulties in speaking and swallowing when used in the neck;

• palpable suture knots and sutures themselves beneath the skin if large, stiff, permanent sutures used;

• occasional erosion of the overlying skin by suture knots, necessitating their removal.

Research and development continue on suture lift techniques, and it remains to be seen whether current problems can be solved. The fundamental problem in these procedures is that one must rely on a small rigid thread to support a relatively large area of delicate, inherently soft, mobile facial tissue. Over a short period of time these sutures typically cheese-wire through tissues they were intended to support, and can injure important neuromuscular structures. Suspension sutures also prevent natural depression and downward movement of facial tissues, impeding certain expressions and creating unnatural sensations and appearances.

The second major obstacle to be overcome is that although some support of deep layer tissue might be obtained, skin redundancy remains a significant component of the aging deformity for many patients, and suspension techniques do not provide a means for this to be excised. Alternatives to excision including laser resurfacing are inadequate for all but a younger group of patients with small skin excess, and even these procedures have proven to be skin-smoothing and not skin-shrinking technologies. As with endoscopic facelifts, a breakthrough in biomedicine may change this.

MACS lift

The MACS (minimal access cranial suspension) technique was developed and popularized by Tonnard and Verpaele for patients in the European market who were thought to be reluctant to undergo longer and ostensibly more complicated ‘traditional’ facelift procedures that were being performed in the Americas and elsewhere.

The MACS lift combines features of short-scar procedures with the concept of suture suspension of deep facial tissue. Tonnard and Verpaele assert the procedure shares little with traditional versions of these procedures, and clinical evidence indicates that when their technique is used outcomes are improved.

The MACS technique overcomes traditional limitations of suture suspension procedures in two important ways.

• First, unlike many short-scar procedures in which skin only is excised, the MACS procedure provides a means of diverting tension off the skin to deeper tissue layers. This in turn improves the quality of the scars and the longevity of the procedure.

• Second, Tonnard and Veraele assert that the procedure is not a suture lift in the traditional sense in that tissue is suspended by what they regard as a gathering and microplication of the SMAS, and as such produces a more long lasting improvement with fewer problems that when looped or barbed sutures are used.

The MACS procedure has evolved and has been refined from its original description in which one or two plication sutures were placed and non-absorbable permanent monofilament sutures were used. Multiple sutures are now generally placed to more specifically target the midface, cheek, jowl and lateral neck, and this is said to distribute improvement more uniformly over the face and produce a more natural and long-lived improvement. Softer, absorbable sutures have also been substituted for the stiffer more rigid non-absorbable sutures originally recommended.

Although the MACS lift is considered by many who perform it to be a short-scar procedure, the typical incision plan used shortens the scar in the occipital area, but results in an incision along the more exposed temporal hairline, which is more difficult to conceal. This is of questionable benefit to younger patients who are typically thought to be the best candidates for the procedure.

Potential advantages of the MACS technique include:

• seeming simplicity;

• no formal SMAS dissection is required;

• it can be performed under local anesthesia or light anesthesia;

• a shorter scar;

• shorter operating time.

Potential disadvantages of the MACS technique include:

• the procedure is technique dependent and if sutures are not placed carefully, contour irregularities can result;

• problems associated with the placement of a stiff and rigid suture in the superficial layers of the face (e.g. palpability, dimpling, facial creasing, and suture erosion and extrusion) – although these problems can be avoided to some extent by using an absorbable suture, it is unclear what effect this has on the longevity of the procedure;

• injury to the parotid gland, parotid duct, facial nerves, and other deep facial structures during suture placement.

Short-scar

The idea of using small incisions to perform facelift procedures is appealing to patients and surgeons alike. Indeed, the first procedures performed a century ago consisted of small excisions of skin near the ear and along frontal and occipital hairlines. Ironically, and despite the considerable advances in techniques to rejuvenate the face that have been made since, as non-plastic surgeons have begun to perform aesthetic surgery procedures and market their services, a new emphasis has been placed on short-scar procedures of questionable value that are nonetheless alluring in concept to almost any patient.

Although some short-scar techniques such as limited incision forehead lift have merit and have provided new and better options to patients, skin redundancy remains a consistent and undeniable problem for the surgeon seeking to rejuvenate the face and neck, and shorter incision plans involve significant compromises in the overall improvement that can be obtained.

The advantage of short-scar procedures rests largely in their appeal to patients, and their allure and marketability will likely ensure that they will be with us in some form or another for some time.

Short-scar incision plans suffer the drawbacks that they:

• limit access to deep layer structures;

• prevent redundant skin from being shifted along proper vectors that produce the most improvement and most natural appearance;

• often require that skin be gathered up when sutured and prevent skin from being excised in a smooth, well-tailored fashion.

Interestingly, most short-scar procedures have placed their focus on the postauricular area, and are designed to shorten the postauricular scar. This scar is situated in a well-concealed area however, and if tension on the postauricular skin flap is avoided an inconspicuous scar will typically result. This scar is less obvious and less troublesome to the patient than a shorter, but irregular and puckered scar. Shortening a scar under these circumstances in a concealed area is of questionable value to the patient.

Perhaps the most difficult aspect of short-scar incision plans to defend is that to minimize puckering and gathering behind the ear lobe, the cheek skin flap is shifted along an overly superiorly directed vector, necessitating a scar along the less well concealed sideburn and temporal hairline areas. Although an incision is sometimes required in this area in some patients to prevent hairline displacement, shortening a scar in a concealed area by shifting it to a more visible area is of dubious value to the patient who might not have required it.

The real issue for all patients is not how long the facelift scar is, but how well it is concealed. Ultimately, the long versus short scar debate will come to an end when the wound healing process is deciphered and predicted breakthroughs in wound healing research will provide the means to scarless healing.

Mini-lift

Mini-lift is a loose descriptive term not a scientific one, and it is not a specifically defined technique. Typically it is used to describe the simple excision of skin in a younger patient, but is sometimes used to refer to procedures of limited scope performed on older patients. Minilifts typically use short-scar incision plans and do not include modification of the SMAS and platysma.

Unlike skin-only facelifts and mini-lifts in which subsequent procedures worsen skin tightness and problems associated with it, high SMAS facelifts, theoretically at least, can be repeated as often as needed without producing skin tightness and abnormal appearances.

Indications

Three categories of aging:

• Aging and breakdown of the skin surface

• Facial sagging, skin redundancy, and loss of youthful facial contour

• Facial wasting, atrophy and age-related lipodystrophy

Recognizing the changes associated with facial aging and appreciating the underlying anatomic abnormalities is essential to properly advising patients and to recommending appropriate therapy. Most patient problems fall into three broad categories:

• aging and breakdown of the skin surface;

• facial sagging, skin redundancy, and loss of youthful facial contour; and

• facial wasting, atrophy and/or age related lipodystrophy.

Proper treatment depends upon the degree to which each of these problems is present, the patient’s priorities, and the time, trouble and expense the patient is willing to endure to obtain the desired improvement.

Patients primarily concerned with surface aging of their face may not require surgery and may achieve the type of improvement they desire through surface treatments of the skin. These include skin peels, ablative and non-ablative skin resurfacing, chemodenervation (botulinum toxin type A injections), injection therapy and various forms of cutaneous laser and other treatments designed to remove or reduce age spots, spider veins, wrinkles and other age-related skin surface imperfections.

Patients primarily concerned with facial sagging, skin excess, and loss of facial contour will typically be disappointed if surface-only treatments are employed. They require formal surgical lifts in which sagging tissue is repositioned and redundant tissue is excised if these problems are to be properly corrected and an attractive and natural-appearing improvement obtained.

Patients with significant facial atrophy and age-related facial wasting achieve suboptimal improvement from both surface treatments of facial skin and surgical lifts. Smoothing skin will not disguise a drawn, ill, or haggard appearance resulting from the loss of facial volume, and it is difficult to create natural and attractive contours by lifting and repositioning tissues that have abnormally thinned with age. These patients may require volume replacement, by autologous fat grafting or other means, in conjunction with their surgical procedure to achieve a satisfactory result.

Pan-facial rejuvenation

Isolated aging rarely occurs in the lower face and neck, and many if not most patients requesting facelift surgery need forehead and eyelid procedures as well. Many are confused, however, by the term ‘facelift’ and take it to imply correction will be made in all areas. These patients must be counseled carefully because the facelift itself will produce little if any improvement in upper facial deformities and tends to unmask and draw attention to them.

It is also not uncommon for patients to request surgery on their neck only. Although such a plan is acceptable for some men, failure to concomitantly restore attractive cheek contour and lift sagging jowls in women generally results in an unnatural and unfeminine appearance. In addition, if an aggressive platysmaplasty is performed as part of an isolated neck lift, sagging in the cheeks and jowl area can be accentuated as platysma tightening exerts a downward pull on tissue in these areas.

Preoperative Planning

Temporal incision

The temporal portion of the facelift incision has traditionally been placed within the temporal scalp in a well intended, but often counterproductive attempt to hide the resulting scar. When cheek skin redundancy is small and there is abundant temple and sideburn hair, such a plan can be used without producing objectionable sideburn elevation and temporal hairline retrodisplacement.

Patients best suited for this incision plan are usually young and troubled by mild cheek laxity only. In many other situations however, larger skin shifts and the presence of sparse temple hair can result in unnatural and tell-tale displacement of the temporal hairline and sideburn if such a plan is used (Fig. 9.3A&B).

Fig. 9.3 incision plan resulting in displacement of the sideburn and temple hair. A&B, The tempoPoorral portion of the facelift incision was made in the traditional location in the temporal scalp in a well-intended effort to hide the resulting scar. Because there was large cheek flap redundancy and poor skin elasticity, advancement of the cheek skin flap resulted in objectionable hairline displacement. An incision along the hairline would have prevented this deformity.

Proper analysis, careful planning and the use of an incision along the hairline, when indicated, can avert this problem with out compromising the overall outcome of the procedure (Fig. 9.4A&B).

Fig. 9.4 Healed incisions along the temporal hairline. When indicated, the use of an incision along the hairline can prevent hairline and sideburn displacement without compromising the end result. A&B, Although a scar is present along the hairline in each of these patients, it is not evident upon casual inspection. Note the preservation of lush temple hair and a full youthful natural-appearing sideburn.

Important factors in choosing incision placement

Distance between the lateral orbit and anterior aspect of the temporal hairline

In choosing the location of the temporal portion of the facelift incision it is important to note the distance between the lateral orbit and the anterior aspect of the temporal hairline (Fig. 9.5) because this distance is aesthetically significant and generally increases with age.³ In healthy, youthful-appearing individuals it usually measures no more than 4–5 cm, but in older patients, or in those who have had a prior facelift, it will often be seen to be considerably more.

Fig. 9.5 Assessment of temporal skin show. The distance between the lateral orbit and the temple hairline and how it changes with skin flap shift must be considered when planning the temporal portion of the facelift.

Estimate of the skin redundancy over the upper cheek

Equally important as the distance from the lateral orbit to the temporal hairline, is the surgeon’s estimate of the skin redundancy over the upper cheek, and therefore the skin shift that will occur when the facelift flap is repositioned.⁴ This can be easily assessed by simply pinching up redundant skin and measuring it. Assessment of skin redundancy over the cheek, in conjunction with the amount of existing temporal ‘skin show’, allows rational selection of the best site for temporal incision placement.

When to place the incision in the traditional location

In patients in whom minimal temporal skin shift will occur and for whom the temporal hairline will remain within 5 cm of the lateral orbit, the temporal portion of the facelift incision can be placed in the traditional location 4–5 cm within the temporal scalp, extending superiorly up from the superior aspect of the helical facial junction (Fig. 9.6).

Fig. 9.6 Plan for incision in the temporal scalp. This plan is used for patients predicted to have minimal shift of sideburn and temple hair after elevation of the cheek flap. It will not be appropriate for all patients.

When to place the incision along the hairline

When the temporal hairline is predicted to be moved more than 5 cm away from the lateral orbit, however, or the sideburn hair shifted above the junction of the ear with the scalp, consideration should be given to placing the incision along the hairline (Fig. 9.7) rather than within the temporal scalp. This incision will allow large postero superior skin flap shifts while simultaneously providing maximum improvement in the upper lateral face.⁵ If it is made with care and closed under no tension, the resulting scar is usually inconspicuous and far less trou-blesome for the patient than a displaced hairline (see Fig. 9.3A&B)

Fig. 9.7 Plan for incision along the temporal hairline. An incision along the temporal hairline should be considered whenever objectionable displacement of the sideburn and temple hair is predicted.

Assessment of skin redundancy over the cheek in conjunction with the amount of existing temporal skin show allows rational selection of the best site for temporal incision placement.

Patient considerations

Options for the placement of the temporal portion of the facelift incision should be discussed with any patient in whom significant displacement of the temporal hairline or elevation of the sideburn might occur. Incision placement is best presented as a choice between two imperfect alternatives and it is wise that the final decision about where the incision is located is made by the patient after appropriate discussion has been made.

The patient should be informed that placing the incision in a traditional location within the temporal scalp will help conceal the scar, but often at the expense of a large and objectionable displacement of the temporal hairline and sideburn, and compromised improvement over the temporal face. This inevitably results in an old and unnatural appearance and is usually immediately obvious, even upon a casual glance and at a distance.

An incision along the hairline will prevent hairline displacement, and although a scar will be present where the incision was made, it is usually inconspicuous and will not be noticed by others if wound closure is properly performed.

A suboptimally healed incision along the hairline can be concealed with makeup or tattooed or revised, but a significantly displaced hairline is difficult to conceal and a challenge to correct. In my experience most patients are disturbed by the prospect of temple and sideburn hair displacement, and recognize this occurrence as a tell-tale sign that a facelift has been performed. When counseled properly and given the choice, many readily consent to incision placement along their hairline.

Preauricular incision

Open to scrutiny, the preauricular region exists as a frequent point of reference for those seeking to identify a facelift patient.

Traditional incision vs retrotragal incision

Traditionally, incisions in the preauricular region are made well anterior to the anterior border of the helix and continued inferiorly, anterior to the tragus (Fig. 9.8). This design, however, works well only for the unusual patient with cheek and tragal skin of similar characteristics who, in addition, exhibits favorable healing. Unfortunately, most patients have a marked gradient of color, texture, and surface irregularities over the preauricular area and a tell-tale mismatch will be evident, even in the presence of an inconspicuous scar.

Fig. 9.8 Traditional location of the preauricular incision. This plan places the preauricular scar in an area open to scrutiny and brands the patient as having had facelift surgery.

For these reasons, and in all but the unusual case, the preauricular portion of the facelift incision should be precisely placed along the posterior margin of the tragus, rather than in the pretragal sulcus (Fig. 9.9). In this location a mismatch of color, texture, or surface irregularities will not be noticed and the scar, if visible, will appear to be a tragal highlight⁶ (Fig. 9.10A&B).

Fig. 9.9 Marginal tragal (retrotragal) plan for the preauricular portion of the facelift incision. Placing the incision along the natural anatomic interfaces conceals the scar and disguises differences in skin color and texture on each side of it.

Fig. 9.10 Before and after secondary facelift to move pretragal incision scar to retrotragal position. A, Preoperative view. A pretragal incision has healed satisfactorily but is visible because of differences in color and texture on each side of it. B, Postoperative view. The incision was moved to the posterior margin of the tragus (retrotragal position). Color and texture differences and the scar itself are now concealed along natural anatomic interfaces.

In addition, and despite claims to they contrary, a properly planned and executed incision along the margin of the tragus will not produce tragal retraction or other anatomic irregularity (Fig. 9.11A&B).

Fig. 9.11 Healed retrotragal incisions. A&B, Postoperative close-up views of patients who have had a facelift with a preauricular incision along the margin of the tragus. The scars are well concealed and there is no tragal distortion.

In the male patient, the tragus can be kept free of beard hair by intraoperative destruction of beard follicles from the underside of the tragal flap (Fig. 9.12A&B).

Fig. 9.12 Healed retrotragal incisions. A&B, In these male patients the incision has been made along the posterior margin of the tragus and the tragus has been kept free of beard hair by intraoperative destruction of beard follicles from the underside of the tragal flap.

The superior portion of the preauricular incision should be planned as a soft curve in the helicofacial sulcus paralleling the curve of the anterior border of the helix. This will result in a natural-appearing width to the helix and the resultant scar, if visible, will appear to be a helical highlight.

As the tragus is approached, the mark for incision is carried into the depression superior to it and then continued along its posterior margin. In this location the scar, if visible, will appear to be a natural highlight. It is an error to place this incision in a true ‘retrotragal’ position on the inner surface of the tragus. This usually results in a bulky, amorphous appearing tragus and obliteration of natural tragal anatomy.

At the inferior portion of the tragus the incision must turn anteriorly and then again inferiorly, into the crease between the anterior lobule and cheek. If a more relaxed plan is made, or if a straight line incision is used, skin settling and scar contraction will result in crowding of the incisura, obliteration of the inferior tragal border, and a tell-tale elongated and ‘chopped off’ tragal appearance (Fig. 9.13).

Fig. 9.13 ‘Chopped-off tragus’. The unnatural and objectionable-appearing elongated tragus with an indistinct inferior border that results from poor incision planning and improper excision of the skin at the time of incision closure.

Perilobular incision

To obtain a natural perilobular appearance, it is essential to preserve the natural sulcus between the ear lobe and the cheek and to avoid excision of this aesthetically important anatomic subunit.⁷ This is accomplished by marking the incision a 1–2 mm inferior to this junction. All other factors being equal, a superior result will be obtained when such a plan is used, in comparison to any plan in which the incision is placed directly in the sulcus.

Postauricular incision

Traditionally, the postauricular portion of the facelift incision has been made over the posterior surface of the concha. This was done as part of a well-intended effort to offset inevitable descent of the postauricular flap and inferior migration of the resulting scar that occurred when skin was tightened in an attempt to improve neck contour. Many surgeons have since come to realize that such a plan embodies erroneous assumptions and can result in undesirable effects including hypertrophic scarring, postauricular webbing and obliteration of the auriculomastoid crease.⁸

The postauricular portion of the facelift incision should be marked directly in the existing auriculomastoid groove and the mark turned posteriorly at the approximate level of the anterior crus of the antihelix. Marking must be made with the ear resting near its natural anatomic position. If the ear is pulled too far forward while marks are made, mastoid skin will be pulled anteriorly over the posterior surface of the concha and the incision will end up posterior to its intended location. Incorrect marking in this manner is the most common cause of a poorly situated postauricular scar.

Occipital incision

Planning the location for the occipital portion of the facelift incision is conceptually similar to that of the temple region and the incision plan must address similar concerns of hairline displacement and scar visibility. Traditionally this incision is arbitrarily placed transversely, high on the occipital scalp, in a well-intended but usually counter-productive attempt to hide the resultant scar (Fig. 9.14).

Fig. 9.14 Traditional plan for the occipital portion of the facelift incision. The incision is placed transversely high on the occipital scalp in a well-intended but usually counterproductive attempt to hide the resultant scar.

Important factors in determining incision placement

For patients with a small amount of neck skin redundancy is small and for whom excision of postauricular skin is unnecessary, such a plan is appropriate and will result in a well-concealed scar. Patients in this category are usually young and troubled by mild neck deformity only. In these situations the incision is used for access to the lateral neck only, and not as a means to remove postauricular skin. Skin excision using this incision plan will result in the advancement of neck skin into the occipital scalp and ‘notching’ of the occipital hairline (Fig. 9.15A&B).

Fig. 9.15 Notching of the occipital hairline. A&B, Examples of notching of the occipital hairline in two patients whose surgeons used traditional occipital incision plans.

Although not all patients will recognize this deformity for what it is, most are nonetheless self conscious of it, especially those who wear their hair up or back or who lead active lives where wind, water and outdoor activities may displace camouflaging wisps of remaining hair. Proper analysis, careful planning and the use of an incision along the hairline when indicated, can avert this problem with out compromising the end result (Fig. 9.16A&B).

Fig. 9.16 Healed incisions along the occipital hairline. A&B, Postoperative close-up views of scars along the occipital hairline. Note that an inconspicuous scar will result if this incision is planned carefully and properly closed.

In choosing the location of the occipital portion of the facelift incision an estimate must be made of the skin redundancy along the predicted posterior-superior direction of flap shift. This can be accomplished by pinching up tissue over the upper lateral neck and measuring it:

• if 2 cm or less of excess neck skin is present, a traditional incision over the mastoid extending posteriorly into the scalp at the level of the mid ear (see Fig. 9.14) may be used and will not result in objectionable disruption of the occipital hairline if the postauricular skin flap is not advanced and is returned to its original position;

• if more than 2 cm of neck skin redundancy is present, however, the incision should be placed along the occipital hairline, but designed in such a manner that a tell-tale scar will not be visible in front of the fine hair on the nape of the neck – this can be accomplished by turning the inferior portion of the incision back into the scalp at the junction of thick and thin hair. (Fig. 9.17).

Fig. 9.17 Plan for incision along the occipital hairline. The incision is planned so that its inferior portion turns posteriorly into the occipital scalp at the junction of thick and thin hair. This plan prevents hairline displacement and results in a well-concealed scar.

From a practical standpoint the traditional incision on the occipital scalp should be used for access to the neck only and closed without shift or advancement. Any patient with significant neck skin redundancy will require an incision along the occipital hairline if hairline displacement is to be avoided.

From a practical standpoint the traditional incision on the occipital scalp should be used for access to the neck only and closed without shift or advancement. Any patient who has significant neck skin redundancy will require an incision along the occipital hairline if hairline displacement is to be avoided.

Patient considerations

As with temporal incision placement, options for the placement of the occipital portion of the facelift incision should be discussed with the patient and presented as a choice between two imperfect alternatives:

• a scar ‘hidden’ in the scalp and hairline displacement; or

• a scar along the hairline with hairline preservation.

It is wise that the final decision about where the incision is located is made by the patient after the advantages and disadvantages of each option have been discussed. It has been my experience that most patients are concerned by the prospect of occipital hairline displacement and recognize it as an objectionable sign that a facelift has been performed. When properly advised and given a choice, most consent to a hairline incision.

Submental incision

Most facelift patients require modification and repair of the neck and submental regions that can only be performed through a submental incision, and optimal improvement in the neck can generally not be obtained unless a submental access incision is made.⁹^–¹¹ Traditionally this incision is placed directly in and along the submental crease in a well intended, but counter-productive attempt to conceal the resulting scar(Fig.9.18). This incision plan should be avoided, however, because:

• it will surgically reinforce the crease and accentuate a double chin or witch’s chin deformity;¹²

• exposure of the submental region will be compromised, and there will be difficulty suturing or dissecting beneath the skin in the lower neck.

Fig. 9.18 Traditional but incorrect placement of the submental incision. The submental incision should not be placed directly along the submental crease because this will accentuate it and reinforce a double-chin appearance. Note that the typical plan of skin undermining also promotes a double chin because the crease is not undermined and the retaining ligaments are not released.

A more posterior placement of this incision will eliminate these problems, but still result in an inconspicuous and well-concealed scar (Fig. 9.19 and Fig. 9.20A-D).

Fig. 9.19 Correct placement of the submental incision. Placing the submental incision posterior to the submental crease prevents accentuation of the double chin and witch’s chin deformities and provides for easier dissection and suturing in the anterior neck. Note that this incision plan allows the submental crease to be undermined (shaded area) and released, and the fat of the chin pad and neck to be blended.

Fig. 9.20 Correction of the double chin deformity. A-D, Pre and postoperative views. The submental incision was made posterior to the submental crease to allow undermining and release of the submental-retaining ligaments and blending of chin and neck fat.

The submental incision should be placed well posterior but parallel to the submental crease at a point lying roughly one half of the distance between the mentum and the hyoid (Fig. 9.21). This usually corresponds to a site situated approximately 1 cm posterior to the crease.

Fig. 9.21 Plan for the submental incision. The submental portion of the facelift incision (solid line) should be placed posterior to the submental crease (dotted line), approximately one half of the distance between the mentum and hyoid (arrows).

The incision should be approximately 3.5–4.5 cm in length, but may be made longer provided neither end will be advanced up upon a visible portion of the face when skin flaps are shifted. Healing will be best and the scar best concealed if it is made as a straight rather than a curved line (Fig. 9.22).

Fig. 9.22 Healed submental incision. Placement of the submental incision posterior to the submental crease will result in an inconspicuous well-healed scar.

Operative Approach

Planning modification of the SMAS

All patients undergoing a facelift will benefit from some modification of the SMAS and a high posterosuperior advancement of the cheek SMAS serves as the fundamental step in rejuvenation of the face and avoidance of secondary deformities (Fig. 9.23A&B).

Fig. 9.23 High SMAS flap. A, Plan for basic high SMAS flap. Note that the superior margin of the flap is planned at the level of the zygomatic arch (i.e. not inferior to it). B, High SMAS flap after advancement and suturing.

SMAS advancement provides a natural appearing and long-lasting correction in the cheek and jowl and will consolidate the lower face. When a high-SMAS plan is used improvement can be obtained in the midface and infraorbital area without the need for a separate midface lift procedure.13

Operative technique

Skin flap elevation

• After incisions are made skin flaps are elevated according to the preoperative plan over the cheek and neck. Skin flaps should be elevated sharply under direct vision. This is especially important in the preauricular region and over the cheek where a deep or careless dissection can injure the underlying SMAS and render it useless as a flap.

• Subcutaneous undermining should not arbitrarily include the entire face. If SMAS dissection is planned, preservation of the anterior platysma-cutaneous ligaments will allow attractive and youthful appearing elevation of perioral tissue that cannot be obtained with a skin-only technique or when wide skin undermining is performed (Fig. 9.24). These ligaments anchor the dermis of the perioral cheek to the SMAS and upper platysma and provide a means of lifting and supporting the lateral perioral area without overtightening the skin of the upper-lateral face.

Fig. 9.24 Extent of subcutaneous undermining. The shaded area shows the area of subcutaneous undermining. Note that the platysma-cutaneous ligaments (black dots) are not undermined and are preserved. Preservation of platysma-cutaneous ligaments and proper elevation and fixation of the SMAS will provide support for the lateral periorbital tissues and prevent the lateral sweep deformity.

If subcutaneous dissection is extended too far anteriorly and the platysma-cutaneous ligaments are divided, the SMAS effect on the superficial tissues of perioral cheek and jowl will be negated and a significant portion of the benefit of SMAS elevation and advancement will be lost.

Temple incision and flap dissection

• The temple incision is made according to the preoperative plan based on the redundancy present over the upper cheek and the predicted degree of displacement of the sideburn and temporal hairline.

Flap dissection with traditional incision on the temporal scalp

• When a traditional incision on the temporal scalp is indicated, it is made precisely parallel to hair follicles. This generally requires that the incision is beveled to varying degrees and in different directions along its length.

• The dissection is then deepened and carried down through the galea (superficial temporal fascia) to the fascia of the temporalis muscle and the temporal hair bearing fasciocutaneous flap anterior to the incision undermined.

• The bridge of fascia lying inferiorly between the deep dissection in the temple and the subcutaneous dissection in the cheek can be safely and conveniently partially divided posterior to the temporal hairline (Fig. 9.25). Usually this bridge of tissue contains the anterior branch of the superficial temporal artery and it must be divided and ligated when encountered, or thoroughly cauterized. This is of no clinical consequence, and is a routine part of the dissection of this area. The frontal branch of the facial nerve lies well anterior and inferior to this chosen point of transition between planes, and this dissection, when executed as described, is clinically safe.

• Partially dividing the bridge of tissue between the deep plane of the temple and the subcutaneous plane of the cheek allows the two planes of dissection to be joined laterally, and this in turn facilitates exposure in the upper cheek and lateral orbit, dissection of the SMAS, and re-draping of the temporal portion of the facelift flap.^14,¹⁵ This method of dissection also protects hair follicles on the undermined temporal scalp by moving the plane of dissection deep to them.

Fig. 9.25 Dividing the mesotemporalis. The bridge of tissue situated between the subfascial (subgaleal) dissection in the temple and subcutaneous dissection in the cheek can be safely divided posterior to the course of the frontal branch of the facial nerve (dotted line). This bridge of tissue usually contains the anterior branch of the superficial temporal artery, which must be divided and cauterized or ligated.

Flap dissection with incision along the temple hairline

• When an incision along the temporal portion of the anterior hairline is indicated, it is made a few millimeters within it with a slight bevel, or parallel to the hair follicles.

• The temporal skin flap is then carefully undermined subcutaneously and joined with the subcutaneous dissection in the cheek. No transition between planes is necessary under these circumstances, no hair-bearing flaps are raised, and the superficial temporal vessels and frontal branch of the facial nerve are left undisturbed, beneath the superficial temporal fascia (Fig. 9.26).

Fig. 9.26 Flap dissection with a temporal hairline incision. When an incision is made along the temporal hairline all dissection will be in a subcutaneous plane and no transition between planes will be necessary, no hair-bearing flaps are raised and the superficial temporal vessels are left undisturbed beneath the superficial temporal fascia.

Plan for high SMAS flap

• Once the skin flaps have been elevated they are retracted and the zygomatic arch is palpated.

• A line is then traced “high” over the mid portion of the zygomatic arch in water-soluble surgical ink (methylene blue) beginning over the outer malar region at the level of the infraorbital rim and extending laterally to a point approximately 1 cm anterior to the superior portion of the tragus. This line lies higher that the dissection made in most other techniques, and well above the malar origin of the zygomaticus major muscle.

• The mark is then turned inferiorly and carried over the preauricular portion of the parotid 1–1.5 cm anterior to the ear.

• Inferior to the lobule the line is carried inferiorly and posteriorly in a soft curve to the anterior border of the sternocleidomastoid muscle (Fig. 9.27).

Fig. 9.27 Plan for high SMAS flap and the frontal branch of the facial nerve. The superior margin of the flap is planned over the zygomatic arch and not below it. The frontal branch of the facial nerve (dotted line) lies safely posterior and deep to most of the dissection.

Advantages of the high flap

A basic high flap of this type is used for most patients and there are several important aspects of its design worth considering.

• Planning the superior margin of the flap over and along the zygomatic arch, rather than inferior to it, expands the effect of the flap to include the upper midface and allows a better vector to be applied to it.

• Carrying the incision posteriorly and inferiorly over the tail of the parotid to the anterior border of the sternocleidomastoid muscle in the upper lateral neck maintains a safety zone between the incision and the mandibular margin and moves the dissection away from the marginal mandibular nerve (Fig. 9.28).

Fig. 9.28 Plan for high SMAS flap and the marginal mandibular branch of the facial nerve. The marginal mandibular branch of the facial nerve (yellow line) emerges from the anterior border of the parotid gland well anterior to the SMAS incision in the preauricular region. Note that the posterior incision curves posteriorly to the anterior border of sternocleidomastoid.

Incising the SMAS and flap elevation

• Flap elevation is begun by incising the SMAS over the zygomatic arch. This is accomplished by grasping the preauricular tissue overlying the lateral arch with an Allys clamp on each side of the marked line and using them to provide tension to the SMAS layer tissue plane.

• An incision is then made with Metzenbaum scissors and continued medially 2–3 cm along the marked line in the tensed plane.

• The Allys clamps are then released and reapplied incrementally as the dissection proceeds further medially along the marked line in the tensed plane in 2–3 cm increments in a similar fashion.

A considerable amount of tissue lies over the arch and the frontal branch will be safely concealed beneath several millimeters of fibrous fat if the dissection is performed as described. The margin for error may be reduced in the thin, aged patient with advanced facial atrophy and less soft tissue cover over the arch or in a secondary procedure. Extra caution must be taken under these circumstances.

• The preauricular limb of the SMAS incision is then made using a similar technique over the posterior parotid along the marked line in the preauricular region. It is continued inferiorly and posteriorly to the anterior border of the sternocleidomastoid muscle. These two incisions define the high SMAS flap to be elevated.

• After initial SMAS incisions have been completed preauricular tissue comprising the posterosuperior corner of the SMAS flap is grasped with Allys clamps. Flap elevation is then begun using careful scissors technique. Undermining should be limited in the pre-parotid cheek and more extensive over the zygoma and upper midface (Fig. 9.29). SMAS flap elevation entails dissection in the plane of the facial nerve in close proximity to important motor branches. Although flap elevation over the parotid is safe, great care must be taken when dissecting more medially, and over the zygomatic arch.

• A separate and distinct plane exists medial to the parotid between the SMAS-platysma and the parotidomasseteric fascia. This plane is most easily identified and established in the lower cheek where it can usually be entered by gentle blunt dissection. The paroti-domasseteric fascia will be seen as a thin, shiny transparent layer covering the masseter muscle, parotid duct, buccal fat and the branches of the facial nerve. Blunt dissection on top of this layer is safe and will not result in nerve injury, but great caution must be exercised when dissecting sharply, or when clamping or coagulating in this area. Frequently motor nerve branches accompany perforating vessels and each bleeding point must be carefully identified when hemostasis is being performed. Blind clamping should not be performed and low coagulation current should always be used. The patient’s face should also be carefully watched whenever cauterization is performed and the current discontinued immediately if facial movement is noted.

• Sub-SMAS dissection must generally be carried over the anterior border of the parotid in the lower cheek to ensure that the paroti-domasseteric ligaments tethering the SMAS are released. These are most easily identified by fingertip palpation along the front of dissection. If these restraining attachments are not released an optimal SMAS effect will not be realized and minimal overall benefit will be obtained.

• As SMAS flap dissection is made anteriorly, and medially in the upper cheek over the superior portion of the parotid and its accessory lobe, the SMAS will thin and invest the lip elevators. At this point the dissection must be taken superficial to the superior portion of the zygomaticus major muscle and its origin carefully exposed.

• Just at the malar origin of the zygomaticus major muscle the zygomatic ligaments will be encountered. These fibrous connections between the periosteum and skin must be divided and when completely released a significant liberation of the flap will be obtained. The lateralmost ligaments are typically more substantial and generally require sharp dissection and formal transection. The ligaments lying more medially are generally softer and can often be disrupted bluntly with open scissors tips.

• Directly inferomedial to the origin of the zygomaticus major muscle and superomedial to the accessory lobe of the parotid and the parotid duct is the zone of transition between the zygomatic and masseteric-cutaneous ligaments and the most potentially dan gerous part of the SMAS dissection. Proper liberation and release of the SMAS flap usually requires at least partial division of restraining attachments in this area, but moves the dissection into very close proximity to the zygomatic branch of the facial nerve (Fig. 9.30).

• Dissection of the SMAS flap and release of restraining ligaments is continued until gentle traction on the flap produces motion at the nasal ala, philtrum and stomal angle, and elevation and compression of infraorbital and lower eyelid tissue. This ‘traction test’ clinically confirms adequate flap release and is a more important indicator of a complete dissection than any arbitrary anatomical endpoint.

• If flap release is incomplete, residual tethering fibers are identified and carefully divided and the traction test repeated.

• When dissection is complete, the malar pad and attached skin should move freely as part of the high SMAS flap superiorly and laterally as needed, and no separate malar pad suturing, midface anchoring, or subperiosteal dissection is required.

Fig. 9.29 Approximate extent of SMAS undermining. Complete release of the SMAS flap will require that both the parotidomasseteric ligaments (squares) and the zygomatic ligaments (circles) are released.

Fig. 9.30 Completed SMAS flap dissection. Inferior to the origin of the zygomaticus muscle and superomedial to the accessory lobe of the parotid lies the transition between the zygomatic and masseteric-cutaneous ligaments (dots) and the most potentially dangerous part of the SMAS dissection. Proper liberation and release of the SMAS flap usually requires at least partial division of restraining attachments in this area, but moves the dissection into very close proximity to the zygomatic branch of the facial nerve.

Directly inferomedial to the origin of the zygomaticus major muscle and superomedial to the accessory lobe of the parotid and the parotid duct is the zone of transition between the zygomatic and masseteric-cutaneous ligaments and the most potentially dangerous part of the SMAS dissection.

SMAS suspension

Securing the superior margin

• Once the SMAS flap has been elevated and adequately released, the superior edge of the flap is grasped and it is shifted variously to determine which direction produces the best effect on the upper midface, cheek and jowl. In all but the unusual case this is along a posterosuperior vector parallel to the long axis of the zygomaticus major muscle. If an overly ‘vertical’ or posterior vector is used, the function of the zygomaticus major muscle may be corrupted and this may result in abnormal appearances during animation (Fig. 9.31).

Fig. 9.31 Proper and improper vector of SMAS shift. A, Correct shift of the SMAS flap is along the long axis of the zygomaticus major muscle. This allows for the natural muscle function. B, If the SMAS is shifted along a posteriorly directed vector and not along the axis of the zygomaticus muscle, the muscle will be pulled off its axis and its function will be compromised. This can result in deepening of the nasolabial fold and abnormal appearances during animation. C, An analogous problem is encountered when a vertical vector is used in a vertical facelift.

Variation in the management of the superior margin of the SMAS flap

Management of the superior margin of the SMAS flap and the technique of flap suspension will vary depending on the problems present and other considerations particular to the patient including sex, racial features and overall facial morphology.

• In most cases the superior margin of the flap is not trimmed because the overlapping tissue segments of SMAS add volume to the upper lateral cheek and restore lost projection over the zygomatic arch. In these situations the superior edge of the flap is anchored with multiple interrupted sutures of 3–0 braided polyester (Mersilene) well over the zygomatic arch directly to the deep temporal fascia, superior to the mesotemporalis. Suspension in this manner is greatly facilitated if the mesotemporalis is gently pushed inferiorly as the sutures are placed. This allows the midface, upper cheek and jowl to be securely suspended with little if any risk of injury to the frontal branch of the facial nerve.

• No suturing is needed or should be performed over the zygoma or along the infraorbital rim. These parts of the face are mobile and need to move during animation and to impart natural expression. Directly suspending the midface along the zygoma or infraorbital rim, especially rigidly, can result in tissue tethering and dimpling sometimes referred to as ‘smile block’.

• If direct anchoring of the flap to the temporal muscle fascia is not possible, even when the mesotemporalis is pushed inferiorly, suspension can still be made in this manner if sutures are allowed to bridge the intervening gap.

• In patients with wide faces and a small mandible, in many men, and in many patients of Asian or Slavic ancestry, enhancement of the upper cheek and arch obtained by overlapping the SMAS may not be artistically appropriate, necessary, or desired. In such cases the redundant tissue along the superior flap margin can be excised and discarded, and the superior flap margin sutured edge to edge to the superior margin of the initial incision made in the SMAS over the zygomatic arch.

• When an incision along the temporal hairline is used and temporal dissection is made in a subcutaneous plane, temporal muscle fascia will not be exposed and a mesotemporalis will not be present. In these cases the superficial temporal fascia can be incised along the edge of the sideburn, posterior and superior to the frontal branch of the facial nerve. The sideburn can then be reflected superiorly in a subgaleal plane, the newly created mesotemporalis pushed inferiorly, and the SMAS flap suspended to the deep temporal fascia (see Fig. 9.32). Alternatively, the redundant tissue along the superior flap margin can be excised and discarded, and the superior flap margin sutured edge to edge to the superior margin of the initial incision made in the SMAS over the zygomatic arch.

Fig. 9.32 High SMAS flap suspension. The SMAS flap has been advanced superiorly, the mesotemporalis pushed inferiorly, and the flap secured to the temporalis muscle fascia.

Securing the posterior margin of the SMAS flap

Regardless of how the superior margin of the flap is secured, some trimming of the posterior margin of the cheek SMAS flap is invariably required thereafter to allow an edge-to-edge approximation of the SMAS flap to the SMAS remnant in the preauricular region. Overlapping of the SMAS in the preauricular area is functionally unproductive and artistically inappropriate because such an arrangement lends no additional support to the anterior face and obliterates natural preauricular contours and the pretragal hollow.

• Trimming of the posterior margin of the cheek SMAS flap should be performed after the superior margin has been suspended over the zygomatic arch.

• Excision is accomplished by placing gentle traction upon it and tracing a line in marking ink over the cut edge lying beneath it.

• The amount of tissue excised will vary depending upon the size of a given face, the degree of release of the flap, and the chosen vector of advancement.

• It is unproductive and an error to place excessive traction on the SMAS in the preauricular region and the posterior margin of the flap should be trimmed carefully to avoid overexcision and a tight closure. Excessive posterior traction on the SMAS will result in perioral distortion, a ‘pulled appearance’ and other abnormal appearances.

• After trimming of the posterior margin of the SMAS flap, the cut edge is approximated to the preauricular remnant with multiple interrupted sutures of 3–0 braided polyester (or other suture of choice). These sutures consolidate the cheek and help support the superior suture line.

• Upon completion of suturing of the cheek SMAS improved facial contour should be seen and a faint smile on the ipsilateral face should be evident. Usually elevation of the lid-cheek junction and compression of the ipsilateral lower eyelid will also be noted.

Use of excess tissue as a postauricular transposition flap

• To provide additional support in the anterior neck and along the submental region, the excess tissue along the posterior margin of the cheek SMAS flap can be left attached to the cervical-submental platysma and used as a postauricular transposition flap.

• This flap improves neck contour by correcting horizontal platysma redundancy and increasing submental support. Frequently this cannot be accomplished by lateral platysmapexy alone due to mobility of the tissues in the upper lateral neck. Suturing the transposed segment of cheek SMAS to the mastoid fascia, while leaving it attached to the cervical platysma, circumvents this problem and produces an improved result. In addition, a dynamic sling is created that tightens the submental region when the patient looks down. This tightening is obtained because the mastoid moves superiorly during neck flexion and away from the anterior neck, pulling the transposed flap, and attached tissue, with it.

• When a postauricular transposition flap is used it must be carefully designed and its effect thoroughly tested intraoperatively.

• The SMAS must be incised in such a fashion that the transposition flap exerts its effect on the cervical platysma below the mandibular border, and not more superiorly on the SMAS in the cheek.

• Flap suspension is best delayed until after anterior platysmaplasty is completed.

• A postauricular transposition flap when used in conjunction with anterior platysmaplasty, results in a mastoid to mastoid sling of autologous tissue. This is a more natural and superior maneuver that any attempt to accentuate neck contour by the placement of suspension sutures.

Drain placement

Drains are used routinely and experience has shown that they reduce postoperative ecchymosis and seromas, and allow patients to return to their work and social lives sooner. Drains will not, however, substitute for poor hemostasis and will not prevent hematoma formation.

• A 10 F round soft Silastic Jackson-Pratt-style closed-circuit suction drain is used. It is placed through a small stab incision on the occipital scalp 1–2 cm superior to the apex of the occipitomastoid incision and is anchored at its exit site with a 4–0 nylon or similar suture. The drain tip is then passed beneath the cervical skin across the anterior neck to the opposite side of the face.

• No drains are needed or placed in the cheeks. Blood or fluid originating from these areas will move under the influence of gravity to the neck area.

Skin flap repositioning and suspension suture placement

The goal of skin excision should be to remove redundancy, and not to tighten the skin flap. In addition, to avoid unnatural appearances, skin flaps must be shifted in a slightly more posterior, less superior direction than that of the SMAS. Shifting skin along an overly superior or posterior vector or suspending skin flaps under tension will result in hairline displacement, unnatural appearances, poor scars, and other objectionable problems.

Cheek skin

Cheek skin flaps should be shifted along a vector approximately perpendicular to the nasolabial fold. This will minimize sideburn elevation and displacement, and skin will lie more naturally over the tragus once healing is complete. Maximum improvement will also be obtained in the nasolabial area when this vector is used.

Postauricular area skin

In the postauricular area skin should be shifted along a vector roughly parallel to the mandibular border. This provides optimal improvement in the anterior neck and allows maximum excision of skin flap redundancy without compromising the flap’s covering function. If the postauricular skin flap is shifted along a more superiorly directed vector, improvement in the anterior neck will be compromised, skin will be mistaken excised over the apex of the occipitomastoid incision, and a wide scar will result once healing is complete.

Points of skin flap suspension

There are two points of skin flap suspension that should be set first before the remainder of the closure is performed.

• The first point is located in the supra-auricular area where the anterosuperior most part of the ear joins the scalp. To set this point the cheek skin flap should be shifted along a vector roughly perpendicular to the nasolabial fold and skin redundancy gauged with a facelift marker or similar implement (Fig. 9.33). The skin flap should be held under normal skin tension when the mark is made and an incision made into the flap up to the marked point. The flap should then be anchored at this point with a half buried vertical mattress suture of 4–0 nylon with the knot tied on the scalp side. No deep sutures are necessary or used.

• The second point of suspension is located in the postauricular crease at the anterosuperior aspect of the occipitomastoid incision. The postauricular flap should be shifted posteriorly and superiorly roughly parallel to transverse neck creases and the mandibular border in such a manner that skin is suspended under minimal or no tension and that little or no skin is trimmed from the anterior (postauricular) flap border. The flap is then secured at this point with a simple interrupted suture of 4–0 nylon. No incision into the flap is necessary and no deep suture is used.

Fig. 9.33 Facelift marker. A, Close-up view of the tip design. B, Diagram showing the instrument in use. Use of a flap marker provides a reliable means for making appropriate excisions of skin. The pin on the lower jaw of the marker is designed to be placed near the edge of the incision. The skin flap is then pulled over the lower jaw of the instrument and when proper tension is set the instrument is closed. On closing, the upper jaw of the instrument marks the precise position of the edge of the scalp flap beneath it. This serves as a valuable guide to the degree of redundancy present and is particularly useful in gauging the depth of pilot incisions initially made into the flap at points of initial flap suspension.

Incision to exteriorize the lobule

• Once the initial two suspension sutures have been placed, the stage is set for the remainder of the closure and the flap overlying the inferior portion of the ear can be carefully divided and the lobule exteriorized.

• Incision of the flap and exteriorization of the lobule is a key step in the procedure that must be performed incrementally and with great care if a visible scar, lobular malposition and other objectionable secondary deformities are to be avoided.

• If the incision to exteriorize the lobule is made correctly, the apex of the incision should rest snugly against the inferiormost portion of the conchal cartilage beneath the lobule. If the incision into the cheek flap is made too far anteriorly or inferiorly, however, artistically appropriate resetting of the lobule will be impossible, and the outcome of the overall procedure will be significantly compromised.

Skin flap trimming and closure

Skin flap trimming and incision closure is conveniently begun in the postauricular area along the auriculomastoid sulcus, and should be completed before trimming and closure of the occipital portion of the incision and resetting of the lobule.

Trimming and closure of the postauricular skin flap

This stage is begun by conservatively trimming the anterior border of the postauricular skin flap into a soft curve to match the curve of the incision made behind the ear in the auriculomastoid sulcus. Typically, no more than a few millimeters of tissue are removed. The incision is then closed with several interrupted sutures of 4–0 nylon. No deep suture is used.

It is an error to excise any skin over (superior to) the apex of the occipitomastoid incision and to shorten the postauricular flap along the long axis of the sternocleidomastoid muscle as is commonly practiced. Despite an apparent redundancy in this area when the patient is supine on the operating table, there is never a true skin excess at this location. This deceptive pseudoexcess of skin is present only because of the patient’s high shoulder position in the supine position, and will vanish when the patient sits up and the shoulders drop to a normal location. Skin along the long axis of the sternocleidomastoid muscle in the postauricular region is also needed for side-to-side head tilt. Inappropriate excision of skin over the apex of the occipitomastoid defect is the underlying cause of hypertrophic healing in the postauricular region and a wide postauricular scar (Fig. 9.34).

Fig. 9.34 Incorrect trimming of the postauricular skin flap. It is an error to excise any skin over (superior to) the apex of the occipitomastoid incision and shorten the postauricular flap along the long axis of the sternocleidomastoid muscle. There is no true excess of skin along this vector nor any aesthetic benefit from shifting the skin in this direction. Excision of the skin in this fashion is the underlying cause of hypertrophic healing in the postauricular area and a postauricular scar.

Trimming and closure of the occipital incision

• Trimming and closure of the occipital portion of the facelift incision should be performed after closure of the postauricular area.

• If the occipital incision was made into the occipital scalp (see Fig. 9.14), it should be closed without shifting or excision of skin or scalp in one layer with multiple simple interrupted sutures of 4–0 nylon (or other suture of choice). This incision plan is used to provide access to the lateral neck only and cannot, by design, accommodate skin excision in this area without producing displacement and notching of the occipital hairline or shifting of the postauricular skin flap along an inappropriate vector. Because this incision is typically beveled when properly made, staples will not provide precise wound edge approximation. Sutures are usually required if wound malalignment and step-offs are to be avoided.

• If the occipital incision has been made along the occipital hairline as is most often the case (see Fig. 9.17), skin will be excised from the posterior border of the postauricular skin flap. A facelift marker should be used to gauge skin flap redundancy, and it must be remembered that the goal of skin excision is to remove redundancy and not to tighten the cervical skin flap. If trimming is performed correctly wound edges should abut one another before sutures are placed. The incision is then closed in one layer with multiple half buried vertical mattress sutures of 4–0 nylon with the knots tied on the scalp side and a simple running suture of 6–0 polypropylene (Prolene) (Fig. 9.35). No deep sutures are required and staples should not be used. This scheme will provide precise wound edge alignment and prevent cross-hatched scars (suture marks).

Fig. 9.35 Suturing scheme for incision along hairlines. A, Wound edges are approximated with interrupted half-buried vertical mattress sutures of 4–0 nylon with the knots tied on the scalp side. B, Final approximation is made with simple interrupted sutures of 6–0 nylon.

If there is a dog-ear

• If the postauricular skin flap has been shifted along a proper vector, and tissue distributed appropriately under no tension over the occipital area, a near precise fit should be obtained. If there is a large amount of neck skin redundancy or if the postauricular flap has been suspended under tension, a dog-ear will often be present at the inferiormost portion of the occipital incision.

• A dog-ear, if present should not be chased down the occipital hairline because an obvious scar will result in the fine hair on the nape of the neck. A better result is obtained under these circumstances if the dog-ear is inset posteriorly into the occipital scalp, above the junction of thick and fine hair, and secured with simple interrupted sutures of 4–0 nylon. This requires excision of a small ellipse of scalp from the scalp side of the incision, but moves the end of the incision into dense hair where it is well concealed.

Trimming and closure in the preauricular area

• Once the postauricular and occipital areas have been closed attention should be turned to the preauricular area.

• Skin flap redundancy should be carefully gauged using a facelift marker while the pretragal portion of the skin flap is held down into the pretragal hollow with an instrument by the assistant. This ensures that enough skin will be present to fill the pretragal sulcus and to provide natural and attractive preauricular contours once healing is complete. This is also a key step in avoiding a ‘retracted tragus’ deformity.

• Using marks made by the facelift marker as points of reference, the prehelical portion of the flap is trimmed to form a soft curve that matches the prehelical incision. If trimming is performed correctly wound edges will abut one another before sutures are placed. The incision is then closed in one layer with a simple running suture of 6–0 polypropylene. No deep sutures are necessary.

• The prelobular (subtragal) portion of the cheek skin flap is trimmed next, guided by marks made with the facelift marker. If trimming is performed correctly, wound edges will abut one another before sutures are placed. The incision is then closed in one layer with several simple interrupted sutures of 6–0 nylon or polypropylene. No deep sutures are necessary.

• Only after the prehelical and prelobular areas have been closed should the tragal flap be trimmed. This trimming must be performed with great care and while the assistant holds the pretragal portion of the skin flap into the pretragal hollow. As elsewhere in the periauricular closure, the tragal flap should be trimmed with 2–3 mm of redundancy. Closure is then made with a simple running suture of 6–0 polypropylene. No deep sutures are necessary.

Overexcision of skin from the tragal skin flap is a serious technical error that will result in tragal retraction and an unnatural chopped off tragal appearance.

Insetting the lobule

• The lobule should be inset into the cheek flap as the last step in the closure of the peri-auricular area because little is as tell-tale and aesthetically objectionable as abnormal position of the ear lobe.

• Trimming the cheek flap in the lobular area must always be performed incrementally with great care to prevent over-excision. In addition, the cheek flap should be trimmed and the ear lobe inset in such a manner that the lobule ends up situated in a posterior and somewhat superior position, even it if was in a more anterior or inferior position before surgery. This is because the long axis of the ear lobe of an artistically ideal nonsurgical-appearing ear sits approximately 15 ° posterior to the long axis of the ear itself in the lateral view (Fig. 9.36A). If this angle is reduced or shifted anteriorly or the lobule is mistakenly placed too far inferiorly, an unnatural and facelift look is produced (Fig. 9.36B).

Fig. 9.36 Proper insetting of the ear lobe. A, In the artistically ideal nonsurgical-appearing ear the long axis of the ear lobe (dotted line) is approximately 15 ° posterior to the long axis of the ear itself (solid line) in the lateral ear. B, As this angle is reduced or the axis of the lobule is shifted anterior to the long axis of the ear, an old, unnatural and facelift look is produced.

Abnormal position of the ear lobe results in an aesthetically objectionable, unnatural, facelift look. Because of this the lobule should be inset into the cheek flap as the last step in the closure of the periauricular area.

• Insetting the lobule into the cheek so that its long axis sits posterior to the long axis of the rest of the ear often requires release of the lobule from tethering tissue.

• The lobule is then secured in two layers. The first layer consists of several deep dermal sutures of 4–0 chromic gut (or other absorbable suture). These sutures provide initial alignment, and protect the incision from disruption in the first few weeks after surgery when patients pull clothing, jewelry and other items off over their heads. Final approximation is then made with a simple running suture of 6–0 polypropylene. A running polypropylene suture is much easier to remove at this location than a running or interrupted suture of 6–0 nylon.

• If the lobule has been inset correctly, there is often some skin redundancy on the posterior surface of the ear at the lobularconchal junction. This is easily and conveniently managed by excising a triangle of skin corresponding to the tissue redundancy in this area. Closure is made in one layer with several simple interrupted sutures of 4–0 nylon or other suture of choice.

Closure of the temporal incision

• If foreheadplasty is to be performed as part of the procedure,¹⁶^–¹⁹ closure of the temporal portion of the facelift incision is delayed until after it is complete. This preserves access to the upper lateral face and affords precise realignment of tissue in this area.

• If the temporal portion of the facelift incision has been made on temporal scalp (see Fig. 9.6) the incision is closed in one layer without excision of any hair-bearing temporal tissue with multiple simple interrupted sutures of 4–0 nylon. A small amount of cheek skin and scalp only will be excised immediately above the ear at the completion of the closure. Because the incision on the temporal scalp is usually beveled when properly made, sutures, and not staples, are generally required, if malalignment and step-offs are to be avoided. It is clinically unproductive, a conceptual error, and a serious technical mistake to excise scalp over the temple region in attempt to tighten the forehead or upper lateral face.

• If the temporal portion of the facelift incision has been made along the temporal hairline (see Fig. 9.7), skin only will be trimmed when it is closed. A facelift marker should be used to gauge temporal skin excess and the flap intentionally trimmed with 2–3 mm of redundancy. If trimming is performed correctly the wound edges should abut one another and no gaps should be before the sutures are placed. The incision is then closed in one layer with a combination of half-buried vertical mattress sutures of 4–0 nylon with the knots on the scalp side and a simple running suture of 6–0 polypropylene (see Fig. 9.35). Staples should not be used. This scheme will provide precise wound edge alignment and will prevent cross-hatched scars (suture marks).