Vancouver, British Columbia, Canada;New York, N.Y.; and Toorak, Victoria,
Australia
Learning Objectives: After reading this article, the participant should be ableto: 1. Identify and describe the anatomy of and changes to the aging face,including changes in bone mass and structure and changes to the skin, tissue,and muscles. 2. Assess each individual’s unique anatomy before embarking onface-lift surgery and incorporate various surgical techniques, including fat graft-ing and other corrective procedures in addition to shifting existing fat to ahigher position on the face, into discussions with patients. 3. Identify risk factorsand potential complications in prospective patients. 4. Describe the benefits andrisks of various techniques.Summary: The ability to surgically rejuvenate the aging face has progressed inparallel with plastic surgeons’ understanding of facial anatomy. In turn, a moreclear explanation now exists for the visible changes seen in the aging face. Thisarticle and its associated video content review the current understanding offacial anatomy as it relates to facial aging. The standard face-lift techniques areexplained and their various features, both good and bad, are reviewed. Theobjective is for surgeons to make a better aesthetic diagnosis before embarkingon face-lift surgery, and to have the ability to use the appropriate techniquedepending on the clinical situation. (Plast. Reconstr. Surg. 128: 747e, 2011.)
For treating the structure of the aging face,face-lift surgery is the standard against whichall other methods must be measured. Despite
the introduction of less invasive surgical proce-dures and many nonsurgical modalities, nothingcan match a face lift in its ability to return the basicarchitecture of the human face to a more youthfulconfiguration.
ANATOMY OF FACIAL AGINGThe visible changes of age are the net result of
anatomical alterations that occur in all structuresof the face; no tissue is spared. As our understand-ing of these basic structural changes has grown, sotoo has our technical ability to reverse them.
BoneWith age, some bone mass is lost from the
facial skeleton in certain specific areas. In the mid-face, there is a gradual retrusion of the infraorbitalrim and the anterior maxilla, contributing in partto development of the tear trough deformity anda negative vector of the anterior globe in relation
to the soft-tissue cheek mass (Fig. 1).1,2 The orbitexpands inferolaterally and superomedially (Fig.2).3,4 If dentition is lost, there is also a reductionin overall facial height because of loss of alveolarbone in the mandible and maxilla.5,6
SkinMany recognized changes occur in the skin.7
There is a gradual loss of elasticity, a reduction inskin appendages, decreased dermal thickness, andthe development of folds and wrinkles. Acceler-ating the process are external variables such as sunexposure, smoking, and weight fluctuations.
Soft TissueThe most dramatic changes occur in subcuta-
neous soft tissue. The face can be considered a lam-
Disclosure: The authors have no financial interestto declare in relation to the content of this article.
Related Video content is available for this ar-ticle. The videos can be found under the “Re-lated Videos” section of the full-text article, or,for Ovid users, using the URL citationsprinted in the article.
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inated structure, analogous to the five layers of thescalp. In the face, these layers are skin, subcutaneousfat, musculoaponeurotic layer, spaces that containnerves and retaining ligaments, and the deep fascia/periosteum (Fig. 3). (See Video 1, in which BryanMendelson gives a lecture on facial anatomy and theaging of the face, available in the “Related Videos”section of the full-text article on PRSJounal.com or,for Ovid users, at http://links.lww.com/PRS/A418.This clip covers the overview of bone, bony cavities,and the differences between the lateral and the an-terior face. It then describes the soft-tissue layers ofthe face.)
In the normal individual, the bulk of facial softtissue is fat. One study demonstrated that in thecheek area, 56 percent of the fat is superficial to thesuperficial musculoaponeurotic system (SMAS) and44 percent is deep.8 The superficial and deep fat arepartitioned into a number of compartments by ver-
tical septa.9,10 The superficial fat has five compart-ments: nasolabial, medial cheek, middle cheek, lat-eral temporoparietal, and inferior orbital fat. Thetwo primary components of the malar fat pad are thenasolabial and medial cheek fat (Fig. 4). The deepfat is divided into the deep medial fat and the sub-orbicularis oculi fat. Loss of volume in the deepmedial fat may be responsible for the loss of fullnessseen in the aging midface.10,11
Facial skin is directly adherent to underlyingfat by means of the retinacular cutis system. (SeeVideo 2, in which Bryan Mendelson continues hislecture on facial anatomy and the aging of theface, available in the “Related Videos” section ofthe full-text article on PRSJounal.com or, for Ovidusers, at http://links.lww.com/PRS/A419. This clipcovers the retaining ligaments and septa.) Multi-ple small septa compartmentalize the subcutane-ous fat, and in areas overlying any deep soft-tissueligaments, the septa run vertically, making the dis-section of skin from the underlying fat more difficultand bloody; McGregor’s patch is such an area.
Traditionally, surgeons have considered facialfat to be a ptotic tissue, sliding down over themuscles of facial expression, which do not elon-gate with age. The fat tends to bunch up at thenasolabial fold and at the mandibular ligament,where it creates the jowl.12
Recently, there has been a greater appreciationfor the loss of soft-tissue volume in the middle andupper thirds of the aging face.13–15 One study sup-ports the concept that tissue along the inferior or-bital rim does not become ptotic but instead appearsto do so because of volume loss.10 Meanwhile, fatappears to accumulate in the lower third, especiallythe neck and jowl area, a so-called radial expansion,which changes the overall facial shape (Fig. 5).16,17
Immediately deep to the subcutaneous fat isthe SMAS, described by Mitz and Peyronie in1976.18 Subsequent studies identified this layer asinvesting the elevators of the upper lip on theirsuperficial and deep surfaces.19–21 The SMAS iscontinuous with the platysma muscle inferiorly, andsuperiorly it is analogous to the superficial temporalfascia (temporoparietal fascia), which continuesinto the scalp as the galea aponeurotica.22 The thick-ness of the SMAS varies between patients, and alsovaries in every individual face, being thicker andadherent over the parotid, and thinner anteriorly.The SMAS is tenuous under the malar fat pad,where it splits to encompass the zygomaticus ma-jor and the orbicularis oculi. The SMAS has im-portant surgical implications because it can act asa carrier for overlying subcutaneous fat, and it hasbeen shown to be much more resistant to stretch
Fig. 1. Age-related retrusion of the inferior orbital rim. (Re-printed from Pessa JE. An algorithm of facial aging: Verification ofLambros’s theory by three-dimensional stereolithography, withreference to the pathogenesis of midfacial aging, scleral show,and the lateral suborbital trough deformity. Plast Reconstr Surg.2000;106:479 – 488; discussion 489 – 490.)
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than skin.23 Furthermore, below the zygomaticarch, all branches of the facial nerve are deep tothe SMAS.
The muscles of facial expression are arranged inprogressively deeper layers, with the most superficialbeing of interest to surgeons: zygomaticus major,zygomaticus minor, orbicularis oculi, and platysma.These muscles are encased by the SMAS and areinnervated by branches of the facial nerve on their
deep surface. Consequently, surgical dissection onthe superficial surface of these muscles will not en-danger the facial nerve. The only facial muscles in-nervated on their superficial surface are the levatoranguli oris, mentalis, and buccinator.
Retaining LigamentsThe existence of retaining ligaments was orig-
inally described by Bosse and Papillon24 and
Fig. 2. Age-related enlargement of the orbital aperture. (Reprinted fromPessa JE. An algorithm of facial aging: Verification of Lambros’s theory bythree-dimensional stereolithography, with reference to the pathogenesis ofmidfacial aging, scleral show, and the lateral suborbital trough deformity.Plast Reconstr Surg. 2000;106:479 – 488; discussion 489 – 490.)
Fig. 3. The five layers of the face, analogous to layers of the scalp and neck. The facialnerve travels deep to layer 3, becoming more superficial within layer 4. (Reprinted withpermission from Mendelson B. Facelift anatomy, SMAS retaining ligaments and facialspaces. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. London:Elsevier; 2009:57.)
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Furnas,25 and later refined by Stuzin et al.26 Thesetethering structures attach the SMAS and overly-ing soft tissue to underlying muscle and bone andthe parotid gland. Zygomatic and mandibular lig-
aments take their origin from the zygoma andmandible, whereas masseteric ligaments originatefrom the masseter muscle. Overlying the parotidgland adjacent to the ear lobe is firm fascia that isreferred to by a number of different anatomicalnames, such as platysma-auricular ligament, parotidcutaneous ligament, and Lore’s fascia. This networkof retaining ligaments has been characterized assepta that not only tether the overlying SMAS butalso delineate various anatomical spaces (Fig. 6).27
(See Video 2, in which Bryan Mendelson continueshis lecture on facial anatomy and the aging of theface, available in the “Related Videos” section of thefull-text article on PRSJounal.com or, for Ovid users,at http://links.lww.com/PRS/A419.)
The prezygomatic space is a triangular spaceoverlying the body of the zygoma; it is boundedsuperiorly by the orbicularis retaining ligamentand inferiorly by a row of zygomatic cutaneousligaments. The roof of this space is the orbicularisoculi muscle. With age, ligamentous laxity resultsin bulging of this space; this has been proposed asthe cause of malar mounds.27,28 The masticatorspace lies anterior to the masseter in the midcheekand contains the buccal fat pad. The premasse-teric space overlies the lower portion of the mas-seter. Its roof is the platysma, and aging results inthe formation of jowls as this space bulges againstthe mandibular ligament (Fig. 7). (See Video 3, inwhich Bryan Mendelson continues his lecture onfacial anatomy and the aging of the face, available
Fig. 4. The malar fad pad is roughly triangular and overlies thezygomaticus major, the zygomaticus minor, and the lower orbic-ularis oculi. It is a thickened portion of the superficial fat layer.(Reprinted with permission from Aston SJ, Walden J. Facelift withSMAS techniques and FAME. In: Aston SJ, Steinbrech DS, Walden JL,eds. Aesthetic Plastic Surgery. London: Elsevier; 2009:74.)
Video 1. Video 1, in which Bryan Mendelson gives a lecture onfacial anatomy and the aging of the face, is available in the “RelatedVideos” section of the full-text article on PRSJounal.com or, forOvid users, at http://links.lww.com/PRS/A418. This clip cov-ers the overview of bone, bony cavities, and the differencesbetween the lateral and the anterior face. It then describes thesoft-tissue layers of the face.
Video 2. Video 2, in which Bryan Mendelson continues hislecture on facial anatomy and the aging of the face, is available inthe “Related Videos” section of the full-text article on PRSJounal.com or, for Ovid users, at http://links.lww.com/PRS/A419. Thisclip covers the retaining ligaments and septa.
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in the “Related Videos” section of the full-textarticle on PRSJounal.com or, for Ovid users, athttp://links.lww.com/PRS/A420. This clip coversthe facial spaces and surgical implications.)
The visible effect of soft-tissue aging aroundthese structures is seen with development of the mid-cheek groove, which is caused by the cutaneous exten-sions of the zygomatic ligament and loss of fat. Simi-
Fig. 5. A patient is shown at age 20 years (left) and at age 70 (right). This healthy woman hasnever undergone surgery, has gained 10 pounds, and has aged 50 years. There has beenvolume loss in the periorbita and middle third of her face, revealing underlying bone. Theremaining soft tissues have become ptotic, flattening her cheeks and widening her jawline.
Fig. 6. Ligaments line up in a linear fashion, forming septa thattether the overlying SMAS but also act as boundaries aroundbony cavities and anatomical spaces. (Reprinted with permissionfrom Mendelson B. Facelift anatomy, SMAS retaining ligamentsand facial spaces. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aes-thetic Plastic Surgery. London: Elsevier; 2009:63.)
Fig. 7. From above, the orbicularis retaining ligament and thezygomaticocutaneous ligaments delineate the preseptal space,the prezygomatic space, and the masticator space. The premas-seteric space is posterior to the masseteric cutaneous ligaments.(Reprinted with permission from Mendelson B. Facelift anatomy,SMAS retaining ligaments and facial spaces. In: Aston SJ, Stein-brech DS, Walden JL, eds. Aesthetic Plastic Surgery. London:Elsevier; 2009:60.)
larly, the nasojugal groove (tear trough) is partlycaused by the tethering effect of the orbicularis re-taining ligament (orbitomalar ligament), as well asloss of overlying fat, and bulging of orbital fat supe-rior to the grove.29,30 In the posterior cheek, wherethe SMAS is adherent to the parotid gland, there islittle soft-tissue ptosis with age. This is the “fixedSMAS” that can be used to support the surgicallymobilized portion of the more anterior “mobileSMAS” (Fig. 8). (See Video 2, http://links.lww.com/PRS/A419.)
NERVE ANATOMY
Facial NerveWithin the parotid gland, the facial nerves di-
vide into an upper portion and a lower portion,which in turn divide into five branches: temporal,zygomatic, buccal, marginal mandibular, and cer-vical. Exiting the parotid gland deep to the pa-rotid-masseteric fascia, the temporal branch di-vides into two or three branches that coursesuperiorly, crossing the middle third of the zygo-matic arch. The buccal and zygomatic branchesfrequently interconnect.31 The buccal branchestravel across the buccal fat pad, in close proximityto the parotid duct and the transverse facial artery.The marginal mandibular branch exits the pa-rotid and normally courses 1 or 2 cm below theborder of the mandible. Aging causes little changein the branches of the facial nerve, although inolder individuals the marginal mandibular branch
has been seen as much as 4 cm below the man-dibular border.32
Great Auricular NerveThe great auricular nerve, a branch of the
cervical plexus, provides sensation to the earlobeand lateral portion of the pinna. This nerve crossesthe midportion of the sternocleidomastoid muscleapproximately 6.5 cm below the external auditorycanal. It then runs parallel and just posterior to theexternal jugular vein. The nerve is technicallydeep to the superficial cervical fascia, but overly-ing the posterior border of the sternocleidomas-toid, the platysma is absent, placing it in a super-ficial location and therefore at risk during surgicaldissection.33
PATIENT EVALUATIONAs with any elective surgery, patients present-
ing for facial rejuvenation should have a thoroughpreoperative medical assessment. Normally, thesepatients are middle-aged or older and may havechronic conditions such as respiratory disease, car-diac disease, diabetes, and obesity, all of which canpreclude surgery. In otherwise healthy individuals,
Video 3. Video 3, in which Bryan Mendelson continues his lec-ture on facial anatomy and the aging of the face, is available in the“Related Videos” section of the full-text article on PRSJounal.comor, for Ovid users, at http://links.lww.com/PRS/A420. This clipcovers the facial spaces and surgical implications.
Fig. 8. The fixed posterior face is held in place by the platysmaauricular fascia (large red area) and a vertical column of retainingligaments: temporal adhesion (orbital ligament), lateral orbitalthickening (superficial canthal tendon), zygomatic ligaments,masseteric ligaments, mandibular ligament. (Reprinted withpermission from Mendelson B. Facelift anatomy, SMAS retain-ing ligaments and facial spaces. In: Aston SJ, Steinbrech DS,Walden JL, eds. Aesthetic Plastic Surgery. London: Elsevier;2009:62.)
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specific issues that can be problematic in the face-lift population include the following:
Patients with a tendency to be hypertensive are atincreased risk for hematoma, the most com-mon face-lift complication. This should be in-vestigated, and treated appropriately beforesurgery. If patients are intermittently hyperten-sive (the white coat syndrome) or they are typeA individuals who are easily excitable, periop-erative treatment with a medication such asclonidine can be helpful.
Smokers are at increased risk for skin necrosis intheir face-lift flaps. They should avoid nicotine-containing substances for 3 weeks before sur-gery. Despite the risks involved, some surgeonsare willing to perform face-lift surgery on activesmokers, although the nature of the procedureshould be modified appropriately with thickerflaps, less dissection, and minimal tension.
Female patients in the face-lift age group may betaking hormone replacement and are there-fore at increased risk for deep vein thrombosis.In addition to all normal preventative mea-sures, this medication should be discontinued3 weeks before surgery.
Patients taking medications, herbs, or supple-ments that inhibit platelet function and pro-mote bleeding should be taken off these agents3 weeks before surgery.
Once a patient is considered medically and men-tally fit for facial rejuvenation, there should be anobjective assessment of the entire face, including theforehead, eyelids, cheeks, the perioral area, and theneck.Facialagingisaninterrelatedphenomenon,withchanges inonepartof the faceaffectingadjacentareas.Specific factors to observe are any facial asymmetries,quality of the skin, the thickness of facial soft tissue, thedegreeofsoft-tissueptosis, themobilityof thetissue, thedegree of soft-tissue loss in some areas or accumulationin other areas, and any age-related changes in muscle,particularly the platysma.
Surgical ObjectivesThe purpose of facial assessment is to derive an
aesthetic diagnosis from which specific surgicalobjectives can be determined. The most commondiagnosis is soft-tissue ptosis in the cheeks, andhistorically, surgeons have been guided by the sim-ple fact that people appear rejuvenated whenlower cheek fat is shifted into the middle andupper cheek. However, it is also apparent thatpeople can be rejuvenated with volume augmen-tation alone.34,35 Increasingly, volume augmenta-
tion with fat grafting is performed in conjunctionwith face-lift surgery.
Other issues that should enter the surgicalplan include the possibility of augmenting areas ofbone loss, correcting lax platysma muscles, andtreating aged skin by surgical tightening or withresurfacing techniques. Lastly, to produce harmo-nious results, neighboring anatomical areas suchas the forehead, eyelids, and mouth will oftenbenefit from simultaneous or staged correction.Many patients will not have considered other partsof their face; discussing such interrelated issuesmay prevent postoperative disappointment.
FACE-LIFT TECHNIQUESSubcutaneous Face Lift
The first face lift, dating from the early twentiethcentury, was a simple skin excision along the tem-poral hairline and anterior to the ear; several authorslay claim to this innovation.36–38 The approach soonevolved into a subcutaneous dissection of a largerandom pattern skin flap that was shifted in a su-perolateral direction.39,40 Still used today, this classicprocedure relies on skin tension to tighten the skinand shift underlying soft tissue (Fig. 9).
The advantages of the subcutaneous face liftare that it is relatively safe, it is easy to perform, andpatient recovery is rapid. For the thin patient with
Fig. 9. Illustration depicting subcutaneous face lift with pretra-gal incision. (Reprinted with permission from Pitman GH. Foun-dation facelift. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aes-thetic Plastic Surgery. London: Elsevier; 2009:121.)
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excess skin and minimal ptosis of deep soft tissue,this procedure is effective. However, the reverse,namely, a heavier patient with ptosis of deep tis-sue, is a poor candidate. The inherent disadvan-tage is that skin placed under tension to supportheavy underlying soft tissue tends to stretch, lead-ing to a loss of surgical effect. Furthermore, excessskin tension flattens the face and may lead towidened scars or compromised skin flaps.
Deep Subcutaneous Face LiftThe deep subcutaneous lift involves a dissec-
tion plane immediately superficial to the SMAS;this generates a thick skin flap that carries all thesuperficial facial fat in the same direction as theskin (Fig. 10).41 The advantages are that the flapis robust and there is no penetration of the SMAS,theoretically removing the risk of facial nerve in-jury. The fat on the underside of the flap can becontoured and also sutured to underlying struc-tures. The disadvantages are that the flap is uni-directional (skin and fat move together), and fix-ation depends on suture tension in fat and skin.
Subcutaneous Face Lift with SutureManipulation of Superficial Fat and SMAS
Once surgeons were able to raise a subcutaneousface lift flap, it became apparent that facial shapecould be changed and stability achieved if sutures
were used to manipulate and fix the underlying softtissue.42 Numerous variations of this theme haveevolved. Using dissolving or permanent sutures, thesuperficial fat is infolded on itself, drawing fat fromthe lower face into the midcheek. This technique ismost effective when the sutures are placed into themobile SMAS anterior to the parotid.43 Multiple su-tures with customized vectors can be used. Propo-nents claim long-lasting results, without the need formore invasive, deeper dissection.44
A variation of this method is the minimal ac-cess cranial suspension, which itself was derivedfrom the S-lift, a procedure using a short anteriorscar.45,46 Instead of individual plication sutures,this technique uses long suture loops that takemultiple small bites of soft tissue. Some of thesebites are placed strategically into the SMAS andplatysma. The loop sutures are fixated to the deeptemporal fascia just superior to the zygomatic archand anterior to the ear (Fig. 11).
The advantages of all SMAS suturing techniquesare the same as those of the subcutaneous face lift,with the additional advantage of reshaping the faceusing deep soft-tissue sutures rather than with skintension alone. The direction of deep tissue pull canbe different from the skin, and skin tension need notbe as great. Potential disadvantages include thechance of catching a facial nerve branch with adeeply placed suture and the concern that sutures
Fig. 10. Illustration showing the deep subcutaneous plane: dissection raises skin andall subcutaneous fat off the underlying SMAS layer. [Reprinted from Hoefflin SM. Theextended supraplatysmal plane (ESP) face lift. Plast Reconstr Surg. 1998;101:494–503.]
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may eventually pull through (the “cheese wire ef-fect”), with early loss of surgical effect.
Subcutaneous Face Lift with SMAS Removal(SMASectomy)
The SMASectomy procedure involves the re-moval of a strip of SMAS and overlying fat, with
direct suture closure.47 This popular methodoffers the security of direct suture fixation be-tween two cut surgical edges, without the risk ofa deep plane dissection (Fig. 12). Disadvantagesinclude the possibility of cutting a facial nervebranch (if the SMAS removal is performed an-terior to the parotid) and the fact that the malarfat pad is not detached before traction is appliedto it, perhaps limiting its long-term fixation.
The Skoog ProcedureTord Skoog, in1974, published his method
of raising skin, subcutaneous fat, and the SMASas a single flap.48 This thick, robust flap containsstretch-resistant material (the SMAS), with thepromise of a better, more long-lasting result.The disadvantages are that the dissection is in adeeper, more dangerous plane, the skin anddeep tissues move in only one direction, and theeffect in the anterior face may be limited. It wassubsequently found that the anterior tissues canbe tethered by the SMAS attachment to the lipelevators: zygomaticus major and minor, andlevator labii superioris.19 To overcome some ofthese shortcomings, multiple variations havebeen developed21,49 –51 (Figs. 13 and 14). Disad-vantages of these variations are the risks of deepplane dissection, and a longer learning curve forsurgeons.
Fig. 11. Illustration showing the minimal access cranial suspen-sion lift with loop sutures tethering soft tissue to the deep temporalfascia. (Reprinted with permission from Tonnard PL, Verpaele AM,Morrison CM. MACS face lift. In: Aston SJ, Steinbrech DS, Walden JL,eds. Aesthetic Plastic Surgery. London: Elsevier; 2009:138.)
Fig. 12. Illustration showing an SMASectomy with vectors of advancement. [Reprintedfrom Stuzin JM. MOC-PSSM CME article: Face lifting. Plast Reconstr Surg. 2008;121(1 Suppl):1–19.]
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Subcutaneous Face Lift with Separate SMASFlap
To separate the direction of movement of theskin and the SMAS, the sub-SMAS dissection prin-ciple has been used in conjunction with a subcuta-
neous dissection, resulting in a two-layer face lift.Many different variations have emerged52–58 (Fig.15). (See Video 4, in which the SMAS flap is raisedin the midcheek, available in the “Related Videos”section of the full-text article on PRSJounal.com or,for Ovid users, at http://links.lww.com/PRS/A421.)
By raising the subcutaneous flap first, and thenraising a completely separate SMAS flap, there isthe flexibility of two different vectors of move-ment, plus the advantage of firm fixation by meansof the SMAS, with minimal tension on the skin.Disadvantages are the added dissection in creatingtwo surgical planes, the risks associated with deepplane dissection, and a longer learning curve forsurgeons.
Subperiosteal ApproachPaul Tessier, in 1979, first presented his con-
cept for a subperiosteal approach using craniofa-cial principles to elevate facial tissue.59,60 Varia-tions were developed,61,62 but it was not until theintroduction of the endoscope that surgeonswidely adopted this concept.
Approaching from the temple, the midfacecan be dissected in either the subperiosteal63,64 orthe supraperiosteal plane.65,66 Additional under-mining can be accomplished through the upper
Fig. 13. Illustration showing Hamra’s original composite face liftflap, with orbicularis, malar fat, and platysma raised in continuitywith overlying skin. (Reprinted from Hamra ST. Composite rhyt-idectomy. Plast Reconstr Surg. 1992;90:1–13.)
Fig. 14. Illustration showing Barton’s “high SMAS,” with cheeksoft tissue raised along with overlying skin. (Reprinted with per-mission from Barton FE Jr, Meade RA. The ‘HIGH SMAS’ facelifttechnique. In: Aston SJ, Steinbrech DS, Walden JL, eds. AestheticPlastic Surgery. London: Elsevier; 2009:133.)
Fig. 15. Illustration showing Stuzin’s extended SMAS, with ma-lar fat being raised in continuity with the midcheek SMAS. Theskin flap is moved along a vector that is less vertical than theSMAS vector. (Reprinted with permission from Stuzin JM. Ex-tended SMAS facelift: Restoring facial shape in facelifting. In: As-ton SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery.London: Elsevier; 2009:92.)
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buccal sulcus. The advantages of a subperiostealdissection are that it is deep to the facial nervebranches, there is a short incision, and harmoni-ous lifting of the midface and lateral brow is pos-sible. Disadvantages include the additional tech-nology involved, a limited effect in the lower face/neck region, and minimal effect on facial skin.
ADJUNCTIVE TECHNIQUESMalar Fat Pad Lift
Elevation of the large malar fat pad restoresthe appearance of cheek fullness below the in-fraorbital rim and over the malar prominence.This structure may be approached by means of thetemple, the lower lid, or through a face-lift inci-sion. If a face lift is used, there are several optionsfor elevating the fat pad. It can be identifiedthrough a subcutaneous flap and simply sutured.It can be freed from underlying muscle (orbicu-laris oculi and zygomaticus major) but left at-tached to overlying skin.11 It can be freed fromboth surfaces (skin and underlying muscle) andraised as part of a large SMAS flap67 (Fig. 16). (SeeVideo 5, which demonstrates the raising of themalar fat pad off the underlying orbicularis oculimuscle, along with elevation of the midcheekSMAS in continuity with the malar fat, available inthe “Related Videos” section of the full-text articleon PRSJounal.com or, for Ovid users, at http://links.lww.com/PRS/A422.) Alternatively, it can befreed from its deep surface, using the skin as acarrier.68,69 To accomplish this, Aston has de-scribed the finger-assisted malar elevation proce-
dure (Fig. 17). [See Video 6, in which the raisingof the malar fat pad along with the orbicularisoculi (finger-assisted malar elevation procedure)is described, available in the “Related Videos” sec-
Video 4. Video 4, in which the SMAS flap is raised in the mid-cheek, is available in the “Related Videos” section of the full-textarticle on PRSJounal.com or, for Ovid users, at http://links.lww.com/PRS/A421.
Fig. 16. Illustration showing Aston’s finger-assisted malar ele-vation technique. The surgeon’s finger enters the prezygomaticspace, raising the orbicularis, the malar fat pad, and the skin. (Re-printed with permission from Warren RJ. The oblique SMAS withmalar fat pad elevation. Paper presented at: 29th Annual Meetingof the Canadian Society for Aesthetic Plastic Surgery; October3– 4, 2002; Toronto, Ontario, Canada.)
Video 5. Video 5, which demonstrates the raising of the malar fatpadofftheunderlyingorbicularisoculimuscle,alongwithelevationof the midcheek SMAS in continuity with the malar fat, is available inthe“RelatedVideos”sectionofthefull-textarticleonPRSJounal.comor, for Ovid users, at http://links.lww.com/PRS/A422.
tion of the full-text article on PRSJounal.com or,for Ovid users, at http://links.lww.com/PRS/A423.]
Fat GraftingAlthough soft-tissue elevation can restore full-
ness to the middle third of the face, it is evidentthat tissue shifts alone will not always restore theloss of fat that occurs with aging. Techniques forthe injection of fat have been improving steadily,
making the procedure more predictable. In themiddle and upper thirds of the face, there is a highrate of fat graft, but long-term results are less re-liable around the vascular, mobile lips.70 Specificareas that are amenable to fat grafting are theupper lid sulcus, the tear trough, the midfacialgroove, and the malar prominence. Grafting themidfacial groove involves augmenting both super-ficial and deep fat compartments; deep fat aug-mentation below the orbital rim will aid in cor-rection of the V deformity associated with formationof the tear trough. This grafting can be per-formed independently or in combination withface-lift surgery. (See Video 7, in which fat graft-ing is demonstrated in the midcheek, over themalar prominence, and in the V deformity of theinfraorbital rim region, available in the “RelatedVideos” section of the full-text article on PRSJounal.com or, for Ovid users, at http://links.lww.com/PRS/A424.)
Transblepharoplasty Midface LiftIn an attempt to lift the tissue immediately
inferior to the infraorbital rim (the midface), anapproach through the lower lid has evolved. Thisinvolves a subciliary or transconjunctival incisionfollowed by a subperiosteal dissection over theface of the maxilla. After inferior periosteal re-lease, the elevated cheek mass can be fixated ad-jacent to the lateral orbital rim71 or, using a verticalvector, to the infraorbital rim.72 Another variationinvolves a supraperiosteal dissection.73 The advan-
Fig. 17. Illustration showing Aston’s finger-assisted malar ele-vation technique, with a separate skin and SMAS flap. (Reprintedwith permission from Aston SJ, Walden J. Facelift with SMAStechniques and FAME. In: Aston SJ, Steinbrech DS, Walden JL,eds. Aesthetic Plastic Surgery. London: Elsevier; 2009:76.)
Video 6. Video 6, in which the raising of the malar fat pad alongwith the orbicularis oculi (finger-assisted malar elevation proce-dure) is described, is available in the “Related Videos” section ofthe full-text article on PRSJounal.com or, for Ovid users, at http://links.lww.com/PRS/A423.
Video 7. Video 7, in which fat grafting is demonstrated in themidcheek, over the malar prominence, and in the V deformity ofthe infraorbital rim region, is available in the “Related Videos”section of the full-text article on PRSJounal.com or, for Ovid users,at http://links.lww.com/PRS/A424.
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tages of the lower lid approach include an imper-ceptible incision and a more vertical vector of liftapplied to the critical midfacial soft tissues. Dis-advantages include the potential for lower lid re-traction and a steep learning curve for surgeons tofeel comfortable with the approach.74
FACE-LIFT INCISIONSExcept for the isolated temple and lower eye-
lid approaches, all face lifts require an extensiveincision around the ear for which there are manysubtle variations (Fig. 9). In the temple, the inci-sion can be placed in the hair, at the anteriorhairline, or by means of a hybrid of the two, withan incision in the hair plus a transverse extensionat the base of the sideburn. The advantage of theincision in the hair is that it is hidden, but whenthe flap is advanced, there will be some shift in theanterior hairline and base of the sideburn. If theincision is placed at the anterior hairline, the scaris more visible, but there will be no shift of thehairline. A transverse incision at the base of thesideburn ameliorates much of the hairline shiftand preserves a largely hidden scar.
Anterior to the ear, the incision can be pre-tragal or on the tragal edge. The advantage of thetragal incision is that it is hidden, but care mustbe taken to create a thin flap of skin to cover thetragus to simulate a normal tragal appearance.Furthermore, as pointed out by Connell,75,76 thenormal tragus has the shape of a rectangle, anappearance that can be replicated by making ashort transverse cut at the inferior end of the tragalincision. In some cases, a pretragal incision is pre-ferred; an example is a patient with thick discol-ored facial skin that will appear out of place whencovering the tragus. In men, a pretragal incisionmay be preferable because of thick bearded skin,although it is possible to manage this issue byremoving hair follicles before drawing the cheekskin up onto the tragus.
If there is minimal laxity of neck skin, a “shortscar” approach may be used.45,77 This involves thefull anterior portion of the face-lift incision butonly a short posterior extension at the earlobe todeal with bunching of skin. Conversely, whenthere is significant excess neck skin, and a poste-rior shift is anticipated, a posterior incision will berequired. Multiple variations for the posterior in-cision have been devised, ranging from a low in-cision following the posterior hairline, to an ex-tremely high incision that courses almostvertically. A compromise between the two is usu-ally preferred, with the incision following a lazy-Sconfiguration, arching high over the mastoid,
along the hairline for 1 to 2 cm, and then anglinginto the posterior hair. In this area, it is importantto avoid excess tension.
Closure of face-lift incisions must be per-formed with precision and thought. Specific issuesto be dealt with include the degree of tension,handling of the sideburn, insetting of the earlobe,and treatment of the postauricular hairline. (SeeVideo 8, in which careful closure of the face-liftskin incision is demonstrated, available in the “Re-lated Videos” section of the full-text article on PRS-Jounal.com or, for Ovid users, at http://links.lww.com/PRS/A425.)
NECK SURGERYLike the face, to devise a surgical plan, the
layers of the aging neck must be assessed inde-pendently. Superficially, the skin of the neck istypically thinner and less elastic than facial skin.With age, further skin laxity develops, causing ver-tical wrinkles and pleats. These can be correctedby tightening the skin in a lateral-oblique, or su-perior-oblique direction. Subcutaneous fat oftenaccumulates with age and may be dealt with usingopen resection through a submental incision orthrough closed liposuction.78
Deep to the subcutaneous fat are the pairedplatysma muscles, which have well-recognized vari-ations in their anatomy: the majority (roughly 75percent) of necks exhibit interdigitation of thetwo platysma muscles for the first 1 to 2 cmsuperiorly.79,80 The remaining 25 percent eitheroverlap extensively or do not overlap at all. With
Video 8. Video 8, in which careful closure of the face-lift skinincision is demonstrated, is available in the “Related Videos”section of the full-text article on PRSJounal.com or, for Ovidusers, at http://links.lww.com/PRS/A425.
age, there is a loss of tethering of the platysmamuscles to the deep cervical fascia. As a result, theplatysma falls away from the cervical mandibularangle, contributing to the obtuse angle of age.Visible bands in the anterior neck usually repre-sent the leading edge of the underlying platysmamuscles. These bands are considered either static(present at rest) or active (only present on ani-mation). There are two different options to dealwith platysma bands in the anterior neck. Oneapproach involves mobilizing the posterior bor-ders of the paired platysma muscles, drawing themin a superior oblique direction and fixating themuscle to firm fascia (parotid cutaneous ligamentor the Lore fascia) (Fig. 18).81,82 Alternatively, thepaired platysma muscles can be drawn mediallyand approximated centrally.83,84 Conventional ac-cess is a 2- to 3-cm incision placed adjacent to orin the submental fold (Fig. 19).
Through a submental incision, a number ofanatomical structures can be addressed: subcuta-neous fat, subplatysmal fat, the platysma muscles,and the submandibular glands. Fat can be re-moved directly. A common approach is to approx-imate the anterior platysma edges centrally and toperform a partial transection inferior to the line ofsutures. Some surgeons advocate multiple rows ofsutures to aggressively advance the platysma mus-cles medially—the corset platysmaplasty.85
Excess subplatysmal fat can be excised beforemuscle approximation. Hypertrophic digastricmuscles can be thinned. Ptotic submandibularglands can be repositioned86 or partially excised.87
In some face-lift cases, only minimal correc-tion of the neck is required. For example, in the
younger person with good quality skin, the neckcan be treated as an isolated procedure using anumber of different techniques: isolated liposuc-tion, liposuction plus platysma plication and tran-section, or a retroauricular approach to tightenthe platysma posteriorly.88 If there is skin laxitybeyond the ability to retract after submental sur-gery, it can be tightened with a retroauricular in-cision or with a full face-lift incision.
In some older men, the preferred proceduremay be a direct neck excision of excess skin, leav-ing a scar in the midline. This can be accom-plished with a zigzag pattern or with a verticalellipse broken up with two or more Z-plasties89
(Fig. 20).
COMPLICATIONS
HematomaPostoperative hematoma is the most common
face-lift complication, with a reported incidenceof 2 to 3 percent in women and up to 8 percent inmen.90 The incidence in men can be reduced toapproximately 4 percent with careful attention topostoperative blood pressure control.91 Numerousvariables have been explored, including dressings,drains, fibrin glue, and platelet gel. A positiveassociation has been found when simultaneousopen neck surgery is performed, with patients tak-ing platelet inhibitors such as acetylsalicylic acidand/or nonsteroidal antiinflammatory medica-tions, with hypertension in the postoperative pe-riod, and with the rebound effect when epineph-rine wears off postoperatively.92,93 An expandinghematoma is most likely to occur in the first 24
Fig. 18. Cadaver dissection showing posterior traction on the platysma. (Reprinted from Labbe D, Franco RG,Nicolas J. Platysma suspension and platysmaplasty during neck lift: Anatomical study and analysis of 30 cases.Plast Reconstr Surg. 2006;117;2001–2007; discussion 2008 –2010.)
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hours after surgery and should be evacuatedpromptly.
Sensory Nerve DamageSensory innervation of the face-lift flap is al-
ways damaged, although the effects are self-limit-ing, usually resolving in 12 months. The common-
est nerve to sustain damage during face lift is thegreat auricular nerve, which should be repaired ifthe injury is identified intraoperatively.
Motor Nerve DamageDamage to facial nerve branches usually will
go unnoticed by the surgeon until muscle paralysis
Fig. 19. Medial suturing of paired platysma muscles with partial transection of the an-terior border. [Reprinted with permission from Stuzin JM. MOC-PSSM CME article: Facelifting. Plast Reconstr Surg. 2008;121(1 Suppl):1–19.]
Fig. 20. An elderly man with open fat contouring, platysma plication, and Z-plasty after skinexcision.
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is identified postoperatively. Nerve dysfunction inthe first few hours after surgery is common and isattributable to the lingering effects of local anes-thetic. Dysfunction identified days later may beattributable to traction, cautery, sutures, or surgi-cal division. The most commonly injured branchesare thought to be the buccal branches, althoughlong-term sequelae are rare because the buccaland zygomatic branches are multiple and inter-connected. Conversely, the temporal and mar-ginal mandibular are terminal branches; damageto them can result in a permanent deformity.
Unsatisfactory ScarsImproper incision placement can lead to ob-
vious scars, distortion of the ear, and unnaturalshifting of the hairline. Excessive tension can leadto loss of hair, depigmentation, and widened scars.Some scars can be improved with scar revision ata later date when tissues have relaxed. Hypertro-phic scars can be helped with steroid injections.
Skin LossFace-lift dissection creates a large, relatively
thin, random pattern skin flap that is then placedunder tension; it has a remarkable ability to sur-vive. Factors that can contribute to the avascularloss of skin include an overly thin flap dissection,excessive tension, hematoma, constrictive dress-ings and, the most damaging of all, smoking. Skinnecrosis should be dealt with conservatively; themajority of such cases will eventually heal sponta-neously.
InfectionInfection is a rare problem with face-lift sur-
gery, reported in the range of 1 percent. Treat-ment is with appropriate wound care and antibi-otics.
CONCLUSIONSFace-lift surgery has evolved in parallel with
our understanding of the anatomy of facial aging.For over a century, innovative surgeons have de-veloped a wide variety of approaches to treat age-related changes. Excellent results have been dem-onstrated with all of these surgical techniques.There is no one correct way to perform a face lift.Rather, surgeons should be familiar with manydifferent approaches to individualize their ap-proach for an overall, age-appropriate facial reju-venation.
Richard J. Warren, F.R.C.S.C.Division of Plastic Surgery
University of British Columbia777 West Broadway, Suite 1000
PATIENT CONSENTThe patient provided written consent for the use of
her images.
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