Cosmetic Facial Surgery

Chapter 8  •  RHINOPLASTY
233
Case 10
FIGURE 8-79.  A 38-year-old female patient before and 4 years after staged open rhinoplasty reconstruction. The patient report-
edly had well over 10 previous nasal surgeries and presented with an infected Gore-Tex dorsal graft. The initial surgery consisted
of exploration and débridement of the infected graft, with limited nasal vestibular skin grafts and dermal augmentation. Second-
stage surgery 3 months later involved major grafting using auricular cartilage for batten grafts and dorsal augmentation, along
with irradiated rib cartilage grafting and dermal grafting. No significant septal cartilage was present, and she preferred irradiated
cartilage over a rib harvest.
Dorsal
augmentation
using cartilage
and dermis during
2nd stage surgery
Auricular
batten
grafts
Stacked
shield
grafts
Dermal grafting
Irradiated
cartilage graft
A
B
C
D
E
F
G

234
Chapter 8  •  RHINOPLASTY
Case 11
FIGURE 8-80.  A 34-year-old Asian female before and 2 years after placement of a silicone “Capriotti” implant (also known as a
style 7) that augments the dorsum as well as tip and columella. Alar base resection was performed to narrow the base and
aid in some tip projection.
Silicone
dorsal columellar
graft
A
B
C
D
E

Chapter 8  •  RHINOPLASTY
235
Silicone
dorsal columellar
graft
A
B
C
D
E
F
G
FIGURE 8-81.  A 34-year-old Asian female before and 6 months after placement of a silicone “Capriotti” implant (style 7 implant)
that augments the dorsum and the tip for increased projection. Alar nasal base reduction was also performed. Both this patient
and the patient in Figure 8-80 could have been treated with autologous tissue, but Asian patients often have thin facial cartilage,
and rib harvest may be required for adequate strength and volume.
Case 11—cont’d

236
Chapter 8  •  RHINOPLASTY
Case 12
FIGURE 8-82.  A 63-year-old female patient before and 8 months after open rhinoplasty with rib cartilage columellar tip grafting
as well as batten grafting to correct external valve collapse. The patient reports having two previous nasal and septal surgeries
many years ago. Rib cartilage was selected for strength, size, and lack of other suitable cartilage required in fibrotic cases.
The thicker cartilage aids in stability of this difficult case but will make the tip firmer to the touch.
Batten grafts placed to increase
caudal projection and improve
alar retraction and external
valve collapse
Rib graft for strut
Rib cartilage
placed as large
central strut and
as bilateral
batten grafts
A
D
E
F
G
H
B
C

Chapter 8  •  RHINOPLASTY
237
Case 13
FIGURE 8-83.  A 32-year-old female patient before and 1 month after open rhinoplasty. The patient reports she had previous
rhinoplasty and at least one revision. This is a classic case in which apparent overresection of the tip cartilages produced alar
retraction and loss of tip projection. Underreduction of the anterior septal angle, a hanging columella, and a large anterior nasal
spine made the result even worse. Correction was achieved by reduction of the excesses and placement of large, sturdy strut
and batten grafts. Also, rotation of lateral crural flaps up to the strut were used to further increase tip projection. This is known
as a lateral crural steal technique or modified Goldman.
Batten
graft
Shield
graft
Reduction of
anterior septal
angle
Lateral
osteotomy
Reduction
of the
anterior
nasal spine
Reduction of
caudal septum
Shield graft
Reduction of
anterior septal
angle
Lateral crural steal
and strut
A
D
F
G
H
E
B
C

238
Chapter 8  •  RHINOPLASTY
Case 14
FIGURE 8-84.  A 39-year-old male patient before and 2 years after open rhinoplasty and septoplasty. The patient had a history
of severe nasal trauma with resulting severe septal deviation and saddle nose deformity. Minimal adequate useable straight
septal cartilage was present for dorsal augmentation. Synthetic silicone onlay grafts are available in various sizes and shapes.
The graft in E augments both the dorsum and nasal tip. A standard silicone dorsal-only onlay graft (H) was used to correct
this patient’s saddle nose deformity. The patient also had alar base reduction.
A
B
C
D
E
F
G
H

Chapter 8  •  RHINOPLASTY
239
Case 15
FIGURE 8-85.  A 23-year-old female patient before and 3 months after open rhinoplasty. The patient had a very constricted base
as well as nasal tip and hanging columella with retracted ala. The enlarged anterior spine was reduced along with excess
caudal septum. A columellar strut was placed to support and increase projection of the nasal tip. Batten grafts help correct
the constricted and retracted ala. The constricted nasal base is further improved by releasing the tissue attached to the pyriform
rim with aggressive subperiosteal dissection. The dorsum was slightly reduced at the cephalad portion to deepen a preop
obtuse nasofrontal angle.
Reduction of the anterior
nasal spine and caudal septum
Sub-periosteal
elevation
Auricular
batten
grafts
A
B
C
D
E
F
G
H

240
Chapter 8  •  RHINOPLASTY
Case 16
FIGURE 8-86.  A 24-year-old female patient before and 3 years after open rhinoplasty. Tip narrowing is performed with excision
of cephalic strips of lower lateral cartilage, strut placement, and transdomal suturing. The middle third is drastically narrowed
by trimming upper lateral cartilages and with both lateral and medial osteotomies. Horizontal sutures across the dorsum to
upper lateral cartilages were used to help prevent internal nasal valve collapse.
Lateral and medial
osteotomies
Minor dorsal
reduction and trimming
of upper lateral
cartilages
Strut and tip sutures
A
B
C
D
E
F
G

Chapter 8  •  RHINOPLASTY
241
Case 17
FIGURE 8-87.  A 50-year-old male patient before and 1 year after open rhinoplasty. A dorsal hump was reduced along with
reduction of excess caudal septum. Cephalic strip cartilage excision was performed on lower lateral crural cartilages. Transdomal
suturing was used after cross-cuts are made (where cartilage was thick and firm) at the dome to narrow the tip and increase
tip projection. Caudal septum was trimmed and medial crura sutured to the residual septum more cephalically. Alar base exci-
sion is used to narrow a wide base width and nostril size.
A
B
E
F
G
H
I
C
D
Cross cuts to weaken rigid domal
cartilage before tip suturing

242
Chapter 8  •  RHINOPLASTY
Case 18
FIGURE 8-88.  A 53-year-old female patient before and 8 months after reconstructive rhinoplasty. The patient presented with a
defect many months after reported cancer treatment. A large columellar strut was placed for tip projection, and auricular cartilage
was used to replace the missing lower lateral cartilages. A right nasolabial rotational flap was selected over a forehead flap,
since her nasolabial folds were relatively thick and flexible. Mucosal advancement flaps from each side of the septum and nasal
floor were also required. Vascular tissue is needed on each side of the free cartilage grafts.
Cartilage
grafts and
mucosal
advancement
flaps
Right
nasolabial
rotation flap
Cartilage grafts and mucosal
advancement flaps
A
D
F
G
E
B
C

Chapter 8  •  RHINOPLASTY
243
Case 19
FIGURE 8-89.  A 20-year-old female patient before and 1 month after open septorhinoplasty. The nose was lengthened by sepa-
rating the anterior septum and advancing it caudally. A “bar-type” graft was used to span the defect and maintain caudal
displacement of the septum. Alar batten onlay grafts were required to help further lengthen the nose at the alar rim and decrease
nostril show. A large strut graft was securely sutured to the caudal septum and angled forward to derotate the nasal tip. Tip-
defining points were moved caudally. Excess caudal septum was trimmed to an ideal shape and size.
Bar graft to
maintain
septal
advancement
Resection of excess
caudal septum
Harvested
septum
Strut
Minor hump
reduction
Internal
septal
separation
Alar
batten
grafts
Strut angled to
de-rotate the tip
A
D
E
F
G
H
B
C

244
Chapter 8  •  RHINOPLASTY
Case 20
FIGURE 8-90.  A 53-year-old male patient before and 2 years after open septorhinoplasty. A large nasal dorsal hump was reduced
and a strut placed for tip refinement and support following resection of a large amount of surrounding cartilage. Alar batten
grafts were required to prevent external valve collapse and obtain a pyramidal tip shape versus a pinched appearance following
cephalad reduction of cartilages. The anterior strut was also required following removal of significant deviated septal cartilage
near the tip and base.
Strut
Major septal
deviation
resected
Strut
Alar
batten
grafts
Lateral
osteotomy
Dorsal hump reduction
A
B
E
H
C
F
G
D

Chapter 8  •  RHINOPLASTY
245
Conclusion
Cosmetic rhinoplasty requires dedication to continued learning
and improvement over a surgeon’s entire career. It is a surgery
that deals in millimeters, and mistakes unfortunately may not
be obvious until years later. No surgical method works for all
noses. Nevertheless, it is imperative to have a systematic method
for evaluating the nose and planning treatment. This chapter
has offered an overview only; lifetime study is essential for
obtaining consistent results. We hope to have provided a general
understanding of classic rhinoplasty and presented logical treat-
ment options. The chapter was also meant to help prevent
common mistakes that can lead to an unhappy patient.
A perceived “deformity” in the middle of a person’s face that
has troubled them for years can be corrected by skillful rhino-
plasty. The transformation can be life changing for the patient
and exhilarating for the surgeon. The minutiae of this surgery
mandates a thorough understanding of nasal anatomy. Further-
more, achieving a harmonious nose in perfect proportion to its
own subunits and the rest of the face separates the good rhino-
plasty surgeon from the great.
Rhinoplasty may be the most complex and demanding cos-
metic procedure, yet it can be one of the most rewarding.
Endeavoring to create the perfect nose is always the elusive goal
of a rhinoplasty surgeon, and mastering this challenging surgery
is a kind of quest. There is a story of an Italian surgeon who
reportedly performed 30,000 rhinoplasties over his lifetime.
When asked by a peer how many he would like to do over if
he had the chance, his answer was, “All of them but two!”
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35. McCollough EG, Mangat D: Systematic approach to correction of the nasal
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38. Sheen JH: Achieving more nasal tip projection by the use of a small autog-
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39. Tebbetts JB: Shaping and positioning the nasal tip without structural dis-
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40. Tardy ME, Jr, Walter MA, Patt BS: The overprojecting nose: anatomic
component analysis and repair. Facial Plast Surg 9(4):306–316, 1993.
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42. McCurdy JA, Jr: Surgery of the nasal tip: Current concepts. Ear Nose
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43. Webster RC, Hopping SB, Hall B, et al: Intraoral insertion of grafts to
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44. Garcia-Velasco J, Garcia-Velasco M: Tip graft from the cartilaginous
dorsum in rhinoplasty. Aesthetic Plast Surg 10:21, 1986.
45. Tebbetts JB: Rethinking the logic and techniques of primary tip rhino-
plasty: a perspective of the evolution of surgery of the nasal tip. Otolaryngol
Clin North Am 32(4):741–754, 1999.
46. Ellis DAF, Halik JJ: The analysis and correction of nasal columella defor-
mity: A review. J Otolaryngol 14:103, 1985.
47. Constantian MB: Functional effects of alar cartilage malposition. Ann Plast
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48. Ellenbogen R, Blome DW: Alar rim raising. Plast Reconstr Surg 90:28,
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49. Nicolle FV: Secondary rhinoplasty of the nasal tip and columella: The
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Chapter 8  •  RHINOPLASTY
51. Kaufman AJ, et al: Reconstruction of a large surgical defect on the nasal
tip and ala. Dermatol Surg 27:83–86, 2001.
52. Waite PP, Matukas VJ: Simultaneous orthognathic and septoplasty. Oral
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53. Sheen JH: Spreader graft: a method of reconstructing the roof of the
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54. Bottini DJ, Gentile P, Donfrancesco A, et al: Augmentation rhinoplasty
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56. Gunter JP, Rohrich RJ: Correction of the pinched nasal tip with alar
spreader grafts. Plast Reconstr Surg 90:821, 1992.
57. Toriumi DM: Surgical correction of the aging nose. Facial Plast Surg
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58. Adams WP, Jr, Rohrich RJ, Hollier LH, et al: Anatomic basis and clinical
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65. Kridel RW, Konior RJ, Shumrick KA, et al: Advances in nasal tip surgery.
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66. Foda HM, Kridel RW: Lateral crural steal and lateral crural overlay: an
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67. Park SS: The flaring suture to augment the repair of the dysfunctional nasal
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68. Jackson IT, Choi HY, Clay R, et al: Long-term follow-up of cranial bone
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1998.
69. Celik M, Tuncer S: Nasal reconstruction using both cranial bone and ear
cartilage. Plast Reconstr Surg 105(5):1624–1627, 2000.
70. Parker Porter J: Grafts in rhinoplasty: alloplastic vs. autogenous. Arch
Otolaryngol Head Neck Surg 126(4):558–561, 2000.
71. Adamson PA: Grafts in rhinoplasty: autogenous grafts are superior to
alloplastic. Arch Otolaryngol Head Neck Surg 126(4):561–562, 2000.
72. Romo T, 3rd, Sclafani AP, Jacono AA: Nasal reconstruction using porous
polyethylene implants. Facial Plast Surg 16(1):55–61, 2000.
73. Gibson T, Davis WB: Some further observations on the use of preserved
animal cartilage. Br J Plast Surg 8(2):85–92, 1955.
74. Walton RL, Burget GC, Beahm EK: Microsurgical reconstruction of the
nasal lining. Plast Reconstr Surg 115:1813, 2005.
75. Tardy ME, Jr, Cheng EY, Jernstrom V: Misadventures in nasal tip surgery.
Analysis and repair. Otolaryngol Clin North Am 20(4):797–823, 1987.
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77. Horton CL, Matthews MS: Nasal reconstruction with autologous rib
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247
9 
Cervicofacial Rhytidectomy
A
textbook on cosmetic facial surgery has the power to
influence surgeons, surgeries, and outcomes in positive
or negative ways. In giving advice, teaching, or showing
how a given procedure is performed, its author is in a position
to share a lifetime of learning, teaching, and trial-and-error
experience with the book’s readers. Some editorialization relates
to hows and how nots distilled from days past, new technology,
and opinions that are solely those of the author. All readers must
keep in mind that there are many successful means of achieving
aesthetic outcomes for all procedures, and there is rarely one
way to do any procedure.
My goal in writing this chapter is to share my experience of
facelift surgery and focus on what I believe are sound, safe, and
effective means of achieving predictable outcomes—tenets
based on performing almost 700 facelifts. I have written numer-
ous articles on facelift surgery, so the chapter will occasionally
quote my own material, but it offers in-depth discussion of
facelift surgery from the consult to the thank-you note.
Facelift surgery, or cervicofacial rhytidectomy, remains the
ultimate rejuvenative cosmetic procedure. No other procedure
can produce results patients can clearly see and appreciate 24
hours a day and do so much to boost confidence and self-
esteem. Contemporary facelift surgery is a combination of art
and science and requires significant experience to become pro-
ficient. Many subtle, technique-sensitive operative steps and
nuances must be appreciated by the surgeon to provide predict-
able results with low complications. I feel this is one of the most
challenging procedures to learn.
Like so many other things in life, the basics of facelift surgery
are relatively straightforward, but the key to success is in the
details, and the details take years to appreciate. Any given detail
of the procedure may work well for some surgeons but not so
well for others. Facelifts can be taxing; they can take from 212
to 4 hours. Most frequently, I am doing concomitant procedures
such as blepharoplasty, brow lift, laser resurfacing, chin and
cheek implants, and so forth along with the facelift. This some-
times translates into 5- to 6-hour cases. This has required me to
make many changes in my office. I had our facility accredited
by the Accreditation Association for Ambulatory Health Care
(AAAHC) and equipped hospital-caliber operating rooms
(Figure 9-1).
My original discipline is maxillofacial surgery, so I am well
trained in ambulatory outpatient anesthesia and licensed in my
state to perform intravenous (IV) sedation and general anesthe-
sia. For many short procedures on healthy patients, we are able
to use IV sedation with tumescent anesthesia. For longer cases
or those on older or medically compromised patients, we use
nurse anesthetists or physician anesthesiologists. I have also
built a hospital-grade recovery suite suitable for ambulatory
outpatient anesthesia but capable of overnight stay with nursing
care (Figure 9-2). I have privileges at several local hospitals
and surgery centers but rarely use them (with the exception
of cases of medically compromised patients), opting for the
convenience of my office surgery center. Although I believe I
currently have a state-of-the-art facility, this did not happen
overnight. Over the past 12 years, I have upgraded from rela-
tively humble but safe facilities as the practice grew and the
patient base expanded.
FIGURE 9-1.  One of the author’s accredited in-office ambulatory operating
suites.
FIGURE 9-2.  The author’s in-office recovery facility.

248
Chapter 9  •  Cervicofacial Rhytidectomy
and if they provide safe procedures with great outcomes, then
they cannot be criticized. For the novice surgeon, however, it is
preferable to begin with safe and predictable techniques before
advancing to more complex procedures. Walk before you run!
At some time, the surgeon and patient are going to have to
agree on what type of facelift is preferable for the given situation,
and herein can lie a contemporary problem: many surgeons who
are just learning facelift surgery may fixate on one of the “miracle
lift” procedures promoted as being “easy, done under local anes-
thesia, no bandages, 48-hour recovery,” and the like. Since this
type of lift is easier to learn, the novice may attempt to apply
this single type of lift to all types of patients. These small lifts
may work well on younger patients, but on older patients or
those with more advanced aging, conservative techniques will
not produce an adequate or lasting result. Patients with bigger
problems need bigger procedures.
There is a time, place, and patient for short-cut procedures,
but not all facelift patients can be painted with that brush.
Someone once said, “Before learning the tricks of the trade,
learn the trade,” and this sums up my point. There is no one-
size-fits-all operation for facelifting. Each patient and operation
must be customized specifically for the situation at hand. On a
regular basis, I see unhappy patients who drove hours to get
some trendy “franchise” lift that sounded too good be true, and
they now present to my office with results that are less than
promised and promoted. Almost unanimously, they spent more
money getting half a facelift at a franchise than they would have
spent getting a “real” facelift in my office.
Facelift History
The scientific literature is replete with descriptions of early face-
lift techniques from the early 20th century that primarily
detailed skin tightening and excision.1-11 In 1973, Skoog pre-
sented a technique of elevating the platysma muscle without
detaching the skin.12 In 1976, Mitz and Peyronie described the
superficial musculoaponeurotic system (SMAS),13 and later
other authors described techniques of SMAS plication and
imbrication.14-16 By the late 1970s and mid-1980s, a combina-
tion of complete platysmal muscle transection, plication of
medial borders, and pulling laterally was presented as the way
to get the “best result.”17,18 Patient complaints, complications,
and overoperated necks occurred, and many of these techniques
were abandoned.19 Deep-plane and subperiosteal techniques
have been described by multiple authors,20-22 as well as endo-
scopic approaches.23
Many other techniques have been described, and some
surgeons have gone as far as “inventing” new techniques and
patenting catchy names to describe some minimally invasive
facelift that is supposedly revolutionary. For the most part, these
“new” techniques are a rehashing of previously described tech-
niques (Figure 9-3). When reviewing the literature, it should be
kept in mind that just because a technique has been published
or promoted does not mean it is better or safer. It will be men-
tioned many times throughout this chapter that patient safety
and outcome are testaments to “the best” facelift technique.
Some techniques may work well in the hands of a given surgeon,
A
B
FIGURE 9-3.  Despite efforts to market “new, revolutionary” facelift techniques, conservative facelift history shows that the same
short-scar facelift with purse-string sutures was described in 1927, which means it was employed earlier than that. (From
Virenque M: Traitement chirurgicale des rides de la face et du cou. In Pauchet V: La Pratique Chirurgicale Illustrée, Gaston
Doin et Cie, Paris, 1927.)

Chapter 9  •  Cervicofacial Rhytidectomy
249
Facelift Anatomy
Facelift surgery and anatomy are inseparable, good surgeons
are great anatomists, and facial anatomic expertise is imperative
to performing competent facelift surgery and avoiding compli-
cations. With the unique anatomy of the face, it is impossible
to cover everything in this chapter; we will discuss the most
relevant anatomy as it applies to the procedure.
The first layer concerned in facelift anatomy is obviously
the skin. The dermal plexus of blood vessels nourishes the
skin (and facelift flap) and must at all times be respected. The
handling of lipocutaneous flaps in cosmetic facial surgery should
be as gentle as other procedures in which the vascularity of
the flap is essential to its survival. When dissecting a facelift
flap, several millimeters of fat is left adherent to the dermal
undersurface to protect this area and enhance flap viability. A
good general rule is that there should be fat on both sides of
the facelift flap.
The next layer is the subcutaneous layer (Figure 9-4). This is
the layer of fat that is intimate to the dermis superficially and
also with the deeper SMAS. The subcutaneous layer is basically
a safe layer in the face and can be undermined in the subcutane-
ous plane without damage to significant anatomic structures.
This layer is of varying thickness depending upon the location
and patient. This layer also becomes thickened over the malar
region, where dissection can be tenuous. This tissue is attached
to the malar periosteum by retaining ligaments that run from
the underlying periosteum through the malar pad and insert
into the dermis. This area is very tenacious and because of its
fibrous nature provides resistance when dissecting; it is referred
to as McGregor’s patch. Brisk bleeding is also frequently seen in
the area due to accompanying vasculature.
FIGURE 9-4.  The subcutaneous layer of the face in the area of the facelift
flap is illustrated. This is generally a safe surgical plane, especially over the
parotid gland.
1
2
3
4
FIGURE 9-5.  The SMAS represents an extension of the superficial cervical
fascia (4) extending into the face. The thickened portion over the parotid
gland is what most surgeons refer to as the SMAS in rhytidectomy (3).
This layer is referred to as the temporoparietal fascia above the zygomatic
arch (2) and as the galea in the scalp (1).
The third layer is the SMAS layer. This layer separates the
overlying subcutaneous fat from the underlying parotid-masse-
teric fascia and facial nerve branches (Figure 9-5). The SMAS
layer, as described by many leading authors, is said to be con-
tinuous with the galea in the scalp, the temporoparietal fascia
in the temples, and the superior cervical fascia in the neck. This
structure was initially described by Mitz and Peyronie as mus-
cular and fibrous tissues and termed the superficial musculoapo-
neurotic system.13 They stated the SMAS exists in the parotid and
cheek region and invests the muscles of facial expression. In
their original article, the authors state, “To us, the SMAS
appears to be a fibromuscular network located between the facial
muscles and the dermis, one which covers the facial motor
nerves.” They note that the SMAS separates two layers of fat in
the face into superficial and deep layers. Their work also implied
that the SMAS was continuous with the platysma.
Various authors contest Mitz and Peyronie’s finite descrip-
tion of the SMAS and related layers, and some surgeons do not
agree that there is any such thing at all as the SMAS. Jost and
Levet24 refuted the work of Mitz and Peyronie and dispute their
findings. In this study, the authors combine embryology and
comparative anatomy of other mammals as well as cadaver dis-
sections and summarize that the SMAS as described previously
is incorrect. These authors describe the SMAS as a double-lay-
ered system. The first layer is the superficial system which is
consistent with primitive platysma and includes parotid fascia
and has no direct bone insertion. In addition, they state that a
deep system exists which includes the sphincter coli profundus.
This group of muscles in the perioral region does possess bony
attachments. These authors also contradict Mitz and Peyronie

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Chapter 9  •  Cervicofacial Rhytidectomy
in the desired vector. This makes sense; it is said that the physi-
ologic function of the SMAS is to more effectively transfer
mimetic muscle movement to the facial skin by septae that
extend from the SMAS to the dermis. In theory, this would
allow the face to move more as a unit (as opposed to each indi-
vidual muscle), thus making expression more efficient.
The fourth surgical plane commonly involved in facelift
surgery is the sub-SMAS plane (Figure 9-7). This surgical plane
contains the facial nerve motor branches and the parotid duct
and is best avoided by novice surgeons. The facial nerve branches
are deeper in the parotid gland until they emerge at the anterior
border of the gland and cross the masseter muscle. The parot­
idomasseteric fascia is the facial layer that overlies the parotid
gland and masseter muscle; when operating superior to this
layer, the facial nerve branches are generally protected. Just as
the SMAS is an extension of the superficial cervical fascia, the
parotidomasseteric fascia is an extension of the superficial layer
of the deep cervical fascia into the face and the deep temporal
fascia above the zygomatic arch. The novice surgeon should not
violate the parotidomasseteric fascia, although many seasoned
surgeons perform deep plane dissections beneath the layer rou-
tinely. Obviously the deeper and more anteriorly the dissection
proceeds beneath this layer, the greater the chance of injury to
the facial nerve branches. There is a sub-SMAS loose areolar
tissue plane that extends from the anterior border of the parotid
to the anterior border of the masseter. Blunt dissection in this
plane allows the deep plane facelift dissection to proceed safely
even though it is almost intimate with the underlying facial
nerve branches.
and state that the SMAS is not continuous with the platysma,
but rather it is the parotid fascia that is continuous with the
platysma. Additionally, they comment that the parotid fascia is
the uppermost part of the primitive platysma, which is a muscle
that has undergone fibrous degeneration. Applying this to face-
lift surgery, these authors suggest dissection deep to the parotid
fascia.
In an additional article denying that the SMAS exists as
originally described,25 Gardetto et al. state that according to the
work of Mitz and Peyronie, “no SMAS exists in any of the
described regions that agrees with the basic criteria of Mitz
and Peyronie.” This paper corroborates through comparative
anatomy and fresh cadaver dissection studies that the “SMAS
does exist in the parotid region, where it is thick but becomes
very thin and discontinuous in the cheek where it is impossible
to identify or dissect it, even with microsurgical technique.”
They further state that “there is no evidence of continuity of the
SMAS and the temporal fascia but in contrast, in the lower
eyelid there is continuity with the lateral portion or the orbicu-
laris oculi muscle.”
Having said all this, one can call the fibromuscular layer
anything they wish (or deny its existence). Most surgeons will
agree it separates the subcutaneous fat from the underlying
parotidomasseteric fascia. When a surgeon states that they pick
up the SMAS, in reality they are picking up adipose tissue of
the subcutaneous fat and fibromuscular tissue above the parot­
idomasseteric fascia. This is what is frequently plicated, excised,
imbricated, and otherwise managed in facelift surgery (Figure
9-6). Whether you agree about the embryology and histology,
we will refer to this layer as SMAS throughout this text. All
motor nerves providing movement of the facial muscles are deep
to this plane. When this layer is stretched or pulled, it pulls on
the mimetic muscles and basically moves the entire lateral face
FIGURE 9-6.  A representation of how pulling the SMAS in a positive vector
will “reset” and reposition the sagging facial soft tissues as a unit.
1
1
1
1
2
3
4
5
6
FIGURE 9-7.  The parotidomasseteric fascia overlies the parotid gland and
masseter muscle. The facial nerve branches and parotid duct lie beneath
this layer and are vulnerable if it is violated. The facial nerve branches (1)
exit the parotid gland (2) and traverse over the masseter muscle (3). Other
deep significant structures that are vulnerable in the lateral neck include
the sternocleidomastoid muscle (4), the external jugular vein (5), and the
greater auricular nerve (6).

Chapter 9  •  Cervicofacial Rhytidectomy
251
(cutaneous ligaments). The exact name and location of these
ligaments are described differently by various authors but col-
lectively can be appreciated during facelift dissection, where
they can be felt (fibrous tissue difficult to bluntly dissect) or
visualized directly. Figure 9-10 shows a rendition of the approxi-
mate position of these retaining ligaments.
FIGURE 9-8.  The motor innervation to the perioral musculature uniformly is
from the seventh cranial nerve. The facial nerve has temporal, zygomatic,
buccal, marginal mandibular, and cervical branches. The buccal and
marginal branches primarily supply innervation to the perioral musculature.
Interconnection between the branches is common, with at least 4 con-
nections formed after exiting the parotid gland. The fibers supply the
majority of the muscles of the face from their undersurface. The exceptions
are the three deepest perioral muscles, namely, the buccinator, levator
anguli oris, and mentalis. (Adapted from Patton KT, Thibodeau GA:
Anatomy and Physiology, ed 7, St. Louis, Mosby, 2010.)
A
B
FIGURE 9-9.  Staying superior to the SMAS in the
neck is a safe surgical plane. The subcutaneous
and SMAS planes become very thin over the
midbelly of the sternocleidomastoid (SCM)
muscle. The greater auricular crosses the SCM
approximately 6.5 cm inferior to the external
meatus (A), and the external jugular vein is
frequently in close proximity. These structures
are therefore vulnerable, as shown in a live
patient (B).
As the facial nerve branches course anteriorly, they overlie
the buccal fat pad then innervate the mimetic muscles. Besides
the facial nerve branches and parotid duct, the buccal fat pad
and facial artery and vein also lie in the plane under the parot­
idomasseteric fascia.
The relationship between the parotid gland and the facial
nerve branches will be referenced many times in this text, and
the reader should keep in mind that dissection over the parotid
gland is safe, but the facial nerve branches are at risk as they
exit the gland and traverse the masseter. Staying over the parotid
and above the parotid fascia is the safest anatomic area for
novice facelift surgeons. So long as dissection stays superficial
to the SMAS and platysma, the motor nerves are protected.
One reason the facial nerves are protected in deep plane dis-
section as they branch in the anterior face is that most nerves
innervate the muscle on its posterior surface. The only muscles
of facial expression that are exceptions are the levator anguli oris,
the buccinator, and the mentalis, which are all innervated on
their anterior surface (Figure 9-8).
Several other structures are frequently encountered in facelift
surgery and are vulnerable to injury. The sternocleidomastoid
muscle is significant because the external jugular vein and
greater auricular nerve are intimate and traverse this muscle in
the midlateral neck (Figure 9-9). The greater auricular provides
sensory innervation to the earlobe and lateral cheek. The exter-
nal jugular vein and greater auricular nerve lie deep to the
SMAS and are protected as long as the dissection remains in the
subcutaneous plane. The subcutaneous tissue becomes very thin
in this part of the neck, and the dermis is sometimes intimate
to the fascia of the sternocleidomastoid muscle, which can put
the nerve and vein in jeopardy.
The youthful face is in part suspended by retaining ligaments
that support the skin over the facial bones. These ligaments
become lax with age and in part are responsible for the sagging
of facial tissues. This connective tissue can run from bone to
dermis (osteocutaneous ligaments) or from soft tissue to dermis

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Chapter 9  •  Cervicofacial Rhytidectomy
consultation is to explain the procedure and educate the patient
about what the procedure does and does not do. Should the
case come to fruition, I have a special consent, “What Your
Facelift Won’t Do.” This is important information; patients may
assume that all their wrinkles will be improved or that their
result will last forever or that they may look 20 years younger.
Many patients are surprised when I explain that a facelift is
a procedure primarily for the lower face. It is not uncommon
for patients to present and request “just a little tuck to pull back
my cheeks.” They place their fingers on their cheeks and reset
their cheeks, jowls, and neck (Figure 9-11, A). It must be
explained to these patients that no procedure exists that corrects
Patient Selection
In theory, most patients in their fourth decade are candidates
for some type of facelift. Younger patients may seek consultation
for minor jowling and neck changes and be candidates for
minimally invasive rhytidectomy, whereas older patients may
require larger procedures with other concomitant mid- and
upper facial cosmetic surgery correction.
One problem is that the word facelift conjures different ideas
for each patient. Some patients think a “full” facelift includes
eyelid and brow surgery or other procedures. Likewise, I have
had postoperative facelift patients complain that they still have
wrinkles around their mouth. The first goal of facelift
B
1
2
3
4
A
FIGURE 9-10.  A, Representation of facial ligaments. Osteocutaneous retaining ligaments such as the zygomatic (1) and man-
dibular (2) originate on bone and insert on dermis. Cutaneous ligaments, such as the masseteric retaining ligament (3) and the
parotid retaining ligament (4), are thickenings of connective tissue that join deeper soft-tissue structures to the dermis. Col-
lectively these ligaments support the facial structures and may be violated during facelift dissection. B, Cadaver dissection of
cutaneous retaining ligaments.
A
B
No
Maybe
FIGURE 9-11.  A, What many patients do in front of their mirrors and request as a surgical result. This is an inaccurate preview
of what a facelift will do. B, Pulling the cheeks in a more posterior vector is more representative.

Chapter 9  •  Cervicofacial Rhytidectomy
253
Many classifications exist for grading aging changes, but I
truly believe it is easier to think in terms of small, medium, and
large (Figure 9-13). As stated earlier, a facelift is primarily a
procedure for the lower face. No other procedure can address
the jowls and sagging neck. Many shortcuts exist, such as lipo-
suction and submentoplasty, but in the average patient with
noticeable aging changes, cervicofacial rhytidectomy is a time-
proven procedure to provide natural and lasting results.
Patients with large neck and jowl changes are poor candidates
for the novice surgeon. Beginners should initially concentrate
on thinner patients with mild aging and normal chin position.
When considering candidates for rhytidectomy, chin and sub-
mental position is also of significant consideration. In patients
with retrognathia or microgenia, the final result will not be as
dramatic unless chin augmentation with implants or osteotomy
is performed. Even more important is the position of the hyoid
bone and associated muscles of the submental region. In patients
with a hyoid position and laryngeal anatomy that is superior
and posterior, the skin can be pulled to form an acute angle that
approximates 90 degrees (Figure 9-14, A). Patients with this
type of anatomy are better candidates than those with inferior
and posteriorly situated hyoid bones and submental anatomy
(see Figure 9-14, B). The novice surgeon must realize these
implications. On patients with anatomy consistent with Figure
9-14, B, chin augmentation can improve the final outcome, but
these patients must realize that their particular anatomy limits
the result when compared to a patient with normal hyoid and
submental position. I keep a picture of Figure 9-14 in my evalu-
ation rooms to explain this concept to prospective patients.
Correct diagnosis of the patient’s condition and how best to
improve it can be a challenge for the novice surgeon. Appreciat-
ing the vectors of facial aging (described in Chapter 1) can shed
light on an orderly manner for the diagnosis and rejuvenation
of the aging face. Figure 9-15 shows a rendition of a patient
with panfacial aging and the respective vectors that need cor-
rection. Having a mental picture of this can assist the surgeon
in developing an appropriate treatment plan. Actually showing
a picture similar to Figure 9-15 to the patient can improve their
understanding of the proposed surgery.
aging in that vector. By pulling the skin in a more lateral direc-
tion, a more representative correction can be explained (see
Figure 9-11, B). A more accurate means of illustrating the
potential changes from cervicofacial rhytidectomy is to place the
patient supine and have them look in a mirror while elevating
their chin. By removing gravity from the equation, the brows
and midface are elevated, and the jowls and neck are vastly
improved. I find this to be a relatively accurate prediction of the
final lower face result (Figure 9-12). Obviously, digital morph-
ing can be performed, but oftentimes the patient will set their
sights on the morphed postop image and express unhappiness
if that picture is not duplicated by the surgery.
I also show the patient before-and-after pictures of actual
facelifts I have done and refer them to my website for more
pictures and explanations. I offer them the opportunity to speak
with other patients who also have had similar procedures.
FIGURE 9-12.  Placing the patient in a recumbent position negates gravity
and provides an idea of the facelift result.
A
B
C
FIGURE 9-13.  Aging changes of the middle and lower face can be categorized as small, medium, and large and require cor-
responding small, medium, and large procedures.

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Chapter 9  •  Cervicofacial Rhytidectomy
rhytidectomy procedures, it is not uncommon that they have
systemic problems such as hypertension, cardiovascular disease,
diabetes, hyperlipidemia, arthritis, osteoporosis, and other con-
ditions. Patients are living longer and taking more medications,
so the medical status may be complex. Most of these patients
are candidates for cosmetic surgery if their diseases are con-
trolled and/or medically managed. Patients taking anticoagu-
lants or medications that affect platelet function present special
problems and may require intense medical management. The
Determining Status for Potential
Cosmetic Facial Surgery
During facelift consultation, I give patients four criteria required
to be a candidate in my office: health, psychological stability,
recovery, budget.
Health
The patient must be in adequate health for the planned proce-
dure. Although most patients are candidates for some type of
A
B
FIGURE 9-14.  A, Patient shows an example of a superior and posteriorly positioned hyoid bone, larynx, and submental structures,
which enables good chin/neck aesthetics. B, Another patient shows the inverse, and such patients must realize their outcome
may be compromised by their natural anatomy. Chin augmentation can assist by providing horizontal mandibular length.
A
B
FIGURE 9-15.  A, Patient with panfacial aging and the approximate vectors of lift, support, and elevation required to rejuvenate
the patient. B, Postsurgical photograph after facelift, cheek and chin implants, browlift, four-lid blepharoplasty, and CO2 laser
skin resurfacing.

Chapter 9  •  Cervicofacial Rhytidectomy
255
If it should occur with elective surgery, it is even more disas-
trous. Besides the loss of life and the sorrow of the family,
surgeon, and staff, an event like this could end a practice. As
more and more cosmetic surgery is performed in the ambulatory
office outpatient setting where there is less emergency help and
trained personnel, meticulous health screening is imperative. All
the required preoperative details of lab tests, histories and physi-
cals, and similar screening can be very time consuming and fall
between the cracks. Strict staff monitoring of these details is
invaluable and can be lifesaving.
Psychological Stability
Patients should be requesting cosmetic surgery for the correct
reasons, but emotional stability is difficult to ascertain because
it is difficult to quantify. Panfacial rejuvenation involves a sig-
nificant recovery process, and patients who seem psychologically
strong preoperatively can decompensate emotionally in the
recovery period to the point at which they need psychiatric
assistance.
A number of warning signs exist that should be taken into
serious consideration when deciding whether a patient is a suit-
able candidate for any cosmetic surgery. Frequently the office
staff is quite astute at picking up on the potentially unsuitable
patient, and we have witnessed common scenarios that serve as
red flags. It is not uncommon for this type of patient to be dif-
ficult to deal with throughout the entire process. They are pushy
and demanding to the receptionist when scheduling, they
exhibit the same behavior with the evaluation staff, they are
resistant to the inconvenience of having a medical workup and
labs, and they fight with the financial coordinator. The best way
to handle such a patient is to not treat them. We have all had
the experience of unpleasant dealings with patients we know we
shouldn’t have accepted. It is not a comfortable position to be
in. Learn to say no. Telling a patient you feel you can’t make
them happy is an easy and polite means of discharging them
preoperatively.
Over the past 25 years, I have seen repeating red flags for
cosmetic surgery:
• Patients who are rude or pushy
• Patients who are too busy to cooperate
• Patients who speak negatively about previous surgeons but
overly compliment the current surgeon
• Patients who present after intense Internet searches and
detail how they want their surgery performed
• Young patients who have already had multiple cosmetic
surgery procedures
• Patients traveling great distances to have a procedure that
could easily be performed locally
• Patients who expect perfection instead of improvement
• Patients who expect unrealistic life changes with cosmetic
surgery, such as a new or improved relationship, job promo-
tion, or improved physiologic status
• Patients who do not smile or make eye contact
• Patients who present with a huge list of questions or ask an
inordinate number of detailed questions
• Patients who talk without letting the surgeon talk
• A patient who does not need surgery but thinks they do
more problems a patient has, the more risky surgery and anes-
thesia can be. There comes a point at which the risk of surgery
outweighs the benefits of looking younger. In and of itself, age
is not a contraindication to facelift surgery. I have treated
78-year-old patients who were healthier than some of my
50-year-old patients. Older patients, even healthy ones, may
have decreased function or not tolerate extended surgeries and
recoveries as well as younger patients, and the treatment plan
must be tempered. All my facelift patients are required to have
a history and physical and electrocardiogram from their physi-
cian, as well as age-appropriate laboratory studies. All patients
get coagulation studies and HIV and hepatitis C screening.
Chest x-ray, pulmonary function tests, and cardiac workup,
including stress test and echocardiograms, are performed if sus-
picion exists concerning specific health status. Tolerating the
surgery is obviously a concern, but tolerating the anesthesia can
also be critical. When patients present with questionable cardiac
status, I refer them to a cardiologist and inquire about the
following:
• What is the valve function?
• What is the ventricular function?
• What is the status of the coronary artery system?
• Is the patient arrhythmogenic?
For all patients, it is imperative to have a written document
from the needed health providers that the patient is stable and
cleared to undergo anesthesia and surgery. In the event of anes-
thesia or surgery problems, this omission is one of the first
things a plaintiff’s attorney would seek.
Smoking, alcohol, or drug abuse are lifestyle factors that
could influence surgery and anesthesia as well. Smoking is a
particularly common factor encountered. Some surgeons refuse
to operate on smokers. I practice in Richmond, Virginia, where
smoking is common. I would estimate that 25% of my patients
smoke cigarettes, and this is not a contraindication to facelift
surgery. I am somewhat more cautious with smokers and avoid
very large dissections. I will usually perform concomitant laser
resurfacing but treat the flaps with much less fluence. For
extremely heavy smokers (two packs per day), I don’t place
as much tension on the flap or perform simultaneous laser.
The average smoker will report their habit as a pack a day,
and these patients generally fare well. Patients who smoke two
packs per day, in my experience, have increased airway and
anesthesia-related problems. All smokers must sign a smoker’s
consent for all cosmetic surgery procedures. This consent details
the facts of compromised healing and other negative factors that
are particular to smokers. Another problem is patients under-
reporting the extent of their smoking or denying smoking at all
when they are actually smokers. A simple, low-cost saliva nico-
tine test, NicAlert, (Nymox Corp., Hasbrouck Heights, NJ), is
available and could be used to truly determine if a patient
smokes or otherwise abuses tobacco. Although many surgeons
and anesthesiologists recommend smoking cessation before
surgery, I usually do not. I have had several patients who used
their facelift as reason kick their habit, but it is rare. I have also
seen patients decompensate from the physical and emotional
aspects of nicotine withdrawal and complicate their pre- and
postsurgical experience. Patient death with any surgery is a hor-
rible circumstance.

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Chapter 9  •  Cervicofacial Rhytidectomy
long-term investment. Some patients desire cosmetic surgery
but in reality cannot afford it. In normal circumstances, there
is significant stress for the patient when having cosmetic surgery.
Add the stress of a poor financial situation, and this may put
some patients over the edge. In addition, patients who cannot
afford a procedure tend to skimp on details that are important,
such as not purchasing expensive antivirals or antibiotics. If the
financial stress causes family problems, the experience can turn
into a negative one. Some patients should simply postpone
surgery until they can afford it; otherwise they may ask the
surgeon to compromise throughout the surgical experience.
Offering alternate financing options to patients is helpful but
occasionally can enable them to do something that at this point
is impractical.
Preoperative Consultation Workup
Facelift surgery, especially when combined with ancillary pro-
cedures, is very detailed. There are many specifics such as
preoperative workup, prescriptions, and postoperative and
follow-up appointments. This can be very logical for the office
that does it every week but very complicated for the patient who
does it once in their life. It helps to have very detailed instruc-
tions and a check-off list for your staff to follow the progress of
the communication process.
As stated earlier, all facelift patients are required to have a
physician history and physical, ECG, coagulation profile, com-
plete blood count, and HIV and hepatitis C screening. We ask
that this information be back to our office at least 2 weeks before
the surgery, and inevitably we are pushing the deadline. The
staff must stay on top of the progress; otherwise there is no time
to work up abnormal studies before surgery. The preoperative
appointment generally takes 45 to 60 minutes, most of which
is attended by the staff. At the preoperative appointment,
patients are given their prescriptions and a prescription for
compression stockings. They are also given instructions to use
an antibacterial bath soap for body and shampoo the night
before and the day of surgery. They are given their postoperative
appointment schedule and also take care of their financial
arrangements. Our policy is that half the surgical fee is due 2
weeks before the procedure, and the other half is due on the
day of surgery. All consents are signed at this appointment, and
the doctor is present for any final questions. Preoperative digital
photographs are taken at this appointment, traditionally with
the patient wearing makeup. A second set of preoperative digital
photographs are taken on the day of surgery without makeup.
These images are essential for medicolegal records and market-
ing and can prove integral to resolving conflicts with unhappy
patients.
Finally, the patient’s home support is discussed. They are
informed that they need a responsible adult to monitor them
the first several days postoperatively and drive them to my office
on the first postoperative day. If there is no caregiver, they are
given the option of private duty nursing at their home or at my
office on the night of the surgery.
It is not uncommon for patients to be quite nervous at this
appointment, since they have read multiple consents; some
patients consider canceling surgery. I explain to them that
• Patients who present with self-morphed photographs of their
anticipated surgery result
• Patients who present with pictures of celebrities, desiring
specific chin, neck, lips, and the like
• Patients who present with their own youthful pictures,
wanting that appearance back
• Patients who desire surgery but present with a spouse totally
against it
• Patients who sign up for surgery but cannot afford it
• Patients who don’t follow initial demands in the preop
period
• Patients who require numerous preoperative visits, continu-
ally ask the same questions, and appear not to comprehend
the important aspects
• Unkempt, disheveled, or obese patients who desire a cos-
metic procedure
This list does not necessarily mean I won’t operate on such
patients, but any of the above and especially a combination of
the above should serve to alert the surgeon and staff of a poten-
tially difficult experience.
Recovery
Patients must be able to take time away from work or play
commensurate with the procedure(s) considered. Everyone is
busy, and with more women in the work place, it is difficult to
balance cosmetic surgery and work. One of the biggest mistakes
a surgeon can make is to undersell a recovery. If you tell a patient
they will recover in a week and it takes 2 weeks, they can be
furious. If you tell them it takes 3 weeks and they recover in 2
weeks, you will be a hero. Many of the aspects of surgery, such
as incisions, sutures, anesthesia, bandages, and so forth, can be
objectively and accurately described. Recovery, on the other
hand, is very subjective. I have, on several occasions, performed
the same procedure on identical twins, and one twin did great
while the other twin had unusual swelling and bruising. It is
impossible to guarantee exact recovery, and the surgeon must
rely on the mean recovery of a procedure or procedures. I tell
facelift and laser patients that the average patient can return to
work or social situations at 2 weeks. I explain to them that on
the bell curve, some patients may look great at 9 days and others
may still be bruised at 3 weeks. The surgeon should always err
on the high side; if the patient is given a range of 6 to 14 days,
6 days is the only number they will remember. All of this needs
to be covered in the consent and presurgical material issued to
the patient. I give patients the option of a Friday surgery which
gives them a weekend, a full work week, and another weekend
to recover. This is sufficient for selected surgeries, but I tell them
that no surgeon can guarantee a specific recovery. If they are
having a facelift before a big event like a child’s wedding, a
reunion, or an important vacation, I suggest 4 to 6 weeks for
recovery. I also explain that the recovery process in actuality
takes about 90 days, and they will see positive changes through-
out this period.
Budget
Patients must have adequate finances for the procedure(s). Cos-
metic surgery is expensive, and I tell my patients it is a good

Chapter 9  •  Cervicofacial Rhytidectomy
257
There is no substitute for a formal operating table, and these
can be purchased refurbished. Alternatively, a dental or minor
surgical chair can suffice. Having the ability to position patients
laterally (airplane) can be of great assistance, especially with
older patients with limited neck mobility which makes position-
ing the head difficult. This prevents the surgeon from bending
over and working in a hole. An additional item that has become
personally indispensable is an operator stool that can be verti-
cally repositioned (Figure 9-16). Cosmetic facial surgery and
especially facelift surgery requires many different patient and
surgeon positions, and having the ability to pump up or lower
the stool makes it much easier to perform seated surgery. I begin
in an elevated position but frequently “drop down” to look
under the preauricular flaps and other structures.
I always show prospective patients my accredited operating
suite with pride and point out that it is set up with the same
standards as the hospital. Besides the safety and convenience it
provides for me, my staff, and patients, an accredited facility is
an excellent marketing tool. Operating at a hospital or remote
surgery center is fine, but many times there is a loss of privacy
for the patient. They may have friends, neighbors, or acquain-
tances who work there or may see their name on the schedule.
In addition, the hospital environment is usually less personal
than your own staff and facility. You also have greater ability to
control the patient’s safety in your own environment, and noso-
comial infection is much less common. Finally, the convenience
for the doctor and patient is the ultimate benefit of an office
surgery center. There is no waiting for room turnover, late cases,
emergencies, and other problems.
Office accreditation is actually a relatively simple process if
a consultant is employed to facilitate the accreditation process.
Usually your nurse and staff bear the brunt of the work, and
the doctor serves to coordinate and oversee. Many doctors think
that office accreditation is mostly concerned with the physical
plant, with the need to make a significant purchase of hospital-
grade equipment. In reality, accreditation is much more about
governance, policies, and paperwork than buildings and equip-
ment. In my situation, the only things I had to actually purchase
were a $3000 emergency power backup system, several lighted
exit signs and emergency room lights, several emergency drugs
associated with our use of general anesthesia, and nonporous
ceiling tiles in the surgical suites. What was laborious and time
consuming was policy institution and benchmarking. Again,
this is something the staff can handle.
In essence, you are setting up a “mini hospital,” and your
processes, cross-checks, and controls must be of similar quality,
although much less complex. All surgical cases require dictation,
and there are numerous checks and balances, but the goal is to
have a credible, safe, and efficient facility.
I think most doctors who have gone through accreditation
will attest that it takes some work and effort but makes you a
better and safer facility and, as stated earlier, is also an excellent
marketing point.
Instrumentation
Although many specialized instruments exist specifically for
rhytidectomy, in reality the procedure can be performed with
significant complications are rare, but no surgeon can guarantee
complication-free surgery. I also tell them that if they do have
a complication, I will stand by them and do everything possible
to correct it.
The topic of revision surgery should be addressed verbally
and in the consent. What will happen if the result is not as
planned? Will the surgeon perform revision surgery, and who
will pay for it? Once in a while, the best-executed facelift will
relapse earlier than expected. It can occur from the patient’s
inherent problems with excess skin elasticity, weight gain or loss,
or from surgical relapse. My personal policy is to perform free
of charge, reasonable surgical revisions that relate to the initial
result, such as small areas of skin or fat excess or scar revision.
I do not apply a surgical fee but do require a nominal materials
and anesthesia fee. From time to time, a patient will expect free
revision surgery for a situation that is within normal limits for
the procedure performed; those patients can be dealt with in a
different manner. Again, I always try to remember that “the
customer is always right.” If these topics are discussed preopera-
tively, they are generally easy to negotiate after surgery, but if
the topic is not discussed until after surgery, communication
can be uncomfortable, awkward, and emotional.
This should all be in the consent. “If it is not written down,
it didn’t happen” is another rule to remember.
When the patient walks out the door at this appointment,
all the i’s should be dotted and the t’s crossed. The patient may
be apprehensive but reassured and medically, physically, and
emotionally prepared for the upcoming procedures.
Facility
Although many surgeons perform facelift surgery in a hospital
or accredited facility, it is not an absolute requirement. The
supreme importance is patient safety. If the surgeon is per­
forming surgery with local or tumescent anesthesia or light
IV sedation, then the actual facility is less important. With IV
sedation, one must have the appropriate emergency equipment:
vital sign monitors, oxygen, instruments for emergency airway
placement, medications for such anesthetic emergencies as
anaphylactic shock, allergy, hypertension, hypotension, and
the like.
Many novice facelift surgeons begin with office-based surgery
performed in their ambulatory office surgical suite. Although
most surgeons perform facelifts with full sterile technique, some
doctors operate in a “clean” surgical environment. Postoperative
infections are rare in head and neck surgery, and I have not
experienced a significant one after thousands of cosmetic facial
procedures, regardless of sterile versus clean technique. This is
especially true for minimally invasive procedures. I personally
perform facelift surgery in a full scrub, sterile environment as
done in the hospital. Being gowned is important for the surgeon
and staff to be protected from potentially bloody procedures.
Most practitioners already have minor surgery suites in their
offices that can easily accommodate basic rhytidectomy. If
longer cosmetic cases such as facelift with other procedures
become a significant portion of one’s practice, a more formal
and elaborate setup is required.

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Chapter 9  •  Cervicofacial Rhytidectomy
10. Facelift scissors (I prefer Padgett “Gorney” facelift scissors.
Padgett Inc., Kansas City, MO, Item #P-6831TC.)
11. Pickup forceps
a. Medium
b. Small
c. Long bayonet
12. Radiowave or electrosurgery system for coagulation
13. Mosquito hemostats of various sizes, including long, thin
tonsil clamp for placing cheek implants
14. Needle holders, various sizes
15. Micro skin stapler and staple remover
16. Suture scissors
17. Sutures
a. 2-0 braided nylon
b. 4-0 gut
c. 5-0 gut
d. 6-0 fast-absorbing gut
e. 4-0 Vicryl
f. 6-0 nylon
18. 4 × 4 gauze
19. Comb
20. Suctions, various size Frazier-tipped and tonsil suction.
21. Local anesthetic (2% lidocaine with 1 : 100,000 epine­
phrine) and syringes with 112-inch 25-gauge needles (or
32-gauge needles for eyelid injections)
22. Tumescent local anesthesia mixture (0.1% lidocaine with
1 : 1 million epinephrine), 60-mL syringe, and 22-gauge
spinal needle
23. Hair wash
a. Hydrogen peroxide (H2O2)
b. Sterile water
24. Dressings
a. Triple antibiotic ointment
b. Xeroform gauze
c. 3-inch Kling
d. 3-inch Coban bandage
e. Gauze “fluffs”
relatively basic surgical instruments most surgeons already have
in their offices (Figure 9-17). A basic list follows:
  1. Operating table
  2. Headlight and loupes (All surgeons can do better work
when they can see well. The loupes may not be required for
the entire procedure.)
  3. Marking pen, surgical ruler, measuring caliper
  4. Techni-Care surgical prep (Care-Tech Labs Inc., St. Louis,
MO) or other surgical prep
  5. Tissue dissector cannulas (KMI Kolster Methods Inc.,
Corana, CA)
  6. Liposuction cannulas (I use 2 mm, 3 mm, and 5 mm for
various areas.)
  7. Retractors
a. One pair of Senn retractors
b. One pair of Army/Navy retractors
c. One pair of 6-inch small skin hooks
d. One pair of double-ended skin hooks
e. One Aufricht nasal retractor for generalized soft-tissue
retraction
  8. Periosteal elevator
  9. Scalpel
A
B
C
FIGURE 9-16.  A comfortable operator’s stool that can be raised and lowered by foot controls is a good investment to protect
the surgeon’s posture and facilitate intraoperative repositioning.
FIGURE 9-17.  Comprehensive facelift instrumentation.

Chapter 9  •  Cervicofacial Rhytidectomy
259
or general anesthesia, the main goal of cosmetic anesthesia is
to provide a safe procedure that renders the patient relaxed and
insensate with stable vital signs and without hypertension. This
includes a rapid emergence, no postoperative nausea and vomit-
ing, and adequate pain control. That is a tall order and in many
patients is the norm, but in others, one or more of the above
can be problematic. Chapter 4 addresses these anesthesia con-
siderations in more detail. Since hypertension will increase
bleeding, it is important to maintain a normotensive anesthetic,
especially toward the end of the procedure. It is not uncommon
to maintain low blood pressure during surgery and have a
hemostatic surgical field, only to bleed as the patient emerges.
This can contribute to postoperative hematoma which can be
quite problematic. Some surgeons prefer hypotensive anesthe-
sia, and in this situation it is important to slowly increase the
blood pressure to a normal range before closing the wounds to
make sure that new bleeding does not occur. This will be dis-
cussed at a greater level in the complications section of this
chapter.
Local and Tumescent Anesthesia
Even when using general or IV anesthesia, local and tumescent
anesthesia is used for all facelift surgery. This is invaluable
for pain control, hemostasis, and tissue hydrodissection and
reduces the amount of IV or gas anesthetic agents required. I
have performed small facelifts with local and tumescent anes-
thesia only, but no one can ever convince me that the experience
for both surgeon and patient is not better with an unconscious
patient.
I first inject all incision sites for the entire lift with about
10 mL of 2% lidocaine with 1 : 100,000 epinephrine. After
this, tumescent solution (0.1% lidocaine with 1 : 1 million
Some surgeons use many other instruments, and some use
less. It is important to have what you are comfortable with and
the correct instruments for the procedure. Of all the instru-
ments, good-quality, sharp facelift scissors are the most impor-
tant single instrument. In my experience, the more facelifts one
does the fewer instruments they require.
The Day of Surgery
The patient arrives and pays the remaining balance of their
surgical fee. They were previously told to wear lose clothing
without pullover tops, leave all jewelry home, and not to wear
any makeup, moisturizer, or hairspray. They also bring their
previously prescribed compression stockings with them and
change into them when they gown. When they arrive, an addi-
tional set of digital photographs are taken (without makeup).
The patient meets with the anesthesia personnel for a final exam.
A surgical marker is then used to mark the following structures
(Figure 9-18):
1. Pre- and postauricular incisions
2. Extent of the proposed flap dissection
3. Inferior border of mandible
4. Outline of jowls
5. Outline of submental area to be liposuctioned
6. Outline of platysmal bands if they are to be addressed
7. Submental crease
8. Submalar areas if implants are planned
9. Blepharoplasty and or brow markings if upper facial surgery
is planned
Anesthetic Considerations
Details of anesthesia are covered in Chapter 4 and are particu-
larly relevant to facelift anesthesia. Whether local, IV sedation,
A
B
FIGURE 9-18.  Typical preoperative markings for facelift and concomitant procedures—in this case facelift, endoscopic browlift,
blepharoplasty, jowl liposuction, cheek implants, and platysmaplasty.

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Chapter 9  •  Cervicofacial Rhytidectomy
much of it depends on the surgeon’s preference. I personally
like to do the procedures that demand the most precision first;
after 5 or 6 hours of surgery, fatigue can make delicate and
precise surgery more difficult. For this reason, I perform bleph-
aroplasty first and wear loupes and headlight. After the eyelid
surgery, I remove the loupes and retain the headlight for the
remainder of the procedure. I have found the PeriOptix head-
light and loupe system to be extremely useful for this type of
surgery (PeriOptix Inc., San Clemente, CA). This system is
mounted on a lightweight plastic frame with powerful magnets
that retain the independent components so they can be added
or removed in any combination without the surgeon touching
them or significantly interrupting the procedure. The headlight
is connected to a battery about the size of a cell phone that
clips to the belt or scrubs, and the intensity can be adjusted
sterilely through the gown. This system allows the use of a
headlight, loupes, and eye protection simultaneously, separately,
or in any combination (Figure 9-19).
Submental Liposuction
Removing fat from the body with suction is called liposuction,
but liposculpture is a more accurate term and better describes
the desired result. Fat deposition in the face and neck is variable
and subject to changes with aging and weight gain. Most nor-
mal-weight patients have adequate fat in the subcutaneous
tissues, and with age the jowls become ptotic and accumulate
fat, as does the submental region. In addition, the fat deep to
the platysma can become pronounced. Figure 9-20 shows a
rendition of lower-face and neck-fat deposits. Although isolated
liposuction can be very effective in younger patients with iso-
lated fat deposits, liposuction in itself is not a treatment for
obesity. Patients presenting with physical characteristics similar
to Figure 9-21 are not candidates for isolated liposuction. This
type of patient is even a poor candidate for liposuction with
facelift and submentoplasty and definitely not a candidate for
epinephrine) is injected into the submental area. This is made
by mixing 50 mL of 2% lidocaine (1 gm) with 1 L of normal
saline and adding 1 mL of epinephrine 1 : 1000. I generally
inject 40 to 60 mL into the area from the inferior border of the
mandible to the thyroid cartilage, extending to the sternocleido-
mastoid muscles on each side. This will correspond with the area
to be liposuctioned and where platysmaplasty will be performed.
Immediately after this injection, I inject a similar amount into
the pre- and postauricular areas on both sides of the facelift. It
makes sense to perform all the tumescent injections at once
because the anesthetic and hemostatic effects last for hours, and
the relatively small volumes used in facial surgery should not
present problems with lidocaine toxicity.
For this type of surgery and anesthesia, I prefer to keep IV
fluids to a minimum. Most cosmetic facial patients do not
experience significant blood loss, and administering excess fluid
may necessitate a urinary catheter to prevent intraoperative mic-
turition of bladder distention.
Prep and Drape
As stated earlier, small facelifts (especially as standalone proce-
dures) are sometimes performed in a “surgical clean” environ-
ment, although all facelifts in my office are done under full
sterile technique. I prefer a gel-filled head “doughnut” to cradle
the patient’s head on the operating table. The face and hair are
washed with a surgical prep, and sterile towels and a split sheet
are draped over the operating field. The surgeon and staff wear
sterile gloves, mask, and surgical cap. All instruments, of course,
are sterile.
Although infections are rare in the head and neck, I believe
it is the standard of care to use sterile technique. In addition,
especially when performing simultaneous brow lift and other
procedures, the procedure can be relatively bloody. Using sterile
technique, completely gloved and gowned, and fully draping
the patient’s entire body protects not only the patient but also
the surgeon and staff.
Females or patients with long hair present a relative problem
for surgery in that the hair can continually be an obstacle during
the procedure. Some surgeons braid the hair to keep it out of
the incision sites. This author prefers to comb the hair with a
large-tooth comb in rows, parted to expose the incisions. In any
event, the longer or thicker the hair, the more of an obstacle it
presents.
For long procedures, pressure points such as elbows and
knees must be cushioned. We also utilize pneumatic leg gar-
ments for longer procedures if general anesthesia is used.
As stressed earlier, all facelift patients are also prescribed
compression hose to be worn for the procedure and the next
24 hours.
The Surgical Procedure
When performing multiple procedures, it is important to stage
the procedures in a manner that makes sense. Facelifts are rarely
a single procedure; most patients also have upper and midface
procedures as well as skin resurfacing. The surgeon and surgical
team should stage the procedures to optimize the anesthesia,
keep bleeding to a minimum, and keep the flow efficient. There
is generally no right or wrong way to stage procedures, and
FIGURE 9-19.  A portable battery-powered component system of headlight,
loupes, and eye protection that can be easily and rapidly interchanged is
very useful when performing multiple surgical procedures that call for dif-
ferent combinations of lighting and magnification.

Chapter 9  •  Cervicofacial Rhytidectomy
261
have significant fat in the submental and jowl regions, and
submental liposuction is very important to sculpt the submental
area. Thin patients may not have any appreciable fat in the neck
or submental region, and removing this fat layer can cause severe
contour problems. Fat is not always the “enemy” and serves to
provide a cushioning layer between the dermis and platysma
musculature. If the fat is over-resected, the dermis can adhere
to the muscle and show significant irregularities that are difficult
to correct (Figure 9-24). Remember, if a patient does not have
fat, they do not need liposuction, or if performed, it needs to
be very conservative.
For submental liposuction, I begin by injecting 75 to 100 mL
of previously described tumescent anesthesia in a midline sub-
mental crease with a stab incision. This incision need only be
large enough to accommodate the largest cannula that will be
used, so it is usually 3 to 5 mm in length and made just through
the dermis. The important concept of liposuction is to stay in
the subcutaneous plane, which is a safe surgical plane in the face
and neck. The correct plane is below the dermis and above the
platysma muscle. Many surgeons perform subplatysmal liposuc-
tion (or open lipectomy), but this should be reserved for expe-
rienced hands.
Although I own a $4000 liposuction machine, I now perform
all cervicofacial liposuction with standard wall suction. This is
more than adequate to suction and contour the small face and
neck fat deposits. The area to be liposuctioned is confined supe-
riorly by the inferior border of the mandible, laterally by the
medial border of the sternocleidomastoid muscles, and inferi-
orly at the thyroid cartilage level (Figure 9-25, B). Although this
is usually a safe plane, the external jugular and the anterior
jugular veins can be at risk if the subcutaneous layer is
violated.
I begin with a 2-mm small, round cannula (which may be
all I use for a thin patient); I proceed to a 3-mm spatulate
the novice surgeon. Being a good cosmetic surgeon means
knowing how to say no.
Directly under the skin is the subcutaneous fat which overlies
the platysma (Figure 9-22). Below the platysma lies an accumu-
lation of deep fat that can be addressed as well. One common
problem seen with novice (and sometimes experienced) sur-
geons is to over-resect this fat, which can cause a significant
concavity known as a “cobra” deformity (Figure 9-23).
Submental and neck liposuction is a routine part of facelift
surgery and the first step I perform. The first thing to determine
is whether the patient needs liposuction. Many facelift patients
A
B
FIGURE 9-20.  A, The approximate location of superficial fat in the jowls and neck in a patient with normal body weight. B, A
Hollywood “fat suit” actors wear to appear obese. This mask illustrates the areas of significant fat deposition in overweight
patients.
FIGURE 9-21.  Liposuction as a sole procedure is appropriate for isolated
fat accumulations, especially in younger patients in which the slight excess
skin can tighten. In patients such as the one shown, removing fat without
skin would cause a significant “turkey-neck” deformity. Even with a facelift,
this type of morphology is challenging.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
C
FIGURE 9-22.  This cadaver dissection shows the subcutaneous fat layer in the submental region (A), the underlying platysma
(B), and the subplatysmal fat (C).
FIGURE 9-23.  Overtreatment of subcutaneous and especially subplatysmal
fat can result in a very unsightly concavity known as a “cobra” deformity
that can be difficult to correct.
FIGURE 9-24.  For both functional and aesthetic reasons, subcutaneous fat
is a very important cushion between the muscle and dermis. Overresecting
the subcutaneous fat allows the dermis to adhere to the platysma, which
can create an unsightly deformity that is very resistant to correction.
A
B
FIGURE 9-25.  A, Various-sized liposuction cannulas are used in increasing order when performing cervicofacial liposuction.
B, The area traditionally liposuctioned. This area is defined between the sternocleidomastoid muscles laterally, the inferior
border of the mandible superiorly, and the thyroid cartilage inferiorly.

Chapter 9  •  Cervicofacial Rhytidectomy
263
mandible). Many facelift surgeons place chin implants from a
submental crease incision. I will only employ this approach if I
am already performing surgery in that area. If I am not perform-
ing platysmaplasty or submentoplasty, I place my chin implants
from an intraoral approach, which avoids an unnecessary scar.
When placing a chin implant in conjunction with submental
liposuction and platysmaplasty, I first perform the liposuction,
then the chin implant, and finally the platysmaplasty. This order
prevents unnecessary trauma to the chin implant when perform-
ing liposuction, which requires significant manipulation that
area. The procedure order is only subject to the individual pre­
ferences of the surgeon. Detailed description of chin implant
placement is covered in Chapter 10 of this text.
Platysmaplasty
Controversy exists about the need to perform midline platys-
maplasty. Some surgeons feel that it is requisite, while other
surgeons feel it is not necessary and in fact could be detrimental.
These surgeons speculate that if one is performing posterior
platysma plication, it does not make sense to perform an ante-
rior midline procedure; it will pull against the posterior repair
and loosen it.
I initially performed midline platysmaplasty on all facelift
patients but after hearing numerous well-respected surgeons
decry the necessity, I stopped performing it for several years
except on patients with severe banding. At first I did not notice
any significant difference, but after several years I noticed earlier
relapse of submental skin excess and banding in enough patients
that it made me rethink my usage of the procedure. After rein-
stating midline platysmaplasty for all but the youngest patients,
cannula (see Figure 9-25, A). All these cannulas are used with
wall suction. For necks with significant fat, I finish the liposuc-
tion with a larger 6-mm spatulate cannula (see Figure 9-25, A).
This is a very aggressive cannula, and care is used because it can
remove significant fat very quickly. The cannula is moved in
rapid back-and-forth reciprocal motions, and the surgeon
should see fat begin to come through the suction tubing. Some-
times the suctioned fat is not visible until the cannula is removed
from the pocket, breaking the suction and rapidly removing the
fat bolus from the cannula. It is also helpful to crisscross the
cannula by suctioning a fan-shaped area, then crisscrossing the
path of the cannula over the previous cannula paths. The end
point is a well-contoured lipocutaneous flap without excessive
thinning or contour irregularities. For novice surgeons, it is
preferable to underliposuction than to overliposuction. A means
of determining the end point is to pinch the skin over the tip
of the cannula so the entire region has a similar thickness.
Further pinching the skin over the suctioned area to determine
even flap thickness can assist in end point determination.
Whereas liters of fat are removed from the body, tablespoons of
fat are removed from the face. The surgeon must also be mindful
of the position of the port of the end of the cannula. The port
or ports should always face away from the dermis, otherwise
they can etch the dermis with lines or grooves that can be
permanent.
Jowl liposuction can be performed in many ways and as a
sole procedure without facelift and SMAS suspension is not a
dramatic procedure. Although considerable jowl fat can be
removed with closed liposuction, the result is not dramatic
without suspending the surrounding tissue and skin. Further-
more, solitary jowl liposuction can leave a concavity in that area.
Some patients simply need a facelift for proper rejuvenation.
For closed liposuction (solitary liposuction without raising a
facelift flap), the jowl can be accessed from an inferior or lateral
approach. Inferior access is performed from the submental stab
incision, but the approach requires the cannula to cross the
mandibular border in a superolateral direction, and this can
fulcrum against the mandible. The marginal mandibular nerve
runs superficial as it nears the oral commissure (corner of the
mouth) and can be injured by the inferior approach (Figure
9-26). A safer means of accessing the jowl is through an earlobe
incision. A stab incision is made at the junction of the lobe and
cheek to the subcutaneous level (Figure 9-27). The cannula is
then inserted and remains in the subcutaneous plane as it
approaches the jowl. Conservative liposuction is then performed
in this area. The jowl is much more easily accessed directly
through the facelift flap using open liposuction, which will be
discussed later in this chapter.
Laser- and ultrasound-assisted liposuction is also gaining
popularity, but purchasing dedicated equipment for only face
and neck lipo does not justify the means in my opinion, and I
believe simple closed or open liposculpture with traditional
suction and cannulas is adequate if not preferable.
Chin Implants
In my experience, about a third of facelift patients will benefit
from chin augmentation, especially those with low hyoid/larynx
position and microgenia/retrognathia (recessive chin and/or
Danger zone
Marginal mandibular
Nerve
FIGURE 9-26.  The marginal mandibular nerve becomes superficial in its
course to innervate the perioral region. A danger zone exists in an area
approximately 2 cm lateral to the oral commissure. This area is vulnerable
to nerve injury when approached from any direction but can be com-
pressed over the mandible when performing jowl liposculpture from a
submental incision.

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Chapter 9  •  Cervicofacial Rhytidectomy
platysma in a patient can illustrate the borders and actions of
the muscle (see Figure 9-29).
Platysmaplasty Technique
Like all cosmetic surgery procedures, numerous ways have been
described to address the platysma. Some surgeons simply sew
the midline together, others only suspend the platysma with
sling sutures, while still others employ cutbacks or resect the
platysma altogether. I have experimented with most of the
common platysmaplasty techniques. My favored approach
involves removing a wedge of muscle and fat in the midline,
conservatively removing subplatysmal fat in the midline (in
selected patients), and bringing the medial borders back together
with midline sutures. This has proven safe and effective and has
provided improved longevity as opposed to posterior platysmal
plication only.
The basic technique is relatively simple. The anterior neck
is infiltrated with about 75 mL of tumescent anesthesia, and
local anesthesia is placed in the skin at the planned incision.
A 3 to 4 cm incision is made approximately 5 mm inferior to
the submental crease. Many surgeons advocate using the actual
submental crease, but this can cause retraction within the crease
and actually produce an unpleasant deformity and accentuate a
“witch’s chin” by forming a depression between the chin and
neck. An advantage of using a more inferior incision is that the
surgeon can extend the soft-tissue dissection more superiorly
and actually undermine the submental crease and improve the
trough deformity some patients have in that region (Figure
9-31; see Figure 9-30).
After adequate liposuction is performed, the submental inci-
sion is made through the dermis about 3 cm wide. Using facelift
scissors, a subcutaneous flap is developed within the previously
defined boundaries. Since the liposuction has predissected the
I feel that it makes a tighter neck with a longer-lasting result,
hence it reentered my baseline facelift technique.
The 1918 edition of Grey’s Anatomy26 describes the platysma
and related anatomy as follows:
“The Superficial Fascia of the neck is a thin lamina investing the
Platysma, and is hardly demonstrable as a separate membrane. The
Platysma is a broad sheet arising from the fascia covering the upper
parts of the Pectoralis major and Deltoideus; its fibers cross the clavicle,
and proceed obliquely upward and medially along the side of the neck.
The anterior fibers interlace, below and behind the symphysis menti,
with the fibers of the muscle of the opposite side; the posterior fibers
cross the mandible, some being inserted into the bone below the
oblique line, others into the skin and subcutaneous tissue of the lower
part of the face, many of these fibers blending with the muscles about
the angle and lower part of the mouth. Sometimes fibers can be traced
to the Zygomaticus, or to the margin of the Orbicularis oculi. Beneath
the Platysma, the external jugular vein descends from the angle
of the mandible to the clavicle. Variations occur in the extension
over the face and over the clavicle and shoulder; it may be absent or
interdigitate with the muscle of the opposite side in front of the neck;
attachment to clavicle, mastoid process or occipital bone occurs. A
more or less independent fasciculus, the Occipitalis minor, may extend
from the fascia over the Trapezius to fascia over the insertion of the
Sternocleidomastoideus.”
The Platysma is supplied by the cervical branch of the facial
nerve. When the entire Platysma is in action it produces a slight
wrinkling of the surface of the skin of the neck in an oblique
direction. Its anterior portion, the thickest part of the muscle,
depresses the lower jaw; it also serves to draw down the lower
lip and angle of the mouth in the expression of melancholy. The
platysma can be a very thin muscle, especially in females, in
which it can be translucent (Figures 9-28 and 9-29). Flexing the
A
B
FIGURE 9-27.  Accessing the jowls from an earlobe incision is a safer method when using closed liposuction or liposuction as
a sole procedure. When accessing the jowls during facelift surgery, it is much easier and can be performed under the flap with
direct vision.

Chapter 9  •  Cervicofacial Rhytidectomy
265
The procedure is begun by using a forceps to pick up the
excess fatty and muscular tissue in the midline of the neck. A
large tonsil hemostat is used to pinch redundant tissue in the
midline over the previously liposuctioned platysma (Figure
9-33, A). The tissue at the base of the hemostat is excised using
a radiowave or electrosurgery system (see Figure 9-33, B). After
removal of the redundant tissue, the borders of the platysma
muscle are secured with 2-0 braided nylon suture and tied with
a buried knot. Several sutures are placed above and below the
first suture to secure the platysmal edges in the midline (Figure
9-34). Again the area is rechecked for any bleeding or oozing
prior to closing. The skin incision is closed in two layers using
5-0 gut suture and 6-0 nylon suture for the skin. Figure 9-35
illustrates the corset platysmaplasty procedure on a cadaveric
specimen.
Many surgeons advocate placing a cutback from medial to
lateral at the thyroid region to prevent a “bowstring” deformity
of the taut platysma visible through the skin (Figure 9-36).
I personally have not witnessed this with hundreds of facelifts
and do not perform a cutback when performing platysmaplasty.
If the surgeon does make this release, he or she must be
extremely judicious, because numerous vessels traverse this
area, including the anterior jugular vein, which can present
brisk bleeding and difficult visualization when attempting to
control it.
Many other platysma techniques exist, including platysma
suspension sutures that cross the midline and pull each medial
platysmal border to the opposite side, securing them to the
mastoid fascia (Giampapa technique), as well slings that suspend
the submental region (Figure 9-37) from one mastoid region to
the other.
I am always impressed by the amount of redundant skin
that is left after performing liposuction and platysmaplasty
(Figure 9-38). Having this excess skin drape allows the operator
to tightly pull this region and obtain impressive cervicofacial
region, the flap is usually easily developed by spreading and
pushing the facelift scissors. Care is taken when dissecting under
this flap; controlling bleeding in this area can be difficult. To
control bleeding in this area, I prefer the Ellman radiofrequency
system (Ellman International, Oceanside, NY) with a long
bayonet bipolar forceps. If bleeding or oozing is left unchecked,
blood can gravitate to both facelift flaps, causing bilateral
hematomas.
There are many described methods to address platysma
dehiscence. Some techniques are complex and involve inferior
release or excision of the cervical platysma. These are best
reserved for experienced surgeons. The most common technique
is the midline corset platysmaplasty, which is conceptualized in
Figure 9-32.
A
B
FIGURE 9-28.  A, Cadaver dissection. Skin and subcutaneous layers have been removed to show the platysma muscle to the
left of the midline. B, The thin and virtually translucent left-sided platysma retracted.
FIGURE 9-29.  Patient flexing the platysma, illustrating its medial and lateral
borders. The platysma fibers also thin out and interdigitate with perioral
and cheek soft tissue.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-30.  The submental incision is not made in the submental crease but 5 to 8 mm inferior to the crease. This allows
liposuction or dissection (A) and undermining (B), which can improve this deep trough in patients with this situation.
A
B
FIGURE 9-31.  A, Preoperative photo illus-
trates the unsightly deep submental
crease and “witch’s chin” deformity. B,
Postoperative photo shows excellent
cosmetic improvement of the submental
and chin deformity using the lower sub-
mental incision and crease undermining
along with cervicofacial rhytidectomy and
silicone chin implant.
A
B
FIGURE 9-32.  Conceptualization of the corset platysmaplasty procedure. A, The platysmal laxity that occurs with aging contrib-
utes to the senescent banded neck. B, Liposculpture and midline plication of the lax medial platysma borders from the man-
dibular border to the thyroid cartilage region.

Chapter 9  •  Cervicofacial Rhytidectomy
267
A
B
FIGURE 9-33.  After liposuction and flap elevation, a controlled but generous “bite” of the midline tissues (muscle and fat) is
grasped with a large clamp (A) and the tissue excised below the clamp. This exposes the subplatysmal fat, which can also
be conservatively recontoured. Finally, the medial platysmal borders are closed (B).
A
B
FIGURE 9-34.  The ptotic medial borders of the platysma are secured with a buried 2-0 braided nylon suture (A) from the man-
dibular border to the thyroid cartilage region (B).
A
B
C
FIGURE 9-35.  The corset platysmaplasty procedure conceptualized on a cadaver dissection A, Subplatysmal fat. B, Fat
removed. C, Lax medial platysmal borders being sutured together.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-38.  Redundant skin is shown after aggressive submentoplasty,
including superficial and deep fat recontouring and midline platysmaplasty.
A
B
FIGURE 9-36.  Backcutting the platysma at the inferior level of the repair is performed by some surgeons to prevent a “bowstring”
effect of the taught muscle border that can be visible through the skin. The author does not perform this maneuver when
performing platysmaplasty.
FIGURE 9-37.  Many surgeons favor crisscross suspension sutures to
suspend the ptotic platysma. A large-gauge permanent suture is used to
secure the medial border of the right medial platysma to the mastoid fascia
on the left side. The left platysma medial border is then secured and
suspended to the mastoid fascia on the right. The crisscrossing sutures
not only pull each border to the other side but also form a sling that pulls
up the ptotic platysma into the cervicomental region, producing a youthful
angle.
aesthetics on the average patient. The reader can imagine that
if the submental fat and underlying muscle and deep fat were
not addressed, this area would remain convex and not yield as
efficiently to skin pull. Submentoplasty allows the surgeon to
develop the cervicomental angle over which to pull the skin.
It is important to mention that some surgeons advocate
excising excess skin from the submental incision. This is a pro-
cedure that I never perform. It can leave significant “dog ears”
that are unsightly and when addressed can extend the suture

Chapter 9  •  Cervicofacial Rhytidectomy
269
methods have proven the most effective and predictable, backed
up by several facelift procedures per week.
As stated earlier, all tumescent anesthesia is administered
simultaneously at the onset of the case. This can be performed
with a simple 60-mL syringe with an 18- to 23-gauge spinal
needle or hand pump. Electric pump mechanisms are available
to expedite the infiltration (Figure 9-39).
Minimally invasive (short scar) facelifts may only utilize a
preauricular incision, but most traditional facelifts require inci-
sions in front of and behind the ear. Many surgeons advocate
making a vertical superior temporal extension that extends supe-
riorly from the helical attachment into the temporal hairline.
There is no doubt that this incision can simplify the facelift
procedure, but it carries high liability of elevating the temporal
tuft of hair in the sideburn area (Figure 9-40). Proponents of
this vertical temporal extension will say that the pull on the skin
flaps should not be such that the hairline is pulled in a vector
that displaces the tuft, but judging from the obliterated tempo-
ral tufts and sideburns I see from other offices, its effectiveness
is questionable, producing unsightly baldness in the temple
region.
I prefer and exclusively use a horizontal releasing incision in
the sideburn on all of my facelift patients. The positive aspect of
this is approach is that it cannot elevate the temporal tuft or
sideburn. In addition, this horizontal component provides a
releasing incision that allows the surgeon more direct visualiza-
tion under the dissected cheek flap. On bigger facelifts, a vertical
release incision may be necessary to deal with dog-eared tissue
from large cheek flaps or extended dissection to the lateral orbital
rim. In this case, the vertical release is made more proximally
as opposed to the distal end of the sideburn, which preserves
most of the sideburn and temporal tuft (Figure 9-41).
The design of the tuft-sparing incision involves placing the
incision just into the follicles of the natural hairline above the
A
B
C
Effortless
high-speed
infiltration
• Easily adjustable flow-rate dial
• Convenient pneumatic footswitch
• Easy-load tubing head
• Optical cutoff switch
• Operates on any voltage worldwide
FIGURE 9-39.  Tumescent anesthesia can be
delivered by simple syringe by hand or by electric
pump (HK Surgical Klein Pump, HK Surgical,  
Inc., San Clemente, CA), which expedites the
procedure.
line laterally where it is quite noticeable. Puckering and other
unsightly defects can also occur when skin is excised at the
submental platysmaplasty incision. Even with significant skin
excess, well-designed facelift flaps will almost always tighten
this area.
Facelift Procedure
The beginning of this section will detail the steps and procedures
of traditional facelift with pre- and postauricular incisions. The
most common type of lift will be discussed prior to minimally
invasive or short-scar techniques, which will be discussed in
detail later in the chapter.
Incision Design
A lot of surgery goes on during a facelift, dealing with numerous
tissues and techniques, but most all of this will remain invisible
to the patient. For the most part, the only lifelong reminder of
their surgery is their incision scars. While many surgeries are
about what happens under the incision, so much of the success
or failure of facelift surgery revolves around how the incisions
were designed. Poor incision design can not only leave unsightly
scars but more importantly, aesthetic deformities that are very
difficult to correct on areas such as the earlobe, anterior and
posterior hair and hairline, temple, tragus, and other areas. One
could also say that much of the success or failure of producing
a natural result also is influenced by how the initial incision is
made.
The design of the pre- and postauricular incisions is perhaps
the most critical step in successful facelift surgery. A properly
designed incision will preserve the natural hairline and related
incision anatomy. Incisions should also be perpendicular to the
desired vector of tension of the undermined flaps. Like any
other part of cosmetic surgery, different surgeons can argue for
or against any given incision design. My goal is to describe what

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Chapter 9  •  Cervicofacial Rhytidectomy
the horizontal cut to the anterior temporal tuft. This maneuver
will masquerade the incision within the temporal tuft instead
of in front of it. Figure 9-41 shows this type of abbreviated
incision, and Figure 9-42 shows a tuft incision that has no
vertical component and is carried to the anterior extent of the
sideburn.
After making the temporal tuft release, the incision is carried
to the helical attachment and proceeds inferior in a curvilinear
fashion along the helical attachment just superior to the tragus.
The curvilinear region of the helical attachment should be
carefully delineated and marked in the standing position before
injection of local anesthesia. Placing a scalpel handle in the helix
sideburn. This means that the incision is placed into the area
where the temporal tuft or sideburn follicular density changes
from the sparse, fine hairs to the actual denser “real” hairline.
Beveling this incision will allow the sideburn hairs to grow
through the incision scar and further improve the cosmetic
result.
Many surgeons describe extending the horizontal sideburn
incision all the way anterior along the sideburn. Although this
provides good release and preserves the temporal tuft, unfavor-
able scarring in this area is very apparent. A more aesthetic
alternative is to change from horizontal to vertical direction
with the scalpel about 2 cm into the hairline instead of carrying
A
B
FIGURE 9-40.  The vertical temporal extension incision favored by some
surgeons and the resultant temporal tuft elevation with unsightly baldness
that can result from that incision design and common vector tension
direction. A, The incision; B, patient whose surgery was performed at
another office and who was aesthetically compromised by incorrect
incision utilization.
A
B
FIGURE 9-41.  If a vertical temporal release is desired, it can be made as an extension of the temporal tuft (A), but without
extending the incision to the distal end of the sideburn incision. B, Incision design; right image shows an actual patient
incision.

Chapter 9  •  Cervicofacial Rhytidectomy
271
blunted and deformed. This is infrequently noticed by the
patient because they rarely see it, but it is quite obvious to the
surgeon and other observers. If a surgeon can use this incision
with predictable postoperative results, it is (in my opinion) an
optimum approach. In males with hair-bearing skin that extends
into this area, other problems can be encountered. It is possible
to pull the bearded skin onto the tragus and into the auditory
canal. This is a difficult area to shave and thus presents a “daily”
problem. Some authors advocate using electrosurgery to destroy
the hair follicles on the dermal side of the flap, but the blood
supply to the skin can be easily disrupted, causing necrotic tissue
loss and scarring of the tragus, so this should not be attempted
by the novice surgeon. Laser hair removal is an option that
previously did not exist and can assist this situation. I routinely
use a retrotragal incision in all females unless they have a previ-
ous pretragal facelift scar or have a very defined skin rhytid in
the preauricular area. I also frequently use a posttragal incision
in males but sometimes opt for a pretragal incision if they have
a heavy preauricular crease, which many do (see Figure 9-42).
To summarize, in females I always try to use a posttragal inci-
sion, and in males I will use either, depending upon their spe-
cific anatomy. One of the reasons to avoid pretragal incisions is
that they frequently heal with noticeable demarcation, as shown
in Figure 9-44, C.
When making the incision behind the tragus, it is a mistake
to place the cut too posteriorly deep inside the ear. In reality,
one need only make the incision at edge of the tragus, which is
generally defined by a light reflex reflection. Figure 9-45 shows
the extreme repositioning of the tragal skin when the facelift
flap is pulled in a positive vector. Figure 9-46, A shows the
author’s favored facelift incision outline and figure 9-46, B
shows an actual postoperative scar at 3 months.
As the incision progresses inferiorly, the earlobe is encoun-
tered. Some authors advocate leaving a small dart of tissue
and pushing anteriorly will help define the exact spot for the
incision (Figure 9-43). Failure to mark the exact junction of the
ear and cheek skin will create a very noticeable delineation due
to the differences in skin color and textures (Figure 9-44).
The next and perhaps most critical part of the incision
involves the tragus. Most surgeons will use either a pretragal or
posttragal (endaural) incision. There are advantages and disad-
vantages of either incision. The retrotragal incision, when per-
formed correctly, will hide the scar. It is more technically difficult
to master and requires much more attention when cutting
away and recontouring excess skin. If attention to detail is not
followed (and sometimes even if it is), the tragus can become
A
B
FIGURE 9-42.  A, Temporal tuft release with retrotragal incision design. B, Temporal tuft release with pretragal design. In males,
either A or B is acceptable; in females, I only use A.
FIGURE 9-43.  Pushing the helix forward with a scalpel handle can assist
the surgeon in locating the precise region for the upper preauricular
incision.

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Chapter 9  •  Cervicofacial Rhytidectomy
contract several millimeters and postoperatively end up in the
depth of the sulcus, thus hiding the incision. In males with
hair-bearing postauricular skin, the incision is made directly in
the sulcus. This is done to avoid pulling bearded skin onto the
mastoid or posterior ear skin, which is very difficult to shave. I
have performed many facelifts employing both techniques, and
I feel that making the incision at the depth of the sulcus in both
males and females produces the most favorable scar. Figure 9-47
shows the two commonly used areas, and Figure 9-48 shows a
well-placed and well-healed posterior auricular scar. Placing
a 2-0 suture through the helical rim at two sites enables a
convenient retractor that is available throughout the case
(Figure 9-49).
inferior to the lobe, and others routinely make the incision
directly in the crease formed by the lobe where it meets the
cheek. This is another one of those areas in which preoperative
marking in the upright position and before local anesthesia
injection is essential. Once the patient is recumbent and the area
distorted with local anesthesia, the landmarks are lost. Progress-
ing to the posterior surface of the earlobe, the incision is kept
in the crease as it rounds the lobe. At this point the incision will
be directed superiorly, and multiple options exist. Some sur-
geons advocate making the incision 4 to 5 millimeters anterior
to the postauricular sulcus. This means that the incision is
placed outside the crease several millimeters onto the conchal
cartilage. The theory in this placement is that the scar will
A
B
C
FIGURE 9-44.  The final scar is always a prime consideration in facelift surgery. A, An unfavorable scar can be visible if the
temporal tuft incision is carried all the way to the front of the tuft. B, Problem associated with not precisely placing the helical
attachment scar. C, Problems with using preauricular (antetragal) scars, especially on females.
A
B
FIGURE 9-45.  The tragus (shown in blue) is repo-
sitioned superolaterally, illustrating the movement
of this tissue region during facelift surgery.

Chapter 9  •  Cervicofacial Rhytidectomy
273
A
B
FIGURE 9-46.  A, Preauricular facelift incision with posttragal approach. B, Healed incision at 90 days.
FIGURE 9-47.  Typical posterior auricular incision. Some surgeons advocate
placing the incision 3 to 5 mm above sulcus for females (solid line) and
at the depth of the sulcus for males (dotted line) with bearded postauricular
skin (so as not to pull hair-bearing skin into the sulcus). The author favors
the dotted line position in either gender.
The incision must come off the ear and enter the hairline,
and much discussion exists concerning the best method to
design this incision. Many points must be taken into consider-
ation when planning the posterior incision, but the ultimate
influence is the final aesthetic result. A great facelift with poor
scars is no longer a great facelift. When considering the incision
placement of the posterior auricular incision, the optimum site
of incision placement is the area where the scar is least obvious.
This is largely determined by the posterior hairline. In the
average patient, there is less visible skin at the superior portion
of the ear than the inferior portion (Figure 9-50). At the greatest
width of the pinna (see yellow line on Figure 9-50), the hairline
meets the ear. There is little exposed skin in this region, so the
surgical scar is less obvious when placed here. Some surgeons
make incisions over the mastoid skin. This lower incision enables
a shorter flap that may make the procedure easier, but it can
leave a very noticeable scar. I never use the low-placed incision
for this very reason (Figure 9-51).
The next consideration is the horizontal placement of the
posterior postauricular incision. Many surgeons choose to run
the posterior incision at the level of the cervical hairline (see
dotted line on Figure 9-52). There are some advantages to this
technique. A low incision requires a shorter flap, which is easier
and faster to undermine, trim, and close. The operator is also
“closer” to the base of the flap (when compared to a more supe-
riorly placed incision) and can more easily address bleeders or
significant anatomy such as the greater auricular nerve. The
biggest advantage may lie in the fact that the natural hairline is
not disrupted because the incision follows the hairline in the
cervical and occipital regions. A significant drawback of this
low-placed incision is that if an unfavorable scar develops for
any reason, it is extremely noticeable in this area (Figure 9-53).
This is especially true for scars that are hypopigmented, hyper-
trophic, or hypotrophic. For male patients or for female patients
who desire to wear their hair up, an unfavorable scar in this
region is even more problematic.
In the vast majority of facelifts, I employ the superiorly
placed incision at the greatest width of the pinna and tail
off this incision well into the hair-bearing scalp (see the solid
line on Figure 9-52). The scar is hidden in the hair, and a
poor scar is less likely to prevent the patient from wearing
the hair up. I make one exception to using the higher incision,
and that is for patients who have very excessive neck skin. The
reason is that if a higher incision is used with grossly excessive
neck skin, the inferior flap may require significant elevation to
pull on the excess. This extreme elevation can raise the posterior

274
Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-48.  Well-placed intrasulcular postau-
ricular incisions can be imperceptible after
surgery.
FIGURE 9-49.  A 2-0 suture engaging the helical rim serves as a convenient
retractor and is applied at the beginning of the case.
1
2
FIGURE 9-50.  A superior incision (1) placed at the greatest width of the
pinna (yellow line) produces a less noticeable scar, whereas an incision
over the mastoid skin (2) will produce a more obvious scar.
hairline to the point of creating postauricular baldness (Figure
9-54). In my practice, I reserve the low hairline incision for
patients with a severe “turkey-gobbler” submental skin excess
(Figure 9-55).
After extending the incision from the back of the ear at the
greatest width of the pinna, the incision changes from vertical
to horizontal with a 90-degree angle at this juncture. As the
incision enters the hair-bearing scalp, it traverses posteriorly and
inferiorly in a gentle angle for 3 to 6 centimeters, as shown in
Figure 9-56.
Occasionally, one will encounter a female patient who wears
her hair pulled up, and it is a “trademark” look on which they
will not compromise. Should a patient like this be left with an
unsightly scar and have to compromise the appearance they have
had for years, they will be very unhappy. I feel that it is impor-
tant to explain to all patients, male and female, that if a given
hairstyle is of huge importance in their life, they should think
twice about having a facelift, since no surgeon can guarantee
that a visible scar won’t occur.
Flap Development
After making the appropriate incisions, the lipocutaneous
flap is developed. This is frequently a difficult step for the
beginner, and it is not infrequent for novice surgeons to dissect
too superficially or too deep. It is imperative to perform a
smooth, consistent, and gentle dissection with homogenous

Chapter 9  •  Cervicofacial Rhytidectomy
275
A
B
FIGURE 9-51.  Placing the postauricular incision over the mastoid area can produce noticeable scars and should be avoided.
FIGURE 9-52.  The horizontal component of the postauricular incision can
be made superior and into the hair-bearing scalp (solid line) or lower and
following the cervical hairline (dotted line).
FIGURE 9-53.  Although the cervical or occipital hairline incision is used by
some surgeons, unfavorable scarring in this area is very visible and
problematic.
flap depth and thickness. The dissection should leave sufficient
fat on the dermal surface of the flap as well as on the underly-
ing SMAS. If the dissected flap is too thin, the dermal plexus
of blood vessels of the fragile skin flap can be compromised.
If the flap is too thick, the operator may invade the parotid
gland or facial nerves. The key is to dissect a lipocutaneous
facelift flap with several millimeters of fat on the dermal surface
of the skin and several millimeters of fat over the deeper struc-
tures. Tumescent anesthesia assists flap dissection insofar as
liquid will hydrodissect the flap and actually create a potential
space below the dermis and above the SMAS. Another simple
aid in maintaining the correct plane is to pretunnel the flap
with a dissector or liposuction cannula not connected to a
suction source (Figure 9-57). After the incision and before
other dissection, I use spatulate-tipped dissection cannulas to
develop the correct plane. This can also be performed with a
2- to 3-mm liposuction cannula that is inserted in the subcu-
taneous plane. The dissector or the cannula is inserted in the

276
Chapter 9  •  Cervicofacial Rhytidectomy
(Figure 9-58). With adequate pretunneling, the scissor dissec-
tion is performed by merely pushing and spreading the scissors,
as opposed to actually using the scissors to cut the tissue. Most
facelift scissors are designed to cut on the outside edges of the
blade as well as the inside. By spreading the scissors, a more
blunt-cutting dissection is achieved.
It should be noted that in the area of the mastoid and the
sternocleidomastoid muscle, the dermis basically is connected
to the fascia and muscle, because there exists almost no subcu-
taneous fat in these areas (Figure 9-59). The dermis is tightly
bound down in these areas, scissors dissection is difficult, and
the skin is easily perforated if the operator is too superficial. The
greater auricular nerve and external jugular vein are at risk if
the dissection proceeds too deeply. Pretunneling in this area
temporal tuft region to undermine the preauricular area. It is
then inserted at the junction of the postauricular incision to
undermine the posterior flap, and finally at the inferior lobe
region to undermine the cervical region. The dissector is
pushed and pulled in a reciprocal motion (similar to liposuc-
tion but without the suction source) under the area that will
underlie the flap. This technique also greatly facilitates the
scissors dissection.
Pretunneling creates small microtunnels that are connected
by fibrous septae. If the area has been adequately pretunneled,
the remainder of the dissection is very easy and almost auto-
matic. Facelift scissors are inserted in the subcutaneous plane,
and with the blades slightly spread, the scissors are easily pushed
through the tissue while cutting the septae and freeing the flap
A
B
FIGURE 9-54.  Using a superiorly placed postau-
ricular incision in a patient with excessive neck
skin can elevate the flap to a point of unnatural
baldness behind the ear.
A
B
FIGURE 9-55.  Patients with significant submental skin excess, in which the author would employ a low cervical hairline
incision.

Chapter 9  •  Cervicofacial Rhytidectomy
277
A
B
C
FIGURE 9-57.  A, Dissection cannulas with blunt spatulate tips can be used
to “pretunnel” the facelift flap, which helps determine the correct subcu-
taneous plane and maintain consistent flap thickness. The inset photo
shows the tip configuration. B–C, Cannula in the subcutaneous plane in
the anterior (B) and posterior (C) regions.
90
FIGURE 9-56.  The vertical limb of the postauricular incision meets the hori-
zontal limb at a 90-degree angle and gently tapers into the posterior scalp
in the hair-bearing scalp. A patient with alopecia is shown to better illustrate
the incision.
A
B
FIGURE 9-58.  A, Predissecting effects of the cannula. This predissection maneuver creates tunnels and septae that remain
between them. B, The ease of dissection that can be performed after predissection, in which the scissors can be used to
spread or push through this plane with minimal effort and trauma.
facilitates this dissection and guides the surgeon to a safe surgical
plane.
Another aid in maintaining a consistent dissection is to have
the assistant wear a headlight while the surgeon dissects. The
headlight reflects through the flap and assists the surgeon in
judging the thickness as dissection proceeds (Figure 9-60).
As stated earlier, there are many of types of facelift tech-
niques. Some methods require small skin flaps of 2 to 5 cm,
other methods use extended flaps to the nasolabial fold. Some
involve only a skin dissection, whereas others involve deep-plane
dissection. Novice facelift surgeons should concentrate on
subcutaneous dissection with simple plication techniques for
the SMAS. Aggressive techniques should be avoided by the
novice surgeon. They are more difficult to master and have the
propensity to produce more complications. The possibility of
permanent motor nerve damage and disfigurement are a reality,
and all surgeons should temper their progression on mastering
basics.
“Long-flap” facelift dissection involves dissecting very ante-
rior in the face (6 to 10 cm anterior to the ear), frequently to
the nasolabial folds. This extensive dissection is more technically
difficult, more prone to complications, and requires extended

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Chapter 9  •  Cervicofacial Rhytidectomy
healing. “Short-flap” facelift dissection involves a shorter dissec-
tion (2 to 6 cm anterior to the ear) that stops at the malar
region. This is a faster, safer, quicker healing technique. Many
surgeons feel that extensive anterior techniques do not produce
significantly better results than short-flap procedures. Figures
9-61 and 9-62 compare various sizes of common facelifts.
After the incision and pretunneling, the scissor dissection is
begun. If the flap was predissected, most of the dissection can
be done by advancing and spreading the scissors (Figure 9-63).
Actual scissor-tip cutting can be performed, but doing this
blindly can cause increased bleeding or an unpredictable tissue
plane (especially by the novice). When dealing with lipocutane-
ous flaps, the surgeon must always be aware that this biological
unit is dependent upon compromised vascularity and must
always be handled with gentle care. Pulling too hard when dis-
secting, rough treatment with cannulas and scissors, and extreme
pressure with forceps and clamps should be avoided. The entire
success of the facelift procedure is built around flap viability,
and this must be appreciated by the surgeon and the staff at all
phases of the procedure. Watching a seasoned facelift surgeon
wield facelift scissors is a beautiful thing: they don’t simply cut
M
F
D
FIGURE 9-59.  The intimate nature of the dermis (D) and muscle fascia (F)
that overlies the mastoid and sternocleidomastoid muscle (M). Owing to
the paucity of subcutaneous fat in this region, dissection that proceeds
too superficial or deep can produce complications.
FIGURE 9-60.  Transillumination of the skin side of the flap can assist the
surgeon in maintaining a homogenous subcutaneous layer on the dermal
side of the flap.
A
B
C
FIGURE 9-61.  Facelifts are performed to varying degrees but can be most simply classified as small, medium, and large. Much
of this is determined by the extent of the dissection, which can vary from 2 cm in front of the ear to past the nasolabial fold.
This image illustrates flap extension circumferentially from the external auditory canal.
8
6
2
FIGURE 9-62.  Short-scar, anterior incision–only facelift flaps may be as
small as 2 cm. Larger techniques warrant more aggressive flap dissection.
Again, thinking in terms of small, medium, and large provides a platform
that is easy for patients to comprehend.

Chapter 9  •  Cervicofacial Rhytidectomy
279
A
B
FIGURE 9-63.  A, Initial stage of dissection; B, scissors extending the flap.
If the flap was predissected with tunneling, the scissor dissection is
effortless.
particular importance are the use of several configurations of
bipolar coagulation. I use short and long bipolar forceps with
fine and normal tips. Also having a bayonet configuration is
useful for working under flaps without obstructing vision. The
surgeon needs to be aware of all potential bleeding points,
whether encountered in visible areas or from hidden locations
such as the deep proximal corner of an elevated flap (Figure
9-67). Attention must also be paid to bleeding sources on the
dermal side of the flap.
Most of my facelift flaps extend about 6 to 8 cm circumfer-
entially from the external auditory canal. The importance of
allowing adequate adipose tissue on both sides of the flap is
stressed. Novice surgeons should limit initial flap procedures to
those that stay over the parotid gland where the facial nerve
branches are well protected. If nerve injury occurs, it is fre-
quently from the inexperienced surgeon encountering the
motor nerve branches anterior to the parotid gland as they cross
the masseter muscle. The parotidomasseteric fascia is a layer that
should be well respected by the novice surgeon.
As stated earlier, great care must be used when dissecting over
the mastoid and sternocleidomastoid areas because of the
paucity of subcutaneous fat. Dissection that is too superficial
can buttonhole the skin (Figure 9-68), and dissection that is too
deep can easily injure the greater auricular nerve that lies very
superficial over the sternocleidomastoid muscle (6.5 cm inferior
to the external auditory canal) (see Figure 9-9).
Care must also used when dissecting the scalp flap posterior
to the ear. The superior margin of the postauricular flap is one
area where deep dissection is safe. It is optimum to leave the
flap a bit thicker in this region to protect the superficial hair
follicles; dissection or cautery trauma can damage them. Dis-
section can (but does not need to) safely proceed to the glisten-
ing white mastoid fascia in this region, then transition to a more
superficial level when below the follicular skin. As this dissection
nears the cervical and mastoid region, skin perforation or
damage to deep structures is common, so dissection should
proceed meticulously. Figure 9-69 shows various stages of post-
auricular flap development, and Figure 9-70 shows the hair
follicles on the dermal side of the flap. Care is taken to keep the
hair-bearing flap thicker when possible so as not to expose the
follicles. Some surgeons say that if the follicles are visible on the
dermal side of the flap they will die, but this is not true. It does
make sense to respect the follicles and avoid them when possi-
ble. Figures 9-71 and 9-72 show the flap in other views.
Once the flap is developed, the deeper tissues are addressed.
Most surgeons will treat the first side to entirety then turn the
patient’s head and complete the second side. Some surgeons will
leave the first side open and perform flap suspension, trimming,
and closure at the same time. As mentioned earlier, some sur-
geons at this point will not address the deeper tissues and merely
pull the skin back, trim it, and close the incisions. This skin-only
type of facelift is no doubt faster to perform and was a common
technique years ago but does not provide the tightness or lon-
gevity of techniques that address the SMAS.
After flap elevation, I address specific areas of fat deposition,
namely the lateral neck and jowl region. Since these areas are
lipocontoured from within the open flap, the procedure is
referred to as open liposuction. The jowl is addressed from under
but use the scissors to spread, push, expand, and dissect (Figure
9-64). Dissecting under direct vision allows the surgeon to be
more precise, and as noted earlier in this chapter, having a chair
that can be lowered assists direct subflap observation without
the surgeon having to contort their body. I know numerous
surgeons with significant neck injuries from continually bending
their neck in unusual positions for prolonged periods. Another
means of assisting direct vision is to use retractors and clamps
to keep the flap elevated. Between the surgeon and the staff, the
flap is always retracted (Figure 9-65).
As the subflap dissection begins, tissue bleeding will
occur. Although significant blood loss from a facelift is rare,
the potential complications experienced from unchecked post-
operative bleeding can be disastrous. No surgeon should perform
facelift surgery without some available means of controlling
intraoperative hemorrhage. Electrosurgery cautery or radiowave
surgery are common hemostatic modalities. Since bleeding can
present in a variety of locations, some of which are difficult to
access, the surgeon must have multiple means of control. The
presence of my radiowave machine is invaluable, and I use it
throughout the entire case. Figure 9-66 illustrates common
methods of controlling intraoperative facelift bleeding. Of

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
C
D
FIGURE 9-64.  Facelift scissors are an integral part of dissection and can be used for cutting, pushing, and spreading. A–B
illustrate the spreading technique; C–D show the scissors in place, illustrating dissection by pushing forward with the blades
open.
FIGURE 9-65.  Maintaining direct vision under the facelift flap increases precision and decreases complications. Using clamp
and retractors can also assist the dissection.

Chapter 9  •  Cervicofacial Rhytidectomy
281
A
B
C
FIGURE 9-66.  Multiple means of controlling bleeding, including direct ball cautery (A), indirect forceps conduction (B), and
bipolar radiowave hemostasis (C).
A
B
C
FIGURE 9-67.  Bleeding can come from diffuse tissue ooze or from larger veins and arteries. A, Flap perforator. B, Small vessels
on the dermal side of the flap. C, Superficial temporal vein. Bleeding from any and all vessels must be controlled throughout
the facelift procedure.
A
B
FIGURE 9-68.  Care must be exercised to maintain proper flap thickness, or perforation can result.