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Facelift
HISTORY
 First facelift done in the 1st decade of the 20th century.
 Early procedures merely skin incision.
 Later, subcutaneous undermining, re-draping and excision of excess skin.
 Skoog (1974): Dissection of the superficial fascial layer in the face in continuity with platysma in the neck.
The myo-fascial unit was advanced in a cephalo-posterior direction.
 Tessier took up Skoog’s principles
 Mitz and Peyronie (1976) who worked for Tessier defined the SMAS.
 SAL was added as an adjunct in 1983 (Ilouz)
 Recent techniques: composite, deep plane and sub-perisoteal, MACS
 The trend, these days, is to more undermining, rather than less.
Problem areas
1. Forehead and brow
2. N-L fold
3. Submental and inframandibular area
4. Anterior neck
PATIENT PRE-OP EVALUATION
PSYCHOLOGICAL ASPECTS
1. Assess the true motivation for surgery
2. Are the expectations realistic?
3. Will they be satisfied with the result?
 Want to restore previous beauty or look younger.
 Proper patient selection is one of the most important aspects of facelift surgery.
Red Flags (Rees)
1. Insatiable cosmetic surgery candidates or Hx of multiple revisions for aesthetic surgery
2. Transient volatile inter-personal relationships or unstable personality
3. Patients with a disturbed body image
4. Patients who are not clear about what they want
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5. Degree of deformity does not correlate with the degree of personal inadequacy
6. Patients with a Hx of dissatisfaction
7. Psychotic or depressed patients
“If you don’t operate, she will be mad at you for 20 minutes. If you do operate, she will be mad at you for 20
years.” (Rees).
Generally, facelift should be postponed until psychological adjustment has occurred following a recent traumatic event, eg, divorce, children leaving home, death of a spouse, etc.
MEDICAL HISTORY
Full medical history with particular attention to:
1. Medications: anticoagulants, aspirin, Vit E, OCP, HRT (must stop 2 weeks before surgery).
2. Smoking -The relationship between smoking and skin slough is unequivocal.
3. Medical problems (must be well controlled and stable). Hypertension.
4. Hx of blood dyscrasias, easy bruising following minor trauma
5. Previous Bell’s palsy (facelift can cause recurrence)
6. Previous surgery (mastoidectomy or thyroidectomy are not C/I)
7. Previous DXRT
8. Allergies
EXAMINATION
 General examination to assess fitness for surgery.
 Local examination to assess deformity and surgery required.
 The ideal candidate:
1) Thinnish woman in her middle 40’s
2) Prominent or strong malar eminences and mandibular angles
3) Strong chin without being prominent
4) C-M angle naturally about 90o
5) Good skin with minimal actinic damage
6) Full head of hair with a hairstyle that covers the ears,
 The poor candidate:
1. Small, retruded chin with a narrow mandible
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2. C-M angle obtuse
3. Fatty: submental, sub-platysmal
 In these patients, consider ancillary measures, eg chin implant.
EXAMINATION OF THE FACE
Best done with the patient sitting. Examine from above down. Examine smiling, frowning, whistling, grimacing, eyes open and closed.
A) Examination of Tissues
1. Skin: Excess, elasticitiy, texture, colour, wrinkles, etc.
2. Fat: Distribution and quantity
3. Muscle: Relation to skin, platysmal bands
B) Regional Examination
1. Hair: Texture, thickness and hairline. Dyed?
2. Forehead: Transverse wrinkles. Frown lines: vertical and transverse (glabella) wrinkles in the glabella
region. Brow ptosis (eyebrows in relation to the orbital margin).
3. Ears: Lobe anatomy important. Pre-auricular skin excess.
4. Eyelids: See blepharoplasty: Excess skin, ptosis.
5. Mid face: Skin: Thickness elasticity and mobility; Bone: Malar area (cheek bones) for contour and symmetry; Malar pouches (fluid collections in the fatty tissues over the malar area). Naso-jugal groove.
6. N-L folds: Note prominence and depth. N-L folds are d/t:
a) SMAS insertion into the skin
b) Gravitational descent of the facial tissues, especially malar fat pad
c) Atrophy of adjacent subcutaneous tissue
d) Buccal fat pad atrophy
7. Perioral region: Vertical wrinkles (needs dermabrasion, peel or laser).
8. Jaw line and jowls: Contour, fullness and laxity. Fat (submandibular or submental) that needs SAL?
Ptosis of the submandibular gland. Mandibular contour. Chin.
9. Neck: Platysma anatomy: divarification, bands.
 Cervico-mental angle. May be obtuse for a number of reasons:
1. Excess, redundant skin
2. Excess fat (subcutaneous, submuscular)
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3. Fullness of the medial aspect of the platysma muscle
4. Low hyoid (in respect to C5 vertebral body or chin): bone
 Position of the larynx and hyoid
LIMITATIONS OF SURGERY
1. Forehead and glabella creases need brow lift or some other adjunctive procedure
2. Crow’s feet not improved by facelift.
3. Malar pouches are not improved and may be accentuated early after the procedure.
4. N-L crease is not eliminated, but may be softened. SAL may help.
5. Down lines or marionette lines from the oral commissures to the lower border of the jaw are not improved.
6. Fullness of the depressor muscles lateral to the oral commissures are not improved.
7. Anterior larynx prevents a sharp C-M angle.
8. Ptotic submandibular gland is difficult to rectify
9. Texture of sun damaged skin still remains.
ANTICIPATING THE POOR RESULT
1. Poor skeletal structure (cheek bones, mandible)
2. Poor skin: actinic damage, pigmentory changes, thin transparent skin
3. Patients with telangiectasia
4. Keloid diathesis may result in hypertrophic scars (keloids in the facelift incision are extremely rare)
5. Obesity or recurrent weight loss and weight gain (TE effect)
PHOTOGRAPHS
Invaluable for
1. Pre-op evaluation and planning
2. Documentation of pre-op status
3. Use in the theatre
4. Post-op discussion in the patient who no longer remembers the pre-op condition
5. Medico legal documentation
Views
1. Full face in repose
2. Full face smiling
3. Chin tilted up in repose
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4. Chin tilted up with platysma tightened (jaws clenched)
5. R and L lateral profiles
6. 3/4 views
7. Close ups of problem areas
PRE-OP PREPARATION
1. No make up
2. Betadine, chlorhexidine or pHisoHex face wash and shampoo the night before and the morning of surgery.
3. Single shot of IV antibiotic with induction of anaesthesia.
4. Sedative the night before prn.
5. Gel or ointment in the hair.
6. Jelonet in the ear.
7. Patient slightly head up with the facility to raise it further.
ANAESTHESIA
 GA – change to laryngeal mask at the end for a smoother, lower blood pressure wakeup
 Do not use laryngeal mask in any procedures involving neck due to distortion by the tube.
 Local anaesthesia with vasoconstrictor give. 60 ml per side of face, including neck.
 GA should be stable with the systolic BP maintained at between 100 to 120 mmHg.
 Fluctuations in pulse and BP are not desirable, nor is a hypotensive anaesthetic.
 Patient should breathe spontaneously. Mechanically assisted ventilation can induce venous bleeding.
 Monitoring important. Pulse oximeter especially useful.
Options for facial rejuvenation
1. Resurfacing techniques – laser, peels
2. Lifting the sagged soft tissues
3. Augmenting deflated areas with autologous or other materials
4. Fat/skin Excision
5. Paralysing overactive muscles – resection/Botox
6. Combination
SURGERY
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Current Approach to Face and Neck Rejuvenation Focus on:
1. Skin re-draping and resection
2. Controlled removal of excess subcutaneous fat
3. Tightening of the SMAS
4. Re-positioning of the malar fat pad
5. Trimming and contouring of the jowls
6. Resection of central sub-platysmal fat contributing to fullness in the submental region
7. Central/medial platysma resection/tightening
8. Avoid iatrogenic stigmata of facial rejuvenation:
a.
the lateral sweep
b. Hollow/gaunt eyes
c.
the elevated and widened medial brow
d. the distorted palpebral fissure
e. the over-operated neck.
f. elevated hairlines, sideburns
g. ear deformities
CLASSIFICATION OF FACELIFT OPERATIONS
1. Skin and subcutaneous procedures
2. Conventional SMAS procedures
a. Plication
b. Limited
c. SMASectomy
d. SubSMAS flap (Skoog)
3. Extended procedures
a. SMAS,Plastymal flap
b. Deep plane facelift
c. Composite rhytidectomy
d. Sub-periosteal facelift
4. Suspension methods
a. Mini lifts – S lift
b. MACS – minimal access cranial suspension
Facelift Incision
 Preauricular incision, superiorly extending into temporal hair or along sideburn
 Pretragal in males ( so hair doesn’t get pulled into tragus), retrotragal in females to hide scars
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 Round the ear lobe, up post auricular (on the concha so that the scar will lie in the sulcus) and back into
the occipital hair at the level of the helical crus
 The length of the occipital incision is determined by the amount of excision required, but one must be cautious as this incision has a propensity for scar aloplecia which can be troublesome
 If a lot of lax neck skin requires excision, the incision may best follow the occipital hairline so that with
excision of the excess skin, the hairline is not altered. This is achieved at the expense of a more visible
scar.
 On closing:
 Traction on the flaps is mainly superiorly above and posteriorly below, and ensure minimal tension in
pre-auricular closure, otherwise a stretched scar will result.
 In males, the traction needs to be mainly superiorly to spare the sideburn.
 2 key sutures:
1) 1 cm above the top of the ear in the temporal scalp
2) at the apex of the post-auricular incision
A. CLASSIC
1. Classic
 Subcutaneous undermining, no SMAS work. Does not address deeper structures.
 Try to leave all fat on the flap - provides more natural contouring
 Indications:
1. young patient with minimal ptosis of tissues and little or no submental fat
2. secondary or tertiary facelift – safer dissection plane
 Disadvantage:
1. does not address jowls, submental fat or platysmal banding
2. relapses fairly quickly due to skin’s poor viscoelastic properties
B. CONVENTIONAL SMAS PROCEDURES

Minimal effect on midface
o Fails to address NL folds

Strong lateral vector
1. SMAS plication (Pangman)
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
Subcutaneous undermining with no deep dissection

SMAS gathered in multiple upward and lateral vector
2. SMAS-skin flap (Skoog)

Preauricular incision

Superficial fascia of lower cheek “Buccal fascia” undermined to naso labial fold (SMAS-Skin flap)

Advance “Buccal fascia” posteriorly

Posteriorly displaced “Buccal fascia” sutured to “Masseteric fascia”

Problem due to insufficient transmission of tension across the cheek – failed to improve NL folds and anterior neck.
3. Lateral SMASectomy – Baker PRS 1997
 Subcutaneous dissection to lateral orbital rim, over malar eminence, beyond the jowl and to the inferior
transverse cervical crease. Stops few centimeters short of NL fold.
 A strip of SMAS equal to the width of soft tissue correction is excised from over the anterior edge of the
parotid gland. This strip runs parallel to the N-L fold and from anterior end of zygomatic arch to the angle of the mandible. No SMAS undermining is done.
 Vector is perpendicular to NL fold
 Defatting of the neck using either closed liposuction or open liposuction through a submental excision is
performed
 If platysma bands are prominent with animation (evaluated preoperatively), a wedge excision at the level
of the thyroid cartilage. Approximation of the medial platysma borders is usually unnecessary and tends to
compromise the lateral tension that can be put on the platysma.
 After contouring of the preplatysmal fat, a flap of the lateral platysma is developed in the region inferior to
the mandibular border.
 After raising this lateral platysma flap, the platysma is secured to the mastoid periosteum with figure-ofeight 2-0 Maxon to help define the jawline and improve the contouring in the submandibular region
 Below the angle of the mandible, a platysma flap is elevated which is sutured to the mastoid fascia.
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C. EXTENDED PROCEDURES
1. SMAS Flap (Mendelson PRS May 2001)
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 Principles
1. SMAS flaps tighten connective tissue laxity to reposition and restore tone to the superficial fascia. This
approach reduces apparent muscular hyperactivity.
2. Complete SMAS release is necessary to avoid tension and distortion including release of retaining ligaments
3. SMAS flap fixation should replicate the original fixation of the superficial fascia.
a. Vector over levator superioris should be upwards
b. Vector over zygomaticus minor and major should be up and lateral
c. Overlying the zygoma, the vectors for orbicularis oculi are more complex. Lateral to the lateral
canthus, the sutures are oriented partly parallel to the muscle fibers but with an outward vector. In
the temple, the direction of the sutures follows the direction of the superior temporal line
4. Use of nonabsorbable sutures mimic ligaments.
5. The fixation respects the natural boundaries between facial regions.
6. Fixation at the several original locations avoids the need for a mass tightening and flattening of the
SMAS.
 Subcutaneous dissection extends over the malar area to the N-L fold.
 SMAS incised as above, but sub-SMAS dissection continues further: over the malar eminence to the N-L
fold,
 The investing fascia of the upper lip elevators is lifted. Superiorly, the dissection continues over the arch,
releasing the zygomatic ligaments and mobilising McGregor’s patch. Inferiorly, the SMAS dissection is
carried anterior to the facial artery.
 Platysma dissected as above and the platysma-SMAS flap rotated supero-posteriorly, excess excised and
sutured (platysma to mastoid fascia).
 Advantage:
1. Flexibility - Allows a multi-vectoral facelift (from above down: up, back, up) thus avoids lateral sweep
 Disadvantages
1. Extensive dissection
2. May compromise vascular perfusion of SMAS flap and skin
3. Dermis has to take skin tension.
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2. Deep-Plane Rhytidectomy (Hamra PRS 1990)
 Developed to address malar pad.
 By releasing the zygomatic cutaneous ligaments from the malar eminence and dissecting inferomedially to
the nasolabial crease – this keeps the cheek fat (malar fat) attached to the skin.
 No subcutaneous undermining is done. The flap is lifted sub-galeal, sub-SMAS and sub-platysmal in the
face and subcutaneously only in the neck.
 Hamra on followup noticed that although the neck maintained its lift, the NL fold relapsed as well as the
development of lateral sweep deformity. He now proposes the composite rhytidectomy
 Hamra believes that the skin and subcutaneous tissue descend as a large composite flap and do not lose
their intimate relationship with each other. He therefore believes in elevating them together as a composite flap.
3. Composite Rhytidectomy (Hamra PRS 1992,1998)
 According to Hamra, gravity and aging cause 3 main effects:
1) Sagging of the orbicularis oculi  brow ptosis and excess eyelid skin and fat. Hamra uses the
term malar crescent for the malar bags or festoons that appear due to descent of the orbicularis oculi.
2) Sagging of the cheek fat  deep, prominent N-L fold
3) Sagging of the platysma  jowls

Believes that rejuvenation in incomplete without preservation and repositioning of the orbital fat and repositioning of the entire orbicularis oculi muscle.
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 Lower blepharoplasty is done in all and the dissection continues beneath the orbicularis oculi which are
then positioned supero-medially by extraordinary tension.
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
A transcanthal canthoplasty is performed percutaneously. (canthal tendon not divided)

Arcus marginalis is released and septal fat is repositioned and the orbital septum is reset over the orbital
rim.
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 The subcutaneous dissection is limited.
 He raises two dissection planes. From laterally, same as the deep plane face lift dissection, subSMAS and
elevating the cheek fat overlying the zygomaticus muscle with the skin. The facial portion of the platysma
is also in this flap.
 A separate zygorbicularis plane is raised suborbicularis and under the medial portions of zygomaticus minor and major
 The upper most extent of the face lift flap is 2 to 3 cm superior to the inferior extent of the zygorbicular
dissection, leaving a mesenteric flap on the deep lateral aspect of zygomaticus for innervation.
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 Below the mandible dissection is both pre and sub-platysmal. Via a submental incision, the excess anterior platysmal bands are excised and the platysma is sutured together in the midline.
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 Advantage:
a. orbicularis muscle is repositioned in a superomedial vector. (avoids lateral sweep)
b. Addresses NL fold and malar fat pad ptosis
c. additional level of support to the flap, which lessened the closing tension of the skin – safer for smokers
4. Sub-periosteal Facelift

Described by Tessier for brow lift in 1980, later extending the subperiosteal dissection for treatment of
the mid face

Due to frequent occurrence of frontal nerve injury (11%), dissection was often limited to the anterior one
third of the zygomatic arch.

Difficult to perform a vertical elevation of the soft tissues since they were still tethered at the region of the
zygomatic arch.

Ramirez’s technique
o Using the endoscope, release the attachments of the arch going deep to the seuperficial leaf of the
deep temporal fascia from above.
o Intraoral incision to elevate the periosteum to the piriform aperture medially, to the inferior orbital
rim superiorly, and to the body of the zygoma. The endoscope is then inserted to dissect around
the infraorbital nerve, zygomaticofacial nerve, and the anterior two thirds of the zygomatic arch.
Incise the periosteum over the inferior orbital rim and excise fat pads as required. Buccal fat pads
can be dealt with similarly.
o Dissection is then continued inferiorly from the zygomatic arch to raise the masseter fascia from
the muscle for about 25 mm. This allows a vertical lift of the lateral superficial soft tissues.

Advantages
o central face/forehead ptosis - nasal glabellar soft tissues, NL crease, cheeks, angle of the mouth,
and jowls.
o
tear trough deformity
o secondary facelifts
o ectropion
o smoker
o those requiring bony work.
o only technique that allows repositioning of the soft tissues with relation to their bony attachments
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o better optical cavity than subgaleal or subcutaneous dissections

Disadvantages:
o By raising the periosteum, tissue is moved to a position where it has never been
o Significant persistent oedema - overcome with increasing speed of dissection and decreasing soft
tissue trauma.
o Facial nerve damage – less with Ramirez’s technique
o Alopecia 2%
Type IV: Open Subperiosteal Face Life with Skin Excision
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Type V: Full endoscopic facelift no skin excision
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Type VI: Endoscopically Assisted Biplanar Face Lift
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D. Minimal Access Cranial Suspension (Tonnard PRS May 2002)

Developed as a modification of the S lift

Advantage:
o pure vertical-vector face lift
o skin excision is in a vertical direction thus little elevation of the hairline
o quick procedure, local anesthesia, no hospital admission, a short recovery period, and an inconspicuous, short scar
o low risk of facial nerve injury, skin slough, hematoma and postoperative numbness
o combination of centrofacial laser resurfacing and a MACS lift can be performed very safely.
o pleasing and natural look, eliminating the classic face-lift stigmata

Indications
o Jowl, marionette lines and malar fat ptosis
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o Relatively young with elastic skin

inverted L-shaped preauricular incision

Two strong, permanent purse-string sutures are woven into the superficial musculoaponeurotic system
tissues in a vertical U and an oblique O shape, initiating from a strong anchorage in the deep temporal
fascia at the level of the helical crus

Often combined with moderate-to-aggressive fine-needle liposuction of the submental region

Anterior corset platysmaplasty only if anterior bands do not resolve after pulling on them laterally with
the sutures
The dotted line indicates the extent of undermining, and the arrow indicates the vector of traction.
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Extended MACS lift - a third narrow purse-string suture to address the malar fat pad. Anchorage point now
modified to the lateral orbital rim
COMPARATIVE STUDIES
1. Rees and Aston (1977): Skin lift on one side vs conventional SMAS lift on the other side in 25 patients.
No difference at one year.
2. Tipton (1974): Skin lift on one side vs SMAS plication on the other - no difference.
3. Webster (1982): SMAS plication on one side vs SMAS elevated and imbricated on the other in 15 patients. No difference.
4. Ivy, Lorenc and Aston (PRS, Dec 1996): Limited or conventional SMAS on one side vs extended or
composite on the other in 20 patients. No difference at 1 year. Criticised by Hamra as operations performed by fellows.
THE MALE PATIENT
Problems and differences
1. Psyche  Careful pre-op selection.
2. Males are less co-operative and more difficult during surgery and require more pre-med, sedation and anaesthesia as well as longer surgical time.
3. Skin is thicker and more rubbery.
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4. The SMAS and platysma are thicker.
5. The incision poses problems and has caused debate and controversy. Bi-coronal incision (for brow lift)
will become visible with balding. Shorter haircuts mean less camouflage for incisions. Sideburns and
beard need to be dealt with.
6. Sideburn allows little posterior movement of the flap. Superior movement must be done instead.
7. More numerous fibrous connections between SMAS and dermis making dissection more difficult and time
consuming
8. Intra-operative and post-op bleeding is more common and the incidence of post-op haematoma is twice
that in the female pt  Haemostasis must be meticulous.
9. Aggressive platysma work can give an over-operated look to the neck and an excessively thin artificial appearance  A more conservative approach to the neck is indicated.
10. Post-op oedema persists for longer than in the female patient.
11. The results are often less dramatic than in the female patient.
The Incision
 One does not want to thin the beardless area just in front of the ear (behind the sideburn) excessively, nor
does one want to pull beard tissue behind the ear. Since this is always a possibility, patients must be
warned pre-op that this can happen.
 Most use the same incision as in the female patient, but alter the vector of flap movement so that the pull
is more up.
 Some advocate modified incisions (Baker and Gordon), ie, transversely across in the temple in the line of
the crow’s feet to the lateral canthus.
 It is prudent to leave a small base plate around the earlobe to avoid bringing any bearded skin into this area.
 Submental incision should be in the crease (as opposed to female patients in whom the incision is made
just anterior to the crease). There is a greater likelihood that skin excision will be required in the submental area (poorer draping) and a z-plasty has been advocated here. Others use a W or H shaped incision to
excise excess skin, but according to Rees (in McC) this is rarely required and leaves unsightly scars.
POST-OP CARE
 Change to laryngeal mask prior to waking patient up for smooth BP
 Semi Fowler’s position. Analgesia.
 Restrict talking, but allow gentle ambulation.
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 Warn the patients pre-op about post-op swelling and bruising.
 According to Rees, a firm case cannot be made for either drains or dressings following facelift surgery.
 Some still use soft rubber drains, either suction or other are still often used, especially if the wound is
oozy.
 A dressing helps promote immobility of the head and will aid in the absorption of serum and minor bleeding.
 If the patient complains of pain, remove the dressing and look for haematoma.
 Usually drains and dressings are removed after 24-48 hrs and the wounds left open.
 Gentle face and hair washing after 48 hrs.
 Hair dryers can be hazardous as the ear may have ed sensation.
 ROS from pre-auricular wound at 5 days, other sutures removed later.
 Gentle massage of wounds.
 Many patients go through a period of depression following surgery, partly because of physical reasons:
pain, swelling, bruising; partly for other reasons not apparent.
SECONDARY FACELIFT
 Since facelift became popular a quarter of a century ago, there is an ever ing number of patients requesting secondary facelifts.
 A facelift usually lasts 5-10 years.
 Although the procedure is permanent in that there is skin excision, the process of aging continues.
 The younger the first facelift is done, the longer the interval can be to the next.
 The aims of secondary facelift are:
1. To re-lift the face and neck
2. to remove the primary surgical scars
3. to preserve a maximal amount of temporal and sideburn hair
 Unless there was a haematoma at the 1st procedure, secondary dissection is easier than primary  less
bleeding and a lower incidence of post-op haematoma formation.
 The first operation acts as a delay.
 The amount of skin excised is usually less at the secondary and subsequent procedures - often, just the scar
is excised. Tension must be avoided.
 Dissection naturally follows the same plane as the first operation – so if had nerve problems first time
round, patient will have same issue second time round
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 The benefit from lifting comes from undermining and flap rotation, not skin excision.
 The effect of the 2nd or subsequent facelift is usually less dramatic but more prolonged than the first.
 Repeated facelifting with skin excision and excess tension can give a mask-like look to the face.
 Neck work is more difficult and planes less clearly defined. Care is therefore needed to avoid injury to the
nerves and other structures.
ANCILLIARY AND ADJUNCTIVE PROCEDURES IN FACELIFT
THE N-L FOLD
 One of the problem areas in facelift.
 N-L folds are d/t:
1. SMAS insertion into the skin
2. Gravitational descent of the facial tissues
3. Atrophy of adjacent subcutaneous tissue
4. Buccal fat pad atrophy
 N-L folds should be absent in repose, but present when animated.
 Traction on the SMAS has little effect on the N-L fold and medial cheek skin and can even deepen the
fold.
Methods of dealing with the N-L fold
1. Conventional facelift
 Must be advancement of skin and not SMAS as traction on SMAS will accentuate the N-L fold.
a) Subcutaneous cheek advancement (ie, skin only).
b) Because traction on the SMAS can exaggerate the N-L fold, Barton suggests that when doing a subSMAS facelift, the plane of dissection should become more superficial when zygomaticus major is encountered and should continue anterior to the muscle in a subcutaneous plane. This ensures that the supero-medial pull in the N-L area is skin only and not SMAS. By doing the dissection in this way, traction on the SMAS will elevate the medial cheek skin smoothing the N-L fold.
2. Midface lift
a. Can be done via blepharoplasty (subciliary) approach (Hester PRS 2000)
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(Above) Full subperiosteal cheek lift demonstrating vertical elevation of midface with direct fixation to deep temporalis fascia through the lateral aspect of the upper blepharoplasty incision. (Below) Modified cheek lift demonstrating more limited dissection superficial to the periosteum with
similar fixation.
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Cross-sectional anatomy showing the full subperiosteal cheek lift with release of the periosteum
and inferior transposition of orbital fat following arcus marginalis release. Dissection releases origins of zygomaticus muscles resulting in effect in lower midface. (Below) Cross-sectional anatomy showing modified cheek lift demonstrating plane of dissection superficial to periosteum with
release of the orbitomalar ligament. Inferior dissection is limited with origins of the zygomaticus
muscles undisturbed, limiting the effect in the lower midface.
3. Removal of tissue
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a) Skin
 Direct skin excision, ie excise the excess and re-suture the fold.
b) Fat
 De-fatting under direct vision
 Suction
4. Filling the crease

In severe facing aging, volume replacement is needed, not facial lifting.
a) Autologous tissue
 Dermal fat grafts
 Fat injections
b) Non-autologous material
 Silicone, PTFE or other prosthetic filler
 Xenogeneic collagen injection
SAL IN FACELIFT
 Either percutaneously before elevating skin or under direct vision after elevation.
 Either blunt (better, less risky) or sharp cannulas.
 Use tempered by reports of waviness that can occur and by concerns relating to cheek fat atrophy that occurs naturally with aging.
 SAL can be used, in moderation for N-L fold and jowls.
 If the N-L fold is prominent, SRPS states that excision is still the best option.
 Can be used for the buccal fat pad of Bichet.
 The main indication, however is for de-fatting the neck superficial to the platysma - SAL in this region is
simple, safe, effective and may facilitate dissection of skin flaps.
 Suction deep to the platysma may be hazardous and is not recommended.
THE NECK - DEALING WITH THE PLATYSMA
 The anterior neck has proved problematic for many yrs.
 Platysma bands were described by Padgett and Stevenson (1948).
 A number of classification systems have been proposed, but rather view the deformity with respect to its
components:
1. skin redundancy
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2. platysmal separation and banding
3. fat excess (either superficial or deep to platysma)
 Consider these against the underlying musculo-skeletal architecture of the neck:
1) neck length
2) position of the hyoid bone (normal = high, low)
3) C-M angle
4) mandible projecton
Platysmal bands
According to McKinney (PRS, Nov 96), platysmal bands are not the medial edge of the muscle, but rather
lateral pleats caused by laxity of the muscle.
Mendelson says bands are not due to muscle activity but to weakening of the fascial support around the muscle.
Methods of dealing with them are:
1. resection of the medial platysmal bands with plication and horizontal incision
2. division and suspension of the posterior one half of the platysma
3. partial division of the platysma at its medial and lateral borders
4. division and suspension of the entire platysma
5. anterior “corset” plication
All transect the platysma near the midcervical crease or at the level of the thyroid
cartilage, and most combine platysma division with submental plication and cervical defatting.
According to McKinney, all work, but when a midline approach is used, ed Cx may occur: haematoma, infection, scar, temporary “leather neck” deformity.
Classified by McKinney into 4 types:
Bands I: Barely visible  Lateral SMAS alone without midline work.
Bands II: Moderate bands  Require only a midline suturing of platysma muscle.
Bands III:  Require resection of redundant edges of muscle and midline suturing
Bands IV:  Require a lateral pull as well as midline work
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Criteria of a youthful neck (Ellenbogen)
1. Distinct inferior mandibular border
2. A C-M angle of between 105o and 120o
3. Anterior border of SCM visible
4. A sub-hyoid depression
5. A visible thyroid cartilage
Platysmal slings
The SMAS facelift advances cheek and cervical tissue en masse. Greater soft tissue redundancy in the lower
face and the neck is, however, problematic. To overcome this, the SMAS-platysma can be rotated about an
axis near the zygoma to create a suspensory, platysmal sling. To facilitate this rotation, the platysma may require transverse division at either its medial or lateral borders, or both, or right across. When the platysma is
transected, it should be done at the level of the thyroid cartilage (mid-cervical crease). These techniques can
be combined with excision of medial bands and anterior vertical suture or plication. De-fatting of the subcutaneous layer or deep to the platysma can also be done by either SAL or with scissors under direct vision. If
sub-platysmal work is done care must be taken to avoid injury to the underlying structures, especially the
MM br which can loop up to 4 cm below the inferior border of the mandible in the neck.
Disadvantages of platysmal sling procedures
1. Incomplete suspension of the sub-mental area
2. Unveiling and ptosis of the submandibular glands
3. Occasional prominence of the cut edges of the platysma
Whether the creation of a platysmal sling works or not is inconclusive. Rees did a sling on one side and not
on the other in 25 patients. Only one showed a difference between the 2 sides.
Turkey Gobblers
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
 Initially thought to be skin redundancy and were therefore treated by Z-plasty or similar.
 Morel-Fatio (1964) – used a horizontally orientated H incision ultimately closed with a Z plasty in the vertical limb
 Cronin&Biggs(1971) – similar skin incision, but with fat excision pre and post platysma and platysma plication and closure with Z plasty
 Adamson (1964) showed that the cause of the deformity was the medial edge of the platysma and that the
skin was only a secondary factor.
 Various methods have been advocated to deal with the turkey gobbler: imbrication, excision, Z-plasty of
the medial edges to lengthen them.
 Tendency has been for no skin excision and platysmal plication
 Tim Miller (PRS 2005)

The ellipse of neck skin and fat marked with the patient in the sitting position is excised down to the
platysmal muscle.

Skin flaps are dissected laterally above the platysma as shown by stippling.

Excess fat in the neck flaps is contoured under direct vision.

The Z-plasty is marked so the transverse portion lies along the new neck crease.
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 Alan Matarasso (PRS 2003)

Botulinum A toxin useful for Types I-III

50-100 units injected into muscle belly

absolute contraindications: inappropriate anatomy (redundant skin, excess fat, hypertrophic submandibular glands), pregnancy (or attempting to get pregnant), lactation, sensitivity to human albumin,
pre-existing neuromuscular conditions (myasthenia gravis, Eaton-Lambert syndrome), and use of medications that could potentiate the effects of botulinum (i.e., aminoglycoside antibiotics).
Side effects: bruising, transient neck pain, dysphagia, dysphonia

 Gilbert Gradinger (PRS 2000)

Zplasties to platysma in 2 locations in addition to one Zplasty on skin

Superior platysma Z plasty is at the level of the skin z-plasty = level of intended cervico-mandibular
angle.

A second platysma Z-plasty is usually done in the lower portion of the muscle to avoid creating a postoperative band or scar contracture
The Short fat neck and the double chin
 D/t excess fat deposition.
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 Marino stressed the importance of the hyoid. If it is in its normal high position, one can expect an improvement with surgery, but if it is low, the effect of surgery will be minimal and the patient will still be
left with a poor C-M angle.
 The surgical treatment is otherwise the same as above with the emphasis on fat removal by either SAL or
direct methods.
 Robbins and Shaw advocate an en bloc removal of fat from the neck (both superficial and deep to the platysma).
 For the low lying hyoid, Guyuron suggested dividing the muscles that insert into the inferior border of the
hyoid to allow it to elevate. Because radical surgery it has not been widely accepted, although it may
work.
Submandibular gland ptosis
 May be unmasked further by platysma transaction
 Mild ptosis may be improved by SMAS suspension or platysma plication
 De Pina and Quinta suggested partial resection through a direct incision or from laterally through the
facelift incision accessing it via a myotomy.
 Singer (PRS 2003) advocates a medial approach via a submental incision thus less likely for injury to the
MM nerve.
 Complications: MM nerve injury, hematoma, salivary fistulas
THE AGING LIP
Changes that occur to the lip with aging
1. Upper lip lengthens and sags (ed distance between the nose and the vermilion)
2. Vermilion thins and takes on a ‘set’ look
3. Less pout
4. The corners droop
5. Philtrum flattens
6. CB loses its curve
7. Lower, rather than upper teeth show when the lips are parted.
8. Vertical wrinkles
9. N-L folds deepen
10. Down-turned unhappy look
Lower lip ages similarly, but less dramatically
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Shortening the upper lip and vermilionplasty
Excess skin can be removed from the base of the nose or the vermilion border of the upper lip. Overcorrection is necessary since descent is inevitable.
The vermilion border may excised FT or only de-epithelialised. The vermilion is then undermined and advanced. It is difficult to achieve a good result with this procedure d/t the formation of scars and the loss of
the natural white line
Lip augmentation
Either autogenous or non autogenous
Non autogenous
1. Liquid silicone (does not have FDA approval)
2. xenografts or allografts of collagen
Autogenous
1. Dermofat - satisfactory results although resorption rates of 20-60%.
Possibility of epidermal inclusion cysts.
2. Temporalis fascia grafts (easy to harvest at the time of facelift)
3. Collagen - unpredictable. Can be lumpy. Needs to be repeated every 3-4 mths.
4. Lip border advancement (vermilion advancement as above)
5. Internal V-Y plasty to push more mucosal out. Can do a double V-Y along the length of the lip.
6. Rotation flaps of muscle and mucosa of inner cheek.
The Corner Lift
 Small inverted triangle of skin excised from outer, upper corner of upper lip.
 Patient must understand that the procedure will leave external scars.
 Over-correction done.
THE WITCH’S CHIN DEFORMITY
 Can occur at any age, usually older patients.
 Often worse with smiling.
 May be associated with deep submental crease.
 May have associated lack of anterior chin projection.
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 Loss of the lower teeth can worsen the condition.
Approach to Treatment
1. Simple excision of ptotic structures: muscle, fat and skin; with no attempt to lift.
2. Mentopexy: reefing up. Often results in inadequate chin correction.
3. Combine approach: excision plus augmentation or advancement genioplasty.
Pre-op Considerations
 Make a proper Dx.
 Is the chin prominent or ptotic?
 Is the offending tissue soft tissue or bone?
 Feel the chin pad.
 Push the chin caudally to examine.
 X ray may sometimes help.
ALLOPLASTIC BONY CONTOURING
Alteration of the facial skeleton can induce profound changes to facial aesthetics.
4 bony promonotories influence a persons features. In order of importance, they are:
1. the nose
2. the cheek bones (the malar-zygomatic eminences)
3. the chin and jaw line
4. the supra-orbital ridge
 These areas must be in harmony and proportion.
 The nose is dealt with by rhinoplasty.
 The cheek by repositioning of the malar fat pad or malar implants (see separate sheet)
 The chin by either advancement genioplasty or augmentation.
Tips
1. Gentle soft tissue elevation
2. Create a large enough pocket
3. Implants should be placed on bone
MIMETIC MODULATION
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 Hyperkinetic facial muscles can cause wrinkles and may be treated by selective myotomy, myectomy, neurotomy or with Botulinum toxin (Botox).
 Mulbauer reported 60 cases of selective myotomy, myectomy and neurotomy.
 These techniques have been applied to
1. frown lines
2. crow’s feet
3. N-L folds
4. vertical bands in the neck
COLLAGEN INJECTIONS
 Developed at Stanford University (1977).
 Bovine collagen used as all mammalian collagen similar and foreign collagen not readily identified by the
human immune system.
 Widespread clinical use since 1981. Available as Zyderm (type 1-3).
 Collagen must be inserted into the dermis
 Must overcorrect to 50-100%.
 Many patients require multiple injections over time (average 4-5).
 About 10% of patients experience rapid resorption and disappearance of collagen.
 About 3% of patients experience hypersensitivity reactions (?previously sensitised to bovine collagen via a
dietary route).
Zyderm I (35 mg/ml of collagen)  for fine wrinkles especially around the eyes and mouth.
 Zyderm II (65 mg/ml of collagen) - more robust  for scars and deep lesions.
 Zyplast (cross linked with glutaraldehyde) - stable and more long-lasting.
 Burke (using Yorkshire pigs and biopsies as well as human subjects) established that the bovine collagen
disappeared from the dermis or subcutaneous tissue by 5-16 weeks, probably d/t inflammation, but that the
resorbed collagen is replaced by human type III collagen and thus there may be a lasting clinical effect.
 Similar studies have shown resorption and replacement of zyplast (although it takes longer).
EYELIDS
Hamra routinely use arcus marginalis release and instead of excision the 3 compartments of orbital fat, he
teases it over the bony inferior orbital rim to soften it. Occasionally it is necessary to excise excess fat from
the medial or middle compartments, never the lateral. The fat is then sutured in position with 5-0 Vi interrupted.
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