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

168
SECTION I
CHAPTER 6.5 • Facelift: Lateral SMASectomy facelift
The choice of preauricular incision is up to the surgeon.
When executed properly, all these incisions heal well and are
imperceptible. We usually prefer a curved incision anterior to
the helix and continue inferiorly anterior to the tragus in a
natural skinfold. This preserves the thin, pale, hairless tragal
skin and its demarcation from the usual coarser, thicker,
darker cheek skin with its lanugo hairs. We perform intratra-
gal incisions in patients in whom the cheek and tragal skin
are similar and the tragal cartilage is not sharp or prominent.
All of these incision choices can yield excellent results. It is
important to recognize no one incision pattern will work best
for everyone and it is important to customize this decision
based on the patient’s anatomy. As always, closure must be
without tension and the flap overlying the tragus should be
defatted to dermis.
In minimal-incision rhytidectomy, efforts are made to end
the incision at the base of the ear lobe. This is usually possible
in young patients, but sometimes a short retroauricular
incision is necessary to correct a dog-ear after the facial flap
rotation.
Skin flap elevation
All skin flap undermining is carried out under direct vision
(with scissors dissection) to minimize trauma to the subder-
mal plexus and preserve a significant layer of subcutaneous
fat on the undersurface of the flap (see Fig. 6.5.2). We usually
perform some subcutaneous dissection in the temporal
region to allow the skin to redrape better. (We believe that
hair loss results primarily from tension rather than superfi-
cial undermining.) Subcutaneous dissection in the temporal
region must be performed carefully to avoid penetrating the
superficial temporal fascia that protects the frontal branch of
the facial nerve. All dermal attachments between the orbicu-
laris oculi muscle and the skin are separated up to the lateral
canthus.
Dissection extends across the zygoma to release the zygo-
matic ligaments but stops several centimeters short of the
nasolabial fold. In our opinion, further dissection provides
little benefit; on the contrary, the only result is increased bleed-
ing. In the cheek, dissection releases the masseteric-cutaneous
ligaments and, if necessary, the mandibular ligaments.
Subcutaneous dissection continues over the angle of the
mandible and sternocleidomastoid for 5–6 cm into the neck.
This exposes the posterior half of the platysma muscle. If a
submental incision has been made, the facial and lateral neck
dissection is connected through and through to the submental
dissection.
Defatting the neck and jowls
Whenever possible, we prefer closed suction-assisted lipo-
plasty in the neck and jowls. We use a 2.4-mm Mercedes tip
cannula, keeping it under constant, steady motion in the
subcutaneous space. We attempt to leave a layer of subcutane-
ous fat on the undersurface of the cervical skin. If we suction
the jowls, this is always done conservatively.
We rarely suction or remove subplatysmal fat because (1)
the facial nerves run just beneath the platysma and (2) any
patient with significant subplatysmal fat probably has a fat,
round face, so removing subplatysmal fat could create an
overoperated look.
because most of the deep dissection is over the parotid gland.
If the SMASectomy is performed anterior to the parotid, the
deep fascia will similarly provide protection for the facial
nerve branches as long as the resection of the superficial fascia
is done precisely and the deep fascia is not violated. Third,
because SMAS flaps have not been elevated, they tend to hold
suture fixation more strongly, and the potential for postopera-
tive dehiscence and relapse of contour is decreased.
There are certainly other rhytidectomy techniques that
produce excellent results. Each surgeon must adopt a tech-
nique that serves his or her patients best. Ideally, the technique
should be safe, consistent, easily reproducible, and applicable
to a variety of anatomic problems. The surgeon also must
have the versatility to adapt and modify his or her technique
to the needs and desires of each patient. At present, the lateral
SMASectomy provides this for most of my patients. In the
future, as endoscopy and fixation techniques advance, I will
seek to modify and further improve my present rhytidectomy
operation.
It must be emphasized that I do not perform SMASectomy
in every rhytidectomy. Patients with thin faces and minimal
subcutaneous fat undergo simple plication or imbrication.
Surgical technique
Anesthesia
Virtually all of our facelifts are performed with the patient
under monitored intravenous propofol sedation. Patients are
given oral clonidine, 0.1–0.2 mg, 30 min before surgery to
control their blood pressure. The face and neck are infiltrated
with local anesthesia, 0.5% lidocaine with 1 : 200 000 epineph-
rine, through use of a 22-gauge spinal needle. The face is
injected before we scrub to provide the requisite 10 min for
vasoconstriction.
Incisions
When the temporal hairline shift is assessed as minimal, the
preferred incision is well within the temporal hair. With this
incision, it is often necessary to excise a triangle of skin below
the temporal sideburn at the level of the superior root of the
helix. Keep in mind that this incision will move the natural
hairline. This may be acceptable if the shift is minimal or if
the hairline is low.
However, when larger skin shift is anticipated (frequently
the lift is more vertical with minimal-incision rhytidectomy)
or the distance between the lateral canthus and temporal
hairline is greater than 5 cm, we prefer an incision a few
millimeters within the temporal hairline (Figs 6.5.1–6.5.3).
Although this is a compromise, the alternative of a receding
temporal hairline is never acceptable to a female patient.
When the incisions are executed properly, these scars heal
well and are easy to revise or camouflage. The only exception
might be in a patient with deeply pigmented skin in whom
the scar will contrast and appear as a white line. The temporal
hairline incision should be made parallel to the hair follicle
and no higher than the frontotemporal hairline.
The temporal hairline incision allows for the more vertical
elevation of the facial flap that is usually required in a short scar
rhytidectomy. Other indications for this incision are a receding
hairline from previous facelifts and a fine, fragile hairline.

169
Surgical technique
Fig. 6.5.1  Lateral SMASectomy dissection. The temporal
hairline incision allows for a more vertical elevation of the
facial flap that is usually required in a short scar
rhytidectomy. Subcutaneous dissection is performed
extending across the zygoma to release the zygomatic
ligaments but stops several centimeters short of the
nasolabial fold. The SMAS resection is performed on a
tangent from the lateral malar eminence to the angle of the
mandible in the region along the anterior edge of the
parotid gland. The width depends on the laxity of the
tissues and the desired elevation. Vectors are
perpendicular to the nasolabial fold. A platysma flap is
elevated and secured to the mastoid periosteum.
Preferred incision
Optional temporal
incision for
recessed hairlines
Usual extent of
subcutaneous
undermining to
lateral canthus
and release of
malar ligaments
Submental incision
in normal skin crease.
Undermining
connects laterally
Optional preauricular
or intratragal incision
Subcutaneous undermining
into neck allows for
exposure of platysma
and skin redraping
Usual lower border of
undermining
Fig. 6.5.2  The incision and area of dissection in lateral
SMASectomy. The temporal hairline incision is utilized to
allow a more vertical elevation of the facial flap. A curved
incision anterior to the helix is utilized, continuing inferiorly
anterior to the tragus in a natural skinfold. Facial
subcutaneous dissection is performed, extending across the
zygoma to release the zygomatic ligaments but stopping
short of the nasolabial fold. Subcutaneous dissection
continues over the angle of the mandible and
sternocleidomastoid for 5–6 cm into the neck. This exposes
the posterior half of the platysma muscle. If a submental
incision has been made, the facial and lateral neck
dissections are connected through and through to the
submental dissection.
SMAS and platysma
approximation suspension.
Suture is just beneath
SMAS
Malar fat pad vector
Facial vectors
Submandibular
vertical vector
Medial and lateral
platysma vectors create
a muscular hammock
support and define
the jawline
Suture from submandibular
platysma SMAS to anterior
tympano-parotid fascia
(vertical vector)
Platysma flap
sutured to mastoid
periosteum (lateral
oblique vector)
Wedge resection of
4-5cm medial
platysma border
to interrupt bands
We usually perform lipoplasty before elevating the skin
flaps. In doing so, we are careful not to oversuction the portion
of the SMAS-platysma that will be elevated over the mandible
with the lateral SMASectomy. It is better to be conservation
with liposuction at the beginning of the case as you can always
remove more fat at the end of the case.
Open submental incision with
medial platysma approximation
For many patients, excellent results can be achieved with closed
lipoplasty and strong lateral platysma pull. However, with
short scar rhytidectomy there is limited access to the platysma

170
SECTION I
CHAPTER 6.5 • Facelift: Lateral SMASectomy facelift
essentially in the region along the anterior edge of the parotid
gland (see Figs. 6.5.1 & 6.5.3). In most patients, this involves
a line of resection extending from the lateral aspect of the
malar eminence toward the tail of the parotid gland. Usually,
a 2- to 3-cm segment of superficial fascia is excised, depending
on the degree of SMAS-platysma laxity.
In SMAS resection, we like to pick up the superficial fascia
in the region of the tail of the parotid, extending the resection
from inferior to superior in a controlled fashion. When SMAS
resection is being performed, it is important to keep the dis-
section superficial to the deep fascia and avoid dissection into
the parotid parenchyma. Note that the size of the parotid
gland varies from patient to patient; consequently, the amount
of protection for the underlying facial nerve branches will also
vary. Despite this, as long as one carries the dissection super-
ficial to the deep facial fascia, ensuring that only the superficial
fascia is resected, facial nerve injury as well as parotid gland
injury will be prevented. In essence, this is a resection of the
superficial fascia in the same plane of dissection in which one
would normally raise the SMAS flap.
Continuous with the lateral SMASectomy is the resection
of a strip of posterior platysma muscle several centimeters
long over the tail of the parotid and anterior border of the
sternocleidomastoid. The facial nerves are protected here.
Vectors
The various vectors accomplish correction of the anterior
neck, the cervicomental angle, the jowls, and the nasolabial
fold. The first key suture grasps the platysma at the angle of
the mandible and advances it in a posterosuperior direction;
it is secured with 2-0 Maxon (United States Surgical Corp.,
Norwalk, CT) to the fixed lateral SMAS (Figs. 6.5.3–6.5.5). This
lifts the cervical platysma and cervical skin.
Interrupted 3-0 PDS buried sutures are used to close the
SMASectomy, the fixed lateral SMAS being evenly sutured to
more mobile anterior superficial fascia (see Fig. 6.5.5). Vectors
are perpendicular to the nasolabial fold. The last suture lifts
the malar fat pad, securing it to the malar fascia. It is important
to obtain a secure fixation to prevent postoperative dehiscence
and relapse of facial contour.
If firm monofilament sutures are used, such as PDS or
Maxon, the sutures should be buried and sharp ends on the
knot trimmed. Final contouring of any SMAS or fat irregulari-
ties along the suture line is completed with scissors. Fat can
also be trimmed at the sternomandibular trough, final con-
touring being accomplished with lipoplasty.
For the neck, a flap of the lateral platysma is developed in
the region inferior to the mandibular border. After this lateral
platysma flap is raised, the platysma is secured to the mastoid
periosteum with figure-of-eight 2-0 Maxon sutures to help
define the jawline and improve contouring in the subman-
dibular region. This is the basic rhytidectomy operation that
the senior author has performed since July 1992.
Skin closure, temporal and earlobe dog-ears
After SMAS and platysma approximation, some tethering of
the skin might appear at the anterior extent of the subcutane-
ous dissection because of the pull of the underlying SMAS.
This can also occur in the lower eyelid with elevation of the
malar fat pad. Further subcutaneous undermining is neces-
sary to free these tethers, allowing the skin to redrape.
and the lateral vector has changed. Therefore, in these patients
as well as patients with significant active platysma bands on
animation, the medial approximation provides another vector
to enhance the cervicomental recontouring (Fig. 6.5.4).
The submental incision is made either in the submental
crease or just anterior to it. The subcutaneous dissection is
performed with the neck hyperextended, and undermining is
usually to the level of the thyroid cartilage and angle of the
mandible. Suction-assisted lipoplasty is then performed with
a large, single-hole cannula under direct vision. Direct fat
excision is carried out if necessary, but to avoid depressions,
subplatysmal fat is rarely removed.
The medial borders of the platysma muscle are identified
and elevated for several centimeters. To break the continuity
of the bands, a wedge of muscle is removed at the level of the
hyoid. The medial borders of the muscle are then sutured
together with interrupted buried 4-0 PDS (Ethicon, Inc.,
Somerville, NJ).
The submental incision is left open to allow for final hemo-
stasis and recontouring after communication with the facial
dissection and completion of the lateral SMASectomy.
Lateral SMASectomy including
platysma resection
The outline of SMASectomy is marked on a tangent from
the lateral malar eminence to the angle of the mandible,
Fig. 6.5.3  Outline of the SMAS excision. The SMAS resection is performed on a
tangent from the lateral malar eminence to the angle of the mandible in the region
along the anterior edge of the parotid gland. Continuous with the lateral
SMASectomy is the resection of a strip of posterior platysma muscle several
centimeters long over the tail of the parotid and anterior border of the
sternocleidomastoid.
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

171
Surgical technique
Fig. 6.5.4  Medial platysma approximation.
Subcutaneous dissection through a submental
incision is performed with the neck
hyperextended. The dissection usually extends to
the level of the thyroid cartilage and angle of the
mandible. Suction-assisted lipoplasty is then
performed. The medial borders of the platysma
muscle are elevated for several centimeters. To
break the continuity of the bands, a wedge of
muscle is removed at the level of the hyoid. The
medial borders of the muscle are then sutured
together.
Last suture lifts
malar fat pad
Temporalis fascia
Zygomatic arch
Plication of
mobile to fixed SMAS
Fig. 6.5.5  Pre- and 1 year postoperative on patient who underwent lateral SMASectomy.
A
B
C
D
The first key skin suture rotates the facial flap vertically and
posteriorly to lift the midface, jowls, and submandibular skin.
Suture fixation is at the level of the insertion of the superior
helix. We like to use a buried 3-0 PDS through the temporal
fascia with a generous bite of dermis on the skin flap. Closure
is under minimal to moderate tension. Staples are used to
close any incisions in the hair. A wedge is usually removed at
the level of the sideburn to preserve the hairline. If an anterior
hairline incision has been made, we like to close it with buried
4-0 PDS sutures (Ethicon, Inc., Somerville, NJ) and 5-0 Nylon
sutures on the skin. Extra time and attention must be spent
on this closure to eliminate any dog-ears and obtain the finest
scar. Excess skin is then trimmed from the facial flap so that
there is no tension on the preauricular closure. Wound edges
should be “kissing” without sutures.
In short scar rhytidectomy, trimming at the earlobe must
be without tension, and the skin flap is tucked under the
lobe with 4-0 PDS sutures, taking a bite of earlobe dermis,
cheek flap dermis, and conchal perichondrium to minimize
any tension. A small dog-ear might be present behind the
earlobe; this is easily trimmed and tailored into a short inci-
sion in the retroauricular sulcus. A closed suction drain is
usually brought out through a separate stab in the retroau-
ricular sulcus. Figs. 6.5.6 and 6.5.7 are representative pre- and
postoperative photos of patients who have undergone lateral
SMASectomy.

172
SECTION I
CHAPTER 6.5 • Facelift: Lateral SMASectomy facelift
most common problems are minor revisions of earlobe and
temporal hairline scars. Secondary lifts are occasionally per-
formed, but we require all patients to allow healing for 1 year
before considering any revisions. Our goal is to keep the
occurrence of all revisions to less than 5%. When revisions
exceed this limit, it is time to re-evaluate the technique.
Postoperative care
For the first 48 h of the postoperative period, blood pressure
monitoring is continuous to avoid systolic spikes and poten-
tial bleeding. Treatment of rising blood pressure is essential
to minimize hematoma formation.
We usually utilize suction drains and a soft head dressing
to cover the flaps and incisions. Although drains never prevent
expanding hematomas, I prefer to remove serosanguineous
fluid in this manner. Sutures are removed on the seventh and
tenth postoperative days.
When large hematomas are recognized early, they are
usually successfully managed at the bedside with sedation,
blood pressure control, and irrigation. The overall incidence
of hematoma for women is about 1.5%; for men it is 4%.
Complications
Table 6.5.1 summarizes the complications of this technique,
which are consistent with other standard facelift operations.
Despite special attention to blood pressure control in the
postoperative period, the hematoma rate is still 1.5%. The
Fig. 6.5.6  Preoperative (A,C) and 2 year postoperative views (B,D) after lateral SMASectomy, perioral dermabrasion, advanced fluorescence technology (AFT) to face, and
chin implant.
A
B
C
D
Fig. 6.5.7  Preoperative (A,C) and 1 year postoperative views (B,D) after lateral SMASectomy, advanced fluorescence technology (AFT) to face, and perioral dermabrasion.
A
B
C
D
Table 6.5.1  Complications associated with 3500 lateral
SMASectomy facelifts
Complication
Incidence (%)
Hematoma (female/male)
1.5/4.0
Facial nerve weakness
0.1*
Earlobe scar revision
2.0
Skin slough
2.0
Retroauricular and temporal scar revisions
2.0
Infection
1.0
“Minilift” after 1 year
2.0
*All resolved in 6 months.

173
Complications
Baker DC. Minimal incision rhytidectomy (short scar facelift) with
lateral SMASectomy: evolution and application. Aesthet Surg J.
2001;21:68–79.
Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy
hematomas. Plast Reconstr Surg. 2005;115:2119–2222.
Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy.
Anatomical variations and pitfalls. Plast Reconstr Surg.
1979;64:781–795.
Baker DC, Rees TD. Complications of cosmetic facial surgery. In: Lewis
JR, ed. Aesthetic Plastic Surgery. Boston, MA: Little, Brown & Co.;
1989.
Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematomas
requiring surgical evacuation following male rhytidectomy: a thirty
year review of 985 cases. Plast Reconstr Surg. 2005;116:1973–1985.
Further reading
Baker DC, Aston SJ, Guy CL, et al. The male rhytidectomy. Plast
Reconstr Surg. 1977;60:514–522.
Baker DC. Anatomy and injuries of the facial nerve in cervicofacial
rhytidectomy. In: Kaye BL, Gradinger GP, eds. Symposium on
Problems and Complications in Aesthetic Plastic Surgery of the Face. St.
Louis, MO: CV Mosby; 1984.
Baker DC. Deep dissection rhytidectomy: a plea for caution. Plast
Reconstr Surg. 1994;93:1498–1499.
Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:509–513.
Baker DC. Rhytidectomy with lateral SMASectomy. Facial Plast Surg.
2000;16:209–213.

SECTION I • Aesthetic Surgery of the Face
6.6 
Facelift: The extended SMAS technique in
facial rejuvenation
James M. Stuzin
SYNOPSIS
■ As the human face ages, many of the stigmata that are typically seen
in aging relate to a change in the anatomic relationship that occurs
between the superficial and deep facial fascia.
■ Improving technical control when contouring the superficial facial
fascia and platysma provides for a more consistent, aesthetically
pleasing result.
■ Performing a two-layer SMAS-type facelift requires commitment on the
part of the surgeon, not only to understand facial soft-tissue anatomy,
but also to perform a procedure that demands technical precision.
■ A two-layer SMAS-type facelift is a time-consuming operation, with
both the skin flap elevation as well as the dissection of the SMAS
requiring meticulous and accurate dissection.
■ Obtaining consistency with this procedure is challenging because of
the variability in thickness of subcutaneous fat and the SMAS that
exists among individual patients
■ Following precise dissection, secure fixation of both SMAS and platysma
is mandated to maintain the shaping desired in postoperative contour.
■ Meticulous hemostasis followed by careful skin flap inset are required
to minimize postoperative scar perceptibility and ensure a rapid
postoperative recovery.
■ The biggest advantage of the extended SMAS technique remains its
aesthetic versatility, allowing the surgeon to vary the contouring aspects
of the procedure according to the aesthetic needs of the patient.
Introduction
Surgical rejuvenation of the aging face has evolved into one
of the most frequently performed surgical procedures in the
United States. Facelifting, initially performed as a skin tight-
ening procedure since the early 1900s, has technically matured
during the last quarter of a century. This evolution is directly
related to the scientific investigation of facial soft-tissue
anatomy, resulting in a better understanding of the facial
anatomic changes that occur with aging. Over the last 30
years, a plethora of procedures have evolved that utilize a
variety of technical approaches, having as a common goal the
reconstruction of aging-related anatomic changes.
The public’s perception and the aesthetic concepts in facelift-
ing have similarly evolved over time. Initially, both patients
and surgeons focused solely on the laxity that occurs with facial
aging, attempting to tighten what was loose rather than shape
the face. Hence the term “facelift” (as opposed to “facialplasty”),
a mechanical term implying a procedure, the goal of which is
to lift what has fallen. Unfortunately, this mechanical approach
to facial rejuvenation often produced a tight-appearing, oper-
ated look, the stigma of the “wind-tunnel appearance” so often
associated with surgical rejuvenation of the aging face. None-
theless, based on a better understanding of facial soft-tissue
anatomy and the anatomic changes that occur in aging, facelift-
ing has developed into both a reconstructive procedure (whose
goal is to reconstruct the anatomic changes that occur with
aging) as well as a more artistically defined technique that
attempts to enhance facial appearance while minimizing signs
that a surgical procedure has been performed.
There are many treatment goals in facelifting besides
simply correcting the hallmarks of the aging face, including
improvement of the nasolabial folds and facial jowling, and
correction of obliquity of cervical contour. As important as the
mechanical aspects of tightening a loose, aged face are the
aesthetic concepts of improving facial shape and bringing out
the beauty in the face that existed during youth. To these
goals, the surgeon attempting facial rejuvenation must have
a thorough understanding of facial soft-tissue anatomy, com-
prehend the anatomic changes that occur in aging that produce
a change in facial shape, and understand the ideal facial shape
that can be obtained for a particular patient. Artistic design of
surgical access incisions to minimize scar perceptibility, as
well as prevent hairline distortion, is also key in preventing
surgical stigmata.
The evolution of aging in the human face is complex and
multifactorial. Problems that the plastic surgeon confronts in
midface rejuvenation include (1) the dermal component of
aging related to intrinsic and extrinsic skin changes (dermal
  Access video lecture content for this chapter online expertconsult.com

175
Aesthetic analysis and treatment planning
discussed in Chapter 6.1. These structures fixate facial soft
tissue in normal anatomic position, resisting gravitational
forces.1,7 In the evolution of midface aging, the zygomatic
and masseteric cutaneous ligaments bear particular attention.
The zygomatic ligaments originate from the periosteum of the
malar region. Their function is to fixate the malar pad to the
underlying zygomatic eminence in the youthful face.
Support of the soft tissues of the medial cheek is provided
by a series of fibrous bands that extend along the entire
anterior border of the masseter muscle. These are the “mas-
seteric cutaneous ligaments”, and are identified superiorly in
the malar area where they mingle with the zygomatic liga-
ments and extend along the anterior border of the masseter
as far inferiorly as the mandibular border. These fibers repre-
sent a coalescence between the superficial and deep fascia,
extending from the masseter muscle vertically to insert into
the overlying dermis. These masseteric ligaments support the
soft tissues of the medial cheek superiorly above the man-
dibular border in youth.
The surgical significance of the retaining ligaments is that
they represent the anatomic communication between super-
ficial and deep facial fascia. As this support system becomes
attenuated, facial shape changes. The position of the retaining
ligaments also dictates the degree of dissection required in a
facelift. To adequately mobilize the skin flap, the dissection
needs to be carried at least to the peripheral extent of the
retaining ligament system, specifically dissecting the skin flap
into the malar region, as well as past the anterior border
of the masseter. Similarly, the location and restrictiveness of
the retaining ligaments dictates the degree of SMAS eleva-
tion required to adequately release the superficial fascia. In
general, this requires the surgeon to extend the SMAS dis-
section into the malar region, releasing the superficial fascia
from the restraint of the zygomatic ligaments, the upper
masseteric ligaments, and medial to the anterior border of the
parotid.
Aesthetic analysis and
treatment planning
As the human face ages, facial shape changes; morphologic
facial changes are multifactorial. Some of these changes are
straightforward to address, while others remain difficult
technical challenges. A paradox has always been that facial
anatomy (in terms of basic soft-tissue architecture) is essen-
tially unchanged from youth to middle age, but facial appear-
ance changes greatly over time and is patient-specific.
Although each face ages differently, there are common themes
noted in all aging faces.
Descent of facial fat
As the human face ages, facial fat descends and, consequently,
facial shape changes. Typically, the youthful face is full of
well-supported fat. Volumetric highlights are located within
facial aesthetic subunits, which have a high density of retain-
ing ligaments (zygomatic eminence and zygomatic arch,
preparotid, orbital rim) and serve to fixate this volume of fat
to underlying structures. Juxtaposed to the volumetric full-
ness (or convexity) of the malar and preparotid region is
commonly a concavity within the submalar region, overlying
elastosis); (2) facial fat descent; (3) facial deflation, which
tends to be regionally specific; (4) radial expansion as facial
fat becomes situated centrifugally away from the facial skel-
eton; and (5) the degree of skeletal support of the soft tissue,
which influences both loss of volumetric highlights, as well
as the descent of facial fat.1–4 All of these factors influence
facial shape changes with aging. Individual patients will
exhibit various degrees of these problems at the time they
request surgery, and each component of the aging face should
be addressed according to individual patient needs.
Evaluation of patient photographs taken during youth and
middle age are helpful in determining how a specific patient
has aged. Young photographs will usually demonstrate the
location of the volumetric highlights present in youth or serve
to document areas that have deflated over time, delineating
both the position and vector of facial fat descent. These factors
illustrate patient-specific changes in facial shape from youth to
middle age, as well as clarifying the possibilities of methods
that facial fat repositioning can improve and restore shape.
From my perspective, the restoration of facial shape is a more
worthy aesthetic goal than attempting to tighten a loose face.
Anatomic considerations
The anatomic basis that allows rhytidectomy to be performed
safely is that the facial soft tissue is arranged as a series of
concentric layers. This concentric arrangement allows dissec-
tion within one anatomic plane to proceed completely separate
from structures lying within another anatomic plane. The
layers of the face are the (1) skin; (2) subcutaneous fat; (3)
superficial musculo-aponeurotic system (SMAS; superficial
facial fascia); (4) mimetic muscles; (5) parotidomasseteric
fascia (deep facial fascia); and (6) plane of the facial nerve,
parotid duct, buccal fat pad, and facial artery and vein. (This
information is thoroughly reviewed in Chapter 6.1.)
In an overview of the architectural arrangement of the
facial soft tissue, the essential point is that there is a superficial
component of the facial soft tissue that is defined by the super-
ficial facial fascia and includes the SMAS and those anatomic
components that move facial skin (including superficially
situated mimetic muscle invested by SMAS, the subcutaneous
fat, and skin). This is in contrast to the deeper component of
the facial soft tissue, which is defined by the deep facial fascia
and those structures related to the deep fascia (including the
relatively fixed structures of the face, such as the parotid
gland, masseter muscle, periosteum of the facial bones, and
facial nerve branches). As the human face ages, many of the
stigmata that are typically seen in aging relate to a change
in the anatomic relationship that occurs between the super-
ficial and deep facial fascia. With aging, facial fat descends
in the plane between superficial and deep facial fascia, and
the radial expansion of the superficial soft tissue away from
the facial skeleton occurs within this plane. In my opinion,
these anatomic changes justify repositioning facial fat through
subSMAS dissection to restore facial shape.5,6
Retaining ligaments
The communication between the superficial and deep facial
fascia occurs at the level of the retaining ligaments, which are

176
SECTION I
CHAPTER 6.6 • Facelift: The extended SMAS technique in facial rejuvenation
the buccinator muscle and buccal recess. The combination of
fullness in the malar region and lateral cheek, associated with
submalar concavity and a well-defined mandibular border,
accounts for the angular, tapered appearance of the youthful
face.
With aging, facial fat can descend and produce significant
changes in facial shape. In middle age, as ligamentous support
becomes attenuated, facial fat volumetrically becomes situ-
ated anteriorly and inferiorly in the cheek, producing a
contour that is square and bottom heavy, with little differential
between malar highlights and submalar fat. As facial fat is
situated more inferiorly in the face, middle-aged faces appear
vertically longer than young faces (see Fig. 6.2.5).3,4
Volume loss and facial deflation
Youthful faces are full of well-supported facial fat. Over time,
deflation occurs, and tends to be most apparent in regions of
the face with a high density of retaining ligaments. For this
reason, the areas that are noted to be volumetrically full in
youth (malar, preparotid, lateral and infraorbital rim, lateral
chin) become volumetrically deflated over time. With defla-
tion, soft tissue becomes less supported and therefore appears
lax. Youthful faces have a smooth blending of contour between
the aesthetic subunits of the face. Middle-aged faces, second-
ary to both deflation and facial fat descent, develop lines of
demarcation between one region of the face and another,
which is intuitively identified as old. An accurate aesthetic
treatment plan to improve facial shape requires repositioning
descended soft tissue into areas of facial deflation to improve
shape, not only by restoring volume to the position noted in
youth, but also serving to blunt the lines of demarcation
between aesthetic subunits. Volumetric augmentation through
autologous fat injection or other injectable soft-tissue fillers
are ancillary agents that can be useful in augmenting areas of
deflation.
Fig. 6.6.1  (A) Preoperative appearance of
a 42-year-old patient with early facial aging
resulting primarily from deflation. Note the
hollowing effect within the lateral cheek and
preparotid region. Deflation in this young
patient has occurred in the fat
compartments lateral to the zygomaticus
major muscle. (B) Postoperative result
following face and necklift. Note, as
anteriorly situated fat is brought into the
upper lateral midface, it fills the areas of
deflation, thereby blunting the lines of
demarcation between aesthetic subunits that
develop with age. Notice also the change in
facial shape, which now appears more
structured and supported following facial fat
repositioning.
A
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B
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Deflation in the aging face is a complex process that tends
to be regional and age-specific. Key elements in understand-
ing how deflation occurs have been enlightened following an
elucidation of the compartmentalization of subcutaneous fat
within the cheek as defined by Rohrich and Pessa.8 What these
investigators realized was that the cheek subcutaneous fat,
rather than being homogeneous, is compartmentalized, with
each facial fat compartment surrounded by specific septal
membranes and with each compartment having an indepen-
dent perforator blood supply. Aesthetically, the significance of
compartmentalization of facial fat is that deflation tends to
occur within a specific region of the cheek, explaining why
the entire cheek does not deflate homogeneously (Fig. 6.6.1).
At the risk of over-simplification, one key to understanding
facial deflation is the recognition of the location of zygomati-
cus major muscle, which traverses from the malar eminence
to the oral commissure. Deflation of the cheek lateral to the
zygomaticus major muscle tends to occur independently from
deflation in the malar region, medial to the zygomaticus
major. For many patients, lateral cheek deflation develops at
an earlier age than malar pad deflation and is often noted in
patients in their forties. Medial cheek and malar pad deflation
tend to occur later in life and is responsible not only for the
loss of volumetric support within the anterior cheek, but also
leads to the development of what has been termed the infra-
orbital V-deformity. Deflation in this region results in an
apparent increase in the vertical length of the lower lid, as the
lid–cheek junction visually descends inferiorly into the poorly
supported anterior cheek (Fig. 6.6.2).
An interesting region of deflation develops in some patients
in the submalar region lateral to the oral commissure. In these
patients, deflation can result in accentuation of the submalar
concavity, which can become more obvious following the
vertical soft-tissue shifts associated with facelifting proce-
dures. An accentuation of submalar depression lateral to the
oral commissure can result in the development of what has

177
Radial expansion
been termed “joker lines” or cross-cheek depressions, which
are a typical stigmata that a patient has undergone a facelift.
Avoidance of vertical soft-tissue repositioning in conjunction
with volume addition in the submalar recess lateral to the oral
commissure is useful in preventing the accentuation of post-
operative cross-cheek depressions (Fig. 6.6.3).9
Radial expansion
Not all facial aging is vertical, and a major challenge in facial
rejuvenation is the radial expansion of facial soft tissue that
occurs along specific areas of the midface. In youth, the skin
and underlying subcutaneous fat are densely attached to the
deep facial fascia by retinacular fibers that transverse between
skin, subcutaneous fat, and superficial fascia and insert into
the deep fascia and facial musculature. Over time, with pro-
longed animation such as smiling, the skin along the nasolabial
line is forced deep to the subcutaneous fat, positioned lateral
to the nasolabial fold, attenuating these retinacular attach-
ments. Prolonged animation therefore forces the skin and fat
lateral to the nasolabial fold to expand radially and prolapse
outward from the facial skeleton, accounting for much of the
nasolabial fold prominence in the aging face. Radial expan-
sion lateral to the oral commissure and marionette line simi-
larly accounts for the prominence of the jowl in many
middle-aged patients, making the older face appear square in
shape and bottom heavy.4,10
Radial expansion is technically difficult to correct, as there
are few surgical solutions to re-establish the retinacular
attachments between skin, subcutaneous fat, and deep fascia.
Nonetheless, repositioning of facial fat through some form
of support to the superficial fascia will not only reposition
fat vertically, but will also provide some degree of internal
Fig. 6.6.2  (A,C) Preoperative appearance of a 59-year-old male following a 90-lb weight loss from a gastric bypass procedure. Notice the significant areas of facial
deflation along the infraorbital rim, lateral orbital rim, and malar region. Also note the apparent length of the lower lid as the infraorbital V-deformity develops in association
with malar pad deflation. Note also the radial expansion of skin and fat lateral to the nasolabial fold, most marked on the right side. Not only does malar fat deflate and
descend, but attenuation of the retinacular connections between skin, fat, and deep facial fascia lateral to the nasolabial line allows centrifugal prolapse of soft tissue, which
accentuates nasolabial prominence. (B,D) Postoperative result. The areas of deflation along the infraorbital rim, lateral orbital rim, and malar region are improved as facial
fat has been repositioned into these regions. The nasolabial folds are somewhat improved following malar pad repositioning, but correction is incomplete, especially on the
right. Malar pad elevation helps to flatten the prominent nasolabial fold, and improve the infraorbital V-deformity, but does little to correct radial expansion, with the skin
lateral to the nasolabial line remaining prolapsed from its attachments to the facial skeleton. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support
in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–376.)
A
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Fig. 6.6.3  A cadaver dissection illustrates the muscular insertions into the oral
commissure and modiolus. The small arrow overlies the facial portion of the
platysma and points to the risorius muscle. The large arrow points to the depressor
anguli oris in the region where it merges with the platysma. Superiorly, note the
insertion of the zygomaticus major into the lateral commissure with a slip of
muscle inserting inferiorly into the modiolus. Following deflation in this area, the
medial component of the cross-cheek depression develops in the watershed
between the elevator and the depressors of the lip. (From Lambros V, Stuzin JM.
The cross-cheek depression: surgical cause and effect in the development of the
“joker line” and its treatment. Plast Reconstr Surg. 2008;122:1543–1552.)
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178
SECTION I
CHAPTER 6.6 • Facelift: The extended SMAS technique in facial rejuvenation
repositioning such that the superficial facial soft tissues lie
closer to the facial skeleton. As the soft tissues become situ-
ated closer to the underlying deeper structures of the face,
facial morphology tends to be restored to a more youthful
configuration. Because of the technical difficulty in completely
treating radial expansion in many faces, incomplete correction
of both the jowl and nasolabial fold resulting in undercorrec-
tion can be noted postoperatively despite heroic efforts at
repositioning descended facial fat.
Role of skeletal support in formulating
a surgical treatment plan
Facial shape and contour is intuitively evaluated when ana-
lyzing a patient for facial rejuvenation. Often the two-
dimensional considerations seen in photographs are the
easiest aspects of aging to identify, and such factors as naso-
labial fold depth, jowl prominence, and cervical contour
become the primary objectives to improve appearance in the
middle-aged face. While these factors are certainly important
considerations in treatment planning, the more subtle three-
dimensional qualities of facial shape are equally important to
evaluate, and are greatly influenced by underlying skeletal
support.
In evaluating facial shape during preoperative analysis,
there follow some of the major factors that are helpful to
consider.4
Facial width, bizygomatic diameter,
and malar volume
The emphasis in facelifting over the last 30 years has focused
on malar pad elevation.2,11–19 While malar pad elevation and
restoration of malar highlights is an important factor in
improving facial shape, it needs to be patient-specific. Many
patients present preoperatively with wide faces, strong malar
eminences, and large malar volume, with little evidence of
malar fat descent. In these individuals, it is necessary to evalu-
ate preoperatively the degree of malar pad elevation required
to improve facial shape. While limited degrees of malar pad
elevation can be helpful in patients who present with wide
bizygomatic diameters, in general, if the malar volume is
significantly enhanced in these types of individuals, the aes-
thetic effect is to make a wide face appear even wider on the
front view postoperatively. In patients with adequate facial
width, I tend to limit both SMAS release and malar pad eleva-
tion to the lateral aspect of the zygomatic eminence such
that bizygomatic diameter is not increased postoperatively
(Fig. 6.6.4).
Facial length and the relative vertical heights of
the lower and middle third of the face
Compared with wide faces, patients who present with vertical
maxillary excess often have long, thin faces on front view. As
facial fat descends in middle age, it becomes situated anteri-
orly and inferiorly in the face, and the face appears even
longer with age. Malar pad elevation and enhancing malar
volume in these types of patients is usually beneficial. As
malar volume is enhanced and bizygomatic diameter is
increased, the face appears wider on the front view, detracting
from relatively excessive facial length (Fig. 6.6.5).
Fig. 6.6.4  Facial width and bizygomatic diameter reflect the underlying degree of
skeletal support. Patients who exhibit strong malar eminences and wide bizygomatic
diameter often benefit from having malar highlights restored but usually do not
require significantly enhancing malar volume (which will cause a wide face to
appear wider postoperatively). Shaping considerations in these types of faces
usually focus on improving the appearance of the lower two-thirds of the cheek,
specifically addressing jowl fat repositioning, as well as creating submalar
hollowing, which improves the aesthetic relationship between malar and submalar
regions. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal
support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg.
2007;119:362–376.)
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Convexity of the malar region juxtaposed to the
concavity of the submalar region
In youth, facial fat is situated overlying the malar and prepa-
rotid region. This malar fullness is juxtaposed to a concavity
within the submalar region overlying the buccinator. As
patients age, the relationship between the malar and submalar
regions changes and with it, facial shape changes. As facial fat
descends and facial deflation occurs, there is less volume
overlying the malar eminence and an associated increase in
fullness resulting from radial expansion within the submalar
region. As the aesthetic relationship between the malar and
submalar region becomes modified with time, there is a loss
of the angular, tapered configuration in shape noted in youth,
and middle-aged faces often appear oval. With greater facial
fat descent, and an increase in submalar fullness, older faces
appear square.
Preoperatively, an evaluation of the relationship between
the malar and submalar region on front view is an essential
component of aesthetic treatment planning. For many patients,
a restoration in this relationship by increasing malar high-
lights and malar volume, in association with a restoration of
concavity in the submalar region through repositioning fat
internally overlying the buccinator muscle, becomes a central
component in improving facial shape (Figs. 6.6.6 & 6.6.7).

179
Radial expansion
Fig. 6.6.6  (A) Preoperative appearance.
Note that facial shape is oval, secondary to
malar deflation associated with an increase
in submalar fullness. (B) Postoperatively,
following malar pad elevation, malar
volume is enhanced in association with a
restoration of submalar concavity, producing
a more angular appearance to facial shape.
(From Stuzin JM. Restoring facial shape in
facelifting: the role of skeletal support in
facial analysis and midface soft-tissue
repositioning. Plast Reconstr Surg.
2007;119:362–376.)
A
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B
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Fig. 6.6.5  Long, thin faces often benefit from an enhancement of malar volume. SMAS dissection and facial fat repositioning carried anteriorly over the zygomatic
eminence allows the surgeon to restore malar volume, thereby increasing bizygomatic diameter. When malar volume is enhanced, the face appears wider, detracting from
the relatively excessive facial length. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning.
Plast Reconstr Surg. 2007;119:362–376.)
A
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The vertical height of the mandibular
ramus and the horizontal length of the
mandibular body
The vertical height of the mandibular ramus and the horizon-
tal length of the mandibular body provide skeletal support
for the lower two-thirds of the face. Patients who present with
a normal mandibular ramus height, as well as adequate hori-
zontal length of the mandibular body, usually have excellent
skeletal support for soft-tissue repositioning and are, there-
fore, less of a surgical challenge. In contradistinction, patients
with a short mandibular ramus, an open mandibular plane
angle, and a short length of the mandibular body typically
have poor skeletal support for midface and perioral soft-tissue
repositioning. These patients are a greater surgical challenge
in restoring facial shape, and often benefit from volumetric
augmentation, either alloplastic or autogenous, to enhance
skeletal support.
The aesthetic advantages of formal
SMAS elevation in a two-layer dual
plane SMAS facelift
All modern techniques share a commonality in that postop-
erative contour is largely dependent on facial fat repositioning
through some form of SMAS manipulation. The advantage of

180
SECTION I
CHAPTER 6.6 • Facelift: The extended SMAS technique in facial rejuvenation
Surgical technique: Extended
SMAS dissection
Restoration of support to the underlying deeper facial soft
tissues has become the key ingredient to the approach to
improve facial aging. If the SMAS is thin, plication is an
alternative method. Nonetheless, better contouring and longer
lasting results are obtained following a formal dissection of
the superficial fascia. In my experience, after the superficial
fascia is freed from the restraint of the retaining ligament, it
slides freely, allowing greater control in vertically reposition-
ing of facial fat. Full release of the SMAS also allows the
superficial fascia to better conform internally to the underly-
ing deeper facial soft tissue and facial skeleton. Greater control
of internal fat repositioning provides for more complete cor-
rection of radial expansion.
The key to performing successful dissection of an extended
SMAS flap is precise dissection of the skin flaps during sub-
cutaneous undermining, with care to leave a moderate amount
of fat intact on the superficial surface of the SMAS, especially
in the regions where the SMAS is to be dissected. If the skin
flaps are dissected so that little fat is left along the superficial
surface of the SMAS, the SMAS becomes more difficult to
raise, appearing thin, tenuous, and prone to tearing. In a
SMAS-type facelift, much of the contouring that is obtained
is due to elevation and fixation of the SMAS layer. The more
substantial the SMAS flap, often the better long-term results
that can be obtained in terms of facial contouring. The use
of contralateral transillumination is helpful in providing a
clearer definition of the interface between subcutaneous fat
and superficial fascia, allowing for greater precision in skin
flap elevation.
formal SMAS flap elevation lies in its aesthetic versatility.
Once the superficial fascia has been freed from the restraint
of the retaining ligaments, it offers the surgeon several advan-
tages, including (1) vector versatility; (2) greater control in
terms of long-term vertical facial fat repositioning; and (3)
greater control in terms of long-term internal facial fat
repositioning.
Regarding vector versatility, dermal elastosis and skin
laxity in the aging face often do not occur in the same direc-
tion, nor at the same rate as aging related to the descent of fat.
The main advantage of performing skin dissection separate
from SMAS dissection is that it allows these two layers to be
draped along vectors that are independent of one another
(Fig. 6.6.8).2,19–21 Another advantage of a two-layer SMAS
facelift is that the tension of contouring is placed on the
superficial fascia, thereby allowing the surgeon to use less
tension for skin closure. This improves control regarding scar
perceptibility.20,21 In terms of vectors, in my experience, facial
fat is commonly repositioned in a more vertical vector than
skin flap redraping. Strong vertical shifting of the cervicofacial
flap is a maneuver that has traditionally been utilized in many
facelift techniques. While skin tightening can produce a dra-
matic effect in terms of improvement of facial laxity, the aes-
thetic effects of vertical skin vectoring unfortunately have
been poorly delineated. Specifically, when skin is shifted in a
cephalad direction, the effect of skin tension commonly pro-
duces an accentuation of flatness in the preparotid region, an
area that typically deflates with aging. In my opinion, vertical
skin shifting can produce an unnatural tightness to facial
shape, producing some of the typical stigmata associated with
rhytidectomy. If the surgeon has been successful in reposition-
ing descended facial fat, the use of strong vertical skin tension
is neither desirable nor required to enhance the postoperative
result (Fig. 6.6.9).
Fig. 6.6.7  (A) Preoperatively, the patient
shows a similar blunting of the relationship
between the malar and submalar regions.
(B) Postoperative appearance. Enhancing
malar volume (and bizygomatic diameter)
and restoring the concavity within the
submalar region make the face appear more
angular, as well as vertically shorter. (From
Stuzin JM. Restoring facial shape in
facelifting: the role of skeletal support in
facial analysis and midface soft-tissue
repositioning. Plast Reconstr Surg.
2007;119:362–376.)
A
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B
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181
Surgical technique: Extended SMAS dissection
SMAS elevation
The dissection of the superficial fascia allows the surgeon to
re-elevate jowl and descended malar fat back upwards into
the face toward their previous, normal anatomic location.2,5
In patients with prominent nasolabial folds and significant
infraorbital hollowing, it is my feeling that the SMAS dissec-
tion should extend into the malar region in an effort to
re-elevate the malar fat pad back upward overlying the zygo-
matic eminence. An added benefit of performing a more
extensive anterior dissection of the SMAS is that it frees this
layer from the restraint of both the zygomatic and masseteric
ligaments, and this anterior release provides for a more com-
plete elevation of the facial fat below the oral commissure and
along the anterior portion of the jowl.
The incisions (Fig. 6.6.11) for extended SMAS dissection
begin approximately 1 cm inferior to the zygomatic arch to
ensure frontal branch preservation. This horizontal incision is
continued several centimeters forward to the region where the
zygomatic arch joins the body of the zygoma. At this point,
the malar extension of the SMAS dissection begins with the
incision angling superiorly over the malar eminence toward
the lateral canthus for a distance of 3–4 cm. On reaching the
edge of the subcutaneous skin flap in the region of the lateral
orbit, the incision is carried inferiorly at a 90° angle toward
the superior aspect of the nasolabial fold. A vertical incision
is designed along the preauricular region, extending along
the posterior border of the platysma to a point 5–6 cm below
the mandibular border. In essence, the malar extension of the
SMAS dissection simply represents an extension of a standard
SMAS dissection into the malar region in an attempt to obtain
a more complete form of deep layer support.
The SMAS in the malar region is then elevated in continuity
with the SMAS of the cheek. When elevating this flap, the
fibers of the orbicularis oculi, as well as the zygomaticus
major and minor, are usually evident and the flap is elevated
directly along the superficial surface of these muscles. It is
important to carry the dissection directly external to these
muscle fibers, where a natural plane exists, remembering
that the facial nerve branches lie deep to these muscular
bellies. The malar SMAS is then elevated until the flap is freed
from the underlying zygomatic prominence. Freeing of the
SMAS completely from the zygomatic attachments is an
important technical point in obtaining the mobility necessary
to reposition the malar soft tissue superiorly. To obtain this
mobility usually also requires a division of the upper fibers of
the masseteric cutaneous ligaments, which will expose the
underlying body of the buccal fat pad. The cheek portion of
the SMAS dissection is performed beginning directly overly-
ing the parotid gland and then extending this dissection
anterior to the parotid utilizing a combination of sharp and
blunt dissection toward the anterior border of the masseter.
In most patients, following extended SMAS dissection of
the cheek and malar regions, mobility of the soft tissues lying
lateral to the nasolabial fold remain restricted unless the dis-
section is carried more medially. This restriction in movement
results from the undivided retaining ligaments that originate
medial to the zygomaticus minor. To improve mobility, I com-
monly continue malar pad elevation medially in an area where
I have not subcutaneously undermined the skin. This dissec-
tion is carried directly in the plane between the malar fat and
the superficial surface of the elevators of the upper lip. It is
Fig. 6.6.8  The direction of SMAS redraping in the face tends to be cephalad in its
orientation as opposed to skin flap redraping, which is oriented along a more
horizontal vector. The aesthetic versatility of vectoring the SMAS in a direction
independent of skin flap redraping is a major advantage of a two-layer SMAS-type
facelift.
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Preoperatively, I decide the extent of subcutaneous skin
flap undermining based on the most medial aspect of where
I want to end the SMAS dissection, which typically is situated
just medial to the retaining ligaments. I prefer to limit the
skin undermining several centimeters lateral to the nasolabial
fold rather than undermining the skin to this facial landmark.
The reason is that if one limits the dissection of the skin flap
in the medial aspect of the cheek, this will preserve some
of the attachments that go from the deep fascia through the
SMAS to facial skin. The preservation of these attachments,
followed by adequate undermining of the superficial facial
fascia (SMAS), will allow the surgeon to re-elevate anteriorly
displaced fat and skin through SMAS rotation rather than
to redrape the superficial fascia completely independent of
skin flap redraping. The ability to re-elevate and resuspend
facial soft tissue through SMAS rotation produces a more
pleasing aesthetic result and a greater degree of correction of
radial expansion within the cheek, as the facial fat is brought
internally to conform to the underlying buccinator muscle
(Fig. 6.6.10).

182
SECTION I
CHAPTER 6.6 • Facelift: The extended SMAS technique in facial rejuvenation
Fig. 6.6.9  These two patients show the
effect of vertical rotation of the cervicofacial
flap associated with hairline distortion. A
skin flap that is overly rotated in a cephalad
direction not only can compromise the
temporal hairline, but also tends to produce
flatness in the lateral midface overlying the
masseter and parotid. This imparts a tight,
unnatural appearance to the face. Also
notice the effect of scar perceptibility when
strong skin tension is used in an attempt to
contour the aging face.
A
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B
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Fig. 6.6.10  (A) If an extended SMAS dissection is to be performed, it is important not to widely undermine the skin all the way to the nasolabial fold, but rather to
preserve some of the attachments that exist between the skin and the SMAS (the limit of subcutaneous undermining is the shaded area). If these attachments are left intact,
this allows the surgeon to simultaneously resuspend undissected anterior facial skin at the time of SMAS rotation and fixation. (B) It is important to understand which
portion of the SMAS flap will affect facial contouring. In this diagram, the most superomedial aspect of the SMAS dissection affects contour along the nasolabial fold,
whereas the more lateral portion of the SMAS dissection is used to re-elevate jowl fat upward into the cheek. A portion of the SMAS flap is rotated into the postauricular
region with the vector of rotation of this portion of the SMAS dissection affecting submental and cervical contouring.
A
B

183
Surgical technique: Extended SMAS dissection
usually quite easy to delineate this level of dissection after the
malar SMAS elevation is complete, and the superficial surface
of the elevators of the upper lip visualized. The scissors are
then inserted directly superficial to the elevators of the upper
lip, and blunt dissection is quickly performed by pushing the
scissors in a series of passes bluntly toward the nasolabial fold.
I find that when we insert the scissors in the proper plane, the
dissection quickly glides through the malar soft tissues and I
usually will feel a “snap” as we dissect through the remaining
retaining ligaments. Once these structures are divided, one
notes greater mobility when traction is applied to the malar
portion of the SMAS flap, translating into greater movement
along the uppermost portion of the nasolabial fold (Fig. 6.6.12).
A
B
Fig. 6.6.11  (A) In patients with malar deflation or malar pad descent, I typically perform what is termed an extended SMAS dissection. By this, I mean I extend the SMAS
dissection into the malar region in an attempt to re-elevate ptotic malar fat back upward over the zygomatic prominence. The incisions begin at the junction where the
zygomatic arch joins the body of the zygoma. From this point, the incision in the SMAS is angled superiorly toward the lateral canthus and along the lateral orbital rim. The
incision in the SMAS is then carried medially and inferiorly toward the peripheral extent of skin flap undermining, angling toward the uppermost portion of the nasolabial
fold (the amount of subcutaneous undermining is shaded in pink, whereas the amount of SMAS undermining is shaded in yellow.) (B) The malar-SMAS dissection is then
performed in continuity with the cheek-SMAS dissection. Dissecting in the malar region carries the dissection directly along the superficial surface of the zygomaticus major
and usually exposes the lateral aspects of the zygomaticus minor as well. To obtain adequate mobility in terms of SMAS dissection, it is necessary to elevate the malar
portion of the dissection completely from the zygomatic eminence and free it from the zygomatic ligaments. To obtain mobility in terms of SMAS movement affecting the
jowl contour, the uppermost portions of the masseteric cutaneous ligament commonly are divided, especially where they merge with the zygomatic ligaments of the malar
area. If these fibers are not divided, they will restrict the upward redraping of jowl fat. On division of the upper portion of the masseteric cutaneous ligaments, the buccal fat
pad becomes evident, and commonly the zygomatic nerve branches traversing toward the undersurface of the zygomaticus major muscle are visualized. This diagram
illustrates the typical degree of mobilization performed in our extended SMAS dissection.
SMAS fixation
Repositioning and closure of the SMAS is then performed.
The malar SMAS flap is advanced superolaterally over the
zygomatic prominence in a direction perpendicular to the
nasolabial fold and usually paralleling the zygomaticus major
muscle. After superior and lateral advancement, if a malar
augmentation is not planned, the excess tissue can be excised
and the flap securely fixated to the zygomatic periosteum
with interrupted sutures (Fig. 6.6.13).
Once the malar flap is secure, the cheek-SMAS flap is
rotated superiorly perpendicular to the mandibular border.
This portion of the SMAS flap is used to contour jawline and

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SECTION I
CHAPTER 6.6 • Facelift: The extended SMAS technique in facial rejuvenation
degree of redundancy between the key sutures to minimize
tension along the incision sites.
To summarize, the key points in mobilizing the superficial
fascia from the restraint of the retaining ligaments of the cheek
are as follows:
1. The SMAS overlying the parotid gland and malar
eminence tends to be substantial and easy to dissect,
with both the parotid and zygomaticus major and minor
muscles protecting the underlying facial nerve branches.
These areas are very safe regions to begin SMAS
elevation and delineate the subSMAS plane.
2. The thinnest fascial component of an extended SMAS
dissection is in the region just lateral to the zygomaticus
major muscle, where the SMAS splits to invest the
elevators of the upper lip. Dissecting the skin flap thinly
in this region leaves a substantial amount of
subcutaneous fat intact along the surface of the
superficial fascia, providing greater ease in SMAS
dissection and minimizing the possibility of tearing this
layer.
3. The most difficult portion of an extended SMAS
dissection is freeing the superficial fascia from the
restraint of the superior masseteric ligaments, which are
lateral to the zygomaticus major muscle. If these
Fig. 6.6.12  It is commonly necessary to extend the malar SMAS dissection more
peripherally than the subcutaneous dissection to obtain adequate flap mobility of
the soft tissues lateral to the nasolabial fold. This portion of the dissection is easily
performed by simply inserting the scissors in the plane between the superficial
surface of the elevators of the upper lip and the overlying subcutaneous fat. Once
the scissors are inserted in the proper plane, the surgeon bluntly dissects in a
series of passes past the nasolabial fold (area marked in green). As long as the
scissors remain superficial to the elevators of the upper lip, motor nerve injury will
be prevented. Usually three or four passes are required to obtain adequate flap
mobility.
Fig. 6.6.13  The vectors of redraping of the extended SMAS flap are determined
according to the preoperative evaluation of the patient and are generally more
cephalad than skin flap redraping.
jowl. The SMAS overlying the preauricular region and ear is
then treated as a transposition flap and carried posteriorly
behind the ear, helping to restore tone to the submental region
and neck. Following trimming, the SMAS flap is carefully
secured with multiple interrupted sutures. Occasionally, skin
dimpling is noted after securing the SMAS flap, and this
results from the forces of SMAS rotation on resuspended
facial skin. Skin dimpling is treated by simply performing a
bit more subcutaneous undermining prior to skin flap
redraping.
Following proper contouring of the SMAS dissection, the
facial skin flaps are rotated and closed in the direction decided
upon, based on preoperative evaluation. In general, these skin
flaps are inset with a minimum degree of tension placed along
the key sutures and then the skin flaps are trimmed with a

185
Vectors of fat elevation: facial asymmetry
How much to release the SMAS, and how high and anterior
to carry the SMAS dissection, needs to be decided preopera-
tively. As discussed previously, in patients who present with
adequate malar volume, wide bizygomatic diameter, and little
evidence of malar pad descent, it is usually unnecessary to
carry the SMAS dissection medial to the lateral orbital rim
(although I usually carry the dissection high within the malar
eminence to allow fat repositioning along the infraorbital and
lateral orbital rims). Most commonly, these types of patients
require only a restoration of malar highlight and not signifi-
cant anterior malar volume enhancement. Limiting the SMAS
dissection to the lateral aspect of the malar eminence will not
increase facial width on the front view.4 Typically, the shaping
considerations for these patients is focused on reducing full-
ness in the submalar region (Fig. 6.6.14).
Vertically long faces often benefit from carrying the malar
portion of the extended SMAS dissection anteriorly, medial to
the lateral orbital rim, so that malar volume restoration is
performed along the anterior aspect of the zygomatic emi-
nence. Carrying the SMAS dissection more medially allows
the surgeon to enhance malar volume and restore malar
highlights anteriorly over the zygomatic eminence, thereby
increasing facial width on the front view (Fig. 6.6.15).
Vectors of fat elevation:
facial asymmetry
All patients exhibit some degree of facial asymmetry. Com-
monly, one side of the face is vertically longer, and the short
side of the face is usually wider than the long side. Malar
highlights are typically more superiorly located on the long
ligaments are not mobilized, restricted movement is
noted in the portion of superficial fascia that affects
contouring along the lower nasolabial fold, oral
commissure, and anterior jowl. The zygomatic branches
of the facial nerve are in close proximity to the upper
masseteric ligament. At times it can prove difficult to
differentiate between ligaments and facial nerve
branches. Caution is stressed in this region of dissection.
Variations in extended SMAS technique
to affect a restoration in facial shape
The biomechanics of SMAS repositioning have been previ-
ously described and are influenced by the degree of release,
vector of fat repositioning, and how the superficial fascia is
fixated.22 As postoperative contour is dependent on each of
these factors, preoperative planning needs to be patient-
specific in terms of the degree of SMAS release required, the
vectors in which facial fat is repositioned, and the location and
method for SMAS fixation.
Release
The incision design of an extended SMAS dissection allows
for complete release of the SMAS from its underlying retain-
ing ligamentous attachment in the lateral midface. As sur-
geons, there is a tendency to believe that a greater degree of
SMAS dissection equates with a better result, but this has not
been my experience. Rather, precision in the degree of SMAS
dissection and its release from the retaining ligaments as
dictated by the aesthetic needs of a patient increases surgical
control and consistency in while minimizing morbidity.3
Fig. 6.6.14  Patients with wide bizygomatic diameters and good underlying skeletal support typically do not require a significant anterior malar dissection to improve facial
shape. Most commonly, the SMAS dissection in these patients (while kept high) is extended only as medial as the lateral orbital rim, so that malar volume restoration is
limited to the lateral aspect of the zygomatic eminence. The shaping considerations for these types of faces usually emphasize reducing fullness within the submalar area,
as well as jowl fat elevation. Notice that postoperatively the patient’s face appears more tapered and thinner in morphology through facial fat repositioning without removal
of facial fat. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg.
2007;119:362–376.)
A
B
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C
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186
SECTION I
CHAPTER 6.6 • Facelift: The extended SMAS technique in facial rejuvenation
Fig. 6.6.15  Faces that are more dominated
by their facial length (especially the lower
third of the face) usually benefit from malar
volume restoration. To enhance malar
volume requires the SMAS dissection be
carried toward the anterior aspect of the
zygomatic eminence, such that malar
volume is increased in this region. (From
Stuzin JM. Restoring facial shape in
facelifting: the role of skeletal support in
facial analysis and midface soft-tissue
repositioning. Plast Reconstr Surg.
2007;119:362–376.)
A
Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.
B
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in electronic media.
Please refer to the printed publication.
Fig. 6.6.16  Vectors of SMAS elevation
have a significant impact on facial shape.
Vertical repositioning of the SMAS allows
the surgeon to enhance malar volume and
reduce fullness within the submalar region,
as fat is forced up along the concavity of
the buccinator. Restoration of submalar
hollowing through SMAS vectoring is useful
in contouring full faces, making them
appear thinner postoperatively. In this
patient, a small amount of jowl defatting
through needle aspiration was also
performed. (From Stuzin JM. Restoring
facial shape in facelifting: the role of skeletal
support in facial analysis and midface
soft-tissue repositioning. Plast Reconstr
Surg. 2007;119:362–376.)
A
Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.
B
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in electronic media.
Please refer to the printed publication.
side of the face and, with age, facial fat tends to descend in a
more vertical direction on the long side. As facial asymmetry
and facial skeletal configuration are asymmetric in most
individuals, it follows that the vectors of fat elevation (SMAS
repositioning) should be specific for the right and the left side
of the face.
The vector in which the SMAS is repositioned has a signifi-
cant impact on the location and volume of elevated facial fat,
thereby influencing facial shape. Decisions regarding the
direction of SMAS vectoring for the right and left side of the
face are best determined preoperatively, as it is very difficult
to make aesthetic vector judgments intraoperatively with the
patient recumbent.
SMAS vectors influence postoperative facial shape. Vertical
SMAS repositioning typically provides a larger amount of fat
for malar eminence enhancement, as well as allowing for a
reduction in fullness within the submalar region as fat is
forced internally along the concavity of the buccinator. For
this reason, vertical SMAS vectors are often indicated to
reshape round, full faces, allowing them to appear more
tapered and thinner postoperatively (Fig. 6.6.16). If the SMAS
is vectored more obliquely, there is less volume of fat brought

187
Correction of platysma bands and cervical obliquity
into the malar region and a greater volume of fat repositioned
into the submalar region. Oblique SMAS repositioning is
therefore helpful in elderly patients who appear gaunt over
the buccal recess, as it allows the surgeon to volumetrically
enhance the submalar region (Fig. 6.6.17).
SMAS fixation
In a two-layer SMAS-type facelift, the tension of contouring
is placed on the superficial fascia rather than the skin enve-
lope. For this reason, the fascial quality and tensile strength
of the superficial fascia has an influence on both the longevity
of result, as well as the volume of fat that can be repositioned
intraoperatively and maintained postoperatively. In other
words, soft-tissue quality influences long-term contour and is
the primary reason why facelifts in young patients are more
predictable.
In an effort to improve fascial quality in a SMAS facelift,
for over a decade I incorporated Vicryl mesh into the SMAS
fixation.3 It was my initial observation that incorporating
Vicryl mesh into fixation improved not only longevity of
result, but greater aesthetic control. Nonetheless, I have
stopped using Vicryl mesh, as I have come to realize that what
was the predominant factor in improving fixation is the
method in which the superficial fascia was secured. Obtaining
a secure fixation utilizing multiple sutures placed deeply
within the superficial fascia allows the surgeon greater control
in postoperative shape. Suturing the SMAS securely under
moderate tension affects facial shape in two ways: (1) adding
more sutures allows the surgeon to stack volume in specific
areas of the midface, which is useful in augmenting areas of
deflation, as well as augmenting volume along the malar
eminence; (2) as the superficial fascia is sutured under tension,
facial fat is not only repositioned vertically, but also reposi-
tioned internally, forcing the soft tissue to conform to the
Fig. 6.6.17  This patient exhibits
asymmetry in the submalar region
preoperatively. Notice that she appears
hollow and concave on the right, while she
is fuller on the left side. For this reason, the
SMAS was vectored obliquely on the right
to volumetrically enhance the submalar
region, while it was vertically vectored on
the left side to restore submalar hollowing
and balance the two sides of her face.
(From Stuzin JM. Restoring facial shape in
facelifting: the role of skeletal support in
facial analysis and midface soft-tissue
repositioning. Plast Reconstr Surg.
2007;119:362–376.)
A
Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.
B
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in electronic media.
Please refer to the printed publication.
underlying deep facial structures. This gives the surgeon
greater control in improving radial expansion (Fig. 6.6.18).
Correction of platysma bands
and cervical obliquity
Correction of the neck is thoroughly reviewed in Chapter 12.
In my hands, the best approach to the anterior platysma is via
a submental incision, placed just caudal to the submental skin
crease.5,23–26 If this crease is very deep, the skin cephalad is
elevated toward the base of the chin pad and along the caudal
mandibular border to free any retaining mandibular liga-
ments, which tend to accentuate the crease. Following this,
the cervical skin is carefully elevated. The cervical skin is
usually undermined at least to the level of the cricoid.
Upon exposing the platysma muscle anteriorly, most
patients exhibit a decussation of platysmal fibers across the
midline, at least for a few centimeters below the mentum.
When platysma band surgery is contemplated, these decus-
sating fibers must be sharply divided with scissor dissection
directly in the midline. Following this, the medial edge of the
platysma is mobilized from the mentum inferiorly at least to
the hyoid and commonly as caudal as the cricoid cartilage.
Mobilization, usually performed using a combination of sharp
and blunt dissection, separates the platysma from the under-
lying subplatysmal fat, the anterior belly of the digastric
muscle, and the strap muscles overlying the thyroid cartilage.
At times, numerous small venules are encountered within the
subplatysmal fat and careful hemostasis must be obtained.
Following mobilization of the medial edges of the platysma,
the subplatysmal fat is conservatively contoured according to
preoperative planning.
Following mobilization, the medial edge of the platysma
muscle is grasped on either side and overlapped in the midline

188
SECTION I
CHAPTER 6.6 • Facelift: The extended SMAS technique in facial rejuvenation
Following edge-to-edge approximation of the platysma,
some form of muscular release is performed. This muscular
release commonly involves a partial transection of the pla-
tysma muscle with the myotomy performed inferiorly within
the neck.
Platysma transection is an effective technique in the treat-
ment of platysma bands and in obtaining the desired cervical
contour. This procedure must be performed meticulously
because the early experience with transection was fraught
with complications. Specifically, if the transection is performed
at a high level, it can be associated with unveiling of the
submaxillary glands and denervation of the platysma associ-
ated with lower lip dysfunction. Also, obvious contour
depressions associated with divided muscular edges can be
noted in the overly thin neck (Fig. 6.6.19).
The key to platysma transection is that the transection of
the muscle be performed lower in the neck, often as inferior
as the level of the cricoid cartilage. The disadvantage of hori-
zontal transection at this level is that a depression in the neck
can develop if preplatysmal fat has been removed at the level
where the transection is performed. Preservation of preplatys-
mal fat lower in the neck where the transection is to be per-
formed is obviously an important factor in preventing this
problem.
in order to estimate the amount of excess muscle present.
Muscle excess will vary from patient to patient. A portion of
the medial edge can be excised to remove redundancy within
the platysma. A conservative resection is performed so that
undue tension is not present at the time of suture plication.
Muscular plication consists of edge-to-edge approximation
using multiple interrupted sutures at the mentum and extend-
ing at least to the level of the hyoid. Suture placement back
from the leading edge of the muscle, in areas of intact mus-
cular fascia, is an important technical point in preventing
suture pull-through postoperatively.
In most patients, the edge-to-edge suturing below the
hyoid is continued inferiorly toward the cricoid cartilage. The
goal of muscular plication is to produce an even, smooth
contouring of the platysma that is tightly adherent to the
underlying floor of the mouth and thyroid cartilage, provid-
ing a flat framework for redraping of cervical skin. A low
plication joining a widely separated platysma over a promi-
nent thyroid cartilage also tends to blunt a prominent larynx
and produce a rounder, more feminine appearance to the
neck.
Fig. 6.6.18  This diagram illustrates how the excess SMAS, rather than being
excised, is rolled onto itself to form a double layer of SMAS thickness. Once the
SMAS has been rolled, it is fixated to the periosteum of the zygomatic eminence.
An added benefit of preserving the excess SMAS rather than excising it is that, as
the thickened SMAS layer is secured to the zygomatic eminence, it highlights the
malar region, serving as an autogenous malar augmentation. Highlighting the malar
area tends to enhance angularity in facial contour. (From Stuzin JM. Restoring facial
shape in facelifting: the role of skeletal support in facial analysis and midface
soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–376.)
Fig. 6.6.19  After edge-to-edge approximation of the platysma from the mentum to
the cricoid cartilage, some form of muscular release is performed. This usually
consists of a horizontal cut extending from the midline to the anterior border of the
sternocleidomastoid muscle.

189
Correction of platysma bands and cervical obliquity
In most patients, only partial division is required. The
myotomy is performed from the midline laterally until the
tension is completely released from the platysmaplasty closure
(approximately the anterior border of the sternocleidomastoid
muscle in most patients).
The muscular release seen following platysma transection
serves many purposes:
1. It alleviates tension along the medial portion of the
platysma transection following plication.
2. It allows the platysma to shift superiorly, producing a
deeper cervicomental angle.
3. It prevents the conversion of two platysmal bands to a
single band following edge-to-edge approximation,
which can be visible when the neck is extended.
In most patients in whom I perform a platysmaplasty, small
drains are placed and left in place until drainage is minimal
and the skin flaps are adherent. In my experience, the use of
drains has lessened postoperative edema, ecchymosis, and
seroma formation (Fig. 6.6.20).
Sequence of SMAS fixation
versus platysmaplasty
Because the SMAS and the platysma represent the same
anatomic layer, if platysmaplasty is performed before the
SMAS dissection, it can adversely affect facial contour.3,20,21
Contouring the neck before the midface can also be prob-
lematic. When the platysmaplasty is performed first, the
descended jowl fat is locked down into the neck, and move-
ment of the superficial fascia diminishes following elevation
of the SMAS. This diminished movement tends to lessen
surgical ability to modify facial shape; it also produces a loss
of aesthetic contour. If the SMAS dissection is performed
Fig. 6.6.20  (A) Preoperative appearance.
Note the hollowed contour in the lateral
cheek, which represents the region from
which the facial fat has descended and
deflated, as well as the marked cervical
obliquity. (B) Postoperative result following
extended SMAS dissection. If the surgeon
can re-elevate descended facial fat back to
its previous anatomic location and secure it
there postoperatively, this will help to
enhance the mandibular border, providing
for predictable cervical contouring through
platysmaplasty. This lessens the need for
preplatysmal fat removal. In general, necks
look softer if cervical fat is preserved.
(From Stuzin JM, Baker TJ, Baker TM.
Refinements in facelifting: enhanced facial
contour using Vicryl mesh incorporated into
SMAS fixation. Plast Reconstr Surg.
2000;105:290–301.)
A
Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.
B
Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.
before platysmaplasty, descended jowl fat is brought cephalad
to the mandibular border and easily repositioned. After the
SMAS has been securely sutured bilaterally, the mandibular
border appears more distinct, making cervical contouring less
demanding. When performing platysmaplasty subsequent to
SMAS fixation, the surgeon will notice less redundancy along
the medial borders of the platysma; there is also less need to
resect muscle at the time of platysmaplasty. The enhanced
contour effects of extended SMAS dissection, associated with
precise platysmaplasty, tend to diminish the need to remove
cervical fat. In general, the neck and jawlines appear softer
if preplatysmal fat is preserved when contouring the neck
(Fig. 6.6.21).
Incisions
Incisions have been reviewed in Chapter 6.2. The importance
of incision quality cannot be over-emphasized in diminishing
signs that the patient has undergone a surgical procedure.
One of the major advantages of a two-layer facelift is that the
tension of contouring is along the superficial fascia and thus
there is less need to redrape the skin flap with great force.
Decreased tension on the key sutures in both the preauricular
and postauricular region provides greater control for scar
perceptibility. If the incisions are artistically designed, patients
can typically wear their hair up off their ears without obvious
stigma that a facelift has been performed.21
Whereas many authors have described the salient factors
regarding incision design, I would delineate the main points:
1. I prefer tragal incisions, performed at the margin of the
tragus, rather than preauricular incisions, because the
color difference between the pale skin of the ear and the
blush skin of the cheek is usually better camouflaged
when the incision is brought internally into the ear.

190
SECTION I
CHAPTER 6.6 • Facelift: The extended SMAS technique in facial rejuvenation
conviction that improving technical control when contouring
the superficial facial fascia and platysma provides for a more
consistent, aesthetically pleasing result, which is non-surgical
in appearance. The difficulty in performing a two-layer
SMAS-type facelift is that it requires a commitment on the
part of the surgeon, not only to understand facial soft-tissue
anatomy, but also to perform a procedure that demands
technical precision. A two-layer SMAS-type facelift is a time-
consuming operation, with both the skin flap elevation, as
well as the dissection of the SMAS, requiring meticulous and
accurate dissection. Obtaining consistency with this procedure
is challenging because of the variability in thickness of sub-
cutaneous fat and the SMAS that exists among individual
patients. Following precise dissection, secure fixation of both
SMAS and platysma is mandated to maintain the shaping
desired in postoperative contour. Meticulous hemostasis fol-
lowed by careful skin flap inset are required to minimize
postoperative scar perceptibility and ensure a rapid postop-
erative recovery.
Despite these demands, I have found the extended SMAS
technique to be personally rewarding, with a high degree of
patient satisfaction. All techniques have advantages and dis-
advantages. For me, the biggest advantage of the extended
SMAS technique remains its aesthetic versatility, allowing the
surgeon to vary the contouring aspects of the procedure
according to the aesthetic needs of the patient.
Fig. 6.6.21  (A) Preoperative appearance.
(B) Postoperative appearance. Another
example of how facial fat re-elevation
influences cervical appearance. Sequencing
errors can lead to loss in contour; it is my
preference to perform SMAS elevation and
fixation before performing platysmaplasty.
As the facial fat and skin is re-elevated back
into the midface through SMAS rotation, the
mandibular border becomes more distinct,
making cervical contouring more
predictable.
A
Rights were not granted to include this figure
in electronic media.
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B
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in electronic media.
Please refer to the printed publication.
2. Tragal incisions are more demanding than preauricular
incisions, requiring precise design and insert so that the
tragus is not distorted. The aesthetic unit of the tragus is
rectangular as opposed to semilunar. If the surgeon
designs the tragal incision properly, respecting the
incisura of the tragus, the tragus will appear normal in
its shape postoperatively, exhibiting both a visual
beginning at its junction with the helix and a visual
ending along the preserved incisura.
3. Detached earlobes tend to appear more natural than
attached earlobes. If a small cuff of cheek skin is left
attached to the earlobe, it will allow surgical rotation of
the skin up under the earlobe during skin flap
redraping, suturing the earlobe distinctly from the cheek
flap. The earlobe should be inset in an axis posterior to
the axis of the pinna, thereby avoiding a pixie
deformity.
There is increasing public demand for natural appearing
results in facial rejuvenation. This places the onus on the
surgeon to create incisions that are imperceptible if these
procedures are to be justified. No matter how well deep-layer
support is obtained and facial contour improved by SMAS
elevation and platysmaplasty, if the incision is obvious, scar
quality poor, the hairline disturbed, or the earlobe deformed,
the overall result remains disappointing.
Summary
From a personal perspective, after two decades of striving
to improve techniques in facial rejuvenation, it is my firm

191
Summary
1. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS dissection
as an approach to midface rejuvenation. Clin Plast Surg.
1995;22:295–311.
2. 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. Facial anatomy is characterized
as a series of concentric layers based on cadaveric and intraoperative
dissection. These findings inform a discussion of the anatomic basis of
facial aging.
4. Stuzin JM. Restoring facial shape in facelifting: the role of
skeletal support in facial analysis and midface soft-tissue
repositioning. Plast Reconstr Surg. 2007;119:362–376. The authors
emphasize the importance of establishing patient-specific aesthetic goals
in planning a facelift. Skeletal anatomy is a key component of this
analysis.
7. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr
Surg. 1989;83:11–16. The anatomy of the facial retaining ligaments is
reviewed. The importance of addressing these structures in facelift
procedures is addressed.
8. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy
and clinical implications for cosmetic surgery. Plast Reconstr Surg.
2007;119:2219–2227. Cadaveric dissection demonstrated multiple discrete
compartments of subcutaneous fat in the human face. The clinical
significance of this finding is addressed.
10. Lambros V. Fat contouring in the face and neck. Clin Plast Surg.
1992;19:401–414.
11. Lemmon ML, Hamra ST. Skoog rhytidectomy: a five-year
experience with 577 patients. Plast Reconstr Surg. 1980;65:283–297.
14. Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr
Surg. 1992;90:601–607. The Skoog facelift was modified to free the SMAS
from the underlying mimetic muscles of the face. A sizeable clinical series
demonstrated improvement in nasolabial fold aesthetics.
15. Owsley JQ Jr. Lifting the malar fat pad for correction of prominent
nasolabial folds. Plast Reconstr Surg. 1993;91:463–474.
22. Mendelson BC. Surgery of the superficial musculoaponeurotic
system: principles of release, vectors, and fixation. Plast Reconstr
Surg. 2001;107:1545–1552.
Access the complete reference list online at

191.e1
References
References
1. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS dissection
as an approach to midface rejuvenation. Clin Plast Surg.
1995;22:295–311.
2. 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. Facial anatomy is characterized as a
series of concentric layers based on cadaveric and intraoperative dissection.
These findings inform a discussion of the anatomic basis of facial aging.
3. Stuzin JM, Baker TJ, Baker TM. Refinements in facelifting:
Enhanced facial contour using Vicryl mesh incorporated into SMAS
fixation. Plast Reconstr Surg. 2000;105:290–301.
4. Stuzin JM. Restoring facial shape in facelifting: the role of skeletal
support in facial analysis and midface soft-tissue repositioning.
Plast Reconstr Surg. 2007;119:362–376. The authors emphasize the
importance of establishing patient-specific aesthetic goals in planning a
facelift. Skeletal anatomy is a key component of this analysis.
5. Baker TJ, Gordon HL, Stuzin JM. Surgical Rejuvenation of the Aging
Face. 2nd ed. St Louis, MO: CV Mosby; 1995.
6. Freilinger G, Gruber H, Happak W, et al. Surgical anatomy of the
mimic muscle system and the facial nerve: importance for
reconstructive and aesthetic surgery. Plast Reconstr Surg.
1987;80:686–690.
7. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr
Surg. 1989;83:11–16. The anatomy of the facial retaining ligaments is
reviewed. The importance of addressing these structures in facelift
procedures is addressed.
8. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy
and clinical implications for cosmetic surgery. Plast Reconstr Surg.
2007;119:2219–2227. Cadaveric dissection demonstrated multiple discrete
compartments of subcutaneous fat in the human face. The clinical
significance of this finding is addressed.
9. Lambros V, Stuzin JM. The cross-cheek depression: surgical cause
and effect in the development of the “joker line” and its treatment.
Plast Reconstr Surg. 2008;122:1543–1552.
10. Lambros V. Fat contouring in the face and neck. Clin Plast Surg.
1992;19:401–414.
11. Lemmon ML, Hamra ST. Skoog rhytidectomy: a five-year
experience with 577 patients. Plast Reconstr Surg. 1980;65:283–297.
12. Mendelson BC. Correction of the nasolabial fold: extended SMAS
dissection with periosteal fixation. Plast Reconstr Surg.
1992;89:822–833.
13. Hamra S. The deep plane rhytidectomy. Plast Reconstr Surg.
1990;86:53–61.
14. Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr
Surg. 1992;90:601–607. The Skoog facelift was modified to free the SMAS
from the underlying mimetic muscles of the face. A sizeable clinical series
demonstrated improvement in nasolabial fold aesthetics.
15. Owsley JQ Jr. Lifting the malar fat pad for correction of prominent
nasolabial folds. Plast Reconstr Surg. 1993;91:463–474.
16. Connell BF, Marten TJ. The trifurcated SMAS flap: three-part
segmentation of the conventional flap for improved results in the
midface, cheek and neck. Aesthet Plast Surg. 1995;19:415–420.
17. Aston SJ Facelift with FAME technique. Paper presented at the 32nd
Annual Baker Gordon Symposium on Cosmetic Surgery, Mercy
Hospital, Miami, FL; February, 1998.
18. Little JW. Three-dimensional rejuvenation of the midface:
volumetric resculpture by malar imbrication. Plast Reconstr Surg.
2000;105:267–285.
19. Owsley JQ Jr. SMAS-platysma facelift: a bidirectional cervicofacial
rhytidectomy. Clin Plast Surg. 1983;10:429–440.
20. Connell BF. Neck contour deformities: the art, engineering,
anatomic diagnosis, architectural planning, and aesthetics of
surgical correction. Clin Plast Surg. 1987;14:683–692.
21. Marten TJ. Facelift planning and technique. Clin Plast Surg.
1997;24:269–308.
22. Mendelson BC. Surgery of the superficial musculoaponeurotic
system: principles of release, vectors, and fixation. Plast Reconstr
Surg. 2001;107:1545–1552.
23. Connell BF. Cervical lifts: the value of platysma muscle flaps. Ann
Plast Surg. 1978;1:32–43.
24. Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast Surg.
1979;3:529–539.
25. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg.
1990;85:333–343.
26. Feldman JJ. Neck Lift. St Louis, MO: Quality Medical Publishing;
2006.

SECTION I • Aesthetic Surgery of the Face
6.7 
Facelift: SMAS with skin attached – the
“high SMAS” technique
Fritz E. Barton Jr.
SYNOPSIS
■ The patient consultation considers both the potential for anatomic
improvement as well as the patient’s expectations.
■ Maintenance of facial “harmony” is paramount.
■ A “high SMAS” facelift vertically repositions the skin and the
subcutaneous tissues as a single unit.
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Patient consultation
The patient consultation is divided into three portions: (1)
evaluation of the patient’s health; (2) evaluation of the facial
anatomic features; and (3) evaluation of the patient’s
appropriateness.
First and foremost, cosmetic surgery is only appropriate for
healthy patients. As physicians, our overriding responsibility
is to do no harm. A patient’s life should never be placed at
significant risk for improvement of appearance. Intercurrent
illnesses such as cardiac disease, cerebrovascular disease,
major organ dysfunction, and potential healing impairment
may preclude safe surgery.
Assuming the patient is healthy, the evaluation turns to the
anatomic analysis. From my perspective, maintaining facial
harmony is paramount. The worst of all outcomes is to look
“operated”. There are a number of causes of an “operated”
look, and these will be addressed in more detail later in the
chapter. But surgical disharmony – that is, correcting one aging
feature(s) while leaving other aged areas uncorrected – is dis-
harmony by design. Regardless of the effectiveness of the surgi-
cal technique, segmental disharmony compromises the result.
Young patients may have only segmental aging. Most com-
monly, early aging involves the forehead and orbit before the
lower face and neck. If the only disharmony is brow ptosis, a
forehead procedure alone may suffice. The same may be true
regarding the eyelids in young patients. In such a situation,
correcting a single aged feature, so as to match the remaining
youthful features, actually restores facial harmony.
However, after the age of 40, most patients have aging
changes throughout multiple areas. They may look slightly
aged, but they look natural, since all areas match. If natural
facial harmony is to be maintained, all aged areas need simul-
taneous correction.
Such an approach is often met with resistance by patients,
particularly young patients. They are used to the traditional
approach of sequential segmental surgery – an approach that
most of us were trained to do. Adding to the confusion is the
patient’s faulty logic that, by doing less at a single stage, they
are less likely to look operated.
While debate remains regarding the relative roles of defla-
tion (loss of fat) and descent, there are several inescapable
truths.
The practical fact is that aging patients have lax facial
tissues. And when standing erect (as most people judge their
appearance), gravity causes the facial tissues to descend. The
second fact is that aged people have excess facial skin.
Re-inflating the skin envelope to the point of eliminating
laxity would create an unattractively puffy face. Third, the
descended tissues look better when repositioned superiorly.
Finally, a method of maintaining the tissues in their upward
position has to be found, even if the repair is non-anatomic.
While the “high SMAS” approach to the cheek is the
assigned focus of this chapter, the need to maintain facial
harmony necessitates a brief description of pan-facial
analysis.
Starting at the top, forehead analysis begins at the hairline.
The determination of hairline height is assessed from mid-
pupil to hairline – not brow to hairline. While forehead reju-
venation is colloquially referred to as a “browlift”, the brow
is actually only one element of forehead improvement. Lateral
brow hooding, corrugator lines, and procerus creases also
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192.e1
Historical perspective
Historical perspective
Triggered by the appearance of surface laxity, early attempts
at facial rejuvenation focused on skin excision. Since the
surface skin was sufficiently mobile to efface anterior redun-
dancy, undermining and release seemed unnecessary. Limited
peripheral skin excisions dominated the gestation period of
facelifts1–3 in the first quarter of the 20th century. While these
procedures yielded improvement, they were limited in ante-
rior effect and temporary in duration.
Seeking greater effect, Lexer4 lengthened and combined
the separate temporal, preauricular, and mastoid incisions.
Bames5 later added skin undermining to further enhance the
result. This concept of wide skin undermining dominated the
thinking of the mid-20th century6–8 and remains popular
today.9,10
The presence of the subcutaneous facial mass may have
been recognized as early as the 1930s by Pires.11 Pires placed
suspension loops from the preauricular fascial to anterior
nasolabial fat in an effort to better efface anterior jowling. But
the importance of specific suspension of the subcutaneous
mass, in addition to skin redraping, was best described by
Aufricht in 196012: “In order to understand the mechanics of
the sagging cheek, one must consider the behaviour of the
skin and the areolar fatty layer separately. Both layers are
subject to histo-morphological changes of their own. This fact
is important. It indicates that the surgical correction for
sagging cheeks generally requires a two phase procedure: (1)
subcutaneous suspension (or lift), i.e., suspension of the fatty
areolar layer; and (2) cutaneous suspension after the removal
of excess skin”.
The concepts of removal and/or repositioning of both the
skin as well as the subcutaneous fatty mass remain the cardi-
nal points of modern surgical facial rejuvenation. What to
do is generally agreed upon. How best to do it remains
controversial.

193
Patient consultation
must be addressed. Perhaps most important, the upper lid
cannot be correctly assessed without restoring the brow to
proper position. The upper eyelid and brow thus form a
combined unit. A similar combination occurs with the lower
eyelid and cheek. Finally, the neck serves as a relatively
independent unit, though its best correction often involves
addressing the lower face. We will focus here in detail on the
lower eyelid and cheek.
The lower eyelid and upper cheek overlap, and as a
result, they should be addressed together in the patient over
the age of 40. The delicate lower eyelid is separated from
the heavier cheek by two fascial partitions. The orbicularis
retaining ligament13 (orbitomalar membrane14) extends from the
junction between the preseptal and periorbital portions of
the orbicularis muscle to attach to the bony skeleton. The
orbicularis retaining ligament (ORL) inserts into the orbital
rim medially, then courses down and lateral onto the body
of the zygoma. A second fascial partition, the malar mem-
brane15,16 (zygomaticocutaneous ligament17) extends from the
lower border of the periorbital orbicularis to insert in the
malar bone below. Medially, the malar membrane origins
align with the orbicularis retaining ligament at the medial
tear trough. Laterally, however, it courses obliquely across
the cheek, inserting into bone in the bare area above the deep
origins of the upper lip levators. Together, these two partitions
protect the eyelid suspensory apparatus from the weight of
the cheek.
There are six essential elements of the lower eyelid that
require assessment. Beginning from deep: (1) the prominence
of the orbital bony rim – a positive, negative, or neutral vector
orbit; (2) the prominence of the arcus marginalis insertion; (3)
the competence of the orbital septum and fat herniation; (4)
presence of orbicularis ptosis; (5) skin laxity and wrinkling;
and (6) competence of the lateral canthal tendon. Essentially,
all aging patients develop ptosis of the orbicularis muscle.
They may or may not have abnormalities of any or all of the
other elements.
Likewise, evaluation of the cheek involves six elements: (1)
skin surface abnormalities (dyschromia, actinic damage, etc.);
(2) dermal quality; (3) degree of skin laxity; (4) facial skeletal
shape; (5) overall facial volume; and (6) contour of the subcu-
taneous mass.
For the purposes of this chapter, we will focus on the
degree of facial laxity and the variations of contour of the
subcutaneous fatty mass.
Variations in the volume, shape, and position of the subcu-
taneous fatty mass influence the ultimate surgical plan. The
superficial layer of the subcutaneous fatty mass – that portion
external to the superficial layer of the mimetic muscles – is the
portion that influences facial shape and that is most malleable
in facial rejuvenation surgery. The upper border of the fatty
mass is at the lower orbital rim and zygomatic arch; the lateral
border is the auricle, the lower boundary is the mandibular
border, and the medial border is the fusion plane at the naso-
labial fold.
The specific sub-areas to be addressed are the malar
prominence, the nasolabial fold, and the jowl (Fig. 6.7.1).
The typical aging face shows descent of the malar portion
of the subcutaneous mass, so that the maximal cheek promi-
nence is submalar, rather than over the body of the zygoma.
Anteriorly, the upper anterior portion of the cheek fat
shelves over the fixed fusion plane at the nasolabial fold.
Fig. 6.7.1  The superficial subcutaneous fatty mass.
Malar fat pad
Jowl
Nasolabial fold
And finally, the lower anterior fat accumulates along the
jowl at the mandibular border. The analysis of the indi-
vidual patient involves identifying the extent of each of these
changes.
Consideration of the degree of facial laxity introduces the
discussion of the ideal age and stage for facial rejuvenation
surgery. The traditional timing for facial rejuvenation was
mid-50s to mid-60s. Timing was based upon the experience
with skin-based facelifts in which significant relapse of skin
laxity from dermal stress relaxation was inevitable. Therefore,
if half of the benefit was to be lost quickly, there needed to be
a great deal of laxity present for a net gain. With more power-
ful fascial (SMAS)-based procedures available, the strategy
changes. The author has come to recognize that, actually, the
ideal time for facial rejuvenation is when aging changes are
present, but early. The best strategy is to try to maintain
youthful appearance, rather than losing it, then trying to
recapture it. Specifically, the ideal time for facial rejuvenation
in most women is in their early 40s.
Finally, before formulating a surgical plan, the surgeon
must decide whether the patient’s goals are both achievable
and realistic.
Sometimes, the patient’s analysis of the problem is accurate,
but there may not be a predictable correction. Making a full
face thin or permanently removing every wrinkle are exam-
ples. Conversely, the patient may grossly exaggerate a minor
problem and seek an unrealistic result. Surgery should be
avoided in both situations. Often, the accurate evaluation of
the patient’s mind is more difficult than the evaluation of their
anatomy.

194
SECTION I
CHAPTER 6.7 • Facelift: SMAS with skin attached – the “high SMAS” technique
the arch to fuse with the temporoparietal fascia. And most
importantly, the frontal branch of the facial nerve lay beneath
a second fascial layer over the zygomatic arch. This finding
allowed us to safely divide the SMAS horizontally above the
zygomatic arch to facilitate upward mobilization of the upper
(malar) portion of the fatty mass along with the lower buccal–
mandibular portion.
Anterior release of the SMAS from the zygomatic retaining
ligaments as well as from the investment of the anterior
mimetic muscles, combined with horizontal SMAS division
above the zygomatic arch, provided complete cheek mobiliza-
tion. This dissection became known as the “high SMAS”
technique.
As my experience with the “high SMAS” technique grew,
I began to make technique variations to match patient varia-
tions. Compiling the data of my first clinical series,26 it became
clear that dissection completely across the nasolabial fold was
not necessary in every patient. I subsequently developed
three variations, which I will delineate below in the surgical
planning portion of this chapter. The direct vertical relocation
vector of the technique caused accentuation of the orbicularis
oculi ptosis. Influenced by the work of others,27–29 I routinely
added correction of the lower eyelid to the cheek procedure.
And finally, being made aware of the tendency to a rounded
Evolution of the “high SMAS”
technique
The modern “high SMAS” technique evolved from my (the
author) failed experiences with other methods. Early in my
clinical practice, I performed a moderately wide skin under-
mining with redraping. It yielded good results in younger
patients who had excellent quality skin, thin faces, and good
lower orbits. I believe the procedure can still yield good
results in that sub-group of patients.
But not all of my patients were of that type. As I encoun-
tered older patients, those with more jowls and deeper
nasolabial folds, my results with skin-only facelifts were often
disappointing and brief in duration. Worst of all, as I became
more aggressive with the procedure to overcome these defi-
ciencies, some patients developed a “stretched” look. It was
then that I became acutely aware of the viscoelastic relaxation
(“stress relaxation”) of skin placed under tension.
Aufricht12 and others18 had pointed out the need to directly
address suspension of the subcutaneous facial fat as an essen-
tial component of facelifting. I, therefore, went through a
phase of skin dissection followed by suture plication, as
described by Aufricht. My experience was that the initial
facial contours of the nasolabial fold and jowl were improved.
But in follow-up, only about one-half of the patients achieved
a lasting correction. Moreover, using the dermis to secure
the skin advancement still caused many patients to look
“stretched”. My overall results improved, and some patients
maintained a natural improvement, but the results were too
inconsistent for my satisfaction.
In 1974, Tord Skoog published his classic text,19 in which
he described a revolutionary facelift procedure. Undermining
the skin and superficial subcutaneous mass together as a
composite, the cheek mass was then resuspended using the
superficial subcutaneous fascia (later termed the superficial
musculo-aponeurotic system or SMAS20). This approach
offered repositioning of the skin along with the superficial
subcutaneous mass as a single unit, without placing tension on
the skin. Unfortunately, Skoog died before he was able to work
out the nuances to develop his concept into a maximally effec-
tive procedure. But the concept of cheek repositioning while
avoiding skin stretching was very appealing.
Other surgeons21,22 adopted Skoog’s basic idea and set out
to modify it. Their early attempts focused on the buccal and
mandibular area, where the SMAS was more defined and
more mobile. The upper cheek, or malar area, was left only
dermal support.23 It seemed clear to me that such differential
suspension – fascia in the lower face and only dermal suspen-
sion of the malar portion of the subcutaneous fatty mass –
would give incomplete repositioning of the malar prominence.
And worse, over time, the weak dermal support would relax
faster than would the lower fascial portion.
It was that dilemma that fostered our anatomic dissections
in the late 1970s and early 1980s.24,25 We first demonstrated
that the dissected subSMAS cheek flap was supplied as an
axial myocutaneous flap from the anterior facial artery
branches. Second, we found that anteriorly, the SMAS became
the investing layer of the superficial layer of the mimetic
muscles (Fig. 6.7.2). Third, we found that the upper SMAS did
not insert into the zygomatic arch, but rather, continued over
Fig. 6.7.2  Release of the SMAS investment of the zygomaticus major muscle.
SMAS

195
Surgical technique
extension is used for the cheek dissection. If only an endo-
scopic approach or no forehead surgery is planned, then only
a horizontal sideburn incision is done. With use of the side-
burn incision, it is critical to limit the upward extent. The
fine, posterior-directed upper temple hair will not hide an
incision.
A post-tragal auricular incision is used routinely in both
males and females. The only exception is dark-skinned males
with very dark, heavy beards. In most males, skin displaced
to the tragus can have the hair follicles excised from beneath
the dermis. Any remaining hair can be controlled with an
alexandrite laser. The location and extent of the mastoid inci-
sion depends upon the amount of neck skin laxity.
Sequencing of the facial units is the next consideration. The
author usually starts at the midline of the neck and works in
an upward sequence. This moves the redundancy upward
through the cheek and eyelid, then out the top. One criticism
of this sequence is that the anterior platysmal closure in the
neck might restrict the upward motion of the platysma
(SMAS) in the cheek. This restriction can be avoided by merely
connecting the medial platysmal borders loosely to each other
in the midline, so as to allow later upward motion in the
cheek.
The cheek dissection is begun by elevating the skin in the
preauricular area sharply. Above the level of the zygomatic
arch, a subcutaneous tunnel is formed to the lateral border of
the orbicularis oculi muscle. This tunnel will facilitate later
horizontal division of the upper SMAS. From the zygomatic
arch down, the skin flap is thinly dissected only to the extent
of estimated skin excision (Fig. 6.7.4). Care is taken not to
overly separate the skin from the SMAS, especially at the
upper corner where the previous tunnel was made. The lower
extent of the subcutaneous cheek dissection extends below the
mandibular border. If no anterior platysmal plication or defat-
ting is needed, the submandibular skin dissection is carried
approximately half way down the neck and half way to the
midline. This release is necessary to allow partial division of
the lateral platysma, and its investing fascia, to facilitate
upward displacement of the cheek composite tissues.
With the skin dissection complete, attention is turned to the
SMAS. The safest place to penetrate the SMAS is between the
top of the tragus and the bottom of the ear lobule. Here,
the SMAS is the thickest, and the facial nerve lies deep within
the parotid gland. In this location, the SMAS is a multilayer
fibrofatty structure laminated to the parotid capsule. The
proper dissection plane leaves a thin translucent fibrous layer
over the visible parotid acini. As this dissection plane is
extended anteriorly and inferiorly an areolar plane on the
underside of identifiable platysma fibers can be visualized.
Once in this areolar plane, dissection is carried to the anterior
border of the parotid gland and down the anterior border of
the sternocleidomastoid muscle.
At the anterior border of the parotid gland, the dissection
method changes from sharp to blunt spreading in the anterior
areolar plane. Over the parotid gland, the SMAS is fixed to
the gland capsule – the so-called “fixed SMAS”. Anterior
to the parotid gland, in the buccal area, there is an areolar
gliding plane which can be separated bluntly to avoid any
risk to the underlying facial nerve branches. It is impera-
tive to maintain the filmy, near-transparent deep fascia over
the masseter muscle, since the facial nerve branches lie just
beneath.
eye in lower blepharoplasty from laxity of the lateral canthal
tendon with aging,30–32 additional lateral canthal tightening
was added. Otherwise, I have remained consistent with the
“high SMAS” technique for over 25 years (Fig. 6.7.3).24,33,34
Surgical planning
Surgical planning involves both the surgical sequence as well
as patient preparation. As previously mentioned, in the
patient who has not had previous surgery, I believe a pan-
facial approach is usually necessary. The actual components
of the procedures of the forehead, orbit, and neck vary with
the patient’s anatomy and aging deformity. (Those planning
details are beyond the scope of this chapter, however.)
Preoperative patient preparation means stabilizing any
intercurrent medical problems or medications not serious
enough to preclude surgery. The most common intercurrent
illness to stabilize is hypertension.
Preparation of the healthy facelift patient involves mainly
avoidance of any interference with wound healing. It has been
my observation that the body will heal well if not interfered
with. Avoidance focuses on nicotine products and medica-
tions that interfere with clotting (aspirin, non-steroidal anti-
inflammatory drugs (NSAIDs), etc.).
Surgical technique (Video 6.7.1 )
The initial incision location in the temporal area depends
upon what is to be done with the forehead. If a bicoronal or
hairline incision is to be utilized for the forehead, then that
Fig. 6.7.3  “High SMAS” elevation of the subcutaneous fatty mass with orbicularis
suspension separately.
Orbicuarlis
moves alone
Malar and
bucccal/mandibular
areas move together

196
SECTION I
CHAPTER 6.7 • Facelift: SMAS with skin attached – the “high SMAS” technique
cheek flap (Fig. 6.7.6). This allows elevation of the cheek to
spread the medial fat away from the fold. The limited dissec-
tion also minimizes swelling by preserving the anterior facial
venous and lymphatic supply.
In patients with moderately deep nasolabial folds, the
same limited cheek dissection is done, but a fibrofatty SMAS
graft,35,36 trimmed from the lateral dissection, is tunneled
beneath the nasolabial fold (Fig. 6.7.7). I find this graft to
survive most of the time; however, accurate placement is
critical.
In patients with deep nasolabial folds, usually associated
with a thin face, complete dissection across the nasolabial fold
into the lip is done (Fig. 6.7.8).
In the rare patient, the upper one-third of the nasolabial
fold may be quite deep. In such a case, more anterior cheek
elevation is needed. In this situation, the author combines the
“high SMAS” cheek lift with a subperiosteal “malar lift”.37,38
With the cheek supporting its own weight, rather than being
suspended from the lid, the risk of secondary ectropion is
greatly reduced.
With completion of this release, the entire subcutaneous
cheek mass, from mandible to orbit, will freely move superi-
orly. It is paramount to mobilize the cheek in a pure vertical – not
horizontal or oblique – direction. The primary vector is vertical
along the lateral orbital rim (Fig. 6.7.9).
Key sutures are placed in the deep temporal fascia and in
the mastoid fascia. The periauricular SMAS is then completely
closed with a continuous suture to disperse the tension from
the key sutures.
Redundant skin is trimmed in place – with no additional
tension. It is paramount to the “high SMAS” concept that all
Inferiorly, the dissection continues down the fascial fusion
plane at the anterior border of the sternocleidomastoid muscle.
Here the cervical investing fascia of the platysma continues to
invest the sternocleidomastoid muscle. Without a “back cut”
in this fascia, upward motion of the platysma (SMAS) can be
restricted. Thus, a short 2–3 cm “back cut” in the investing
fascia and platysma is made about 4 cm below the mandibular
border. The “back cut” is made at this level to avoid any
aberrant branches of the marginal mandibular facial nerve.
At this point in the dissection, the buccal–mandibular
portion of the cheek will mobilize well, but the upper (malar)
portion of the cheek mass is little affected.
The SMAS is divided horizontally above the zygomatic
arch over to the lateral orbicularis. Using the visible edge of
the orbicularis as a depth marker, the dissection is carried over
the malar area to release the zygomatic retaining ligaments.
Again, using the inferior–lateral border of the orbicularis oculi
muscle as a depth gauge, the dissection is carried over the
lateral border of the zygomaticus major muscle into the sub-
cutaneous plane. Since the anterior SMAS is attached to the
zygomaticus major as its investing fascia, the muscle attach-
ment will restrict upward cheek mass mobilization unless
released. By making a transition in the cheek dissection plane
from a subSMAS plane to over the surface of the zygomaticus
major muscle, the investing fascia is released. Dissection is
then carried down the lateral border of the zygomaticus major
muscle to the level of the modiolus (Fig. 6.7.5). The extent of
anterior subcutaneous dissection depends upon the character-
istics of the nasolabial fold.
In patients with minimal nasolabial fold depth, dissection
stops short of the fold to preserve attachment of the fat to the
Fig. 6.7.4  The skin flap is thinly dissected
only to the extent of estimated skin excision.
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

197
Surgical technique
Fig. 6.7.6  Cheek dissection I stops short of the nasolabial fold.
Stops before anterior
facial vascular and
lymphatic territory
Fig. 6.7.7  Cheek dissection II stops short of nasolabial fold with tunneled SMAS
graft.
SMAS fat graft
Limited dissection
Fig. 6.7.5  Complete release of the
SMAS.
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

198
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CHAPTER 6.7 • Facelift: SMAS with skin attached – the “high SMAS” technique
liposuction of the buccal area should be avoided. Secondary
grooving is too likely.
Two areas respond well to fat grafting. There is often a
small redundant strip of excess in the SMAS mobilized to the
mastoid. This fibrofatty strip can be used to tunnel beneath
the nasolabial fold or to provide lip fullness.35,36,39 As previ-
ously mentioned, the graft takes reliably in the nasolabial
area, but survives only about 50% of the time in the lips.
Vertical upper lip lengthening is present in some patients.
In the properly selected individual, a “gull wing” excision at
the nostril sill40,41 will provide subtle improvement.
Perioral lines, either from actinic damage or recurrent
orbicularis contraction, are very common in aging patients.
While a number of corrective methods exist, all have limited
benefit. The dilemma is that in order to completely remove
deep wrinkles, you often remove pigment and skin append-
ages. This can leave the patient with a smooth, but white,
waxy appearance. Lighter peels and fractionated lasers have
fewer side effects, but less complete correction (Fig. 6.7.10).
Postoperative care
Immediate postoperative care consists of basic post-anesthesia
recovery and avoidance of hematoma. Due to the depth and
precision of dissection, most patients are under general
anesthesia.
suspension load is placed on the fascia (SMAS) – the skin is
never placed under greater than normal tension.
This upward cheek mobilization, however, does not elevate
or redrape the ptotic orbicularis oculi. Care is taken not to
undermine the lower orbicularis with the cheek dissection, in
order to avoid denervation. But by leaving the ptotic orbicu-
laris in place, upward cheek movement accentuates the shelv-
ing of the lower orbicularis. It is therefore necessary to add
orbicularis suspension, with or without correction of other
lower lid malformations, to the routine “high SMAS” cheek
lift.
While the cheek mass, including anterior cheek skin, moves
in a vertical direction, correction of neck redundancy neces-
sitates posterior (horizontal) redraping. This is accomplished
by lateral suspension of the SMAS to the mastoid fascia,
accompanied by lateral skin redraping and excision. As
opposed to the cheek, where the skin and subcutaneous fat
are mobilized as a composite, the neck dissection separates
the skin from the underlying platysma. Thus, the redundant
cervical skin can be mobilized horizontally, while the cheek
mass moves vertically.
Ancillary procedures
Defatting the face presents a different challenge when using
the “high SMAS” facelift. The dissection plane is deep to the
platysma at the jowl, while the jowl fat lies superficial to the
platysma. The author finds liposuction, through a nasal ves-
tibule incision, to be most expeditious. A 2.4-mm cannula
works quite well. It should be cautioned, however, that
Fig. 6.7.8  Cheek dissection III across the nasolabial fold into the lip.
Dissection across
nasolabial fold onto lip
Fig. 6.7.9  The cheek mass is suspended vertically (shown with key sutures), and
the entire SMAS flap is closed with a continuous suture to disperse the tension
from the key sutures. An orbicularis flap is then done to suspend the orbicularis.

199
Postoperative care
The other major element to control in the postoperative
period is swelling. Any facial dissection, whether subcu-
taneous or subSMAS, temporarily interrupts part of the
lymphatic drainage. While the lymphatics reconstitute over
3–6 months,42 during that interval, swelling can compromise
the result. Even young skin, maintained under stretch,
undergoes stress relaxation. But young patients’ skin can
recoil back to normal dimension. Older patients, however,
do not have skin recoil. If skin is held under stretch from
prolonged edema, the initial surgical improvement can be
compromised.
Intraoperatively, a 0.2-mg clonidine dermal patch is placed.
The maximal onset of action coincides nicely with maximum
absorption peak of the adrenalin in the local anesthetic solu-
tion, 4–6 h postoperatively. The patch is usually left in place
until the first postoperative morning, unless the patient dem-
onstrates hypotension.
Xylocaine 0.5% with 1 : 400 000 adrenalin is used for local
anesthesia and hemostasis. The 1 : 400 000 adrenalin strength
seems to provide adequate tissue hemostasis, and results in
less postoperative rebound hypertension than the stronger
dilutions.
Fig. 6.7.10  (A–C) This 53-year-old woman underwent hairline browlift, upper and lower blepharoplasty, “high SMAS” rhytidectomy with dissection short of the nasolabial
fold, submental plication, and SMAS grafts to the lips. (D–F) The result is shown at 6 months postoperatively.
A
B
C
D
E
F

200
SECTION I
CHAPTER 6.7 • Facelift: SMAS with skin attached – the “high SMAS” technique
Skin necrosis is quite rare, since the cheek flap is thick and
well vascularized. On rare occasions in previous smokers, a
small patch of skin necrosis can occur in the thin mastoid skin.
While patients can discontinue the immediate exposure to
smoke products, some degree of permanent obliterative
endarteritis always remains.
Incisional infection is also very rare (<2%). Infection is
usually caused by one of two organisms. Many patients,
particularly healthcare workers, may carry Staphylococcus
aureus in their nostrils. If a carrier status is suspected, topical
mupirocin ointment will usually eradicate it. The second
problematic organism is Pseudomonas aeruginosa. This organ-
ism is most commonly harbored in the external auditory canal.
The greatest concern of surgeons performing more exten-
sive dissections, is facial nerve injury. In the publication of the
initial clinical series, the author reported a 15% temporary
neurapraxia. All were of the marginal mandibular branch,
and all promptly recovered. In re-examining the cause, it was
realized that the neurapraxias were due to spreading dissec-
tion of the platysma over the anterior mandible. It was also
realized that that degree of anterior dissection under the
“mobile SMAS” was unnecessary. Subsequent elimination of
the dissection over the mandible eliminated the temporary
neurapraxias in subsequent patients. The author has never
had a permanent facial nerve injury in over 1000 “high SMAS”
dissections.
Three things are helpful to control postoperative swell-
ing. First, dexamethasone 8–10 mg is given intravenously
prior to dissection and a Dosepak of dexamethasone or
methylprednisolone is continued orally for 4 days to mini-
mize initial surgical edema. Second, strict control of fluid
intake is very beneficial. Patients are instructed to minimize
fluid volume intake. They can drink when thirsty, but they
are cautioned not to force excess fluids in an attempt to
improve health. Third, strict attention to sodium intake is
crucial. A low-sodium diet is very difficult to achieve. All
preserved foods, fast foods, and food sauces are loaded
with sodium. Patients are instructed to calculate sodium
intake for 3–6 months. Ideally, they should restrict sodium
intake to <2000 mg/day. The closer to 1000 mg/day, the
better.
Complications
As mentioned above, the most common postoperative com-
plication is hematoma. In non-hypertensive patients, the fre-
quency is 3%; in hypertensive patients, the frequency may
approach 8%. Very small collections restricted to the mastoid
may be treated by closed aspiration. But larger collections,
particularly located low in the neck, are best surgically
evacuated.
7. Rees TD, Wood-Smith D. Cosmetic Facial Surgery. Philadelphia, PA:
W.B. Saunders; 1973.
12. Aufricht G. Surgery for excess skin of the face. In: Transactions of the
Second International Congress of Plastic and Reconstructive Surgery.
Edinburgh: E & S Livingstone; 1960.
13. Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the
ligamentous attachments of the lower lid and lateral canthus. Plast
Reconstr Surg. 2002;110:873–884. Cadaveric dissections and histological
analyses were performed to characterize the deep attachments of the lower
eyelid region. Surgical considerations are discussed.
17. Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the
midcheek and malar mounds. Plast Reconstr Surg. 2002;110:885–896.
The surgical anatomy of the malar region is defined through cadaveric and
clinical dissections. The anatomical basis for midfacial aging is discussed.
19. Skoog T. Plastic Surgery – New Methods. Philadelphia, PA: W.B.
Saunders; 1974.
20. Mitz V, Peyronie M. The superficial musculoaponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg.
1976;58:80–88. This seminal study details SMAS anatomy and its clinical
implications.
22. Lemmon ML, Hamra ST. Skoog rhytidectomy: a five-year
experience with 577 patients. Plast Reconstr Surg. 1980;65:283–297.
23. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg.
1990;86:53–61. The subSMAS facelift is discussed as a means to address
the prominent nasolabial fold. Outcomes are reported in over 400 patients.
26. Barton FE Jr. The SMAS and the nasolabial fold. Plast Reconstr Surg.
1992;89:1054–1057.
37. Hester TR, Codner MA, McCord CD. The “centrofacial” approach
for correction of facial aging using the transblepharoplasty
subperiosteal cheek lift. Aesthet Surg Quart. 1996;16:51–58. The
anatomical basis for midface aging is described. Outcomes in over 750
patients are assessed after direct transblepharoplasty midface rejuvenation.
Access the complete reference list online at

200.e1
References
References
1. Miller CC. Cosmetic Surgery. The Correction of Featural Imperfections.
Chicago, IL: Oak Printing; 1908.
2. Bourguet J. Notre traitement chirurgical de “poches” sous les yeux
sans cicatrice. Arch Fr Belg Chir. 1928;31:133–137.
3. Noel A. La Chirurgie Esthetique. Clermont (Oise): Theron et Cie;
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4. Lexer E. Zur geischtsplastik. Arch klin Chir. 1910;92:749.
5. Bames OH. Truth and fallacies of face peeling and face lifting. Med J
Rec. 1927;126:86.
6. Conway H. The surgical face lift-rhytidectomy. Plast Reconstr Surg.
1970;45:124–130.
7. Rees TD, Wood-Smith D. Cosmetic Facial Surgery. Philadelphia, PA:
W.B. Saunders; 1973.
8. Stark RB. A rhytidectomy series. Plast Reconstr Surg. 1977;59:
373–378.
9. Hoefflin SM. The extended supraplatysmal plane (ESP) face lift.
Plast Reconstr Surg. 1998;101:494–503.
10. Duffy MJ, Friedland JA. The superficial-plane rhytidectomy
revisited. Plast Reconstr Surg. 1994;93:1392–1403.
11. Pires D. Kosmetische chirurgie der gesichtsrunzein. Fortschr Med.
1934;52:576.
12. Aufricht G. Surgery for excess skin of the face. In: Transactions of the
Second International Congress of Plastic and Reconstructive Surgery.
Edinburgh: E & S Livingstone; 1960.
13. Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the
ligamentous attachments of the lower lid and lateral canthus. Plast
Reconstr Surg. 2002;110:873–884. Cadaveric dissections and histological
analyses were performed to characterize the deep attachments of the lower
eyelid region. Surgical considerations are discussed.
14. Kikkawa DO, Lemke BN, Dortzback RK. Relations of the superficial
musculoaponeurotic system to the orbit and characterization of the
orbitomalar ligament. Ophthal Plast Reconstr Surg. 1996;12:77–88.
15. Pessa JE, Garza JR. The malar septum: the anatomical basis of
malar mounds and malar edema. Aesthet Surg J. 1997;17:11–17.
16. Pessa JE, Zadoo VP, Adrian EK, et al. Anatomy of a “black eye”: a
newly described fascial system of the lower eyelid. Clin Anat.
1998;11:157–161.
17. Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of
the midcheek and malar mounds. Plast Reconstr Surg. 2002;110:
885–896. The surgical anatomy of the malar region is defined through
cadaveric and clinical dissections. The anatomical basis for midfacial aging
is discussed.
18. Pangman WJ II, Wallace RM. Cosmetic surgery of the face and
neck. Plast Reconstr Surg. 1961;27:544–550.
19. Skoog T. Plastic Surgery – New Methods. Philadelphia, PA: W.B.
Saunders; 1974.
20. Mitz V, Peyronie M. The superficial musculoaponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg.
1976;58:80–88. This seminal study details SMAS anatomy and its clinical
implications.
21. Owsley JQ. Platysma-fascial rhytidectomy. Plast Reconstr Surg.
1977;60:843–850.
22. Lemmon ML, Hamra ST. Skoog rhytidectomy: a five-year
experience with 577 patients. Plast Reconstr Surg. 1980;65:283–297.
23. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg.
1990;86:53–61. The subSMAS facelift is discussed as a means to address
the prominent nasolabial fold. Outcomes are reported in over 400 patients.
24. Barton FE Jr. Facial Rejuvenation. St Louis, MO: Quality Medical
Publishing; 2008.
25. Barton FE Jr. Rhytidectomy: the anatomical basis for complete dissection.
Presented at the Annual Meeting of the American Society for
Aesthetic Plastic Surgery, Los Angeles, CA; 1989.
26. Barton FE Jr. The SMAS and the nasolabial fold. Plast Reconstr Surg.
1992;89:1054–1057.
27. Furnas DW. Festoons of orbicularis as a cause of baggy eyelids.
Plast Reconstr Surg. 1978;61:540–546.
28. Hamra ST. Repositioning the orbicularis oculi muscle in composite
rhytidectomy. Plast Reconstr Surg. 1992;90:14–22.
29. Fogli AL. Orbicularis myoplasty and face lift: a better orbital
contour. Plast Reconstr Surg. 1995;96:1560–1570.
30. Ousterhout DK, Weil RB. The role of the lateral canthal tendon in
lower eyelid laxity. Plast Reconstr Surg. 1982;69:620–623.
31. Flowers RS. Canthopexy as a routine blepharoplasty component.
Clin Plast Surg. 1993;20:351–365.
32. Heinrichs HL, Kaidi AA. Subperiosteal face lift: a 200-case, 4-year
review. Plast Reconstr Surg. 1998;102:843–855.
33. Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr
Surg. 1992;90:601–607.
34. Barton FE Jr, Hunt J. The high-superficial aponeurotic system
technique in facial rejuvenation: an update. Plast Reconstr Surg.
2003;112:1910–1917.
35. Guyuron B, Michelow B. The nasolabial fold: a challenge, a
solution. Plast Reconstr Surg. 1994;93:522–529.
36. Lassus CA. A surgical solution to the deep nasolabial fold. Plast
Reconstr Surg. 1996;97:1473–1478.
37. Hester TR, Codner MA, McCord CD. The “centrofacial” approach
for correction of facial aging using the transblepharoplasty
subperiosteal cheek lift. Aesthet Surg Quart. 1996;16:51–58. The
anatomical basis for midface aging is described. Outcomes in over 750
patients are assessed after direct transblepharoplasty midface rejuvenation.
38. Hester TR Jr, 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.
39. Leaf N, Firouz JS. Lip augmentation with superficial
musculoaponeurotic system grafts: report of 103 cases. Plast
Reconstr Surg. 2002;109:319–326.
40. Austin HW. The lip lift. Plast Reconstr Surg. 1986;77:990–994.
41. Austin HW, Weston GW. Rejuvenation of the aging mouth. Clin
Plast Surg. 1992;19:511–524.
42. Meade R, Griffiths L, Barton FE Presented at the Annual Meeting of
the American Society for Aesthetic Surgery, New York; 2006.

SECTION I • Aesthetic Surgery of the Face
6.8 
Facelift: Subperiosteal midface lift
Alan Yan and Michael J. Yaremchuk
SYNOPSIS
■ Midface aging is characterized by volume loss, ptosis of the cheek
skin, and descent of the attenuated lower eyelid.
■ These changes manifest as lengthening of the lower eyelid, obliteration
of the cheek–lid interface, hollowing of the tear trough, loss of malar
prominence, and deepening of the nasolabial folds.
■ The subperiosteal midface lift elevates the midface and restores
midface contours.
■ Midface lift, however, does not address the tear trough deformity,
which often requires fat grafting or fat transposition.
■ Subperiosteal dissection allows en bloc mobilization of the soft tissues.
■ The midface can be accessed via various combinations of eyelid,
temporal, and intraoral incisions.
■ Soft-tissue elevation can be maintained by using facial skeleton drill
holes, anchored sutures, or prefabricated suspension systems (such
as Endotines).
■ Patients with midface skeletal deficiency (negative vector) will benefit
from infraorbital rim augmentation as an adjunct to midface lift.
■ Zygomatic branches of the facial nerve (ZBFN) and the infraorbital
nerve (ION) are at risk for damage during release of the upper
zygomatic ligaments and placement of the periosteal suspension
sutures during midface elevation procedures.
■ Complications of the procedure include hematoma, asymmetry,
transient paresthesia, infection, and lower lid malposition.
Access the Historical Perspective section online at

Introduction
Midface aging is characterized by soft-tissue volume loss,
ptosis of the cheek skin, and descent of the attenuated lower
eyelid skin below the inferior orbital rim. This results in
lengthening of the lower eyelid and obliteration of the cheek–
lid interface. In addition, gravitational decent of the malar fat
pad is manifested by hollowing of the tear trough, loss of
malar prominence, and deepening of the nasolabial folds.
With the exception of the tear trough, the subperiosteal
midface lift corrects the stigmata of midface aging. For the
majority of clinical situations, we prefer the transpalpebral
subperiosteal midface lift, which employs a central direct
approach, elevating the midface vertically by suspending the
subperiosteal cheek flap to the orbital rim.1 In contrast to
the temporal approach, the transpalpebral approach avoids
the need for extensive peripheral-to-central intermediate
plane dissection. Since the vascular supply to the face is not
significantly reduced during subperiosteal elevation of the
midface, concomitant skin rejuvenation is possible.
The subperiosteal midface lift is a powerful technique
in facial rejuvenation. It is generally considered safe with
reported low complication rates.
Surgical anatomy
Cadaveric study by Doumit et al. details the surgical anatomy
of the subperiosteal midface lift.1
Midface skeleton
The midface skeleton relevant to midface lifting consists of
the anterior facial surface of the maxilla medially and the
zygoma laterally. Its superior boundary is the infraorbital rim
and inferior boundary is the apices of the teeth (Fig. 6.8.1).
The zygoma forms the prominence of the cheek and part
of the lateral wall of floor of the orbit, as well as parts of the
temporal and infratemporal fossae. It articulates with the
maxilla medially and presents malar, orbital, and temporal
surfaces. The malar surface is convex and is perforated in its
midaspect by the zygomaticofacial foramen for passage of the
zygomaticofacial nerve and vessels. Just below this foramen
is a slight elevation of the bone, from which the zygomaticus
major and the levator labii superioris arise.
The anterior surface of the maxilla is very irregular. Inferiorly,
this is due to a series of eminences and corresponding
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201.e1
Historical perspective
Historical perspective
The origin of subperiosteal facelift can be traced back to Paul
Tessier’s mask lift.2 Adopted from reconstructive craniofacial
procedures, exposure obtained using bicoronal, intraoral, and
eyelid incisions (usually transconjunctival) allowed mobiliza-
tion and elevation of the entire facial soft-tissue mask via
subperiosteal dissection.
The subperiosteal midface elevation remained predomi-
nantly in the domain of craniofacial surgeons for correcting
post-traumatic and congenital deformities until Ramirez and
Yaremchuk combined subperiosteal midface elevation with
facial rhytidectomy.3,4
Shorr’s “Madame Butterfly” procedure elevated the
midface to correct post-surgical lower lid deficiency, which
included lower lid shortening and lateral canthal supraplace-
ment.5 Hester modified Shorr’s procedure for aesthetic
applications.6
All of these procedures involved extensive degloving of the
midface soft tissues in the subperiosteal plane with suture
suspension of the midface to orbital or temporal landmarks.
Realizing the aesthetic benefits of midface elevation but
concerned with the extensive dissection unfamiliar to many
surgeons, a wave of enthusiasm arose for suspension devices
placed through limited access that purchased and elevated the
cheek mass without freeing it from the underlying skeleton.
Problems with relapse and asymmetry have tempered the
enthusiasm for this approach.

202
SECTION I
CHAPTER  • Facelift: Subperiosteal midface lift
oris as well as the skin of the upper lip. The levator anguli
oris (caninus) lies deep to the above muscles. It arises from
the canine fossa of the maxilla immediately inferior to the
infraorbital foramen. It inserts into the angle of the mouth.
The facial vessels travel across its lower border. Branches of
the infraorbital nerve travel in the connective tissue between
it and the overlying musculature. The levator labii superioris
alaeque nasi originates from the frontal process of the maxilla
lateral to the nose. It inserts into the skin and alar cartilage of
the nose and into the skin and musculature of the upper lip.
Branches of the infraorbital nerve are adherent to the under-
side of the levator muscles. The orbicularis oculi originates
from the nasal process of the frontal bone, the frontal process
of the maxilla, and the anterior surface of the medial canthal
tendon. The fibers are directed laterally to surround the entire
circumference of the orbit. Manipulation of this muscle may
lead to a transient decrease in lower lid tone.
Nerves
As detailed below, zygomatic branches of the facial nerve
(ZBFN) and the infraorbital nerve (ION) lie in close proximity
to the subperiosteal plane in the midface. These branches are
at risk for damage during release of the upper zygomatic liga-
ments and placement of the periosteal suspension sutures
during midface elevation procedures.
Zygomatic branches of the facial nerve
The zygomaticus major muscle is innvervated by ~3 branches
of the facial nerve (upper, middle, and lower).1 On average, 1.8
branches of the ZBFN enter the muscle superior to the caudal
depressions reflecting the apices of the teeth. The incisive fossa
is the depression above the prominent incisors, which also gives
rise to the origin of the depressor septi. The canine tooth forms
a vertical ridge that separates the incisive fossa from the canine
fossa, which is deeper and larger than the incisive fossa. The
canine fossa gives rise to the levator anguli oris.
The infraorbital rim is comprised of the zygoma laterally
and the maxilla medially. The zygomaticomaxillary (ZM)
suture is located at the midpupillary line. Approximately
1 cm below the rim is the infraorbital foramen through which
the infraorbital nerve exits.
Muscles
The muscles of the midface largely provide facial expression
(see Fig. 6.8.1). They arise from the facial bones and insert into
the skin. These muscles seldom remain distinct throughout
their entire length; rather, they tend to merge with the neigh-
boring muscle where they terminate.
The zygomaticus major muscle originates from the lateral
surface of the zygoma just medial to the zygomaticotemporal
suture, and sometimes intermingles with the orbicularis oculi.
It passes obliquely downward and forward to the corner of
the mouth, where it inserts into the skin and mucosa. The
zygomaticus minor lies medial to the zygomaticus major. It
originates from the malar surface of the zygoma immediately
lateral to the zygomaticomaxillary suture, and passes down-
ward and medially to insert into the lip just medial to the
corner of the mouth.
The levator labii superioris originates from the lower
margin of the orbit just above the infraorbital foramen. It
travels downward and medially inserts into the orbicularis
Fig. 6.8.1  Midface skeletal anatomy with muscle origins and nerve foramina.
Infraorbital nerve
Zygomaticofacial nerve
Zygomaticofacial nerve
Infraorbital nerve
Zygomaticus major
Zygomaticus minor
Levator labii superioris
Levator anguli oris
Levator anguli oris (origin)
Nasalis (transverse part)
Orbicularis oculi
Orbicularis oris
Levator labii superioris
alaeque nasi
Levator labii superioris (origin)

203
Indications
Zygomatic cutaneous and upper
masseteric cutaneous ligaments
The zygomatic cutaneous and upper masseteric cutane-
ous ligaments represent a continuous row of dense and
stout fibers originating from the anterolateral aspect of the
maxillary buttress, upper anterior masseteric muscle, and
zygomatic body (Fig. 6.8.5). Their release from the under-
lying skeleton is crucial to successful midface elevation
(Fig. 6.8.6).1
Indications
■ Senile midface descent
■ Lower lid malposition
■ Repositioning the degloved midface mask after midface
skeletal reconstruction.
border of the ZM suture (Fig. 6.8.2). The upper ZBFN lies
~6.2 ± 1.6 mm cranial to the inferior border of the ZM suture,
6.4 ± 0.4 mm from the tragus, and at 1.4 ± 0.4 mm of elevation
from the bone. The middle branch lies ~2.3 ± 4.2 mm cranial
to the inferior border of the ZM suture, 6.9 ± 0.3 mm from the
tragus, and at 1.3 ± 0.4 mm of elevation from the bone. The
lower branch lies ~4.8 ± 3.3 mm inferior to the caudal border
of the ZM suture and 7.2 ± 0.1 mm from the tragus (see Fig.
6.8.2). The lower branch does not overlie the bone.
Infraorbital nerve
The ION exits the infraorbital foramen ~9.4 ± 1.8 mm below
the infraorbital rim. It then divides into an average of 5.2
branches: lower eyelid, alar, medial upper lip, lateral upper
lip, and lateral cheek.1 A second alar branch is present 14% of
the time. The terminal branches of the ION travel supraperi-
osteally before they pass into a superficial plane (Fig. 6.8.3).
The lower eyelid branch has the shortest supraperiosteal
course (~5.9 ± 1.2 mm), followed by the alar branch and lateral
cheek branches that enter the subcutaneous layer at
~8.0 ± 2.2 mm and ~9.9 ± 3.4 mm, respectively. The medial
and lateral upper lip branches travel ~12.6 ± 2.2 mm and
12.2 ± 2.1 mm before becoming superficial (Fig. 6.8.4).
Zygomaticofacial nerve
The zygomaticofacial nerve exits through its foramen on the
lateral aspect of the zygoma at 8–10 mm beneath the infraor-
bital rim and in line with the lateral orbital rim. It supplies
a small portion of the skin of the upper cheek. Whereas the
ION must be protected during subperiosteal midface lift, the
zygomatciofacial nerve can be sacrificed with the ensuing
sensory loss rarely noted by the patient.
Fig. 6.8.2  Cadaver dissection of left midface. The skin flap is raised and retracted
medially. The superior zygomatic branch of the facial nerve (ZBFN) passes above
and the inferior branch passes below the inferior margin of the zygomaticomaxillary
(ZM) suture. The arrow indicates the zygomatic major muscle, and the dot marks
the caudal border of the ZM suture. (Reproduced from Doumit G, Gharb BB,
Rampazzo A, et al. Surgical anatomy relevant to the transpalpebral subperiosteal
elevation of the midface. Aesthet Surg J. 2015;35:353–358.)
Fig. 6.8.3  The infraorbital nerve fascicles run on the anterior maxillary periosteum
after exiting the infraorbital foramen (A), and the fascicles are shown entering the
subcutaneous tissues (B). The arrows indicate the point of elevation from the
periosteum. (Reproduced from Doumit G, Gharb BB, Rampazzo A, et al. Surgical
anatomy relevant to the transpalpebral subperiosteal elevation of the midface.
Aesthet Surg J. 2015;35:353–358.)
A
B

204
SECTION I
CHAPTER  • Facelift: Subperiosteal midface lift
Patient evaluation
In addition to a detailed history and physical examination, a
thorough facial analysis should be performed with a focus on
midface descent and effacement of the cheek–lid interface.
Assessment of the globe and lower lid is important in
Fig. 6.8.5  Cadaver dissection of right midface. The skin flap is raised and
retracted laterally. Masseteric cutaneous ligaments are stout, fibrous ligaments that
originate from the maxillary buttress and the anterior margin of masseter muscle.
(Reproduced from Doumit G, Gharb BB, Rampazzo A, et al. Surgical anatomy
relevant to the transpalpebral subperiosteal elevation of the midface. Aesthet Surg J.
2015;35:353–358.)
identifying patients with lid retraction who might also benefit
from a midface lift as a means to recruit otherwise deficient
lower lid tissue. Projection of midface skeleton is also assessed.
Patients with a negative vector and midface descent will
benefit from placement of infraorbital rim implants as an
adjunct to support the midface lift.
Surgical technique (Video 6.8.1 )
Incisions
It is the senior author’s preference to perform the procedure
via the transconjunctival lower lid and intraoral incisions. If
necessary, the transconjunctival incision is combined with a
crow’s foot incision for increased lateral exposure. This small
incision avoids lateral canthotomy, thus preserving the integ-
rity of the lateral canthus. A retroseptal dissection to the
orbital rim is performed. A lower lid skin muscle flap is an
alternative approach.
Soft-tissue mobilization
Once the infraorbital rim is identified, subperiosteal dissec-
tion proceeds medially and laterally while preserving the
ION. A second incision is made at the upper gingivo-buccal
sulcus. The anterior maxilla and zygomatic body are dis-
sected subperiosteally. The origins of the upper masseteric
and the zygomatic cutaneous ligaments are exposed and
released.
5.9 ± 1.2mm
9.9 ± 3.4mm
8.0 ± 2.2mm
12.2 ± 2.1mm
12.6 ± 2.2mm
Fig. 6.8.4  The branching pattern of the infraorbital nerve is shown, and the average
supraperiosteal course is summarized for lower eyelid, alar, lateral cheek, and
medial and lateral superior lip branches.
Zygomatic
branch
of facial nerve
Upper
massteric
ligament
Zygomatic
ligament
Fig. 6.8.6  The zygomatic branch of the facial nerve runs in close proximity to the
upper masseteric and zygomatic ligaments and can be damaged when releasing
these ligaments from their skeletal attachments.

205
Surgical technique
polyethylene (e.g. MEDPOR, Stryker Corporation, Kalamazoo,
MI; OMNIPORE, Matrix Surgical, Atlanta, GA) infraorbital rim
implants are placed in the same surgical setting, the elevated
midface soft tissues can be directly sutured to the implants.
Using these techniques, the midface tissues are fixated to the
underlying skeleton as opposed to being suture-suspended
from more remote fixation points when temporal approaches
are employed. Another method of soft-tissue suspension uses
prefabricated suspension system (e.g. Endotines; Microaire
Aesthetics, Charlottesville, VA),7 which may decrease opera-
tive time and thus postoperative edema.
The upper gingivo-buccal sulcus incisions are reapproxi-
mated with chromic sutures, and temporary tarsorrhaphy
sutures are placed to minimize chemosis.
Clinical examples of patients who have undergone sub-
periosteal midface lift using the above-mentioned technique
are shown (Figs. 6.8.7 & 6.8.8).
Soft-tissue fixation
Two figure-of-eight non-absorbable, braided poly(ethylene,
terephthalate) sutures (e.g., Ethibond Excel, Ethicon, Somer-
ville, NJ) are placed in the periosteal layer and overlying soft
tissue, 3 cm inferior to the midpupil and lateral canthus, which
correspond to the level of the malar fat pad prominence. These
sutures are placed radially (at 13 and 22 mm lateral to the
infraorbital foramen), and deep passage of the sutures through
the periosteum and into the soft tissues is avoided to decrease
the chance of inadvertent injury to the ION.1 Traction is then
applied to test the elevation of the soft tissues in relation to the
pupil and lateral canthus. The soft tissues are then sutured to
the orbital skeleton using drill holes made in the infraorbital
and often the lateral orbital rim. Anchored sutures (e.g., Mitek,
DePuy Synthes Companies, Raynham, MA) to the infraorbital
rim provide alternative stable points of fixation. When porous
Fig. 6.8.7  A 32-year-old woman who had previously
undergone endoscopic browlift, blepharoplasty, and
midface fat grafting was treated with a subperiosteal
midface lift as well as lowering of her hairline and
brows. (A,B) Preoperative frontal and left oblique
views; (C,D) 7-year postoperative frontal and left
oblique views.
A
B
C
D

206
SECTION I
CHAPTER  • Facelift: Subperiosteal midface lift
serum. Hematoma typically occur within the first 24 h of
surgery, as in other facelift procedures.6 This is treated by
surgical drainage. Paresthesia and zygomatic palsy are not
uncommon complaints but are usually self-limited. Infection
is extremely rare and is treated accordingly.
Lower lid malposition has not occurred using the senior
author’s technique described here. Since the goal of the surgery
is to recruit cheek soft tissue to restore lid-cheek contours, it
is, therefore, unusual for the senior author to remove eyelid
tissue during these procedures. Lower lid malposition has
been reported as a complication in subperiosteal midface lift.8
These procedures often remove large amounts of lower lid
tissue that appear redundant after midface elevation. Loss of
fixation results in collapse of the midface flap (which includes
the lower lid) and descent of the lower lid. Lower lid malposi-
tion results in ectropion, scleral show, and can lead to clinically
significant dry eyes.6,9–11 Long-term treatment of this complica-
tion may consist of canthoplasty, correction of horizontal
laxity, and skin or spacer grafts.12
Postoperative care
As with other facelift procedures, blood pressure control
is imperative to avoid postoperative hematoma. A suction
drain is routinely placed at the operative site and removed
the morning after surgery. A supportive tape dressing is
placed at the completion of the surgery and is removed the
next day. Since intraoral incisions are used, patients are asked
to remain on a soft diet for the first 72 h after surgery. They
are also instructed to refrain from strenuous exercise for 2–3
weeks postoperatively.
Complications
Hematoma is uncommon since the subperiosteal dissection
involves a plane of limited vascularity. A suction drain
(removed in 24 h) evacuates small accumulation of blood and
Fig. 6.8.8  A 58-year-old woman with midface descent
underwent subperiosteal midface lift, upper and lower
blepharoplasty, lateral browlift, and full-thickness skin
rhytidectomy. (A,B) Preoperative frontal and left
oblique views; (C,D) 7-year postoperative frontal and
left oblique views.
A
B
C
D

207
Complications
7. Saltz R, Ohana B. Thirteen years of experience with the endoscopic
midface lift. Aesthet Surg J. 2012;32:927–936. Description of the
endoscopic midface lift.
8. Hester TR Jr, 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 407–398. Description of the transblepharoplasty
midface lift and its complications.
9. Korn BS, Kikkawa DO, Cohen SR. Transcutaneous lower eyelid
blepharoplasty with orbitomalar suspension: retrospective review
of 212 consecutive cases. Plast Reconstr Surg. 2010;125:315–323.
10. Seitz IA, Llorente O, Few JW. The transconjunctival deep-plane
midface lift: a 9-year experience working under the muscle. Aesthet
Surg J. 2012;32:692–699.
11. Cornette de Saint-Cyr B, Garey LJ, Maillard GF, et al. The vertical
midface lift. An improved procedure. J Plast Reconstr Aesthet Surg.
2007;60:1277–1286.
12. Yin VT, Chou E, Nakra T. The transeyelid midface lift. Clin Plast
Surg. 2015;42:95–101.
References
1. Doumit G, Gharb BB, Rampazzo A, et al. Surgical anatomy relevant
to the transpalpebral subperiosteal elevation of the midface. Aesthet
Surg J. 2015;35:353–358. Cadaver study of the surgical anatomy of
Subperiosteal midface lift.
2. Tessier P. Le lifting facial sous-périosté. Ann Chir Plast Esthet.
1989;34:193–197. Tessier’s description of the mask lift.
3. Yaremchuk MJ. Subperiosteal and full-thickness skin rhytidectomy.
Plast Reconstr Surg. 2001;107:1045–1058. The senior author’s description
of combining subperiosteal midface lift with rhytidectomy.
4. Ramirez OM, Maillard GF, Musolas A. The extended subperiosteal
face lift: a definitive soft-tissue remodeling for facial rejuvenation.
Plast Reconstr Surg. 1991;88:227–236, discussion 237–228.
5. Shorr N, Fallor MK. “Madame Butterfly” procedure: combined
cheek and lateral canthal suspension procedure for post-
blepharoplasty, “round eye,” and lower eyelid retraction. Ophthal
Plast Reconstr Surg. 1985;1:229–235.
6. Hester TR, Codner MA, McCord CD. The “centrofacial” approach
for correction of facial aging using the transblepharoplasty
subperiosteal cheek lift. Aesthet Surg J. 2002 1996;15:51–58.

SECTION I • Aesthetic Surgery of the Face
6.9 
Facelift: Male facelift
Timothy J. Marten and Dino Elyassnia
SYNOPSIS
■ Over the past few decades men have increasingly sought facial
rejuvenation as prevailing attitudes regarding aging and appearance
have shifted.
■ During this time, plastic surgeons have come to recognize that male
facial aesthetics differ from those thought desirable in females and
attractive masculinity is not as closely equated with youth and beauty
as is femininity.
■ Surgeons have recognized that a diminished margin for error arguably
exists in male patients, due to the fact that men have fewer options to
conceal their scars or a mediocre result.
■ Men generally seek a somewhat different outcome from facial
rejuvenation surgery, and this has led to a rethinking of techniques that
have evolved mainly to treat facial aging in women.
■ New approaches and modifications of techniques have thus emerged
that provide attractive rejuvenation of the male face while preserving a
natural, masculine appearance.
Aging of the male face and
male facial aesthetics
Treatment strategies in men will be different than those in
women and it is not appropriate to arbitrarily apply concepts
and techniques that evolved largely for treating the female
face to that of a man. The male face is arguably more nuanced
than that of a female whom we have come to accept as having
a more contrived and made-up appearance, and certain
aspects of male facial aging are often regarded as signs of
experience, wisdom, and power that many men wish not to
lose. In these and other ways, men often have different goals
to women when seeking rejuvenation of their faces, with the
man arguably more concerned about a natural appearance,
free of signs that a surgical procedure has been performed. In
our society, there are differences in attitudes towards aesthetic
surgery in women and men. For example, if we see a woman
whose face looks younger than the rest of her body, or if her
face has visible signs that a facelift might have been per-
formed, we smile and tell ourselves “she has had something
done”. If we see a man with an overdone or unnatural appear-
ance, or telltale signs that surgery has been performed, we are
often more judgmental and disapproving. Women, who typi-
cally wear longer hairstyles and make-up, also have more
ways to hide signs that surgery has been performed than
a man. In this sense, there is perhaps less room for error,
both technically and artistically, when a male facelift is
performed.
In the time since history has been recorded, female beauty
has been closely associated with smooth skin, the absence of
wrinkles, and youth – whereas male attractiveness often
encompasses a certain weathered ruggedness, and even a
certain disdain for skin care and the like. These conventions
and attitudes are indeed changing, but nonetheless are a
consideration when performing male facelift procedures.
In our current cultural climate, female attractiveness is seen
as correlated with smooth skin, a wrinkleless forehead, an
arched eyebrow, a stylized eye appearance, a high cheek
profile, a tight jawline, and overall inverted oval facial shape.
Male attractiveness on the other hand rests more in a bottom
heavy rectangular facial shape, a heavier and bolder jawline,
a good neck line, a lower and more horizontal eyebrow, a
flatter cheek profile, and less meticulously maintained skin.
When these differences are considered, it can be seen that a
different endpoint is typically sought in the male patient
seeking facelift surgery, and the goals of the procedure and
accompanying technique must be modified accordingly.
Men typically seek and desire a bold, athletic neck and
jawline, and more subtle and less dramatic changes on other
areas of the face. All things considered, a surgeon who can
deliver a good result in the neck and jawline, provide well-
concealed scars, and exercise restraint when operating on the
forehead, eyes and mouth, is likely to be successful when
treating male patients. In contrast, surgeons who overtreat the
orbital area, do not provide well-concealed scars, and do not
deliver a good result in the neck are likely to have more
unhappy patients.
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209
Recognizing the components of the aging deformity of the face
saggy face with no improvement in contour. This sort of
“smooth-saggy look”, typically seen in older patients who
have undergone laser resurfacing or deep skin peels, is incon-
sistent with a natural appearance, as patients with loss of
facial contour generally also have concomitant skin surface
aging. It is arguably more masculine and natural appearing
to have youthful facial shape with a few wrinkles and surface
imperfections, than a smooth but saggy face.
Many, if not most, of the changes associated with loss of
facial contour in men represent primarily “deep layer” prob-
lems that will be inadequately corrected if traditional “skin-
only” techniques are used. Regrettably, many surgeons
unfamiliar with deep layer techniques, and other physicians
insufficiently trained to perform them, often employ a variety
of conceptually flawed procedures including skin-only “mini-
lifts”, “suture lifts”, and “short scar” lifts, and resort to other
misguided and misapplied ancillary procedures to overcome
the shortcomings of these methods in men. These procedures
include facial liposuction, buccal fat extraction, malarplasty,
submalarplasty, and polytetrafluoroethylene (PTFE; “Gore-
Tex”) implantation. Although some of these ancillary proce-
dures are at times indicated in male patients, they will be
unnecessary in the majority of cases if a SMAS (superficial
musculo-aponeurotic system) facelift and deep layer rejuve-
nation is performed (Fig. 6.9.1).
Male patients with significant facial atrophy and age-related
facial wasting will generally achieve suboptimal improve-
ment from both surface treatments of facial skin and surgical
lifts. Smoothing skin will not hide a drawn appearance due
to loss of facial volume, and it is difficult to create natural and
masculine contours by lifting and repositioning tissues that
have abnormally thinned and deflated with age. Restoring
lost facial volume with autologous fat grafting is a powerful
technique that has gained increased acceptance in treating the
aging face. Properly performed, the addition of fat to areas of
the male face that have atrophied due to age or disease
can produce a significant and sustained improvement in
Recognizing the components of the
aging deformity of the face
Recognizing the components of the aging deformity of the
face and appreciating the underlying anatomical abnormali-
ties is essential to properly advising patients and fundamental
to the planning of any surgical procedure. Careful analysis
will reveal that most patient problems will fall into three
broad categories: (1) aging and breakdown of the skin surface,
(2) facial sagging, skin redundancy, and loss of youthful facial
contour, and (3) facial wasting, atrophy and/or age-related
lipodystrophy. Proper treatment will depend upon the types
of problems present, the patient’s priorities, and the time,
trouble, and expense he is willing to endure to obtain the
desired improvement.
Male patients primarily concerned with surface aging of
their face do not require formal surgical procedures and may
achieve the type of improvement they desire through derma-
tologic surface treatments of the skin. These treatments
include skin peels, skin resurfacing, chemodenervation (neu-
rotoxin injections), filler injections, and various forms of
cutaneous laser, radiofrequency, ultrasonic, and other treat-
ments designed to remove or reduce age-related skin surface
imperfections. Few men’s concerns typically fall in this
category.
Patients primarily concerned with facial sagging, skin
excess and loss of facial contour will achieve minimal ultimate
improvement, however, if surface treatments only are
employed, and will require formal surgical lifts in which
sagging tissue is repositioned and redundant tissue is excised
if these problems are to be properly corrected and an attrac-
tive and natural-appearing improvement is to be obtained.
Most men’s concerns fall solidly in this category. The misap-
plication of surface treatments of the skin to the sagging face
with excess tissue will produce little more than a smooth
Fig. 6.9.1  (A) Before surgery view of patient, age 59.
He can be seen to have combined surface aging of his
skin, tissue sagging and redundancy, and facial
atrophy. Note heavily wrinkled forehead, hollow  
cheeks, deep cheek folds, and sagging facial tissues.
(B) Same patient, 1 year and 6 months after facelift,
necklift, forehead lift, upper blepharoplasty with levator
reinsertion, lower blepharoplasty, and partial facial fat
grafting. Note improvement in forehead wrinkling, brow
position, eye appearance, lower eyelid fullness,
posture of perioral tissues, and overall facial sagging.
Increased facial fullness following fat grafting is also
evident. The patient has a more youthful, healthy, and
masculine appearance without a tight, pulled, or
“facelifted” look. (All surgical procedures performed by
Timothy Marten, MD, FACS. Photos courtesy of the
Marten Clinic of Plastic Surgery.)
A
B

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SECTION I
CHAPTER 6.9 • Facelift: Male facelift
appearance unobtainable by other means (see Fig. 6.9.1 and
Case studies 6.9.1 & 6.9.3). In addition, autologous fat graft-
ing may represent the first true anti-aging therapy plastic
surgeons have to offer patients, in that there is a growing body
of evidence that adult stem cells transferred with fat exert a
rejuvenating effect on tissues in areas adjacent to areas where
fat is injected.
Case studies 6.9.1 & 6.9.3 appear online only.
Age-related facial atrophy rarely exists as an isolated event
in the healthy patient however, and thus male patients troubled
by it are not always logically or appropriately treated by fat
grafting alone. Isolated fat grafting is also arguably of ques-
tionable benefit to the patient troubled by significant facial
sagging and skin redundancy. Although aggressive filling of
the sagging face with fat can produce improved contour and
a smoother appearance, it generally results in an unusually
large, overfilled face that appears unnatural. Such an over-
filled face is hard to correct in an attractive manner at a later
date, and it is both more logical and practical to perform fat
grafting in conjunction with formal surgical lifts if needed, or
after ptotic tissue has been repositioned and redundant tissue
has been removed. When a SMAS facelift technique is used
in conjunction with fat grafting, both loss of facial contour and
facial atrophy can be corrected and optimal improvement in
the patient’s appearance can be obtained.
Treatment strategies in the
male patient
There are a number of situations one encounters in treating
men in which a somewhat different strategy than one would
use in women can be employed.
The bald man and the man with short hair
The bald man or the man with short hair, while often regarded
by some as a significant challenge above and beyond that of
the typical patient, can in reality be treated largely the way a
man or woman with abundant hair is treated. Even sparse,
Fig. 6.9.2  Occipital hairline scar in men
with short hair. The bald man or the man
with short hair, while often regarded by
some as a significant challenge above and
beyond that of the typical patient, can be
treated the way a man or woman with
abundant hair is treated. Even sparse, short
hair provides good cover for the temple and
occipital incisions if properly planned, as
the short hair worn by most men falls over
them and conceals them. This is the case
even in the man who wears a “military
style” haircut. (All surgical procedures
performed by Timothy Marten, MD, FACS.
Photos courtesy of the Marten Clinic of
Plastic Surgery.)
A
B
short hair provides good cover for the temple and occipital
incisions if properly planned, as the short hair worn by most
men falls over them and conceals them. This is the case even
in the man who wears a “military style” haircut. In these
patients, the basic facelift incision plan need not be specifi-
cally modified (Fig. 6.9.2, see also
Case study 6.9.3).
Small incision and endoscopic foreheadplasty is also
usually possible in these patients if indicated, as incisions can
be sited on the temple scalp and at the superior-most spot that
hair is present (see
Case study 6.9.3). Alternatively, a fore-
head lift can be performed by excising forehead skin along a
transverse forehead crease (see Fig. 6.9.23), or by using a
supracillary incision (see Fig. 6.9.24). Both these strategies
result in inconspicuous scars and represent a worthwhile
trade-off in most men in the facelift age group.
Man with a shaved head
While once an oddity, the shaved head has gradually become
a near cultural norm and an increasingly common fashion
statement, and this has resulted in plastic surgeons encounter-
ing a growing number of these men seeking facelifts and
related procedures. Although these patients may initially
present a quandary and are often turned away, they are very
good candidates for “facelift” surgery if a thoughtful surgical
plan is employed.
In treating the man with the shaved head one can exploit
the fact that a key and quintessential feature of an attractive,
athletic appearing man is a good neckline. Unlike women –
for whom optimal appearances are more closely tied to youth,
an inverted oval facial shape, high cheek contour, and a tight
jawline – the male face is more tolerant of a rectangular shape,
a lower cheek profile, and a lax jawline. As such, a short scar
necklift performed in conjunction with ancillary procedures
such as fat grafting, supercillary eyebrow lift, nasolabial fold
excision, and conservative eyelid surgery, can result in quite
satisfactory improvement without the need for a full facelift
and periauricular scars (Fig. 6.9.3).
In a short scar necklift, a submental incision only is used
and improved neck contour is obtained by modification

211
Treatment strategies in the male patient
Fig. 6.9.3  Facial rejuvenation strategy in the man with the shaved head. In treating the man with the shaved head, one can exploit the fact that a quintessential feature of an
attractive, athletic-appearing man is a good neckline. As such, a short scar necklift performed in conjunction with ancillary procedures as indicated, such as facial fat
grafting, supercillary eyebrow lift, nasolabial fold excision, and conservative eyelid surgery, can result in quite satisfactory improvement without the need for a full facelift
and periauricular scars. (A and C) Male patient with shaved head seen preoperatively. On casual consideration, it seems treating him would be difficult. (B and D) Same
patient following short scar necklift (note that no scar is present around the ear), facial fat grafting, and conservative eyelid surgery. (E) The patient appears remarkably
rejuvenated, even though a periauricular incision was not used and no periauricular scar is present. (All surgical procedures performed by Timothy Marten, MD, FACS.
Photos courtesy of the Marten Clinic of Plastic Surgery.)
A
B
C
D
E
of deep layer neck structures and not the excision of neck
skin. These modifications include subplatysmal lipectomy,
submandibular gland reduction, partial digastric myectomy,
and platysmaplasty. Skin is then allowed to redrape over the
deeper and geometrically longer concave surface created and
this, in effect, takes up “loose” neck skin. Short scar necklift
can be productive in men well into their sixties in most cases
(Fig. 6.9.4).
If a man with a shaved head feels excess skin is present that
needs to be removed, an “extended necklift” incision plan can
be used – a typical periauricular facelift incision with no
temporal portion (Fig. 6.9.5) modified by shortening or elimi-
nating the occipital portion of the incision. Typically, men
needing and requesting this are older (in their 60s or 70s) and
the scar is less of an issue and better concealed on their
more aged skin than in the typical “short scar” candidate (40s
to 60s).
The “facelift” phobic man
Many men are simply put off by the word “facelift”, and
even when their typical fears of “looking different”, “having
a pulled or tight appearance”, or “having obvious scars” are
countered with explanations as to how those occurrences can
be avoided, it can be difficult to convince them to undergo
the procedure. Often it seems that they want the improve-
ment afforded by the facelift but just cannot get past the
name of the procedure. In such cases, an accord can usually
be struck by simply calling the procedure an “extended
necklift” and modifying the facelift incision plan slightly
accordingly.
In the extended necklift a typical periauricular facelift inci-
sion is employed but no temporal portion of the incision is
made (see Fig. 6.9.5). Such a plan places the incision and
resulting scar in a well-concealed location but negates the
possibility of a poorly concealed scar in the temporal area.
This incision plan will allow a limited low cheek SMAS flap
to be elevated (or a low cheek SMAS plication to be performed)
as part of the procedure that provides improvement in the
lower face and along the jawline, which would not otherwise
be obtained if an isolated necklift only was performed. In
addition, it allows the excision of a significant amount of skin
from the lower face, jawline, and neck that would not other-
wise be removed. It should be noted that the extended necklift

212
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
Fig. 6.9.4  Short scar necklift. (A) Patient before
surgery; (B) same patient after short scar necklift. A
submental incision only is used and improved neck
contour is obtained by modification of deep layer neck
structures and not the excision of neck skin. Skin is
then allowed to redrape and redistribute itself over the
deeper and geometrically longer concave surface
created and this takes up “loose” neck skin. No scar is
present around or behind the ear. (All surgical
procedures performed by Timothy Marten, MD, FACS.
Photos courtesy of the Marten Clinic of Plastic
Surgery.)
A
B
Fig. 6.9.5  Extended necklift incision plan. The incision plan for an “extended
necklift” is similar to the typical periauricular facelift incision plan without the
temporal portion of the incision. This incision plan allows lower facial skin to be
excised and a “low” SMAS flap to be elevated and advanced or low SMAS plication
to be performed that provides improvement in the lower face and along the jawline
that would not otherwise be obtained if an isolated necklift only was performed.
(Photos courtesy of the Marten Clinic of Plastic Surgery.)
encompasses certain compromises, however, including the
fact that no upper cheek or midface improvement is obtained.
While this is often an unacceptable compromise when operat-
ing on the female face, it can be a very acceptable trade-off in
the male patient.
The extended necklift can be combined with fat grafting to
offset some of its limitations and to obtain improvement on
the upper face. Conservatively performed forehead and eyelid
surgery, as discussed above and in following sections, can
further enhance the outcome.
Short scar facelifts in men
A traditional short scar incision plan offers little benefit for
most men and can, in reality, be problematic in many cases.
The basic premise of shifting facial skin strongly in a vertical
direction is conceptually flawed and typically results in the
need for aggressive temple or forehead lifts and tedious
gathering of redundancy along a temporal hairline incision
that might not otherwise be required. Gathering of tissue, and
the often resulting puckering and bunching of skin along
incisions in the temple and postlobular areas that typically
occurs when short scar incision plans are used can be con-
cealed to some extent by women who typically wear longer
hairstyles, but can be a significant source of embarrassment
to men (Fig. 6.9.6). Vertical skin shifts can also move deep
cervical wrinkles up onto the lower face, a problem not
encountered when a postauricular incision is used and a
proper more posteriorly directed vector for skin shift is
employed. And because neck improvement is of paramount
importance in men, it could be argued that shortening the scar
in the postauricular area where it should be well concealed
(see Figs. 6.9.2–6.9.4), even in a man with short hair, and
compromising overall result in the cervico-submental region
is of dubious value.
Shortening the occipital portion of the facelift incision may
be useful in the man with the shaved head, however (see
previous discussion).
Preoperative planning in the
male facelift patient
It is not possible to design or use a “universal” male facelift
technique as each male patient will present with a unique set
of problems that require precise anatomic diagnosis and an
appropriately planned and individualized surgical repair.
Committed study, careful planning, and avoiding the use of
a “formula technique” will maximize improvement, limit
complications, and minimize secondary deformities.