Geoffrey 2 C. Gurtner, Peter C. Neligan, Daniel Z. Liu – Plastic Surgery Principles. 2-Elsevier (2018)

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SECTION I
CHAPTER 6.2 • Facelift: Principles of and surgical approaches to facelift
A significant surgical decision is whether to extend the
postauricular incision across the non-hair-bearing skin into
the occipital region. Generally speaking, the occipital inci-
sion should be made when there is a need to remove excess
redundant skin in the neck. A “short scar” facelift is one
that avoids the occipital incision and will suffice for certain
patients.117 If the incision is kept short, the lateral neck is
accessed from the earlobe and retroauricular incision, and
any bunching of skin is redistributed within the retroauricular
sulcus. Disadvantages of the short scar incision are that access
to deep tissues is somewhat limited and there is a tendency
to draw the skin flap in a more superior direction, possibly
requiring a pre-hairline incision in the temple and possibly
causing traction lines and wrinkles to course too superiorly.
Also, the short scar approach is less effective for the patient
with excess neck skin; attempts to deal with this may result
in a gathering of skin in the retroauricular sulcus, creating
pleats.
When a long scar is planned with an extension into the
occipital hair, many variations have been described, ranging
from an incision that goes vertically into the scalp118 to an
incision that courses inferiorly along the hairline of the neck.
Most commonly, surgeons use an incision that is between
these two extremes. The principal objectives of the occipital
incision are to gain access to the neck in order to take up
redundant neck skin, while making the incision as invisible
as possible with little or no distortion of the occipital hairline.
If a small amount of skin is going to be removed, the retroau-
ricular incision can curve posteriorly into the occipital hair
from the retroauricular sulcus. If more skin from the neck is
going to be removed, this approach could create a notch in
the posterior hairline, so a “lazy S” pattern can be used, where
the incision follows the occipital hairline for 1–2 cm, before
angling more posteriorly into the scalp. A rough guide is to
use the lazy S approach if 2 cm or more of neck skin is to be
removed at the incision line.113 This approach allows an ade-
quate excision of skin without a stair-step deformity, while
hiding the lower, potentially most visible part of the scar
in the wispy hair of the lower occipital scalp (Figs. 6.2.14
& 6.2.15 and Video 6.2.3
).
Facelift skin flap dissection
Either the temple dissection or the postauricular dissection
can be done first, depending on surgeon preference. Dissec-
tion is usually begun with a scalpel for the first 1–2 cm, at
which point many surgeons switch to scissors. In the postau-
ricular area, the flap is firmly attached to the deep cervical
fascia of the sternocleidomastoid and the mastoid. Also, this
is the most common location to see skin flap necrosis, so the
flap should be raised sharply under direct vision, keeping the
dissection against the underlying deep fascia in order to
maintain flap thickness. As the dissection continues inferior
to the earlobe level, the surgeon must be cognizant of the great
auricular nerve, where it is most at risk over the posterior
border of the sternocleidomastoid. By keeping the dissection
in the subcutaneous plane, this nerve will be protected.
In the temple, if the incision has been made along the ante-
rior hairline, dissection is begun directly in the subcutaneous
plane. If the incision has been made in the hair-bearing scalp
of the temple, dissection can be carried out in one of two
planes: superficial to the superficial temporal (temporoparietal
The advantage of the incision in the hair is that it is hidden,
but when the flap is drawn up, the anterior hairline and
sideburn will shift, the degree of this depending on skin laxity.
If the incision is placed at the anterior hairline, the scar is
potentially more visible, but there will be no shift of the
hairline. A transverse incision at the base of the sideburn is a
compromise solution, which ameliorates much of the hairline
shift, while preserving a largely hidden scar. Other compro-
mises have been described.112 Several factors should be
assessed before committing to an incision within the temple
hair. First, a preoperative estimate of skin redundancy will
give some sense of how far the skin flap will move. The dis-
tance between the lateral orbital rim and the temporal hairline
should be assessed. In youth, this distance is generally
<4–5 cm, while in older patients, the distance increases.113 If
the distance is already excessive, or if the expected movement
of the temporal hairline will create a distance over 5 cm, then
an incision in the hair should be avoided (Fig. 6.2.13C). On
the other hand, patients must be informed that the alternative
incision along their temporal hairline will leave a potentially
more visible scar. Because of this problem, a number of solu-
tions have been devised along the temple hairline including
beveling the incision to encourage growth of hair through the
scar and the use of zigzag incisions.114,115 In any circumstance,
the anterior hairline incision should be meticulously sutured
under minimal tension. Also, the patient’s wishes should be
considered prior to surgery, because the location of the tem-
poral incision is inevitably a compromise and the patient may
have preferences that will influence this choice.
Anterior to the ear, the incision can be pretragal, or along
the tragal edge (Fig. 6.2.13D,E). The advantage of the tragal
edge incision is that it is hidden, but care must be taken to
thin the flap covering the tragus in order to simulate a normal
tragal appearance. Furthermore, as pointed out by Connell,113,116
the tragus looks like a rectangle, with a top and a bottom, and
to preserve a distinct lower border, a short transverse cut at
the inferior end of the tragus (the incisura) should be made.
Before committing to a tragal edge incision, the quality of
tragal skin and that of facial skin must be compared; if
the difference is too great, drawing thick cheek skin onto the
tragus may be problematic because the skin covering the
tragus will not be anatomically appropriate. Therefore, in
certain cases, a pretragal incision is preferred. For example, in
men, the pretragal approach may be beneficial if it appears
that thick-bearded skin will be drawn up onto the tragus and
the surgeon is concerned that removing hair follicles and
thinning the flap will not ameliorate the appearance of cheek
skin on the tragus. Elsewhere in front of the ear, the superior
portion of the incision should follow a curved line along the
helix and a slightly straighter curve along the anterior attach-
ment of the earlobe; a long, straight line incision in front of
the ear should be avoided (Video 6.2.2
).
Around the earlobe, the incision can be place either in the
cleft of earlobe attachment or 1–2 mm distal to the cleft,
leaving a cuff of skin along the earlobe. This cuff will ease the
process of insetting the earlobe on closure.
In the retroauricular sulcus, the incision can be placed
directly in the conchal groove as it courses superiorly.
Various landmarks have been described to determine how
high to carry this incision. These include the level of the
external auditory canal, or slightly higher, at the level of the
antihelix.

127
Surgery
fat pad (see Chapter 6.7), or alternatively, carry on over the
fat pad, freeing it from the overlying skin in the temple and
cheek (see Chapter 6.6). Lower in the cheek, immediately
anterior to the ear and the earlobe, overlying the parotid,
the skin is tethered to underlying structures (described
earlier by various names: platysma auricular fascia, parotid
cutaneous ligament, and Lore’s fascia). Beyond this zone, the
subcutaneous dissection proceeds relatively easily. Once the
skin flaps anterior and posterior to the ear have been raised,
the two dissections are joined. The extent of the facelift flap
dissection into the cheek and neck will depend on the type
of deep tissue technique being employed. When a submental
incision is used for midline platysma plication, there will be
traction on the cervical skin toward the midline of the neck.
In that circumstance it is important to widely mobilize the
cervical skin from the underlying platysma in order to allow
the cervical skin to be redraped along a vector opposite to that
in which the platysma is being moved. If, on the other hand,
there is no submental incision and the neck platysma and
neck skin are moved in the same direction, the neck dissection
can be more limited (Figs. 6.2.17 & 6.2.18).
Deep tissue surgery
As reviewed in Chapter 6.1 the anatomy of facial aging is a
complex process involving all layers of the face from the skin
to the bone. Logically, surgical rejuvenation of the aging face
should address all or most of these tissue layers. The surgeon
fascia), which will continue directly into the subcutaneous
facelift plane, or between the superficial temporal fascia and
the deep temporal fascia. If the deeper approach is used, the
dissection proceeds quickly against deep fascia, but at the
anterior hairline, the dissection plane must transition into the
subcutaneous facelift plane. This change of plane results in a
narrow ribbon of superficial temporal fascia that will contain
the superficial temporal artery and vein and branches of the
auriculotemporal nerve. This has been called the “mesotem-
poralis” and must be divided, often requiring ligation of the
superficial temporal vessels. The argument in favor of the
deeper dissection is to protect temporal hair follicles, although
vessels and a nerve must be sacrificed (Fig. 6.2.16A). The
superficial plane has the reverse attributes: vessels and nerves
within the superficial temporal fascia are preserved, but the
hair follicles can be injured during the dissection unless care
is taken (Fig. 6.2.16B).
Anterior to the anterior hairline, the subcutaneous plane
is then developed. Commonly referred to as the “facelift
plane”, the level of dissection normally leaves about 2 mm of
fat on the dermis which creates a cobblestone appearance
of fat on the underside of the flap. This dissection results
in a large random-pattern skin flap, the survival of which
will entirely depend on the subdermal plexus. In the upper
face, this dissection normally continues anteriorly until the
orbicularis oculi is encountered where it encircles the lateral
orbital rim. Depending on the type of deep plane surgery
planned, the midcheek dissection may stop short of the malar
Fig. 6.2.14  When there is minimal skin shift expected, the incision is limited to
the retroauricular sulcus only (“short scar” technique). When more skin shift is
expected, especially from the neck, the incision is extended across non-hair-bearing
skin into the occipital hair. A wide range of patterns for this extension have been
described, from a nearly vertical incision down to an incision that follows the
hairline. Most surgeons follow a course somewhere in between, as in this photo,
where a “lazy S” follows the occipital hairline for 1 or 2 cm before entering the
occipital hair.
Fig. 6.2.15  The traditional incision for a facelift flap curves vertically or slightly
anteriorly in the temple, follows the contours of the ear, both anteriorly and
posteriorly, and then angles into the posterior scalp.

128
SECTION I
CHAPTER 6.2 • Facelift: Principles of and surgical approaches to facelift
Fig. 6.2.16  (A) Facelift flap has been
raised in two different planes, initially deep
to the superficial temporal fascia, against
the deep temporal fascia (seen as an oval
window), with a change of planes near the
anterior temporal hairline into the
subcutaneous plane. The “mesotemporalis”
is a bridge of tissue that develops between
these two planes. In order to unify the
planes, it has been divided with ligation of
the superficial temporal artery. (B) Facelift
flap has been raised in a single
subcutaneous plane, with dissection directly
on the superficial temporal fascia and deep
to the hair follicles of the scalp. The purple
line outlines the course of the anterior
branch of the superficial temporal artery.
A
B
Fig. 6.2.17  Subcutaneous facelift flap has been raised.
is typically presented with two age-related changes: soft-
tissue descent and loss of midface volume. In addition, there
may be an age-related volume increase in the jowl and neck.
The subcutaneous facelift flap allows for tightening and
removal of excess skin but does not address the descent of the
thicker and heavier underlying soft tissue. In order to manage
the descent of deeper soft tissue, a host of surgical approaches
have been described. These will be outlined here and in
subsequent chapters will be described in greater detail.
SMAS plication
After surgeons learned to raise large random-pattern skin
flaps, it became apparent that facial shape could be more
effectively changed by using sutures to manipulate the under-
lying soft tissue.27
Suture plication creates an in-folding of the superficial fat,
drawing superficial fat from the lower face up to the point
where the sutures are placed. Areas of fixed tissue, such as the
fixed SMAS (Fig. 6.2.19) over the parotid gland are less
movable and can act as an anchoring point, whereas anterior
to the parotid, mobile tissues can be easily manipulated.119
Multiple sutures with customized vectors can be used, allow-
ing reshaping of the superficial facial fat. The technique is
relatively easy to master; it can be customized for the indi-
vidual case and can be modified intraoperatively by removing
and replacing sutures as necessary. The superficial fat can be
shifted in a different direction than the skin, usually along a
more vertical vector. When plication sutures are placed prop-
erly, there is little or no risk to branches of the facial nerve.
Proponents of plication claim long-lasting results without the
need for invasive and potentially dangerous dissections.120
The primary concern with plication is the potential loss of
effect if sutures cut through the soft tissue (the “cheese wire”
effect). Another concern is that the degree of improvement

129
Surgery
superior to the zygomatic arch and anterior to the ear. The
theoretical explanation for the efficacy of this technique relates
to the use of multiple bites of tissue, which the developers of
the technique feel creates “microimbrications” of the superfi-
cial fat and SMAS.122 Anteriorly, a third suture can be placed
to advance the malar fat pad, although the fat pad is not surgi-
cally released and its repositioning depends on its own
intrinsic mobility. If required, direct treatment of the neck can
be done with closed liposuction or with an open procedure
done through a submental incision as described in Chapter
12. Proponents of this technique recommend a nearly vertical
vector for the skin flap, with a short scar incision. The advan-
tages with this technique are similar to those of plication,
although proponents point to the added benefit of using a
more firm point of fixation (deep fascia) and the improved
effect of microimbrications. Disadvantages are the same as
SMAS plication: potential loss of effect if the sutures pull
may be limited by the tethering effect of the retaining liga-
ments, which in this technique are not released at their deeper
extent; they are, however, released at the subcutaneous level
during skin flap dissection. When the subcutaneous fat is
fragile, suture fixation may fail. Also plication may have a
limited effect in patients with very heavy jowls and ptotic
tissues in the neck.
Loop sutures (MACS lift)
A variation of suture plication is the loop suture method (Fig.
6.2.20), for which the main variant is the MACS lift (minimal
access cranial suspension). This procedure, which itself was
derived from the “S-lift”, relies on long suture loops that take
multiple small bites of soft tissue.121,122 Some of these bites are
strategically placed into the SMAS and platysma. The loop
sutures are secured to the deep temporal fascia at a point just
Fig. 6.2.18  (A, B) Subcutaneous flap dissection
with no submental incision. Platysma and skin are
being moved in the same direction, superolaterally,
thus requiring minimal separation of skin from
platysma. (C, D) Subcutaneous flap dissection with
submental incision. The paired platysma muscles,
when sutured together in the midline, are shifted
medially. As the skin is being moved in the opposite
direction, a more thorough separation of skin from
platysma is required.
A
B
C
D

130
SECTION I
CHAPTER 6.2 • Facelift: Principles of and surgical approaches to facelift
SMASectomy
In the SMASectomy procedure (Fig. 6.2.22), a strip of SMAS
and overlying fat is removed with direct suture closure of the
resulting defect.124 The excised strip angles obliquely across
the cheek from the angle of the mandible to the lateral malar
eminence at the edge of the malar fat pad. The procedure can
be done with a conventional facelift incision or a short scar
approach. If required, the neck can be treated directly with
closed liposuction or with an open procedure through a
submental incision. Advantages of this technique include the
fact that the location of traction is close to the ptotic lower
facial tissues, such as the jowl, and therefore potentially more
effective than a SMAS flap, which is raised more superiorly
in the face. The technique allows for skin and SMAS to be
moved along different vectors. By suturing two freshly cut
edges, fixation may be more secure than plication alone.
Compared with doing a separate SMAS flap, the procedure is
more rapid, with less theoretical risk to the facial nerve
because there is no deep plane dissection. Also, the cut edges
have not been undermined, potentially making them more
viable than undermined SMAS flaps. Proponents feel that
fixation is effective because the location of the SMASectomy
resection is roughly at the junction of the fixed and mobile
SMAS, allowing the mobile tissue to be advanced and
anchored to the fixed SMAS. Disadvantages include the pos-
sibility of injuring a facial nerve branch (if the SMAS removal
is done too deeply) and the lack of any ligamentous release,
through, the lack of deep ligament release, and concerns about
the effectiveness of sutures holding heavy jowls and ptotic
neck tissues against gravity. Lastly, surgeons using this tech-
nique must address the tendency for loop sutures to cause fat
to bunch up, potentially leaving bulges that can be visible
through the skin.
Supraplatysmal plane facelift
The supraplatysmal plane facelift (Fig. 6.2.21) involves a deep
subcutaneous dissection carried out immediately superficial
to the SMAS and platysma. Originally called the “extended
supraplatysmal (ESP)” facelift, this procedure raises the skin
and superficial fat as a single layer, leaving the SMAS layer
untouched.123 The zygomatic ligaments are released as dissec-
tion of the superficial facial fat extends over the malar promi-
nence as far forward as the nasolabial folds. The theory behind
this technique is the belief that the superficial fat is ptotic, but
the underlying SMAS and platysma are not.123 After the flap
has been raised, the fat on the underside of the flap can be
contoured and sutures can also be placed from this fat to
underlying fixation points. This technique provides good
mobilization because ligaments are released, and it produces
a thick robust flap. Also, with no surgical penetration of the
underlying SMAS, there is theoretically no risk to branches of
the facial nerve. Concerns about this method are that the flap
is unidirectional (the skin and fat move en bloc) and the fact
that repositioning the weight of this flap depends primarily
on skin tension at the suture line.
Fig. 6.2.19  Subcutaneous flap with SMAS plication.
Fig. 6.2.20  Subcutaneous flap with loop sutures (minimal access cranial
suspension (MACS) lift).

131
Surgery
which may limit the movement of certain tissues such as the
malar fat pad.
SMAS flap with skin attached
(deep plane facelift)
Tord Skoog in 1974 published his method of raising skin,
subcutaneous fat, and the SMAS as a single layer, which
created a thick robust flap with excellent blood supply. It also
contained a stretch-resistant structure (the SMAS), giving the
promise of a long-lasting result.125 In concept, this procedure
is like the ESP procedure (above), except that the SMAS is also
included in the flap being raised. Originally, the Skoog proce-
dure afforded only limited improvement in the anterior face
with little or no change to the nasolabial fold. This lack of
anterior movement was later found to be due to tethering of
the SMAS to the lip elevators: zygomaticus major and minor
and levator labii superioris.78 In order to overcome some of
these shortcomings, multiple variations have been developed
(Barton: high SMAS; Hamra: deep plane) (Fig. 6.2.23).53,126–128
The skin is normally raised for only 2–3 cm anterior to the
tragus, the SMAS is then incised, and the rest of the dissection
is done deep to the SMAS as far as the zygomaticus major
muscle from which the SMAS is released. The skin and sub-
cutaneous fat are left attached to the SMAS, and the entire
flap is then advanced and fixated as the surgeon desires.
Advantages of this technique are the robustness and physical
strength of the flap, and the requirement for only one plane
of dissection. Ligaments are also thoroughly released. Certain
Fig. 6.2.21  Supraplatysmal plane (extended supraplatysmal plane (ESP) lift).
A
Area of skin and
subcutaneous fat
elevation in extended
supraplatysmal plane (ESP)
B
SMAS/platysma
SMAS/platysma
ESP dissection
Superficial fat
Fig. 6.2.22  Subcutaneous flap with SMAS excision (SMASectomy).
Lateral SMASectomy
extends from tail of
parotid to lateral
canthus
Resection is at interface of
fixed and mobile SMAS.
Width of resection
determined by SMAS laxity
and desired debulking
Undermining posterior border
of platysma for advancement
to mastoid

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SECTION I
CHAPTER 6.2 • Facelift: Principles of and surgical approaches to facelift
Fig. 6.2.23  SMAS flap with skin attached
(deep plane facelift).
Subgaleal
dissection
Subcutaneous
dissection 4cm
Subcutaneous tunnel
superior to arch
Only skin expected
to be removed is undermined
Subcutaneous dissection of neck from
mastoid to midline superficial to platysma
SMAS incision
Upper lateral
corner of SMAS
remains attached
to skin
Temporal branch,
facial nerve
Marginal mandibular
branch of facial nerve
Dissection from
beneath SMAS
over zygomaticus
major thus releasing
restraint of investing
fascia

133
Surgery
variations of the technique also allow for repositioning of the
malar fat pad.126,128 Disadvantages include the inherent risk of
dissecting under the SMAS with the potential for damage to
the facial nerve. Also, unlike a dual plane technique (below),
these procedures are mostly “monobloc” techniques, where
the skin, subcutaneous fat, and SMAS are generally moved in
one direction.
Subcutaneous facelift with separate
SMAS flap (dual plane facelift)
Surgeons wishing to move the SMAS and subcutaneous fat
in a different direction than the skin arrived at the concept of
two separate flaps: the random-pattern facelift skin flap and
a SMAS flap carrying the superficial fat (Fig. 6.2.24). Multiple
variations of this concept have been developed with terminol-
ogy introduced by different authors (extended SMAS: Stuzin;
high SMAS: Connell and Marten; FAME: Aston).47,51,55,129–134
As in plication, MACS, and SMASectomy, proponents of this
method feel that that moving the skin and subcutaneous soft
tissues along different vectors will result in a more accurate
reversal of the aging process. Typically, the deep tissue flap is
shifted more vertically than the skin flap. A second advantage
is the ability to reposition deep facial tissues by mobilizing
and fixating the SMAS flap internally without the need to rely
on skin tension for support. The disadvantages of excess skin
tension are therefore avoided. Also, as in the deep plane tech-
nique, ligaments are surgically released, resulting in excellent
mobilization and advancement for the SMAS and overlying
fat. Disadvantages relate to a more time-consuming proce-
dure because two different surgical planes are developed. In
Fig. 6.2.24  Subcutaneous
facelift with separate
SMAS flap (dual plane
facelift).
addition, these two planes introduce the inherent problems
of each: potential damage to deep structure when doing the
SMAS flap dissection and potential problems with the skin
flap if it is too thinly dissected or if it is placed on too much
tension. In a thin patient, both layers can be quite thin, which
increases the technical demands placed on the surgeon.
Subperiosteal facelift
Paul Tessier, in 1979, first presented his concept for a subperi-
osteal approach using craniofacial principles to elevate facial
tissue.57,135 Variations were developed,59,136 but it was not until
the introduction of the endoscope that surgeons widely
adopted this concept (Fig. 6.2.25).
Approaching from the temple, the midface can be dissected
in either the subperiosteal58,137 or supraperiosteal plane.138,139
Added exposure can be achieved with a lower eyelid or an
intraoral incision. The advantages are a dissection that is deep
to all vital structures, a relatively short incision, and harmoni-
ous lifting of the midface and lateral brow. There is little or
no tension on the skin, thus eliminating problems from excess
tension on the skin. Some feel this technique is uniquely
advantageous for the patient requiring improvement in the
infraorbital midface in conjunction with lateral browlifting.
The younger patient who requires midface improvement
without skin tightening has also been proposed as a good
candidate. Disadvantages include the additional technology
and equipment involved, a limited effect in the lower face/
neck region, and limited effect on superficial structures, par-
ticularly loose skin. Furthermore, the early aging midface,
which seems suited to this technique, may in fact be due to

134
SECTION I
CHAPTER 6.2 • Facelift: Principles of and surgical approaches to facelift
volume loss, a problem which can be correctable with less
invasive procedures such as fat grafting.
Comparison of techniques
With so many different methods described, it is difficult for
the novice to choose the appropriate approach. In subsequent
chapters, leading proponents of the various deep tissue tech-
niques described here will review their methods in detail. This
is a field where personal opinions are strong, and at the time
of this writing, the greatest difference of opinion among
facelift surgeons relates to the way in which they manage the
deep facial tissue. For all surgeons, the objective is the same:
an effective procedure with a long-lasting result and a high
margin of safety. Over the years, a number of studies have
been done to compare different facelift techniques.32,140–148 In
order to assess the available data, a systematic review of the
world literature over a 60-year period was done in an attempt
to locate reliable studies that could attest to the efficacy and
safety of one method over another.149 Despite this exhaustive
review, no clear indication could be found that any one facelift
technique was superior to any other. Therefore, surgeons
must continue to use their own judgment for technique selec-
tion based on their patient’s needs, balanced against their
personal convictions about quality, longevity, and safety.
Skin flap closure (Video 6.2.4 )
Regardless of the technique used (excepting a pure subperi-
osteal approach), skin flap mobilization and closure is part of
any facelift; this portion of the procedure must be done accu-
rately and carefully. Errors made during closure can create
some of the most obvious facelift deformities. At all times, the
skin should be considered a covering layer, not a structural
one. Therefore, skin flap repositioning should be seen as a
removal of redundancy rather than a method to hold up ptotic
soft tissue. Most techniques advance the skin flap along an
oblique vector that is less vertical than the typical vector used
for repositioning deep tissues. In other techniques, such as the
MACS lift, surgeons employ a nearly vertical vector to the
skin flap (Chapter 6.4). One concept is to place the skin flap
“where it lies”, which means moving the cheek skin flap
obliquely to the position it naturally assumes when the patient
is lying in the supine position on an operating table. This is
based on the theory that we all look better lying on our back
with facial skin redraping itself in a natural direction.150
Another commonly used guide is to advance the skin flap
toward the temple along a vector that is perpendicular to the
nasolabial fold. This is approximately along the long axis of
the zygomaticus major muscle. Determining flap tension is a
surgical judgment and a skin flap marking forcep can be very
useful in determining where the skin should be incised. The
anterior anchor point is immediately adjacent to helix of the
ear at the junction of the hair-bearing scalp. It can be held in
place with a half-buried mattress suture in order to minimize
the chance of a visible suture mark (Fig. 6.2.26).
Posteriorly, the skin flap should be drawn along a vector
that roughly parallels the body of the mandible. The second
anchor point will be at the superior-most extent of the
postauricular sulcus at the point where the incision starts to
transition posteriorly. Once again, a half-buried mattress
suture can be used. At this point, trimming of the overlapping
Fig. 6.2.25  Subperiosteal facelift. BF, buccal fat; SOOF, suborbicularis oculi fat.
Fronto-temporal approach
Intraoral approach
Submental approach
Intraoral
incision
Buccal Fat
SOOF
Subcutaneous
dissection

135
Surgery
The skin of the neck is typically thinner and less elastic than
facial skin. With age, neck skin becomes more lax, often causing
vertical wrinkles and pleats. These can be corrected by tighten-
ing the skin in a posterior oblique direction. Some surgeons
believe that the platysma and skin are embryologically formed
together and, as such, should be corrected together by using
a superior/oblique repositioning of the underlying platysma
in the same direction as the skin advancement.122,151
With age, subcutaneous fat may accumulate in the anterior
neck, although this is highly variable; in some aging individu-
als, there is little or no subcutaneous fat in the neck. When
subcutaneous fat is the only problem and the skin is firm or
it will be surgically tightened, the fat can be removed with
closed liposuction.152 One long-term consideration is that
submental liposuction, when done alone, may lead to laxity
of submental skin (Fig. 6.2.28). In general, removal of subcu-
taneous fat should be done conservatively, leaving a layer of
fat on the skin that is thick enough to hide and disguise
underlying anatomic undulations.
The paired platysma muscles have well-recognized varia-
tions in their anatomy. The majority (roughly 75%) of necks
exhibit interdigitation of the platysma muscles in the submen-
tal region for the first 1–2 cm behind the chin.153,154 The
remaining 25% either overlap extensively, or do not overlap
at all (Fig. 6.2.29).
With age, there is a loss of tethering of the platysma muscles
to the deep cervical fascia, analogous to the loss of tethering
of the orbicularis oculi along the infraorbital rim. As a result,
the anterior platysma borders fall away from the cervical
mandibular angle and the sharp angle of youth gives way to
the obtuse angle of age. The leading edge of the paired pla-
tysma muscles may cause visible bands, but clinical experi-
ence has demonstrated that not all visible bands in the anterior
neck are muscle; they may be caused by folds of excess loose
skin. The distinction between muscle redundancy or loose
skin should be determined during pre operative physical
examination. Anterior platysma bands are considered either
static (present at rest) or active (only present on animation).
Fig. 6.2.26  Diagram shows typical skin flap redraping along an oblique direction
which is slightly less vertical than the vector along which deep tissues are moved.
There is considerable variation in this however; some techniques involve a more
horizontal vector (dual plane extended SMAS) while other techniques utilize a
nearly vertical vector (MACS lift).
Fig. 6.2.27  The earlobe should be inset with the long axis of the earlobe (dotted
line) about 15° posterior to the long axis of the ear itself. If the earlobe is pulled
forward, an unnatural appearance results.
Proper insetting of the earlobe
A
B
flap and suturing can be done in the temple and in the occipi-
tal region; the order is based on surgeon preference. Then
excess skin around the ear is trimmed, with absolutely no
tension on the closure. If a tragal edge incision is used, the
tragal flap is thinned and hair follicles are removed. In the
retroauricular sulcus, there is normally little or no skin to be
trimmed if the posterior flap has been correctly positioned.
Earlobe inset is done last and is designed to angle the lobe 15°
posterior to the long access of the ear (Fig. 6.2.27).113,116
Tension on the earlobe can lead to distortions such as the
pixie ear deformity and the malpositioned earlobe, both of
which are difficult to correct (see Chapter 6.10).
Neck surgery
Most commonly, the aging face presents along with the
appearance of an aging neck, and appropriate rejuvenation
will involve correction of both. The basic principles of neck
surgery will be covered here, with a more thorough review
presented in Chapter 12. As described earlier, there are mul-
tiple structures in the neck contributing to the appearance of
aging. These include neck skin, subcutaneous fat, platysma
muscles, subplatysmal fat, the digastric muscles, and the
submandibular glands. As in the face, these anatomic struc-
tures must be assessed preoperatively in order to devise an
appropriate surgical plan.

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SECTION I
CHAPTER 6.2 • Facelift: Principles of and surgical approaches to facelift
platysma muscles usually requires the removal of interpla-
tysma fat and fascia. The muscles can then be approximated
directly, or when redundant enough, in a vest over pants
pattern. In joining the paired platysma muscles together, some
surgeons advocate multiple rows of sutures to aggressively
advance the platysma muscles medially; this has been termed
the “corset platysmaplasty.”157 The logic in suturing the pla-
tysma muscles centrally is that a “hammock” effect is created
to help support the deeper neck tissues and the platysma
bands are eliminated by converting two muscles into one.
Also, the inferior platysma can be partially or completely
transected – an effective adjunct in the short neck.
Deep to the platysma muscles, a deep layer of fat is present.
In individuals with a lifelong blunting of the cervicomental
angle, this fat may be the cause, possibly in conjunction with
a low-lying or anterior-positioned hyoid bone. Deep fat
cannot be suctioned and requires a direct approach through a
submental incision.
Also found deep to the platysma are paired digastric
muscles. In some cases, the anterior digastric muscle bellies
contribute to the appearance of submental fullness. In con-
junction with deep fat removal, these muscles can be surgi-
cally thinned. Lastly, when submandibular glands are visible
below the mandibular border or will become so after neck
tightening, they can be treated with partial excision.158,159
In many cases, only minimal correction of the neck is
required and the presenting problem can be entirely corrected
with superior and oblique tissue repositioning through the
facelift approach. Conversely, in patients whose only concern
is the neck, an isolated neck procedure can be done. In such
a scenario, a submental incision can be used for fat removal,
platysma plication, or transection plus the manipulation of
anatomic structures deep to the platysma.160 If after submental
surgery, there is skin laxity, this can be tightened with an
isolated retroauricular incision – the so called “neck lift”, or
more frequently, with a full subcutaneous facelift.
In some older males with major neck tissue laxity, a pre-
ferred procedure may be a direct excision of excess neck skin,
which provides unparalleled access to the platysma and
The differentiation of these anatomic variances can be deter-
mined by careful preoperative neck examination with and
without platysma contraction.
There are two different surgical theories regarding platysma
bands in the anterior neck. As mentioned above, if a surgeon
considers neck skin and platysma to be a common layer, then
in conjunction with the facial SMAS, the posterior borders of
the platysma muscles can be drawn in a superior/oblique
direction with fixation of muscle to firm fascia (platysma
auricular fascia, or the Lore’s fascia component).86,151,155
Alternatively, the paired platysma muscles can be sepa-
rated from the overlying skin and can be drawn medially,
approximating them in the midline of the neck.28,156 Access for
this is through a 2–3 cm incision, which can be placed adjacent
to or within the submental fold. Central approximation of the
Fig. 6.2.28  This 55-year-old woman had submental liposuction 25 years
previously. She presents with excessive skin laxity in the submental region where
the liposuction was done.
Fig. 6.2.29  Three types of platysma anatomy: limited interdigitation, 75%; extensive interdigitation, 15%; no interdigitation, 10%.
Limited platysma interdigitation
Thyroid cartilage
Mandibular
symphysis
Extensive platysma interdigitation
No platysma interdigitation

137
Ancillary techniques
Chapters 5.1, 5.2, 13 & 14). In recent years the techniques
involved in harvesting, processing, and injection of micro-
droplet fat grafts (lipofilling) have undergone great technical
improvements.63,162 As a result, this technology is now repro-
ducible and for most surgeons has become an integral com-
ponent of their facelift technique.163,164 There is a high rate of
fat graft take after fat injection in the middle third and upper
third of the face; in fact, significant over-grafting should be
avoided in the periorbital area because of the propensity for
visible ridges and lumps if excess fat grafting has been done.
Fat grafting is less reliable around the vascular, mobile lips.
Specific areas that are commonly fat grafted in conjunction
with facelift surgery are temples, the periorbita (orbital rim,
upper lid sulcus, and the tear trough), the midfacial groove,
and the malar prominence. The depth of injection can be in
the superficial fat layer (superficial to SMAS) or, more com-
monly, in the deep fat layer against bone. As mentioned
earlier, it has been proposed that the deep medial fat compart-
ment may play a unique role in support of soft tissue in the
midface, suggesting the benefits of fat grafting these zones.65
Commonly, the suborbicularis fat compartment (SOOF) and
the deep medial fat compartments are grafted to restore
midface volume in the midcheek. Fat injection can be done
independently or in combination with facelift surgery. When
done in conjunction with facelifting, it is done at the surgeon’s
preference, either at the beginning of the procedure before the
facelift flap has been raised or at the end of the procedure
(Video 6.2.5
).
Midfacelift
In an attempt to lift the tissue immediately inferior to the
infraorbital rim (the midface), an approach through the
lower lid was developed.165 This involves a subciliary or a
transconjunctival blepharoplasty-type incision followed by a
dissection down over the face of the maxilla. This procedure
can be done in the subperiosteal plane, which requires an
inferior periosteal release, or it can be done in a supraperi-
osteal plane.166 After mobilization of the cheek mass, the soft
tissue is secured superiorly, either laterally along the lateral
orbital rim,165 or more vertically with anchoring to the bone
of the infraorbital rim.167 Disadvantages have included the
learning curve necessary for surgeons to feel comfortable
with this approach and a significant incidence of revisions
for malposition of the lower eyelid.168 An alternative to the
blepharoplasty approach is an endoscopic approach through
the temple. This involves an extension of the endoscopic
temple dissection along the lateral orbital rim, accross the
malar prominence, into the midface. The midface soft tissue
is then elevated and fixated to the deep temporal fascia with
long cable sutures or with specially made fixation devices.
Some surgeons feel this is a good technique for the younger
patient who has descent of midface soft tissue in the absense of
loose skin.169
Lip procedures
The aging face often develops changes in the perioral region,
but a facelift will not affect this region appreciably. Common
changes include elongation of the upper lip as measured from
Cupid’s bow to the base of the columella, a thinning of the
vermilion, and the development of perioral rhytides.
subplatysmal structures. The major disadvantage of this
approach is the resulting midline neck scar. The vertical
tethering effect of this scar can be improved with a zigzag
pattern or by using a vertical ellipse broken up with two or
more Z-plasties.161
Choice of neck procedure
While most surgeons agree that a youthful neck contour is one
of the principal objectives of facelift surgery, overly aggressive
tissue removal can lead to the appearance of an “overdone”
neck. And while some surgeons feel that any anterior pla-
tysma banding warrants open surgery, others virtually never
do an open neck procedure, relying instead on posterior–
superior platysma traction with or without addressing ante-
rior platysma bands from the posterior facelift approach.
Some surgeons feel that visibly ptotic submandibular glands
should always be addressed, while others feel it need never
be done. The implication of these opposing opinions is that a
perfect, universal procedure for the neck does not exist, and
surgeons must individualize their approach to variations in
anatomy, the expectations of their patients, and their own
comfort level with a particular surgical approach.
Ancillary techniques
Browlift surgery and blepharoplasty
Facial aging is typically a pan-facial phenomenon. Therefore,
a comprehensive approach to facial rejuvenation is required
to achieve a harmonious result. For many patients, surgery
for the brow (see Chapter 7) and the eyelids (see Chapter 9)
are critical components of a global approach for which a
facelift would be only part of the solution.
Volume removal
With radial expansion of the lower third of the face, many
patients require some fat removal. In the cheek, some proce-
dures, such as the SMASectomy result in superficial fat
removal as a normal part of the technique. With any technique,
superficial fat can be removed by direct excision or with
liposuction. This is often done for the jowl area in order to
improve the jaw line. Deep fat removal in the cheek involves
the buccal fat pad, which can be partially removed either
through a facelift dissection or through an incision in the
upper buccal sulcus. In the neck, superficial or deep fat can
be removed when indicated. In all cases of fat removal, caution
is advised because of the potential defects that can be pro-
duced when too much fat is removed.
Volume augmentation
As described earlier, the loss of facial volume is a critical
component in the facial aging process. To properly rejuvenate
the aging face, a facelift should ideally address both soft tissue
ptosis as well as facial deflation. The addition of volume can
be accomplished with a number of different methods includ-
ing synthetic implants (cheek implants, submalar implants,
orbital rim implants), injectable synthetic fillers, hydroxyapa-
tite granules, or injected fat (all of which are reviewed in

138
SECTION I
CHAPTER 6.2 • Facelift: Principles of and surgical approaches to facelift
have included resorption and loss of effect, permanently
overfilled lips, misshaped lips, immobile lips, and in some
cases, tissue necrosis from vascular compromise. Attempts to
augment the lip along the vermilion border lead to a duck-like
appearance, while augmentation along the wet–dry junction
is more likely to achieve a normal-appearing lip.
Perioral rhytides are a common finding in the facelift age
group. They can be effectively treated at the time of surgery
with resurfacing procedures. Options include chemical peel,
surgical dermabrasion, or laser treatment. (These techniques
are discussed in Chapter 5.5.) The most common problem
with resurfacing is permanent depigmentation when the
resurfacing has been overly aggressive.
Dressings and drains
Most surgeons use light dressings to protect the incisions and
to act as an absorbent for wound drainage, although some
surgeons feel that dressings after facelift surgery are not
necessary at all. If used, dressings should not be tight or
constrictive, but rather soft and comfortable. The initial dress-
ing is normally removed on the first postoperative day. Drains
are normally used, although surgeons’ preferences vary in
this regard. When certain tissue glues are used under the
facelift flap, drains are not indicated.
Postoperative care
In the initial postoperative period, the patient is kept still
and blood pressure is monitored closely. Any signs of blood
pressure increase should be taken very seriously; the patient
is examined for possible causes (pain, anxiety, urinary reten-
tion) and appropriate measures taken. If the increase in blood
pressure is endogenous, it should be treated pharmacologi-
cally. If the surgical procedure has been long (greater than
3 h), sequential compression devices are kept on the legs in
the recovery room until the patient can ambulate normally.
The patient is then encouraged to get out of bed with assis-
tance. Patient positioning involves keeping the head slightly
elevated but avoiding flexion of the neck . Avoiding the use
of a pillow for 10–14 days will help keep the patient’s head
in a neutral, non-flexed position. Cool packs to the face will
increase comfort and help decrease swelling. Analgesics and
antinauseants are used as necessary. In some jurisdictions,
patients are discharged home, but in other settings, patients
are kept under the care of a medically trained individual
for the first night after surgery. On the first postoperative
day, the patient is reviewed, paying particular attention to
the possibility of a hematoma, the dressings are changed
or removed, and drains are removed as indicated. After the
first day, options include another light dressing, a commer-
cially available “chin strap”, or no dressing at all. Patients
are usually permitted to have a shower and wash their hair
when the incisions are sealed from the environment – usually
2–4 days postoperatively. Subsequently, patients are seen
for dressing changes, suture removal, and wound inspec-
tion, at intervals up to 7–9 days when the final sutures are
removed. Typically, there is a return visit at 2–3 weeks and
then again between 6 and 8 weeks. Photographic documen-
tation of the surgical result should be deferred for at least
Elongation of the upper lip is highly variable, but if present,
tends to hide the upper teeth, in some cases almost eliminat-
ing the normal upper dental show on smiling. It has been
estimated that the ideal distance from Cupid’s bow to the base
of the columella is 15 mm.170,171
The upper lip can be shortened by performing a skin exci-
sion along the contours of the base of the nose (bull horn
pattern). Skin is excised, with the direct approximation of skin
acting as a subcutaneous lift. Disadvantages include a poten-
tially visible scar and a certain degree of relapse making
revisions common (Fig. 6.2.30).
Alternatively, a strip of skin can be removed along the
vermilion border, advancing the vermilion superiorly. This
has the advantage of immediately increasing the apparent
width of the vermilion lip, but the disadvantages are that the
white roll is eliminated and a permanent scar will be left along
the vermilion border. Women can deal with this by using
lipstick, but this is usually a lifelong commitment when the
scar is visible.
Lip augmentation can be done with many different tech-
niques. Commonly used methods include injectable fillers
(see Chapter 5.2), injected fat, dermal fat graft, acellular
dermis, and SMAS grafts. Many different types of human
tissue and many synthetic materials have been used to thicken
lips. Depending on the technique used, various problems
Fig. 6.2.30  Pre- and postoperative photographs of a lip-shortening procedure
using a bullhorn-shaped incision along the nostril sill.
A
B

139
Surgical complications
to improve for over a year. In this area, some permanent
numbness is possible.
Motor nerve injury
Intraoperative damage to a facial nerve branch can easily go
unnoticed by the surgeon until muscle paralysis is identified
postoperatively. Immediately after surgery, in the recovery
room setting, facial nerve paresthesias are extremely common
and are usually caused by the lingering effects of local anes-
thetic. Once the temporary anesthetic effects are gone (approxi-
mately 12 h for bupivacaine), persisting dysfunction may be
due to surgical traction or the effect of cautery near a nerve
branch; these issues can be expected to resolve spontaneously
over days or weeks. If a facial nerve branch has been transected
or wrapped in a suture, complete functional recovery may still
be possible if the target muscle receives collateral innervation.
The most commonly injured branches are thought to be the
buccal branches, although long-term sequelae are rare due to
multiple interconnections between nerve branches. Damaged
temporal or marginal mandibular branches are less likely to
recover because they are terminal branches with less collateral
support. Fortunately, permanent paralysis of any degree is a
rare event and has been reported as being less than 1%.176
Unsatisfactory scars
Depending on the incision chosen, scars can potentially be
obvious and deforming. Improper placement of incisions can
lead to distortion of the ear and unnatural shifting of the
hairline. Excessive tension can lead to loss of hair, depigmen-
tation, and widened scars. Some scars can be improved with
scar revision at a later date. Hypertrophic scars can be dealt
with by steroid injection and scar revision if necessary (these
issues are discussed in Chapter 6.10).
Alopecia
Loss of hair can occur along the incision line or within the
hair-bearing scalp which has been raised as a flap. The usual
cause is excess tension at the incision line. However, if a flap
of hair-bearing skin is raised, follicles can also be damaged by
the dissection itself, by cautery, or by traction on the flap.
Permanent hair loss can be treated in some cases by mobiliza-
tion of an adjacent flap of hair-bearing scalp. However, for
significant alopecia, achieving adequate coverage with hair
growth in the proper direction is best achieved with micro
hair grafting (Chapter 6.21).
Skin loss
Facelift dissection creates a large relatively thin random-
pattern skin flap that is then placed under tension; it has a
remarkable ability to survive. Factors contributing to skin loss
include excessive tension, an overly thin flap, hematoma,
constrictive dressings, and perhaps the most damaging of all
– smoking. Established skin necrosis should be dealt with
conservatively; the majority of such cases will eventually heal
spontaneously. Scar revision can be done at a later date.
Infection
Infection is reported to be rare in facelift surgery, with various
series indicating an incidence of less than 1%.177–179
6 months to allow for all postoperative swelling to settle
completely.
Surgical complications
Hematoma
Postoperative hematoma is the most common facelift com-
plication and has a reported incidence of 2–3% in women.
The incidence in men has been reported up to 8%, although
this can be decreased to 4% through meticulous surgery
and postoperative blood pressure control.172,173 Numerous
variables have been explored, including dressings, drains,
fibrin glue, and platelet gel. A positive association has been
found with the following: simultaneous open neck surgery,
patients taking platelet inhibitors such as aspirin and anti-
inflammatories, hypertension in the postoperative period,
and the rebound effect when injected epinephrine wears off
postoperatively.174,175 Hematoma prevention involves avoid-
ing these variables as much as possible. Hematomas typically
develop in the first 12 h after surgery. If an expanding hema-
toma is identified it should be considered an urgent problem
and should be dealt with promptly. If skin flap compromise
is suspected and there is a delay in returning to the operating
room, a temporary solution can be the removal of sutures in
order to relieve pressure (Fig. 6.2.31).
Sensory nerve injury
The terminal branches of sensory nerves to a facelift flap are
routinely divided when the flap is raised. This leads to a
self-limiting paresthesia that usually recovers completely in
6–12 months. The great auricular nerve is the major sensory
nerve at greatest risk for damage during facelift surgery.
Transection will lead to numbness of the lateral portion of the
external ear as well as skin anterior and posterior to the ear.
A painful neuroma can also develop. If knowingly transected
during facelift surgery, either partial or complete, it should be
repaired intraoperatively. A portion of the zygomaticofacial
nerve is often transected when the malar fat pad is lifted; this
will lead to numbness of the lateral cheek, which will continue
Fig. 6.2.31  Postoperative hematoma in a hypertensive male. Note the ineffective
suction drain.

140
SECTION I
CHAPTER 6.2 • Facelift: Principles of and surgical approaches to facelift
BOX 6.2.1  Neoclassical canons
1. The height of vertex to endocanthion is equal to the height of
endocanthion to gnathion (two-section canon).
2. The heights of trichion to nasion, nasion to subnasale, and
subnasale to gnathion are equal (three-section canon).
3. The heights of vertex to trichion, trichion to glabella, glabella to
subnasale, and subnasale to gnathion are equal (four-section
canon).
4. The width of the alae equals one-fourth the width of the distance
between the zygomas (nasofacial proportion canon).
5. The length of the nose is equal to the height of the ear
(nasoaural proportion canon).
6. The inclination of the nasal dorsum is equal to the inclination of
the ear (nasoaural inclination canon).
7. The distance between the medial canthi is equal to the width of
the eye fissure (medial to lateral canthus of the eye) (orbital
proportion canon).
8. The distance between the medial canthi equals the width of the
ala (orbitonasal proportion canon).
9. The width of the mouth equals 112 the width of the ala (naso-oral
proportion canon).
However, most authors with published series have only
counted cases requiring surgical drainage or hospitaliza-
tion. Minor cases of cellulitis and stitch abscesses are likely
more common. Should an infection occur, treatment is with
surgical drainage, antibiotics, and appropriate wound care
(Fig. 6.2.32).
Fig. 6.2.32  Abscess under cervical portion of facelift flap 1 week after a facelift.
This was treated with drainage and antibiotics.
Table 6.2.1  Soft-tissue landmarks
Landmark
Description
Vertex (v)
The highest seen point on the head with the head in Frankfort horizontal
Trichion (tr)
The junction of the hairline and the forehead in the midline
Glabella (g)
The most prominent point of the forehead in the midline between the eyebrows
Nasion (n)
The midline point of the junction of the frontonasal suture and the superior nasal bones. Externally, nasion often
corresponds to the point of greatest concavity of the nasal dorsum near a line level with the upper lid lash line
Orbitale (or)
The palpable point of the lowest margin of the inferior orbital rim
Porion (po)
The most superior point of the external auditory meatus
Frankfort
horizontal (FH)
The line connecting porion and orbitale. This line is parallel to the floor for anthropometric measurements. It is
an approximation of neutral head position in straight gaze
Endocanthion (en)
The point of the medial canthus where the upper and lower lids join
Pronasale (prn)
The most prominent point of the nasal tip
Subnasale (sn)
The deepest point at the junction of the base of the columella and the upper lip in the midline
Stomion (sto)
The midline point where the upper lip touches the lower lip
Sublabial (sl)
The midline point at the junction of the lower border of the cutaneous lower lip and the superior border of the
chin. It is the deepest point of the labiomental groove
Pogonion (pg)
The most prominent point of the chin in the midline
Gnathion (gn)
The most inferior point of the lower border of the mandible; also called menton (me). In cephalometric analysis,
gnathion and menton are two different points on the mandible
Facial analysis, anthropometrics and
concepts of facial shape
The standardization of soft-tissue facial analysis and the
application of the neoclassical canons relies on consistent
facial landmarks that can be assessed with standard photog-
raphy (Table 6.2.1 & Box 6.2.1). The initial proportional

140.e1
Facial analysis, Anthropometrics and concepts of facial shape
Fig. 6.2.33  The Greek sculptor Polycleitus’ Doryphorus.
Fig. 6.2.34  Marquardt’s phi mask is based on the “golden ratio”.
Anthropometry involves the study of the human body
in relation to its variations in size and proportions. While
the ancient Egyptians are reported to have been the first to
divide the human body into equal parts, the Greek sculptor
Polycleitus is credited with the development of canons as
exemplified in his statue of Doryphorus (Fig. 6.2.33).180 During
the Renaissance, artists such as da Vinci, Dürer, Pacioli, and
Alberti developed the “neoclassical canons”, which divided
the face into symmetric ideal proportions.
The 20th century was highlighted by the development
of radiographic techniques to indirectly measure the facial
skeleton. Broadbent’s concept of cephalometrics181 allowed
the initial compilation of normative facial data in 5400 chil-
dren over 36 years.182,183
The idea of the “golden proportion” having application to
facial analysis was introduced by Seghers et al.184 and popular-
ized by Ricketts.185,186 The aesthetically attractive 1 : 1.618 ratio,
indicated by the Greek letter phi (Φ), was first recorded in
Marquardt attempted to objectify the concept of an aes-
thetic face with development of the golden ratio phi mask
(Fig. 6.2.34). Although the validity of this concept has been
supported by superimposing the mask on young, white
individuals of European descent,188 there are many limita-
tions, as Guyuron points out,189 in the use of two-dimensional
photographs to define an attractive face.
Modern-day anthropometrics was led by the work of
Leslie Farkas. He defined and measured countless soft-tissue
points and dimensions in hundreds of people of varying
ethnicities and ages.190,191 His extensive work has allowed
the development of a database of normative values to which
subsequent facial analyses may be compared. Perhaps of
equal importance, Farkas realized the limited application of
the neoclassical canons and the golden ratio to only a select
group of patients.192,193
the 3rd century bc by the Pythagoreans and has applications
dating back to the architecture of the Egyptians and Greeks.187

141
Facial analysis, anthropometrics and concepts of facial shape
with age, most notably in the male patient. When examining
the lower third, it can be further divided into thirds such that
the distance from the subnasale to the stomion is one-third
and the distance from the stomion to gnathion is two-thirds
(Fig. 6.2.35C). The four-section canon states that the distances
from vertex to trichion, trichion to glabella, glabella to subna-
sale, and subnasale to gnathion are all equal (Fig. 6.2.35D).
Farkas examined the reliability of these relationships and
analysis of the face begins with the division into halves, with
the height of the vertex to endocanthion being equal to the
endocanthion to gnathion height (Fig. 6.2.35A). One of the
most utilized canons is the division of the face into thirds (Fig.
6.2.35B). The distance from the trichion to the glabella equals
the distance from the glabella to subnasale, which equals the
subnasale to gnathion distance. Obviously, a limitation of this
technique is the position of the hairline which may change
Fig. 6.2.35  (A) The division of the face into
halves. The height from the vertex to
endocanthion is equal to the endocanthion to
gnathion height. (B) The division of the face
into thirds. The distance from the trichion to
glabella equals the glabella to subnasale
distance, which equals the subnasale to
gnathion distance. (C) The lower third of the
face can be divided into thirds, with
subnasale to stomion equal to one-third and
stomion to gnathion equal to two-thirds.
(D) The four-section canon. The distances
from vertex to trichion, trichion to glabella,
glabella to subnasale, and subnasale to
gnathion are equal.
A
B
C
D

142
SECTION I
CHAPTER 6.2 • Facelift: Principles of and surgical approaches to facelift
examination is not normally done for facelift surgery, anthro-
pometric principles still apply. With most facelift techniques,
volume in the midface is typically enhanced while volume in
the lower face is reduced as tissue is shifted superiorly in the
face. However, the wide face may not benefit from volume
enhancement in the midcheek, while the long, thin face
would benefit from combination of soft-tissue shifting and
overlap, as well as additional volume augmentation with fat
grafting. Aesthetic considerations must supersede technical
considerations, and facelift techniques should be selected and
modified to suit the unique requirements of every individual
face.
found that a majority of patients deviate from these propor-
tions.192,193 The upper half of the face, especially in women, is
actually greater than the lower half, and the height of the nose
is typically less than the upper and lower thirds. Men typi-
cally have a larger lower third due to a more prominent
mandible, while women tend to have more equal lower and
middle thirds. Further consideration must be given to propor-
tional variations due to ethnicity, and these differences must
be respected when considering surgical changes. Further divi-
sion of the face into five major aesthetic masses (forehead,
eyes, nose, lips, and chin) allows a more detailed analysis.
Anthropometry is particularly useful in the preoperative
assessment of faces that will surgically undergo fundamental
shape change. This is most pronounced when the underlying
skeletal framework of the face is manipulated with orthogna-
thic procedures or with facial implants. In such cases, anthro-
pometric and cephalometric examination are an integral part
of surgical planning (Video 6.2.6
).
In the arena of facial rejuvenation surgery, facial shape
is an important consideration in determining the procedure
of choice for a given face.74,194 While formal cephalometric
Bonus content for this chapter can be found online at

Historical perspective
Anthropometrics and classical concepts of facial shape
Fig. 6.2.33 The Greek sculptor Polycleitus’ Doryphorus.
Fig. 6.2.34 Marquardt’s phi mask is based on the “golden ratio”.
35. Mitz V, Peyronie M. The superficial musculo-aponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg.
1976;58:80–88. This paper is the first description of the superficial
musculo-aponeurotic system.
46. Stuzin JM, Baker TJ, Gordon HL. The relationship of the
superficial and deep facial fascias: relevance to rhytidectomy and
aging. Plast Reconstr Surg. 1992;89:441–449, discussion 450–451.
Anatomic dissections confirm the presence of retaining ligaments
previously described by other authors as well as newly described
masseteric ligaments. The authors discuss the support these structures
supply between fixed bone and deep fascia and the superficial fascia.
63. Coleman SR. Facial recontouring with lipostructure. Clin Plast
Surg. 1997;24:347–367. A pioneer of facial fat grafting presents early
experience with lipoinjection of the face.
65. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy
and clinical implications for cosmetic surgery. Plast Reconstr Surg.
2007;119:2219–2227, discussion 2228–31. Anatomic dissections are
presented that demonstrate how the subcutaneous fat of the face is
partitioned into multiple, independent anatomical compartments. In
some locations, the septae dividing the fat compartments are aligned with
retaining ligaments.
71. Gosain AK, Amarante MT, Hyde JS, et al. A dynamic analysis of
changes in the nasolabial fold using magnetic resonance imaging:
implications for facial rejuvenation and facial animation surgery.
Plast Reconstr Surg. 1996;98:622–636. A comparative MRI study
demonstrates the changes in subcutaneous fat that develop with age. The
authors conclude that superficial fat in the cheek becomes ptotic while the
underlying elevators of the lip do not elongate with age.
120. Berry MG, Davies D. Platysma-SMAS plication facelift. J Plast
Reconstr Aesthet Surg. 2010;63:793–800. The authors describe their
logic for using soft-tissue plication and describe their particular method,
called the PSP lift (platysma-SMAS plication). A series of 117
consecutive patients is reported, all of whom were followed objectively
with a five-point scale. There was excellent improvement with a low
complication rate: 3.4% hematoma and 3.4% transient facial nerve
palsies.
122. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial
suspension lift: a modified S-lift. Plast Reconstr Surg.
2002;109:2074–2086. The authors report that in 1999 they modified the
previously described S-lift to include improved suture fixation and
soft-tissue elevation, which they named the MACS lift, an acronym for
minimal access cranial suspension. Two long loop sutures are used to
elevate facial soft tissue with fixation to the deep temporal fascia above
the zygomatic arch and a third suture is used for the malar fat pad in the
extended version of the procedure. A total of 88 patients over 20 months
were presented with a low complication rate. The operative technique is
described in detail.
123. Hoefflin SM. The extended supraplatysmal plane (ESP) face lift.
Plast Reconstr Surg. 1998;101:494–503. The author presents his logic
behind using a facelift flap that contains skin and all the subcutaneous
fat down to, but not including, the SMAS. The technique is described in
detail and the results with a series of 300 patients are presented. There
was high patient satisfaction reported, no nerve injuries, and relatively
rapid recovery.
124. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:509–
513. The author presents his personal evolution in arriving at the
SMASectomy technique, describing his logic in doing so, and reports a
series of 1500 cases over 5-year period. One transient buccal branch
injury was encountered. The author feels this technique affords a safe,
effective technique, but acknowledges that other techniques also produce
excellent results.
125. Skoog T. Plastic Surgery. Philadelphia, PA: W.B. Saunders
Company; 1974. In this classic text, the author describes the first
technique to utilize the subSMAS plane to elevate ptotic facial tissue.
Illustrations effectively convey the basics of this new technique.
128. Barton FE, Hunt J. The high-superficial musculoaponeurotic
system technique in facial rejuvenation: an update. Plast Reconstr
Surg. 2003;112:1910–1917. This is a follow-up of a previous publication
by Barton that described his variation for a SMAS-based facelift
technique called the high SMAS technique. In this paper, 267 patient
records were reviewed using the nasolabial fold as an indicator of surgical
result 6 months after surgery. Using this hard endpoint, improvement
was almost universally achieved with a low complication rate.
Recommendations are made as to the extent of dissection required based
on depth of the nasolabial fold.
131. Marten TJ. High SMAS facelift: combined single flap lifting of the
jawline, cheek, and midface. Clin Plast Surg. 2008;35:569–603,
vi–vii. The review article outlines the author’s logic in utilizing a
two-layer facelift, emphasizing that skin has a covering function, and
that deep tissue manipulation is necessary for facial reshaping. The high
SMAS facelift is described in detail, with emphasis on skin incisions, and
the proper selection of vectors.
149. Chang S, Pusic A, Rohrich RJ. A systematic review of comparison
of efficacy and complication rates among face-lift techniques. Plast
Access the complete reference list online at

143
Facial analysis, anthropometrics and concepts of facial shape
Reconstr Surg. 2011;127:423–433. This paper presents the results of a
systematic review that assessed all studies in the English language
literature from 1950 until 2009 in which there was a comparison of
facelift techniques. There were 57 studies identified; only 10 of these
directly compared the efficacy of different facelift techniques. The study
found there to be a lack of quality data regarding the efficacy and safety
of facelift techniques and concluded that there was no evidence to support
the use of any one facelift technique over another.
175. Jones BM, Grover R. Avoiding hematoma in cervicofacial
rhytidectomy: a personal 8-year quest. Reviewing 910 patients.
Plast Reconstr Surg. 2004;113:381–387, discussion 388–90. The
authors review a large facelift series where the most common
complication of facelift surgery, hematoma, is addressed. Variables
thought to influence the formation of hematoma are reviewed,
including the use of dressings, drains, soft-tissue adhesives, and
epinephrine.

143.e1
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115. Tonnard PL. The Macs-Lift Short Scar Rhytidectomy. St. Louis, MO:
Quality Medical Publishing Inc.; 2004.
116. Psillakis JM, Connell BF, Marten TJ. Deep layer techniques in
cervicofacial rejuvenation. In: Deep Face-Lifting Techniques. New
York, NY: Thieme Medical Publishers; 1994.
117. Baker DC. Minimal incision rhytidectomy (short scar face lift) with
lateral SMASectomy. Aesthet Surg J. 2001;21:68–79.
118. Marchac D, Brady J, Chiou P. Face lifts with hidden scars: the
vertical U incision. Plast Reconstr Surg. 2002;109:2539–2551,
discussion 2552–4.
119. Robbins LB, Brothers DB, et al. Anterior SMAS plication for the
treatment of prominent nasomandibular folds and restoration of
normal cheek contour. Discussion. Plast Reconstr Surg. 1995;96:
1279–1288.
120. Berry MG, Davies D. Platysma-SMAS plication facelift. J Plast
Reconstr Aesthet Surg. 2010;63:793–800. The authors describe their
logic for using soft-tissue plication and describe their particular method,
called the PSP lift (platysma-SMAS plication). A series of 117
consecutive patients is reported, all of whom were followed objectively
with a five-point scale. There was excellent improvement with a low
complication rate: 3.4% hematoma and 3.4% transient facial nerve
palsies.
121. Saylan Z. The S-lift: less is more. Aesthet Surg J. 1999;19:406–409.
122. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial
suspension lift: a modified S-lift. Plast Reconstr Surg.
2002;109:2074–2086. The authors report that in 1999 they modified the
previously described S-lift to include improved suture fixation and
soft-tissue elevation, which they named the MACS lift, an acronym for
minimal access cranial suspension. Two long loop sutures are used to
elevate facial soft tissue with fixation to the deep temporal fascia above
the zygomatic arch and a third suture is used for the malar fat pad in the
extended version of the procedure. A total of 88 patients over 20 months
were presented with a low complication rate. The operative technique is
described in detail.
123. Hoefflin SM. The extended supraplatysmal plane (ESP) face lift.
Plast Reconstr Surg. 1998;101:494–503. The author presents his logic
behind using a facelift flap that contains skin and all the subcutaneous
fat down to, but not including, the SMAS. The technique is described in
detail and the results with a series of 300 patients are presented. There
was high patient satisfaction reported, no nerve injuries, and relatively
rapid recovery.
124. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:509–
513. The author presents his personal evolution in arriving at the
SMASectomy technique, describing his logic in doing so, and reports a
series of 1500 cases over 5-year period. One transient buccal branch
injury was encountered. The author feels this technique affords a safe,
effective technique, but acknowledges that other techniques also produce
excellent results.
125. Skoog T. Plastic Surgery. Philadelphia, PA: W.B. Saunders
Company; 1974. In this classic text, the author describes the first
technique to utilize the subSMAS plane to elevate ptotic facial tissue.
Illustrations effectively convey the basics of this new technique.
126. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg.
1992;90:1–13.
127. Hamra ST. The zygorbicular dissection in composite rhytidectomy:
an ideal midface plane. Plast Reconstr Surg. 1998;102:1646–1657.
128. Barton FE, Hunt J. The high-superficial musculoaponeurotic
system technique in facial rejuvenation: an update. Plast Reconstr
Surg. 2003;112:1910–1917. This is a follow-up of a previous publication
by Barton that described his variation for a SMAS-based facelift
technique called the high SMAS technique. In this paper, 267 patient
records were reviewed using the nasolabial fold as an indicator of surgical
result 6 months after surgery. Using this hard endpoint, improvement
was almost universally achieved with a low complication rate.
Recommendations are made as to the extent of dissection required based
on depth of the nasolabial fold.
129. Owsley JQ. Platysma-fascial rhytidectomy: a preliminary report.
Plast Reconstr Surg. 1977;60:843–850.
130. Connell BF. Eyebrow, face, and neck lifts for males. Clin Plast Surg.
1978;5:15–28.
131. Marten TJ. High SMAS facelift: combined single flap lifting of the
jawline, cheek, and midface. Clin Plast Surg. 2008;35:569–603,
vi–vii. The review article outlines the author’s logic in utilizing a
two-layer facelift, emphasizing that skin has a covering function, and
that deep tissue manipulation is necessary for facial reshaping. The high
SMAS facelift is described in detail, with emphasis on skin incisions, and
the proper selection of vectors.
132. Aston SJ. The FAME technique. Presented at the Aging Face
Symposium, Waldorf Astoria Hotel, New York; 1993.
133. Aston SJ, Walden J. Facelift with SMAS technique and FAME. In:
Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery.
Philadelphia, PA: Saunders Elsevier; 2009.
134. Warren R. The oblique SMAS with malar fat pad elevation. Presented
at the Canadian Society for Aesthetic Plastic Surgery 29th Annual
Meeting, Toronto, Ontario; 2002.
135. Tessier P. [Subperiosteal face-lift]. Ann Chir Plast Esthet. 1989;34:
193–197.
136. De La Plaza R, Valiente E, Arroyo JM. Supraperiosteal lifting of the
upper two-thirds of the face. Br J Plast Surg. 1991;44:325–332.

143.e4
SECTION I
CHAPTER 6.2 • Facelift: Principles of and surgical approaches to facelift
137. Hinderer UT. The sub-SMAS and subperiosteal rhytidectomy of
the forehead and middle third of the face: a new approach to the
aging face. Facial Plast Surg. 1992;8:18–32.
138. Byrd HS, Andochick SE. The deep temporal lift: a multiplanar,
lateral brow, temporal, and upper face lift. Plast Reconstr Surg.
1996;97:928–937.
139. Hunt JA, Byrd HS. The deep temporal lift: a multiplanar lateral
brow, temporal, and upper face lift. Plast Reconstr Surg.
2002;110:1793–1796.
140. Rees TD, Aston SJ. A clinical evaluation of the results of
submusculo-aponeurotic dissection and fixation in face lifts. Plast
Reconstr Surg. 1977;60:851–859.
141. Webster RC, Smith RC, Papsidero MJ, et al. Comparison of SMAS
plication with SMAS imbrication in face lifting. Laryngoscope.
1982;92(8 Pt 1):901–912.
142. Ivy EJ, Lorenc ZP, Aston SJ. Is there a difference? A prospective
study comparing lateral and standard SMAS face lifts with
extended SMAS and composite rhytidectomies. Plast Reconstr Surg.
1996;98:1135–1143, discussion 1144–7.
143. Kamer FM, Frankel AS. SMAS rhytidectomy versus deep plane
rhytidectomy: an objective comparison. Plast Reconstr Surg.
1998;102:878–881.
144. Becker FF, Bassichis BA. Deep-plane face-lift vs. superficial
musculoaponeurotic system plication face-lift: a comparative
study. Arch Facial Plast Surg. 2004;6:8–13.
145. Zager WH, Dyer WK. Minimal incision facelift. Facial Plast Surg.
2005;21:21–27.
146. Prado A, Andrades P, Danilla S, et al. A clinical retrospective study
comparing two short-scar face lifts: minimal access cranial
suspension versus lateral SMASectomy. Plast Reconstr Surg.
2006;117:1413–1425, discussion 1426–7.
147. Antell DE, Orseck MJ. A comparison of face lift techniques in eight
consecutive sets of identical twins. Plast Reconstr Surg.
2007;120:1667–1673.
148. Alpert BS, Baker DC, Hamra ST, et al. Identical twin face lifts with
differing techniques: a 10-year follow-up. Plast Reconstr Surg.
2009;123:1025–1033, discussion 1034–6.
149. Chang S, Pusic A, Rohrich RJ. A systematic review of comparison
of efficacy and complication rates among face-lift techniques. Plast
Reconstr Surg. 2011;127:423–433. This paper presents the results of a
systematic review that assessed all studies in the English language
literature from 1950 until 2009 in which there was a comparison of
facelift techniques. There were 57 studies identified; only 10 of these
directly compared the efficacy of different facelift techniques. The study
found there to be a lack of quality data regarding the efficacy and safety
of facelift techniques and concluded that there was no evidence to support
the use of any one facelift technique over another.
150. Fogli AL. pers. comm. (2010)
151. Fogli AL. Skin and platysma muscle anchoring. Aesthetic Plast
Surg. 2008;32:531–541.
152. Courtiss EH. Suction lipectomy of the neck. Plast Reconstr Surg.
1985;76:882–889.
153. Vistnes LM, Souther SG. The anatomical basis for common
cosmetic anterior neck deformities. Ann Plast Surg. 1979;2:
381–388.
154. de Castro CC. The anatomy of the platysma muscle. Plast Reconstr
Surg. 1980;66:680–683.
155. Pelle-Ceravolo M, Angelini M, Silvi E. Treatment of Anterior Neck
Aging without a Submental Approach: Lateral Skin-Platysma
Displacement, a New and Proven Technique for Platysma Bands
and Skin Laxity. Plast Reconstr Surg. 2017;139(2):308–321.
156. Knize DM. Limited incision submental lipectomy and
platysmaplasty. Plast Reconstr Surg. 1998;101:473–481.
157. Feldman JJ. Neck Lift. St. Louis, MO: Quality Medical Publishing
Inc.; 2007.
158. Sullivan PK, Freeman MB, Schmidt S. Contouring the aging neck
with submandibular gland suspension. Aesthet Surg J.
2006;26:465–471.
159. Singer DP, Sullivan PK. Submandibular gland I: an anatomic
evaluation and surgical approach to submandibular gland
resection for facial rejuvenation. Plast Reconstr Surg. 2003;112:1150–
1154, discussion 1155–6.
160. Zins JE, Fardo D. The “anterior-only” approach to neck
rejuvenation: an alternative to face lift surgery. Plast Reconstr Surg.
2005;115:1761–1768.
161. Gradinger GP. Anterior cervicoplasty in the male patient. Plast
Reconstr Surg. 2000;106:1146–1154, discussion 1155.
162. Coleman SR, ed. Structural Fat Grafting. St. Louis, MO: Quality
Medical Publishing Inc.; 2004. This text is a comprehensive review of
the history, basic science, and technical details of fat harvest and fat
injection.
163. Trepsat F. Volumetric face lifting. Plast Reconstr Surg. 2001;108:
1358–1370, discussion 1371–9.
164. Roberts TL, Pozner JN, Ritter E. The RSVP facelift: a highly
vascular flap permitting safe, simultaneous, comprehensive facial
rejuvenation in one operative setting. Aesthetic Plast Surg.
2000;24:313–322.
165. Hester TR, Codner MA, McCord CD. Subperiosteal malar cheeklift
with lower lid blepharoplasty. In: Eyelid Surgery: Principles and
Techniques. New York, NY: Lippincott-Raven; 1995.
166. Moelleken B. The superficial subciliary cheek lift, a technique for
rejuvenating the infraorbital region and nasojugal groove: a
clinical series of 71 patients. Plast Reconstr Surg. 1999;104:1863–
1874, discussion 1875–6.
167. Le Louarn C. The concentric malar lift: malar and lower eyelid
rejuvenation. Aesthetic Plast Surg. 2004;28:359–372, discussion 373–4.
168. Hester TR, Codner MA, McCord CD, et al. Evolution of technique
of the direct transblepharoplasty approach for the correction of
lower lid and midfacial aging: maximizing results and minimizing
complications in a 5-year experience. Plast Reconstr Surg.
2000;105:393–406, discussion 407–8.
169. Anderson RD, Lo MW. Endoscopic Malar/Midface Suspension
Procedure. Plast Reconstr Surg. 1998;102:2196–2208.
170. Austin HW. The lip lift. Plast Reconstr Surg. 1986;77:990–994.
171. Austin HW, Weston GW. Rejuvenation of the aging mouth. Clin
Plast Surg. 1992;19:511–524.
172. Baker DC, Aston SJ, Guy CL, et al. The male rhytidectomy. Plast
Reconstr Surg. 1977;60:514–522.
173. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of
hematoma requiring surgical evacuation following male
rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg.
2005;116:1973–1985, discussion 1986–7.
174. Grover R, Jones BM, Waterhouse N. The prevention of haematoma
following rhytidectomy: a review of 1078 consecutive facelifts. Br J
Plast Surg. 2001;54:481–486.
175. Jones BM, Grover R. Avoiding hematoma in cervicofacial
rhytidectomy: a personal 8-year quest. Reviewing 910 patients.
Plast Reconstr Surg. 2004;113:381–387, discussion 388–90. The
authors review a large facelift series where the most common
complication of facelift surgery, hematoma, is addressed. Variables
thought to influence the formation of hematoma are reviewed, including
the use of dressings, drains, soft-tissue adhesives, and epinephrine.
176. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy.
Anatomical variations and pitfalls. Plast Reconstr Surg.
1979;64:781–795.
177. Zoumalan RA, Rosenberg DB. Methicillin-resistant Staphylococcus
aureus-positive surgical site infections in face-lift surgery. Arch
Facial Plast Surg. 2008;10:116–123.
178. Ullmann Y, Levy Y. Superextended facelift: our experience with
3,580 patients. Ann Plast Surg. 2004;52:8–14.
179. Matarasso A, Elkwood A, Rankin M, et al. National plastic surgery
survey: face lift techniques and complications. Plast Reconstr Surg.
2000;106:1185–1195, discussion 1196.
180. Snijder GAS. Het Onstaan van den Proportie-Kanon bij de Grieken.
Utrecht: A. Oosthoek; 1928.
181. Broadbent BH. A new X-ray technique and its application to
orthodontia. Angle Orthod. 1931;1:45.
182. Broadbent BH. The face of the normal child. Angle Orthod.
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References
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186. Ricketts RM. Divine proportion in facial esthetics. Clin Plast Surg.
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188. Bashour M. An objective system for measuring facial
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189. Guyuron B. Discussion: an objective system for measuring facial
attractiveness. Plast Reconstr Surg. 2006;118:775–776.
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component face lift: developing a systematic approach to facial
rejuvenation. Plast Reconstr Surg. 2009;123:1050–1063.

SECTION I • Aesthetic Surgery of the Face
6.3 
Facelift: Platysma-SMAS plication
Miles G. Berry, James D. Frame, and Dai M. Davies
SYNOPSIS
■ Predominantly oblique, but allows multi-vector traction to individualize
the facelift.
■ Sutures placed closer to the point of lift have the best effect.
■ Delivers a good malar auto-augmentation.
■ Offers reduced downtime.
■ Safe and ideal for thin, attenuated SMAS layers or repeat facelifts.
Introduction
As summarized in Chapter 6.2, facelifting has made great
developmental strides from the skin-only procedures of the
early 20th century. Today, surgeons are faced with an almost
bewildering array of techniques and tissue planes from which
to choose. Whilst each technique will be strongly supported
by its proponent, most will be based on the superficial
musculo-aponeurotic system (SMAS), originally highlighted
by Skoog in the 1970s1 and detailed in Mitz and Peyronie’s
now classic treatise.2 The question remains precisely what to
do with the SMAS in order to balance invasiveness, and thus
tissue trauma from which the patient must recover, with risk
and longevity.
Options for SMAS manipulation include elevation and
advancement,3 dissection at various planes,4,5 combination
with mesh to augment malar projection,6 excision,7 or plica-
tion.8 The multiplicity of techniques bears testament to the fact
that the universal procedure continues to elude us. There is
also evidence of little practical difference, in either short9 or
long term, between techniques of varying aggressivity;10,11
therefore, procedures with lower inherent risk to important
structures, such as the facial nerve, may well be safer. Limita-
tions noted include inconsistent results, a less-than-impressive
effect on the nasolabial folds and jowls, and lengthy opera-
tions with extended periods of careful surgery, particularly
with anterior SMAS dissection. Furthermore, the SMAS is
relatively avascular,12 perhaps behaving more as a graft in
certain circumstances, and may be thin and attenuated thus
providing poor anchorage for sutures. In revision or second-
ary surgery, the poverty of vascular supply to the undermined
SMAS may present the surgeon with little more than a mass
of scar tissue.
Given the inexorable drive towards minimally invasive
techniques, primarily to reduce recovery time but also to limit
facial nerve complications, the minimal access cranial suspen-
sion (MACS) lift was initially enthusiastically promoted.13 It
has proven effective in younger patients with early jowling,
minimal neck ptosis, and the desire for rapid recovery. Itself
a derivation of Saylan’s “S-lift”,14 the MACS lift has, however,
shown certain limitations with time and experience. One, the
relative lack of malar augmentation, was addressed by the
addition of a third suture and quickly became routine.15
Precise purse-string suture placement, however, can be chal-
lenging, and subcutaneous irregularities may not always
settle as well as described. The authors feel it does not always
have a sufficiently potent effect on the lateral neck of older
patients and is rather painful initially, with the added limita-
tion of constrained mouth opening.13 Finally, there are two
areas of tissue excess, or dog-ears, in pure vertical-vector lifts,
which may fail to settle satisfactorily. The first lies inferior to
the lobule. The second, cutaneous bunching at the lateral
canthus, is particularly pronounced with the powerful suture
of the extended MACS15 and frequently needs a lower lid
blepharoplasty incision; however, not all patients wish for
either this additional procedure or its attendant scar. More-
over, restricting tension to the SMAS rather than the skin, both
cutaneous dog-ears and scar stretch3 are minimized.
Experience with these limitations led the authors to the use
of sutures to plicate the SMAS, a procedure termed the
“platysma-SMAS plication” (PSP) lift. Its advantages (Table
6.3.1) include an oblique posterosuperior, as opposed to
purely vertical, vector, which allows a lift tailored to each
individual. The vertically extended skin incision permits
synchronous temporal lift and reduces sideburn elevation and
a visible scar.16,17 Concealing the scar within temporal hair
allows greater flexibility with no risk of highly visible alopecia
  Access video and video lecture content for this chapter online at expertconsult.com

145
Evaluation
in a posterosuperior direction to provide a satisfactory effect
on the jowl (Fig. 6.3.2). The key suture, using 2-0 polydioxa-
none (PDS) (Johnson & Johnson Medical Ltd, Wokingham,
UK), is then inserted to attach this SMAS to the relatively
immobile preauricular parotid-masseteric fascia. Similar
platysma-mastoid sutures (Fig. 6.3.3) serve to tighten cervical
platysma, enhance mandibular angle definition, and help
prevent pixie ear deformity.19 Any surface irregularities are
addressed by suture imbrication with 3-0 Vicryl (Johnson &
Johnson). Excess SMAS in the infralobular region is excised,
following hydrodissection, and closed with 2-0 PDS. Follow-
ing meticulous hemostasis, excess skin is trimmed and closed
without tension over a small suction drain with 4-0 and 6-0
nylon. A light, compressive facelift dressing remains overnight
and is removed with the drain the following morning. These
can be similarly removed immediately prior to discharge in
day-case patients. Sutures are removed at 4–6 days.
Evaluation
Patients and methods
The PSP lift was initiated over a decade ago and a consecutive
cohort of 122 patients reported.20 Pusic et al.’s FACE-Q21 evalu-
ation system was not yet available, so a simple Likert scale
allowed both patient and surgeon to contribute to the assess-
ment. Kappa’s correlation provided the statistical analysis.
Results
Of the original cohort, five were lost to follow-up or had
insufficient data for analysis. Of the remaining 117, the mean
age was 55 years (range 29–79) and all bar eight were women
(two male-to-female transgender patients were analyzed as
biologically male). General anesthesia was employed in the
majority, with only three undergoing sedation–local anesthe-
sia. Additional aesthetic procedures were performed in 104
patients (Table 6.3.2). The neck was addressed with a variety
of procedures in 92 (78.6%) (Table 6.3.3).
Overall, correlation was high (r = 0.76) between patient and
surgeon. Mean scores of 4.45 (range 2–5) and 4.49 (3–5) were
obtained for patients and surgeon respectively initially, and
4.43 (2–5) and 4.45 (3–5) finally. The same score was given
at both stages in 42.9%, improved with time in 39.3%, and
deteriorated in 17.8%.
between the helical root and hairline. A postauricular exten-
sion, not required in all cases, may be employed to ameliorate
the postauricular skin dog-ear, which adds to downtime and
has been similarly reported with the MACS.9 Actually, many
patients do not appreciate that scar length is not based
on surgical whim, rather the quantity of excess skin after
tightening.
With no sub-SMAS dissection, the PSP lift is safer, particu-
larly with respect to the facial nerve, and quicker. It is also
beneficial with poorly vascularized SMAS. Large bites of
SMAS allow greater security and, therefore, potential longev-
ity. A second layer of finer imbrication sutures produces both
a smooth finish and perhaps additional strength. The PSP lift
does produce two dog-ears in the subcutaneous layer. Fortu-
nately, the first, overlying the malar prominence, has the effect
of auto-augmentation and assists with the overall rejuvena-
tion by square-to-triangular facial shape reversion. The
second, in the infra-lobule region, is less beneficial but easily
excised; a maneuver common to both Baker’s7 and Water-
house’s modified SMASectomy procedures.18
Technique (Video 6.3.1 )
The surgical procedure is as follows: Patients are prepared as
for a standard facelift with tumescent subcutaneous infiltra-
tion (20 mL 0.5% bupivacaine and 1 mL 1 : 1000 adrenaline in
200 mL normal saline). The standard retrotragal incision
extends vertically in the temporal scalp and on occasion into
the postauricular sulcus as required (Fig. 6.3.1). A postauricu-
lar extension is used where required and subcutaneous dis-
section tailored to each patient. The anterior SMAS is grasped
Table 6.3.1  Comparison of chief features for the PSP and MACS
facelifts
Feature
PSP
MACS
Incision
Vertical temporal (±
postauricular extension)
Inverted L
(anterior only)
Skin flap
As required
Limited to 5 cm
oval
Dissection into
neck
Yes
No
Platysmaplasty
Direct (infralobular
excision)
Indirect
SMAS fixation
SMAS–SMAS
SMAS–deep
temporal fascia
Malar
augmentation
Yes
No
Vector
Cephaloposterior
Predominantly
vertical
Skin excision
Tailored, no tension
Tailored, high
tension
Neck
Multiple procedures
Liposuction in
>95%
Ancillary
procedures
Yes
No
PSP, platysma-SMAS plication; MACS, minimal access cranial suspension.
Table 6.3.2  Number of synchronous procedures
Procedure
n
Face alone
13
Face + 1 additional
40
Face + 2 additional
41
Face + 3 additional
12
Face + 4 additional
5
Face + non-face additional
6
Total
117
(Source: Berry MG, Davies DM. Platysma SMAS plication facelift. J Plast
Reconstr Aesthet Surg. 2010;63:793–800.)

146
SECTION I
CHAPTER 6.3 • Facelift: Platysma-SMAS plication
Fig. 6.3.1  Incision and area of subcutaneous dissection
employed with the platysma-SMAS plication (PSP) lift.
Note that the posterior extension is not always required
but is useful where excess skin remains in the neck after
SMAS plication. SMAS, musculo-aponeurotic system.
Complications
The most common complication was hematoma, which
occurred in four patients (3.4%), one following drain removal.
All underwent evacuation under local anesthesia without
apparent adverse effect on outcome (mean score 4.75). Some
degree of nerve dysfunction was noted in five patients. Of the
four with motor symptoms, only one lasted more than 6
weeks and was associated with ipsilateral infection. One with
unilateral dysesthesia was referred to a chronic pain clinic
Management of the neck
n
Liposuction alone
54
Band division + platysmaplasty
11
Liposuction + band division + platysmaplasty
9
Lipectomy + band division + platysmaplasty
6
Liposuction + platysmaplasty
3
Liposuction + lipectomy + band division + platysmaplasty
2
Lipectomy + platysmaplasty
2
Management of the neck
n
Band division alone
2
Liposuction + lipectomy
1
Liposuction + lipectomy + platysmaplasty
1
Liposuction + lipectomy + band division
1
Platysmaplasty alone
1
Total
92
(Source: Berry MG, Davies DM. Platysma SMAS plication facelift. J Plast Reconstr Aesthet Surg. 2010;63:793–800.)
Table 6.3.3  Type and number of options employed in management of the neck

147
Discussion
Fig. 6.3.2  Placement of the key suture, which takes a
generous bite of anterior musculo-aponeurotic system
(SMAS), tractioning it posterosuperiorly onto the
parotido-masseteric fascia. It can be trialed and its effect
easily measured by external observing of jowl reduction
and nasolabial fold effacement.
after 3 months. The rate of temporary nerve injury overall was
therefore 4.3%, motor 3.4%, and sensory 0.85%. Five patients
experienced delayed wound healing, all settling conserva-
tively, with oral antibiotics being required in a single case.
Two received intralesional steroid therapy for mild scar
hypertrophy. A small area of alopecia in the temporal incision,
not visible socially, improved spontaneously, and a single
patient underwent corrective fat transfer for persistent surface
irregularity. There was no statistically significant relationship
between any complication and hypertension, smoking, or
secondary surgery.
Discussion
Facial rejuvenation is increasingly viewed by patients as a
suitable recourse in a more ageist society where people live
longer and with better health. Interestingly, studies have
shown no significant differences between highly invasive and
less aggressive procedures,10,11 and more affluent, younger
patients are requesting procedures with as little downtime
as possible. The PSP facelift was designed to address these
issues.
It must be remembered that SMAS advancement, whether
composite or independent, exerts uniform traction, much like
braces on trousers. Elegant studies by Rohrich et al. revealed
discrete subcutaneous facial partitions that go a long way to
explaining why simple SMAS elevation–advancements often
provide only partial correction.22 The PSP lift exploits the fact
that the optimal effect from a suture derives from its proxim-
ity to the point of lift, and plication sutures can be placed
wherever they are required. This addresses one of the major
drawbacks of SMASectomies and conventional SMAS flaps,
where excision is remote from both jowl and nasolabial fold
(NLF). With the PSP lift, SMAS is sutured directly, rather than
the MACS lift’s purse-string, and has the potential for an
infinite multiplicity of vectors, to obtain a precise individual
tailoring. This differs from Robbins’ anterior plication, which
employs a vertical row of SMAS sutures lateral to the NLF.8
While addressing the NLF, this approach obliges anteroinfe-
rior traction on both lateral SMAS and malar fat, thus coun-
terbalancing malar augmentation.

148
SECTION I
CHAPTER 6.3 • Facelift: Platysma-SMAS plication
Additionally, traditional SMAS techniques with no specific
malar fat dissection have a limited effect on malar ptosis and
the NLF.3 As shown in Fig. 6.3.4, PSP can exert a powerful
effect on the malar prominence and NLF due to individualized
plication. Another advantage is that after initial plication, any
residual SMAS irregularities are addressed with secondary
imbrication to leave a smooth surface – this second layer
further contributing to the integrity of the SMAS fixation.
Personal experience has shown that the purse-string technique
may lead to irregularities, which do not always resolve as well
as claimed, leading to patient dissatisfaction. Debate continues
regarding where the anchorage point of the advanced SMAS
should be.25 Deep fixation often leaves the patient with
“marked pain and restricted mouth opening”,13 and the success
of SMASectomy procedures attests to the strength of SMAS–
SMAS fixation.7,18 Furthermore, there is the added benefit of
autologous malar augmentation as originally proposed by
Baker.7 The infralobular platysma-SMAS excess is excised (Fig.
6.3.5) and closed to remove the lateral swelling beneath the ear
lobe, a giveaway feature of more minimal techniques.
Many have reported that the SMAS progressively thins
anteriorly,3,7,10 particularly in secondary surgery.17 Saulis et al.
demonstrated both the weakness and reduced suture reten-
tion of the SMAS when raised alone,23 as compared to a SMAS
flap raised in continuity with the skin, a feature cited by
composite flap enthusiasts. However, they also demonstrated
reduced tissue creep and stress relaxation in the SMAS flap,
lending credence to SMAS-tightening procedures such as
plication, in the pursuit of surgical longevity. The degree of
skin flap undermining is also greater in the PSP than with
procedures such as the MACS in observance of Baker’s phi-
losophy that SMAS vectoring to give maximal anatomic
improvement is not adversely affected by employing a sepa-
rate vector for skin redraping.24
Minimal access supporters stress the importance of vertical
vectors13; however, facial aging occurs in multiple directions,
according to gravity, the locations of retaining ligaments,
and local muscular forces.16 With gravitational senescence
characterized by anteroinferior descent,7 it seems counterin-
tuitive to disregard some vectors at the expense of others.10
Fig. 6.3.3  Tying the key suture produces a “dog-ear” of
musculo-aponeurotic system (SMAS) that produces a
convenient malar auto-augmentation. A second suture
passes between the posterior platysma and the mastoid
fascia to complete the effect on the jowl and commence
the necklift.

149
Discussion
Fig. 6.3.4  Completion of the face and necklift, leaving
the beneficial malar dog-ear and excision of the
undesirable inferoposterior lobule dog-ear.
Fig. 6.3.5  Following tying of the platysma-mastoid suture, the infralobular excess is (A) marked and (B) excised prior to being sutured.
A
B

150
SECTION I
CHAPTER 6.3 • Facelift: Platysma-SMAS plication
Nerve dysfunction, particularly motor, remains the most
feared complication of any facelift, and in our series, none
were permanently affected. Of note, half underwent synchro-
nous endoscopic browlifts that more likely caused the frontal
branch palsies. Interestingly, all nerve complications occurred
in the first third of the study, indicating a learning curve. That
all motor function in this series recovered fully and rapidly
indicates the inherent safety of PSP, and assuages critics’ fears
that blind needle insertion into the premasseteric SMAS is
dangerous.
Patient satisfaction in our series was high (4.45 of 5) within
the limitations of the scoring system. High inter-observer
correlation lent further credence to what is effectively a sub-
jective assessment. Of those few who downgraded their
scores, three-quarters had experienced some problem, includ-
ing persistent dysesthesia, postoperative hematoma, and skin
flap telangiectasia, although all were considered by the
surgeon to have achieved at least a grade 4 surgical outcome.
The neck
The neck continues to be a challenging area for several reasons:
swelling and scarring seem to settle slowly, and platysmal
band correction is often incomplete. In addition, aggressive
submental lipectomy can leave irregularities in thinner skin
and may exacerbate residual jowling. Finally, seroma and
excess skin are a frequent source of complaint and secondary
surgery. The neck is a defining feature as small remnant imper-
fections can spoil an otherwise excellent result in the face.
Management of the neck, therefore, remains controversial,
with supporters at both minimal and aggressive ends of the
spectrum. That such a range and difference of opinion exists
indicates the universal procedure remains elusive, although
the pendulum has swung towards minimalism due to the
limited margin for technical error and healing irregulari-
ties.11,13 The viscoelastic properties of cervical flaps are
inherently different to facial flaps, with greater creep and
stress–relaxation allowing increased relapse, although the
reason for this remains unclear.23 The importance of the pos-
terosuperior part of the neck’s anterior triangle has been
highlighted recently with demonstration of a gliding plane
between the platysma and the sternocleidomastoid such that
superolateral traction exerts a powerful effect on both lateral
and anterior platysma.26
Waterhouse emphasized a similar concept18 for optimal
results in the neck, which we fully endorse. It is worth reiterat-
ing the advantage of infralobular dissection, with or without
a posterior incision, which allows SMAS anchoring to the
mastoid fascia for a strong lateral platysmaplasty. A little over
three-quarters of our patient cohort underwent some addi-
tional management of the neck, the majority (54 of 92) receiv-
ing liposuction alone. Following assessment, nine (7.7%) were
felt to have suboptimal neck outcomes. Distribution was
equal in the first and second halves of the study with no
obvious features to assist in the preoperative selection of such
patients. It is recognized that the follow-up period is short and
that the outcome score used did not specifically address the
neck. Jones and Lo27 looked specifically at neck skin laxity
after facelift procedures and were generally disappointed
with long-term results. Conversely they found the midface
remained in a good position suggesting that facelift per se had
limited influence in dealing with the hanging or banding neck
over time.
Of course, there are different opinions on how best to
elevate a slackening neck, and the general principle applied
to lifting the SMAS from the point of most laxity to give a
satisfactory result in facelift holds equally in the neck. Ana-
tomically, the ribbon-like structure of the platysma muscle is
initially elevated by traction on the SMAS during vertical
vector SMAS facelift. With conventional sutures being above
the jawline, it may be of little surprise that neck laxity recurs,
often within a few weeks after facelift, unless additional
consideration to this area is applied (Fig. 6.3.6).
The surgical options for correction of neck laxity depend
upon the underlying anatomical structures. The founda-
tion upon which all soft tissues are based is the skeleton
and the retruded or projecting mandible with malocclusion
critically impacts neck definition. Soft-tissue variables such
as the congenitally variable platysma midline raphe posi-
tion, sub- and/or supraplatysmal fat pad volume, and skin
laxity contribute to the picture of the hanging “turkey neck”
(Fig. 6.3.7) or platysmal banding associated with aging skin.
Fig. 6.3.6  The 3-month postoperative lateral view in a female having undergone
vector-pull facelift.
Fig. 6.3.7  The classical “turkey neck” seen on profile view in a 63-year old male.

151
Conclusion
Fig. 6.3.8  (A–D) Preoperative images of a 53-year-old woman undergoing I-Guide platysmaplasty. Postoperative views 1 year after surgery.
A
B
C
D
Fig. 6.3.9  (A–E) Operative series in a middle-aged woman showing the stages involved in platysmal band release using the Gigli technique. This series demonstrates the
use of a straight needle and 3-0 Vicryl (Ethicon) to divide preoperatively marked platysmal bands. The skin and platysma are pinched free from the comparatively immobile
deeper structures, and the straight needle is passed behind the platysma. Just before complete exit, the blunt end of the needle is re-passed in front of the platysma to exit
from the same entry point and thus encircles the muscle. By using a saw-like action of the two suture ends, as when using an orthopedic Gigli saw to divide bone, the
platysmal band is safely and easily divided.
A
B
C
D
E
The surgical options are best understood according to a
skeletal and soft-tissue assessment. Most commonly, at the
time of facelift the neck skin is redraped after a vector pull
of SMAS following lipocutaneous mobilization of the skin
from platysma. At this stage, there are those that benefit from
a suture suspension platysmaplasty, as with the I-Guide,28
which may include a neck-defining suture as described by
Mueller29 (Fig. 6.3.8). Where platysmal bands are apparent,
they can be released using a “Gigli” technique (Fig. 6.3.9A–E)
or via open release with or without platysmaplasty, but in
all cases it is important to prevent vertical dislocation of the
submandibular gland. Digastric bands may need releasing
and relocating but this is a rare necessity. Finally, when all else
fails, the best, and most direct, option is for open excision of
the redundant tissue. Access to the muscles after skin removal
is amazingly clear and allows very precise redraping and
neckline definition. In the aging skin, the scars are usually
excellent.
Conclusion
The use of suture plication of the SMAS has been encouraging
both for aesthetic outcome, complication rate and – with 10-
year follow up in the early patients now available – durability
(Fig. 6.3.10). The PSP facelift seeks to combine the advantages
of SMAS advancement with those of plication whilst minimiz-
ing complications and maximizing outcome. It has a sound
anatomical basis, allowing individual, and differential, SMAS
and skin vectoring for specific anatomical correction and to
help ameliorate asymmetry. Moreover, the technique is safe
to perform and readily learned by the less experienced. The
PSP facelift is suitable for either day-case surgery as a single
procedure or combined with other procedures, and is par-
ticularly good for autologous malar augmentation. It works
particularly well where the facial ptosis is concentrated in the
midface and the jowl and has been noted by our patients to
settle rapidly, thereby minimizing downtime.

152
SECTION I
CHAPTER 6.3 • Facelift: Platysma-SMAS plication
Fig. 6.3.10  (A–C) A 54-year-old female former heavy smoker prior to platysma-SMAS plication (PSP) facelift with synchronous endoscopic browlift and perioral CO2 laser.
(D–F) Same patient 1-year postoperatively demonstrating the dual effects on jowl and cervicomental angle improvement. In this instance, malar auto-augmentation is
modest but present. (G–I) Now over 10 years after the original surgery, she remains delighted by both the durability and natural appearance of her PSP facelift.
A
B
C
D
E
F
G
H
I
2. Mitz V, Peyronie M. The superficial musculo-aponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg.
1976;58:80–88. A classic facelift paper in which the SMAS was described.
It opened up a new field for surgery and study in addition to the benefits
of much improved longevity over skin-only lifts.
5. Hamra ST. The zygorbicular dissection in composite rhytidectomy:
An ideal midface plane. Plast Reconstr Surg. 1998;102:1646–1657.
6. Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting:
enhanced facial contour using Vicryl mesh incorporated into SMAS
fixation. Plast Reconstr Surg. 2000;105:290–301. Describes the use of
Vicryl mesh to both improve the fixation and enhance overall contour. This
technique excises no SMAS but utilizes the excess to augment the malar
area.
8. 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;96:1279–1287.
10. Ivy EJ, Lorenc PZ, Aston SJ. Is there a difference? A prospective
study comparing lateral and standard SMAS facelifts with extended
SMAS and composite rhytidectomies. Plast Reconstr Surg.
1996;98:1135–1143. A study with the dual interest of both being able to
undertake different procedures on opposite sides, in addition to the finding
that significant differences were hard to detect.
11. Alpert BS, Baker DC, Hamra ST, et al. Identical twin face lifts with
differing techniques: a 10-year follow-up. Plast Reconstr Surg.
2009;123:1025–1033.
13. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial
suspension lift: a modified S-lift. Plast Reconstr Surg.
2002;109:2074–2086.
16. Mendelson BC. Surgery of the superficial musculoaponeurotic
system: principles of release, vectors, and fixation. Plast Reconstr
Surg. 2001;107:1545–1552. The scholarly treatise of anatomy and vectors
now accepted as one of the benchmarks of principles underpinning
facelifting.
23. Saulis AS, Lautenschlanger EP, Mustoe TA. Biomechanical and
viscoelastic properties of skin, SMAS and composite flaps as they
pertain to rhytidectomy. Plast Reconstr Surg. 2002;110:590–598.
26. Labbé D, Franco RG, Nicolas J. Platysma suspension and
platysmaplasty during neck lift: anatomical study and analysis of
30 cases. Plast Reconstr Surg. 2006;117:2001–2007. An elegant study
that goes a long way to explaining why the neck is frequently the most
disappointing part of a facelift.
Access the complete reference list online at

152.e1
References
References
1. Skoog T. Plastic Surgery. Philadelphia, PA: W.B. Saunders;
1974:300–330.
2. Mitz V, Peyronie M. The superficial musculo-aponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg.
1976;58:80–88. A classic facelift paper in which the SMAS was described.
It opened up a new field for surgery and study in addition to the benefits
of much improved longevity over skin-only lifts.
3. Owsley JQ. Platysma-fascial rhytidectomy: a preliminary report.
Plast Reconstr Surg. 1977;59:843–850.
4. Hamra ST. The deep plane rhytidectomy. Plast Reconstr Surg.
1990;86:53–61.
5. Hamra ST. The zygorbicular dissection in composite rhytidectomy:
An ideal midface plane. Plast Reconstr Surg. 1998;102:1646–1657.
6. Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting:
enhanced facial contour using Vicryl mesh incorporated into SMAS
fixation. Plast Reconstr Surg. 2000;105:290–301. Describes the use of
Vicryl mesh to both improve the fixation and enhance overall contour. This
technique excises no SMAS but utilizes the excess to augment the malar
area.
7. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:
509–513.
8. 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;96:1279–1287.
9. Prado A, Andrades P, Danilla S, et al. A clinical retrospective study
comparing two short-scar face lifts: minimal access cranial
suspension versus lateral SMASectomy. Plast Reconstr Surg.
2006;117:1413–1425.
10. Ivy EJ, Lorenc PZ, Aston SJ. Is there a difference? A prospective
study comparing lateral and standard SMAS facelifts with extended
SMAS and composite rhytidectomies. Plast Reconstr Surg.
1996;98:1135–1143. A study with the dual interest of both being able to
undertake different procedures on opposite sides, in addition to the finding
that significant differences were hard to detect.
11. Alpert BS, Baker DC, Hamra ST, et al. Identical twin face lifts with
differing techniques: a 10-year follow-up. Plast Reconstr Surg.
2009;123:1025–1033.
12. Whetzel TP, Stevenson TR. The contribution of the SMAS to the
blood supply in the lateral face lift flap. Plast Reconstr Surg.
1997;100:1011–1018.
13. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial
suspension lift: a modified S-lift. Plast Reconstr Surg.
2002;109:2074–2086.
14. Saylan Z. Purse string-formed plication of the SMAS with fixation
to the zygomatic bone. Plast Reconstr Surg. 2002;110:667–671.
15. Verpaele A, Tonnard P, Guerao FP, et al. The third suture in
MACS-lifting: making midface-lifting simple and safe. J Plast
Reconstr Aesthet Surg. 2007;60:1287–1295.
16. Mendelson BC. Surgery of the superficial musculoaponeurotic
system: principles of release, vectors, and fixation. Plast Reconstr
Surg. 2001;107:1545–1552. The scholarly treatise of anatomy and vectors
now accepted as one of the benchmarks of principles underpinning
facelifting.
17. Guyuron B. Secondary rhytidectomy. Plast Reconstr Surg.
2004;114:797–800.
18. Waterhouse N, Vesely M, Bulstrode NW. Modified lateral
SMASectomy. Plast Reconstr Surg. 2007;119:1021–1026.
19. Stanek JJ, Berry MG. Platysma-mastoid suture to prevent ear lobule
deformity following facelift. J Plast Reconstr Aesthet Surg.
2009;62:e615–e616.
20. Berry MG, Davies DM. Platysma SMAS plication facelift. J Plast
Reconstr Aesthet Surg. 2010;63:793–800.
21. Klassen AF, Cano SJ, Scott A, et al. Measuring patient-reported
outcomes in facial aesthetic patients: development of the FACE-Q.
Facial Plast Surg. 2010;26:303–309.
22. Rohrich RJ, Pesa JE. The fat compartments of the face: anatomy and
clinical implications for cosmetic surgery. Plast Reconstr Surg.
2007;119:2219–2227.
23. Saulis AS, Lautenschlanger EP, Mustoe TA. Biomechanical and
viscoelastic properties of skin, SMAS and composite flaps as they
pertain to rhytidectomy. Plast Reconstr Surg. 2002;110:590–598.
24. Baker TJ. Rhytidectomy: a look back and a look forward. Ann Plast
Surg. 2005;55:565–570.
25. Baker TJ, Stuzin JM. Personal technique of face lifting. Plast Reconstr
Surg. 1997;100:502–508.
26. Labbé D, Franco RG, Nicolas J. Platysma suspension and
platysmaplasty during neck lift: anatomical study and analysis of
30 cases. Plast Reconstr Surg. 2006;117:2001–2007. An elegant study
that goes a long way to explaining why the neck is frequently the most
disappointing part of a facelift.
27. Jones BM, Lo SJ. How long does a face lift last? Objective and
subjective measurements over a 5-year period. Plast Reconstr Surg.
2012;130:1317–1327.
28. Mueller GP, Leaf N, Aston SJ, et al. The percutaneous trampoline
platysmaplasty: technique and experience with 105 consecutive
patients. Aesthet Surg J. 2012;32:11–24.
29. Mueller GP, et al. Personal communication. 2015.

SECTION I • Aesthetic Surgery of the Face
6.4 
Facelift: Facial rejuvenation with loop
sutures – the MACS lift and its derivatives
Mark Laurence Jewell
SYNOPSIS
■ Limit undermining of skin to planned areas for suture loops or for
redraping of skin. The indiscriminate delamination of skin of neck
structures or in the postauricular region can unduly influence outcomes.
Undermine only as necessary to accomplish the lift, not more.
■ Ensure that the neck loop suture has a good bite of platysma fascia.
This is important to prevent failure of the necklifting component.
■ Do not make the cheek loop too small. This can result in a wad of
tissue that cannot be made smooth.
■ Understand the ability that you have to innovate with the MACS lift,
based on your patient’s individual needs. Too often, we become
wedded to a sequence of techniques and ancillary procedures that
limits our ability to individualize and adapt for each of your patients.
■ The MACS suture loop suspension approach works nicely in
secondary or revisionary situations, where there has been earlier deep
layer work and repeat deep layer dissections could be both challenging
and risky. MACS loop sutures hold well in scar from previous surgery.
■ Critical evaluation of outcomes is part of the learning process in terms
of determining what went right and areas that require improvement.
Refinement of technique comes with an honest analysis of the outcome.
Introduction
Facial rejuvenation surgery has had an interesting evolution
over the last 75 years. It is an interesting exercise to examine
the chronicle of progress of facial rejuvenation surgery and at
the same time, critically ask ourselves, “What were they
thinking when they came up with that particular procedure
for facial rejuvenation?” Our concept regarding facial rejuve-
nation has evolved beyond surgical technique to now encom-
pass facial aesthetics, ancillary treatments, biomechanics of
facial rejuvenation, and consumer preferences for less invasive
procedures with rapid recovery.
In retrospect, we have moved back and forth between a
variety of technical solutions versus a more holistic process of
how to optimally deliver operational excellence in facial reju-
venation for a diverse patient population. As a surgeon, it is
sometimes easier to fall in love with a single technique of facial
rejuvenation and not engage in critical thinking about the
shortcomings and trade-offs of that particular technique. At the
same time, when confronted with newer techniques and con-
cepts for facial rejuvenation, many surgeons adopt a defensive
reasoning mindset that prevents adoption of these approaches.
MACS lift is an acronym for “minimal access cranial sus-
pension”.1 The first time that I (the author) read the MACS
short scar rhytidectomy paper by Tonnard et al.,2–5 it seemed
a puzzling principle that relied on suture loop suspension to
a cranial anchoring point, far different from the sheet tighten-
ing approach of the classic SMAS-lift that I was performing
at the time. It took a trip to the anatomy lab and a visit with
Tonnard and Verpaele in Belgium to convince me that there
was something different (and possibly better) about the MACS
lift. Once this approach for facial rejuvenation was examined
in light of other publications by Labbé,6 Mendelson,7 Besins,8
Pessa/Rohrich,9 and Gardetto,10 there actually appeared to be
a unifying concept that has scientific and biomechanical valid-
ity as a mainstay technique for facial rejuvenation.
First, we should ask ourselves, “Why do we think that it is
necessary to delaminate the face in order to rejuvenate? Can
we accomplish volume redistribution/repositioning without
having to engage in complex, deep anatomic dissections? What
is the validity of using a cranial suspension platform to resus-
pend facial structures over traditional ways?” And finally, “Can
we innovate a less invasive procedure for facial rejuvenation
that gives a durable outcome and allows for future revisions?”
Surgical foundation for the MACS lift
The surgical foundation for facial rejuvenation should address
the biomechanical effects of facial aging and volume loss for
each patient, depending on their particular needs. Surgeons
must be faulted in the past for not having a fundamental
understanding of facial aging, volume loss, laminar anatomy,
and biomechanical engineering. Our current understanding
of the anatomy of facial aging is thoroughly reviewed in
  Access video and video lecture content for this chapter online at expertconsult.com

154
SECTION I
CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
how much force is required to vertically lift facial and neck
structures and suspend them in place with approaches that
are less prone to failure. Surgery is part of the solution for
facial rejuvenation, but ancillary procedures found in cosmetic
medicine such as medical skin care, fillers, neurotoxins, and
light-based treatments work synergistically to produce a
“wow effect” when used masterfully.
The MACS lift concept involves the use of suture loops
placed in a purse-string fashion in order to elevate deep facial
tissue by anchoring to a fixed point. In the basic MACS lift,
there is one anchoring point on the deep temporal fascia, just
above the lateral zygoma, and posterior to the passage of the
temporal branch of the facial nerve. This is a very robust
anchor point that will hold a 0-0 or 2-0 suture without a
pull-out failure. The “CS” part of the MACS lift is “cranial
suspension”, which refers to the deep temporal fascia’s
attachment to the cranium along the temporal crest line. The
MACS lift does not utilize sheet tightening of the SMAS,
SMAS plication, or SMASectomy, but relies purely on special-
ized suture suspension. The basic MACS lift involves two
suture loops, one vertical and one oblique, while the “extended
MACS lift” involves an additional suture to elevate the malar
fat to a more anterior anchoring point (Figs. 6.4.1 & 6.4.2).
Chapter 6.1, giving insight into the complex biomechanics of
facial aging. Aging involves the gravimetric effects on skin
and musculo-aponeurotic system (SMAS), loss of elastic
property of tissue, volume loss and descent within in fat
compartments, and extrinsic effect of sun, genetics, weight
loss/gain, and smoking.11–13 Fat within the face does not exist
as a confluent mass, but in discreet compartments separated
by septae, formerly known as ligaments. Facial anatomy
involves a laminar concept in which movement between
layers is possible without surgical delamination. Proponents
of ligament release feel that such movement is inadequate for
facial rejuvenation, but experience with the MACS lift pro-
vides evidence that sufficient interlayer movement is, indeed,
possible and surgically effective.
From the perspective of biomechanics, surgical approaches
that rely on sheet tightening of attenuated facial structures
(SMAS) may not produce a long-term effect due to the loosen-
ing of this layer over time (shear yield). Suture line repairs
such as linear plication or excision techniques (plication or
SMASectomy) remain vulnerable to disruption (shear failure
and “cheese wiring”) by down-pulling the platysma whose
fascia is contiguous with the SMAS. Facial rejuvenation is
therefore an exercise in biomechanical engineering in terms of
Fig. 6.4.1  The basic MACS lift involves two suture loops
placed into the SMAS in a purse-string fashion. The vertical
loop captures the platysma muscle below the angle of the
mandible, elevating soft tissues of the neck. The cheek loop
captures and elevates soft tissue of the midcheek and jowl.

155
Surgical foundation for the MACS lift
the platysma. By not dissecting skin off the platysma, there is
tightening of the neck skin when the platysma is tightened.7
The zone of adherence just anterior to the earlobe, called
Lore’s fascia, can be used as a fixed structure to pull against
in order to achieve vertical tightening of the platysma as
described by Labbé.5
The traditional skin incision for the MACS lift utilizes a
“short scar” anterior hairline approach with no retroauricular
dissection. After deep tissue reposition, skin redraping is
designed in a purely vertical direction (Fig. 6.4.4).
The amount of skin excision with the vertical approach of
the MACS lift is much less than seen with the classic SMAS-
lift. Attention must be paid to a tension-free skin closure in
order to promote excellent healing and avoid earlobe distor-
tion. In a divergence of philosophy and practice from Tonnard
and Verpaele, patients with greater facial and neck laxity will
require extending the incision into the retroauricular area in
order to manage lax skin (Fig. 6.4.5).
Therefore, the “MA” (minimal access) portion of the MACS
terminology must be expanded to address situations where
there is more tissue laxness necessitating a retroauricular
incision. In optimal situations, with younger patients, the
Suture loops placed within facial tissues results in a gathering
and suspension of tissue. Tonnard and Verpaele describe this
as “microimbrication” (Fig. 6.4.3).
How the loops are designed and sequenced is crucial, as
once the platysma is pulled upward, it is possible to rotate the
layers of the face without a downward traction component of
Fig. 6.4.2  The extended MACS lift adds a third suture to
elevate the malar fat pad. The “hockey stick” dissection
pattern.
Fig. 6.4.3  MACS sutures result in a bunching up of soft tissue. This has been
termed “microimbrication”.

156
SECTION I
CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
Patient evaluation
Each patient is unique with respect to their particular needs
for facial rejuvenation. It then is incumbent on the surgeon to
formulate a strategy that will provide solutions for each
patient. In the author’s experience, a more holistic approach
works best in his own patient population. This involves both
cosmetic medicine and aesthetic plastic surgery, allowing for
care to be ongoing and to advantage each patient with adjunc-
tive services of medical skin care, fillers, neurotoxins, and
light-based treatments.
The following components of a patient’s face require evalu-
ation and strategy.
Facial skeletal structure and asymmetry
Structural needs such as cheek or chin deficiency must be
addressed. Evaluate for facial nerve function, muscular func-
tion, any asymmetry.
Skin quality, character, and looseness
Photodamage and photoaging must be addressed and consid-
eration given for medical skin care or light-based treatments.
Rhytides and looseness in the perioral area cannot be resolved
with rhytidectomy.
short scar approach is preferable yet can be modified when
the amount of loose tissues cannot be managed with a short
scar approach. Extending the incisions into the postauricular
region resolves bunching of loose skin at the level of the
earlobe.
There are numerous advantages of the MACS lift. Deep
tissues are readily repositioned without the deep plane dis-
section that risks injury to the facial nerve. Less dissection is
also likely to result in faster recovery. The short scar approach
avoids dissection over the sternocleidomastoid muscle and
therefore removes the potential for injury to the great auricular
nerve. MACS sutures are anchored at fixed points that avoid
the temporal branches of the facial nerve (Fig. 6.4.6).
It has outcomes that are acceptable over time and favorable
biomechanics that address volume redistribution and facial
tightening without deep layer work. This technique appears
very adaptable to most patients seeking primary and second-
ary facial rejuvenation. It also has the advantage of being
reversible during surgery, as suture loops can be changed or
the entire technique abandoned for a more traditional
approach. The learning curve for successful adoption of the
MACS lift is something that can be mastered by most surgeons
who are willing to invest the time required to learn a new
approach to surgical facial rejuvenation.
Fig. 6.4.5  Vertical skin advancement in the standard short scar approach for a
MACS lift.
Fig. 6.4.6  The temporal branches of the facial nerve course over the middle third
of the zygomatic arch. The MACS suture anchor points are designed to avoid
damage to these nerve branches.
2.0
2.0
1.8
Fig. 6.4.4  The short scar incision used in the standard MACS lift.

157
Surgical strategy
Patient expectations
The management of patient expectations becomes a major part
of facial rejuvenation, whether surgical or medical. It is essen-
tial that patients see themselves for who they are before treat-
ment and that realistic portrayal of outcomes be communicated.
Occasionally, there is the need for revisionary surgery/
procedures that must be addressed prior to treatment rather
than afterwards. Revision surgery may not be successful.
The better informed that patients are regarding their par-
ticular needs and your recommendations, both surgical and
non-surgical, the more likely they will be able to obtain the
best outcome. If a patient does not appear to be capable of
obtaining an outcome from treatments/procedures, it is better
to communicate this upfront and avoid the vexing problem of
a dissatisfied patient who had unrealistic expectations.
Surgical strategy
The use of worksheets and templates has proven useful in
many areas of aesthetic surgery and cosmetic medicine. A
simple form based on your practice helps you develop your
surgical strategy for each patient’s care. It allows you to make
notes, show specific details, and more importantly determine
the trade-offs involved. Such a form is a nice fit with your
informed consent(s) for the surgical procedure or cosmetic
treatments (fillers, neurotoxins, etc.).
How you choose to communicate your strategy with the
patient is also important. Simple aids such as a 10 × 15 cm
print from a digital camera on which you can draw, can be
useful. Other approaches involve drawing on the patient with
an eyeliner marker (easily removed) and taking a photograph.
Both of these are good communication tools to make certain
that your plans are in alignment with the patient’s expecta-
tions and needs. Even something as simple as displaying a
digital photograph on a large-screen LCD television works far
better than using a hand mirror.
Anesthesia for the MACS lift can be (1) minimalistic – local
anesthetic with conscious sedation; or (2) more complex with
monitored anesthesia care (MAC) deep sedation or general
anesthesia (GA). If general anesthesia is contemplated, the
author prefers an endotracheal tube (ET) over the laryngeal
mask device because the ET causes less neck distortion. Other
important considerations would be DVT prophylaxis and a
warming blanket for prevention of hypothermia. Although
some surgeons consider chemoprophylaxis with fractionated
heparin on long cases, there are reasonable concerns of
increased risk of hematoma incidence. Some anesthesiologists
prefer GA over MAC because of better airway management
and the ability of a gas analyzer to measure end tidal CO2 as
an index of ventilation.
Care should be given during the procedure to installing
protective eye ointment in order to prevent corneal exposure
problems. Sterile tape strips may also be used to prevent
eyelid opening. Individuals with a history of laser-assisted in
situ keratomileusis (LASIK) procedures are especially at risk
for corneal problems due to diminished corneal sensory
innervations that trigger tearing. When operating on a post-
LASIK patient, consider an evaluation by an ophthalmologist
for adequacy of tear production and tear film quality.
Forehead and glabellar rhytides
Forehead rejuvenation may involve the use of neurotoxins or
rejuvenation surgery through the endoscopic or transpalpe-
bral approach.
Facial volume
Assessment of the loss of facial volume is made. Volume
enhancement in the submalar sulcus may be done with
surgery, autologous fat grafts, or synthetic fillers. The recogni-
tion of volume loss that occurs due to attritional lipoatrophy
is underestimated.
Ocular region
Dermatochalasis, brow position, brow ptosis, fat bags, lower
eyelid looseness requiring lateral canthal work, lower eyelid
skin, and malar bags should all be assessed. Given the sub-
stantive lift of the MACS lift, a lower eyelid blepharoplasty is
often an integral part of this approach.
Neck
Neck laxness and platysmal banding will influence the need
to consider extended incisions and possibly a submental
approach for direct work on platysma banding. The presence
of submental fat may be addressed either through lipoplasty
if superficial, or direct excision if submuscular. Direct man-
agement of platysmal bands and fat layers is commonplace
and adds to the quality of outcomes.
Jowls
The squareness of the jawline is largely influenced by the
downward descent of facial structures. Depending on the
severity, dissection into the premasseteric space may be
required.
Previous surgery
Patients seeking additional refinements or “maintenance” of
facial rejuvenation from previous surgical procedure may
present with distorted changes due to conflicting traction
vectors or ineffectual outcomes. This type of patient requires
thoughtful consideration of what can be safely addressed
with reoperative surgery.
Medical history
Patients seeking facial rejuvenation may have medical
conditions that can influence their safety during facial
rejuvenation. Not everyone seeking facial rejuvenation
surgery is a candidate for surgery, based on chronic medical
disorders. Attention should be paid to a thorough review
of systems with emphasis on cardiac and circulatory issues.
Unique subsets of patients with surgical weight loss pro-
cedures may present with additional factors such as facial
lipoatrophy, tissue wasting, and obstructive sleep apnea.
Deep venous thrombosis (DVT) risk must be assessed and
managed.

158
SECTION I
CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
The neck suture
The suture loop for the neck is placed first. Going inferiorly
in the natural sulcus that is anterior to the tragus, firm bites
between 1 and 1.5 cm long are taken into the SMAS. Progress-
ing inferiorly past the angle of the mandible, two or three
suture bites are taken into the platysma before the suturing is
directed upward and back to the anchor point. A U-shape
loop about 1 cm wide is created, and the knot is then tied at
the anchor point under tension. The suture loop is tied without
any instrument that might be used to hold the first knot. This
diminishes the possibility of suture damage and breakage. In
my (the author’s) first few cases, I found that I did not have
an adequate grip on the platysma fascia and that neck tighten-
ing was not optimal; for neck tightening to occur, adequate
suture purchase of the platysma below the angle of the man-
dible is imperative. When performing the short scar variation,
a fiber-optic retractor is helpful to visualize correct suture
placement in the depth of the dissection. Additional reinforce-
ment of the neck is accomplished by engaging the platysma
fascia and pulling both superiorly and slightly retrograde by
using the mastoid fascia as a secondary anchor point. Remain-
ing barbed suture is then run through the region of Lore’s
fascia and then back up along the pretragal area (Fig. 6.4.8).
The cheek suture
The cheek loop is placed next. It originates at the same anchor
point from the deep temporal fascia. Taking bites of the SMAS,
suturing progresses inferiorly just anterior to the first loop and
then curves more anteriorly, creating a wider loop above the
jowl extending anteriorly as far as the skin flap has been
raised. The author has found that the loop works best when it
is in the configuration of a logarithmic spiral, like a nautilus
shell. This allows for upward rotation of facial structures and
volume repositioning. The overall angle of the cheek loop is
Surgical sequence (Video 6.4.1 )
The patient is marked before the start of the procedure; key
points are the planned incision, the degree of undermin-
ing, and the location of suture loops. The degree of skin
flap undermining typically extends inferiorly just past the
mandibular angle and anteriorly 5–6 cm in front of the
ear. If an extended MACS lift is planned, undermining is
marked over the malar prominence. The sequence of per-
forming a MACS lift is straightforward. If autologous fat
grafting is considered, the author harvests and processes
fat at the beginning, followed by injection prior to the inci-
sions for the MACS lift. It is preferred not to store fat graft
tissue at ambient temperature for long periods during the
procedure. Any anterior neck surgery, such as lipoplasty,
is performed first. The cheek flap is then dissected and the
loop sutures are placed. If a temporal lift or endobrowlift is
contemplated, it is done next. A blepharoplasty, if planned, is
done last.
Skin incision and undermining
Local anesthetic containing epinephrine is injected along
the incision line. In the area of flap undermining, the author
prefers lipoplasty wetting solution that contains epinephrine
1 : 500 000. The short scar incision extends from the earlobe
below to the anterior hairline above. It follows the attach-
ment of the earlobe from the retroauricular crease, around to
the anterior attachment of the earlobe, following the tragal
edge, the anterior helical attachment to the root of the helix,
then across the lower portion of the sideburn and up the
anterior hairline. Anteriorly, the incision is made in a zigzag
pattern 1–2 mm within the hairline. The zigzag incision effec-
tively increases the length of the temporal incision to better
receive the elevated cheek flap. In the standard MACS lift,
the incision is carried up to the level of the lateral canthus,
while in the extended MACS lift, the incision extends up
to a point opposite the tail of the eyebrow. Flap elevation
is accomplished with scissor dissection. If an extended
incision in the retroauricular zone is required, this is done
early in the procedure as it generally facilitates suture loop
placement and skin redraping when the neck is tightened
vertically.
Anchor point
The deep temporal fascia anchor point is chosen to avoid the
superficial temporal vessels and the temporal branch of the
facial nerve. Small scissors are used to create a window in
the subcutaneous tissue approximately 1 cm above the zygo-
matic arch and 1 cm in front of the helical rim in order to
expose the deep temporal fascia (Fig. 6.4.7).
When placing the suture into the temporalis fascia, the
author sews away from the temporal vessel location. A single
anchor point is used for both the neck loop and the cheek loop
in order to diminish the amount of suture used and the pal-
pability of knots. Absorbable monofilament sutures such as
barbed 0-polydioxanone are preferred over non-absorbable
polypropylene or braided polyester suture. Bunching in the
cheek region can be nicely managed by serpentine imbrication
with the barbed suture and minor amounts of scissor
snipping.
Fig. 6.4.7  The short scar incision has been made, and the skin flap raised. The
zygomatic arch is marked in purple. Note the marks on the skin designating the
location of the suture loops. The scissors are dissecting a window down to the deep
temporal fascia that will be used as the anchor point for the vertical and cheek
suture loops.

159
A personal evolution of the MACS lift
and replace the loops until satisfied with their placement and
tissue gathering.
Tissue bunching is an integral problem with the MACS
suture loops. It is resolved with serpentine imbrications with
the 0-polydioxanone barbed suture or 4-0 polyglactin imbrica-
tions with 4-0 polyglactin braided suture. The author prefers
the version of this suture that contains triclosan, an antibacte-
rial agent, in order to diminish risk of stitch abscess. Before
leaving the deep tissue, it is necessary to place the skin flap
over the tissue and observe for unresolved bunching and
tissue tethering at the margins of the undermined area. Scissor
removal of protruding fat may be needed in order to produce
a smooth tissue surface inside the loops. Imbrication of tissue
in the region just anterior to the tragus is important in order
to preserve this normal sulcus.
Skin advancement and resection
The skin flap is then redraped along a vertical axis, and the
excess skin is resected. If there is excess skin at the level of the
earlobe, it must be resolved by incisions in the posterior ear
region. My philosophy is to resolve this skin by extending my
incisions in the posterior sulcus of the ear, instead of dealing
with skin bunching post-surgery. If necessary, the author uses
a classic rhytidectomy incision in the postauricular region,
depending on the patient’s neck laxity. The goal for skin exci-
sion is to have a tension-free closure with wound margins
coapted against each other.
The author’s personal technique uses approximately 1 cc
of fibrin glue (5 units/mL dilution) that is sprayed on the flaps
and held for 3 min. I find that this diminishes ecchymosis
formation and eliminates the requirement for drains. Care
must be given to not apply excessive fibrin glue as it can
interfere with revascularization of the flaps.
Wound closure is also straightforward with absorbable 5-0
monofilament in the deeper layers and 5-0 and 6-0 polypro-
pylene skin sutures placed as interrupted and continuous
(horizontal mattress).
Dressings involve customary facelift dressings. The author
personally prefers some silicone-backed foam for the anterior
neck if lipoplasty has been performed. Otherwise, aftercare is
similar to standard facelift procedures.
Three representative cases utilizing the MACS lift concept
are shown in Figs. 6.4.9 and 6.4.10.
A personal evolution of the MACS lift
Overview
The original procedure as described by Tonnard, Verpaele,
et al. has evolved into a more holistic approach for compre-
hensive facial rejuvenation. While originally described as a
“minimal access cranial suspension” approach, the procedure
has evolved into “cranial suspension rhytidectomy” (CSR),
where facial structures are resuspended from a cranial anchor
point. This approach uses a strong anchor point versus relying
on sewing age-attenuated SMAS layers back together with
a linear suture repair. Additionally, experience with the origi-
nal MACS and its failures dictates a better approach for
management of the lax neck and platysmal bands than
described by the originators of the MACS lift.
approximately 30° across the cheek, as compared to the verti-
cal neck loop. The suture is then tied under tension. Novice
MACS lift surgeons tend to make too small a cheek loop and
are then faced with a situation of a peculiar wad of tissue when
the loop is tied. Experience teaches that if a suture loop appears
unsatisfactory, the best strategy is to take it out and replace it.
The malar suture
Once the cheek loop is tied, it is possible to add a third loop
for elevation of the malar fat; this constitutes the “extended
MACS lift” variant. A different anchor point is used anterior
to the temporal branch of the facial nerve. This point can
either be the deep temporal fascia just lateral to the lateral
orbital rim, or the periosteum of the zygoma, approximately
1.5 cm lateral to the lateral canthal area. Access to either of
these anchor points requires a small window in the orbicularis
muscle where the fibers run vertically. This purse-string
suture travels obliquely toward the malar fat pad where at a
point 2 cm below the lateral canthus, the direction is reversed,
creating a narrow U-shaped loop that is tight under tension.
In my experience, the direction of pull will be oblique, but
ideally should be as vertical as possible. If the surgeon is
dissatisfied with the placement of the loops, it is easy to cut
Fig. 6.4.8  (A,B) Cadaveric example demonstrating placement and the effect of the
vertical neck suture. The orientation is vertical, and neck traction depends on
achieving excellent suture purchase of the platysma muscle below the angle of the
mandible.
A
B

160
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CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
Surgical facial rejuvenation as part of
the continuum of beauty
While we as surgeons are fascinated with the technical
approaches for facial rejuvenation surgery, the aesthetic mar-
ketplace around us is changing with regard to what patients
are seeking in facial rejuvenation and the utility of non-invasive
procedures. Formerly, we would abandon one surgical
approach for another in order to stay ahead of what competi-
tors were offering in facial rejuvenation. There was little
appreciation of the biomechanics of aging or facial fat compart-
ments, but rather a fixation on technical factors because all that
The technical evolution of the CSR includes the use of
barbed sutures (polydioxanone; PDO), volume restoration
with autologous fat grafting, selection of postauricular inci-
sions as needed to address lax neck skin, use of fibrin glue to
mitigate ecchymosis, and open anterior neck platysmaplasty.
The concept of cranial suspension remains valid, but evolu-
tion of technique and strategy encompasses a more compre-
hensive approach of surgery to reposition lax tissues of face
and neck, volume restoration of orbit and midface, medical
skin care, correction of brow ptosis, tissue fillers, neurotoxins,
and energy-based treatments to improve skin quality/texture
and tighten subsurface layers.
Fig. 6.4.9  Preoperative (A–C) and 12-month postoperative (D–F) photographs of a 61-year-old woman who underwent a three-loop extended MACS lift, submental
liposuction, autologous fat graft to submalar region, and hyaluronic acid fillers to the perioral area.
A
B
C
D
E
F

161
A personal evolution of the MACS lift
we knew was surgical facial rejuvenation. Most plastic sur-
geons were dismissive of non-surgical treatments because it
was not surgery that they knew and loved. “After all, all of this
non-surgery nonsense was being championed by those who
could not operate”, said one plastic surgeon.
In the current era, much has changed regarding what patients
are seeking from facial rejuvenation and their willingness to
only utilize surgery as their treatment of choice. Sure, there is
no substitute for a well-performed, comprehensive rhytidec-
tomy, but patients are looking for more than just surgery, both
before needing it and afterwards to help maintain its results.
Patients find tremendous value in the results that cosmetic
injectables deliver when administered by a skilled injector.
There has been an evolution from filling wrinkles to facial
volumization with long-lasting hyaluronic acid (HA) fillers. The
effects of cosmetic neurotoxins when correctly placed produce
natural outcomes without the stigma of a frozen face. Injections
of lipolytic drugs can reduce fat deposits in the jawline without
liposuction. Micro-focused high-intensity ultrasound or radio-
frequency energy can be an adjunct for skin tightening.
Surgical facial rejuvenation appears to be part of a contin-
uum rather than the entire focus for patients. A holistic concept
A
B
C
D
E
F
Fig. 6.4.10  This 56-year-old woman developed a relapse of neck soft-tissue laxity after a MACS lift. She underwent a secondary procedure with the placement of both neck
and cheek sutures. The result shown preoperatively (A–C), after the MACS lift (D–F), and 12 months after revision surgery (G–I).
Continued

162
SECTION I
CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
Cranial suspension techniques are useful as a primary form
of facial rejuvenation, in secondary and even tertiary situa-
tions over the traditional subSMAS approaches. Other tech-
niques involving deeper plane lifts, SMAS plication, or
SMASectomy have not held up over time with regards to
suitability or durable, natural-appearing outcomes that have
an acceptable recovery time.
Technical evolutions and innovations
of the original MACS lift
Barbed sutures
My current CSR technique has evolved to include the use of
barbed polydioxanone sutures, typically in the #1 or 0 size. This
has been a useful advance that seemingly has improved out-
comes by better resuspension of facial structures, including the
neck. Barbed sutures can produce a powerful lift within the
mobile SMAS and neck. I have also found that they permit
better management of tissue bunching in the cheek region by a
serpentine form of imbrication versus relying on multiple inter-
rupted 4-0 absorbable sutures. I hardly ever use the midface
loop any longer as described by Tonnard and Verpaele.
Neck relapse
One of the known shortcomings of the original MACS lift was
its propensity for neck relapse due to a single point of fixation
within the platysma below the angle of the mandible. This
became apparent in several patients who required revisionary
neck tightening after having a classic MACS lift. My lesson
that I learned out of this was that a better approach for neck
rejuvenation was required with the primary procedure.
Currently, I utilize what I would call a “hockey stick” dis-
section pattern below the angle of the mandible that allows
of facial rejuvenation and maintenance of beauty has now
evolved. The combination of non-surgical treatments and
facial rejuvenation surgery provides better, more natural, and
satisfying outcomes for patients.
In the first part of the chapter, I focused on the MACS lift
as envisioned by Tonnard and Verpaele. Since applying the
MACS lift principles, I have evolved my technique and believe
that I have been able to achieve improvements over what was
originally described. I also decided to add additional sub-
components as needed for each patient, depending on the
concept of “What does it take to achieve a satisfactory facial
rejuvenation outcome for this particular patient?” Moreover,
my appreciation of the value of a comprehensive program of
medical skin care, cosmetic injectables, and energy-based treat-
ments has increased, given the benefits that they provide
patients.
Within the naming conventions of surgical procedures, I
renamed the MACS lift, the “cranial suspension rhytidectomy”
(CSR). I believe that this should no longer be called a minimal
access procedure and that the surgeon should have the ability
to manage what incisions are needed to accomplish the intended
outcome. For example, I believe that it is permissible to utilize
the classic rhytidectomy incision in the retroauricular area if
you are planning on extensive neck tightening. I still believe
that the sideburn incision offers the greatest utility versus inci-
sions in the temporal scalp or a 90° “London Chop” incision.
The concept of cranial suspension or, actually, cranial
“resuspension” remains valid as a way to reposition the
mobile SMAS layer upward and to passively move other
facial structures along. Personally, I like a non-delamination
procedure like the CSR over a subSMAS dissection. I believe
that I can accomplish almost as much from the CSR approach
as a procedure that delaminates the face to rejuvenate. Skin
resection in the pre-/postauricular area remains as described
by Tonnard and Verpaele. Skin closure should be without
tension and signs of skin tethering to deeper layers.
G
H
I
Fig. 6.4.10, cont’d

163
Understanding the learning curve of CSR
I have found that my evolution of Tonnard and Verpaele’s
original MACS rhytidectomy has enabled me to get beyond
the shortcomings of their procedure. While there is no substi-
tution for a well-planned and performed rhytidectomy, I have
been able to holistically improve the quality, durability, and
patient satisfaction with my version of facial rejuvenation
through the addition of other complimentary non-surgical
procedures.
As far as what’s next, I would say that more thought is
needed to find a predictable way to manage the lateral brow
region and a device to help with the lateral canthopexy that is
used to help stabilize the lower eyelid during a blepharoplasty.
Understanding the learning
curve of CSR
The successful integration of a new surgical technique into
one’s armamentarium can be challenging. It involves auditory
and visual learning, bioskills, and ways to deal with events
that are normal occurrences when one performs this proce-
dure. It is a daunting task from the perspective of adult educa-
tion how surgical educators can transfer a knowledge and
skills set to intelligent individuals, especially when the
approach is counterintuitive.
Successful performance of the CSR lift demands technical
excellence in the placement of suture loops and the resolution
of bunching that occurs once the loops are tightened. The CSR
lift effect is equivalent to a gathering phenomenon on the
barbed suture loops to produce volume redistribution and
tightening of deep layer facial structures without delamina-
tion procedures seen in subSMAS procedures. You also may
want to familiarize yourself with some of the reference articles,
as they are a foundation for the procedure.
Advice for how to succeed with the CSR
Planning for a successful outcome
First start with a straightforward, relatively easy facelift situ-
ation rather than a challenging situation that would prove
difficult with any technique. Most likely, your patient will
need the CSR lift (two strands) with extended postauricular
incisions. Relatively few patients are candidates for the short
scar variant of the CSR.
Consider the range of complimentary
surgical procedures
Planning for a patient’s facial rejuvenation usually involves
additional complimentary procedures such as submental lipo-
plasty, anterior platysmaplasty, upper/lower blepharoplasty/
canthopexy, fillers (fat or non-animal stabilized hyaluronic
acid (NASHA) fillers), and management of the brow region.
Be certain that you have planned adequately with regards to
complimentary procedures and consider using a worksheet
or checklist that will help you remember the steps that you
planned for each patient.
Selection of anesthesia
From the perspective of patient safety, the CSR lift can be
performed under monitored anesthesia care, local anesthesia
for more exposure of the platysma. This affords better expo-
sure of the platysma for passage of barbed suture versus a
single point of fixation as originally described. Better exposure
also offers open defatting with a flat liposuction cannula.
Now, I place the barbed sutures below the mandible in the
mobile platysma and utilize a biaxial tightening, primarily
vertical, but with some retrograde pull. The immobile mastoid
fascia offers a robust secondary anchor point for barbed
sutures used for neck tightening. My personal opinion here is
that the mastoid fascia is a stronger anchor point for the neck
than Lore’s fascia.
Management of anterior platysma
I believe that anterior platysma techniques of liposuction and
open management of platysma banding has enhanced my
outcomes for the neck. Bands must be treated openly, and fat,
whether above or below the platysma, must be managed in
order to produce a crisp, angular anterior neck outcome.
Barbed absorbable suture is useful for anterior platysmaplasty,
in my experience.
Fibrin glue avoids drains
Another advance in technique is the use of pre-diluted fibrin
glue to mitigate ecchymosis after the procedure. The combina-
tion of fibrin glue and silicone-faced liposuction foam in the
dressings has solved the bruising issues associated with
rhytidectomy. I no longer use drains.
Facial volume restoration
The matter of facial volume restoration during a rhytidectomy
deserves mentioning. I think that the use of a small amount of
autologous fat grafting to restore attritional lipoatrophy in the
submalar or suborbicularis areas during facial rejuvenation
surgery is straightforward. Newer suborbicularis compart-
ment injections of HA fillers or autologous fat as described by
Lamb, Jelks, and Surek appear promising. Equally, the microfat
injections just under the eyelid skin as described by Tonnard
and Verpaele appear to produce good outcomes. I personally
do not like to inject large volumes of autologous fat into the
face, unlike some colleagues, as I believe that it alters facial
appearance and has a long, swollen recovery for months.
Conversely, long-acting HA fillers that have been devel-
oped for facial volumization deserve a mention because they
are predictable, long lasting, and time-efficient. Personally, I
like the “what you see is what you get” with volumizing
fillers in contrast to autologous fat. I prefer a 0.9-mm cannula
for the deep layer injections of volumizing fillers in the face
and orbit, which reduces risk of accidental intravascular injec-
tion and ensuing catastrophe.
The value of non-surgical treatments to
maintain outcomes after CSR
There is much utility in the non-surgical treatments after a
CSR procedure. This includes neurotoxins for management of
dynamic rhytids, HA fillers for lines and volume restoration/
maintenance, and energy-based treatments to skin and deeper
layers. Medical skin care never stops. High-intensity micro-
focused ultrasound (Ulthera, Inc., Mesa, AZ) has been useful
to add skin tightening in the brows and neck after a CSR.

164
SECTION I
CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
skin dimples underneath the flap will require scissor work to
release them. Other approaches to manage bunching use
excess barbed suture that is used to flatten bunching by
placing sutures in a serpentine pattern (very effective).
Preliminary closure
Skin excess in the CSR lift is resolved by a vertical approach.
Take the time to arrange the skin flap after you are satisfied
with the work done on the deeper layers in terms of sym-
metrical tension, resolution of bunching, and hemostasis. You
will become a believer in the vertical approach if you pull
your skin flap in the wrong (horizontal) direction. You will
rapidly realize that horizontal traction on the skin flap creates
the need for a postauricular incision versus the vertical
approach in patients with minimal/moderate face laxness.
Other patients who need extensive neck tightening will
require a “classic rhytidectomy” incision.
Skin resection is made in order to avoid skin tension on the
wound. This is crucial in order to obtain a favorable postop-
erative scar. Skin resection in the elevated skin is made to
mirror the preauricular regional incision that you made at the
start of the case. Fortunately, due to local anatomic “anchor
points”, the sideburn and tragal areas do not move and facili-
tate the closure process. A lack of facial flap tension is really
important in the closure. Tragal definition requires surgical
defatting of the skin flap with scissors.
When performing a short scar variant of the CSR, you may
find yourself in a situation of having too much loose skin and
worry about skin bunching in the preauricular area; it is
permissible to go behind the ear on its backside in order to
inset the looseness. Remember, this does come with the price
of more dissection and skin shifting to finalize the closure. If
you have to leave behind some bunching in your closure, do
it behind the earlobe and not in front.
Skin closure
Tonnard and Verpaele use small drains that come out in the
area of the earlobe. I prefer fibrin glue (Artiss, Baxter Health-
care, Deerfield, IL) that is supplied at 5 units/mL instead
of drains. I find that fibrin glue also has the advantage of
diminishing ecchymosis in the postoperative period. Fibrin
glue can produce healing problems if excessive amounts are
sprayed in the wound. I have found that a 2-mL syringe of
Artiss is adequate for both sides of a CSR lift (use <1 mL
per side).
As mentioned earlier, skin closure is performed under no
tension. I use some 5-0 Monocryl (Ethicon, Somerville, NJ)
sutures in the subdermal area to hold the wound and 5-0 and
6-0 Prolene (Ethicon, Somerville, NJ) in the skin (horizontal
mattress sutures). A few 5-0 rapid-absorbing plain gut sutures
(Ethicon, Somerville, NJ) can also be used. Be certain to
remove all silk temporary sutures that you may have used in
the planning stage of the closure.
Eye and brow procedures
I wait to perform the eyelid procedures until I have com-
pleted the CSR lift. A significant amount of skin has been
recruited into the orbit with the midface loop, and a lower
eyelid blepharoplasty will be necessary in many cases. Brow
procedures, whether a lateral temporal lift, transpalpebral
with minimal/oral sedation, or general anesthesia. Find a
technique of anesthesia that you are comfortable using. Do
not forget the matter of keeping patients warm, addressing
DVT prophylaxis, and preventing eye dryness if general
anesthesia is used. I personally use tumescent anesthesia with
500 mg lidocaine per liter and 1 : 500 000 epinephrine concen-
tration. Typically, I will use ~50 ml in the anterior neck and
60–75 ml per side for the CSR. I wait 10 min after injection for
the epinephrine effect to occur. I’ll tumesce the opposite side
of the face when I start the closure on the first side.
Sequencing of the procedure
My first sequence in CSR facial rejuvenation is the lipoplasty
and open anterior neck work. I have found the VASER ultra-
sonic lipoplasty device very effective in the anterior neck and
jawline. The process of VASER ultrasonic lipoplasty is very
precise and allows for accurate removal of fat. If anterior
platysma band correction is planned, I do this first, before the
CSR.
Typically, I will infiltrate both the neck and the first face
side for the CSR with liposuction wetting solution containing
epinephrine 1 : 500 000. I find that this helps dissection. In the
case of secondary/tertiary rhytidectomy, the use of wetting
solutions facilitates creation of an accurate surgical plane
through previously operated tissue. While not every patient
needs submental lipoplasty, the combination of wetting solu-
tion and the VASER helps with dissection in this area and
access to platysmal bands and subplatysmal fat.
Next, I go on to the incisions of the rhytidectomy and flap
elevation. Once this has been accomplished, attention is
directed to the neck and cheek loops of the CSR lift. Currently,
I use 0 or #1-PDO barbed suture (Angiotech, Surgical Special-
ties Corporation, Braintree, MA) or 0 Stratafix PDS barbed
(clear) (Ethicon, Somerville, NJ) with a robust anchor point in
the temporalis fascia, approximately 1 cm anterior to the ear.
Once the loops have been placed, I will determine if the third
loop, the midface, is required. It is anchored approximately
1.5 cm lateral to the external canthal area on the periosteum
of the maxilla.
It is important, especially with the neck loop, that you place
it in the platysma below the angle of the mandible. The origi-
nal MACS lift as described by Tonnard and Verpaele has a
high neck relapse propensity, presumably due to poor engage-
ment of the platysma. This has been overcome with the use
of barbed sutures, anterior dissection below the angle of the
mandible, and a secondary anchor point in the mastoid fascia
(behind the concha of the ear). After first loop is secured, next
go on to the second cheek loop without cutting the suture at
the anchor point. This helps minimize the amount of suture
material in the temporalis region. Bidirectional barbed suture
can also be utilized for the cranial suspension of the platysma
and the cheek loop. The excess barbed suture can be placed
in a serpentine fashion in the cheek region to flatten areas of
tissue bunching.
Eyelid procedures are performed at the end of the CSR lift
because there may be a significant amount of vertical skin
recruitment after the suture loops have been placed.
Tips on how to manage bunching of tissue
Depending on the amount of tissue involved, this may require
scissor work and flattening of the ridges with 4-0 Vicryl. Small

165
Understanding the learning curve of CSR
BOX 6.4.1  Troubleshooting
Problem: Neck loop pulls out of tissue
Solution:  Neck loop needs to be in the fascia of the platysma –
place it again, with emphasis on correct technique that includes more
anterior dissection below the angle of the mandible to expose more
of the platysma. A secondary anchor point in the mastoid fascia with
the barbed suture is useful to avoid suture pull-out.
Problem: You have placed the cheek loop, but nothing moves
when it is tightened
Solution:  You have placed too large a loop that is over tissue that
has a zone of adherence (non-mobile SMAS) to bone, e.g. maxilla.
Replace the loop in the correct location.
Problem: Midface loop does not lift midface
Solution:  Look for midface tissue that is mobile and place the loop
again.
Problem: You note a lot of lower eyelid skin has been pushed
upward
Solution:  Given the vertical nature of the CSR lift, eyelid skin is
pushed upward and a lower eyelid blepharoplasty is required. A
simple pinch blepharoplasty can be performed to address skin
excess.
Problem: You have too much skin excess to make this a short
scar facelift
Solution:  You may need to consider extending the incisions behind
the ear to address skin excess. Even though the MACS lift was
envisioned as a short scar facelift, consider the cranial suspension
part of the CSR lift as the lifting engine and the incision management
as up to the surgeon.
Problem: You are worried about neck relapse
Solution:  Neck management, both in terms of bands and tissue
laxness, requires a comprehensive approach. This encompasses
both the possibility of open anterior platysmaplasty with band
transection and the consideration of secondary anchor points in the
mastoid fascia or Lore’s fascia with the barbed sutures.
Problem: Dimples in skin, just beyond the zone of dissection
Solution:  Use your scissors in a vertical spreading motion to stretch
bands that are producing the dimpling. Be careful that this may
cause bleeding, if you are at the edge of where you have infiltrated
wetting solutions/local anesthesia.
Problem: Bunching is hard to correct after you have tied the
cheek loop
Solution:  Excessive tightness in the cheek loop or a small diameter
loop will produce a wad of tissue that defies imbrication. Replace the
cheek loop, but with less tension. Also, some scissors snipping is
helpful if there are small dimples of tissue that are particularly visible
through the skin. Imbrication stitches may be used to control skin
fullness in all areas underneath the flap in order to improve contour.
The “art” of the CSR lift requires that you address these as needed to
achieve the best outcome for your patient. The use of barbed suture
in a serpentine pattern is really useful to help with tissue smoothing in
the cheek or anterior sternocleidomastoid areas.
Problem: You are doing a secondary rhytidectomy and wonder
about using the CSR technique
Solution:  There are additional options with the CSR lift to utilize
the loops as your “lifting engine” for the cranial suspension of
facial structures and to redrape skin, if excessive with a traditional
postauricular approach, if needed. This also works well in
secondary rhytidectomy situations where subSMAS dissection is
challenging and dangerous. The use of uni- or bidirectional barbed
suture of similar size may be a consideration also. In situations of
neck laxness, considerations may be given for additional anchor
points in Lore’s fascia or mastoid fascia. Generally, a secondary
rhytidectomy should be planned with a sideburn incision in order to
avoid narrowing/obliteration of the sideburn. Most likely, there will be
neck laxness that require postauricular incisions and dissection to
manage.
corrugator resection, or an endoscopic brow can be performed
in conjunction with the CSR lift.
Dressings and aftercare
A simple dressing afterwards is all that is needed. I use
silicone-backed foam that is used for lipoplasty procedures in
the anterior neck to control skin wrinkling after neck lipo-
plasty and anterior platysma work. Foam also is a great idea
after an endoscopic browlift to control forehead swelling.
Patients generally recover more rapidly from a CSR lift
than a “classic” rhytidectomy. In most cases, swelling resolves
in 10–14 days and the feeling of “tightness” in 4 weeks.
Additional comments regarding the CSR lift
The CSR lift represents a very flexible approach for facial
rejuvenation. It can deliver a very natural outcome without
the stigma of inappropriate tension vectors, flattening of the
face, and the telltale sweep deformity. This approach also can
address midface laxness and repositions midface fat. It is
important to avoid excessive undermining of the neck because
this separates the skin from its anatomic attachments to the
underlying platysma fascia that is being tightened.
The other remarkable thing about the CSR lift is that it can
be undone and converted back to a traditional under the
SMAS dissection and retroauricular incision if the surgeon
believes that he or she cannot obtain a satisfactory outcome
with the CSR technique. Alternatively, the suture loops can be
kept in place and the skin redraped according to a traditional
approach.
After a surgeon has performed their first ten CSR lift cases,
there will be a sense of comfort in the technique and how to
deal with the nuances of the procedure versus feeling uncom-
fortable with the CSR short scar rhytidectomy technique and
its variants.
We are still not at the end of innovation and refinement in
facial rejuvenation surgery or treatments. Thanks to Patrick
Tonnard and Alex Verpaele, we have discovered a new
approach that repositions fat and deeper layers back to their
natural points of fixation in the younger face through innova-
tive use of suture loops versus surgical delamination of facial
structures. Other considerations relate to isolated necklifting
and the innovative use of HA fillers or autologous microfat
grafting in the periorbital area.
Troubleshooting CSR lift
During the time that it take for you to develop your per-
sonal approach to the CSR lift, you are bound to encounter
situations where something does not work, does not look
right, or you do not feel that subsurface lifting is occurring.
Some situations and recommended solutions are set out in
Box 6.4.1.

166
SECTION I
CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
Summary
The MACS lift is a facelift technique that is ideally suited for
the lower and middle third of the face. By using strategically
placed sutures, deep tissues are repositioned without the
dangers of deeper dissection. The vertical vector ensures that
many patients benefit from a short scar approach with a faster
recovery. The technique is adaptable to a wide cross section
of patients, and it can be mastered by most surgeons who are
willing to learn a new technique. I present a personal evolu-
tion of the technique that expands upon the original MACS
lift principles to improve outcomes.
References
1. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial
suspension lift: a modified S-lift. Plast Reconstr Surg. 2002;109:
2074–2086.
2. Tonnard P, Verpaele A. The MACS-lift short-scar rhytidectomy. St
Louis, MO: Quality Medical Publishing; 2004.
3. Tonnard P, Verpaele A, Gaia S. Optimising results from minimal
access cranial suspension lifting (MACS-lift). Aesthetic Plast Surg.
2005;29:213–220.
4. Tonnard P, Verpaele A. Short scar face lift, operative strategies and
techniques. St Louis, MO: Quality Medical Publishing; 2007.
5. Aston S, Steinbrech D, Walden J. MACS facelift. In: Tonnard P, ed.
Aesthetic Plastic Surgery. Philadelphia, PA: Saunders Elsevier;
2009:137–149.
6. Labbé D, Franco R, Nicolas J. Platysma suspension and
platysmaplasty during neck lift: anatomical study and analysis of
30 cases. Plast Reconstr Surg. 2006;117:2001–2007.
7. Mendelson B, Muzaffar AR, Adams WP Jr. Surgical anatomy of the
midcheek and malar mounds. Plast Reconstr Surg. 2002;110:885–896.
8. Besins T. The “R.A.R.E.” technique (reverse and repositioning
effect): the renaissance of the aging face and neck. Aesthetic Plast
Surg. 2004;28:127–142.
9. Rohrich RJ, Pessa JE. The fat compartments of the face. Plast
Reconstr Surg. 2007;119:2219–2227.
10. Gardetto A, Dabernig J, Rainer C, et al. Does a superficial
musculoaponeurotic system exist in the face and neck? An
anatomical study by the tissue plastination technique. Plast Reconstr
Surg. 2003;111:673–675.
11. Mazza E, Papes O, Rubin MB, et al. Simulation of the aging face. J
Biomech Eng. 2007;129:619–623.
12. Barbarino G, Jabareen M, Trzewik J, et al. Biomedical Simulation:
Physically Based Finite Element Model of the Face. Berlin: Springer-
Verlag; 2008:1–10.
13. Barbarino G, Jabareen M, Trzewik J, et al. Development and
validation of a three-dimensional finite element model of the face. J
Biomech Eng. 2009;131:1–10.

SECTION I • Aesthetic Surgery of the Face
6.5 
Facelift: Lateral SMASectomy facelift
Daniel C. Baker and Steven M. Levine
SYNOPSIS
■ Because the procedure does not require traditional SMAS flap
elevation, there is less concern about tearing of the superficial fascia.
■ The potential for facial nerve injury is lower because most of the deep
dissection is over the parotid gland.
■ Because SMAS flaps have not been elevated, they tend to hold suture
fixation more strongly, and the potential for postoperative dehiscence
and relapse of contour is decreased.
■ SMASectomy is not suitable in every rhytidectomy. Patients with thin
faces and minimal subcutaneous fat should undergo simple plication
or imbrication.
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Senior author’s personal philosophy
For many years I have listened to panels and presentations
and have read articles about the “super-SMAS”, “deep plane”,
“subperiosteal”, and various other extended rhytidectomy
procedures. In their search for the penultimate facelift, these
pioneering surgeons demonstrate superb anatomic studies,
beautiful illustrations, and impeccable photographs. Their
presentations are well organized, stimulating, and seductive.
I have always considered myself to be a bold and aggres-
sive surgeon, and the temptation to utilize these new, deeper
dissections is extremely appealing. However, I am reluctant
to employ them, and I keep asking myself why? The explana-
tion is partly that I am not convinced that the results are
superior to those obtained by the standard SMAS-platysma
techniques. More important, I do not yet believe that the
implied “benefits” outweigh the increased morbidity and
risks, especially to the facial nerve.
The presentations on deep dissection and subperiosteal
rhytidectomies recall the period between 1976 and 1980 when
virtually all panels and courses were advocating complete
platysma muscle transactions and a multitude of platysma
flaps. As a plastic surgeon just completing residency, I was
highly impressed; I became a believer and a convert: The only
way to get the “best result” in rhytidectomy was with these
techniques. However, many years of patient complaints,
complications, and overoperated necks occurred before most
of these techniques were abandoned. I can only speculate on
whether the deep plane rhytidectomy techniques will have a
similar evolution.
In the 21st century, the consumer’s preference has been
for minimally invasive and non-invasive techniques: fillers,
Botox, endoscopy, and limited-incision aesthetic surgery.
The rationale for any minimal-incision surgery is evident:
less invasiveness, less bleeding, presumably less pain, faster
healing, and less scarring. The primary advantages of
minimal-incision rhytidectomy, however, are that it preserves
the posterior hairline and avoids retroauricular scars, which
are particularly important for a woman with a pulled-up or
swept-back hairstyle. It is a ponytail-friendly facelift.
The primary goal of any surgeon performing rhytidectomy
should be to utilize a technique giving consistently good
results with minimal risk, complications, morbidity, and a
speedy postoperative recovery.
My intention is not to discredit these deep dissection tech-
niques, nor to deplete the splendor of creative surgery. Their
contribution is already evident: an increased and clearer
knowledge of facial anatomy, muscle function, and human
expression. I am certain that some aspect of these techniques
will be incorporated by many plastic surgeons. The questions
that remain to be answered are (1)What are the indications for
these newer techniques? (2) How great are the risks and com-
plications? and most important, (3) Do the benefits significantly
outweigh the risks to justify using these techniques routinely?
There are several advantages of lateral SMASectomy in
comparison with traditional SMAS elevation. First, because
the procedure does not require traditional SMAS flap eleva-
tion, there is less concern about tearing of the superficial
fascia. Second, the potential for facial nerve injury is lower
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