Master Techniques in Facial Rejuvenation 2

19  Reshaping Rhytidectomy
223
and subunits have been used as landmarks for planning
scar revisions and facial/nasal reconstruction, the author
has used the concept in obtaining a more natural and
aesthetic facial rejuvenation outcome. Furthermore, a
smooth transition between the various compartments of
the face is paramount in creating a natural, youthful, and
beautiful surface anatomy (Fig. 19.6).
Although the ideal facial shape can differ depending
on gender and ethnicity, there are some general char­
acteristics that convey youth and beauty. The central
oval of the face comprising the nose, eyelids, and lips
is three-dimensional and forms the primary focus of an
individual’s appearance. Even though the lateral subunits
consisting of the cheeks and temple frame a secondary
visual significance, these regions play an important role in
an individual’s facial shape, attractiveness, and youthful­
ness. In the author’s view, the zygomatic cheek subunit
(4b in Fig. 19.5) is the primary framework of a person’s
facial shape, as it should form the most lateral posi­
tion of the face. The tissue in this region is relatively
fixed over the zygomatic arch (malar eminence), and as a
result soft tissue laxity is not a concern during the aging
process in this region. Patients with prominent malar
eminence in the zygomatic subunit that softly transitions
to the surrounding subunits will obtain better results
from the rhytidectomy procedure [54]. This subunit must
be augmented if the area is underdeveloped due to con­
genital maxillary hypoplasia, remodeling, lipoatrophy, or
trauma. The zygomatic subunit should not be augmented
if patients have skeletonized, prominent, and/or exces­
sive bizygomatic width. In fact, patients may have to
have volume augmentation of the surrounding regions to
improve the transition zones (Fig. 19.7).
Superior to the zygoma lies the temple subunit (1b in
Fig. 19.5) of the forehead. The temple subunit is com­
prised of the superior portion of the lateral temporal-
cheek fat compartment, temporalis muscle, and superior
extension of the buccal fat pad [30]. The region should
be flat or convex, and positioned slightly medial to the
zygomatic subunit from the front view. Deep concavity
of the temple subunit creates a gaunt and aged appear­
ance, as well as significantly alters the shape of the face
(Fig. 19.8) [62]. Volume augmentation with autologous
fat grafting or fillers must be considered in every patient
who presents with temple atrophy.
Inferior to the zygomatic subunit are the lateral (4d
in Fig. 19.5) and buccal (4c in Fig. 19.5) subunits of the
cheek. The lateral cheek subunit is comprised of the infe­
rior portion of the lateral temporal-cheek fat compart­
ment, parotid gland, and masseter muscles [30,31,34,35].
The lateral cheek compartment is one of the main areas
where gender differences are crucial in clinical outcomes.
Male attractiveness is related to a more prominent lateral
projection of this region and more defined angle of the
mandible that forms the subunit’s inferior border. In
females, the area should be more narrow, with a soft
transition zone to the zygomatic arch. Regardless of
gender, the subunit should be relatively flat and never be
more lateral than the zygomatic arch (Fig. 19.9). Careful
attention must be paid to address this region if there is
an underlying disproportion. For patients with prominent
and hypertrophic masseters, neuromodulators may be
but must be used with caution due to potential risk of
infection and steep learning curve [54,55].
Long-flap facelifts (SMAS or subcutaneous techniques)
incorporating extensive skin undermining have long been
advocated as a way of releasing the fascioosteocutane­
ous ligaments [38–44]. In attempting to accomplish the
ligamentous release, extensive flap elevation in the sub­
cutaneous plane can destroy the dermal-SMAS attach­
ments, hence invalidating the SMAS support for the lift.
Anatomic studies by Muzaffar and Mendelson have also
demonstrated that the release of retaining ligaments in
the prezygomatic space through extensive subcutane­
ous dissection can potentially cause nerve injury to the
motor branch of the orbicularis oculi [43,44]. It is also
well known that the facial nerve has a more superficial
course near the oral commissure and midportion of the
zygomatic arch, placing it at risk during the dissection
of long skin flaps [56]. If a surgeon desires release of the
fascioosteocutaneous ligaments, we recommend utilizing
the sub-SMAS plane, which can easily be done with the
current technique.
The deep plane facelift also incorporates a short skin
flap elevation and is an excellent rhytidectomy method.
The true deep plane or composite facelift, however, does
not have significant flexibility and requires complete sub-
SMAS dissection over the zygomatic major muscle all
the way to the nasolabial fold in all patients, regard­
less of their aging process and aesthetic goals [16,17].
A lengthy anteromedial dissection can cause extensive
postoperative edema as well as place the branches of the
facial nerve at risk in every patient. In our experience as
well as that of others, the results of the deep plane face­
lift and a well-executed SMAS rhytidectomy are similar,
with the exception of outcomes in older patients with
extensive rhytidosis [57–61]. The outlined SMAS rhytid­
ectomy may incorporate a significant sub-SMAS dissec­
tion similar to deep plane rhytidectomy benefiting older
patients with significant cervicofacial laxity; however, it is
customized to the aging process of the patient in terms of
vector of suspension and extent of sub-SMAS dissection.
FACIAL ANATOMY
The salient features of the facial anatomy have been
discussed in detail in other chapters. In consideration of
obtaining an ideal aesthetic outcome with rhytidectomy
and complementary procedures, the principles of facial
anatomic subunits must be discussed in further detail.
The surface anatomy of the head and neck region is
divided into the various aesthetic units, including the nose,
periorbital region, forehead, upper and lower lip, cheek,
ear, neck, and chin (Fig. 19.5). Some areas such as the
nose, forehead, lips, and cheeks are further divided into
additional subunits. These units and subunits represent
regions of the face that have similar surface topography
and three-dimensional quality based on the underly­
ing anatomic structures, superficial and deep facial fat
compartments, skin thickness, facial muscle activity, and
curvature (flat, convex, or concave) [34–36]. The con­
fluence of and transitions between these subunits from
the forehead to the neck formulate the patient’s facial
shape and youthfulness. Although historically these units

224
MASTER TECHNIQUES IN FACIAL REJUVENATION
C
D
E
F
B
A
Figure 19.7  Preoperative (A, C, and E) and 6-month postoperative (B, D, and F) photos of a 61-year-old female who desired aesthetic improve­
ment of her appearance. The zygomatic cheek subunit is the primary framework of facial shape as it should form the most lateral apex position
of the face. This patient preoperatively has a skeletonized and prominent zygomatic subunit with atrophy of the temple subunit and lateral cheek
subunit. This patient’s zygomatic cheek subunit should not be augmented. She underwent rhytidectomy (horizontal platysma myotomy, corset pla­
tysmaplasty, extensive cervical subcutaneous dissection, 5-cm subcutaneous facial dissection, tunneling of the perioral region, superolateral vector
suspension of SMAS with folding of SMAS on itself in the lateral cheek subunit to augment the region and improve the transition to the zygomatic
arch subunit) and autologous fat grafting (temple, pyriform aperture, prejowl sulcus). Note that the patient also underwent rhinoplasty but did
not desire laser resurfacing that was recommended for perioral rhytids. Postoperatively, the patient has a more harmonious appearance with soft
transitions between the zygomatic arch to angle of the mandible.

19  Reshaping Rhytidectomy
225
individuals seek the rhytidectomy procedure, the buccal
space plays just as important a role in one’s beauty and
aesthetics. The buccal space is at the level of the oral com­
missure and comprised of the buccinator and buccal fat
pads (Fig. 19.11) [63–66]. The buccal fat pad has multiple
ligamentous attachments and extends beyond the buccal
space into the pterygomandibular and temporal regions.
The average volume is 8.9 and 10.2 mL for females and
males, respectively [57–60]. The parotid (Stenson’s) duct
emerges from the parotid gland, travels along the masse­
ter muscle in the buccal space, and pierces the buccinator
muscle entering the oral cavity near the second superior
molar [67]. If the buccal fat pad is prominent, the shape of
used to reduce the bulk of the muscle (Fig. 19.10). Cus­
tomized SMAS imbrication techniques may also be used
during rhytidectomy to narrow prominent parotid and
masseteric fullness. Individuals who present with con­
genital or senile atrophy of the region must have volume
augmentation at the time of the rhytidectomy utilizing
SMAS folding, alloplastic implants, and/or autologous
fat grafting (see Fig. 19.7).
The buccal subunit lies medial to the lateral cheek
subunit and inferior to the zygomatic subunit. The
subunit encompasses the buccal space and midportion
of the body of the mandible where jowling is visualized.
Although jowls are one of the most common reasons
Figure 19.8  Temple and lateral cheek subunit atrophy. The photo shows a young female with facial lipoatrophy involving the temple, buccal,
and lateral cheek subunits (right) and immediate results after poly-L-lactic acid (left). Light reflection and shadows revealed by the black and white
photos clearly demonstrate how significant temple atrophy and cheek atrophy can play a role in one’s facial shape and topography [62]. (Courtesy
Dr. Rebecca Fitzgerald.)
B
A
Figure 19.9  Lateral cheek subunit prominence. Preoperative (A) and early postoperative (B) photos of a young female with bilateral chronic sial­
adenitis of parotid glands who required functional bilateral parotidectomy. Just below the zygomatic subunit are the lateral and buccal subunits of
the cheeks. The lateral cheek subunit is comprised of the lateral temporal-cheek fat compartment, parotid gland, and masseter muscle. Regardless
of gender, the lateral cheek subunit should never be more lateral than the zygomatic arch. In the preoperative photo, the patient has a prominent
lateral cheek subunit due to the chronic parotitis (arrow). The zygomatic subunit is more medial than the parotid region, leading to a disfavored
facial shape. The postoperative photo following bilateral parotidectomy reveals a more aesthetic and ideal facial shape, with the zygomatic subunit
having a more favored position smoothly transitioning to the lateral cheek subunit.

226
MASTER TECHNIQUES IN FACIAL REJUVENATION
A
B
Figure 19.10  Preoperative (A) and early postoperative (B) photos of a young female who underwent botulinum toxin A injection for masseter
hypertrophy. The lateral cheek subunit is comprised of the lateral temporal-cheek fat compartment, parotid gland, and masseter muscle. Ideally,
this subunit should be more medial than the zygomatic subunit. For patients with prominent and hypertrophic masseters (arrow), neuromodulators
may be used to reduce the bulk of the muscle, leading to a more attractive facial shape and appearance. In the preoperative photo, the patient has
a prominent lateral cheek subunit. The zygomatic subunit is more medial, leading to a disfavored facial shape. The postoperative photo reveals a
more aesthetic and ideal facial shape with the zygomatic subunit having a more favored lateral position than the lateral cheek subunit. (Courtesy
Dr. Rebecca Fitzgerald.)
the face appears more round. The buccal fat pad may also
be ptotic, leading to a more exaggerated jowling at the
level of the mandible. The buccal space should be slightly
medial to the zygomatic arch, with curvature that is either
flat or slightly concave. The buccal space must always be
addressed if the region has excessive convexity or concav­
ity. Significant concavity gives an emaciated appearance,
which is a sign of advanced aging. Convexity of the region
results in rounding of the face, which is perceived as less
attractive. As a result, addressing the buccal space is
extremely important in our approach to facial rejuvena­
tion, as some patients may require removal of buccal fat
pad whereas others may require volume augmentation of
the area. The most inferior portion of the buccal subunit,
which overlies the midportion of the mandible, should be
flat, smooth, and in the same plane as the mental subunit
(7 in Fig. 19.5) and inferior portion of the lateral cheek
subunit (4d in Fig. 19.5). This is the area that is directly
addressed with most rhytidectomy procedures.
The medial cheek subunit (4a in Fig. 19.5) is posi­
tioned medially to the zygomatic and buccal cheek
subunit, and is the region most commonly associated
with the “midface” in traditional facial analysis. The
pathophysiology of the aging process of this area involves
inferomedial tissue descent, remodeling of the maxilla
and orbit, as well as variable atrophy of the superficial
and deep fat pockets (see Figs. 19.3–19.4). The lower
eyelid subunit (3a in Fig. 19.5) forms the superior border
of this subunit; the aging process of the two regions is
therefore intimately associated with one another. The
nasolabial fold, which separates the medial cheek and
upper lip subunit (5b in Fig. 19.5), is an area where the
cutaneous insertions of the lip elevators fuse onto the
ligamentous structure formed by the SMAS and deeper
facial fascia. The nasolabial fold becomes more promi­
nent as the maxillary pyriform aperture remodels, various
midface fat compartments atrophy, and the malar fat pad
and suborbicularis oculi fat (SOOF) begin to descend
[30–32]. Progressive remodeling of the orbitomaxillary
complex and facial fat atrophy results in pseudohernia­
tion of the orbital fat pad, tear trough formation, as
well as flattening and cavitary depressions of the medial
cheek, contributing to the overall aging appearance. Our
treatment of the region must therefore focus on creating
soft transitions between the various surrounding sub­
units: zygomatic, lower lid, buccal, medial cheek, and
upper lip. As a result of our improved understanding of
these processes, the concept of volumization rather than
“lifting” of medial cheek has significantly improved out­
comes (Fig. 19.12) [32].
The mental unit is made of the most anterior aspect of
the mandible with the overlying soft tissue and muscles (7
in Fig. 19.5). The neck unit is inferior to the cheek and
mental units (9 in Fig. 19.5). Ideally, patients should have
well-defined cervicomental angles, with limited submen­
tal fat accumulation, minimal cervical platysmal banding,
and sharp transition between the neck to the cheek and
mental units. Male patients ideally should have a more
projected mental unit, as discussed in earlier chapters. Indi­
viduals with poor chin projection and prominent prejowl
sulcus will require further evaluation for simultaneous
chin augmentation, autologous fat grafting, and/or fillers
to enhance the results of the rhytidectomy. Submental
fat accumulation can judiciously undergo suction-assisted
lipectomy, and platysmal banding can be addressed with
platysmal myotomy and corset platysmaplasty. Finally,
patients with low and anteriorly positioned hyoid bone
in the neck unit must be cautioned about the aesthetic

19  Reshaping Rhytidectomy
227
B
A
Figure 19.12  Preoperative (A) and 6-month postoperative (B) photos
of a 58-year-old female who desired improvement of her appearance.
The patient’s preoperative analysis revealed overall aging appearance
and poor facial topography. She had cervicofacial laxity, brow ptosis,
upper lid dermatochalasia, pseudoherniated orbital fat pad with sig­
nificant tear trough deformity and moderate malar edema, and medial
cheek subunit atrophy due to pyriform aperture retrusion and superfi­
cial and deep fat pad atrophy. She underwent autologous fat grafting
(temple, prejowl sulcus, medial cheek subunit, and tear trough), upper
blepharoplasty, transconjunctival lower blepharoplasty, endoscopic
brow lift, fractional CO2 laser resurfacing, and rhytidectomy (corset
platysmaplasty, 5-cm facial subcutaneous dissection with type 1 sub-
superficial muscular aponeurotic system [SMAS] undermining, vertical
vector suspension of SMAS to augment the zygomatic subunit, and
narrowing of the lateral cheek subunit utilizing a posterior SMAS-
mastoid imbrication).
Parotid
gland
Masseter m.
Parotid
duct
Pterygomandibular
extension of
buccal fat pad
Buccinator m.
Body of
buccal
fat pad
Temporal extension
of buccal fat pad
Figure 19.11  Anatomy of the buccal space. The buccal subunit is com­
prised of the buccal space superiorly and mid portion of the mandibular
body where jowling presents during the aging process. Although jowls
are one of the most common reasons individuals seek rhytidectomy pro­
cedure, the buccal space plays just as important a role in one’s beauty
and aesthetics. The buccal space is at the level of the oral commissure
and comprised of buccinator and buccal fat pad. The parotid (Stenson’s)
duct emerges from the parotid gland, traveling along the masseter
muscle in the buccal space and piercing the buccinator and entering
the oral cavity near the second superior molar. The buccal fat pad has
multiple ligamentous attachments and extends beyond the buccal space
into the pterygomandibular and temporal regions. m, Muscle.

228
MASTER TECHNIQUES IN FACIAL REJUVENATION
Facial Nerve
Temporal branch
Zygomatic branch
Buccal branch
Marginal branch
Cervical branch
Figure 19.13  The facial nerve. The facial nerve bifurcates in the
parotid into an upper and lower division. It then divides into five main
branches: temporal (frontal), zygomatic, buccal, marginal mandibular,
and cervical.
Box 19.1  Comprehensive Treatment Options for
Facial Rejuvenation
1. Blepharoplasty
2. Endoscopic brow lift
3. Botulinum toxin type A
4. Fillers
5. Skin resurfacing
6. Rhytidectomy
7. Buccal space modification
8. Alloplastic implants
9. Autologous fat grafting
10. Submental liposuction
11. Horizontal platysmal myotomy and platysmaplasty
12. Mentoplasty
outcome in cervicomental contour [68]. Unlike the other
skeletal regions, the hyoid cannot be manipulated during
the rhytidectomy procedure.
Finally, the safety of the facial nerve is perhaps the
most important aspect of facelift surgery. The facial nerve
exits the stylomastoid foramen and enters the body of
the parotid gland (Fig. 19.13). Within the parotid gland
it bifurcates into an upper and lower division. It further
divides into five main branches, namely temporal (frontal),
zygomatic, buccal, marginal mandibular, and cervical.
Permanent iatrogenic facial paralysis is rare owing to
the extensive arborization of the buccal and zygomatic
branches of the facial nerve. The marginal and cervical
branches also may have arborization as the lower division
separates from the upper division. The frontal branch
is a terminal branch with limited redundancy. Injury to
the frontal branch has the highest risk of causing perma­
nent paralysis. The overall risk of permanent facial nerve
paralysis in standard rhytidectomy is between 0.53% and
2.6% [52,68,69]. There have been very few reports in the
literature regarding the risk of facial nerve injury associ­
ated with more invasive facelifting procedures.
PREOPERATIVE ASSESSMENT
Rhytidectomy is typically indicated for patients with
moderate-to-severe facial aging, as manifested by a
change in facial shape, jowl formation, volume loss, and
neck banding. Patients typically present for rhytidectomy
between the ages of 45 and 65 years. Younger individuals
with significant congenital jowling and a round or rectan­
gular facial shape may also benefit from reshaping facial
surgery that utilizes SMAS rhytidectomy, buccal fat pad
removal, and autologous fat grafting to the zygomatic
arch (Fig. 19.14).
A complete history and physical examination must be
performed at the initial consultation and preoperative
evaluation. The most important aspect of the consulta­
tion is to understand the patient’s aesthetic and functional
goals. Mirror and photographic facial analysis are uti­
lized. As discussed earlier, a comprehensive facial analy­
sis based on aesthetic subunits, skin, cervicofacial laxity,
lipoatrophy, and skeletal remodeling, as well as facial
shape and topography, is a prerequisite for a successful
surgical outcome.
Following the facial analysis, a treatment plan is for­
mulated for the patient. The first feature of the treatment
protocol will focus on preventive measures to slow the
aging process. Antiaging regimen, skin care consultation,
sun protection, and tobacco cessation are discussed with
every patient at this time. In the second phase of the
consultation, nonsurgical procedures that could improve
the facial appearance are considered. Skin resurfacing,
soft tissue fillers, and neuromodulators are discussed at
length. The third feature of the consultation focuses on
areas of the face that will benefit from facial plastic sur­
gical intervention. All regions and aesthetic units of the
face will be evaluated in order to achieve a balanced and
aesthetically pleasing outcome. Box 19.1 highlights the
surgical and nonsurgical options discussed with every
patient. We invite the patients back for a second consul­
tation to further discuss the risks, alternatives, incisions,
aesthetics, and perioperative course of the short-flap rhyt­
idectomy and adjunctive procedures. Photographs are
reviewed in detail with patients at that time.
SURGICAL TECHNIQUE
Rhytidectomy and complementary procedures are typi­
cally performed by the author at a certified ambulatory
surgical center under general anesthesia. Local anesthe­
sia with sedation may be offered as an alternative. The
patients are encouraged to avoid a number of medications
starting 2 weeks prior to the surgical date (Box 19.2). All
herbal products are discontinued at the same time. The
patients are started on arnica and Bromolin starting 3
days prior to the surgery. Although there are very few
studies available, we have found that this regimen helps

19  Reshaping Rhytidectomy
229
B
A
D
C
Figure 19.14  Preoperative (A, C, and E) and 13-month postoperative (B, D, and F) photos of a 34-year-old female who desired improvement of her
appearance. The patient’s preoperative analysis revealed poor facial shape and topography due to inadequate zygomatic subunit, prominent lateral
cheek and buccal subunits, significant submental liposis, as well as microgenia leading to an inadequate mental subunit and premature jowling.
She underwent buccal fat pad removal, chin augmentation, submental liposuction, and rhytidectomy (extensive cervical subcutaneous dissection,
5-cm facial subcutaneous dissection with type 2 sub-superficial muscular aponeurotic system [SMAS] undermining, vertical vector suspension of
SMAS to augment the zygomatic subunit, and narrowing of the lateral cheek subunit utilizing a posterior SMAS-mastoid imbrication). Note that
the patient did not desire lash ptosis repair.
Continued

230
MASTER TECHNIQUES IN FACIAL REJUVENATION
F
E
Figure 19.14, cont’d 
the patients prepare psychologically for their surgery, as
well as reduce the perioperative bleeding, edema, and
ecchymoses [69].
In the preoperative area, ice packs are applied to the
facial region. The markings for the rhytidectomy, blepha­
roplasty, autologous fat grafting donor sites, and endo­
scopic brow lift, as well as important landmarks, are
placed with the patient in the upright position. Patients
are given a mirror to view the proposed incisions. We take
extreme care to mark the patient preoperatively, because
the facial landmarks are distorted once the patient is
supine and local anesthesia has been infiltrated.
After general anesthesia is initiated, the endotracheal
tube is tied in a midline position to the lower teeth with
a 2-0 silk suture or dental floss. Decadron and cefazolin
or equivalent are administered. Foley catheter and lower
extremity pulsatile compression stockings are placed on
all patients. Ice gloves are applied to the areas of the
face and eyes that are not in the immediate operative
field. Autoclave tape is applied to the hair 2 to 4 cm
posterior to the hairline (Fig. 19.15). Lidocaine 1% with
1 : 100,000 epinephrine is infiltrated into all the pertinent
regions prior to the preparation. This will allow ample
time for the vasoconstrictive actions of the epinephrine. A
3-mL syringe and 27-gauge needle are used for face and
brow infiltration. A 1-mL syringe with a 30-gauge needle
is utilized for the blepharoplasty injection. For autolo­
gous fat grafting, a tumescent solution of lidocaine 0.5%
with 1 : 200,000 epinephrine is infiltrated into the donor
sites such as abdomen, flanks, medial and lateral thighs.
We avoid aggressive tumescent infiltration into the face
because so much of our surgery relies on reshaping the
face and volume analysis. Tumescent anesthesia signifi­
cantly improves hemostasis but distorts facial contours.
After local anesthesia is administered, the entire face
and anterior hairline are cleaned with diluted betadine.
Sterile blue towel is stapled to the autoclave tape and the
endotracheal tube is wrapped in a sterile manner. This is
an effective and rapid method of preparing the patient.
Box 19.3 outlines the specific order of procedures in
patients who are undergoing multiple facial rejuvenation
procedures. In general, chin augmentation is performed
first to maintain the most sterile environment, followed
by periorbital procedures, autologous fat grafting, rhyt­
idectomy, buccal fat pad excision, fat grafting touch-
up, and laser resurfacing, as deemed necessary for the
desired facial rejuvenation outcome. Prior to each portion
of the procedure, a second round of local anesthetic
using 0.5% lidocaine with 1 : 200,000 epinephrine is
administered.
The facelift procedure generally begins with suction-
assisted lipectomy of the neck region, if indicated. A
5-mm incision in the submental crease is utilized to access
the region. If platysmaplasty or chin implants are to be
performed, a 2-cm incision is utilized. A 3-mm round
cannula is used for the aspiration. The subcutaneous
region is cannulized first without suction, after which
suction assistance is used. Extreme caution is utilized to
avoid excessive removal of fat, which will increase the
risk of postoperative visibility of the platysma (cobra neck

19  Reshaping Rhytidectomy
231
deformity). A fan-shaped region is aspirated (Fig. 19.16).
The body of the mandible is avoided in order to minimize
the risk of marginal mandibular facial nerve injury.
We will consider performing horizontal transection of
the medial border of the platysma at the cervicomental
junction if the patient is identified preoperatively to have
prominent platysmal banding. Corset platysmaplasty is
performed if the platysmal banding is narrow (Fig. 19.17).
Subcutaneous undermining is performed through the sub­
mental incision. The medial borders of the platysma are
identified. The platysma is also undermined laterally at
approximately 4 to 5 cm inferior to the mandible. Hori­
zontal platysmal myotomy (2 to 3 cm) is then performed
at this region. The corset platysmaplasty is done by using
three to six buried interrupted 3-0 or 4-0 Prolene sutures
(Ethicon, Inc., NJ, USA). The first suture is placed at the
most anterior portion of the platysma where the two sides
are closest to one another. The cervicomental junction
where the platysmal myotomy is performed generally
marks the inferior limit. Platysmaplasty allows the lateral
SMAS/platysma suspension to lift the neck as a sling and
create a more defined cervicomental angle.
The preauricular portion of the facelift starts as a 2-
to 3-cm incision in the anterior temporal hair tuft (Figs.
19.18–19.19). The incision curves back to meet the root
of the helix and follows the preauricular contour down
to the tragus. The incision continues in the retrotragal
region and follows the natural crease of the lobule poste­
riorly onto the postauricular conchal bowl. In men, a pre­
tragal incision is utilized to avoid placing the beard inside
the ear. The postauricular incision is not made directly
onto the postauricular crease, but about 3 mm onto the
conchal bowl up to the point where the helix meets the
occipital hair tuft. The incision takes a soft turn back
into the occipital hair tuft for about 3 cm. The occipital
incision is at a 45-degree angle and does not follow the
hairline because of increased visibility. The postauricular
incision is generally very well camouflaged because of the
high placement and is rarely a source of concern to our
patients. We occasionally perform a short-scar facelift in
selected patients using a limited postauricular incision.
The flap elevation starts at the temporal hair tuft and
facial region in the subcutaneous plane. A Brown-Adson
forceps and No. 15 blade are utilized to begin the dissec­
tion (Fig. 19.20). Double hooks or multiprong cat-paws
are utilized with Metzenbaum scissors for the majority of
the undermining. Retraction by the assistant is of utmost
Figure 19.15  The preparation. Autoclave tape is applied to the hair 2
to 4 cm posterior to hairline. Sterile towel is then stapled to the auto­
clave tape, and the endotracheal tube is wrapped in a sterile manner.
Box 19.3  Sequential Procedure Order
1. Chin implant
2. Lower blepharoplasty
3. Endoscopic brow lift
4. Upper blepharoplasty
5. Autologous fat grafting
6. Submental liposuction
7. Platysmaplasty and horizontal platysmal myotomy
8. Rhytidectomy
9. Buccal fat pad removal
10. Autologous fat grafting touch-up
11. Skin resurfacing
Box 19.2  Medications That Patients Should Avoid
Before Surgery
A.P.C.
Advil
Alka-Seltzer
Anacin
Anaprox
Arthritis Pain Formula
Ascodeen-30
Ascriptin
Aspirin suppositories (all brands)
Aspirin
Bayer Aspirin
Buff-a-Comp
Buffadyne
Bufferin
Butalbital
Carna Arthritis Pain Reliever
Carna-Inlay Tabs
Cheracol Capsules
Congespirin
Cope Coricidin
Coricidin
Darvon Compound
Dristan
Doan’s Pills
Duragesic
Ecotrin
Empirin
Emprazil
Equagesic
Excedrin
Fiorinol
Four-Way Cold Tablets
Indocin
Measurin
Midol
Monacet with Codeine
Motrin
Naprosyn
Norgesic
Nuprin
Os-Cal-Gone
Pamprin
Pamprin (buffered)

232
MASTER TECHNIQUES IN FACIAL REJUVENATION
B
A
Figure 19.16  Submental suction-assisted lipectomy. Fan-shaped aspiration in the submental area is shown (A). The outlined area can be safely
aspirated (B).
Figure 19.17  Platysma transection with platysmaplasty. Platysma
transection at the cervicomental angle followed by corset platysma­
plasty allows the lateral superficial muscular aponeurotic system/pla­
tysma imbrication to lift the neck as a sling and create a more defined
cervicomental angle. At the cervicomental angle, the platysma muscles
on both sides are undermined and the muscle is transected laterally for
2 to 3 cm. The medial borders of the platysma are then plicated together
with three to six buried interrupted 3-0 or 4-0 Prolene sutures. The first
suture is placed at the most superior portion of the platysma.
Figure 19.18  The incision and area of superficial muscular aponeu­
rotic system (SMAS) entrance in rhytidectomy. The temporal and occipi­
tal incisions are limited. A retrotragal route is utilized. The facial region
is dissected for 4 to 5 cm (dotted lines). The neck may be dissected in
the same region or widely to the submental region. The location where
the SMAS is entered or excised must be determined depending on how
much the SMAS will be undermined. If the SMAS is only undermined
to the anterior aspect of the parotid, then the superior portion can be
just in front of the ear, typically 1 to 2 cm anterior to the root of the
helix (SMAS type 1). If an extensive undermining of SMAS takes place,
then the most superior aspect of the sub-SMAS undermining must begin
anterior to the frontal branch of the facial nerve, typically 5 cm anterior
to the root of the helix (SMAS type 2).

19  Reshaping Rhytidectomy
233
angle of the mandible is not performed until posterior
(occipital) neck elevation is completed, thereby decreas­
ing the risk of marginal mandibular injury. The temporal
area also needs to be dissected with extreme care in the
subcutaneous plane, as the frontal branch can have a
superficial course over the zygomatic arch (Fig. 19.21).
After the facial dissection is completed, the posterior
occipital area is elevated initially with a No. 15 blade
(Fig. 19.22). This dissection is more fibrous and difficult
than the anterior dissection. The subcutaneous plane is
importance to allow a safe and predictable depth of dis­
section. At the level of the tragus, we initially dissect a
thick flap just above the perichondrium for 8 to 10 mm.
The facial skin is much thicker than the native tragal skin;
this maneuver, in addition to aggressive thinning of the
tailored skin and a transcutaneous or subdermal suture at
the new pretragal notch, significantly limits postoperative
tragal fullness.
The skin elevation is performed for approximately 4 to
6 cm in the facial region. Lower facial dissection at the
B
A
Figure 19.19  Intraoperative markings for incisions: preauricular (A) and postauricular (B) incision.
C
B
A
Figure 19.20  Facial subcutaneous dissection. The flap elevation
starts at the temporal hair tuft (A). Brown-Adson forceps and No. 15
blade are utilized to start the dissection. A cat paw hook is utilized
with Metzenbaum scissors for the majority of the undermining (B
and C). The assistant retracts the facial skin centrally at all times.

234
MASTER TECHNIQUES IN FACIAL REJUVENATION
ear and facial skin are retracted in opposite directions.
This maneuver helps to further protect the marginal man­
dibular nerve because the subcutaneous plane is easily
dissected. The anterior limit of this dissection is typically
4 to 6 cm. Facial liposuction is strictly avoided because of
unpredictable results, but, similarly to the cervical region,
subcutaneous tunnels may be created with cannulas in the
undissected areas.
The location where the SMAS is entered or excised
must be determined depending on how much the SMAS
will be undermined (see Figs. 19.18, and 19.24–19.26).
If the SMAS is only undermined to the anterior aspect
of the parotid (type 1), then the superior portion can be
just in front of the ear, typically 1 to 2 cm anterior to the
root of the helix, and extend inferiorly down to the angle
of the mandible and the platysma. The segment of SMAS
can be excised using a Brown-Adson forceps and facelift
scissors. If an extensive undermining of the SMAS needs
to take place (type 2), then the most superior aspect of
the sub-SMAS undermining must begin anterior to the
frontal branch of the facial nerve, typically 4 to 5 cm
anterior to the root of the helix (Fig. 19.27). Once the
SMAS is entered, undermining can take place bluntly or
sharply at the level of the parotidomasseteric fascia. The
extent of dissection is variable depending on the patient’s
aging process. The peripheral branches of the facial nerve
run deep to the masseteric fascia, which must be pre­
served at this juncture of the procedure. The marginal
mandibular dips inferior to the angle of the mandible
and turns back up on to the lower border of mandible.
The frontal branch is extremely superficial, and if sub-
SMAS dissection is utilized superiorly, the SMAS must be
entered anterior to the route of the nerve. If necessary,
the platysma can also be safely undermined bluntly, but
small branches of the cervical division will start entering
the muscle on its deep surface just inferior to the angle
of the mandible [70–73]. Injury to these branches are
inconsequential, in the author’s experience performing
selective neurectomy for synkinesis [72].
The SMAS and platysma are suspended with multiple
horizontal mattress or interrupted 3-0 PDS sutures, or by
running a 2-0 PDO Quill knotless barbed suture (Surgi­
cal Specialties Corporation, PA, USA). The vector of the
SMAS suspension is extremely important to not only
improve jowling, but also for reshaping the face and
enhancing the volume in the zygomatic or lateral cheek
subunit in the preauricular region (see Fig. 19.27) [69].
The initial SMAS suture will give the surgeon the insight
for the most appropriate and aesthetic vector. Once the
appropriate vector is set, the inferior portion of the SMAS
and platysma may be sutured posteriorly to the mastoid,
thereby narrowing the parotid and masseteric region for
the patient with broad lateral cheek subunits. This is
extremely useful for patients with round or square faces
who desire a more aesthetic “heart-shaped” appearance.
On the opposite spectrum, in patients with emaciated
lateral cheek subunits, the area must be augmented with
SMAS overlapping, autologous fat grafting, and/or allo­
plastic implants.
At this point, the excess skin is excised and tailored.
Our goal is to minimize tension in the preauricular
more difficult to ascertain. Facelift scissors are utilized to
complete the cervical dissection. The extent of cervical
dissection depends on the patient’s anatomy and aging
process. The lateral cervical dissection may be united
with the central dissection, which was created for the pla­
tysmaplasty and suction-assisted lipectomy. If these areas
are not connected, we use our 3-mm cannula to create
subcutaneous tunnels that aid the final results by creating
pockets of mechanical adhesions in the healing process.
The inferior limit of the dissection is 4 to 5 cm below the
angle of the mandible and at the level of thyroid notch.
The surgeon must be cognizant of the external jugular
as well as the great auricular nerve, as they can be easily
injured. If the great auricular nerve is inadvertently cut,
it can be repaired with 8-0 nylon suture using microscope
or loupe magnification. Complete cervical dissection is
necessary in patients with significant laxity to obtain
adequate aesthetic results.
The lower facial subcutaneous elevation at the level of
the angle of the mandible is performed once the cervical
and superior facial dissections are completed (Fig. 19.23).
Hooks are placed on the facial and cervical regions as the
Figure 19.21  Danger zone for the frontal branch of the facial nerve.
Typically, four rami of the frontal branch of the facial nerve pass over
the zygomatic arch. The most anterior ramus runs about 2 cm posterior
to the anterior zygomatic arch. The branch is almost always anterior to
the superficial temporal vessels.

19  Reshaping Rhytidectomy
235
region. Skin tailoring can be challenging, so a simple
method for consistent results must be considered. Several
anchor points are utilized to allow appropriate retailoring
of the skin (Fig. 19.28). The skin between these anchor
points can subsequently be easily trimmed. Brown-Adson
forceps are utilized to place tension on the skin and cal­
culate the exact distance for skin excision. The anchor
points are all closed in two layers. The root of the helix
serves as the first anchor point (AP-1). Once this location
has been set, excess temporal hair tuft superior to AP-1
is excised. To avoid a “dog-ear” deformity, closure is
performed toward AP-1. Because our temporal incision
is not extensive, we rarely find any significant change in
hair position.
The second anchor point is at the level of the antitra­
gus (AP-2). The intervening skin between the first and
second anchor point can now be safely tailored. Extreme
caution is used not to remove too much skin in this area,
because excess tension can widen the scar and pull the
tragus anteriorly. The tragus is an extremely important
landmark, and a natural pretragal cleat should be created
in order to reduce the detection of the facelift incision.
Using facelift scissors and curved iris scissors, the surgeon
thins the newly positioned facial skin over the tragus.
A PDS suture is then placed either transcutaneously or
D
C
B
A
Figure 19.22  Postauricular skin flap elevation. This posterior dissection is more fibrous and difficult than the anterior dissection (A and B). The
inferior limit of this dissection is 4 to 5 cm below the angle of the mandible. An extensive cervical elevation is performed in order to join the sub­
mental dissection. If these areas are not connected, we use our 3-mm cannula to create subcutaneous tunnels, which aid the final results by creating
pockets of mechanical adhesions in the healing process (C and D).
Figure 19.23  The upper facial dissection and cervical dissection are
joined. Once the cervical and superior facial dissections are completed,
the lower facial subcutaneous elevation at the level of the angle of the
mandible is performed. Hooks are placed on the facial and cervical
regions as the ear and facial skin are retracted in opposite directions.
The dissection is usually carried out for 4 to 5 cm.

236
MASTER TECHNIQUES IN FACIAL REJUVENATION
over the ear lobule. The inferior border of the lobule is
then used to make a split into this intervening skin. This
incision must be performed in a precise manner, as the
apex will become the anchor point of lobule attachment
(AP-4). Pixie ear deformity is avoided by limiting the
tension at this anchor point. Excess skin between AP-2
and AP-4 is excised. In the postauricular area, the skin
between AP-4 and AP-3 is also trimmed conservatively,
completing the skin tailoring in the cervicofacial region.
Deep subdermal 4-0 PDS sutures are placed in interval
regions and the preauricular incision is then closed with
a running locking 6-0 nylon suture between AP-1 and
AP-4. In the postauricular region, a 4-0 fast-absorbing
in the skin flap to recreate a natural tragal notch, and
secured to the underlying tissue. The suture has to pen­
etrate the dermis in order to accomplish its goal. This
deep suture additionally prevents the anterior pull of the
tragus during the secondary healing phase.
Once the anterior facial skin has been tailored, we
turn our attention to the posterior skin. The third anchor
point (AP-3) is the apex of postauricular incision. After
the anchor point is set, excess occipital skin is excised
with the help of a single hook. The occipital hairline is
aligned with deep dissolvable sutures. Staples are then
utilized to close the hair-bearing occipital hair tuft. The
intervening tissue between AP-2 and AP-3 is draped
C
B
A
Figure 19.24  Location of superficial muscular apo­
neurotic system (SMAS) entrance. The SMAS entrance
must be tailored depending on how far the SMAS is
being undermined. If sub-SMAS dissection is limited
to the anterior border of the parotid (type 1), the
superior excision starts at approximately 1 to 2 cm
anterior to the preauricular incision at the level of the
root of the helix and extends inferiorly down to the
infra-auricular platysma (A and B). If it is determined
that an extensive undermining of SMAS is necessary
for optimal outcome (type 2), then the most superior
aspect of the SMAS excision must begin at the level of
the zygomatic arch anterior to the level of the frontal
branch of the facial nerve, typically 5 cm anterior to
the root of the helix (C).

19  Reshaping Rhytidectomy
237
C
B
A
Figure 19.25  Intraoperative excision of superficial muscular aponeu­
rotic system (SMAS) type 1. A segment of SMAS is excised using
Brown-Adson forceps and facelift scissors (A and B). If a determination
is made that the SMAS is only being undermined to the anterior aspect
of the parotid, then the superior portion of the excision can be just in
front of the ear typically 1 to 2 cm anterior to the root of the helix. The
excision then extends inferiorly down to the infra-auricular platysma.
A segment of SMAS after excision is shown (C).
C
B
A
Figure 19.26  Type 1 superficial muscular aponeurotic system (SMAS)
and platysma suspension. The SMAS and platysma are suspended with
3-0 PDS sutures. Multiple horizontal mattress or interrupted sutures are
placed. The vector of the SMAS suspension is extremely important to
improve jowl repositioning, as well as reshape the face and enhance the
volume in the lateral zygomatic arch. Appropriate vertical repositioning
with the very initial SMAS sutures will give the surgeon the insight for
the most appropriate and aesthetic vector. Once the appropriate vertical
vector is set, the inferior portion of the SMAS and platysma are sutured
posteriorly to the mastoid, narrowing the parotid and masseteric region,
further improving the shape of the face.

238
MASTER TECHNIQUES IN FACIAL REJUVENATION
F
E
D
C
B
A
Figure 19.27  Type 2 sub-superficial muscular aponeurotic system (SMAS) undermining and suspension. If an extensive undermining of SMAS
takes place (type 2), then the most superior aspect of the sub-SMAS undermining must begin anterior to the frontal branch of the facial nerve,
typically 5 cm anterior to the root of the helix (A). Once SMAS is entered using a No. 10 blade, the undermining can take place at the level of
the parotidomasseteric fascia using vertical scissor dissection (B) and blunt separation (C). The extent of dissection is variable depending on the
patient’s aging process. If necessary, the platysma can also be safely undermined bluntly, but small branches of the cervical division will start entering
the muscle on its deep surface just inferior to the angle of the mandible (D). The SMAS and platysma are suspended with 3-0 PDS sutures (E). The
vector of the SMAS suspension is extremely important to not only improve jowl repositioning, but also for reshaping the face and enhancing the
volume in the lateral zygomatic arch. Appropriate vertical repositioning with the very initial SMAS sutures will give the surgeon the insight for
the most appropriate and aesthetic vector (F). Once the appropriate vertical vector is set, the inferior portion of the SMAS and platysma are sutured
posteriorly to the mastoid, thereby narrowing the parotid and masseteric region (G).

19  Reshaping Rhytidectomy
239
G
Figure 19.27, cont’d 
AP-1
D
AP–1
AP–3
AP–2
AP–4
C
AP-3
AP-4
B
AP-1
AP-2
A
Figure 19.28  Skin tailoring. Several anchor points are utilized for tailoring the skin (A–C). The root of the helix (AP-1) serves as the first anchor
point (D).
gut suture is used for closure. Staples are used for the
temporal and occipital hair tufts. Drains are placed prior
to closure. If the patient is agreeable, Tisseel fibrin sealant
(Baxter, ON, Canada) can be used prior to closure and
eliminates the need for drains. The submental incision
is closed with a 6-0 nylon suture. A pressure dressing is
applied and the patient is extubated and transferred to the
recovery room. Ice gloves are used throughout the proce­
dure to promote vasoconstriction and limit perioperative
ecchymosis. Figs. 19.7, 19.12, 19.14 and 19.29–19.31
illustrate representative patients who underwent reshap­
ing rhytidectomy with complementary procedures.
POSTOPERATIVE CARE
Patients typically stay in an aftercare facility for one to
two nights. Some patients choose to recover at home.
Continued

240
MASTER TECHNIQUES IN FACIAL REJUVENATION
AP-2
E
K
I
G
J
H
F
Once this location has been set, excess tem­
poral hair tuft superior to AP-1 is excised and staples are used
for closure. The second anchor point (AP-2) is at the level of the
antitragus (E). The intervening skin between the first and second
anchor point is removed (F and G). Using curved iris scissors, the
newly positioned facial skin over the tragus should be aggressively
thinned. A PDS suture is used to create a pretragal cleat; it can be
used transcutaneously (H) and later removed, or used as a subdermal
suture penetrating the dermis of the facial skin and is secured to the
pretragal tissue. The third anchor point (AP-3) is the apex of the
postauricular incision (I). Excess occipital skin is excised with the help
of a hook (J). The occipital hairline is aligned with deep dissolvable
sutures. The intervening tissue between AP-2 and AP-3 is draped over
the ear lobule (K).
Figure 19.28, cont’d

19  Reshaping Rhytidectomy
241
M
L
The inferior border of the lobule is then used to make a split into this intervening skin. The apex of this incision becomes
the anchor point of lobule attachment (AP-4). The excess skin between AP-2 and AP-4 is excised. In the postauricular area, the skin between AP-3
and AP-4 is also trimmed conservatively (L). The preauricular incision is closed with a 6-0 nylon suture in a running locking manner (M).
Figure 19.28, cont’d 
B
A
Figure 19.29  Preoperative (A, C, and E) and early postoperative (B, D, and F) photos of a 55-year-old woman with a history of prior brow lift,
rhytidectomy, and blepharoplasty who desired correction of lateral brow tethering and a more aesthetic and youthful appearance. She underwent
revision endoscopic brow lift, buccal fat pad removal, and revision rhytidectomy (horizontal platysma myotomy, corset platysmaplasty, extensive
cervical subcutaneous dissection, 5-cm facial subcutaneous dissection with type 2 sub-superficial muscular aponeurotic system [SMAS] undermining,
vertical vector suspension of SMAS, and narrowing of parotid region utilizing a posterior SMAS-mastoid imbrication).
We recommend continuous use of cool compresses in the
first 72 hours. Patients are encouraged to have their head
elevated. Antibiotics, analgesics, sleep, and antinausea
medications are prescribed to the patients.
On the first postoperative day, the dressing is removed.
Drains are typically removed on the first postoperative
day in females and on the second day for males. Hydro­
gen peroxide and antibiotic ointments are utilized to keep
the incisions clean and moist for the first 5 days. An
Ace wrap is used when the patient is at home and at
night for the first week. The patient is encouraged to
take light showers starting on the second postoperative
Continued

242
MASTER TECHNIQUES IN FACIAL REJUVENATION
F
E
D
C
Figure 19.29, cont’d

19  Reshaping Rhytidectomy
243
C
D
B
A
Figure 19.30  Preoperative (A, C) and early postoperative (B, D) photos of a 62-year-old female who desired aesthetic improvement of her appear­
ance and neck rejuvenation. She underwent four-quadrant blepharoplasty, rhytidectomy (submental liposuction, 5-cm subcutaneous cervicofacial
dissection with type 1 superficial muscular aponeurotic system [SMAS] imbrication with undermining to the anterior border of parotid, vertical
vector suspension of the SMAS, and narrowing of parotid region utilizing a posterior SMAS-mastoid imbrication), and autologous fat grafting
(3 cm3 to the cheeks and zygomatic arch).

244
MASTER TECHNIQUES IN FACIAL REJUVENATION
B
A
Figure 19.31  Preoperative (A, C, and E) and postoperative (B, D, and F) photos of a 51-year-old female with prior history of thread lift who
desired revision surgery for aesthetic improvement of her appearance. She underwent upper blepharoplasty, endoscopic browlift, rhytidectomy (sub­
mental liposuction, corset platysmaplasty, 5-cm subcutaneous cervicofacial dissection with type 1 superficial muscular aponeurotic system [SMAS]
imbrication, vertical vector suspension of the SMAS, and narrowing of the parotid region utilizing a posterior SMAS-mastoid imbrication), and
autologous fat grafting (anterior midface and prejowl sulcus).
day. The preauricular sutures are removed on the fifth
to seventh postoperative day, and Steri-Strips (3M, MN,
USA) are applied. Staples are removed on the sixth or
seventh postoperative day. The patient is seen again at
the 4-week mark. During this visit, neuromodulators are
utilized to address the perioral and periorbital rhytids.
At the 3-month follow-up visit, fillers are used to further
enhance facial shape and improve facial contours. An
appropriate postoperative skin care regimen will also be
prescribed to the patient if skin resurfacing was per­
formed at the time of rhytidectomy.
COMPLICATIONS
Box 19.4 summarizes potential complications associated
with the short-flap rhytidectomy. We have not performed
a prospective randomized study to ascertain the exact
complication rate with the current SMAS rhytidectomy
technique. However, in the past decade of performing
this procedure, no patient has had permanent facial nerve
weakness. Our experience has also shown that our rhyt­
idectomy approach has minimal risk of flap necrosis. The
rate of cervicofacial hematoma and numbness is similar
to those of other facelift methods [74,75]. We have not
noted an increase in the rate of revision surgery with this
technique.
FUTURE CONSIDERATIONS
The desire of the general population for less invasive
and “novel” aesthetic procedures has become a common
trend over the last two decades. “Vampire” facelifts,
nonsurgical tightening devices, “mini” facelifts, “novel”
thread lifts, and other limited procedures dominate social
media, news outlets, reality TV, and print editorials. As
evident in this textbook, true facial rejuvenation requires
a much more thoughtful analysis and treatment consid­
eration rather than marketing a particular procedure.
The future of facial rejuvenation will likely converge on
combining a variety of surgical and nonsurgical modali­
ties. Longer lasting fillers and new noninvasive technol­
ogy will likely reduce the number of patients who will
opt for surgical intervention. Time-tested procedures such
as rhytidectomy, autologous fat grafting, blepharoplasty,

19  Reshaping Rhytidectomy
245
D
C
F
E
Figure 19.31, cont’d

246
MASTER TECHNIQUES IN FACIAL REJUVENATION
and brow lifts will, however, continue to be very impor­
tant tools for facial rejuvenation. Facial reshaping and
volume modulation will continue to have a prominent
role in the treatment of the aging face and eyes.
References available online at expertconsult.com.
R E F E R E N C E S
7. Mitz V, Peyronie M. The superficial musculoaponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976;
58:80.
29. Meier JD, Glasgold RA, Glasgold MJ. Autologous fat grafting:
long-term evidence of its efficacy in midfacial rejuvenation. Arch
Facial Plast Surg 2009;11(1):24.
30. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy
and clinical implications for cosmetic surgery. Plast Reconstr Surg
2007;119(7):2219.
31. Mendelson B, Wong CH. Changes in the facial skeleton with aging:
implications and clinical applications in facial rejuvenation. Aes­
thetic Plast Surg 2012;36(4):753.
32. Fitzgerald R, Graivier MH, Kane M, et al. Update on facial aging.
Aesthet Surg J 2010;30(1 Suppl.):11S–24S.
37. Stuzin JM. Restoring facial shape in face lifting: the role of skel­
etal support in facial analysis and midface soft-tissue repositioning
(Baker Gordon Sympsium Cosmetic Series). Plast Reconstr Surg
2007;119(1):362–76.
48. Webster RC, Hamdan U, Fuleihan N, et al. The considered and
considerate facelift. Am J Cosmet Surg 1985;2:1.
54. Binder WJ. Submalar augmentation: a procedure to enhance rhyt­
idectomy. Ann Plast Surg 1990;24(3):200.
66. Zhang HM, Yan YP, Qi KM, et al. Anatomical structure of the
buccal fat pad and its clinical adaptations. Plast Reconstr Surg
2002;109(7):2509.
73. Jacono AA, Malone MH, Talei B. Three-dimensional analysis of
long-term midface volume change after vertical vector deep-plane
rhytidectomy. Aesthet Surg J 2015;35(5):491.
Box 19.4  Complications Associated With Rhytidectomy
1. Cervicofacial hematoma
2. Alopecia
3. Scar
4. Skin slough
5. Infection
6. Numbness
7. Need for revision surgery
8. Facial nerve injury

19  Reshaping Rhytidectomy 246.e1
32. Fitzgerald R, Graivier MH, Kane M, et al. Update on facial aging.
Aesthet Surg J 2010;30(1 Suppl.):11S–24S.
33. Gonzalez-Ulloa MA, Castillo A, Stevens E, et al. Preliminary study
of the total restoration of the facial skin. Plast Reconstr Surg
1954;13(3):151–61.
34. Burget GC, Menick FJ. The subunit principle in nasal reconstruc­
tion. Plast Reconstr Surg 1985;76(2):239–47.
35. Fattahi TT. An overview of facial aesthetic units. J Oral Maxillofac
Surg 2003;61(10):1207–11.
36. Menick FJ. Defects of the nose, lip, and cheek: rebuilding the com­
posite defect. Plast Reconstr Surg 2007;120(4):887–98.
37. Stuzin JM. Restoring facial shape in face lifting: the role of skel­
etal support in facial analysis and midface soft-tissue repositioning
(Baker Gordon Sympsium Cosmetic Series). Plast Reconstr Surg
2007;119(1):362–76.
38. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr
Surg 1989;83(1):11.
39. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superfi­
cial and deep facial fascias: relevance to rhytidectomy and aging.
Plast Reconstr Surg 1992;89(3):441.
40. Hoefflin SM. The extended supraplatysmal plane (ESP) face lift.
Plast Reconstr Surg 1998;101(2):494.
41. Mendelson BC. SMAS fixation to the facial skeleton: rationale and
results. Plast Reconstr Surg 1997;100(7):1834–42.
42. Ozdemir R, Kilinc H, Unlu RE, et al. Anatohistologic study of
the retaining ligaments of the face and use in face lift: retain­
ing ligament correction and SMAS placation. Plast Reconstr Surg
2002;110(4):1134.
43. Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the
midcheek and malar mounds. Plast Reconstr Surg 2002;110:885.
44. Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the
ligamentous attachments of the lower lid and lateral canthus. Plast
Reconstr Surg 2002;110:873.
45. Webster RC, Davidson TM, White MF, et al. Conservative face lift
surgery. Arch Otolaryngol 1976;102(11):657.
46. Webster RC, Smith RC, Smith KF. Face lift, Part I: extent of under­
mining of skin flaps. Head Neck Surg 1983;5:525.
47. Webster RC. Facelifts: Conservative vs. radical. In: Ward P, Berman
W, editors. Plastic and reconstructive surgery of the head and neck.
St. Louis: CV Mosby; 1984. p. 363–82.
48. Webster RC, Hamdan U, Fuleihan N, et al. The considered and
considerate facelift. Am J Cosmet Surg 1985;2:1.
49. McCollough EG, Perkins SW, Langsdon PR. SASMAS suspension
rhytidectomy. Arch Otolaryngol Head Neck Surg 1989;115:228.
50. Burgess LP, Casler JD, Kryzer TC. Wound tension in rhytidec­
tomy: effects of skin flap undermining and superficial musculo­
aponeurotic system suspension. Arch Otolaryngol Head Neck Surg
1993;119(2):173.
51. Rees TD, Liverett DM, Guy Cl. The effect of cigarette smoking
on skin flap survival in the face lift patient. Plast Reconstr Surg
1984;73:911.
52. Adamson PA, Moran ML. Complications of cervicofacial rhytidec­
tomy. Facial Plast Surg Clin North Am 1993;1(2):257.
53. Rohrich RJ, Ghavami A, Constantine FC, et al. Lift-and-fill
face lift: integrating the fat compartments. Plast Reconstr Surg
2014;133(6):756e.
54. Binder WJ. Submalar augmentation: a procedure to enhance rhyt­
idectomy. Ann Plast Surg 1990;24(3):200.
55. Binder WJ, Azizzadeh B. Malar and submalar augmentation. Facial
Plast Surg Clin North Am 2008;16(1):11.
56. Seckel BR. Facial danger zones: avoiding nerve injury in facial
plastic surgery. St. Louis: Quality Medical Publishing; 1994.
57. Owsley JQ, Zweifler M. Midface lift of the malar fat pad: technical
advances. Plast Reconstr Surg 2002;110(2):674.
58. Owsley JQ. Rejuvenation of the midface. Plast Reconstr Surg
2001;108(1):262.
59. Owsley JQ. Face lifting: problems, solutions, and an outcome study.
Plast Reconstr Surg 2000;105(1):302.
60. Owsley JQ, Fiala TG. Update: lifting the malar fat pad for cor­
rection of prominent nasolabial folds. Plast Reconstr Surg 1997;
100(3):715.
61. Becker FF, Bassichis BA. Deep-plane vs. superficial musculoaponeu­
rotic system placation face-lift. Arch Facial Plast Surg 2004;6:8.
62. Fitzgerald R, Vleggaar D. Facial volume restoration of the aging
face with poly-l-lactic acid. Dermatol Ther 2011;24(1):2–7.
R E F E R E N C E S
1. Bettman A. Plastic and cosmetic surgery of the face. NW Med
1920;19:205.
2. Bourget J. La disparition chiurgicale des rides et plis du visage. Bull
Acad Med (Paris) 1919;82:183.
3. Aufricht G. Surgery for excessive skin of the face. Transactions of
the second international congress of plastic surgery. Edinburgh:
Livingstone; 1960. p. 495.
4. Guerrero-Santos J, Espaillat L, Morales F. Muscular lift in cervical
rhytidoplasty. Plast Reconstr Surg 1974;54:127.
5. Webster RC, Smith RC, Papsidero MJ, et al. Comparison of SMAS
plication with SMAS imbrication in face lifting. Laryngoscope
1982;92:901.
6. Skoog T. Plastic surgery: new methods and refinements. Philadel­
phia: WB Saunders; 1974.
7. Mitz V, Peyronie M. The superficial musculoaponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976;
58:80.
8. Owsley JO Jr. SMAS-platysma face lift. Plast Reconstr Surg 1983;
71(4):573.
9. Fodor PB. Platysma-SMAS rhytidectomy—A personal modifica­
tion. Aesthetic Plast Surg 1982;6(3):173.
10. Jost G, Lamouche G. SMAS in rhytidectomy. Aesthet Plast Surg
1982;6(2):69.
11. Kamer FM, Halsey W. The two-layer rhytidectomy. Arch Otolar­
yngol 1981;107(7):450.
12. Adamson JE, Todsu AE. Progress in rhytidectomy by platysma-
SMAS rotation and elevation. Plast Reconstr Surg 1981;68(1):23.
13. Rees TD, Aston SJ. A clinical evaluation of the results of submus­
culo-aponeurotic dissection and fixation in face lifts. Plast Reconstr
Surg 1977;60(6):851.
14. Pitanguy I, Machado BH. Facial rejuvenation surgery: a retrospec­
tive study of 8788 cases. Aesthet Surg J 2012;32(4):393.
15. Baker DC. Lateral SMASectomy. Plast Reconstr Surg 1997;
100(2):509.
16. Hamra ST. The deep plane rhytidectomy. Plast Reconstr Surg
1990;86(1):53–61, discussion 62.
17. Kamer FM. One hundred consecutive deep plane face lifts. Arch
Otolaryngol Head Neck Surg 1996;122:17.
18. Godin MS, Johnson CM. Deep plane/composite rhytidectomy.
Facial Plast Surg 1996;12(3):231.
19. Baker SR. Triplane rhytidectomy. Combining the best of all worlds.
Arch Otolaryngol Head Neck Surg 1997;123:1167.
20. Jacono AA, Parikh SS, Kennedy WA. Anatomical comparison of
platysmal tightening using superficial musculoaponeurotic system
plication vs deep-plane rhytidectomy techniques. Arch Facial Plast
Surg 2011;13(6):395.
21. Tessier P. Lifting facial sous-perioste. Ann Chir Plast Esthet
1989;34:193.
22. Psillakis JM, Rumley TO, Carmargos A. Subperiosteal approach as
an improved concept for correction of the aging face. Plast Reconstr
Surg 1988;82:383.
23. Ramirez OM, Maillard GF, Musolas A. The extended subperiosteal
facelift: a definitive soft tissue remodeling for facial rejuvenation.
Plast Reconstr Surg 1991;88:227.
24. Isse NG. Endoscopic facial rejuvenation: endoforehead, the func­
tional lift. Aesthet Plast Surg 1994;18:21.
25. Hinderer UT. Malar implants for improvement of the facial appear­
ance. Plast Reconstr Surg 1975;56(2):157–65.
26. Binder WJ. Submalar augmentation: an alternative to face-lift
surgery. Arch Otolaryngol Head Neck Surg 1989;115(7):797–801.
27. Illouz YG. Note to the editor. The fat cells “graft”, a new technique
to fill depression. Plast Reconstr Surg 1986;78:122.
28. Coleman SR. Long-term survival of fat transplants: controlled dem­
onstrations. Aesthetic Plast Surg 1995;19(5):421.
29. Meier JD, Glasgold RA, Glasgold MJ. Autologous fat grafting:
long-term evidence of its efficacy in midfacial rejuvenation. Arch
Facial Plast Surg 2009;11(1):24.
30. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy
and clinical implications for cosmetic surgery. Plast Reconstr Surg
2007;119(7):2219.
31. Mendelson B, Wong CH. Changes in the facial skeleton with aging:
implications and clinical applications in facial rejuvenation. Aes­
thetic Plast Surg 2012;36(4):753.

246.e2 MASTER TECHNIQUES IN FACIAL REJUVENATION
double-blind, placebo-controlled clinical trial. Arch Facial Plast
Surg 2006;8(1):54.
70. Mustoe TA, Rawlani V, Zimmerman H. Modified deep plane
rhytidectomy with a lateral approach to the neck: an alternative
to submental incision and dissection. Plast Reconstr Surg 2011;
127(1):357.
71. Jacono AA, Parikh SS. The minimal access deep plane extended
vertical facelift. Aesthet Surg J 2011;31(8):874.
72. Peng GL, Irvine LE, Azizzadeh B. Selective Neurectomy for Treat­
ment of Facial Synkinesis in Unilateral Facial Palsy. Poster presenta­
tion at The American Academy of Facial Plastic & Reconstructive
Surgery 2016 Fall Meeting, October 6-8, Nashville TN.
73. Jacono AA, Malone MH, Talei B. Three-dimensional analysis of
long-term midface volume change after vertical vector deep-plane
rhytidectomy. Aesthet Surg J 2015;35(5):491.
74. Rees TD, Aston SJ. Complications of rhytidectomy. Clin Plast Surg
1978;5:109.
75. Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast
Surg 1983;10(3):543.
63. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and
clinical applications of the buccal fat pad. Plast Reconstr Surg
1990;85(1):29.
64. Matarasso A. Buccal fat pad excision: aesthetic improvement of the
midface. Ann Plast Surg 1991;26:413.
65. Loukas M, Kapos T, Louis RG Jr, et al. Gross anatomical, CT
and MRI analyses of the buccal fat pad with special emphasis on
volumetric variations. Surg Radiol Anat 2006;28(3):254.
66. Zhang HM, Yan YP, Qi KM, et al. Anatomical structure of the
buccal fat pad and its clinical adaptations. Plast Reconstr Surg
2002;109(7):2509.
67. Latarjet Michel, Ruiz Liard Alfredo. Human anatomy (Spanish
Edition). Editorial Médica Panamericana; 2005.
68. Dedo DD. “How I do it”—Plastic surgery. Practical suggestions
on facial plastic surgery. A pre-operative classification of the neck
for cervicofacial rhytidectomy. Laryngoscope 1980;90(11 Pt 1):
1894.
69. Seeley BM, Denton AB, Ahn MS, Maas CS. Effect of homeopathic
Arnica montana on bruising in face-lifts: results of a randomized,

247
HISTORY
The tridimensional endoscopic facelift is based upon the
construct of the subperiosteal facelift technique initially
described by Tessier [1].Tessier conceived that this “ortho­
morphic” subperiosteal facelift would be an innovative
way to provide facial rejuvenation in young and middle-
age patients [2]. Subsequently, Psillakis et al. [3] pub­
lished their modifications to the subperiosteal approach,
demonstrating that extensive lateral periorbital dissection
could provide improved rejuvenation of the cheek region.
Soon after, several authors demonstrated their experience
with the subperiosteal techniques [4,5]. The extended
subperiosteal facelift, described in 1991, introduced
several innovative concepts including extensive midface
dissection, improved suspension techniques, and a safer
method of access across the zygomatic arch [6]. Further
refinements in the extended subperiosteal technique [7–9]
ushered in the era of endoscopy. In the mid-1990s, tech­
niques adapted from the open subperiosteal rhytidec­
tomy approach proved that endoscopic methods could be
developed to perform facial rejuvenation [10–12].
Over the past decade, the senior author has dedicated
his practice to facial rejuvenation using the tridimen­
sional endoscopic facelift technique. The knowledge and
experience developed from this approach are presented
in this chapter. The authors hope to provide insight
into their comprehensive approach to endoscopic facial
rejuvenation.
PERSONAL PHILOSOPHY
The aging face is characterized by volumetric change
caused by a reduction of the soft tissues and resorption of
bone [13]. The volumetric changes affect the central part
of the face earlier than the peripheral areas of the face.
The central portion of the face comprises the mimetic
and sphincter muscles allowing facial expressions. The
peripheral portion of the face is more static and thus
more resistant to the aging process. Thus, the face can be
broken down into two distinct aesthetic units: the central
oval and the peripheral hemicircle [14]. The central oval
is composed of the loose, dynamic structures that fall
prey to the gravitational forces of nature. Combined with
loss of bone volume, it becomes evident that the deflation
and gravitational migration of the soft tissues lead to
“earlier aging” of the central oval of the face.
The authors favor a comprehensive approach for reju­
venation of both the central oval and peripheral hemi­
circle of the face. Basic tenets to this approach include
(1) a direct approach to the central oval of the face, (2)
an interconnected subperiosteal plane of dissection in the
upper and midface, (3) use of small hidden slit incisions,
(4) absence of visible incisions on the central oval, (5) use
of endoscopic techniques, (6) absence of traction with the
skin or superficial musculoaponeurotic system (SMAS)
from the peripheral hemicircle, (7) ability to modify the
skeletal framework in the same operative plane, and (8)
ability to correct the deficit of soft tissue volume.
Rejuvenation of the central oval of the face can be
accomplished with endoscopic forehead lift [15], endo­
scopic midface lift [16], and mentopexy procedures. The
endoscopic forehead lift and midface lift procedures can
be used for all degrees of facial rejuvenation. Mento­
pexy is performed in selective cases. Rejuvenation in the
peripheral hemicircle focuses upon the neck and jawline
and can be accomplished through a variety of tech­
niques. Younger patients with good skin tone and mod­
erate submandibular fat accumulation benefit from the
nonexcisional cervicoplasty [17]. The suture suspension
method described is based upon the techniques developed
by Giampapa and DiBernardo [18] and Guerro-Santos
[19], in which important modifications have been made
by the senior author. Patients with severe laxity of the
skin are treated with a traditional excisional cervicoplasty
through submental and periauricular incisions. In select
patients, skeletal augmentation of the jawline is necessary
to achieve harmony between the aesthetic units of the
face. The mandibular matrix system [20] has been devel­
oped to correct skeletal deficiencies of the jawline, give
more angularity to the jawline, and to provide support
for the soft tissues.
Because of the individual nature of the aging process,
facial rejuvenation can be provided through the use of
soft tissue manipulation, soft tissue augmentation, and
alloplastic augmentation (Fig. 20.1). The goal of this
chapter is to provide the authors’ approach toward the
treatment of the aging face. The techniques described
form the components of the tridimensional endoscopic
facelift procedure.
ANATOMY OF FACIAL AGING
Successful rejuvenation of the face requires a thorough
understanding of the anatomic changes associated with
aging. Characteristic features in the frontal region include
visible spasm of the corrugator muscles, deep-set eyes,
and the appearance of deflated brows with hooding and
upper eyelid skin excess. The temporal region becomes
hollowed. The lower eyelids demonstrate orbital fat
C H A P T E R 20 
Tridimensional Endoscopic Facelift
Oscar M. Ramirez, MD, FACS and Charles R. Volpe, MD

248
MASTER TECHNIQUES IN FACIAL REJUVENATION
Bidimensional Lift
Implants
Imbrication
Fat Grafting
Vascularized Fat Mobilization
Figure 20.1  This schematic diagram shows the components available for three-dimensional facial rejuvenation. Bidimensional lifting in vertical
and lateral planes provides the foundation of the endoscopic facelift. Weak skeletal support can be corrected with alloplastic implants, as shown in
the upper left corner of the diagram. Fat grafting, as shown in the upper right corner, is commonly used to enhance areas not corrected by lifting
techniques. In addition, fat grafting is used to treat small areas of depression or creases caused by subdermal damage. Imbrication of soft tissues
is amenable in the brow, maxillary malar area, and mentum, as shown in the lower left corner. The lower right corner of the diagram shows the
areas useful for augmentation by adjacent vascularized fat mobilization, including upper orbital rim augmentation with the upper eyelid fat pads,
the infraorbital rim tear-trough area with the lower eyelid fat pads, and cheek augmentation with Bichat’s fat pad. (From Ramirez OM: Full face
rejuvenation in three dimensions: a “face-lifting” for the new millennium. Aesthet Plast Surg 2001;25:152–64. Used with permission from Springer-
Verlag, New York.)

20  Tridimensional Endoscopic Facelift
249
Addressing the Central Oval of the Face
Heeding the anatomic principles of facial aging, one can
see that a comprehensive approach to facial rejuvenation
is required to maximize the aesthetic results (see Fig.
20.1). The tridimensional facelift technique embraces this
concept. The comprehensive approach developed focuses
on both the central oval and peripheral hemicircle of
the face. The endoscopic forehead lift and endoscopic
midface lift procedures provide the foundation for treat­
ing the central oval of the face, bolstered by the mento­
pexy procedure in select patients.
SURGICAL TECHNIQUE
Endoscopic Forehead Lift Procedure
The endoscopic forehead lift procedure begins with
careful placement of four incisions in the scalp. The first
two incisions are located approximately 2 cm on either
side of the midline, 1 to 2 cm posterior to the hairline.
For patients with excessively long foreheads (>8 cm) these
paramedian incisions are placed directly at the hairline.
It is important to keep the forehead incisions as anterior
as possible. Otherwise, visualization and dissection in
the glabellar region will be compromised. The next set of
incisions is located in the temple region, bilaterally, 2 cm
posterior to the hairline. The incisions should be directed
parallel to the hair follicles to prevent unnecessary alope­
cia postoperatively. Each incision should measure 1.5 cm
in length (Fig. 20.2).
Prior to surgical dissection, local anesthesia using
50 mL of 0.5% lidocaine with 1 : 200,000 epinephrine
is diffusely distributed in both the subcutaneous and
subperiosteal planes. Early administration of the anes­
thetic will provide maximal hemostasis, which is required
during endoscopic visualization.
For optimization of the operative procedure, the fore­
head is methodically divided into four zones that corre­
spond with the sequence of facial dissection (Fig. 20.3).
Zone 1 corresponds to the lateral region bounded by the
temporalis musculature and zygomatic arch. The upper
portion of zone 1 (zone 1a) can be safely dissected in
a “blind” fashion. The lower portion of zone 1 (zone
1b) requires dissection under strict endoscopic guidance.
Important neurovascular structures, including the frontal
branch of the facial nerve, pass through this zone. Zone
2 extends from the hairline to the middle of the forehead.
Zone 3 begins at the hairline and extends posteriorly to
the vertex of the scalp. Zone 4 corresponds to the area
bounded by the superior orbital rims and nasal root
inferiorly and the middle of the forehead superiorly. Vital
structures, such as the supraorbital and supratrochlear
nerves, are located in this zone.
The endoscopic procedure begins with the incision in
the temporal area (the upper portion of zone 1). This
incision is located perpendicular to a tangent drawn
from the nasal ala to the lateral canthal tendon and is
2 cm inside the temporal scalp (see Fig. 20.2). A 1.5- to
1.8-cm incision is made through the skin and subcutane­
ous tissue, deep through the superficial temporal fascia
until the temporal fascia proper is reached. Dissection is
initiated to clear all the soft tissues from the temporal
herniation, and in advanced stages, exposure of the
lower orbital rim leads to creation of a “tear-trough”
deformity. The malar area is characterized by loss of
thickness and ptosis of Bichat’s fat pad. Reduction in
mandibular volume through bone resorption results in
loss of projection at the mandibular border and hollow­
ness around the jowls. The mandibular bone loss is accen­
tuated in edentulous patients [21]. The chin is subjected
to loss of tissue bulk and ptosis leading to the “witch’s
chin” deformity, as coined by Gonzales-Ulloa [22]. Facial
expression lines become accentuated owing to collagen
damage and loss of elastic fibers. Significant skin laxity,
horizontal neck creases, accumulation of fat in the sub­
mental and submandibular regions, platysmal banding,
and development of an obtuse cervicomental angle are
characteristic.
PREOPERATIVE ASSESSMENT
Patients are all examined in a well-lit room, in a seated
position. An initial assessment is performed, noting
medical history, surgical history, current medications
including herbal supplements, and allergies. Social and
family history is noted. A detailed history of previous
cosmetic procedures is obtained. Patients are then given
the opportunity to express their concerns. We find it
extremely helpful to provide the patient with a handheld
mirror during this part of the examination. Understand­
ing the patient’s desires allows the proper surgical plan
to be developed. Finally, a directed physical examination
is performed, noting the stigmata of the aging process.
Access to photographs of the patient at a younger age
can be quite helpful in the creation of a surgical plan.
Patients are encouraged to provide them when possible.
We keep a book of beautiful faces cut from magazines
in each examination room as an aid to explain aesthetic
principles and features. If alloplastic implantation is con­
sidered, skeletal models and sample implants are avail­
able to assist in the explanation of proposed surgical
procedures. A comprehensive collection of preopera­
tive and postoperative patient results is available to the
patients for perusal. In our opinion, these visual aids
are essential to attain the desired aesthetic outcome and
patient satisfaction.
Photographic Documentation
Using a standardized photography studio setup, a series
of photographs are compiled prior to surgery. A full-face
(anteroposterior, AP) frontal view, right and left three-
quarter (oblique) views, right and left lateral views,
and a 45-degree down-tilted frontal (AP) view are the
minimum images acquired. Ancillary images are acquired
based upon the developed surgical plan. The images are
printed prior to the operative procedure and are posted in
the operating room for intraoperative reference. Similar
postoperative photographs are acquired at 3, 6, and 12
months, respectively, and on a yearly basis thereafter.
By maintaining a detailed photographic record of the
preoperative and postoperative results, careful analy­
sis of the three-dimensional contour changes can be
performed.

250
MASTER TECHNIQUES IN FACIAL REJUVENATION
the zygomaticotemporal nerve should be preserved when
possible. Preservation of these structures is facilitated
with a blunt rounded tip elevator. As the procedure pro­
gresses inferiorly, the dissection plane moves from tempo­
ral fascia proper to the intermediate temporal fascia. The
intermediate temporal fat pad will be visualized through
the thin intermediate temporal fascia. Dissection along
the lateral orbital wall progresses inferiorly to the level
of the lateral canthus. This completes the lateral dissec­
tion of the endoscopic forehead procedure.
The paramedian incisions are then made as previously
described and are carried down through the periosteum.
Dissection in zones 2 and 3 can be performed with a blind
sweeping technique, as long as the dissection remains in
a subperiosteal plane. The endoscope is inserted during
dissection in zone 4. In general, zone 4 begins about
3 cm from the superior orbital rims. Endoscopically
assisted dissection should always be performed in zone
4 (Fig. 20.4). The initial dissection proceeds toward the
lateral aspect of the superior orbital rim. Further dis­
section laterally toward the temporal line of fusion will
allow connection of zones 1 and 4. The dissection then
proceeds in a medial direction along the superior orbital
rim. Cautious dissection in this area is mandatory. The
authors have noted variations in the supraorbital nerve
anatomy. Occasionally, an accessory branch of the supra­
orbital nerve can be identified as far as 3 cm superior
fascia proper. Dissection continues inferiorly, remaining
above the intermediate temporal fascia. As mentioned
previously, the initial dissection (upper portion of zone 1)
can be performed blindly in a circumferential fashion for
approximately a 2-cm radius. With the tissues elevated,
a Silastic port protector is inserted and the remainder of
the dissection is performed under endoscopic control.
Elevator No. 8 of the Ramirez endoscopic instrument
set (Snowden-Pencer, Inc., Tucker, GA, USA) is used to
dissect to the temporal line of fusion superiorly. The
elevator is then used to score and elevate the periosteum
1 cm medial to the temporal line of fusion. This is con­
tinued superiorly through the lateral portions of zones 4,
2, and 3, respectively. This dissection will aid in the con­
nection of the temporal and frontal pockets, later in the
case. Dissection continues from the temporal incision in
an inferior and medial direction around the lateral orbital
rim. During the course of this dissection, several temporal
veins will come into view. Temporal vein 1, situated in
the region of the zygomaticofrontal suture, is usually sac­
rificed. Temporal vein 2 (also referred to as the “sentinel
vein”) is encountered while dissecting toward the zygo­
matic arch. Branches of the zygomaticotemporal nerve
may be identified during this dissection. Temporal vein 3
lies just above the zygomatic arch at the junction of its
middle and posterior thirds. This is usually not exposed.
Temporal vein 2, temporal vein 3, and the branches of
2.5 cm
2 cm
3 cm
Figure 20.2  Reference lines and measurements for the placement of
the endoscopic incisions. Note that an imaginary line drawn on a
tangent from the lateral border of the nasal ala through the lateral
canthal tendon determines proper placement of the temporal incision.
Zone 3
Zone 2
Zone 1a
Zone 1b
Zone 4
Figure 20.3  The zone system has been developed to aid safe dissection
during the endoscopic forehead and midface procedures. Endoscopic
visualization is mandatory when dissecting in zones 1b and 4.

20  Tridimensional Endoscopic Facelift
251
thoroughly exposed. Resection of the procerus muscle
should proceed down to the level of the nasoglabellar
angle. Occasionally, bleeding will occur during procerus
resection. Given the superficial location of the dissec­
tion, care must be taken when using cautery in this area.
Overzealous cauterization in this location can lead to
disastrous consequences (burning of the skin). When the
muscle resection is complete, the area is packed with
epinephrine-soaked pledgets. Attention is then directed
back to the temporal region where the endoscopic midface
lift is started at this point. Completion of the endoscopic
forehead lift procedure with elevation and fixation of
the brow typically follows completion of the endoscopic
midface suspension. An example of a pure endoscopic
forehead lift can be seen in Figs. 20.6 through 20.8.
Endoscopic Midface Lift Procedure
The endoscopic midface lift procedure begins with the
temporal dissection in zone 1, as outlined in the previ­
ous section. The temporal vein 2 (sentinel vein), temporal
vein 3, and the zygomaticotemporal nerves are preserved
when possible. The dissection continues in an anterior
and inferior direction, remaining above the intermediate
temporal fascia. Dissection along the intermediate tem­
poral fascia continues down to the level of the zygomatic
arch. The zygomatic arch is entered 2 to 3 mm above the
superior border of the arch. This requires division of the
intermediate temporal fascia, thus exposing the perios­
teum of the zygomatic arch. The anterior two thirds of
the zygomatic arch periosteum are typically elevated. We
find that greater lifting and redistribution of the midface
Figure 20.4  Dissection during the endoscopic forehead facelift should
extend down along the supraorbital rims and nasal radix to completely
elevate the periosteum in the inferior border of zone 4.
Corrugator m.
Procerus m.
Figure 20.5  The endoscopic grasper is used to resect the corrugator
and procerus muscles as shown. m., Muscle.
and lateral to the supraorbital nerve proper. Every effort
should be made to preserve any accessory nerve branch.
After identification of the supraorbital nerve, dissection
continues medially, exposing the origins of the corru­
gator muscles. The supratrochlear nerve travels in the
substance of the corrugator muscles, so careful elevation
of the corrugators is required. Typically, three fascicles
of the supratrochlear nerve are identified and preserved.
Prior to resection of the corrugator muscle, the peri­
osteum of the superior orbital rim is released with a
curved elevator. The periosteum should be released from
the zygomaticofrontal suture line laterally, moving medi­
ally toward the glabella. In patients with heavy tissues,
especially males, the periosteum is released by cutting it
with endoscopic scissors. With the periosteum cut medi­
ally, the supratrochlear nerve and corrugator muscles are
clearly delineated.
The corrugator muscle is extensively resected from
its point of origin to just beyond the supraorbital nerve
(Fig. 20.5). We prefer to resect approximately 80% of the
corrugator muscle to assure that glabellar frown lines are
eliminated. Once the corrugator has been removed, the
depressor supercilii muscle can occasionally be identified.
Resection of the depressor supercilii muscle is indicated
if medial brow ptosis is present. An endoscopic scissors
is then used to divide the periosteum deep to the pro­
cerus muscle. The procerus muscle is resected after being

252
MASTER TECHNIQUES IN FACIAL REJUVENATION
technique increase, dissection can be performed as origi­
nally outlined.
The midface dissection at this point continues through
an intraoral (upper buccal sulcus) incision. The authors’
preferred incision is perpendicular to the alveolar ridge
(vertical) at the level of the first premolar. We find that
the vertically oriented incision preserves the mucosal
integrity at the alveolar ridge, allowing a rapid, water­
tight closure that is associated with fewer complications.
Under direct visualization, the initial subperiosteal dis­
section of the maxilla and malar area is performed. The
endoscope is used for the upper malar dissection. The use
of the endoscope minimizes trauma to the midface struc­
tures caused by excessive traction. The endoscope is most
useful during periosteal elevation along the lateral half of
soft tissues occurs with this approach. The periosteum
of the entire zygomatic arch is elevated only when soft
tissues lateral to the cheek need to be lifted.
A word of caution is necessary at this point. Comfort
with the endoscopic dissection over the zygomatic arch
from the temporal area is associated with a significant
learning curve. Moving from the plane of intermediate
temporal fascia to zygomatic arch periosteum, although
conceptually simple, can be difficult in practice. There­
fore we advocate that surgeons pre-elevate the zygomatic
arch or at least elevate to the superior border of the arch
from an intraoral approach during the learning process.
Pre-elevation in this manner will allow safe communica­
tion of both the temporal and lower midface dissection
pockets, later in the case. As skill and comfort with the
Figure 20.6  Anterior views of a patient who underwent a pure endoscopic forehead procedure. The preoperative view is shown to the left. Improved
brow position is shown in the postoperative view on the right.
Figure 20.7  Three-quarter views of the patient shown in Fig. 20.6. Note the softening of the glabellar creases and more youthful position of the
brows in the postoperative view (right).

20  Tridimensional Endoscopic Facelift
253
is the lower cheek imbrication, or “modiolus” suture.
This suture is placed into the tenuous periosteal/fascia/
fat of the inferior maxillary soft tissue near the upper
buccal sulcus incision. Both ends of this suture are then
directed through the temporal incision and tagged, as
previously described.
Exposure of Bichat’s fat pad follows the placement
of the first two suspension sutures. Bichat’s fat pad is
approached through the superomedial wall of the buccal
space. The periosteum and buccinator muscle are spread
with the use of a blunt dissector. This allows Bichat’s fat
pad to herniate through, maintaining an intact capsular
fascia. The fat pad should be carefully dissected free
from the wall of the buccal space. The fat pad should
be easily movable for repositioning as a pedicle flap. A
4-0 PDS suture is then woven into the fat pad and the
suture ends are delivered to the temporal area, similar to
the previous suspension sutures. The endoscope should
be used to visualize the delivery of the pedicled fat flap
over the zygomatic arch. The endoscope can also assess
the trajectory of the suspensions sutures. It is important
to avoid crisscrossing the suspension sutures as they are
passed temporally.
Each of the suspension sutures is then secured to the
temporal fascia proper, in an ordered fashion. The sutures
should be placed in the temporal fascia proper, below the
level of the temporal incision. The first suture, the Bichat’s
pad fat suspension, should be placed most medially. The
inferior malar periosteum/fascia/fat or modiolus suture
is placed next, in a more lateral location of the temporal
fascia proper. The most lateral suture, the SOOF suture,
is the last to be anchored to the temporal fascia proper.
This completes the suspension of the midface.
Butterfly drains are placed bilaterally through separate
stab incisions in the temporal scalp. Each drain is care­
fully directed into the midface and secured to the temporal
scalp with a suture. The superficial temporal fascia is then
the zygoma body, its extension underneath the fascia of
the masseter muscle, and the anterior two thirds of the
zygomatic arch. The fascia covering the upper (medial)
portion of the masseter tendon is also elevated from the
zygoma. A few longitudinal fibers can be included in
the elevated flap as necessary. Endoscopic visualization
assists in the preservation of the zygomaticofacial nerve.
Dissection continues along the inferior and lateral
orbital rim and continues toward the superior border of
the zygomatic arch. Skeletonization of the infraorbital
nerve is not necessary under most circumstances.
With the initial midface dissection now complete, the
endoscope is returned to the temporal area. An assistant
elevates the soft tissue of the midface, thus allowing the
surgeon to safely connect the temporal and midface dis­
section pockets under endoscopic control. Gentle eleva­
tion during this step protects the frontal branch of the
facial nerve from injury. With wide communication of the
temporal and midface pockets, the endoscope is returned
through the upper buccal sulcus incision.
The inferior orbital rim is dissected further by elevating
the inferior arcus marginalis. A 4-0 polydioxanone (PDS)
suture (Ethicon, Somerville, NJ, USA), introduced endo­
scopically is used to imbricate the medial suborbicularis
oculi fat (SOOF) to the lateral aspect of the inferior arcus
marginalis. It is important to check eye globe mobility at
this point with a forced duction test because improper
placement of this imbricating suture can indirectly trap
or place traction upon the inferior rectus muscle.
The lateral aspect of the SOOF is then grasped with
a 3-0 PDS suture, providing the first of three suspen­
sion sutures (Fig. 20.9). Both ends of this suture are
then passed through the temporal incision, under endo­
scopic guidance. We find it helpful to tag the suture ends
of each suspension suture with a labeled needle driver.
This allows the surgeon to keep track of each suspension
suture without confusion. The second suspension suture
Figure 20.8  Lateral views of the patient in Figs. 20.6 and 20.7. Brow ptosis is evident in the preoperative view (left). The postoperative image
(right) shows an aesthetically pleasing brow position.

254
MASTER TECHNIQUES IN FACIAL REJUVENATION
unicortical hole in the calvarium is drilled. A 1.5-mm
titanium post (Synthes, Paoli, PA, USA) is then placed in
the drill hole. In most cases, two paramedian posts (one
on each side) are sufficient to maintain the proper brow
position (Fig. 20.10). Location of the posts will have a
significant impact on brow position. Under most circum­
stances, post placement corresponds to a superomedial
axis from the lateral brow. This will provide maximal
elevation of the lateral brow. More central post place­
ment is chosen for patients requiring greater elevation
of the central and medial brow. Patient examples of full
endoscopic forehead and midface procedures are shown
in Figs. 20.11 through 20.16.
Mentopexy
In select cases, addition of the mentopexy procedure is
required to provide aesthetic balance to the rejuvenated
central oval. The aging chin is a complex entity that
frequently is not properly addressed during facial reju­
venation procedures. The “witch’s chin” deformity con­
sists of ptosis of the premental soft tissues, a prominent
submental crease, and often a loss of bony projection. In
an effort to address the complex pathophysiology of the
witch’s chin deformity, the authors present a multivari­
ate approach toward correction of the ptotic chin. Soft
anchored to the temporal fascia proper with two 4-0 PDS
sutures, while an assistant provides superomedial traction
to the advanced scalp. This maneuver will provide addi­
tional support to the suspended soft tissues. The intraoral
incisions are then closed with interrupted 4-0 chromic
catgut sutures, to provide a watertight closure.
Attention, at this point, is directed back to the fore­
head region where drain placement, closure of the para­
median incisions, and brow elevation is performed.
Briefly, two suction drains are placed through separate
stab incisions in the scalp, adjacent to the paramedian
access ports. An endoscopic biter is used to direct the
tips of the drains to the level of the glabella and the
anterior forehead. Each drain is secured with a heavy
drain stitch. The paramedian incisions are closed in two
layers. A blunt traction hook is then used to elevate
the scalp and to position the brow. When proper brow
position is obtained, a small stab incision is made in the
scalp, with a No. 11 scalpel. A 1.1-mm drill bit with a
4-mm stop is inserted through the stab incision and a
SOOF
Modiolus
Buccal sulcus
incision
Bichat’s
fat pad
Figure 20.9  Treatment of the midface is performed with key suspen­
sion sutures that provide lifting in a vertical direction. The sutures
are placed from the buccal sulcus incision and directed through the
temporal pocket created endoscopically. The orientation of the anchor­
ing and fixation of the corresponding sutures into the temporal fascia
proper is indicated. Bichat’s fat pad suture is woven through the fat
pad and directed in a superomedial direction to add lateral bulk to
the cheek over the zygomatic arch. The modiolus suture is directed in
a tangential direction to the nasolabial fold and provides lifting of the
lower cheek soft tissues. The suborbicularis oculi fat (SOOF) suspen­
sion suture is directed most laterally and allows improvement of the
tear-trough deformity.
Figure 20.10  Arrows depict the vectors of pull to the soft tissues at the
completion of the endoscopic forehead/midface procedures. Suture fixa­
tion of the temporal scalp to the temporal fascia proper will maintain
the soft tissue position. Screw fixation of the forehead will maintain the
soft tissue position of the brow in the immediate postoperative period.

20  Tridimensional Endoscopic Facelift
255
tissue are dissected down to the level of the platysma. A
skin/subcutaneous tissue flap is then generated 2 cm in
both the anterior and posterior directions. The platysma
is then incised vertically in the midline up to the level of
the inferior border of the mandible.
The periosteum is divided, in a similar fashion, allow­
ing the remainder of the procedure to be performed in
tissue manipulation and the use of alloplastic implants
play a role in the treatment of the ptotic chin. A subperi­
osteal dissection performed through a submental incision
is used for each of the procedures described.
The mentopexy procedure begins with a 3-cm sub­
mental incision, placed one fingerbreadth posterior to
the native submental crease. The skin and subcutaneous
Figure 20.11  This 50-year-old patient had aging changes significant for her chronologic age. She underwent an endoscopic midface lift in conjunc­
tion with an endoscopic forehead lift and a mentopexy type I (refer to Figs. 20.19–20.21). Note the nasolabial folds and the jowling present in the
preoperative (left) view. Considerable brow ptosis and lateral hooding are evident. Postoperatively (right), the patient demonstrates improved midface
fullness and symmetry associated with a more youthful appearance. The improved brow position and absence of lateral hooding are both evident.
Figure 20.12  Preoperative (left) and postoperative (right) three-quarter views of the patient shown in Fig. 20.11. Improvement in the forehead
and midface aesthetic can be clearly seen from the three-quarter view. Support of the cheek mass, transposition of Bichat’s fat pad, and elevation
of the brow contribute to the more youthful appearance.

256
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 20.13  Preoperative (left) and postoperative (right) lateral views of the patient in Figs. 20.11 and 20.12. Elevation of the lateral brow
eliminates the hooding seen in the preoperative view. Midface rejuvenation provides significant improvement of the lower eyelid to cheek transition.
In addition, the degree of jowling is reduced and softening of the nasolabial fold results.
Figure 20.14  This 46-year-old patient underwent an endoscopic midface lift procedure in conjunction with an endoscopic forehead lift and men­
topexy type II (refer to Figs. 20.22–20.24. Preoperative (left) and postoperative (right) frontal views are shown, respectively. Note the improved
cheek mass position and softening of the nasolabial folds.

20  Tridimensional Endoscopic Facelift
257
Figure 20.15  Preoperative (left) and postoperative (right) three-quarter views of the patient shown in Fig. 20.14. Slight elevation of the brow and
increased fullness of the lateral cheek mass in the postoperative view clearly defines a more youthful appearance.
Figure 20.16  Preoperative (left) and postoperative (right) lateral views of the same patient shown in Figs. 20.14 and 20.15. Note the smooth
transition from the lower eyelid to cheek in the postoperative (right) view.

258
MASTER TECHNIQUES IN FACIAL REJUVENATION
is performed with placement of the 3-0 PDS suture at
the level of the lowermost aspect of the mentalis muscle/
periosteum. A bicortical drill hole is then created in the
midline of the mandibular symphysis. The drill hole
should be directed in a caudal fashion as shown in Figs.
20.17 and 20.18. The suture is then directed through the
bone and tied along the posterior border of the mandible.
Evaluation of the proper chin position is noted prior to
skin closure. Patient examples of type I and type II men­
topexy are shown in Figs. 20.19 through 20.21 and Figs.
20.22 through 20.24, respectively.
a subperiosteal plane. A blunt tip periosteal elevator is
then used to elevate the periosteum of the mandible in
an anterior and lateral direction. Anterior dissection pro­
ceeds to the level of the oral mucosa. Perforation of the
oral mucosa is to be avoided. The periosteal dissection
proceeds laterally to the anterior border of the masseter
tendon. Care must be taken when dissecting around the
mental nerve foramina. We do not skeletonize the mental
nerves in an effort to prevent traction-related neuropraxia.
The type I and type II mentopexy procedures utilize
suspension of the ptotic soft tissue structures. Suspension
C
B
A
Figure 20.17  The mentopexy type I. (A) Shows the view seen from inferior to superior. The suture is placed in the chin soft tissue at the inferior
aspect of the mentalis muscle. (B) and (C) show the effect provided by suture fixation. The chin soft tissue is elevated in a superior and anterior
direction. The 3-0 PDS suture is passed through a midline hole drilled through the inferior border of the mandible and is secured to the posterior
aspect of the mandible.

20  Tridimensional Endoscopic Facelift
259
Figure 20.18  Mentopexy type II. The purse-string 3-0 PDS suture provides elevation and imbrication of the chin soft tissue. Fixation follows as
described in Fig. 20.17.
Figure 20.19  Preoperative (left) and postoperative (right) views following a mentopexy type I procedure as seen from the anteroposterior projection.
Figure 20.20  Three-quarter views of the patient in Fig. 20.19. Preoperative (left) and postoperative (right) views.

260
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 20.21  Lateral views of the patient in Figs. 20.19 and 20.20. Note the chin pad ptosis and poor anterior projection of the chin in the preopera­
tive view (left). Postoperatively (right), the reference lines demonstrate the improved anterior projection of the chin following the type I mentopexy.
Figure 20.22  Anteroposterior views of a type II mentopexy patient. Preoperative (left) view and postoperative (right) result are shown.
Figure 20.23  Three-quarter views of the patient in Fig. 20.22. Preoperative (left) and postoperative (right) images are shown. The type II mentopexy
was performed to address the mild clefting in the chin soft tissue seen in the preoperative view. The purse-string suture of the type II mentopexy
obliterated the soft tissue cleft and provided improved chin aesthetics.

20  Tridimensional Endoscopic Facelift
261
lower eyelid skin excess. In situations in which excessive
lower eyelid skin exists, we perform a skin-only blepha­
roplasty procedure, using a standard subciliary incision.
Plication canthopexy or orbicularis muscle suspension
can be performed through this skin-only exposure. We
find this approach associated with a decreased risk of
ectropion and eyelid malposition.
Bichat’s Fat Pad Excision
A certain subset of patients who present for facial rejuve­
nation demonstrate chubby cheeks, significant bulk and
pseudoherniation of Bichat’s fat pad, and good malar
bone support. Augmentation of the cheeks with Bichat’s
fat pad repositioning is relatively contraindicated in this
cohort. These patients benefit from excision, rather than
suspension, of Bichat’s fat pad. As previously outlined,
the periosteum and buccinator muscle are spread apart
in the superomedial wall of the buccal space. This will
provide exposure of Bichat’s fat pad. The fat pad will
readily herniate through the opening in the periosteum/
buccinator muscle. With two pairs of blunt forceps, the
fat pad can be gently teased out and resected. However,
care must be taken during delivery and resection of the
fat pad. Undue traction of the fat pad can result in injury
to neurovascular structures or Stensen’s duct. Bichat’s fat
pad resection should be performed in a similar fashion
to orbital fat pad excision during blepharoplasty proce­
dures. The fat pad is placed on tension during resection
and will retract when divided. Bleeding from the retracted
Bichat’s tissue will be difficult to control safely. Meticu­
lous hemostasis prior to fat pad excision can be facilitated
by the use of bipolar cautery.
Fat Grafting
Structural fat grafting as described by Coleman [23] is
used as an adjunctive component of the tridimensional
facelift in many of our patients. Structural fat grafting
provides an excellent means for treating residual facial
asymmetries or contour irregularities. Deep residual
creases, such as nasolabial and marionette lines, can be
improved with this technique. The fat grafts are typically
harvested toward the end of the rhytidectomy procedure.
The type III mentopexy procedure follows in a similar
fashion. Several caveats should be noted with this tech­
nique. Location of the mental nerves should be noted
prior to chin augmentation. We routinely measure the
distance of each mental nerve from the midline as well as
the inferior border of the mandible with the use of cali­
pers. These measurements are then transferred to the chin
implant. Any overlap of the implant is removed, leaving
a 2- to 3-mm gap around the mental nerve foramina.
The implants are secured to the bone with small titanium
screws placed in a bicortical fashion. The suspension
suture is then driven through the porous polyethylene
implant at the desired level. It is not necessary to place
the suture through the mandible, as described for the type
I and II techniques.
The type IV mentopexy technique, being a redraping
technique, does not require suture fixation, but fixation
as in a type I mentopexy can be used to centralize the
chin. Care must be taken during periosteal scoring to
prevent injury to the underlying mentalis musculature.
Scoring can be performed with a scalpel or electrocautery
placed on a low setting.
Complete mobilization of the periosteum to the level
of the anterior masseter tendon is crucial for the success
of all types of mentopexy. When the proper aesthetic
result is achieved, the dissection pocket is irrigated with
antibiotic solution. The platysma is approximated in
the midline with interrupted sutures. The skin edges
are approximated with 5-0 or 6-0 Prolene sutures. Tape
is then applied to the chin for support. If adjunctive
aesthetic procedures are to be performed in the neck,
the submental incision is covered with a protective bio-
occlusive dressing to prevent desiccation. The incision is
then closed at the completion of the case.
Adjunctive Procedures in the Central Oval of the Face
Skin-Only Blepharoplasty
The endoscopic midface procedure effectively elevates the
cheek soft tissues in a superior direction. The recruitment
of soft tissue toward the lower eyelid can often be sig­
nificant. This effect can be exaggerated in patients with
Figure 20.24  Lateral views of the patient in Figs. 20.22 and 20.23. Ptosis of the chin in the preoperative (left) view is corrected with the mento­
pexy procedure as shown with the postoperative result (right).

262
MASTER TECHNIQUES IN FACIAL REJUVENATION
should be offered a traditional excisional cervicofacial
rhytidectomy.
Anterior Approach Cervicoplasty
Access is obtained through a submental incision measur­
ing 2.5 to 3 cm. A subcutaneous dissection plane is devel­
oped above the platysma. A uniform 4-mm thickness of
subcutaneous tissue is left on the skin flap. Wide subcu­
taneous dissection is performed in an inferior direction
along the midline down to the level of the cricoid carti­
lage. Laterally, the subcutaneous dissection tapers along
the sternocleidomastoid muscles in an oblique direction.
We avoid dissection of the upper one third of the sterno­
cleidomastoid muscle in an effort to prevent injury to the
greater auricular nerve.
The upper limit of dissection is the mandibular border.
The endoscope is used during dissection in the subman­
dibular triangle to avoid injury to branches of the mar­
ginal mandibular nerve. Excess fat on the surface of the
platysma is removed with scissors or with the aid of a
flat suction device applied only on the platysmal surface.
Excessive defatting of the skin flap should be avoided to
prevent contour irregularities or skeletonized appearance.
The fat pad deep to the platysma is then dissected from
the anterior bellies of the digastric muscles down to the
level of the mylohyoid. The space created from resec­
tion of the subplastymal fat pad is obliterated by plica­
tion of the bellies of the anterior digastric muscles. The
muscles are plicated with inverted 3-0 nylon sutures. If
the digastric muscles are bulky or the hyoid bone is low,
we perform a tangential excision of the superficial fibers
of the digastric bellies.
Dissection under the platysma then proceeds from
medial to lateral. The lateral aspect of the dissection
extends beyond the submandibular salivary glands. It is
important to free the platysma from the capsule of the
submandibular salivary gland. Failure to do so will result
in pseudoherniation of the submandibular gland when
the platysma is advanced medially. With the subplatys­
mal plane complete, the medial borders of the platysma
muscles are approximated in the midline. Redundant
muscle is trimmed from the medial borders, which are
plicated with inverted 3-0 nylon sutures.
The next step is to place a 3- to 4-cm backcut in the
platysma muscle below the level of the thyroid cartilage.
The lateral jugular vein should be preserved. If further
definition of the neck is required, a suture suspension
with a double-armed 3-0 Gore-Tex (W.L. Gore, Flag­
staff, AZ, USA) suture is performed. The suture suspen­
sion starts with the placement of bilateral 1-cm incisions
in the occipital scalp, approximately 2 cm posterior to
the mastoid process. The incisions are carried down to
the level of the mastoid fascia. The Gore-Tex suture is
placed beneath the medial edge of the platysma muscle
at the level of the hyoid bone. The suture is directed
superficially 1.5 cm from the medial edge and is directed
toward the occipital incision using an endoscopic needle
holder. After being retrieved, the suture is placed through
the deep mastoid fascia-periosteum and delivered back
through the occipital incision. Again, the suture is brought
over the surface of the platysma muscle back toward
We prefer to obtain our fat grafts from the anterior
abdomen, through a small infraumbilical incision. If the
abdomen has a paucity of fat, grafts should be harvested
from alternative locations. Alternative locations for graft
harvest include the hips, medial thighs, and posterome­
dial knee region.
The donor site is infiltrated with 0.5% lidocaine with
a 1 : 200,000 epinephrine solution. We prefer to infiltrate
an equivalent amount of anesthetic solution to match the
expected fat graft aspirate. All harvesting and graft place­
ment is performed with blunt-tipped cannulas developed
specifically for structural fat grafting (Tulip Medical, San
Diego, CA, USA). The use of blunt-tipped cannulas for
the delivery of the graft material cannot be overstressed.
The authors believe that fat embolization is more likely
with sharp-tipped needle delivery of the graft material.
Inadvertent fat embolization of the middle cerebral artery
[24] and right cavernous sinus [25] has been documented
following aesthetic fat grafting. The fat grafts are placed
in a subcutaneous plane around the face and below the
lip vermilion and white roll for lip augmentation. Admin­
istered in this fashion, fat grafts can be safely placed in
patients undergoing concomitant subperiosteal rhytidec­
tomy. We find this approach advantageous toward the
final aesthetic outcome.
ADDRESSING THE PERIPHERAL HEMICIRCLE
OF THE FACE
Whereas the endoscopic forehead and midface procedures
form the foundation of our comprehensive approach to
facial rejuvenation, cervicoplasty techniques form the
keystone of success in the peripheral hemicircle of the
face. In fact, the most dramatic improvements provided
by facial rejuvenation can often be seen in the cervicofa­
cial region. We offer three techniques to achieve success
when treating the peripheral hemicircle of the face: the
anterior approach cervicoplasty, the excisional cervicofa­
cial lift, and the mandibular matrix system.
Cervicoplasty Versus Cervicofacial Rhytidectomy
The nonexcisional anterior approach cervicoplasty
provides a means of lower face rejuvenation through
minimal access incisions. Considerable aesthetic improve­
ment can be achieved with the technique. However, not
all patients are appropriate candidates for this approach.
Several points need to be addressed. First, the anterior
approach cervicoplasty should be considered an opera­
tion designed to postpone a traditional cervicofacial lift.
Second, definition around the jawline can be achieved
with the nonexcisional cervicoplasty but it is less than
that which can be achieved with an excisional approach.
Patients desiring a tight, defined jawline should be
offered a traditional cervicofacial procedure. Third,
results with the anterior approach cervicoplasty are typi­
cally better in female patients. Finally, addition of struc­
tural support to the jawline or chin can enhance the
final results of a nonexcisional cervicoplasty [26]. The
nonexcisional anterior approach cervicoplasty is effec­
tive in those with young, elastic skin. Patients with poor
skin quality or excessive skin on the neck and jawline

20  Tridimensional Endoscopic Facelift
263
sizes: small, medium, and large. These sizes correspond
to 3, 5, and 7 mm of anterior projection, respectively.
Each implant is composed of right and left sides that are
joined in the center by an alignment tab. The alignment
tab is designed to allow stabilization of the two halves of
the implant. Use of the alignment tab becomes optional
when proper alignment of the implant along the inferior
mandibular border is jeopardized.
Mandibular Angle Implant
These implants are designed to wrap around the inferior
and posterior borders of the mandibular or gonial angle.
The implants are specifically manufactured in right and
left sides and are available in small, medium, and large
sizes. These sizes correspond to 3, 7, and 11 mm of
lateral projection, respectively. The greatest projection of
the implant is at the level of the new gonial angle.
Prejowl Implant
The prejowl implant is designed for patients who dem­
onstrate a significant geniomandibular groove but do not
require chin augmentation. The implant is supplied in
two parts, divided medially. The implant has a 4.0-mm
maximal projection that corresponds with the level of the
prejowl depression.
Button Chin Implant
The button chin implant is a small tridimensional implant
designed for patients who require improved anterior pro­
jection of the chin but do not require lateral augmentation
along the mandible. The implant is available in 3.0-mm
thickness. The implant is designed to comfortably wrap
around the symphysis of the mandible. The wraparound
feature provides stability to the implant, making rotation
or migration of the implant virtually impossible.
Implant Placement
The surgical technique employed with the insertion of the
mandibular matrix system has been refined since the early
description in 2000. General anesthesia is recommended
for all cases. When combined with adjunctive aesthetic
procedures, the matrix system should be placed as early as
possible. Access incisions should be closed immediately, in
order to prevent possible contamination. Retromolar and
lower buccal sulcus incisions can be used for the inser­
tion of the mandibular angle implants and extended chin
implants, respectively. The authors, however, now place
both the mandibular angle and extended chin implants
through a 3-cm submental incision and the assistance
of the 4-mm endoscope, whenever possible. The man­
dibular angle implants are secured with a 2-0 PDS suture
and the extended chin implants are secured with small
titanium self-drilling or self-taping screws, in bicortical
fashion.
Careful planning is necessary for the placement of the
submental incision. Augmentation of the bony symphysis
will advance the soft tissue envelope. This tends to rotate
the submental incision anteriorly. Therefore we typically
place the incision 1 cm posterior to the submental crease.
By doing this, the incision remains hidden in the submen­
tal area.
the midline. As the midline is approached, the suture is
driven through the platysma 1.5 cm from the midline
and is directed to the medial border of the platysma. The
suture is placed in a parallel fashion approximately 1 cm
superior to the first course of the suture. The same steps
are then performed on the contralateral side. The two free
ends of the suture are then tied together under moderate
tension. Appropriate tension can be gauged by the ability
to place a finger beneath the sutures. Where ptosis of
the submandibular glands exists, we weave the sutures
on the superficial fascia overlying the gland similar to
that described by Feldman [27]. If further definition is
required, Z-platysmaplasty or a limited corset platysma­
plasty can be performed.
Mandibular Matrix System
The size and shape of the mandible affects the harmo­
nious relationship of the skeletal support and the soft
tissue envelope that defines a beautiful face. The man­
dible is the framework of the lower face. Deficiencies in
mandibular volume and shape can negatively affect the
aesthetics of the mouth, chin, and neck. The mandibular
matrix system was developed to address the absence of an
inadequate mandibular contour. The mandibular matrix
system allows a method of skeletal support restoration
that can be applied to the entire mandible. The system
provides an excellent construct to redefine the jawline,
especially when combined with standard cervicoplasty
procedures.
The system is composed of a series of implants made
from porous polyethylene. The excellent biocompatibil­
ity characteristics make porous polyethylene the authors’
choice for alloplastic augmentation of the mandibular
framework. The implants allow for rapid vascularization
and tissue ingrowth. The rapid integration of the implant
material makes porous polyethylene the ideal alloplast
for a mobile and dynamic structure such as the man­
dible. The mandibular matrix system can be fashioned to
mimic the normal contour of the jawline. The multiple
components of the implant system allow augmentation
of the entire mandible or individual segments that may
be deficient.
The implants have been designed to provide tridimen­
sional restoration of the mandible. The implants wrap
around the inferior border of the mandible. Owing to
this shape, the implants are self-stabilizing and require
minimal or no screw fixation. This is a significant advan­
tage as compared with two-dimensional onlay implants.
In addition, the component system allows the restora­
tion of the entire mandibular contour through minimal
access incisions. The system is composed of a two-piece
extended wraparound chin implant and gonial angle
implants specifically designed for the right and left man­
dibular angles, respectively. A prejowl implant can be
included in this system when necessary.
The Implant System
Extended Wrap-Around Chin Implant
These implants are available as square or round implants,
as viewed anteriorly. The implants are available in three

264
MASTER TECHNIQUES IN FACIAL REJUVENATION
With the dissection complete, the cavity is irrigated
with antibiotic solution followed by packing with neuro­
surgical pledgets soaked in diluted Betadine and epineph­
rine solution (1 : 30,000). The pledgets are left for several
minutes to provide hemostasis and improve endoscopic
visualization during implant placement.
As stated previously, oral incisions can be used for the
placement of the implant system. However, the authors
feel that this approach may increase the incidence of
bacterial seeding of the implant and development of early
postoperative infection.
Comfort with the endoscopic approach and access to
the appropriate instrumentation should act as a guide to
the method of implant introduction.
The extended chin and mandibular angle implants
have been developed with corresponding Silastic sizers.
Each sizer has a similar projection, length, and depth at
the groove of the implant. The mandibular implant sizers
are introduced followed by the extended chin implant
sizers. The endoscope is then introduced to assess the fit
of the sizers and the adequacy of the soft tissue dissec­
tion. The external contour of the jawline is then assessed.
The appropriate size implants are chosen based upon
fit and desired aesthetic contour. Calipers are then used
to measure the distance of the mental nerves from the
midline and the lower border of the mandible. These
measurements are recorded and transferred to the chosen
extended chin implant. Grooves in the extended chin
implant can then be carved with the use of a No. 10
scalpel and a cutting board. Adequate space (2–3 mm)
around the mental nerve foramina should be created.
Further carving of the extended chin and mandibular
angle implants can be performed with a scalpel or a
high-speed burr. All carving should be done on a back
table away from the patient. The prepared implants are
then washed of debris and soaked in antibiotic solution.
The sizers are removed and the endoscope is inserted
to assure that hemostasis has been achieved. A smooth,
sterile plastic sleeve is then rolled into a conical shape
and inserted into the incision. This sleeve isolates the
implant from the skin surface and creates a smooth,
protected surface for the rough porous polyethylene to
slide against. Without the sleeve, insertion of the implant
can be a humbling experience. The mandibular implants
are then directed to the proper anatomic location under
endoscopic guidance or with a small fiberoptic lighted
retractor. The implants can be manipulated with the assis­
tance of two periosteal elevators.
The mandibular angle implant is then fixed into posi­
tion with either a small titanium screw or a 2-0 PDS
suture passed through a predrilled bicortical hole through
the body of the mandible. The wraparound design of
the mandibular angle implant prevents rocking of the
implant when properly placed and allows fixation of
the implant along its anterior border. If screw fixation
is chosen, trajectory of the infra-alveolar (mental) nerve
must be noted prior to drilling.
With the angle implants secured, the extended chin
implants are inserted in a similar fashion. Use of the
smooth plastic sleeve during implant insertion cannot be
overstressed. Smooth insertion with minimal retraction
The dissection is carried down through the subcutane­
ous adipose tissue to the level of the platysma. A thick
subcutaneous dissection is then performed 2 cm anterior
and 2 cm posterior to the incision. The platysma, mentalis
muscle, and periosteum are then divided in the midline,
perpendicular to the direction of the submental skin inci­
sion. A subperiosteal dissection is then performed in an
anterior direction, to the level of the mentolabial fold.
This can be performed under direct visualization, with
the aid of a lighted Aufricht retractor. Care must be taken
to avoid perforation of the oral mucosa.
The dissection continues laterally to expose the entire
anterior and inferior surface of the mandible. This dissec­
tion is facilitated with the use of a No. 4 Ramirez eleva­
tor (Snowden-Pencer, Becton, Dickinson and Company,
Franklin Lakes, NJ USA). The mental nerves must be
identified and carefully dissected free from the surround­
ing structures. Nerve injury can be prevented by early
identification of the structures and avoidance of excessive
retraction. The lateral dissection proceeds to the level of
the anterior border of the masseter muscle. This can be
accomplished with the assistance of the 4-mm endoscope
or small fiberoptic lighted retractor. At this point, dissec­
tion is complete for the insertion of the extended chin
implant Silastic sizers.
Insertion of the mandibular angle implants requires
careful dissection of the pterygomasseteric sling. The
4-mm endoscope is inserted and a subperiosteal dissection
continues with an angle periosteal retractor (Snowden-
Pencer, Becton, Dickinson and Company, Franklin Lakes,
NJ USA). The pterygomaxillary sling is elevated in conti­
nuity (Fig. 20.25). Under direct visualization, the inferior
aspect of the mandibular angle is freed from the tendi­
nous and periosteal attachments. The posterior border of
the ascending ramus is cleared in a similar fashion. The
bony surface of the mandibular angle is then exposed suf­
ficiently in anterior, inferior, and posterior directions to
allow the insertion of Silastic mandibular angle implant
sizers.
Figure 20.25  The endoscopic dissection of the pterygomasseteric
sling. Note the pink area highlighted on the mandible. This represents
the area of subperiosteal dissection required for placement of the man­
dibular matrix system.

20  Tridimensional Endoscopic Facelift
265
interrupted sutures. A bio-occlusive dressing is applied
over the incision after closure. A tight facelift dressing is
applied at the end of all procedures to reduce swelling
and dead space fluid accumulation. Patient examples are
shown in Figs. 20.27 through 20.32.
POSTOPERATIVE CARE
After extensive facial procedures, patients are monitored
for 24 hours and discharged home under the care of a
well-informed relative or practical nurse. Butterfly drains
are attached to vacuum tubes and changed periodically
during the next 48 hours. We find that evacuation of this
fluid minimizes the amount of facial edema postopera­
tively. Drain output of 10 to 20 mL should be expected,
on average. Drain removal occurs typically on the second
postoperative day. Antibiotics, started prior to surgery,
are continued for 5 days, postoperatively. Steroids have
not provided reduced postoperative edema in our patients
and are not routinely given. Supportive taping of the
forehead and midface begins at the end of the operative
procedure and continues for approximately 7 to 10 days.
A snug-fitting cervical collar dressing is placed postopera­
tively for patients undergoing cervicofacial procedures.
This dressing is kept in place for 24 to 48 hours and
then is changed daily. Loose-fitting dressings and patient
noncompliance can lead to seroma formation in the cer­
vicofacial region. Fluid collections in this region should
be promptly evacuated to minimize postoperative scar­
ring. Sutures are removed by day 7, in most cases. The
titanium forehead posts are removed between days 10
and 14.
COMPLICATIONS
Complications related to the endoscopic subperiosteal
facelift procedures include nerve injury, hematoma,
infection, alopecia, and skin flap necrosis. Nerve injury,
perhaps the most devastating complication, is typically
seen with excessive traction during endoscopic manipula­
tion. In an effort to decrease traction-related nerve injury,
we prefer to use a 4-mm endoscope and a blunt cobra-tip
sleeve to elevate the tissues. Retraction is avoided where
possible and slender retractors are implemented when
retraction is necessary. Miniaturized instruments for dis­
section and manipulation have also been employed. With
implementation of these steps, neuropraxia of the frontal
branch of the facial nerve occurred in 0.4% of patients.
Neuropraxia of the zygomaticus branch of the facial
nerve and the infraorbital nerve occurred in 0.2% and
0.4% of patients, respectively [28]. No permanent injury
to motor nerves has been seen to date.
Hematoma and infection can be minimized with metic­
ulous operative technique and adequate irrigation of the
subperiosteal pockets with antibiotic solution prior to
closure. Subcutaneous hematoma under the cervicofacial
flaps has been seen in 1.2% of patients. These hemato­
mas have typically occurred secondary to acute hyper­
tensive episodes in the immediate postoperative period.
Immediate drainage of collections prevented any adverse
sequelae.
will reduce the incidence of injury to the mental nerves.
The extended chin implant is then positioned along the
inferior border of the mandible. The location of the mental
nerve is checked prior to screw fixation of the implant.
Each side of the chin implant is fixed with a single small
titanium screw in bicortical fashion, after predrilling. The
lateral aspect of the extended chin implant should overlap
the anterior border of the mandibular angle implant
when attempting to achieve a wide profile. The lateral
wings of the extended chin implant can be trimmed (no
overlap with the angle implant) to maintain a narrow
profile (Fig. 20.26).
Should the use of prejowl implants or a button chin
implant be indicated, the implants can be placed through
the same submental exposure. Fixation can be achieved
with small titanium screws in either a unicortical or
bicortical fashion. Aesthetic outcome will dictate the role
these alternative implants play.
Prior to closure, the surgical cavity is irrigated with
antibiotic solution. The platysma is sutured in the midline
with interrupted sutures. If other aesthetic procedures are
to be performed at the level of the neck, the skin inci­
sion is covered with a bio-occlusive dressing. This pre­
vents tissue desiccation prior to skin closure. Skin closure,
when appropriate, is performed with 5-0 or 6-0 Prolene
Figure 20.26  Final placement of the entire mandibular matrix system.
The gonial angle implants are positioned along the mandible beneath
the pterygomasseteric sling. Note that the implants are secured with
titanium screws. The authors secure the chin implants with titanium
screws as depicted. The lateral wings of the chin implant should overlap
the gonial angle implants. This maintains a smooth contour to the aug­
mented mandible. Though screw fixation of the gonial angle implants
can be used, the authors prefer to secure the angle implants with a single
2-0 PDS suture placed through a drill hole in the inferior portion of the
mandible. Significant support provided by the pterygomasseteric sling
makes suture fixation of the gonial implants possible.

266
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 20.27  Anteroposterior preoperative (left) and postoperative (right) views of a 20-year-old patient who underwent placement of the man­
dibular matrix system. The patient’s preoperative concerns centered on the relative mandibular asymmetry and the narrow, pointed chin. Improved
definition of the mandibular angles and balanced chin width are shown in the postoperative view.
Figure 20.28  Three-quarter views of the patient in Fig. 20.27. Preoperative (left) and postoperative (right) views are shown. The mandibular
matrix system improves the definition of the entire mandible. Aesthetic balance of the mandible is achieved postoperatively with greater definition
of the mandibular angle and chin width.

20  Tridimensional Endoscopic Facelift
267
Figure 20.29  Lateral views of the patient in Figs. 20.27 and 20.28, preoperative (left) and postoperative (right). Note the improvement of chin
projection and shape with the extended wraparound chin implant of the mandibular matrix system.
Figure 20.30  This 42-year-old patient demonstrates relative asymmetry of the upper and lower face. Preoperative anteroposterior view (left) shows
a sharp, pointed chin and poor projection of the mandibular angles. Postoperative anteroposterior view (right) after placement of the mandibular
matrix system. Note the improved balance of the upper and lower face. The wraparound chin implant improves lower facial shape and the increased
biangular distance provided by the gonial angle implants improves the overall mandibular width.

268
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 20.31  Three-quarter views of the patient in Fig. 20.30. The preoperative view (left) shows the asymmetry of the broad upper face and
narrow lower face. Postoperatively (right), improved definition of the mandibular angle and projection of the chin creates a more balanced aesthetic
result. Harmony between the upper and lower face has been achieved.
Figure 20.32  Lateral views of the patient in Figs. 20.30 and 20.31, preoperative (left) and postoperative (right). Note the improved projection of
the chin and definition of the mandibular angle.

20  Tridimensional Endoscopic Facelift
269
methods put forth in this chapter are associated with a
significant learning curve. Success with these techniques
requires sound knowledge of the anatomic principles,
surgical skill, and critical appraisal of the aesthetic out­
comes. With time, refinement of the skills required will
allow predictable and lasting results. Proper patient selec­
tion will further guarantee success with this approach.
Patient satisfaction has been tremendous among our
patient population.
We believe that the tridimensional endoscopic facelift
technique will undergo further refinement and benefit from
future technologic advances. However, this advancement
will only come from those who embrace the approach.
Innovation can only be delivered from experience.
References available online at expertconsult.com.
R E F E R E N C E S
1. Tessier P. Face lifting and frontal rhytidectomy. In: Ely JF, editor.
Transactions of the 7th International Congress on Plastic Recon­
structive Surgery, Rio de Janeiro, 1980. p. 393.
3. Psillakis JM, Rumley TO, Camargo A. Subperiosteal approach as
an improved concept for correction of the aging face. Plast Reconstr
Surg 1988;82:383–92.
5. Fuente del Campo A. Facelift without preauricular scars. Plast
Reconstr Surg 1993;92(4):642–53.
6. Ramirez OM, Maillard GF, Musolas A. The extended subperiosteal
facelift: a definitive soft tissue remodeling for facial rejuvenation.
Plast Reconstr Surg 1991;88:227–36.
7. Ramirez OM, Fuente del Campo A. Facial rejuvenation: subperi­
osteal brow and facelift. In: Rees RS, editor. Plastic surgery edu­
cational foundation: instructional courses, vol. 6. St. Louis: CV
Mosby; 1993.
14. Ramirez OM. The central oval of the face: tridimensional endo­
scopic rejuvenation. Facial Plast Surg 2000;16(3):283–98.
16. Ramirez OM. Three-dimensional endoscopic midface enhance­
ment: a personal quest for the ideal cheek rejuvenation. Plast
Reconstr Surg 2002;109(1):329–40.
21. Bartlett SP, Grossman R, Whitaker LA. Age-related changes in the
craniofacial skeleton: an anthropometric and histologic analysis.
Plast Reconstr Surg 1992;90(4):592–600.
22. Gonzales-Ulloa M. Ptosis of the chin: the witch’s chin. Plast Recon­
str Surg 1972;50:54–7.
23. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg
1997;24(2):347–67.
Late infection has been observed in one patient under­
going an endoscopic forehead lift and midface lift proce­
dure. The patient complained of severe pain in the right
cheek region 10 days after operation. Fluctuance and
tenderness of the cheek mound was noted. Incision and
drainage of the collection resulted in resolution of the
infection without further sequelae. Permanent alopecia
is rarely seen following the endoscopic facelift procedure.
Adequate infiltration of local anesthetic, preopera­
tively, and the judicious use of electrocautery can prevent
unnecessary permanent alopecia. With the current method
of forehead fixation, temporary alopecia is seen in 0.2%
of patients. Treatment with a 50 : 50 topical mixture of
0.1% tretinoin and 5% minoxidil, applied twice daily,
is prescribed. Necrosis of the retroauricular skin flaps
following cervicofacial rhytidectomy tends to occur
iatrogenically or associated with a history of smoking.
Treatment involves debridement and local wound care.
Readvancement of the flap may be necessary in severe
cases. Avoiding excessive tension of the cervicofacial flaps
provides a more prudent answer.
For smokers, we recommend a 12-week course of
Trental (Aventis Pharmaceuticals, Bridewater, NJ, USA)
and smoking cessation aided by a 10-week course of
Zyban (GlaxoSmithKline, Greenville, NC, USA) to
prevent skin flap necrosis.
FUTURE CONSIDERATIONS
Aesthetic surgery has benefited from great technologic
advances over the past two decades. Advances in endo­
scopic technology and instrumentation have allowed
pioneering surgical techniques to be developed. This is
especially true in the field of facial rejuvenation. The
tridimensional endoscopic facelift technique, born from
these technologic advances, provides a comprehensive
approach to treat facial aging.
As with any surgical innovation, camps are divided as
to the effectiveness of the endoscopic approach [29–32].
Both positive and negative reports should be evalu­
ated and interpreted with a critical eye. The endoscopic