Facelift with SMAS Flaps

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Chapter 9 Facelift with SMAS Flaps

Timothy J. Marten

The history of surgical modifications of the face is perhaps as old as surgery itself and the historic record is unclear as to when and where the first ‘facelift’ was performed. By the early 20th century surgeons had begun performing procedures to rejuvenate the face and techniques consisting of small excisions of facial skin had begun to evolve. These initial procedures were limited however, because they were performed using small discontinuous incisions, and because no skin undermining was performed.

Summary

1. It is not possible to design a ‘universal’ facelift technique. Each patient will present with a unique set of problems that requires precise anatomic diagnosis and an appropriately planned and individualized surgical repair.
2. Attractive and natural-appearing rejuvenation of the face is not possible without diverting tension away from the skin to the superficial musculoaponeurotic system (SMAS) and platysma, and unless other deep layer structures and the aging midface is addressed.
3. Skin has a covering function rather than a structural or supporting one. Using skin as the vehicle to support sagging deep layer tissue corrupts its function and results in abnormal tension and related secondary problems including poor scars, tragal retraction, ear lobe mal-position, and a tight and unnatural appearance.
4. Using the SMAS to lift sagging facial tissues and restore facial contour circumvents the problems associated with skin-only facelifts because it is an inelastic structural layer capable of providing meaningful and sustained support. Although skin must be excised in SMAS procedures, only redundant tissue is sacrificed and closure can be made under normal skin tension.
5. Most midface lifts are conceptually flawed in that they erroneously assume the problem seen in the anterior upper cheek to be solely one of tissue sagging. Failure to acknowledge the presence of significant atrophy has led to general disappointment for both patients and surgeons following many procedures.
6. Careful evaluation of most patients who need a midface lift will show that they also need a facelift and it is unusual to encounter a patient with significant midface aging who does not also have sagging in the cheek and jowl. Midface lifts as a result are arguably more logically performed in conjunction with a formal facelift procedure rather than as isolated, stand-alone procedures.
7. The conventional low cheek SMAS flap elevated below the zygomatic arch has the drawback that it does not, by design, have an effect on tissues of the midface, perioral, and infraorbital regions. Planning a higher flap along the superior border of the zygomatic arch overcomes this problem and produces an improved result.
8. High SMAS procedures are readily combined with midface fat injections because midface and infraorbital tissue planes are not opened or dissected. This 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.
9. Lamellar dissections in which the skin and SMAS are dissected as two separate layers offer the important advantage that skin and SMAS can be advanced different amounts along separate vectors and suspended under differential tension. This allows each layer to be addressed individually as indicated and results in a more comprehensive and natural appearing improvement, and less sideburn elevation and displacement.
10. Proper analysis, careful planning and the use of an incision along the hairline, when indicated, can avert sideburn elevation and displacement and occipital hairline notching, without compromising the overall outcome of the procedure. This is particularly true of patients with marked skin redundancy and those presenting for secondary procedures.

Introduction

The history of surgical modifications of the face is perhaps as old as surgery itself and the historic record is unclear as to when and where the first ‘facelift’ was performed. By the early 20th century surgeons had begun performing procedures to rejuvenate the face and techniques consisting of small excisions of facial skin had begun to evolve. These initial procedures were limited however, because they were performed using small discontinuous incisions, and because no skin undermining was performed.

In 1920 Bettman described the continuous temporal-periauricular incision plan that became the prototype of that used in contemporary procedures, setting the stage for more comprehensive and balanced improvements, and in 1927 Bames recognized that undermining skin could further enhance outcomes. These developments comprised the foundation of the classical facelift procedures that were subsequently performed without major modification over the next four decades.

The modern era of facelift technique began in 1974 when Swedish surgeon Torg Skoog described dissection beneath the superficial fascia of the face and neck, a tissue layer subsequently described anatomically by Mitz and Peyronie that ultimately became known as the SMAS (superficial musculoaponeurotic system). Dissecting the SMAS allowed sagging deeper facial tissues to be repositioned to a more youthful position by an inelastic fascial layer, and tension to be diverted away from the skin. This resulted in softer more natural appearances, improved scars, and a significant improvement in the longevity of the procedure.

Numerous modifications have been made to Skoog’s procedure, and his idea has spawned alternative ways in which the SMAS is used. Nonetheless, the concept that the SMAS is the tissue layer most closely associated with age-associated facial tissue ptosis and the most logical means by which to correct it forms the foundation of most modern facelift techniques.

Facelift techniques

Some of the advantages and disadvantages of different facelift techniques are listed in Table 9.1.

Table 9.1 Advantages and disadvantages of different types of facelift techniques

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.

SMAS

Repositioning ptotic facial tissue using the SMAS is arguably the single most important advance in facelift technique since the inception of the procedure and various surgeons have devised different strategies to use it to improve the outcome of procedures. Each has certain advantages and disadvantages, but all share advantages over traditional skin-only procedures as follows:

• most changes in the aging face are the result of sagging of tissue deep to the skin, and not the skin itself – the SMAS is more closely associated with the tissues that sag as the face ages than skin, and it is therefore arguably a more logical layer to use to restore them to a more youthful position;
• the SMAS, unlike skin, is an inelastic layer capable of providing sustained support and can be used to divert tension away from the skin, and this will avert most secondary facelift deformities;
• SMAS lifts provide a means by which facelifts can be repeated without producing excessive skin tightness.

SMAS plication

SMAS plication is perhaps the simplest technique to modify the SMAS. In these procedures a skin flap is raised but an SMAS flap is not elevated. Deep facial tissue is then plicated or invaginated with sutures, rather than lifted, to support the lower cheek, jawline, and lateral perioral area.

A potential advantage of the SMAS plication technique is that no sub-SMAS dissection is required and therefore the procedure is viewed by many as technically less demanding and time consuming than procedures in which a flap is raised.

Disadvantages of the SMAS plication technique are:

• it requires wide skin flap undermining because to be effective plication must be made anterior to the anterior border of the parotid, and this can be problematic in smokers or others patients with compromised circulation;
• despite its seeming simplicity the procedure is technique dependent, and if sutures are not placed carefully contour irregularities can result, facial nerve branches can be damaged, and the parotid gland or duct can be injured;
• tissue is redistributed into the mid cheek rather than over the upper malar region as it is in some procedures in which a SMAS flap is raised, and therefore little if any midface improvement can be obtained.

SMASectomy

SMASectomy is a procedure devised and popularized by Daniel Baker. Key elements of the procedure are:

• it includes an extended subcutaneous dissection;
• a SMAS flap is not elevated.

A strip of SMAS is excised obliquely over the anterior parotid, beginning in the upper lateral neck extending to the ipsilateral lateral malar region, and the cut edges of the SMAS are reapproximated to support the jawline and lateral perioral region.

Advantages of SMASectomy technique are:

• no sub SMAS dissection is 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.

Potential disadvantages of SMASectomy are:

• wide skin undermining is required, so the procedure is potentially more hazardous in smokers and other patients with compromised skin circulation;
• facial nerve branches are arguably at risk when SMAS is excised and sutured;
• if cut SMAS edges are not reapproximated carefully contour irregularities can occur;
• tissue is discarded rather than redistributed;
• minimal improvement in the mid-face is obtained

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:

• similar to those for a deep plane lift with the added possible benefit that it allows the orbicularis oculi muscle to be repositioned and the lid-cheek junction to be raised;
• the midface is elevated by a medially vectored flap of orbicularis oculi anchored near the lateral orbit.

Potential disadvantages are:

• similar to those of the deep plane technique – skin and SMAS are repositioned in a unidirectional fashion, and therefore wrinkle shift and sideburn displacement may occur, and extraordinary tension can result in unnatural appearances;
• 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).

image

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).

image

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.

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