Operative Technique in Plastic Surgery – Kevin C.Chung

TECH FIG 3 • A. In retrotragal incisions, the soft tissue
over the tragus is raised as a flap. B. The flap is then
reflected anteriorly and sutured to the preauricular
SMA. The skin that will overlie the tragus at closure is
thinned inferiorly where the incision pattern transitions
to parallel the lower ear and also along its superior
edge. C. The central portion is not thinned in order to
avoid vascular compromise. D. Final closure.
■ Curved Mayo or similar scissors with “tips down” are used to raise the skin
flap under direct vision with transillumination, except in the region of the
great auricular nerve where “tips up” aids in avoiding injury.
■ The proper plane of subcutaneous elevation is most readily identified in the
temporal area, which is then extended over the orbicularis oculi and the malar
eminence.
■ A cobblestone appearance of the subcutaneous flap fat over the lateral
zygoma verifies the correct plane.
■ Dissection of the neck in a subcutaneous plane is next performed.

■ The platysma should not be directly exposed until at least several
centimeters below the mandibular border. Observing this principle prevents
platysma denuded of fat from being repositioned above the mandibular
border when the SMAS is tightened.
■ The skin flap is dissected for a short distance above the mandibular border
in the jowl region, tapering closer to the mandible border as the mentum is
approached.
■ Release of the mandibular ligaments adjacent to the mentum is not critical
although some would disagree.
■ The extent of medial neck dissection is variable depending on conditions
and goals. It can be extended almost to the midline to anticipate dissection
of the anterior neck through a submental incision if that is planned later.
■ It is easiest to raise the skin flap from above to below as described and then
perform the midcheek skin elevation only to the extent necessary for
adequate SMAS exposure.
■ Undermining rarely proceeds within 2 cm of the nasolabial fold.
■ Excessive release of the skin flap is avoided in this area to allow maximum
skin movement with SMAS tightening.
■ SMAS Treatment Options
SMAS Flap
■ A line is drawn over the zygomatic arch to establish the superior border of
the SMAS flap.
■ The SMAS is incised with a no. 10 blade in the preauricular area. Sharp
elevation continues over the surface of the parotid gland and then switches to
scissors.
■ The SMAS is then bluntly dissected anterior to the gland with delicate
vertical spreading of the scissor tips to expose and release the masseteric-
cutaneous ligaments and then the zygomatic-cutaneous ligaments superiorly
(McGregor patch) (TECH FIG 4).
■ The latter usually includes cauterization of a small branch of the transverse
facial artery.
■ The medial extent of SMAS flap elevation can either cease once the border
of the zygomaticus major muscle is identified or can proceed beyond it and
over the zygomaticus minor muscle (extended SMAS dissection) to achieve

greater midface correction.
■ The lateral border of the platysma is then elevated over the tail of the
parotid gland with careful sharp and blunt dissection.
■ The muscle border is mobilized inferiorly for several centimeters with care
taken to identify and avoid both the great auricular nerve and external jugular
vein.
■ The SMAS is then elevated vertically and slightly posteriorly.
TECH FIG 4 • A SMAS flap is shown on the right side.
It is initially incised along the zygomatic arch, elevated
rapidly over the parotid gland, and then dissection
carefully extended medially to expose the
zygomaticus major and the masseteric-cutaneous
ligaments. Small vessels are usually encountered
anterior to the parotid gland (McGregor patch).
■ After initial fixation in the preauricular area with a 4-0 Mersilene suture,
the excess is either folded over superiorly to add volume or excised.
■ The flap is then sutured at the level of the zygomatic arch with interrupted
4-0 Mersilene sutures.
■ The immediate preauricular portion of the SMAS flap is incised inferiorly
while pulling on the cut end in a posterolateral direction in order to transpose
the split portion of the flap behind the ear.
■ It is sutured to the mastoid fascia with 2-0 Maxon (polyglyconate) sutures
chosen for their considerable strength, allowing maximum traction on the

platysma component to improve cervical contour.
■ The SMAS flap suture line is then oversewn with a running 4-0 PDS
(polydioxanone) suture along the zygomatic arch and preauricular area.
■ The suture line is made smooth and isolates the parotid gland from the
subcutaneous plane to help insure against fistula formation.
SMASectomy
■ A line is first drawn over the zygomatic arch to properly orient
SMASectomy design.
TECH FIG 5 • A SMASectomy excision is shown on
the right side. The relation of the excisional design
pattern to the zygomatic arch and angle of the
mandible is illustrated, as is the SMAS/platysma
transposition flap.
■ A second line is drawn between the malar eminence and just above the angle
of the mandible where the preparotid SMAS is still fixed to the gland.
■ The SMAS is placed on traction below this line with Cushing forceps to
assess the degree of soft tissue laxity and the amount of SMAS movement
possible.
■ This is typically 1.5 to 2 cm at the angle of the mandible (less in secondary
or tertiary face-lifts) with somewhat less as the malar area is approached.
■ A second parallel line is then drawn based on this maneuver to indicate the
inferior border of the excision design.
■ The area of SMAS between the two lines is then excised in portions,
carefully observing the depth of the excision as this is done (TECH FIG 5).

■ Medially, where distal facial nerve branches become more superficial, the
excision depth is more conservative.
■ The lateral platysma is then mobilized as described for the SMAS flap and
sutured in the mastoid area with 2-0 Maxon sutures.
■ The cut edges of the SMAS are sutured with 4-0 Mersilene in interrupted
fashion.
■ A 4-0 PDS continuous suture is then placed to smooth contour over the
suture line.
SMAS Plication
■ The SMAS is marked identical to a SMASectomy design.
■ The SMAS within the marked pattern is plicated with interrupted 4-0
Mersilene sutures.
■ The lateral platysma is treated in the same fashion as described with
SMASectomy.
■ A 4-0 PDS continuous suture is then placed to contour smoothly over the
suture line.
■ After all SMAS techniques, the skin is examined to identify dimpling due to
SMAS traction effects, with additional skin release performed as indicated.
This is typically necessary in the midcheek but also commonly over the
orbicularis oculi muscle above and in the neck below.
■ The midcheek release is done very conservatively to minimize the loss of
beneficial skin movement resulting from SMAS tightening.
■ Anterior Neck Treatment
■ The anterior neck dissection can be done either at the beginning of the
procedure or after skin flap elevation and SMAS fixation. Expert opinion is
mixed on this matter, although opening the anterior neck later seems to be
more popular.
■ The theoretical concern in the debate is that tightening the SMAS first will
restrict medial mobilization of the platysma for plication, whereas
approximating the platysmal bands first will limit the degree of SMAS
tightening possible.
■ Platysma bands less than 2.5 cm apart can usually be approximated in the
midline whether or not this is done initially or after SMAS tightening.

■ Platysmal plication becomes more challenging as the gap between the
muscle edges increases. It should probably be deferred when bands are 3
cm apart or more, although dividing the muscle inferiorly improves medial
mobilization considerably.
TECH FIG 6 • A. Example of full-length platysma
bands. B,C. Repair includes approximating the free
edges and dividing the muscle transversely. The
muscle transection is performed low, where the
muscle is thin and extends as far as 4 cm laterally. D.
Result.
■ The access incision for anterior neck dissection is placed in the submental
crease although just posterior to this landmark is common practice.
■ Liposuction is generally avoided although when done briefly with a small
cannula can facilitate dissection.
■ Subcutaneous skin elevation proceeds inferior to the cervicomental angle to
the limits of visibility.
■ Subcutaneous fat is conservatively removed by direct excision with care
taken to leave adequate thickness and a smooth internal flap contour.
■ Subplatysmal fat excision is performed following mobilization of the
platysma edges in patients exhibiting an obtuse cervicomental angle.
■ Submandibular gland resection and shave excision of the digastric muscles
are considered only for extreme cases. The former requires considerable
experience.
■ The medial borders of the platysma are sutured together with interrupted 4-0
Mersilene sutures and can be reinforced with a second running layer of 4-0

Mersilene if desired (TECH FIG 6).
■ A low transverse platysmal transection is performed bilaterally up to 4 cm,
leaving at least a 2-cm lateral band of muscle intact over the sternomastoid
muscle and external jugular vein.
■ Correction of a “witch’s chin” deformity can be performed by defatting the
ptotic chin pad.
■ De-epithelializing an ellipse of skin at the submental incision and burying
it can also help smooth out chin-neck junction depressions.
■ Occasionally, a conservative elliptical skin excision can aid reduction of
submental skin redundancy.
Skin Redraping and Closure
■ Both sides are closed at the end of the procedure, which is preferred to
sequentially closing during the procedure. This allows hemostasis to be
performed once after the SMAS treatment and for the second time just prior
to final closure to provide two opportunities to confirm hemostasis.
■ Additionally, venous oozing on the flap undersurface will become more
apparent later as the epinephrine wears off and also because each side has
been dependent while the other side is dissected. This helps prevent the
development of small collections of venous blood under the flap
postoperatively.
■ Small-diameter closed suction drains are placed on each side if the anterior
neck has not been opened. A single drain is passed all the way from one side
to the opposite if the anterior neck has been opened.
■ The skin is redraped in a superoposterior direction and anchored at the root
of the helix with a 4-0 Vicryl suture.
■ Tension should not be excessive. Blanching of the skin flap and the
appearance of traction lines should both be avoided.
■ The skin is then placed on traction posteriorly and anchored with a 4-0
Vicryl suture at the highest point of the postauricular sulcus incision.
■ Excess occipital area skin is excised while maintaining the skin on tension
with a hook.
■ That portion of the incision is closed with staples.
■ The remaining excess skin in the mastoid area is then conservatively
trimmed so the edges appose with no gap.
■ Patients with short-scar postauricular incision design do not require any of
these steps but simply a minimal trim of excess skin near the lobule (TECH

FIG 7).
■ The temporal incision is closed with clips with care taken not to raise the
sideburn level. Little skin trimming is typically necessary because pre-
excision has already been performed in this area.
TECH FIG 7 • Closure of a short-scar postauricular
incision on the right side is shown. Using the full
length of the sulcus avoids creating pleats with a
shorter incision.
TECH FIG 8 • A,B. Examples of well-healed
preauricular incisions that were properly designed and
closed.
■ This is the time when the need for a subsideburn incision is considered.
This option prevents hairline elevation by excising a small wedge of skin.

These incisions are typically short and heal inconspicuously. They are more
commonly used in secondary or tertiary cases.
■ Excess skin is trimmed in the preauricular area such that the edges are
closely apposed with no tension required for the final closure.
■ Tragal skin defatting for retrotragal incision closure must be done
conservatively and primarily at the edges in order to avoid vascular
compromise of the skin.
■ A 4-0 double-armed Monderm (glycolide and e-caprolactone) barbed suture
is used for intracuticular closure of the preauricular and postauricular
incisions.
■ The suture starts at the lobule attachment point and runs anteriorly and
posteriorly cephalad to complete closure.
■ These incisions heal extremely well if properly designed and closed
(TECH FIG 8).
■ If indicated, a subperiosteal pocket is created over the mentum and a chin
implant placed.
■ It is aligned with a midline skin marking made prior to surgery with the
patient in a sitting position.
■ Curvilinear implants in small and extra small sizes are suitable for most
female patients.
■ The implant is secured with several 4-0 Vicryl sutures. A running 5-0 nylon
is used to close the submental incision after placement of a single 4-0
Vicryl dermal suture in the middle.
Ancillary Procedures
■ Ancillary procedures such as perioral dermabrasion, periorbital (TECH FIG
9A,B).
■ Facial fat grafting is usually done early in the procedure, soon after fat
preparation is complete.
■ At the conclusion of the procedure, the skin flap color is assessed. If the skin
is dusky in the preauricular or postauricular area or both, nitropaste is applied
prior to placement of the dressing as a one-time treatment to reduce vascular
congestion (TECH FIG 9C,D).
■ A light head dressing is placed.

TECH FIG 9 • A,B. Resurfacing of the perioral area
with dermabrasion or other modalities is commonly
indicated. Care must be taken regarding depth of
treatment in order to avoid causing hypopigmentation.
C,D. Nitropaste is routinely placed on the cheeks and
postauricular area to speed resolution of flap
congestion.
PEARLS AND PITFALLS
Patient
factors
■ Patients with BMI greater than 30, sleep apnea, or severe diabetes
should have surgery in a hospital setting.
■ Meticulous perioperative blood pressure control reduces
hematoma rate.7
■ Avoid operating on active smokers.
Incisions
■ Avoid pretrichial incisions and deep temporal dissection.
■ Avoid tragal blunting with meticulous insetting technique.

■ Use pretragal incisions for most men.
■ Consider short-scar technique for young patients.
■ Use subsideburn incisions to prevent hairline elevation.
Skin flap
elevation
■ Avoid excessive medial cheek elevation.
■ Perform more limited flap elevation in smokers.
SMAS
technique
■ Use a SMAS flap for patients needing more midface correction.
■ Use a SMASectomy in patients with prominent skeletal
framework and lighter soft tissues.
■ Use SMAS plication for patients with thin tissues and secondary
or tertiary cases.
Neck
treatment
■ Avoid opening the anterior neck when the medial platysmal
borders are very widely separated and in smokers.
■ Performing a low platysmal transection will allow the medial
borders of the muscle to come together more easily.
■ Avoid excessive subplatysmal tissue resection.
■ Patients with severe cervical skin laxity should be advised
initially that a secondary procedure may be necessary to achieve
an optimal outcome.
Complications
■ Hematomas can be avoided with meticulous hemostasis and
normotensive intraoperative blood pressure maintenance.
■ Patients at high risk for MRSA infection should be cultured by
nasal swab preoperatively and treated prior to surgery if positive.
POSTOPERATIVE CARE
■ Ambulation is encouraged, beginning on the day of surgery.
■ Cool compresses are useful for the first 24 hours.
■ The head dressing is removed on the 1st postoperative day. Drains are
removed on the 1st postoperative day if the anterior neck was not opened and
on the 2nd day if it was.
■ Aquaphor is placed on resurfaced areas until re-epithelialization has occurred,
usually by 1 week.
■ Oral antibiotics can be given for up to 1 week postoperatively although proof
of benefit has not been established.
■ Detailed written instructions are given regarding early postoperative conduct
such as talking, positioning (awake and sleeping), hygiene, and activity
restrictions.
■ Alcohol and excessive salt intake is discouraged for 2 weeks and smoking for

6 weeks following surgery.
■ Patients are seen within 48 hours, at 6 days for suture removal, and typically at
6 weeks for further follow-up.
OUTCOMES
■ Patients undergoing face-lifting and neck lifting can achieve very satisfying
results when the most appropriate techniques are selected and expertly
performed.
■ Results in the cheek generally endure for about 10 years while ongoing aging
changes in the neck become evident sooner.
COMPLICATIONS
■ Massive hematomas of sudden onset require emergent evacuation.
■ Smaller or slow developing hematomas can often be managed by beside
treatment with sterile catheter aspiration and irrigation with an epinephrine-
containing solution.8
■ Nerve injury
■ Great auricular nerve injuries should be immediately repaired with fine nylon
sutures and the repair buried below the platysma muscle if possible.
■ Cervical branch paresis resulting from cautery or traction injury typically
resolves by 6 weeks. If afflicted patients are able to purse their lips, this
confirms that the mandibular branch is intact and spontaneous resolution can
be expected. Neuromodulators can be helpful to disguise the injury, but their
duration of effect is typically longer than the nerve recovery period.
■ Frontal branch injury is of greater concern because overlapping innervation
is not typical in this area. Neuromodulator use is more applicable in this
situation. Failure of the injury to resolve may be an indication for a brow lift.
■ Infection
■ Patients should be routinely seen within 24 hours after surgery and by 48
hours at the latest. Significant postoperative infections become apparent early
on and require aggressive treatment.
■ Early infection is typically bilateral and presents with dusky flaps and
multiple small pustules in the preauricular and postauricular areas (FIG 1).
Intravenous antibiotics should be instituted immediately. Vancomycin is the
drug of choice to cover the possibility of MRSA infection. Patients can be
managed with outpatient intravenous antibiotics but must be seen daily until
resolution appears certain.

■ Delayed infection with Mycobacterium fortuitum is rare and insidious. It
presents with numerous small erythematous nodules. Multiple debridements
and prolonged antimicrobial therapy are typically required. Long-term
outcome is generally excellent with little residual scarring evident.
FIG 1 • A. Early appearance of infection, which is
usually bilateral. B. Skin slough should not be debrided
until sharp demarcation is evident. Ultimately, these
problems usually heal well. C. Parotid fistulas are
heralded by cheek erythema and high output of clear
drainage.
■ Evolving skin slough requires frequent monitoring and treatment with topical
and oral antibiotics (FIG 1B).
■ Debridement, if necessary, is delayed until sharp demarcation is evident. Scar
revision may be necessary at the appropriate time interval.
■ Localized fluid masses in the cheek are usually venous collections that often
not responsive to aspiration.
■ Evacuation of subcutaneous fluid collection through the preauricular incision,
though seemingly an aggressive approach, offers a rapid and definitive end to
the problem.
■ Parotid fistula is a rare complication and is heralded by persistent high
drainage output, predominantly clear, and cheek erythema (FIG 1C). A high
amylase level in the fluid confirms the diagnosis.
■ A short trial of serial aspiration can be undertaken, but lack of response
requires placement of a drain.

■ Injecting the gland with botulinum toxin is a helpful adjunct although this
can result in visible gland atrophy, presumably short term.
■ Excessive scarring results from either skin loss or excessive closure tension.
Both are amenable to revision provided sufficient skin laxity is present.
■ Hypertrophic healing tendency is a more common problem and can usually
be successfully managed with serial steroid injections.
REFERENCES
1. Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS dissection as
an approach to midface rejuvenation. Clin Plast Surg. 1995;22(2):295-311.
2. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100(2):509-513.
3. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS plication for the
treatment of prominent nasomandibular folds and restoration of normal cheek
contour. Plast Reconstr Surg. 1995;96(6):1279-1287.
4. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep
facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg.
1992;89(3):441-449.
5. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in
the parotid and cheek area. Plast Reconstr Surg. 1976;58(1):80-88.
6. Baker DC. Minimal incision rhytidectomy (short scar facelift) with lateral
SMASectomy: evolution and application. Aesthet Surg J. 2001;21(1):14-26.
7. Trussler AP, Hatef DA, Rohrich RJ. Management of hypertension in the
facelift patient: results of a national consensus survey. Aesthet Surg J.
2011;31(5):493-500.
8. Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy
hematoma. Plast Reconstr Surg. 2005;115(7):2119-2122.

43
CHAPTER
Indications and Technique
for Extended SMAS Facelift
and Necklift
James M. Stuzin and Sammy Sinno
DEFINITION
■ Facial aging is the result of many changes that occur in the skin, soft tissues,
fat, and facial skeleton.
■ Early attempts at surgical facial rejuvenation were skin tightening procedures.
■ The works of Skoog, Mitz, and Peyronie demonstrated that soft tissue
repositioning of facial fat can restore a more youthful facial contour.1
■ The primary advantage of skin and superficial musculoaponeurotic system
(SMAS) flap elevation separately is greater aesthetic control in terms of
repositioning facial fat independent of skin flap redraping.
■ Another major advantage of an extended SMAS flap technique is the ability to
restore facial shape of youth by building volumetric highlights over the anterior
and lateral zygoma juxtaposed with submalar concavity.2
ANATOMY
■ The layers of the face are skin, subcutaneous fat, SMAS, the muscles of facial
expression, deep fascia or parotidomasseteric fascia, and the plane of the facial
nerve, parotid duct, and facial vessels.
■ The thickness of these layers, particularly the SMAS, varies region to region.
■ The muscles of the face are all innervated on their deep surface except for the
deepest muscles of facial expression, which are the mentalis, levator anguli
oris, and buccinators.
■ The parotidomasseteric fascia protects the facial nerve branches in the
preparotid area (FIG 1).

PATIENT HISTORY AND PHYSICAL FINDINGS
■ The patient presenting with facial and neck aging demonstrates volume decent,
deflation, and radial expansion of facial soft tissue from the center of the face
to the periphery.
■ The extended SMAS technique attempts to address these concerns by
repositioning and conforming the descended facial fat to more aesthetically
pleasing areas of the facial skeleton.
■ On physical examination, the skin quality, elasticity, amount and location of
subcutaneous fat, depth of the nasolabial fold, degree of jowling, deflation,
skeletal support, malar convexity, and submalar concavity are noted.
■ Platysma position and descent are similarly examined.
SURGICAL MANAGEMENT
Preoperative Planning
■ Patients are asked to bring pictures from their youth. Although patients cannot
be made to look exactly like they were when younger, a similar facial shape to
youth can be restored with this technique in many patients.
■ Antibiotics are started 1 day before surgery and continue for 5 days afterward.
■ An intertragal incision is marked along with a temporal incision and partial
hairline retroauricular incision.
Positioning
■ The patient is in a supine position for this procedure.
■ Induction of anesthesia is achieved with midazolam and fentanyl.
■ Ketamine is given for local injection, which is a mixture of lidocaine and
bupivacaine.
■ Propofol and valium drips are used on an as-needed basis at the discretion of
the anesthesiologist.
Approach
■ A submental incision just caudal to the submental crease is used for neck
contouring.

FIG 1 • A. Cadaver dissection in the parotid area
showing the parotidomasseteric (or deep facial) fascia.
B. When the parotidomasseteric fascia is reflected, the
branches of the facial nerve are visualized.
T E C H N I Q U E S
■ Extended SMAS Face and Neck Lift
Incisions and Dissection
■ The partial hairline retroauricular incision is made with a no. 15 blade.
■ A no. 10 blade is used in the postauricular region for the adherent fascial
dissection over the adherent cervical skin ligaments overlying the
sternocleidomastoid (SCM).
■ The other incisions are dissected with a no. 15 blade. In the temporal area,
dissection is carried deep to the temporoparietal fascia. Deep dissection here
protects the hair follicles and tends to be avascular. However, the superficial
temporal artery must be ligated.
■ The beginning of the subcutaneous dissection over the lateral fat
compartment is fascial. Using facelift scissors, the interface between the
SMAS and the fat can be precisely raised with transillumination.

■ When extending the subcutaneous dissection inferiorly, take care to stay
superficial above the cervical fascia overlying the SCM to avoid injury to the
great auricular nerve.
■ As the anterior subcutaneous dissection proceeds from the lateral to middle
superficial fat compartment, the dissection becomes easier as proceeding
distal to the ligaments overlying the parotid.
■ Skin flaps should be dissected thinner in the region overlying where the
SMAS is to be dissected to leave more fat on the SMAS for subsequent
SMAS flap elevation (and avoidance of tearing).
■ In the neck, the dissection is carried in the interface between the preplatysma
fat and the platysma. In other words, the fat is left intact on the skin flap,
whereas the platysma muscle is kept down.
■ Once over the zygoma, specifically where the arch and body meet,
zygomatic ligaments are encountered, and it is easy to carry dissection deep
to the SMAS.
■ Along the inferior lateral border of the zygomatic eminence, the zygomatic
cutaneous and upper masseteric ligaments emerge, as well as perforators
from the transverse facial artery.
■ The zygomatic branches of the facial nerve also are superficial in this region,
and inadvertent dissection deep to the SMAS in this region may produce a
motor branch injury.
■ Avoid dissecting thick skin flaps in this region; it may be easier to work
from above and below and connect in the middle in terms of defining the
proper plane of dissection when working in this region of high ligamentous
density within the midcheek. This region represents the transition between
the middle and malar fat compartments.
■ Avoid unnecessary dissection in the area of malar bags to avoid malar
edema.
■ After completing the subcutaneous dissection, the SMAS is injected with
local anesthetic just prior to elevation.
■ The incision begins along the zygomatic arch and then extends superiorly
toward the lateral malar eminence at the junction where the arch and body of
the zygoma intersect (TECH FIG 1A).
■ It then angles up toward the lateral canthus along the lateral orbital rim,
then heads inferiorly toward the anterior extent of skin undermining.
■ The lateral incision follows the lateral border of the platysma inferiorly.

■ SMAS elevation begins along the lateral border of the platysma using needle
tip electrocautery.
TECH FIG 1 • A. Blue dashed line shows extended
SMAS flap incisions. Pink indicates the area of
subcutaneous undermining. Green shows the
superficial malar fat pad. B. The dissection is carried
out past the tail of the parotid to ensure all of the
retaining ligaments are released, which allows
adequate SMAS mobility.
■ Once sub-SMAS fat is encountered beyond the tail of the parotid, dissection
can be performed bluntly, which will avoid injury to the marginal mandibular
branch of the facial nerve (TECH FIG 1B).
■ The SMAS tends to thin over the accessory lobe of the parotid, lateral to
the zygoma, and in the region of the transverse facial artery perforator; care
should be taken not to tear the SMAS here.

■ Once the dissection has passed the retaining ligaments,3 dissection can stop,
as further dissection will not provide additional benefit and can only serve to
increase morbidity.
Redraping and Fixation
■ A 3-0 Mersilene suture is placed vertically in the SMAS from the lateral
incision along the zygomatic arch in front of the tragus to 5 to 6 cm below the
earlobe. The exact vector of SMAS fixation will vary from patient to patient,
but in most patients, a very vertical SMAS vector is utilized.
■ Before definitive SMAS fixation, the skin is undermined a bit more
anteriorly as necessary to avoid traction dimpling before the SMAS is
fixated.
■ The cephalic portion of the SMAS flap is rolled prior to fixation (TECH
FIG 2A).
■ 3-0 Mersilene is used for fixation in an interrupted fashion. Several sutures
are placed. The endpoint is when malar convexity and submalar convexity is
achieved.
■ The lateral border of the platysma is fixated posteriorly to the mastoid fascia.
■ Any fat irregularities on the SMAS are trimmed, particularly superiorly to
avoid unsightly bulges.
■ The submental incision is made 5 mm caudal to the submental crease.
■ The crease is undermined, releasing the mandibular ligaments to obliterate
the crease and optimize visualization.
■ Subcutaneous undermining is performed.
■ Preplatysmal fat is directly defatted. Subplatysmal fat in the midline is
defatted on an as needed basis.
■ The medial borders of the platysmal muscle are sutured with a 3-0 Mersilene
suture in interrupted fashion. One or two sutures are placed caudal to the
cervicomental angle and hyoid.
■ The platysma is then divided inferiorly and laterally for approximately 5 cm
(TECH FIG 2B). Care must be taken to avoid injuring the anterior jugular
vein.
■ After release of the platysma, additional Mersilene sutures are placed in the
platysma to restore tension after platysma release and allow the platysma to
conform to the floor of the mouth and thyroid cartilage.
■ Meticulous hemostasis is obtained.

■ Two drains are placed from the retroauricular incision extending to the base
of the neck.
■ The skin is carefully redraped and trimmed without any tension. The skin is
usually redraped with a posterior lateral vector as opposed to the vertical
vectoring of the SMAS flap.
■ Skin incisions are closed with 4-0, 5-0, and 6-0 nylon sutures.
■ Any fat injections are performed following the closure of the facial and
submental incisions.
■ A light head dressing is placed prior to arousal from anesthesia.
TECH FIG 2 • A. The SMAS flap is rolled then sutured
with several 3-0 Mersilene sutures. B. The platysma is
approximated from the mentum to the cricoid
cartilage, followed by a horizontal cut on each side,
which extends to the SCM.

PEARLS AND PITFALLS
Aesthetic
considerations
■ The major advantage of the extended SMAS flap is that it allows
a building of the volumetric highlights of the upper face over the
lateral zygoma, restoring the malar convexity of youth; raising
the skin and SMAS as separate flaps allows a greater degree of
aesthetic control in terms of vector redraping.
■ Contrasting malar convexity with submalar concavity is a
transition seen in youth and should be a goal in aesthetic
repositioning and conforming of facial soft tissues while
combating radial expansion.
■ Avoid cross-cheek depression (“joker lines”); if noted
intraoperatively, fat can be added to the submalar region to
ameliorate. In patients with tendency to cross-cheek depressions,
vertical vectors in skin flap redraping should be avoided.
Dissection
■ The subcutaneous dissection is the most challenging portion of
the procedure; use transillumination for precision.
■ By taking advantage of knowledge of the anatomy in the cheek,
one can appreciate the subcutaneous dissection as it transits from
lateral to medial to superficial malar cheek compartments.
■ Be careful when dissecting between the medial and malar cheek
compartments; there is retaining ligamentous density, perforators
from the transverse facial artery, and zygomatic facial nerve
branches important for smile symmetry transiting in this area.
■ If the skin flap is raised without precision, it is often impossible
to raise a substantial SMAS flap.
■ The SMAS flap must be raised beyond the accessory lobe of the
parotid to ensure all retaining ligaments have been released.
Sequence
■ Perform SMAS fixation first, followed by medial platysma
suturing, then platysma release and more platysma suturing as
needed
Neck
■ Opening the neck offers the greatest aesthetic control in
improving cervical contour.
Hematoma
■ If performing dissection deep in the temporal area and exposing
the superficial temporal artery, ligation is necessary to avoid
postoperative hematoma.
■ Always take time to ensure meticulous hemostasis.
■ Perioperative blood pressure control is critical to avoid a
postoperative hematoma.

Drains
■ Leaving drains in longer (3–4 d) allows removal of serum that
would otherwise build up and cause induration and/or bruising.
■ Place drains extending to the base of the neck.
POSTOPERATIVE CARE
■ The light dressing is removed in 24 hours.
■ The head remains elevated at all times, but neck flexion is not permitted.
■ The drains are removed at 4 days to remove as much serous fluid as possible;
this reduces induration and swelling.
■ Sutures in the preauricular area removed between 5 and 7 days, with
remaining sutures remove on postoperative day 10.
■ If patients develop induration (commonly over the platysma plication), dilute
Kenalog is injected.
■ Dilute Kenalog is also injected into any persistent drain sites.
OUTCOMES
■ With the extended SMAS technique, natural and hopefully long-lasting results
can be obtained that restore facial shaped of youth (FIG 2).
COMPLICATIONS
■ Hematoma (most common)
■ Nerve injury
■ Aggressive scarring
■ Edema/ecchymosis (temporary)
■ Seromas
■ Infection
■ Contour irregularity

FIG 2 • Preoperative and postoperative views of a
patient who underwent an extended SMAS facelift.
Notice restoration of facial shape with malar convexity,
submalar concavity, a cleaner jawline, and improvement
in the appearance of the neck.
REFERENCES
1. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in
the parotid and cheek area. Plast Reconstr Surg. 1976;58(1):80-88.
2. Stuzin JM. Restoring facial shape in face lifting: the role of skeletal support in
facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg.
2007;119(1):362-376.
3. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg.
1989;83(1):11-16.

44
CHAPTER
Lamellar High SMAS Face-
Lift
Dino Elyassnia and Timothy Marten
DEFINITION
■ As face-lift techniques have evolved, it has become clear that an attractive and
natural appearance is not possible without diverting tension away from the skin
to the superficial musculoaponeurotic system (SMAS) and platysma.
■ Using the skin as the vehicle to support sagging tissue will always result in
poor scars, tragal retraction, earlobe malposition, and a tight unnatural look.
■ The SMAS, however, is capable of providing sustained support to facial
tissues while allowing only redundant skin to be excised and wound closure
under no tension. This averts a tight, “pulled” appearance and produces high-
quality scars.
■ A SMAS flap is a reliable and time-tested method of treating the SMAS and
has been shown to provide excellent long-term outcomes. A flap is likely less
destructive to the SMAS compared to various plication techniques and can be
easily raised in secondary and tertiary procedures when carried out skillfully.
■ The conventional “low” cheek SMAS flap elevated below the zygomatic arch
suffers from the drawback that it cannot, by design, have an impact on tissues
of the midface and infraorbital region. Planning the flap “higher” along the
superior border of the zygomatic arch provides the biomechanical means by
which a combined and simultaneous lift of the midface, lower cheek, and jowl
can be obtained and avoids the need to perform a separate mid–face-lift (FIG
1).
ANATOMY
■ The great auricular nerve is a sensory nerve derived from the cervical plexus
and provides sensation to the earlobe and lateral cheek (FIG 2). It runs

obliquely from the posterior belly of the sternocleidomastoid muscle to the
earlobe. The classic external landmark to locate the nerve is at the midbelly of
the sternocleidomastoid muscle 6.5 cm inferior to bony external auditory
canal.1 The most common area of injury is where the nerve emerges from
around the posterior border of sternocleidomastoid muscle.
■ The facial nerve emerges through the stylomastoid foramen and is
immediately protected by the parotid gland. Within the parotid, it divides into
an upper and lower trunk and then into its five major branches: the frontal,
zygomatic, buccal, marginal mandibular, and cervical (FIG 3). The branches
leave the parotid gland lying on the surface of the masseter immediately deep
to the parotidomasseteric fascia. Medial to the masseter, the nerve branches lie
on the buccal fat pad and at the same depth as the parotid duct and facial
vessels. The nerve branches then proceed to innervate the mimetic muscles on
their deep surface (except for the deep layer of muscles, mentalis, levator
anguli oris, and buccinator).
■ The retaining ligaments of the face (FIG 4) are vertically oriented fibers that
penetrate the concentric horizontal layers of the face and function in a
supportive role.2,3 There seems to be two types of retaining ligaments:
■ The first type is true osteocutaneous ligaments that run from the periosteum
to the dermis and are made up of the zygomatic and mandibular ligaments.
■ The second type of retaining ligaments is formed by a coalescence of
superficial and deep facial fascia that form fibrous connections vertically
spanning from deep structures such as the parotid gland and masseter muscle
to the overlying dermis. Examples of these include parotid and masseteric
cutaneous ligaments.
■ The parotid cutaneous ligaments span over the entire surface of the parotid
gland.
■ The masseteric cutaneous ligaments are a series of fibrous bands that are found
along the entire anterior border of the masseter muscle starting in the malar
region down to the mandibular border.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A focused history should include all previous cosmetic surgery or treatments
including previous face-lifts, injectables, or laser treatments.
■ To determine the proper location for the temporal portion of the face-lift
incision, each patient’s cheek skin redundancy must be examined, and location
of temple and sideburn hair noted. Assessing cheek skin redundancy requires

pinching up redundant skin over the upper cheek and measuring it. Also, the
distance between the lateral orbit and anterior aspect of the temporal hairline
must be measured. In youthful individuals, the distance should measure no
more than 4 to 5 cm (FIG 5).
■ If cheek skin redundancy is small and ample temple and sideburn hair is
present, a temple incision can be placed within the temple scalp (FIG 6A).
■ When the temporal hairline is predicted to shift more than 5 cm away from the
lateral orbit or sideburn shifted above the junction of the ear with the scalp, a
temple hairline incision should be used (FIG 6B). Failure to follow this plan
can result in unnatural shifting or displacement of the temporal hair.

FIG 1 • “High” and “low” SMAS techniques compared.
A. Plan for low SMAS procedure. Note that upper
border of the flap lies below the zygomatic arch. B. Low
SMAS flap after dissection and suspension. Area of flap
effect (green solid circle) is limited to the lower cheek
and jowl, and no improvement is obtained in the

midface, infraorbital, or perioral regions (black dashed
circle). C. Plan for high SMAS procedure. Note that
upper border of the flap lies over the zygomatic arch. D.
High SMAS flap after dissection and suspension. Area
of flap effect (green solid circle) includes not only both
the cheek and jowl but the midface, infraorbital, and
perioral regions (black dashed circle) as well.
■ Like the temple, planning the appropriate location for the occipital incision
requires examining each patient’s neck skin redundancy. This is done like the
cheek and entails pinching up tissue over the upper lateral neck and measuring
it.
■ If 2 cm or less of excess neck skin is present, the incision can be placed
transversely, high on the occipital scalp into the hair.
■ If more than 2 cm of neck skin redundancy is present, the incision should be
placed along the occipital hairline but then turned into the scalp at the junction
of the thick and thin hair at the nape of the neck (FIG 7). Failure to follow this
plan can result in a visible notching of the occipital hairline.
IMAGING
■ Typically, radiographs are not necessary in facial rejuvenation surgery.
■ All patients should have standardized photographs taken preoperatively, and
any markings made preoperatively on patients should be photographed as well.
■ These photos should be used intraoperatively to help guide treatment.
SURGICAL MANAGEMENT
■ A lamellar dissection for a high SMAS face-lift involves elevating the skin and
SMAS as separate layers so that they can be advanced “bidirectionally” along
different vectors and suspended under differential tension. Because skin and
SMAS age at different rates and along somewhat different vectors, a lamellar
strategy is needed to address each layer individually and to create a natural
improvement.4,5
■ On the other hand, if a composite dissection is performed, the skin and SMAS
must be advanced with the same amount in the same direction under more or
less similar tension, which can result in skin overshifting, skin overtightening,
and other unnatural appearances.

Preoperative Planning
■ All patients undergo a preoperative physical evaluation, and patients with
significant medical problems must be cleared by their internist.
FIG 2 • The great auricular nerve can be seen lying over
the midbelly of the sternocleidomastoid muscle 6.5 cm
below the external auditory canal.

FIG 3 • The facial nerve and its branches.

FIG 4 • The retaining ligaments of the face.

FIG 5 • Assessing “temporal skin show.” The distance
between the lateral orbit and the temple hairline and
how it will change with skin flap shift must be
considered when planning the temple portion of the
face-lift incision.
■ Patients are required to avoid all medications or supplements that increase the
risk of bleeding for 2 weeks prior to surgery.
■ All patients who smoke are asked to quit 4 weeks before their procedure and
are required to avoid smoking and all secondhand smoke for 2 weeks after.
Patients who smoke or have a significant history of smoking are advised in
writing that their risk of serious complications is significantly higher than is
that of nonsmokers.
■ Patients are instructed no to color, “perm,” or otherwise chemically treat their
hair for 2 weeks before surgery and after surgery as this can result in hair
breakage and hair loss.
■ It is important that adequate OR time be allotted for contemporary face-lift
procedures. A high SMAS face-lift, when performed in conjunction with
foreheadplasty, eyelid surgery, fat injections, or other facial procedures, will
often take up to 6 to 8 hours or more. It is strongly recommended that any
surgeon new to these techniques consider staging a full-face rejuvenation over
2 separate days. Typically, face-lift and neck lift are performed the first day,
and the patient is then kept overnight and then returned to the OR the following
day or a few days later for the remainder of the procedures.

Positioning
■ The majority of our face-lifts are performed under deep sedation administered
by an anesthesiologist using a laryngeal mask airway (LMA).
FIG 6 • A. Plan for incision on the temporal scalp. This
plan is used for patients predicted to have minimal or
modest shift of sideburn and temple hair after elevation
of the cheek flap. It will not be appropriate for all
patients. B. Plan for incision along the temporal hairline.
An incision along the temporal hairline should be
considered whenever objectionable displacement of the
sideburn and temple hair is predicted.
■ The patient is placed supine on a warmed and well-padded operating table
with special effort made to ensure that all pressure points are well protected.
■ The patient’s lower extremities are then elevated and antiembolic pedal
compression devices applied.
■ Each patient receives a full surgical scrub of the entire scalp, face, ears, nose,
neck, shoulders, and upper chest with full-strength (1:750) benzalkonium
chloride (Zephran) solution. The head is then placed through the opening of a
“split sheet” leaving the entire head and neck region including the scalp
unobstructed from the clavicles up.
■ The breathing circuit is draped separately from the patient by wrapping it with
a sterile sheet that allows it to move during the procedure as the patient’s head
is turned from side to side.

■ After the general prep and draping, the surface of the ear is prepped with
Betadine using cotton swabs, and then Kittner “peanut” sponges are placed in
each auditory meatus.
Approach
■ 0.25% bupivacaine with epinephrine 1:200 000 is used for sensory nerve
blocks and for infiltrating the area marked for incision. Areas of subcutaneous
dissection are infiltrated with 0.1% lidocaine with epinephrine 1:1 000 000.
■ All incisions on the scalp or along scalp-skin interfaces must be made
precisely parallel to hair follicles to avoid injury to them that can result in peri-
incisional alopecia.
FIG 7 • Plan for incision along the occipital hairline. An
incision along the occipital hairline should be
considered whenever objectionable displacement of the
occipital hairline is predicted. This incision plan protects
the hairline and prevents hairline displacement.
(Courtesy of T. J. Marten, MD, FACS.)
■ The prehelical portion of the preauricular incision should be made as a soft
curve paralleling the curve of the anterior border of the helix. As the tragus is
approached, the incision is carried into the depression superior to it.
■ Next, the incision is carried precisely along the posterior margin of the tragus
in a retrotragal position. This location provides for the best option for avoiding
a color or texture mismatch in the preauricular skin and the best concealment
of the scar.

■ At the inferior portion of the tragus, the incision must turn anteriorly and then
again inferiorly into the crease between the anterior lobule and cheek. This
creates a distinct inferior tragal border.
■ The incision will then continue around the lobule and then precisely within the
auriculomastoid crease. The occipital and temple portions of the incision are
made according to the preoperative plan (see above).
T E C H N I Q U E S
■ Skin Flap Elevation
■ Cheek flap dissection is begun using Adson forceps and a small Kaye
scissors or scalpel grasping only tissue edges that will later be excised. Once
the edge is elevated, gentle traction is applied by the assistant with double-
pronged skin hooks.
■ Dissection is then carried out using medium Metzenbaum scissors with the
surgeon and assistant working together using a “four-handed” technique
(TECH FIG 1A):
■ The assistant applies gentle skin traction upon the skin flap directed toward
the surgeon with one double-pronged skin hook in each hand, while the
surgeon dissects and provides gentle countertraction toward the assistant
with the fingertips of the nondominant hand.
■ As the dissection advances, one skin hook is exchanged for a small Deavor
malleable-type retractor, and the remaining skin hook is used to drape the
flap over the retractor.
■ Proper assistance will require two team members scrubbed with the surgeon.
One team member will need to be committed to providing retraction, while a
second member is needed to manage all tasks related to passing of
instruments.
■ The assistant must be taught to not apply excessive force on delicate skin
flaps, and the surgeon must avoid retracting for herself or himself as this
invariably leads to rough handling of the flap.
■ Skin flaps should be elevated sharply under direct vision and blind
dissections avoided. This is especially important in the preauricular area and
over the cheek where a deep dissection can injure the underlying superficial

musculoaponeurotic system (SMAS) and compromise its use as a flap.
However, dissection too close to the posterior surface of the skin flap can
result in injury to the subdermal microcirculation.
TECH FIG 1 • “Four-handed” technique. A. The
assistant applies gentle traction upon the skin flap
toward the surgeon with two large double-pronged
skin hooks with one retractor held in each hand. The
surgeon then dissects while providing gentle
countertraction toward the assistant with the fingertips
of the opposite hand. B. Appearance of a
transilluminated skin flap in the cheek. If dissection is
in the proper plane as in this case, the undersurface of

the flap will have a rough, “cobblestone” appearance
to the fat. C. Extent of subcutaneous undermining.
Shaded area shows area of subcutaneous
undermining. Note that the platysma-cutaneous
ligaments (black dots) are not undermined and are
preserved. Preservation of platysma-cutaneous
ligaments and proper elevation and fixation of the
SMAS will provide support of lateral perioral tissues.
■ Some visual clues can be helpful in determining the proper plane for
dissection. This will require proper lighting and transillumination of skin
flaps. If dissection is too deep, the underside of the flap will appear smooth
and cloudy when transilluminated. If dissection is in the proper plane,
however, transilluminated flaps will have a rough, “pebbled,” or
“cobblestone” appearance (TECH FIG 1B).
■ Postauricular skin flap undermining is most easily begun inferiorly if the
occipital incision is made along the occipital hairline as more subcutaneous
fat is usually present and the proper plane is easier to identify compared to
more superiorly where less subcutaneous fat is present and the skin and fascia
lie in close proximity. Once the proper plane is established, two large double-
pronged skin hooks are placed by the assistant, and the dissection continues
posterior to anterior rather than superior to inferior.
■ As the dissection progresses toward the upper lateral neck, care must be
taken to avoid injury to the greater auricular nerve.
■ As dissection is continued further anteriorly into the cervical region,
subcutaneous fat becomes more abundant, and the flap is easier to dissect;
however, care should be taken to remain in a subcutaneous plane. Compared
to the cheek skin flap that must be kept thin, a thicker layer of fat can be kept
on the undersurface of the cervical flap. However, the majority of
preplatysmal fat should be kept on the platysmal surface as this makes fat
sculpting easier later in the procedure.
■ If a submental incision is planned, completing dissection of the anterior neck
skin flap will be more easily performed through it rather than the
postauricular incisions. (For planning the submental incision, see “Neck Lift”
chapter).

■ The neck should be undermined completely in most cases, but it should not
arbitrarily include the entire face (TECH FIG 1C). Preservation of the
anterior platysma-cutaneous ligaments will create attractive and youthful
appearing elevation of perioral tissue that cannot be obtained with wide
undermining. If these platysma-cutaneous ligaments are divided in the
perioral cheek, the SMAS effect on this area will be negated, and the benefit
of SMAS elevation will be lost.
■ Temple Dissection
■ The temple incision is made either on the temporal scalp or along the
anterior hairline based on the preoperative plan.
■ When on the temporal scalp, the incision is taken down to the deep temporal
fascia, and the temporal hair-bearing flap is undermined in the subgaleal
plane anteriorly to the lateral brow, inferiorly to the mid temple, and
superiorly to the temporal line.
■ The bridge of fascia (mesotemporalis) between the deep dissection in the
temple and the subcutaneous dissection in the cheek can be partially divided
posterior to the temporal hairline (TECH FIG 2A). Usually, this bridge of
tissue contains the anterior branch of the superficial temporal artery and must
be ligated. The frontal branch of the facial nerve lies anterior and inferior to
this vessel and is safe.
■ This method of dissection promotes the two planes of dissection to be joined
to improve exposure.
■ When an incision along the temporal portion of the anterior hairline is
indicated, it is made a few millimeters within it with a slight bevel or parallel
to the hair follicles.
■ The incision should be made no higher than the junction of the temporal
hairline with the frontotemporal hairline. If carried any higher, the scar can
be visible as hair tends to grow posteriorly in this area.
■ After the incision is made along the hairline, the skin flap is raised in the
subcutaneous plane connecting with the cheek skin flap dissection, and no
transition between planes is necessary (TECH FIG 2B).

TECH FIG 2 • A. Dividing the mesotemporalis. The
bridge of tissue situated between the subfascial
(subgaleal) dissection in the temple and the
subcutaneous dissection in the cheek can safely be
divided posterior to the course of the frontal branch of
the facial nerve (white dotted line). This bridge of
tissue usually contains the anterior branch of the
superficial temporal artery which must be divided and
cauterized or ligated (black arrows). B. Flap dissection
with hairline incision. When an incision along the
temporal hairline is used, all dissection will be in a
subcutaneous plane, no transition between planes will
be necessary, and the superficial temporal vessels are
left undisturbed, beneath the superficial temporal
fascia.
■ SMAS Dissection
■ To begin, markings are made for the SMAS flap. A line is marked “high”
over the midportion of the zygomatic arch from the infraorbital rim to a point
1 centimeter anterior to the superior portion of the tragus. The marking is
then turned inferiorly and carried over the preauricular portion of the parotid
1 to 2 cm anterior to the ear and continued inferiorly and posteriorly to the
anterior border of the sternocleidomastoid (TECH FIG 3A).
■ Flap elevation is begun by incising the SMAS over the zygomatic arch. This
is done by grasping the preauricular tissue overlying the lateral arch with an
Allis clamp on each side of the marked line. Metzenbaum scissors are then

used to incise along the marking medially for a few centimeters. Allis clamps
are then released and reapplied incrementally as the incision proceeds
medially along the marked line. A considerable amount of tissue lies over the
arch, and the frontal branch will be safely beneath half a centimeter or more
of fibrous fat.
■ The preauricular limb of the SMAS incision is then made using the same
technique, and these two incisions define the “high” SMAS flap to be
elevated.
■ Next, the corner of the flap is grasped with Allis clamps, and elevation is
begun with scissors. Undermining should be limited in the preparotid cheek,
more extensive over the zygoma and upper midface (TECH FIG 3B).
■ Sharp scissors dissection of the flap is usually required posteriorly over the
parotid where the plane between parotid fascia and SMAS is often indistinct.
If a portion of the parotid fascia is incidentally raised with the SMAS flap in
exposing the lobular surface of the gland, this is of no clinical significance
and should be used by the surgeon as an aid in identifying the proper plane
slightly more superficial.
■ A distinct plane does exist, however, medial to the parotid between the
SMAS-platysma and the parotidomasseteric fascia. This plane is most easily
identified in the lower cheek where it can be entered by gentle blunt
dissection. The parotidomasseteric fascia will be seen as a thin, shiny
transparent layer covering the masseter, buccal fat, and facial nerve branches.
Blunt dissection on top of this layer is safe; however, care must be taken to
not violate this layer as it can result in a facial nerve injury. Sub-SMAS
dissection must be carried over the anterior border of the parotid in the lower
cheek to ensure the parotidomasseteric ligaments are released; otherwise, an
optimal SMAS effect will not be obtained.
■ As SMAS flap dissection is made medially in the upper cheek over the
superior portion of the parotid and its accessory lobe, the SMAS will be seen
to thin and invest the lip elevators. At this point, the dissection must be taken
superficial to the superior portion of the zygomaticus major muscle. Just at
the malar origin of this muscle, the zygomatic ligaments will be found. These
fibrous connections between periosteum and skin must be divided, and when
completely released, a dramatic liberation of the flap will be obtained.

TECH FIG 3 • Plan for “high SMAS” flap. A. The
superior margin of flap is planned over the zygomatic
arch and not below it. The frontal branch of the facial
nerve (dashed line) lies safely posterior and deep to
the majority of the dissection. B. Approximate extent
of SMAS undermining. Complete release of the SMAS
flap will require that both the parotidomasseteric
ligaments (squares) and the zygomatic ligaments
(circles) be released. C. Completed SMAS flap
elevation. Inferior to the origin of the zygomaticus
major muscle (large arrow), and superomedial to the
accessory lobe of the parotid, lies the zone of
transition between the zygomatic (blue dots) and
masseteric-cutaneous ligaments (black dots) and the
most potentially dangerous part of the SMAS
dissection. Proper liberation and release of the SMAS
flap usually require at least partial division of
restraining attachments in this area but move the
dissection into very close proximity to the zygomatic

branch of the facial nerve (small arrow).
■ Directly inferomedial to the origin of the zygomaticus major muscle, and
superomedial to the accessory lobe of the parotid, lies the zone of transition
between the zygomatic and masseteric-cutaneous ligaments and the most
dangerous part of the SMAS dissection. Proper liberation of the SMAS flap
usually requires at least partial division of restraining ligaments in this area
but moves the dissection into very close proximity to the zygomatic branches
of the facial nerve (TECH FIG 3C).
■ In this area, it can be difficult to distinguish between nerve branches and
ligamentous attachments. The inexperienced surgeon should consider using
loupe magnification and the use of a disposable nerve stimulator to aid in the
dissection. If confusion is encountered or the anatomy is unclear, it is better
to limit dissection in this area until additional experience is gained as no
amount of improvement in SMAS release is worth a facial nerve injury.
■ The endpoint to the SMAS dissection is ultimately clinical and not anatomic.
Gentle traction on the superior margin of the flap should produce motion at
the nasal ala, philtrum and stomal angle, and elevation of infraorbital and
lower eyelid tissue. If there is limited movement with this traction test, then
residual tethering fibers are identified and released and the traction test
repeated.
■ SMAS Suspension
■ Once the SMAS flap has been properly released, it should be shifted in a
posterior-superior vector parallel to the long axis of the zygomaticus major
muscle. If a more vertical or posterior vector is used, the function of the
zygomatic major muscle will be corrupted, and abnormal appearances during
animation may result.
■ The technique of flap suspension will vary depending on overall facial
morphology. In most cases, no trimming of the superior margin of the flap is
performed as the overlapping tissue segments of SMAS add volume to the
zygomatic arch. In cases where a temporal scalp incision is used, the superior
edge of the flap is anchored well over the zygomatic arch directly to the deep
temporal fascia using 3-0 Vicryl or Mersilene (TECH FIG 4A). Suspension
in this manner is greatly facilitated if the mesotemporalis is gently pushed

inferiorly as sutures are placed. No suturing is needed more medially over the
zygoma or along the infraorbital rim as this can result in unnatural tissue
tethering and dimpling.
■ When an incision along the temporal hairline is used, the deep temporal
fascia will not be exposed. In these cases, the galea can be incised just
inferior to the sideburn to expose the deep temporal fascia. The SMAS can
then be anchored as described above (TECH FIG 4B–E).
■ In patients with a wide midface (ie, Asian or Slavic ancestry) or in many
men, overlapping the SMAS may not be artistically appropriate. In such
cases, the redundant tissue along the superior edge of the flap can be excised,
and the flap margin sutured edge to edge to the superior margin of the initial
incision made in the SMAS over the zygomatic arch.
TECH FIG 4 • High SMAS flap suspension with a
temporal scalp incision. A. The SMAS flap has been
advanced superiorly, the mesotemporalis pushed
inferiorly, and the flap secured to the temporalis
muscle fascia. B–E. High SMAS flap suspension with
temporal hairline incision. To gain access to the
temporalis muscle fascia to suspend the SMAS, the
sideburn is retracted and the galea incised (B).
Completed incision of the galea under the sideburn
exposing the temporalis muscle fascia. Once incised,

a “mesotemporalis” (transition from subcutaneous
plane of cheek to subgaleal plane in temple) is
created (C). The suture has been placed through the
corner of the SMAS flap. Note that the
mesotemporalis is being pushed inferiorly as the
suture is placed (D). Additional sutures have been
placed between the superior margin of the SMAS flap
and the temporalis muscle fascia, securely anchoring
the flap. Once suspension of the SMAS is complete,
the sideburn is placed back in a proper anatomic
place and anchored down (E).
■ Regardless of how the superior margin of the flap is secured, some trimming
of the posterior margin of the flap is needed to facilitate edge-to-edge
approximation to the posterior flap incision as overlapping here is artistically
inappropriate. This should be done after the superior margin of the flap is
secured.
■ Unlike the superior margin of the flap, it is counterproductive to place
tension on the posterior margin of the flap. Thus, the posterior margin should
be trimmed conservatively to avoid a tight closure.
■ To provide additional support to the anterior neck and improve contour, the
excess tissue along the posterior margin of the SMAS flap can be trimmed
but left attached inferiorly to the platysma and used as a postauricular
transposition flap (see FIG 1C).
■ Due to the increased length obtained with this transposition flap, it can be
sutured to the immobile mastoid fascia by creating a dynamic sling that
tightens the submental region when the patient looks down. This tightening is
obtained because the mastoid moves superiorly with neck flexion pulling the
flap up with it.
■ When designing the postauricular transposition flap, the SMAS must be
incised low enough so that this flap exerts its effect on the platysma below
the mandibular border so as to improve submental contour.
■ When using the postauricular transposition flap in conjunction with anterior
platysmaplasty, the transposition flap should be secured after anterior
platysmaplasty is completed or else it may not be possible to approximate the

platysma anteriorly.
■ Skin Flap Repositioning, Trimming, and Closure
■ Skin flap repositioning should be performed with the patient’s head in a
neutral position. To avoid unnatural appearances, the skin flaps must be
shifted in a slightly more posterior direction than that of the SMAS. Also, it
is critical to remember that the goal of skin excision is to remove redundancy
and not tighten the skin flap.
■ Cheek skin flaps should be shifted along a vector roughly perpendicular to
the nasolabial fold, while neck skin should be shifted along a vector parallel
to the mandibular border.
■ There are two points of skin flap suspension that set the stage for the
remainder of the closure. The first point is located just above the ear where
the anterior-superior most part of the ear joins the scalp. The cheek flap is
shifted and the redundancy gauged with a face-lift marker (TECH FIG 5A).
The flap should be held under just greater than normal skin tension when the
mark is made and a small “T” shaped incision made into the flap at the
marked point. The flap is then anchored at this point with a half-buried
vertical mattress suture of 4-0 nylon with the knot on the scalp side.
■ The second key point of suspension is in the postauricular area at the
superior aspect of the occipitomastoid incision. The flap is shifted roughly
parallel to the mandibular border so that skin is suspended under minimal or
no tension and that little or no skin needs to be trimmed from the anterior flap
border that will be sutured to the postauricular incision. The flap is secured
with a simple suture of 4-0 nylon; no incision into the flap is necessary.
■ Once these two key sutures are placed, the flap overlying the inferior portion
of the ear should be carefully divided and the lobule exteriorized. This is a
key step and must be performed incrementally and with great care to avoid
earlobe malposition. If this is done properly, the apex of the incision should
sit snugly against the inferior most portion of the conchal cartilage.
■ Skin flap trimming and incision closure should begin in the postauricular
area along the auriculomastoid sulcus. Little to no skin needs to be trimmed
from the anterior border of the postauricular flap, and the incision is closed
with several interrupted sutures of 4-0 nylon. If it appears that a large amount
of skin needs to be excised from this area, the flap has been shifted too far

anteriorly and superiorly and should be adjusted.
■ Next, trimming and closure of the occipital portion of the incision are
performed. If the occipital incision has been made along the occipital hairline
as usually most appropriate, skin will only be excised along the posterior
border of the postauricular skin flap. It is incorrect to excise any skin over the
apex of the occipitomastoid incision as this will lead to a wide scar (TECH
FIG 5B). A face-lift marker is used to gauge redundancy, and the flap is
trimmed so that closure is performed under no skin tension and the wound
edges about one another before sutures are placed. Closure is then performed
with multiple half-buried vertical mattress sutures of 4-0 nylon and simple
interrupted sutures of 6-0 nylon.
■ The preauricular area is closed next. Skin flap redundancy should be
carefully gauged using a face-lift marker, whereas the pretragal portion of the
skin flap is held down into the pretragal hollow with an instrument by the
assistant. This ensures that enough skin is present to fill the pretragal sulcus
and provide natural preauricular contours. The prehelical portion of the flap
is trimmed to fill in the prehelical incision without any skin tension. This is
closed in one layer using interrupted 6-0 nylon or running 6-0 polypropylene.
■ The prelobular (subtragal) portion of the cheek skin flap is trimmed next
using a similar technique of marking excess with the face-lift marker and
closed under no tension in a single layer with several interrupted 6-0 nylon
sutures.
■ Once the prehelical and prelobular areas have been closed, the tragal flap is
trimmed. As elsewhere in the preauricular closure, the tragal flap must be
trimmed with slight redundancy with the assistant holding the pretragal
portion of the skin flap down into the pretragal hollow. Trimming the tragal
skin flap too short is an error that will result in tragal retraction and an
unnatural “chopped off” appearance. The tragal flap does not need to be
thinned except at its posterior margin, and closure is done in one layer as
above.

TECH FIG 5 • A. The face-lift marker. The use of a
flap marker provides a reliable means for appropriate
excisions of skin to be made. The pin on the lower jaw
of the marker is placed near the edge of the incision.
The skin flap is then draped over the lower jaw of the
instrument, and the instrument is closed. On closing,
the upper jaw of the instrument marks the precise
position of the edge of the scalp flap beneath it. B.
Incorrect trimming of postauricular skin flap. It is an
error to excise any skin over (superior to) the apex of
the occipitomastoid incision and shorten the
postauricular flap along the long axis of the
sternocleidomastoid muscle. There is no true excess
of skin along this vector nor any aesthetic benefit from
shifting skin in this direction. C,D. Proper insetting of

the earlobe. In the artistically ideal “nonsurgical”
appearing ear, the long axis of the earlobe (dotted
line) sits approximately 15 degrees posterior to the
long axis of the ear itself (solid line) in the lateral view
(C). As this angle is reduced, or the axis of the lobule
shifted anterior to the long axis of the ear, an old,
unnatural, and “face-lift look” is produced (D).
■ There is nothing as telltale as an abnormal position of the earlobe, and for
this reason, the lobule should be inset as the last step in the preauricular
closure. The cheek flap should be trimmed and the earlobe inset so that the
lobule ends up situated in a posterior and somewhat superior position even if
it was in a more anterior and inferior position before surgery. This is because
the long axis of a natural appearing earlobe ideally sits approximately 15
degrees posterior to the long axis of the ear itself (TECH FIG 5C,D). As this
shifts anteriorly or too far inferiorly, an unnatural “face-lift look” is
produced. Insetting the lobule in the proper position often requires the lobule
be released from tethering tissue. It is then secured in two layers to protect
the incision in the first few weeks from disruption when patients pull
clothing, jewelry, and other items off over their heads. If the lobule is inset
correctly, often skin redundancy will be present on the posterior surface of
the ear. This can be easily treated by excising a triangle of skin in this area.
■ If the temporal portion of the face-lift incision has been made on the
temporal scalp, the incision is closed in one layer without excision of any
hair-bearing temporal tissue. A small amount of cheek skin and scalp only
will be excised immediately above the ear. If the temporal incision has been
made along the hairline, skin only will be conservatively trimmed and closure
performed in one layer without any skin tension using a combination of half-
buried vertical mattress 4-0 nylon sutures and simple interrupted 6-0 nylon
sutures.
■ After all planned procedures have been completed, the patient’s hair is
shampooed, rinsed, and detangled, and no dressings are required or applied.
PEARLS AND PITFALLS