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isolated jowl fullness preoperatively, open jowl liposuction is
not performed. After the jowl is addressed, a large-bore suction
cannula with a 6-mm portal opening with a spatulate tip is used
to reduce some of the excess neck fat that was not addressed
from the submental incision (Figure 9-74). More importantly,
this aggressive cannula is used to reduce the layer of fat that
overlies the posterior (also called lateral ) platysma muscle under
the mandibular angle and in the lateral and inferior cervical
region. Some patients have significant fat accumulation in this
area, and reducing the volume will assist in a more aesthetic
neck. In addition, when suspending the posterior platysma, it
is helpful to actually visualize the muscle flap, which is fre-
quently obscured by fat. Gentle sculpting of the inferior man-
dibular border with low suction can assist in better defining this
region (Figure 9-75).
SMAS Techniques
SMAS Plication (Open Suspension)
After the lipocutaneous flap is developed and open liposuction
is performed, the SMAS layer is addressed. After significant
discussion earlier in this chapter, it should be apparent that the
SMAS is a controversial structure. For the purpose of this
section, I will refer to the SMAS as the fibromuscular and
adipose tissue that is below the dermis and above the parotido­
masseteric fascia. There are many reasons for tightening or sus-
pending the SMAS. Placing traction on this layer will in turn
pull on most of the face and neck, since the SMAS translates
motion throughout the face and neck. The SMAS can be
thought of as a unit that when tightened will pull on the deep
layer of the cheeks and neck. Tightening this layer will reinforce
the skin tightening and enable a more stable suspension with
increased longevity. It can be thought of as a “belt and suspend-
ers.” Most contemporary facelift surgeons address the SMAS
and the skin.
To describe suspending the SMAS, most surgeons will refer
to SMAS plication or imbrications. Cosmetic facial surgery
textbooks differ in defining these terms. For my purposes, I
FIGURE 9-71.  Bilateral lipocutaneous flaps being elevated with the sur-
geon’s fingers. This illustrates how tension on the cheek and neck flaps
will tighten the lateral face and neck but do little for the central oval of the
face.
FIGURE 9-72.  A typically dissected facelift flap is shown lying passively.
FIGURE 9-73.  Conservative liposuction of the jowl is performed with a
small-tipped cannula through the elevated lipocutaneous flap.
the flap with a very conservative cannula. The goal is not to
obliterate the jowl but rather to conservatively sculpt it (Figure
9-73). Overly aggressive treatment of the jowl will leave a
depression. The surgeon must keep in mind that the jowl will
improve as the SMAS is suspended, so there is no need to
aggressively treat it before that point. If patients did not exhibit

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indivi­dually. Figure 9-76 is an intentionally rudimentary figure
to generalize the configuration of four common SMAS suspen-
sion techniques.
The SMAS is usually easily accessed and secured in the
average patient. Very thin patients may have a very friable
SMAS, and patients with previous facelift may have scar tissue
with no discernable SMAS. Closed SMAS suspension (plica-
tion) is the safest and easiest technique to learn when beginning
facelift surgery. The SMAS (and related tissue) is a mobile struc-
ture, and it can be lifted or tented by picking it up with a
forceps. This also elevates the SMAS off the deeper tissues that
contain the motor nerve branches, so tenting the SMAS when
sewing or cutting is a desired protective maneuver. When per-
forming SMAS suspension, the surgeon must determine the
best area or areas to suspend. Traditionally this is performed in
the jowl area and on the posterior platysma. Using a bayonet
forceps, the surgeon grasps a bite of the SMAS close to the jowl
region and pulls it in a positive vector (a vector opposite to the
sagging tissue). There exists a “sweet spot” that when the SMAS
is secured and pulled, it will optimally lift the jowl, cheek, and
neck. Generally the surgeon picks up a bite of jowl SMAS, pulls
it superolaterally, and observes the result. If significant and
obvious improvement to the ptotic tissues is not observed, the
forceps are moved superiorly or inferiorly, and a different area
of jowl is picked up. This is repeated until the most optimum
point is identified. This is the area that when suspended will
noticeably tighten much of the lower face. When this area is
located, the SMAS is tented and a double throw of a braided
2-0 nylon suture is passed on the inferior surface (to bury the
knot). The suture is then pulled in a positive vector, which is
usually a ten o’clock and two o’clock direction, depending upon
the side. The suture is then sewn to the fixed SMAS over the
parotid gland (Figure 9-77). This first suture is usually secured
superior to the tragus about 1 cm from the incision. This single
suture will actually suspend most of the lower face by itself, and
when accessory sutures are placed, the observed movement is
A
B
C
FIGURE 9-74.  Open liposuction is performed through the facelift flap to sculpt the neck as well as expose the posterior platysma
to facilitate suspension. A, Area under the flap before suction. B, The 6-mm spatulate liposuction cannula in place under the
angle of the mandible. C, The area after suction, with much of the fat removed and the underlying platysma visible.
FIGURE 9-75.  Gentle sculpting of the mandibular border with lower suction
can enhance inferior border definition with the facelift.
consider plication the act of folding tissue over on itself. Plica
is synonymous with “fold” and is a common anatomic term
(plica semilunaris, plica circularis, etc.). A plica or the act of
plication also refers to a fold in drapery and tailoring. Imbrica-
tion is defined as overlapping, such as roof tiles or fish scales.
Overlapping implies that the structure has been incised and the
edges overlapped, and imbrications is used to describe SMAS
management in which the SMAS is incised and the edges
brought together. To sidestep confusion, I prefer to simply
describe any treatment of the SMAS as “open SMAS suspen-
sion” or “closed SMAS suspension.” Closed SMAS suspension
would include plication in which the SMAS is secured and
folded back over on itself or secured with purse-string sutures.
Open SMAS suspension includes SMASectomy and SMAS
flap procedures. These various techniques will be covered

Chapter 9  •  Cervicofacial Rhytidectomy
285
suture. I place 6 to 10 sutures when I address the SMAS and
don’t want to worry about a single suture being ripped or torn
when the patient sneezes or sleeps on their side in the early
postsurgical period. I have performed revision surgery on
patients who had purse-string sutures and have seen these
broken and stretched. Again, if I am putting all the required
effort into a facelift, I am not going to skimp on the mechanism
of suspension and fixation. One argument in support of the use
of any suture technique is that as the facelift flap heals, the
mobile and suspended layers heal together with scar tissue. This
scar tissue probably maintains the suspension regardless of what
type of suture is utilized, but in the weeks before this tissue scars
down, I believe multiple sutures provide added strength.
The plication or closed suspension addresses cheeks and jowls
and to a lesser extent the neck. I always perform posterior
(lateral) plication (suspension), no matter how the facial SMAS
is addressed. This technique will be discussed later in this
chapter.
much less after the first suture. The accessory sutures are placed
to bolster the suspension and spread out the tension forces over
several sutures. By doing this, the repair is strengthened and less
likely to tear or pull through. These ancillary sutures are placed
in various positions to reinforce the original suture. They also
disperse the tension and can address other specific ptotic areas.
There is no “law” about where to place the sutures. As long as
they are not placed too deep (where they could ensnare facial
motor nerve branches), they can be placed in any horizontal or
vertical direction the surgeon feels is appropriate to suspend the
ptotic structures.
Another means of suspending the SMAS is the use of purse-
string sutures. These sutures, as the name indicates, take mul-
tiple bites of the SMAS in a circumference, and then when the
suture ends are tightened, the entire circumference is drawn to
the center and thus suspended. Although this is a very popular
technique for minimally invasive facelifts, I never employ purse-
string sutures. I simply do not trust the suspension of a single
A
B
C
D
FIGURE 9-76.  Contemporary means of SMAS management. A, The folding-over effect of placation. B, Representation of a
purse-string suture. C, The SMASectomy technique in which a strip of SMAS is excised and the edges brought together with
sutures. D, The imbrications technique of a SMAS flap.

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nerve crosses the zygomatic arch, the incision is positioned
several millimeters below the arch. After making the incision,
the flap is undermined several centimeters inferiorly and ante-
riorly to release the SMAS. At this point, a skin cutback is made
in the 90-degree angle, and the SMAS is pulled in a positive
vector (superolaterally) and secured with a suture. Cutbacks are
made on the excess vertical and horizontal tissues where the
retracted SMAS overlaps (see Figure 9-79). Multiple 2-0 braided
nylon sutures are then placed along the remainder of the inci-
sions to reinforce the suspension (Figure 9-80). The SMAS flap
can be very dramatic in that pulling on the corner can basically
tighten the entire lower face and neck as a unit in a single
vector. If the SMAS is very thin or in patients with previous
facelifts, the SMAS may not be thick enough to incise, under-
mine, or suspend. Some surgeons split the SMAS flap and pull
the posterior portion posteriorly and suspend it to the mastoid
region. I personally still perform a posterior platysma suspen-
sion when doing the SMAS flap (or any SMAS procedure, for
that matter).
SMASectomy
SMASectomy technique was intimidating in my early experi-
ence but is now my first-line means of managing the SMAS.
For the novice facelift surgeon, the thought of intentionally
working around the facial nerve is menacing, but as one gains
experience, this technique is actually quite safe and very effec-
tive. The SMASectomy procedure allows the deeper layers of the
face to be moved as unit. The big advantage of this technique is
that it allows excellent mobilization of the lower face (and some-
times midface) as a single unit without extensive dissection.
The basis of SMASectomy is to excise a portion of
SMAS and bring the two incised edges together in a vector
that tightens the ptotic cheeks, jowls, and neck.27,28 A tongue-
in-cheek statement common in cosmetic facial surgery is that
“the nasolabial fold remains undefeated.” This means that we
Purse-String Sutures
As stated earlier, many surgeons advocate purse string–suture
SMAS suspension, especially with minimally invasive or short-
scar facelifts. In theory, the purse-string technique is efficient; a
single suture can be used to “draw up” and tighten ptotic SMAS.
Since the direction of the purse-string technique is pretty much
a single direction, several purse-string sutures may be used at
slightly different vectors. Another advantage of the purse-string
technique is that it can easily be performed by beginners because
the SMAS is not violated. I have stated earlier that I do not trust
a single suture technique. The possibility of a broken or stretched
suture can compromise the entire suspension when compared
to numerous single sutures. Figure 9-78 shows a revision facelift
case I operated on. The chief complaint of the patient was that
she had a “new-age” facelift in another city, and it relapsed
shortly after surgery. When the flap was raised, the single purse
string was broken. Other surgeons disagree with me, but again,
when it comes to suspension, I feel that more is better. Having
said that, it underlines the fact that certain techniques work
better in the hands of some surgeons than others, and if a
surgeon has safe and predictable outcomes with happy patients,
then their technique is probably pretty good.
SMAS Imbrication (Open Suspension)
SMAS Flap
As stated earlier, imbrication is a technique of overlapping the
cut edges of the SMAS, and we will also call it open suspension,
since the SMAS is incised. In this technique, the SMAS is
incised in the horizontal direction, several millimeters inferior
to the zygomatic arch and vertically 1 to 2 cm anterior to the
skin incision margin, as shown in Figure 9-79.
The incision is made through the subcutaneous fat and
SMAS with care not to violate the parotid gland and/or the
parotidomasseteric fascia. Since the frontal branch of the facial
A
B
*B
*A
FIGURE 9-77.  A, The ptotic jowl tissue (A) secured with a 2-0 braided nylon suture and pulled in a positive vector and secured
to the soft tissue (B) near the tragus. The suture being clamped to prevent slack when tying. B, Another view of a simple SMAS
plication (closed suspension). After the primary suture is placed, three to four additional sutures are placed to reinforce the
suspension.

Chapter 9  •  Cervicofacial Rhytidectomy
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A
B
FIGURE 9-78.  A, The broken purse-string suture. B, Loose segments highlighted with a surgical marker. The area shows the
area of separation.
A
B
FIGURE 9-79.  The SMAS flap technique involves making a right-angle SMAS incision and undermining several centimeters from
each incision. Pulling the flap in the correct vector will place tension on most of the lower face and upper neck. The advantage
of a SMAS flap is that much of the proximal ptotic face can be mobilized without significant anterior dissection. Pulling at the
angle of the flap will lift much of the face as a unit. A, incision position; B, the flap excess to be trimmed.
have never developed a definitive technique to efface the naso-
labial folds that is natural, effective, and lasting. More impor-
tantly, adults would look unnatural without a nasolabial fold,
so the goal should be to reduce the depth and severity of the
nasolabial fold, not to eliminate it. Although many various
techniques claim to influence the nasolabial fold, I believe (and
my experience shows) that the SMASectomy technique can have
an appreciable effect on the nasolabial folds. When designing
the SMASectomy, the proposed SMAS excision is made parallel
to the nasolabial fold. This means that the vector of pull will be
perpendicular to the nasolabial fold and hence mitigate its
severity.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
C
FIGURE 9-80.  The SMAS flap is outlined several millimeters below the zygomatic arch (A), incised, and undermined several
centimeters (B). The SMAS flap is then placed on tension and the overlapping edges excised and sutured (C).
The SMASectomy procedure is performed as follows. The
nasolabial fold is marked with a surgical marker. A line that is
parallel to the nasolabial fold is then drawn on the SMAS. This
line runs from the malar area to the angle of the mandible and
sometimes past the mandible into the neck. Generally a 2 to
3 cm width of SMAS in the configuration of a rectangle is
removed (Figure 9-81). The actual amount of SMAS to be
removed is commensurate with the degree of aging and ptosis.
The crux of this procedure is to remove the intended width of
SMAS (and associated fat) but not to violate the parotidomas-
seteric fascia, which is just above the facial nerve. Frequently,
some SMAS and/or fat tissue remains after excising the SMAS,
but in some patients, the facial nerve branches can be visualized
as they cross the masseter muscle. Like any SMAS technique, if
the SMAS is exceedingly thin or if the patient has had previous
facelift surgery, the SMAS may not be substantial enough to
incise and suture. For the novice surgeon beginning the SMA-
Sectomy procedure, it is important to keep most of the SMAS
excision over the parotid gland; the motor nerve branches are
protected until the anterior border of the parotid gland where
they cross the masseter muscle.
A convenient means to facilitate the SMAS incision (and
excision) is to pick up the SMAS with a forceps, which creates
a “tent” effect. By tenting the SMAS, it is lifted off the underly-
ing parotidomasseteric fascia, facilitating dissection and pro­
tecting the underlying nerves (Figure 9-82). This SMAS layer
is very pliable and can be easily lifted off the deeper fascia.
After the predetermined rectangle of SMAS is outlined with
a surgical marker, the outlined SMAS borders are incised
with either a radiowave surgical microelectrode or facelift
scissors. After the incision, the tented SMAS is undermined
with gentle scissor dissection, as performed in the skin under-
mining. Finally, the entire undermined rectangle of SMAS is
removed (Figure 9-83).
The next step is to pull the distal SMASectomy border in a
positive vector to lift the ptotic cheek, jowls, and neck. The
proximal SMASectomy border is grasped with two forceps at
several regions to determine the most favorable area of lift
(“sweet spot”) and a 2-0 braided nylon (or the surgeon’s pre-
ferred suture) is placed in a buried fashion to bring the proximal
incision border to the distal incision border in a positive vector
(Figure 9-84). This single suture is placed at the sweet spot,
which is the area lateral to the jowl region that when placed
under tension will visibly tighten the cheek, jowl, and neck.
Again, this area is determined by grasping the jowl area in
several regions until the optimum facial lift is visualized. When
these sutures are placed, the tension sometimes requires them
to be retained with a clamp while the tie is completed, in a
manner similar to using a finger to stabilize a bow when wrap-
ping a present. Next, five to eight more sutures are placed from
the malar area to the mandibular angle area or even further in
the neck. The primary SMAS fixation suture establishes the
initial vector of tightening, and the secondary sutures bolster
the suspension with cumulative tightening Figure 9-85. The
facial tightening seen with this maneuver is impressive, and it
is important to realize that the SMAS can be tightened along
the entire length of the SMASectomy excision. The most notable
tightening is in the jowl and lower face, but tightening can also
be appreciated in the midface, cheek, jowl, and neck. With these
numerous sutures, the tension on the ptotic SMAS can be
adjusted from the malar region all the way into the neck (Figure
9-86). Figures 9-81 to 9-86 illustrate the SMASectomy
technique.
With experience, the SMASectomy procedure can be cus-
tomized to optimize vector control. Although removing the
conventional rectangle of SMAS from the malar to the cervical
region will move the ptotic tissues as a unit, changing the con-
figuration of the excision can more precisely control lift and
vector. One change I have personally made in the traditional
SMASectomy procedure is to taper the superior margin of the
SMASectomy in the malar region. If a rectangular configuration
is used, the tissues may not primarily approximate in the malar

Chapter 9  •  Cervicofacial Rhytidectomy
289
exert tension in customized vectors. Figure 9-88 shows an
example of an “arrowhead” configuration of SMASectomy that
I occasionally use. The superior vector of pull is for the cheeks
and jowls, whereas the inferior vector more specifically addresses
the neck.
region. By tapering the superior margin like the top of the letter
D, the SMAS is easier to close with direct-edge approximation
(Figure 9-87). The more experienced surgeon who can antici-
pate precision vector control can configure the SMASectomy
excision and resultant defect to pull in multiple directions or to
A
B
FIGURE 9-81.  A, Outline of the section of SMAS to be excised. This rectangle is parallel to the nasolabial fold. B, Borders of
the outline defined with superficial incision with a radiowave microneedle.
A
B
FIGURE 9-82.  A, The SMAS section being “tented” off the parotidomasseteric fascia and incised with the radiowave microsurgery
needle. B, The SMAS rectangle being undermined above the parotidomasseteric fascia with facelift scissors.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-83.  A, The SMAS rectangle is carefully excised off the underlying parotidomasseteric fascia. B, Resultant excision
site.
A
B
FIGURE 9-84.  The ptotic SMAS is secured with braided 2-0 nylon suture in a buried fashion, pulled in a positive vector (dotted
arrow), then secured to the attached SMAS over the parotid region. A, Inverted needle securing the ptotic SMAS in the jowl
region. B, Needle holder used to maintain suture tension while the knot is tied.
After the SMAS is addressed (regardless of the technique),
the tension of the deep layer will be changed, and this can result
in dimpling of the overlying skin. The dimple may not have
been apparent during the skin dissection, but after SMAS tight-
ening, the changing vectors can exert pull, and the unattached
(undissected) tissue still adherent to the dermis produces the
dimple. This is then undermined to a point at which the dimple
is no longer apparent when tension is applied to the skin (Figure
9-89). Failure to address this dimpling can produce a long-
lasting or permanent depression. This brings about an interest-
ing question. When I was learning facelift surgery, I once asked
a well-known surgeon, “How far does one need to dissect the
facelift flap?” His answer was, “As far as you need to!” That
answer confounded me until one day I figured it out while
“chasing” a skin dimple. One needs to dissect to a point at
which the skin has a normal contour, especially at the junction
of the dissected and undissected junction of the flap.
Excised SMAS tissue can be used elsewhere in the face for
augmentation. The SMAS can be placed en masse in the naso-
labial folds or the lips (Figure 9-90). This is performed by
making stab incisions on either side of the structure to be aug-
mented and passing the SMAS strip with sutures or tendon

Chapter 9  •  Cervicofacial Rhytidectomy
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A
B
C
FIGURE 9-85.  This image shows the primary jowl suture (A) and additional sutures placed above (B) and below (C) the initial
suture. Sutures are placed along the entire span of the SMASectomy site.
A
B
FIGURE 9-86.  Proximal and distal SMASectomy margins are sutured from the malar region to the superior cervical region (A).
Dotted white line marks the mandibular border. B, The excised SMAS placed on the skin over the approximate SMASectomy
site.

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Chapter 9  •  Cervicofacial Rhytidectomy
various open SMAS procedures to see which technique provides
the most natural and lasting results. As stated earlier, I prefer
the SMASectomy procedure and apply it to virtually all facelifts,
including short-scar or “weekend” facelifts. I am not a propo-
nent of purse-string suture techniques; I am convinced that they
are not as strong or effective as multiple single sutures. Finally,
it is important to realize that some patients (very thin patients
or those with previous facelift surgery) don’t have a well-defined
SMAS layer, and it is difficult to incise or suspend any signifi-
cant tissue that can withstand suture tension.
I have intentionally not elaborated on “deep-plane” tech-
niques in this chapter for several reasons. The biggest reason is
that in my experience (as well as that of many other respected
surgeons) there are no significant advantages of this aggressive
technique. The chance of nerve damage is increased, recovery
time can be increased, and the results are not significantly dif-
ferent from other SMAS techniques. Having said this, every
surgeon has a specific favorite technique that works well in his
or her hands and can defend their technique and rationale.
Posterior Platysma Suspension
Depending on one’s nomenclature, the platysma border in the
lateral neck is termed the lateral or posterior platysma. This is the
border shown in animation in Figure 9-29. By suspending the
lateral platysma border, the neck is subsequently tightened. A
very common maneuver in rhytidectomy is to secure the lateral
platysma border (and/or associated tissues) and to secure it to
the mastoid fascia in a positive vector.
As discussed earlier (see Figures 9-74 and 9-75), open lipo-
suction is used to defat the lateral neck and visualize the poste-
rior platysma. Sometimes the actual platysma muscle and fibers
passer. This can be trying inasmuch as the SMAS tends to tear
if pulled through too small an opening. Another way to use the
excised SMAS for augmentation is to cut it into pieces small
enough to be injected through a large needle.
To summarize the management of the SMAS, it is important
to address this layer with all facelifts. For beginners, SMAS
plication (closed SMAS suspension) is the easiest, safest, and
most predictable procedure to begin with. Intermediate and
advanced facelift surgeons are encouraged to experiment with
FIGURE 9-87.  Employing a tapered configuration of the superior portion of
the SMASectomy excision allows easier coaptation of the margins when
compared to the classically described rectangle.
A
B
FIGURE 9-88.  A bidirectional SMASectomy configuration. The arrowhead pattern allows the cheek and jowl to be pulled in more
precise and individual vectors.

Chapter 9  •  Cervicofacial Rhytidectomy
293
technique. The lateral undermining allows the muscle border to
be secured as a unit with the suspension sutures (Figure 9-95).
Figure 9-96 shows the author’s preferred suspension suture
for facelift surgery. Many different types of temporary and per-
manent suture are used; the choice is the individual preference
of the surgeon. Braided nylon is a permanent suture with good
strength, and it handles and ties like silk.
The mastoid region just posterior to the earlobe contains
dense fascia without significant underlying anatomy. This is a
dense, tough tissue that can maintain the suspension tension
without pulling through the tissue, thus it makes an excellent
anchoring point. Although this region is usually preferred to
anchor the platysma sutures, in reality, the sutures can also be
placed more inferiorly because dense fascia exists throughout
the upper cervical region. Some surgeons shun this technique,
believing these sutures can compress the greater auricular nerve
where it underlies the tight sutures. I have performed over 700
facelifts employing lateral platysma/mastoid sutures and have
never experienced nerve problems from this technique. Addi-
tionally, some surgeons feel that if midline platysma plication
sutures were utilized in the midline of the neck that lateral
platysma suspension acts to pull against those sutures. I believe
this is true, but I also believe that the dual vector suspension
actually makes for a better, tighter neck suspension as opposed
to weakening the original midline sutures. I believe that using
midline and lateral suspension serves to make a strong sling that
will produce a tighter, more aesthetic neck that will last longer
than not addressing the platysma in facelift surgery. I will say
that patients initially complain of tightness in the submental
region in the early postoperative period, but this is allayed by
are well visualized, whereas in other cases the muscle is closely
associated with fat and connective tissue. The first lateral pla-
tysma suture is placed inferior to the mandibular border. The
lateral (posterior) border of the platysma (or associated tissues)
is then secured with a braided 2-0 nylon (or preferred suture)
and sewn to the mastoid fascia. This initial suture is adjusted to
the most optimum vector that tightens the neck in a natural
manner (see Figure 9-90). Several additional sutures are placed
to assist in tightening the neck and reinforcing the strength of
the original suture (Figures 9-91 and 9-92). The remaining
sutures are placed inferior to the first suture. At a given point
inferiorly, additional sutures do not exert a noticeable pull on
the neck, and this is the end point of suspension. Figure 9-93
is a graphic representation of lateral platysma suspension.
Figure 9-94 illustrates a case in which the SMASectomy was
carried well into the cervical region in addition to lateral
platysmaplasty.
Some surgeons prefer to undermine the lateral platysma to
better define the lateral platysma border. This is a more advanced
A
B
FIGURE 9-89.  After tightening the SMAS, it is possible to have skin dimpling
at the junction of the dissected area and the untreated skin. This must be
addressed by extending the dissection beyond the dimple. A, Typical skin
dimple. B, Dimple being undermined with facelift scissors.
FIGURE 9-90.  Excised SMAS strips can be used to augment lips or folds
during the rhytidectomy procedure.

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Chapter 9  •  Cervicofacial Rhytidectomy
explaining to them that this tightness will produce a defined
and long-lasting correction. The overtightened feeling will spon-
taneously resolve in the coming weeks of recovery.
Addressing Excess Skin
After the skin flaps are dissected and the ptotic deep tissues are
addressed, the excess skin must be suspended and trimmed.
Again, before proceeding to the next step, hemostasis is assessed
prior to skin closure. Some surgeons prefer that the anesthetic
be lightened at this point to normalize the blood pressure;
bleeding that was previously unapparent because of the patient’s
relative hypotension may thus be identified.
A
B
FIGURE 9-91.  The posterior (lateral) platysmal border is secured with a
suture and sewn to the mastoid fascia in a vector that suspends and
tightens the neck. A, Lateral platysma secured with a suture. B, Platysma
sewn to the mastoid region.
FIGURE 9-92.  The lateral platysma is suspended to the mastoid fascia
using multiple 2-0 braided nylon sutures. The SMASectomy sutures are
also seen in the upper face.
A
B
FIGURE 9-93.  The suspension of the lateral platysma to tighten and suspend the neck.

Chapter 9  •  Cervicofacial Rhytidectomy
295
FIGURE 9-94.  The main suspension sutures in a facelift case. The upper
SMASectomy sutures can be seen along with the lateral platysma suspen-
sion sutures in addition to lower cervical SMASectomy sutures. The author
does not generally carry the SMASectomy this far into the neck but on
occasion does.
A
B
FIGURE 9-95.  Some surgeons prefer to undermine the posterior platysma to develop a flap (A), which is then suspended by
its border (B) to the mastoid region.
FIGURE 9-96.  Although many different permanent and absorbable sutures
can be used in rhytidectomy, this author prefers 2-0 braided nylon suture.
(Surgilon, Covidien, Dublin, Ireland.)
In progressing to the next step, it may sound rudimentary,
but a timeout should be taken by the staff to make sure that all
previous steps have been carried out. The novice surgeon would
do well to make an intraoperative facelift checklist and have the
staff check off boxes as the procedure progresses. In the heat of
the battle, it is sometimes easy to omit an important step.
Suspending the skin is a step that can ruin an otherwise
well-performed lift. Improper attention to detail in this step can
make a facelift appear either natural or “done.” The operated or
wind-tunnel look that patients disdain is frequently caused by
pulling the skin in an incorrect vector. The general vector is
superolateral but is actually somewhat different for each patient.
If the side of the face is viewed as a clock face, the general vector
of pull is about two o’clock on the right and ten o’clock on the
left. It is of absolute importance to pull the skin flap in a natural
vector. Failure to do this will contribute to an unnatural or
wind-tunnel look, especially when significant skin wrinkling is
present. Patients with significant skin wrinkling should be coun-
seled about laser skin resurfacing options, because it is difficult
to pull wrinkled skin into a natural vector. This should be well
documented in the preoperative consent. Frequently the wrin-
kles run horizontal, and when the common superolateral tension
is applied, the wrinkled skin takes on an unnatural upswept
appearance (Figure 9-97). Laser skin resurfacing before, during,
or after the facelift can greatly improve this problem.
It should be remembered that surgery is a three-dimensional
entity. When the surgeon contemplates the correct vector of
tension for a particular patient, vertical and horizontal vectors
come into play. Although some surgeons prefer a rigid vector
for all facelifts, I truly think that each case is different. Although
all patients have the same generalized tension vectors for skin

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Chapter 9  •  Cervicofacial Rhytidectomy
After the correct vector is established, the next step is key
suture suspension in the pre- and postauricular regions. Some
surgeons will tack the suspension points with a towel clip or
similar retaining clamp while determining the correct vector
appearance and preparing for the skin cutbacks (Figure 9-100).
The skin cutback (referred to as backcut by some surgeons)
process is extremely important. Underestimating the flap
cutback can cause residual skin laxity, and overestimating the
flap cutback can make it difficult to achieve primary tissue
approximation. This can lead to overstretching the flap, which
can cause skin necrosis and tissue loss at the point of the key
pull, it can different depending upon individual anatomic con-
cerns as well as the level of invasiveness of the specific lift. Figure
9-98 shows the numerous vectors of choice in a typical patient.
Figure 9-99 illustrates an important point made earlier in the
incision-planning section of this chapter. Many surgeons still
use a straight vertical temporal incision. The more contempo-
rary incision uses a release in the temporal tuft region to prevent
unaesthetic temporal balding. In addition to preserving the
hairline, this type of incision enables more options for vector
control when compared to the straight vertical temporal
incision.
A
B
FIGURE 9-97.  Patients with significant skin wrinkles present a conundrum when suspending skin. The change in direction can
produce an unnatural result. These patients must be offered a resurfacing option before, during, or after the facelift.
A
B
C
FIGURE 9-98.  A, A vertical vector. B, A combination vertical/horizontal vector, which is optimal. C, A more horizontal vector. It
is important to construct the optimum vector to produce the most natural-appearing result.

Chapter 9  •  Cervicofacial Rhytidectomy
297
A
B
FIGURE 9-99.  Using the temporal tuft–type releasing incision (B) as opposed to the commonly used vertical temporal incision
(A) allows more control of tension vectors without the worry of displacing the sideburn and causing temporal balding.
A
B
FIGURE 9-100.  The suspended flaps are tensioned in the preferred vector and then clamped with towel clips while the remainder
of the face is inspected for correct aesthetics.

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Chapter 9  •  Cervicofacial Rhytidectomy
surgeons prefer to suspend the posterior flap first, but others do
the inverse. In practice, I personally do not think it makes a
difference.
When addressing the posterior flap, it is extremely important
to control the vector to create a natural posterior hairline. If
close attention is not paid to this vector, a stepped hairline can
suture. The key sutures are unique; they bear the brunt of the
flap tension, enabling a tight suspension. As the name implies,
they bear the tension of the suspension as a keystone bears the
forces in a roman arch. With the exception of the key sutures,
all other portions of the facelift flaps are sutured without
tension. This is a tenet of successful facelift surgery and when
violated can produce unaesthetic wounds. The surgeon must
remember that his or her competence may be judged on the
appearance of the incisions. A great and successful lift can be
spoiled by unaesthetic incisions that were closed under tension
(Figure 9-101).
A pre- and postauricular skin cutback is made that enables
the anterior skin flap to be pulled and suspended with key
sutures. After the initial skin cutback is made, the flap is pulled
into the desired vector. This is an adjustable step. Pulling more
superiorly or inferiorly will have different effects on the ptotic
jowl and neck skin. The flap is pulled into the basic vector, and
the jowls and neck skin are examined for required tightness.
Simultaneously, the surgeon examines the “look” of the sus-
pended skin to see if the vector of pull appears natural. This is
especially important in patients with skin wrinkling. If the
wrinkles are pulled in an incorrect vector, the face takes on the
unnatural windblown look. Novice surgeons will frequently ask
how tight to pull the flap. This is a bit like describing how hard
to throw a bowling ball, as it is difficult to put into words
without demonstrating. Generally, significant tension can be
exerted on the flap when placing the anchoring sutures. Pulling
too hard on a skin flap can have an effect on the lip elevators
and change their direction, producing an unnatural appearance
and animation when smiling. Once the skin vector is correctly
determined, the preauricular key suture is placed using 4-0
Vicryl (Figure 9-102). A long-lasting suture is preferred because
these sutures will remain in place for at least 14 days and need
strength to support the tension placed at these key areas. Some
FIGURE 9-101.  Facelift performed by another surgeon illustrates unaes-
thetic scarring as well as a distorted lobe from closing the pre- and
postauricular incisions under tension.
A
B
FIGURE 9-102.  A, The preauricular key suture (arrow); B, the postauricular key suture (arrow).

Chapter 9  •  Cervicofacial Rhytidectomy
299
neck and submental skin excess after the key sutures were placed
and before any skin was excised. Figure 9-107 shows the amount
of excess flap skin in a patient with moderate skin excess of the
neck and submental region.
Experienced surgeons may choose to extend their subcutane-
ous dissection to the lateral canthal region (Figure 9-108). This
can improve deeper wrinkling in some patients, and some sur-
geons even claim that the lateral brow can be elevated. Younger
patients do not generally need such aggressive dissection. The
subcutaneous dissection in this case proceeds over the lateral
orbicularis muscle (Figure 9-109). Although this extended dis-
section can be beneficial, it also produces increased tissue to deal
result. Instead of merely pulling the posterior auricular skin flap
in a two o’clock vector, it is also rotated anteriorly to prevent a
discontinuous step in the hairline (Figures 9-103 and 9-104).
After the anterior and posterior auricular flaps are cut back
and suspended with key anchor sutures, the next step is to
deliver the earlobe and trim the excess flap skin. Depending
upon the nature of the specific patient’s aging, the amount of
excess skin is variable and related to the aggressiveness of the
lower flap dissection. Figure 9-105 shows a picture of a patient
with minimal aging and a short flap dissection compared to a
patient with advanced aging and a long flap dissection. Figure
9-106 shows four different patients with significant anterior
A
B
FIGURE 9-103.  The vector of the posterior flap is superior and anterior, so it is rotated toward the back of the ear. By doing
this, the natural flow of the hairline is preserved. A, Improper vector that will produce a stepped hairline. B, Proper rotational
vector that will preserve the natural curve of the posterior hairline.
A
B
FIGURE 9-104.  Two different post-rhytidectomy patients. A, Naturally reconstructed and flowing posterior hairline. B, Stepped
hairline from failure to rotate the flap slightly anteriorly in addition to the posterior vector.

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Chapter 9  •  Cervicofacial Rhytidectomy
sometimes only a few millimeters of skin incision is made to
accommodate the earlobe. In larger surgeries, a slightly longer
incision is required. The key is conservative cutback and deliv-
ering the lobe through as small of an incision as possible. The
inferior flap incision should rest in the base of the incised
earlobe. Only then should extremely cautious incision be made
to finalize the lobe/flap interface. Since the skin flap will slightly
retract, the lobe should be slightly tucked superiorly, and it will
heal into a natural position. Figure 9-112 shows various steps
in delivering the earlobe through the inferior facelift flap. In
patients with minimal skin covering the lobe (as shown in
Figure 9-112), only a small cutback is needed, whereas in cases
of excessive skin (see Figure 9-106), a more significant cutback
is required. The novice surgeon may be confused as to the
angulation of the skin cutback. If this cut is not made at the
correct angle, the lobe will be distorted. The easiest means of
predicting the correct place to make the cutback for lobe deliv-
ery is to follow the curvature of the antihelix (Figure 9-113).
Lobe delivery is one of the biggest pitfalls of facelift surgery. It
is important to remember that the patient is lying supine; when
they stand up, the force of gravity will further pull down the
lobe. A surgeon is much better off undercutting the flap and
having a bunched up lobe than overcutting the flap and ending
up with a stretched pixie lobe. Sometimes the lobe is left
slightly bunched intentionally because it will slightly retract
postoperatively. Figure 9-114 shows another series of earlobe
management. The base of the neck flap lies superior to the lobe.
The lobe is then sewn to the flap and when completed, the
suture line should lie superior to the tip of the lobe. This leaves
the lobe in a neutral position, but even a slight superior bunch-
ing of the lobe is acceptable, since it will contract with healing
and undergo slight tension with the patient standing. Notice
that in Figures 9-112, C and 9-114, C, the suture line remains
superior to the lobe. Another means of estimating how much
skin to remove before anchoring the lobe is to make a conserva-
tive flap cutback as previously described (Figure 9-115, A). The
bloody surface of the inferior lobe is then used to make a
“stamp imprint” on the underlying skin (see the dotted line of
Figure 9-115). Then a third to half of this skin is removed in
a U shape (see Figure 9-115, B). The tendency is to remove the
entire U, but this can result in overcutting and a resultant
stretched lobe. Figure 9-115, C shows a conservative excision
with the Ellman radiowave microneedle.
It is also important to mention at this point that it is prudent
to detach the lobe 4 to 5 mm from its base for several reasons.
First, it allows the lobe to be more mobilized, which gives the
surgeon more control. Second, and most important, it allows
the skin of the neck flap to be positioned more superiorly so
as not to pull on the lobe. It is helpful to have the patient’s
preoperative pictures in the room during the facelift for numer-
ous reasons, including the adjustment of the lobe position. The
normal earlobe lies about 15 degrees from the vertical plane,
but it is generally obvious when the lobe is not in a normal
position. It is prudent to note the earlobe position at the pre-
operative visit; some patients have detached lobes, whereas
others have pendulous lobes. The preoperative position is
pointed out to the patient, and the option is given to have the
with which can form a significant “dog ear” at the sideburn
region (see Figure 9-108, C). This requires more complex han-
dling of the skin excision in this region and again is reserved for
more advanced surgeons.
Delivering the Earlobe
Since the excess skin is pulled over the inferior ear, the lobe is
covered and must be delivered from its buried position. This is
an extremely critical step in the facelift procedure. Failure to
properly address the earlobe can result in a number of deformi-
ties, most notably the “pixie ear.” A pixie earlobe is one that is
stretched unnaturally and is the sine qua non of a bad facelift
(Figure 9-110). This deformity is usually caused by “hanging
the cheek on the earlobe.” The most frequent cause of the pixie
ear is overzealous cutback of the inferior skin flap. If the cutback
is too long, closure becomes difficult and the earlobe has to be
stretched to achieve primary closure and is thus deformed
(Figure 9-111). The adage “measure twice, cut once” applies to
the skin cutback in the earlobe area. In small flap facelifts, the
lobe can sometimes be delivered without any skin cutback, or
A
B
FIGURE 9-105.  The amount of skin excess is relative to the amount of aging
and the aggressiveness of the flap dissection. A, The younger patient had
a short flap dissection, whereas the older patient had advanced aging and
a long flap dissection (B). The author’s palm is placed in the large flap to
demonstrate its boundaries.
Text continued on page 305.

Chapter 9  •  Cervicofacial Rhytidectomy
301
A
B
C
D
FIGURE 9-106.  These four different patients illustrate the significant amount of flap excess seen in patients with a “turkey-gobbler”
deformity of excess anterior neck and submental skin.
FIGURE 9-107.  This patient is representative of only moderate anterior and submental neck skin excess and has less flap excess
when compared to the cases shown in Figures 9-102 and 9-103.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
C
FIGURE 9-108.  A, Some patients exhibit significant lateral canthal rhytids. B, Larger dissections can proceed to the orbital rim
to undermine lateral canthal rhytids. C, When dissections proceed to this extent bunching is encountered when closing the
incision and needs to be addressed by superior extension of the temporal incision to manage the skin excess. Note the
improvement of the lateral canthal rhytids in C.
FIGURE 9-109.  When more aggressive dissection is performed as shown
in Figure 9-108, the orbicularis oculi muscle is frequently encountered
(arrows).
FIGURE 9-110.  Patient had a facelift done by another surgeon and was left
with a disfiguring pixie earlobe.

Chapter 9  •  Cervicofacial Rhytidectomy
303
A
B
C
FIGURE 9-112.  A, Earlobe hidden by the retracted excess skin. B, Conservative release incision to deliver the lobe. It is impera-
tive not to overcut this incision to avoid a retracted lobe. C, The earlobe delivered into a normal position through the flap.
FIGURE 9-113.  To estimate the correct angle of incision to deliver the lobe
to remain in a natural position, the scissors follow the curve of the tail of
the antihelical fold on the ear.
FIGURE 9-111.  The pixie earlobe was released in a revision facelift. The
observer can see how the released lobe retracts superiorly, as well as the
gap between the base of the lobe and the flap. Excessive skin had been
removed in the prior surgery at the base of the lobe and the case was
doomed for aesthetic failure in the earlobe region.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
C
FIGURE 9-114.  The resultant steps in anchoring the lobe to the cheek flap. A, Notice the crouch of the facelift flap rides high
into the lobe. B, A 4-0 Vicryl anchoring suture securing the lobe; C illustrates how the earlobe hangs down over the
attachment.
A
B
C
FIGURE 9-115.  A, A means of predicting the necessary and conservative removal is to use the blood side of the detached lobe
to make an imprint on the underling skin (dotted line in Figure 9-114, A). Only a third to half of this skin is removed (B) so the
lobe will ride high. C, Actual skin excision with the Ellman radiowave microneedle.

Chapter 9  •  Cervicofacial Rhytidectomy
305
puckering or dog ears (Figure 9-118). In cases in which a very
large flap is raised or when undermining to the lateral canthus
is performed (as described previously), a significant amount of
redundant tissue can remain in the temporal tuft area. This “dog
ear” must be specifically managed to obtain an aesthetic closure
with a normal hairline. Sometimes simple undermining of the
temporal tuft region will assist in mobilizing the tissues, as
shown in Figure 9-119.
If significant skin excess occurs in the temporal tuft region,
a vertical releasing incision may be necessary to “distribute” the
excess skin superiorly in the temple where it can be trimmed
and remain hidden in the hairline. When addressing this, I
prefer to extend the incision vertically as shown in Figure 9-120.
This incision is then undermined and the excess tissue moved
cephalad and retained with a single staple. In effect, this moves
lobes positioned attached or detached. Many patients are happy
with the lobes they always had, but some patients jump at the
chance to have detached lobes, especially those who love ear-
rings. Although infrequent, some patients have lobes that con-
genitally resemble pixie lobes, and this must be pointed out to
them in the preoperative visit as well (Figure 9-116).
The excess skin is now removed on all aspects of the incision.
The temporal tuft area can be beveled on both sides of the inci-
sion to accommodate hair regrowth to hide the scar. For smaller
flap procedures, trimming the temporal tuft is generally straight-
forward, and the excess skin is simply trimmed with scissors or
radiowave microneedle (Figure 9-117). Larger dissections can
provide more complicated closure of this area. If there is some
gapping, the skin cutback in the temporal tuft area is trimmed
while stretching the incision with a skin hook to avoid
A
B
C
FIGURE 9-116.  Patients pictured have congenitally attached lobes resembling pixie lobes but never had facelift surgery. If
these patients decide to undergo facelift surgery, they can be given a choice to have the lobes remain the same or be
unattached.
A
B
C
FIGURE 9-117.  A, Excess skin flap to be excised. B, The curvilinear incision. C, A skin hook being used to assist in controlling
the incision closure. Retracting the incision with the skin hook will facilitate plastic closure.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
C
FIGURE 9-118.  When closing the temporal incision with larger facelifts, the excess skin must be geometrically trimmed to facilitate
an aesthetic closure. A, Undermining the temporal tuft can provide increased mobility to approximate the incision without
tension. B, The tension-free incision is shown after closure.
A
B
FIGURE 9-119.  Minor undermining of the temporal tuft can provide extra mobilization to assist in a plastic closure and managing
excess tissue in this region.
A
B
FIGURE 9-120.  In cases of large flaps or those with significant periorbital undermining, excess skin in the temporal tuft can
present challenges. The excess skin is repositioned cephalad with the excess spread out and bunched up at the superior
incision margin. Trimming the “dog ear” in this region with a Burow’s triangle will hide the incision in the hair-bearing scalp.

Chapter 9  •  Cervicofacial Rhytidectomy
307
amount skin to be removed. The surgeon must keep in mind
that the incision lines will contract with healing; allowing some
tissue excess will compensate for this. Besides blunting, tragal
skeletonization can occur where excessive skin was removed.
After wound contraction, the tragus is pulled anteriorly, expos-
ing the external auditory canal (Figure 9-123).
Postsurgical tragal problems are rarely noticed by patients
but are very disconcerting to the surgeon who strives for
optimum aesthetics. In addition, they are very noticeable to
friends, other medical personnel, and hair dressers, all of whom
are potential referral sources. For these reasons, reconstructing
a natural tragus should be a goal of every facelift surgeon. Obvi-
ously a preauricular incision eliminates the need for tragal
reconstruction but presents its own aesthetic problems.
The reconstructed tragus should have a natural flow curva-
ture similar to a Cupid’s bow (Figure 9-124, A and B). Like
the “dog ear” superiorly, where it is addressed with a Burow’s
triangle excision.
The preauricular skin at the helical attachment is trimmed
next. The overlapping skin will actually form a crease that can
guide the surgeon where to make the incision. This is one area
in which the curved facelift scissors are used to conform to the
curvature of the helical attachment. By simply following the
curve of the scissors, a very precise cut is made to perfectly
conform to the attached ear (Figure 9-121).
Although there is no rigid protocol for which tissue is
trimmed first, I prefer to address the tragus at this point. Like
the earlobe, a natural tragus is extremely important for an aes-
thetic facelift incision. Failure to pay close and controlled atten-
tion to reconstructing the tragus can lead to tragal blunting
which is very noticeable (Figure 9-122). Another potential
problem when addressing the tragus is to underestimate the
A
B
C
FIGURE 9-121.  A, Excess skin at the helical attachment; dotted line indicates the incision site. B, Curvature of the facelift scis-
sors making the curved cut. C, The precise fit after excision.
A
B
FIGURE 9-122.  Two examples of tragal blunting from poor incision planning, closure under tension, or wound contraction.

308
Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-123.  A, Preoperative normal tragus. B, A skeletonized and retracted tragus with excessive exposure of the external
auditory canal.
A
B
D
C
FIGURE 9-124.  A-B, The normal tragus is curvaceous, and this anatomy should be replicated on the new skin cutback. C, Skin
cutbacks are made at the superior and inferior tragal notch. The tragal anchor sutures (D) firmly retain the mobile tragal skin
so it can be precisely sculpted with a radiowave microneedle (E).

Chapter 9  •  Cervicofacial Rhytidectomy
309
G
H
E
F
The radiowave microneedle makes a pressureless incision, making it superior when trimming mobile
tissue. F, Underside of the new tragus is defatted using the radiowave microneedle. G, Newly sculpted tragus. H, Final closure
with 5-0 gut suture.
FIGURE 9-124, cont’d
Continued

310
Chapter 9  •  Cervicofacial Rhytidectomy
I
J
I–J, A pretragal cinch suture can be placed to help define the pretragal depression; I, the intraoperative
placement of a 5-0 gut suture; J, the suture in place 1 week later, creating the desired pretragal depression.
FIGURE 9-124, cont’d
most surgeons, I have experimented with numerous means of
addressing the tragus. I have developed my own technique of
sculpting the tragus that has performed very well for hundreds
of facelifts. My method is to make skin cutbacks at the natural
notch superior and inferior to the tragus (see Figure 9-124, C)
and place anchor sutures of 5-0 gut suture (see Figure 9-124, D
and E). This maneuver defines the basic anatomy of the tragus
and more importantly, it anchors the very mobile skin flap so
it can be sculpted with precision. After the tragal anchor sutures
are placed, the curvature of the tragal prominence is made with
a radiowave microneedle on a pure cutting setting to minimize
lateral thermal damage (see Figure 9-124, F). As mentioned
previously, the sculpted tragus is overcut slightly to allow for
postsurgical wound contraction. After sculpting the tragal
prominence, the underside of the tragus is defatted using the
same instrumentation (see Figure 9-124, G–H). This thinning
of the skin allows for a more normal drape over the delicately
shaped tragal cartilage. Finally, the margins are closed with 5-0
gut suture (see Figure 9-124, I–J ).
While working one’s way around the ear, excess skin is
trimmed at all required areas. After the tragus is set, a small
triangular infratragal area of skin usually remains and is trimmed
in a similar manner (Figure 9-125). On the postauricular area,
variable skin can remain. Some cases present significant excess
in this area, whereas others require very little skin removal. This
is also a convenient area to utilize the inherent curvature of the
facelift scissors to excise the posterior auricular excess skin in a
crescent (Figure 9-126, A). As the surgeon cuts, the assistant
retracts and releases the ear numerous times so the correct
amount of skin is removed. This incision is then closed with 4-0
gut suture (see Figure 9-126, B). Figure 9-127 illustrates the
predictable outcomes of tragal reconstruction when following
the above techniques.
Finally, the postauricular scalp skin excess is addressed.
By this time, all the key sutures have been set and the flaps
positioned. Removing this posterior excess is straightforward
but requires attention to detail. Although facelift scissors can
easily be used to trim the scalp, this thick tissue can “spring”
the scissors and decrease their fine-cutting ability. Larger, heavier
facelift scissors are available, and some surgeons use these only
for scalp tissue and use the normal facelift scissors for thinner
tissues. I prefer the Ellman radiowave microneedle for almost
FIGURE 9-125.  After trimming the tragal skin excess, the infratragal area is
addressed.

Chapter 9  •  Cervicofacial Rhytidectomy
311
The importance of aesthetic postoperative incisions cannot
be overstressed. An otherwise great facelift can be ruined by
unaesthetic incisions. As stated earlier, patients returning to
everyday life after facelift surgery are scrutinized by friends,
workmates, and hairdressers for incision quality. Dealing with
incision scar problems will be discussed in the complications
section of this chapter.
Figures 9-135 to 9-139 illustrate the achievable quality of
incision aesthetics when flaps are carefully handled and close
attention paid to technique. Figure 9-138 shows excellent post-
auricular sulcus aesthetics. Figure 9-139 shows the natural cur-
vature of the posterior hairline which is recreated without a step
when proper flap rotation technique is followed.
Postoperative Care
Although many surgeons use drains in the early postoperative
period, I have never used a drain in almost 500 facelift cases.
Drains will not prevent a hematoma, although they do have
some benefit for limiting early collections of blood or seromas.
One significant reason for not using drains is that patients
disdain them, and one of the most frequent questions at con-
sultation is whether the surgeon intends to use drains. They are
uncomfortable and unsightly and in my opinion serve as a nega-
tive marketing aspect of rhytidectomy acceptance. One of the
biggest reasons that patients opt for “miracle” facelifts that are
marketed by various companies is that they advertise facelift
surgery without drains, bandages, or anesthesia. I am a firm
believer in employing any technique that will enhance safety
and result, but I think that teaching dogma has led to unneces-
sary steps which make facelift surgery more unattractive to
patients, and drains are one of them. Although technically not
a drain, and much less cumbersome, I have recently begun using
all flap contouring. It is important to use the smallest electrode
diameter and the lowest pure cutting settings. By paying atten-
tion to these, atraumatic skin excision is possible that has no
effect on scarring or follicular damage, owing to the minimal
lateral thermal damage generated with low fluence and the fine-
wire electrode. Figures 9-128 and 9-129 show flap trimming
with scissors and radiowave microelectrode. Figure 9-130 shows
preservation of the natural hairline curvature without step-off
of the incision.
When the flaps are trimmed, it is not uncommon to end up
with a “dog ear” of excess tissue at the distal portion of the
postauricular incision (Figure 9-131). This is especially common
in larger facelifts or those with significant neck dissection. A
Burow’s triangle or similar geometric excision is necessary to
remove the “dog ear.” It is very important to keep this incision
inside the hair-bearing scalp to camouflage it. It should also be
noted and explained to the patient that advanced neck and
submental skin excess will require larger neck flaps and hence
longer postauricular scars. In some cases, the longer scar and the
extension required to accommodate the “dog ear” can place the
scar significantly posterior in the occipital region.
After all the skin flaps are trimmed, the flaps should be
tension free with the exception of the key sutures. If the key
sutures are cut, the flaps should lie passively, as shown in Figure
9-132.
Figure 9-133 shows a recap of the excess skin and the pattern
of excision, and Figure 9-134 shows the common sutures used
by the author. Although many surgeons use subcutaneous
sutures for all suture lines, I only use them routinely in the
sideburn and the hair-bearing scalp incisions. After using sub-
cutaneous sutures for all incisions for many years, eliminating
them from all but these two areas has not shown any negative
effects on wound healing.
A
B
FIGURE 9-126.  A, Excess skin is trimmed on the postauricular region to match the natural crescent curvature of the sulcus.
B, Posterior sulcus skin is excised and closed with 5-0 gut suture.
Text continued on page 316.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
C
D
FIGURE 9-127.  These two cases are indicative of the predictable means of tragal reconstruction with the methods described
herein.

Chapter 9  •  Cervicofacial Rhytidectomy
313
A
B
FIGURE 9-128.  Radiowave microneedle is used to trim the flap excess in the posterior scalp region.
A
B
C
FIGURE 9-129.  Excess skin from the neck flap is trimmed with facelift scissors.
FIGURE 9-130.  A normal posterior hairline curvature is maintained without “step off” by properly rotating the flap before
trimming.

A
B
FIGURE 9-131.  A, Smaller flaps may require no distal trimming, but moderate-sized flaps may present a small “dog ear” to
address. B, A more significant amount of distal incision skin excess that will require more attention to control the “dog ear.”
Keeping the final incision inside the hair-bearing scalp is important for wound camouflage.
FIGURE 9-132.  After final flap trimming, the key sutures were removed in
this patient to illustrate the passive nature of the wound edges. Suturing
any facelift incision (with the exception of the key sutures) invites postop-
erative scar problems.
FIGURE 9-133.  Excess skin is shown with the accompanying pattern of
skin excision awaiting the surgeon after the key sutures are placed.
A
B
1
2
3
4
FIGURE 9-134.  Closure methods for the various inci-
sions. 1, Temporal tuft incision closed with 4-0 gut.
2, Preauricular incision closed with 5-0 or 6-0 fast-
absorbing gut suture. 3, Posterior auricular suture
closed with 5-0 gut suture. 4, Scalp incision hair-
bearing scalp is closed with staples.

Chapter 9  •  Cervicofacial Rhytidectomy
315
A
B
FIGURE 9-135.  A, Facelift performed with a pretragal
preauricular incision. B, 3 months postoperatively.
The lobe and postauricular area are also very
aesthetic.
A
B
FIGURE 9-136.  Another example of temporal tuft preservation from incorporating the release incision just within the sideburn.
A
B
FIGURE 9-137.  A 3-year result of a posttragal facelift incision as described within the chapter.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-138.  The postauricular sulcus incision can be almost imperceptible if the incision is made in the sulcus, the skin
trimmed precisely, and a buried intracuticular gut suture is utilized.
A
B
FIGURE 9-139.  Natural unstepped hairlines are obtainable when the postauricular flaps are properly repositioned.
14-gauge IV catheters to help drain the bilateral neck. I place a
single catheter, parallel to each SCM muscle, in the subcutane-
ous plane from the mid-neck to the angle of the mandible.
The “drains” allow decompression of blood, serum, and tumes-
cent anesthesia and are removed after 24 hours. since the
inception of using the catheters, I have not had to aspirate
a single postoperative collection of blood or serum. After
all incisions are closed, the hair is washed with a 50 : 50 mixture
of normal saline and hydrogen peroxide (Figure 9-140). This
allows the clotted blood to be removed from the hair. The
hair is also gently combed with a wide-toothed comb. Saline
is recommended over tap water, because mycobacterium
infections have been associated with the use of tap water
postsurgically.
After the hair is towel dried, Xeroform gauze (Integrity
Medical, Elwood, NJ) is wrapped around the ear to cover and
protect the pre- and postauricular incisions (Figure 9-141, A).
At this point, fluffed 4 × 4 gauze is placed over the areas of

Chapter 9  •  Cervicofacial Rhytidectomy
317
undermined skin on the front and back of the ear (see Figure
9-141, B), and a gauze pad (or sanitary napkin) is placed over
the submental region (see Figure 9-141, C). Next, a Kling gauze
wrap (Johnson and Johnson Inc., New Brunswick, NJ) is placed
to maintain all of the previous dressings (see Figure 9-141, D),
and finally, this is covered with Coban elastic wrap (3M Inc.,
St. Paul, MN) (see Figure 1-141, F) or specially designed face
and neck compression dressing (see Figure 1-141, E). It is
important to place the final dressing snug but not overly con-
strictive, which could damage the flaps. Also, it is important to
not overly compress the neck; anticipated swelling could
obstruct the airway. A notch can be placed at the bottom of the
submental bandage to relieve pressure on the neck and airway.
Some surgeons do not use postoperative full-face dressings. This
is probably acceptable for very small flap procedures, but I
routinely use the described dressing protocol.
FIGURE 9-140.  The hair is washed and combed immediately post surgery
with a 50% mixture of normal saline and hydrogen peroxide. A double
trash bag is placed beneath the patient to contain the runoff.
A
B
C
D
FIGURE 9-141.  The facelift dressing begins with a Xeroform gauze wrapped around the ear (A), followed by fluffed gauze (B).
Next, a pad is placed under the chin (C) and the fluffed gauze and pad are retained with a gauze wrap (D).
Continued

318
Chapter 9  •  Cervicofacial Rhytidectomy
Since these patients are frequently placed on numerous
medications (e.g., antibiotics, antivirals [if skin resurfacing
is performed], analgesics, steroids), they should be given an
easy-to-read medication schedule at the preoperative appoint-
ment. Any activity that increases postoperative blood pressure,
including bending, lifting, coughing, straining during bowel
movements, vomiting, and retching, should be prevented or
controlled to prevent postoperative bleeding and hematoma. I
give all my patients my cell phone number and check on their
progress the night of the surgery. Postoperative pain should be
minimal, since most patients will experience paresthesia in the
early weeks of facelift surgery. Sudden unilateral severe pain or
swelling can signal postoperative hematoma and should be
evaluated immediately. Postoperative facelift pain is more
common in patients who underwent concomitant cosmetic pro-
cedures, especially laser skin resurfacing. Postoperative nausea
or vomiting should also be addressed with appropriate medica-
tions. Generally, patients will be lethargic and rest without
problems the night of their surgery.
At the follow-up appointment the next morning, dressings
are changed and wounds inspected. The postoperative course
varies greatly from patient to patient. Anecdotally, reflecting on
hundreds of facelifts, I can say that patients that present on
the first postoperative day energetic and smiling will have an
uneventful postoperative. Those patients that present with leth-
argy and negative emotional energy will, in my experience, have
a tougher postoperative course and require much hand holding.
Figure 9-142 shows a patient 24 hours after facelift with blepha-
roplasty, browlift, cheek implants, and full-face laser skin resur-
facing. At this appointment, all bandages are removed and the
suture lines cleansed with hydrogen peroxide and coated with
antibiotic ointment. All flaps are assessed for vitality, and those
with a dusky appearance must be observed closely. Obviously if
a major hematoma is present, it must be drained and the offend-
ing vessels controlled. This will be covered in the complications
section of this chapter. Minor hematomas or seromas
E
F
The final dressing can be an elastic facial dressing
(E) or elastic tape (F).
FIGURE 9-141, cont’d
The patient is scheduled for follow-up the next morning for
inspection of the wounds and the possibility of hematoma.
Older patients, patients with multiple procedures, or those
patients without competent caregivers should be held overnight
or discharged with a private duty nurse.
Instructions for the first postoperative day include keeping
the patient’s head elevated. Sleeping the first day or two in a
recliner or with the head elevated in bed is optimal. The patient
should rest but is encouraged to walk to the bathroom or take
limited walks around the house to keep lower extremity circula-
tion intact. The leg compression hose are worn continuously for
the first 24 hours. It is important for the patient to sleep on the
back with the head upright facing the ceiling. Sleeping on the
side can flex the neck and compromise the flap circulation. Full
liquid or soft diet is preferable and drinks such as Gatorade
contain essential electrolytes and can be beneficial in hydration.
Chewing should be kept to a minimum for the first 48 hours.
If concomitant cosmetic surgery was performed on the brows,
lids, or skin, this wound care should be addressed as well. Some
surgeons recommend ice, but the large, bulky dressings are
likely to make this ineffective.
FIGURE 9-142.  Patient 24 hours after facelift with four-lid blepharoplasty,
brow lift, cheek implants, and full-face laser skin resurfacing.

Chapter 9  •  Cervicofacial Rhytidectomy
319
pictures are generally taken at the 6- to 8-week period. Most
patients are released after the 90-day appointment unless prob-
lems develop. Most of these patients will be returning to the
office for skin care, injectables, and so forth. Postoperative pic-
tures are emailed to the patient as well as presented in a print-
out format. Patients love to show their before-and-after images
to friends. This serves as great marketing for the practice, as does
providing the patient with some wallet-sized before-and-after
images. If the surgeon contemplates using the patient’s photos
for educational or promotional purposes, written consent must
be obtained. Lawsuits have been brought for unauthorized use
of patient images.
Short-Scar/“Weekend” Facelift
As previously mentioned, conservative facelifts have been
around for decades, although some surgeons and companies
market them as new, miracle procedures. Positive aspects of
these conservative procedures are that they are simpler to learn
and perform, can be done with local anesthesia, don’t require
bandages, have shorter recoveries, and are easier to market com-
pared to larger procedures.
These procedures also have serious drawbacks. They do not
and cannot address moderate and advanced aging to the level
of larger lifts. Patients must be told that their result will not be
as tight or last as long as conventional lifts. Also of significant
importance is the fact that these procedures are designed for
younger patients with minimal excess submental and neck skin.
Performing a short-scar facelift on the right 38- to 42-year-old
patient can be quite effective, whereas performing the same
procedure on an older patient or one with advanced aging can
be very disappointing for both surgeon and patient. These con-
servative lifts involve a sole preauricular incision with some
mastoid extension but do not include the posterior auricular
are aspirated transcutaneously. I personally do not replace the
dressing except for those cases of extreme skin excess with very
large flaps or for cases with large amounts of submental fat
removal. One reason for this is that many of my facelift patients
undergo simultaneous laser skin resurfacing, and the dressing
can abrade the facial skin and lead to scarring. For patients who
require extended post-facelift dressing, I either reapply a fresh
head and neck compression garment or fabricate a new small
dressing from an ACE-type elastic bandage (Figure 9-143). This
is done by taking a rolled elastic bandage and measuring the
correct amount needed to cover the submental, cheek, and skull
regions with moderate tension. Then several strips of the desired
size are cut and the ends stapled with a conventional stapler.
The patient is given several of these mini bandages and instructed
to wear them (with the staple ends out) continuously for the
next 5 days then at night for an additional week.
Figure 9-144 shows a patient 24 hours post rhytidectomy
with SMASectomy, platysmaplasty, and upper blepharoplasty.
This is a relatively normal presentation of a first-day postopera-
tive patient.
Patients are told they can wash their hair on postoperative
day 2 and cautioned to be careful not to disrupt sutures or
staples when combing. Additionally, if the patient is to use a
hair dryer, it is imperative to use it on a low setting, because it
is easy to burn the numb skin. Curling irons are discouraged
for the same reason. Patients are asked to refrain from wearing
collared clothing or turtle necks, which can tear the earlobes
when being pulled on and off.
Generally, patients are then scheduled for 1-week follow-up
(eyelid sutures are removed at 5 days) (Figure 9-145) to observe
and remove any nonabsorbable sutures, then at 2 weeks for
staple and key suture removal. After this point, the uncompli-
cated patient is seen monthly for several months. Postoperative
A
B
FIGURE 9-143.  A convenient and inexpensive post-facelift dressing can be fabricated by stapling premeasured strips of common
elastic bandage and dispensing several of these to the patient for postoperative use.

320
Chapter 9  •  Cervicofacial Rhytidectomy
from the office, no bandages, go back to work the next day” can
be very inviting to a patient who does not fully understand other
available options or the limitations of these lifts. I have seen
brochures that show obviously uncontrolled before-and-after
pictures, with the chin down in the preoperative picture and the
chin pointed up in the postoperative picture or the preoperative
picture taken without a flash and the postoperative picture
taken with a flash. Conservative facelifts have been around for
almost a century and do have a place, but any surgeon who
promises results with these procedures rivaling those of more
comprehensive facelifts will soon get caught up in their own
misinformation.
A
B
C
D
FIGURE 9-144.  A–B, Patient immediately after bandage removal on the day after her facelift. The flaps are healthy and flat without
signs of vascular compromise or hematoma. C–D, Another view of the patient, showing a normal presentation. The early
bruising is average, but some patients will exhibit significantly more bruising.
incision. For any surgeon who truly understands the patho-
physiology and vectors of aging and facelift surgery, the postau-
ricular incision is a requirement to truly tighten the neck with
a lasting result.
The short-scar facelift (SSFL), sometimes called weekend face-
lift (WEFL), is built around omitting the postauricular incision
and is limited in that feature when considering significant jowl
and neck aging. These “franchise” lifts go by many names and
when performed correctly, they do offer a result, but they are
not new miracle procedures, and cannot produce comparable
results to more comprehensive facelifts. Frequently the proce-
dure sounds too good to be true: “local anesthesia, drive home

Chapter 9  •  Cervicofacial Rhytidectomy
321
The preauricular work with the SSFL is very similar to a
conventional facelift but generally more conservative. The side-
burn release incision is generally shorter, and the actual preau-
ricular incision is identical. The main differences are seen when
the incision turns the corner of the earlobe. Most of the con-
servative lifts utilize a postauricular incision that is made in the
postauricular sulcus and extends 2 to 4 cm superiorly. Some
surgeons advocate making a horizontal releasing incision across
the mastoid region, which is a huge mistake because it will be
very noticeable postoperatively. To pull the jowl and especially
the ptotic neck skin in a positive vector without a traditional
postauricular hairline horizontal releasing incision, bunching
will occur behind the ear. There is no way to prevent this, and
it will be commensurate with the amount of skin present in the
neck and submental region. Fortunately, much of this bunching
will dissipate with healing, but some will persist and can be
noticeable with certain hairstyles. The tradeoff of an improved
appearance versus some posterior skin bunching is usually not
a problem as long as the patient has been made aware of this
preoperatively.
Weekend Facelift Procedure
In the minimally invasive procedures, I do not routinely perform
midline platysmaplasty. If the patient has enough aging to
warrant midline platysmaplasty, they probably need a conven-
tional facelift. I will perform submental liposuction if the
patient has excess submental fat.
The short scar or weekend incision for the preauricular
region and temporal tuft is identical to a smaller conventional
facelift. Figure 9-147 shows the similar incision. The short-flap
subcutaneous dissection can be seen in Figure 9-148.
When addressing the SMAS during SSFL surgery, SMAS
plication is the most conservative means of SMAS management
The main reason I am not a huge proponent of these con-
servative lifts is simply that the average patient who needs a
facelift needs a larger one. When I do treat patients with
WEFL, I ask them to give me permission to add a full posterior
auricular incision to obtain a better result if I feel intraopera-
tively that the small procedure will not do the job. I have done
this numerous times when my hunch was that these patients
would ultimately be short changed with the single incision
procedure. What continues to amaze me is the amount of
excess skin these specific patients exhibit, even with minimal
outward signs of aging. In short, although they may not have
visible skin, most patients in their fourth decade are candidates
for traditional-incision facelift. Figure 9-146 shows two such
patients.
Conservative lifts certainly have a place in the armamentar-
ium of the cosmetic surgeon, but my personal requisites are
illustrated by the fact that I perform over 80 facelifts a year, and
usually only 2 or 3 of these are short-scar procedures. My per-
sonal indications for performing a short-scar (limited incision)
facelift are:
• Young patients with minimal aging
• Slightly older patients with minimal to moderate jowl and
neck aging
• Older patients who have medical problems that preclude a
larger facelift or anesthesia
• Older patients with budget or recovery limitations who
cannot have a larger lift
When I do perform this procedure on a patient, they are
required to sign an additional consent that details the limita-
tions of this type of facelift. Although some surgeons perform
these procedures with only local and tumescent anesthesia, no
one can convince me that IV sedation does not make the pro-
cedure easier and faster for the patient and surgeon.
A
B
FIGURE 9-145.  Patient 7 days after cervicofacial rhytidectomy with SMASectomy, platysmaplasty, and light CO2 laser skin
resurfacing.

322
Chapter 9  •  Cervicofacial Rhytidectomy
microneedle, the tragus is sculpted (see Figure 9-149, G–I). The
excess skin of the temporal tuft incision and lobe are then
excised (see Figure 9-149, J–K ) and the earlobe set with a 4-0
Vicryl suture (see Figure 9-149, L).
The next step is to manage the posterior auricular skin, which
is the tricky part of this type of facelift. Any skin that is tight-
ened in the cervical region will proportionally present excess
behind the ear. Since there is no horizontal releasing incision,
this skin must be managed by conservative excision (Figure
9-150, A) and redistribution. I prefer to use a skin hook to
elevate the skin superiorly (see Figure 9-150, B). This will
and probably produces less swelling and faster recovery. In most
cases, I prefer the same SMASectomy procedure as described
earlier but on a smaller scale. Figure 9-149, A–B show a SMA-
Sectomy performed. When possible, I also try to utilize at least
one lateral platysma suture, which is fixated to the mastoid fascia
(see Figure 9-149, C).
Next, the preauricular flap is cut back and suspended with a
key suture as shown in Figure 9-149, D. At this point, the excess
tissue is trimmed from the helical attachment region (see Figure
9-149, E–F). The tragal skin is then cut back and anchored with
two 5-0 gut sutures as previously described. Using a radiowave
A
B
C
D
FIGURE 9-146.  Two patients each requested a short-scar facelift. Although neither of them had outward signs of significant
aging or skin excess, the procedure was converted intraoperatively, with permission, to a traditional incision facelift. The amount
of skin excess after raising a posterior flap is impressive.

Chapter 9  •  Cervicofacial Rhytidectomy
323
The postoperative care is very similar to conventional face-
lifts. For the smaller, minimally invasive lifts, no bandage is
necessary but can be used for 24 hours. It is not uncommon for
WEFL patients to have surgery on a Thursday and return to
work the following Tuesday, hence the “weekend” recovery.
Figure 9-151 shows a WEFL patient the morning following her
procedure.
Simultaneous Laser Skin Resurfacing
Laser resurfacing is relegated to the final procedure. The proce-
dure of simultaneous laser resurfacing over facelift flaps is con-
sidered controversial by some surgeons, although I routinely
laser many of my facelift patients. Having performed simultane-
ous facelift with laser resurfacing in several hundred cases
without an incidence of significant flap necrosis is testament to
the safety of this procedure when performed with care. Smokers
are usually not lasered at the same time as the facelift unless it
is an extremely low fluence. Lasering over a facelift flap is a pro-
cedure reserved for surgeons with significant experience with both
facelift and laser.
Generally, the central oval of the face (the areas of the face
excluding the undermined flaps) is lasered at a normal fluence
with the same amount of laser passes one would use when laser-
ing without facelift. The fluence must be reduced, however,
when lasering over the undermined flaps. Since different lasers
have different spot sizes and power settings, no cookbook set-
tings are mentioned in this article. I use the Lumenis Encore
Ultra Pulse CO2 laser (Lumenis Ltd, Yokneam, Israel) and
laser the central oval of the face as I would on a patient
not undergoing facelift. To give a basis of settings, using the
aforementioned laser, the central oval is treated with multiple
passes of 80 mJ with a density of 6. I no longer débride
between laser passes, because it increases erythema and pain and
distribute the skin over the sulcus incision but will frequently
leave a “dog ear” the distal incision, as shown in Figure 9-150,
B. The “dog ear” is managed with a Burow’s triangle excision;
remnant bunching in the posterior auricular region is common.
Because of the lose skin in the mastoid region, blood accumula-
tion can occur. This dead space can be reduced by placing several
skin staples over the mastoid region for 24 hours. Finally, the
preauricular incision is closed with 5-0 gut suture (see Figure
9-150, C–E).
A
B
FIGURE 9-147.  A, Incisions for the minimally invasive procedure area are identical for the preauricular region. B, Postauricular
incision extends superiorly in the posterior auricular sulcus. The incision can be carried up the sulcus further for patients requir-
ing a bigger lift.
FIGURE 9-148.  These conservative lifts generally require smaller lipocutane-
ous flap dissection of 3 to 5 cm from the ear.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
C
D
E
F
FIGURE 9-149.  A, The ptotic SMAS in the jowl region is secured with a 2-0 braided nylon suture and sewn to the fixed SMAS
over the parotid region. B, The SMASectomy incision is then closed with multiple sutures from the malar region to the man-
dibular border. C, The lateral (posterior) platysma (and related tissues) are secured with a 2-0 braided nylon suture and secured
to the mastoid fascia. D, After the skin cutback, a 4-0 Vicryl key suture is placed. E–F, Skin excess is removed from the
preauricular helical attachment; E shows the facelift scissors trimming excess skin, and F shows the precise alignment of the
incision.

Chapter 9  •  Cervicofacial Rhytidectomy
325
G
H
I
J
K
L
G, The tragus is cut back and anchored with 5-0 gut suture. The radiowave microneedle is then used
to sculpt and thin the tragus (H), which should then lie passively, conforming to the normal tragal anatomy (I). J–K, The excess
skin of the temporal region and earlobe are similarly excised. L, The earlobe is set to the neck flap with a 4-0 Vicryl suture.
FIGURE 9-149, cont’d

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
C
D
E
FIGURE 9-150.  A, The excess posterior auricular skin is trimmed. As the excess skin is elevated, a dog ear will frequently form
(B) and as there is no postauricular incision in the short-scar facelift, it must be treated with a geometric excision. It is important
to keep the release hidden by the posterior auricle. C, Incision management in the postauricular region. D, Skin staples used
to minimize dead space in the mastoid region. E, The final preauricular 5-0 gut sutures.

Chapter 9  •  Cervicofacial Rhytidectomy
327
A
B
C
FIGURE 9-151.  A “weekend” facelift patient 24 hours after surgery.
A
B
FIGURE 9-152.  A, Undermined area of the flap being marked with a surgical
marker to discern where the laser power is decreased. B, The central oval
of the face treated with aggressive multipass resurfacing and the under-
mined facelift flap treated with lower power.
delays healing. For the flaps, I use the same fluence of 80 mJ
but lower the density to 4 for a single, nondébrided flap.
To protect the flaps, the extent of the undermining is marked
prior to lasering (Figure 9-152, A), and either the fluence or the
density is lowered when lasering the skin over the undermined
flaps (see Figure 9-152, B). The laser eschar over the central face
may or may not be débrided between passes, but the under-
mined flap is treated with a single nondébrided pass and never
débrided.
For postoperative care after resurfacing, the face is coated
with Vaseline or Aquaphor continuously for the first week, then
a hypoallergenic moisturizer for the next week. Sun screen is
added after reepithelialization occurs, and skin care is resumed
at 3 to 4 weeks.
Concomitant or Ancillary Procedures
In my practice, it is rare to perform an isolated facelift without
other simultaneous aesthetic procedures. Blepharoplasty, brow
and forehead lift, chin or cheek implants, and laser resurfacing
are procedures commonly performed at the same setting as
facelift surgery. Different surgeons may stage these procedures
in different order as determined by personal preference. There
is no right or wrong order in which to perform procedures, and
it is individual surgeon preference, although I personally perform
procedures requiring loupes first. My energy level and that of
my staff is better at the beginning of the case than 4 hours later.
For novice surgeons, it is better to break up the procedures into
two surgeries to better concentrate on each procedure. Also, for
medically compromised patients or heavy smokers in which
anesthesia considerations come into play it may be prudent to
divide the procedures into two sessions.
Figures 9-153 to 9-173 show before-and-after pictures of
facelift cases. Some of the pictured patients have also undergone
other cosmetic procedures such as upper and midfacial rejuvena-
tion and skin resurfacing.
Text continued on page 337.

328
Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-153.  Patient before and after cervicofacial rhytidectomy with SMASectomy and platysmaplasty with simultaneous
blepharoplasty, cheek and chin implants, and full-face CO2 laser resurfacing.
A
B
FIGURE 9-154.  Patient before and after cervicofacial rhytidectomy with SMASectomy and platysmaplasty with simultaneous
brow lift, blepharoplasty, cheek and chin implants, and full-face CO2 laser resurfacing.

Chapter 9  •  Cervicofacial Rhytidectomy
329
A
B
FIGURE 9-155.  Patient before and after cervicofacial rhytidectomy with SMASectomy and platysmaplasty.
A
B
FIGURE 9-156.  Patient before and after cervicofacial rhytidectomy with SMASectomy, blepharoplasty, and laser resurfacing.

330
Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-157.  Patient underwent cervicofacial rhytidectomy with SMASectomy and platysmaplasty with simultaneous cheek
implants and aggressive CO2 laser resurfacing.
A
B
FIGURE 9-158.  Patient before and after “weekend” facelift with SMASectomy along with platysmaplasty and chin implant.

Chapter 9  •  Cervicofacial Rhytidectomy
331
A
B
FIGURE 9-159.  Patient before and after “weekend” facelift with SMASectomy and upper blepharoplasty.
A
B
FIGURE 9-160.  Patient before and after cervicofacial rhytidectomy with platysmaplasty. She declined full-face CO2 laser resurfac-
ing, which would have improved the final result.