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Preoperative and postoperative views are shown after Connell’s upper face thick
aps (below the SMAS), suspension of the anterior SMAS to the zygomatic arch
SMAS, Peterson’s platysma redraping, and Millard’s submental lipectomy.
The effect of suture suspension of the anterior SMAS on the surface anatomy is
demonstrated.
The results achieved with this type of SMAS suspension were impressive and nat-
ural looking: the interlabial curved line was corrected, the jowls practically disap-
peared, and the labiomandibular fold became attened.

These two patients show the effectiveness of the elevation of the anterior SMAS to
the zygomatic arch by a suture.
More impressive are the long-term results, seen 10 years later.
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This patient is seen in preoperative and 10-year postoperative views following sus-
pension of the anterior SMAS to the region above the zygomatic arch.

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In this patient the markings show the vector of skin redraping as a 90-degree an-
gle in relation to the nasolabial fold.The nasolabial fold was improved by the vec-
tor of pull from the fold.
The SMAS ap followed the accepted design of the times, which began approxi-
mately 1 inch below the projection of the zygomatic arch.18 This is generally lower
than that performed today.The suspension of the anterior SMAS offered one sig-
ni cant improvement over Skoog’s suture to the masseteric fascia: it allowed a dif-
ferent, more vertical elevation of the perioral structures, enhancing the malar
prominence at the same time (see the photo on p. 226).The suspension of the an-
terior SMAS to the fascia over the zygomatic arch set a new standard of postoper-
ative midface surface anatomy for the new SMAS ap technique to meet (compare
the photos on p. 226 with those on p. 246).
Although the suture suspension of the anterior SMAS over Bichat’s fat pocket was
performed exclusively for many years without a single nerve injury, I realized that
this sterling safety record could be attributed to the clear view of the roof to the
suctorial fat pad and the nerves that cross that area, which helped the surgeon avoid
catching them in the suture loop. In 1989 Connell19 proposed the use of an inci-
sion over and even above the zygomatic arch projection for the beginning of the
SMAS elevation. I realized, as he certainly had, the potential of this modi cation.

The entire anterior face could be elevated with one broadly based, deeply supported, anterior
SMAS ap. Dissections accomplished by blunt thumb-pushing over the malar em-
inence—a bit higher but similar to the direction proposed by Skoog—disclosed
that in the perioral region the skin is very rmly attached to the perioral muscles
of expression. Both the free muscles and the free ends of the xed muscles20 con-
tribute signi cantly to expression and concentrate at the modiolus labii.
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Note the perioral and mimetic muscles of expression. Elevation of this entire block
of perioral tissues, without undermining the attachments of the muscles of expres-
sion from the overlying skin, was incorporated into the technique. A peninsula of
skin was preserved over these muscles.
The markings show the peninsula of skin not to be undermined; this protects ne
expression secondary to the attachments of the perioral muscles to the overlying
skin. An exception to this rule of noninvasion of the peninsular area is the release
of the skin over the attachments of the depressor anguli oris muscle to the skin, as
demonstrated in the following images.21
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The Stille scissors elevate the skin
over the depressor anguli oris muscle
and lower portions of the depressor
labii inferioris muscle.
The skin is elevated over the lower
part of the chin.
Sub SMAS area
Subcutaneous area
The need for a strong and supportive SMAS ap forced surgeons to fashion thin and
delicate midface skin aps similar to the ones abandoned in the mid-1970s. Great delicacy
and gentleness are essential to the modern two-layered SMAS and skin face lifts.
Again, the use of scissors that are neither blunt nor sharp14 is essential for the devel-
opment of nearly perfect aps. There is no doubt that this technique is signi cantly less
forgiving than the Skoog-type techniques.
Because the effects of smoking on face-lift aps are so serious, they merit special
mention.22 Nicotine, a powerful vasoconstrictive alkaloid, has been implicated in
ap necrosis.23-25 I did not question the effect of nicotine on aps until some years
ago when I asked a smoker—who had a awless postoperative recuperation from
a face lift—if it had been dif cult for him to stop smoking.“Not at all, I chewed
Note the extent of the undermining
over the chin.

Nicorette gum the whole time!” was his answer. This statement prompted my re-
view of the issue, and after examining the published data,26 I became convinced that
the major culprit in ap necrosis is carboxyhemoglobin (COHb).22 The oxygen-
carrying capacity of hemoglobin may be diminished between 6% and 20% in a
smoker. This represents the amount of hemoglobin tied to carbon monoxide.
This COHb molecule is very stable and has a long half-life. Aside from this fact,
there are other toxic effects of COHb, such as the poisoning of cytochromes in
respiratory enzymes and platelets.22 Nicotine is a short-acting sympathomimetic
drug, and a signi cant number of vessels in a face-lift ap undergo sympathetic
denervation.27-30 Therefore, since I made this observation, we prescribe Nicorette
for all prospective face-lift patients who smoke, but we forbid smoking. Postoper-
ative oxygen inhalation therapy for the rst night is helpful.22-26 The high concen-
tration of oxygen molecules dislodges the remaining carbon monoxide molecules
from the hemoglobin. Since we began the practice of this therapy, postoperative
vascular impairment of the ap has for practical purposes diminished appreciably.31
THE ROLE OF THE SMAS
IN FACIAL REJUVENATION SURGERY
The SMAS is a fascinating structure that lends itself to high art, depending on the
surgeon’s interest in expressing this potential.The SMAS affects all areas of facial re-
juvenation:midface, mouth, malar eminence, neck, labiomandibular fold, and eyes.
The SMAS affects the nasolabial fold positively.When the SMAS ap is advanced,
the nasolabial fold changes signi cantly in direction and attens out. Direct inter-
ference with the underlying muscles of the nasolabial fold32,33 by dividing them
from the overlying crease through a 3 mm facial incision34 improves its appearance
signi cantly, and results are lasting.
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This patient is seen preoperatively and 11⁄2 years after a face lift,neck lift,forehead lift,
lower blepharoplasties, and division of extensions of muscles to the nasolabial fold.

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Bosse,35 in his keen observations, demonstrated that the SMAS in the midface of
primates is still a muscle. In essence, the platysma continues as a muscle over the en-
tire parotid to form a solid sheet with the occipitofrontalis muscle:“This anatom-
ical fact can be observed when a monkey grins by the formation of skin folds that
extend from his mouth to his ears.”35
In the malar region the dissection does not have to extend further into the levator
labii superioris muscle. Any traction on these muscles elevates the lip and exposes
the canine teeth, causing a snarl (left). The elevation of the zygomaticus major mus-
cle, possible with the SMAS technique, creates a pleasing result (right).
OUR PREFERRED ANESTHESIA
Since my arrival at the California Paci c Medical Center in San Francisco in 1973,
our anesthesiologists have used a technique known as “closed-system” anesthesia.36
The advantages of this method as opposed to the use of vaporizers are quite impres-
sive. Because the great majority of plastic surgery procedures are now performed in
private facilities and accredited of ces, use of this clean, inexpensive, and precise ap-
proach is worth noting.
“Closed-circuit” anesthesia was introduced in the 1920s when cyclopropane be-
came available. The gas was extremely expensive (and explosive), and efforts were
made to use it sparingly;therefore, as with ether, it was used in a closed system. Ni-
trous oxide, narcotics, curare, and oxygen became available in the 1940s;they were
Observe that the SMAS dissection be-
comes super cial to the zygomaticus
major muscle. The green circle repre-
sents the area of the retaining ligament
that must be divided.

inexpensive and therefore easy to use in multiliter ows.The risk of explosion was
removed and, unfortunately, the technique of closed-circuit anesthesia was forgot-
ten.Therefore an entire generation of anesthesiologists has never experienced this
superior technique.
Harry J. Lowe, MD,37 a chemist as well as an anesthesiologist, took it upon himself
in the 1970s to resurrect the closed system.The anesthesiologists at our center were
greatly influenced by this remarkable gentleman, and since that time they have been
using the closed system for the following reasons:
Oxygen consumption is continuously monitored, allowing rapid detection of
malignant hyperthermia. Cardiac output, which is directly related to oxygen
consumption, is known.
Anesthetic consumption becomes quantitative, because it is injected directly
into the system. Disconnections are immediately evident.
Pregnant operating room personnel (such as physicians, nurses, and physician
assistants) are not exposed to any anesthetic gases. (We have worn monitors
for several months, and absolutely no gases have been detected.)
Use of only halocarbon (iso urane) and oxygen allows maximum transport
of oxygen to tissues, which is calculated to be equivalent to an additional
400 ml of blood.
There is immediate and precise control of the depth of anesthesia, blood pres-
sure, and recovery time.
The closed system is invaluable in rhinoplasty; systolic pressures can be
dropped to 80 mm Hg, allowing essentially a dry eld, without any untoward
effects on the patient.
Closed-system anesthesia was taught at the University of Chicago, City of Hope
(Los Angeles), Massachusetts General Hospital, and the University of Alabama, but
not widely throughout the country. The basic concepts are simple and can be
learned by any anesthesiologist.This method affords several advantages in terms of
safety, cost, and legal issues.
CURRENT TECHNIQUE
In the past, on occasion I mused that current technique could not get any better,
only to be proved wrong in my assumption. At the beginning of this millennium,
I again tried to initiate improvements. My goals were to obtain results equivalent to
the two- ap midface approach while reducing the risk to the blood supply inher-
ent in the two- ap (SMAS and skin) approach.38,39
Some surgeons had not fully adopted the extended two- ap technique, with two
vectors in the nal midface redraping.The results were good and natural, and I de-
cided to explore their approach. Results again were good, but in my opinion the
two- ap technique offered longer-lasting outcomes and better perioral rejuvena-
tion. I wondered whether a third technique—one that used elements of both of the
previously mentioned approaches—would produce safety (a thick ap) with long-
lasting, excellent results.
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Beginning in 2003, I started to use the following approach to rejuvenation. First, I
establish and mark on the skin the position of the zygomaticus major muscle and
the position of the roof of the suctorial fat pad.
Second, I establish the most effective position for the suspension on the SMAS and
also mark it on the skin. I observed that left and right “ideal” points of SMAS sus-
pensions can vary from side to side in the same patient.
If this advice is ignored, the technique will not work properly. The
green triangle (above photo) indicates the point that the surgeon judges
to be best for elevation of the SMAS.This anatomic location is always
just behind the posterior edge of the zygomaticus major and is usually
a few millimeters below the zygomatic arch. If this cardinal rule is not
followed, the skin will redrape with dif culty and the result will be
compromised. (Higher anchoring triangles will necessitate the eleva-
tion of the temporal hair ap at the subcutaneous level to place the
SMAS ap under it; not ideal anchoring.)
Third, I delineate the degree of subcutaneous and sub-SMAS undermining. The
dissection of the thin skin ap must extend to that ideal SMAS ap suspension
area, but not beyond. Anterior to this key elevation point (green triangle) (frequently
The facial skin drawing shows the roof
of Bichat’s fat pocket (red circle) and the
suture (purple) to the SMAS over the zy-
gomatic arch.Note that the orientation is
almost vertical.This is the rst elevation
of the SMAS.
The anteriormost green triangle is the
second area of the SMAS to be elevated
(note the vertical vector), and the poste-
rior red triangle is the third area to be el-
evated.

just posterior to the insertion of the zygomaticus major), all the forward dissection
is below the SMAS.
The dissection of the subcutaneous ap is now limited to the following:
The key suspension in the malar region.
Over the platysma, including the release of the submental and depressor of
the lip ligaments.
The sub-SMAS incision starts at the junction of the posterior and middle
portion at the lower edge (not above) the zygomatic arch. It descends parallel
to the preauricular incision to the angle of the mandible. It descends in front
of the sternocleidomastoideus for another inch. If division of the platysma (at
the cricoid level) is indicated to reduce bands, now is the ideal time to do it.
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The dissection of the sub-SMAS begins with a No. 10 Personna Plus blade, fol-
lowed by a change to the new Stille-Ristow14 curved scissors. An important techni-
cal aspect of these scissors is that the end tips are neither sharp nor blunt. If the
points are too sharp, the proper plane can be easily lost. If the points are too blunt,
in scarred faces the effort to advance the dissection is too dif cult, and the surgeon’s
trapezium/scaphoid joint eventually pays the price.The extent of the sub-SMAS dis-
section advances overthe lateral aspects of the orbicularis occuli, overand anterior to
the zygomaticus muscle, releases the zygomatic and masseteric ligaments, and ends
with full view of Bichat’s fat pocket. A suspension suture (3-0 Nylon) from the spe-
cialized and strong SMAS over Bichat’s fat pocket to the SMAS over the zygomatic
arch adds to the rejuvenation.The elevation can be up to 3 cm and the attachment
is to the cut edge of the SMAS at the level of the zygomatic arch.The vector is aes-
thetically pleasing but has a signi cant vertical component. Before securing the su-
ture, one should observe the best result and then tie the knot. In fact, experience
shows that the SMAS only drapes easily in one direction; that is the correct vector.
The second SMAS suspension, with a vertical vector, is now tied to the SMAS
above the zygomatic arch. Two additional elevation sutures are placed; the last one
has a superoposterior vector and attaches to the supraauricular SMAS.The overall
effects on the face are beautiful: the corners of the mouth are raised, jowls atten
out, and malar fat pads again cover the lateral orbital region. The lower eyelids,
which appeared short or loose preoperatively, now have extra tissue or at least a
normal appearance.
Whenever possible, a SMAS sling is af xed to the occipital region9 as well. Sculp-
ting by removing excess fat that overlies the platysma follows.

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SYNERGY BETWEEN THE PLATYSMA
AND THE SMAS
Bilateral elevation of the SMAS aps has a profound effect on the contour of the
neck. Before I had the technical know-how to make full use of the SMAS poten-
tial, I performed plication of the platysmal bands in the neck fairly often. The ap-
proximation was performed to two different distances: to the thyroid or to the
cricoid cartilage. The outcome was quite good, and excellent jaw-neckline angles
were obtained.
Observe the good jaw-neck angle obtained by midline approximation of the
platysma, but also the subtle restriction of the midface elevation.
If you plicate the midline platysmal edges before elevating and secur-
ing the SMAS, the upward displacement of the SMAS aps is severely
restricted with results that are detrimental to the midface elevation.
THE NECK
In recent years I came to the realization that the neck is more complex than gen-
erally recognized.The sequence of events with my surgical approach is as follows:
I delineate the submental incision at 2.5 cm, which is approximately 1 cm behind
the submental crease. The degree of subcutaneous undermining varies by patient,
but it normally extends to the level of either the thyroid cartilage or cricoid carti-
lage.The attachments to the depressors of the lip and the submental ligament to the
skin are released next.The fat overlying the platysma is now removed. A vertical in-
cision opens the platysma between the symphysis of the mentum and the thyroid
cartilage. Excess fat, if present, and very rarely some digastric muscle, if indicated, are

removed.The platysma between the symphysis of the mentum and the thyroid car-
tilage is now resutured edge to edge. When performed as described above, the sub-
mental platysma will not restrict the midface SMAS in its upward movement. It will,
however, accentuate the jaw-neck angle, which is a positive and desirable result.
How the SMAS is redraped has a profound effect on the face. Removing excess SMAS
from the preauricular area will significantly thin a round face. It is the upward
movement of the SMAS that is responsible for returning midface structures to their
youthful position.
Finally, a word about skin closure.With the technique described earlier, little or no
variation is possible in the skin closure of the midface;all was decided at the deeper
levels. In the retroauricular/occipital areas, variations of the vector are possible.
However, a vector of 90 degrees between the neck and redraping of the skin gives
the best results.40
In the temporal area, if the supraauricular incision extends backward over the ear
(a common approach I have now abandoned (see the gure on p. 228 in favor of
an “at-the-hairline” temporal incision), it will be technically impossible to drape the
midface correctly. A gap of tissue will result, and to close it, an inef cient vector of
pull will be created. The technique I describe brings so much excess skin to the
temporal region that only an at-the-hairline incision will preserve a natural hairline.
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An intraoperative image depicting the signi cant skin advancement of a typical pri-
mary face and neck lift dictating the necessity of “at the hairline” suture techniques.
More complex approaches to reconstruct the hairline have been described,40 but to
achieve the best results, a wide variation of incisional directions is not advised.

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THOUGHTS ON REOPERATION
The earlier a surgeon grasps the issues pertinent to facial rejuvenation, the more sat-
isfying his or her professional life will be. Among these issues are preservation of the
normal hairline, mastery of ap tension (a principal component of our specialty),
and concealment of incisions.
Surgeons who early in their careers comprehend these essential elements can often
anticipate reoperating on their own satis ed patients. Repeating a well-conceived
procedure that was performed years earlier is easy. Beginning 1 or 2 mm behind the
original scars will eliminate them, and the subtle shift in the hairline downward
will again place incisions and the hairlines precisely at their ideal positions.
However, we are also faced with far more dif cult problems. Some of the more
frequently occurring problems include elevation of the temporal hairline, blunting
of the tragus with forward displacement, earlobes that are pulled forward and down-
ward, retroauricular scars that have migrated to the occipital region, displacement
of glabrous neck skin in the occipital region into areas normally lled with hair, and
removal of soft, delicate hairs in the lower neck.41
ELEVATION OF THE TEMPORAL HAIRLINE
During the years when a face lift almost always included a temporal lift, it became
imperative that a solution to the problem of hairline displacement be found. The
question was:If the scalp is cut posteriorly (temporal incision), inferiorly (to return
it to the front of the upper part of the ear), anteriorly, and from underneath (dur-
ing elevation), could the hair follicles survive? Their only blood supply would be
from the stump of the temporal artery by the retrograde ux (see Chapter 12), and
the superior base should support adequate venous return as well.40 In essence, the
super cial temporal artery is divided just above the ear. The ux in the stump re-
verses and supplies the temporal ap. The ap is elevated in a subgaleal plane and
subsequently lowered in front of the upper aspect of the ear.

R ATIONALE BEHIND THE TECHNIQUE
Numerous anatomic dissections of the temporal region were reviewed.The super-
cial temporal artery is posterior to the branches of the seventh cranial nerve (see
the Terzis dissection in Chapter 12), which makes it possible to leave the temporal
artery stump within the ap as well as preserve the branches of the seventh cranial
nerve to the forehead.
After the temporal ap is elevated, the trajectory of the temporal artery is identi-
ed in the ap either by palpation or direct visualization. A needle is passed just an-
terior to the artery (leaving the seventh cranial nerve branches anterior to the fu-
ture ap). The galea is divided from the needle to the incision just above the ear.
This is a ap with a broad superoanterior base and, lined by the galea, supports the
viability of the hair follicles.This composite ap of skin, a layer of subcutaneous hair
follicle, and galea is suf ciently healthy to be positioned lower, thus correctly cre-
ating a new temporal hairline.
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Note the position of the super cial temporal artery and the frontal branch of the
facial nerve showing the incision of the galea between these structures. By nature
I am averse to risk, but these aps do survive along with their hair.

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The sequence of lowering a temporal hairline is shown.
Where the patency of the super cial temporal artery below the temporal hair can-
not be ascertained, this maneuver theoretically is riskier. Although not completely
clear to me, the body creates new vessels and enlarges existing ones making this
possible (tube flaps come to mind as an example of this neovascularization).27
Where the temporal hair has been lost, the only option is hair transplants;note the
excellent result in the hands of competent surgeons with this expertise.

Results of hair transplants to the temporal region.
BLUNTING OF THE TRAGUS
Here the strategy requires suf cient mobilization of the midface so that enough
skin can be redraped over the tragus.
The cartilage itself should be cut free from its base to allow it to fold posteriorly,
again partially covering the ear canal. A transcutaneous suture is used from the skin
of the concha through the posterior skin of the tragus, encompassing the tragus, ex-
iting again, and then tying it over the concha.This ensures healing of the tragus in
the correct position.The suture is removed in 5 to 7 days.The pretragal concavity
is created by placing a thin, long-term, biodegradable suture 1 cm anterior to the
tragal crest.This suture also de ects tension on the tragal cartilage.
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FORWARD-DISPLACED AND LONG EARLOBES
Earlobes that are displaced forward or are too long are caused by a failure to mas-
ter tension and result from too much traction; therefore the repair involves reduc-
tion or elimination of tension on the earlobe. The aps of the midface and neck
must be mobilized to rectify this problem.The earlobe is set back by 15 degrees and
secured deeply with a long-term biodegradable suture (encompassing the earlobe,
occipital fascia, and deep dermis). Frequently the length of the earlobe must be
trimmed to obtain a natural contour.
R ETROAURICULAR SCAR MIGRATING
TO THE O CCIPITAL R EGION
Again, tension is the original culprit. Mobilization of neck skin is essential for suc-
cess.The skin is anchored to the retroauricular groove with long-term biodegrad-
able sutures to promote sustained support during the rst weeks of healing.
DISPLACEMENT OF GLABROUS NECK SKIN IN THE OCCIPITAL
R EGION INTO AREAS NORMALLY FILLED W ITH HAIR
This displacement re ects an error in the original planning and, unfortunately, is
dif cult to correct. First, a high incision into the hair negates the proper vector to
correct the sagging neck. Second, the defect is visible with the hair worn up. Be-
cause even extensive mobilization of the scalp yields a minimal downward shift—
particularly in this area—complete improvement of this defect continues to be dif-
cult. Our limitations are very disappointing to patients who wish to wear their hair
up.The surgeon faces dif cult choices;if there is a signi cant amount of loose skin
on the neck, repeating this poor incision can be catastrophic in that the hair below
it will be lost. Abandoning the “high scar” and placing the scar properly will leave
the patient with two scars. Each patient is evaluated individually, and suggestions for
improvements are discussed.

ABSENCE OF THE SOFT, DELICATE HAIR LOW ON THE NECK
Incisions should completely avoid this area by going upward for 1.5 or 2 cm in
this region.These hairs are attractive and are included in a small ap designed in the
original drawing. At the end of the procedure, a recipient area is cut above, and
the ap with these soft hairs is tted into the scalp.34,40 If the original incision has
ablated these hairs, there is no possible solution. Skillfully applied tattoos or individ-
ual microtransplants of hair may offer some camou age.
Because of the long-term effects of a poor outcome, correct planning in the initial
stages is essential. All problems appear to be linked to mistakes in planning the ini-
tial procedure.With skilled implementation of the proper strategies for face lifts, dif-
cult reoperative problems can be avoided. Unfortunately, these strategies have not
yet been universally adopted.
PROGRESS IN FACE-LIFT TECHNIQUES
EXAMPLES OF DIFFERENT FACE-LIFT TECHNIQUES
Single Midface Flap (Mid-1970s)
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Preoperative and postoperative views after Connell’s upper face thick aps (below
the SMAS), suspension of the anterior SMAS to the zygomatic arch SMAS, Peter-
son’s platysma redraping, and Millard’s submental lipectomy.

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Preoperative and 2-year postoperative views of a patient who underwent a face
lift, forehead lift, upper and lower blepharoplasties, and upper and lower autolo-
gous lip augmentation.
Two-Layer Flap and Two Distinct Flaps

Results of a face and neck lift, forehead lift, and upper and lower blepharoplasties
performed in 1992 in a 64-year-old woman. A distinct two- ap (SMAS and skin)
technique was used in this patient.
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Preoperative and postoperative views demonstrating the results that can be achieved
with the application of current face-lift concepts.

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The proper position of the secured upper SMAS ap before skin redraping.
Two distinct layers are seen in midface (SMAS and skin) face and neck lifts, upper
and lower blepharoplasties, forehead lift, and perioral dermabrasion.

Note the appearance of the temporal and preauricular (at the tragal crest) healing
24 days after surgery.
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The technique seen here was used in the early 1990s, with two distinct aps, SMAS
and skin, face and neck lifts, autologous tissue lip volume restoration, upper and
lower blepharoplasties, and forehead lift.

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TWO-LAYER DISSECTION CLOSED AS A SINGLE LAYER
The following ve patients demonstrate the current technique.
Postoperative views of this patient demonstrate the current technique (2005), which
included a face and neck lift, upper and lower blepharoplasties, and autologous tis-
sue lip volume restoration.

This patient is shown before and after undergoing face, neck, and forehead lifts,
lower lid blepharoplasties, and autologous lip volume resoration by the current
technique.
The current technique has produced good results.The greatest difference is in the
accurate understanding of the anatomy, which in this technique ultimately overlaps
the SMAS, creating a solid fascia-to-fascia healing.What role does artistry play? A
large one, I would venture to say. Studying the reason that certain faces are harmo-
nious and beautiful should be a constant endeavor of aesthetic surgeons. How can
we measure such an element? What about proposed technical innovations?
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This prematurely aged 45-year-old patient was treated by the current technique, in-
cluding face and neck lift, upper and lower blepharoplasties, forehead lift, and au-
tologous restoration of lip volume.
The natural results in this patient seen 6 months postoperatively are characteristic
of the current technique.

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The bene ts of the current technique are also evident in this patient, who had a
face and neck lift, upper and lower lid blepharoplasties, and autologous tissue lip
volume restoration.
There have been many new techniques with no measurable positive, lasting results.
And the role of technologically advanced instruments? To a degree, advances such
as capnography and oximetry have provided greater security, which allows us to
accept a hopeful older patient and offer her a secure surgical journey. Note the re-
sults of a modern face lift in this 85-year-old patient.

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CONCLUSION
To return to the questions at the beginning of this chapter, has progress in face lifts
been real? If we look at the results of the last 40 years, it is not easy to answer. If we
measure progress in face lifts by control of re nements in the surgical outcome,
then progress has been real (preservation of hairlines, better surgical outcomes of
necks, understanding the role of SMAS as fundamental to natural results, and so
on). No longer will well-trained young surgeons be defeated by a round face, as was
common in the 1960s. The techniques, thoughts, and advice of many illustrious
surgeons are now recorded for us to consider. Excellent surgical technique cannot
be inherited. Each of us has to learn it by constantly thinking about the issues. A
few distinguished surgeons made signi cant contributions in the past, and I sin-
cerely believe the impact of their concepts will continue to be felt. According to
Will and Ariel Durant,“History is, above all else, the creation and recording of that
heritage;progress is its increasing abundance, preservation, transmissions, and use.”2
In face lifts this concept appears valid. Individual progress also depends on the sur-
geon’s ability to take advantage of innovations but to quickly recognize the false path-
ways. In this regard, we should be cautious, realizing that in several periods of our
civilization, and in aesthetic surgery as well, progress has been adverse; in other
words, knowledge has been lost. Familiarization with the concepts devised by vi-
sionary surgeons will help future generations maintain and improve the excellence
of current results.
In retrospect, we have known what is beautiful for 2000 years of Western culture.
Fibonacci’s lines of the eyelids, the soft malar prominence of Phidias’s sculptures, and
the serenity and corner lip elevations of Leonardo da Vinci’s Mona Lisa are exam-
ples known to all. We have also known the de ciencies of face lifts: shifts in hair-
lines, the at midface that can result from unilayer techniques, displaced earlobes,
and tragal blunting. Understanding the anatomy of aging42,43 and how to technically
reverse it brings us ever closer to our ambitions in facial rejuvenation. Aesthetic
vision, knowledge of anatomy, and technical skills have been instrumental in arriv-
ing at our current level of achievement.
References—With Key Annotated References
1. Durant W, Durant A. The Story of Civilization. New York: Simon & Schuster, 1935 through
1967.
2. Durant W, Durant A.The Lessons of History. New York: Simon & Schuster, 1968.
3. Gillies H, Millard DR.The Principles and Art of Plastic Surgery, vol 2. Boston: Little Brown,
1957, pp 396-397.
4. Rees TD,Wood-Smith D. Cosmetic Facial Surgery. Philadelphia:WB Saunders, 1973, p 162.
5. Zalman A, Sutherland AE,Weiner A. Stay Slim for Good. New York:Walker & Johnson, 1976.
6. Leonard G. Mastery. New York: Penguin Books, 1992, p 14.

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Milestones in the Evolution of Face-Lift Techniques
7. Millard DR Jr, Garst WP, Beck RL, et al. Submental and submandibular lipectomy in conjunc-
tion with a face lift, in the male or female. Plast Reconstr Surg 49:385-391, 1972.
Submental lipectomy through a small, transverse incision, in continuity with submandibular through
a male or female lift incision, achieves excellent neck contour with hidden scars.
8. Friedland J. Personal communication re:R. Peterson’s technique on lateral platysma, May 1975.
9. Randall P, Skiles MS. The “SMAS sling”: An additional xation in facelift surgery. Ann Plast
Surg 12:5-9, 1984.
10. Skoog T. Plastic Surgery. Stockholm: Almqvist & Wiksell, 1974.
11. Mitz V, Peyronie M. The super cial musculo-aponeurotic system (SMAS) in the parotid and
cheek area. Plast Reconstr Surg 58:80-88, 1976.
The authors studied anatomic dissections, radiographs, and histologic sections of the super cial mus-
culoaponeurotic system (SMAS) in the parotid and cheek areas.They found that the SMAS may be
helpful in corrective surgery for facial palsy and during face-lift operations if a retrofascial approach is
used. Although this procedure is safe in the parotid area, the surgical cleavage points are very appar-
ent anterior to the gland, and with good technique, there should be no injuries to the nerves.
12. Connell B. Rhytidectomy with special emphasis on lower face and neck. American Society of
Aesthetic Plastic Surgeons Teaching Course, Los Angeles, March 1977.
13. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidec-
tomy. Plast Reconstr Surg 66:675-679, 1980.
14. Stille-Ristow Facelift Scissors. Article No. 101-8454-1.
For 20 years, Oscar Ortiz, a naval weapons machinist, has modi ed scissors for me to my speci ca-
tions.The tips should be neither blunt nor sharp, but somewhere in between (see this chapter’s text for
the reasons).The president of Stille Instruments (Solna, Sweden) visited me and asked whether I had
some ideas for his company. I decided to share my concept for the scissors. I gave him one of mine (I
had six pairs). He produced a prototype that I put through extensive testing (using the scissors in pro-
cedures on more than 100 faces). I found that Prototype 1 was superb. Stille produced Prototype 2,
and after testing it, I felt that Prototype 1 was superior. I recommended that one, and they decided to
produce a model based on Prototype 1 for their line.The production of such an item is immensely com-
plex. Numbers have to be assigned, quality control exercised, and so forth. It takes a long time before
it reaches the market.This chapter is the rst report on these scissors.The Stille-Ristow scissors will
be available by the time this book’s is published, bringing another excellent device to the world of plas-
tic surgery.
15. Ristow B. Facial rejuvenation. Presented at the Annual Meeting of the Southeastern Society of
Plastic Surgery, Boca Raton, June 1986.
16. Ristow B. Midface rejuvenation. Presented at the Annual Meeting of the American Society of
Plastic and Reconstructive Surgeons, Atlanta, Nov 1987.
17. Ristow B.The suspension of the anterior SMAS to the zygomatic arch [ lm]. Presented at the
Annual Meeting of the American Society of Plastic and Reconstructive Surgeons, Atlanta,
Nov 1987.
18. Peterson RE, Johnson DL.Facile identi cation of facial nerve branches. Clin Plast Surg 14:775-
778, 1987.
19. Connell BE. Personal communication, Jan 1989.
20. Bosse JP.The anatomy of the SMAS. Presented at the Annual Meeting of the Canadian Soci-
ety of Aesthetic Plastic Surgery, Quebec, Sept 1990.
21. Pontes R. Witch’s chin correction [ lm]. Presented at the Annual Meeting of the American
Society of Plastic and Reconstructive Surgeons, Atlanta, Nov 1987.
22. Goodman LS, Gilman A. The Pharmacological Basis of Therapeutics. New York: Macmillan,
1990.
23. Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin- ap survival in the
face lift patient. Plast Reconstr Surg 73:911-915, 1984.
24. Lawrence WT, Murphy RC, Robson MC, et al.The detrimental effect of cigarette smoking on
ap survival: An experimental study in the rat. Br J Plast Surg 37:216-219, 1984.

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R EOPERATIVE SURGERY OF THE HEAD AND NECK
25. Riefkohl R,Wolfe J,Cox E, et al. Association between cutaneous occlusive vascular disease, skin
slough after rhytidectomy, and cigarette smoking. Presented at the Annual Meeting of the
American Society of Aesthetic Plastic Surgery, Boston, April 1985.
26. Rudolph R. Problems in Aesthetic Surgery:Biological Causes and Clinical Solutions. St Louis:
Mosby, 1986, pp 76-82.
27. Hynes W.The blood vessels in skin tubes and aps. Br J Plast Surg 3:165, 1950.
28. Jurell G, Norberg K, Palmer B. Surgical denervation of the cutaneous blood vessels. Acta Phys-
iol Scand 74:511-512, 1968.
29. Norberg KA, Palmer B. Effects of noradrenaline and felypressin on cutaneous local blood ow
after sympathetic denervation. A study on rats. Scand J Plast Reconstr Surg 6:106-109, 1972.
30. Palmer B. Sympathetic denervation and reinnervation of cutaneous blood vessels following
surgery. An experimental study on rats by means of a histochemical fluorescence method.
Scand J Plast Reconstr Surg 4:93-99, 1970.
31. Ristow B. Midface rejuvenation. Presented at the Symposium on Surgery of the Aging Face.
Plastic Surgery Education Foundation, Laguna Nigel, CA, Jan 1993.
32. Barton E. The SMAS anatomy. Presented at the Symposium on Surgery of the Aging Face.
Plastic Surgery Education Foundation, Laguna Nigel, CA, Jan 1993.
33. Pessa JE.The anatomy of the labiomandibular fold: A gross and histological study in fresh ca-
davers. Presented at the Annual Meeting of the American Society of Aesthetic Plastic Sur-
geons, Boston, April 1993.
34. Connell B. Personal communication, Santa Ana, CA, 1989.
35. Bosse JP. The anatomy of the SMAS. Presented at the Symposium on Surgery of the Aging
Face. Plastic Surgery Education Foundation. Laguna Nigel, CA, Jan 1993.
36. In collaboration with Laurens N. Garlington, MD, Chief Emeritus of the Department of Anes-
thesia, California Paci c Medical Center, San Francisco, CA.
37. Lowe HJ.The Quantitative Practice of Anesthesia:Use of Closed Circuit. Baltimore:Williams
& Wilkins, 1981.
38. Ristow B. Facelift subtleties and highlights.“Primary Face Lift” Panel. Presented at the Annual
Meeting of the American Society for Aesthetic Plastic Surgery, Orlando, 2000.
39. Ristow B. About Face Symposium. American Society of Plastic Surgeons, Plastic Surgery Ed-
ucational Foundation, American Society for Aesthetic Plastic Surgery, Aesthetic Surgery Ed-
ucational and Research Foundation, Colorado Springs, CO, 2003.
40. Ristow B. A personal technique for facial rejuvenation. Aesthetic Surg J July-August 20:325,
2000.
41. Peck GC, ed. Complications and Problems in Aesthetic Plastic Surgery. New York: Gower
Medical Publishing, 1992.
42. Hester TR, Codner MA, McCord C. Operative techniques in plastic and reconstructive sur-
gery. Mid Face Rejuv 5:167, 1998.
43. Ristow B. Aesthetic Plastic Surgery of the Upper Face. Surgery Technology International.
London: Century Press/ Grosvenor Press, 1991, pp 325, 327.

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Milestones in the Evolution of Face-Lift Techniques
1. The proper surgical elevation of the SMAS will:
a. Have no effect on the jaw-neck angle
b. Only slightly improve the nasolabial fold
c. Increase the possibility of surgical bleeding
d. None of the above
e. All of the above
2. Elevation of the SMAS will:
a. Recruit tissues under the lower eyelid
b. Elevate the corners of the lips
c. Have an effect on the modiolus
d. Accentuate the jaw-neck angle
e. All of the above
3. If a smoker is accepted for surgery, he or she will:
a. Have a safer result by the two-layer face lift
b. Have a safer result by Skoog’s technique
c. Be permitted to smoke only ve cigarettes a day
d. Be prohibited from chewing Nicorette gum
e. All of the above
4. Submental liposuction is best:
a. Because it leaves the normal anatomy of the platysma intact
b. Because one can gauge exactly how much fat to preserve
c. In young patients
d. A simple small drain will prevent most swelling
e. All of the above
5. For best results, unilayer face-lift techniques may:
a. Require internal suspension of the SMAS
b. Have a tendency to atten the midface
c. May be further enhanced by small SMAS grafts to the cheeks
d. All of the above
e. None of the above
6. In a primary face lift in a patient with suf cient hair:
a. It is best to place the incision high into the hair
b. A high (into the hair) incision is the best vector to correct a saggy neck
c. For the rst-time face lift, it is ne because the hair can always be lowered
later
d. One should follow the hairline and then move the incision upward cre-
ating a small ap
e. All of the above
R EVIEW QUESTIONS

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7. Division of the platysma is best done:
a. At the thyroid cartilage level to accentuate the contour
b. At the cricoid cartilage level
c. Never, because the platysma will roll up like a window shade
d. Never; bands quickly reappear
e. All of the above
8. Retroauricular (auricular groove) scars appear to migrate into neck skin. An ef-
fective prevention may be to:
a. Place the incision high behind the ear so when it migrates, it goes to the
groove
b. Create no tension and use catgut sutures
c. Close the incision with buried long-term biodegradable suture material
(such as Monocryl)
d. Leaves excess skin there to avoid tension
e. All of the above
9. Strong plication of the platysma in the midline of the neck is a good technique:
a. When only the neck is being operated on
b. When a complete SMAS elevation is planned
c. Should never be done
d. But rarely achieves anything signi cant
e. All of the above

257
Reoperative Rhytidectomy
James C. Grotting and James M. Stuzin
C ha pter 1 1
Reoperative Problems
Scars
Earlobe deformities
Hair pattern changes
Cervical obliquity
Fat irregularities and de ciencies
Platysmal banding
Descended facial or cervical fat
Misdirected rhytids
Skin laxity
Attenuation of deep layer support
How old would you be
if you didn’t know how old you were?
Satchel Paige

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With the ever-increasing popularity of aesthetic surgery, most plastic surgeons
encounter patients seeking facial rejuvenation who have already undergone a facial
procedure. In many ways, these patients come better prepared for the realities of
surgical intervention than those who have never experienced it. On the other hand,
reoperative patients present certain challenges that must be anticipated and planned
for to optimize outcomes, and that is the subject of the pages that follow. Further,
both primary and secondary rhytidectomy patients have early and late complica-
tions that must be dealt with, and these will be addressed as well.
Ours is a changing paradigm with regard to evaluation and possible treatment op-
tions for patients seeking additional rejuvenation. It is likely that patients who pre-
sent having had surgery in the remote past underwent standard variations on the
classic rhytidectomy. However, we are also seeing more patients who may have less
than desirable outcomes from the newer procedures, which include limited incision
lifts, endoscopic lifts, suture suspension lifts (“thread-lifts”), autologous fat injec-
tions, and implant surgery. Over time, we anticipate seeing these patients back who
had good improvement with less-invasive procedures, but who now desire more
de nitive correction.
“How long will my face lift last, Doctor?” Almost every patient undergoing facial
rejuvenation will ask this question. Of course, there is no one right answer, since so
many factors come into play, all of which can affect the longevity of a rhytidectomy.
Some patients want to do things at more frequent intervals to maintain a certain
look, whereas others may wish to have one procedure done in their entire life and
are satis ed with that.The point is that all patients understand that the results of a
face lift will not last forever and that they will continue to be affected by aging
and gravity.

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Anatomic Considerations
James M. Stuzin
The anatomic principle that allows a rhytidectomy to be performed safely is the fact
that facial soft tissue is architecturally arranged as a series of concentric layers.This
arrangement allows dissection within one anatomic plane to proceed completely
separate from the structures lying within another anatomic plane.The layers of the
face, from super cial to deep, are the skin;subcutaneous layer;super cial facial fas-
cia (super cial musculoaponeurotic system [SMAS]); mimetic muscles; deep facial
fascia (parotidomasseteric fascia);and the plane of facial nerve, parotid duct, buccal
fat pad, facial artery, and facial vein.
SKIN
The outermost layer of the face is the skin.The aging of facial skin is in uenced by
actinic damage as well as intrinsic genetic factors. Because the skin envelope has
been tightened in the primary face-lift procedure, little skin is removed in second-
ary rhytidectomy. Skin envelope tightening is not as important a factor in improv-
ing the facial contour in the secondary procedure. Similarly, patients with facial
rhytids in whom the cervicofacial aps were rotated in a cephalad direction during
the primary procedure are at greater risk for having an abnormal postoperative ap-
pearance if the cervicofacial ap is again redraped in a cephalad direction. Before
the secondary procedure is performed, these factors must be carefully evaluated to
determine the best direction to redrape the facial skin.
SMAS
Parotidomasseteric fascia
Mimetic muscle (platysma)
Subcutaneous layer
Skin
Mimetic muscle
SMAS
Subcutaneous layer
Parotidomasseteric fascia
Buccal fat pad
Plane of facial nerve

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This patient, who was operated on by another surgeon, was dissatis ed with the un-
natural facial appearance and the distorted temporal hairline.
Because the facial skin has been previously delayed following the pri-
mary procedure, the vascular supply to cervicofacial skin is usually
healthy at the time of secondary rhytidectomy.
For this reason, the risk of skin slough or hypertrophic scarring associated with
wide undermining of facial skin secondarily was minimal.This factor is especially
relevant when dealing with a patient with a history of cigarette smoking.
SUBCUTANEOUS LAYER
Directly deep to the skin lies a variable amount of subcutaneous fat.This fat sits di-
rectly above the SMAS and is the anatomic plane of dissection we use in face-lift
procedures.The thickness of this layer varies from patient to patient. Most patients
undergoing reoperative rhytidectomy have a thinner layer of subcutaneous fat com-
pared with primary rhytidectomy patients, because a variable amount of fat is lost
through the trauma of the original procedure. This problem is compounded in a
thin patient undergoing secondary rhytidectomy, and it is sometimes dif cult to
precisely undermine within the scant subcutaneous layer. This clinical situation
presents the possible hazard of the dissection being carried inadvertently deep in a
sub-SMAS plane; great care is required during dissection. Similarly, it is not un-
common to encounter a fair amount of cicatrix in the subcutaneous layer during
undermining;dissection through this brous tissue should be performed cautiously
to ensure that the proper level of undermining is maintained.

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SUPERFICIAL FACIAL FASCIA (SMAS)
The super cial musculoaponeurotic system represents a discrete fascial layer that
separates the overlying subcutaneous fat from the underlying parotidomasseteric
fascia and facial nerve branches. When rhytidectomy is being performed, identi -
cation of the SMAS is of paramount importance. As long as the integrity of this
layer is maintained, facial nerve injury will not result from the dissection.
The SMAS represents an extension of the super cial cervical fascia cephalad into
the face.1 This super cial fascia forms a continuous sheath throughout the face and
neck, extending into the temporal region, forehead, scalp, malar regions, nose, and
upper lip.2 The thickness of the SMAS varies greatly from patient to patient, as
well as from one region of the face to another.The super cial facial fascia is thick
overlying the parotid gland; it is this anatomic component that many physicians
clinically refer to as the SMAS. Superiorly cephalad to the zygomatic arch, this fas-
cial layer is referred to as the temporoparietal fascia (within the temporal region)
and galea (within the scalp), both of which are of substantial thickness.
As the SMAS is traced medially into the cheek over the masseter muscle and the
buccal fat pad, this layer tends to become thinner and less distinct.3 Within the
malar region, the SMAS is quite thin, essentially comprising the epimysium of the
elevators of the upper lip.
Much of the contouring obtained in secondary rhytidectomy involves
tightening of the super cial facial fascia, or SMAS, which commonly
is lax compared with the tight skin envelope in this type of patient.
The SMAS layer in the secondary rhytidectomy patient is thinner than that pres-
ent in the primary surgical patient; most likely this change results from the loss of
subcutaneous fat overlying the SMAS following the original procedure. Some pa-
tients will have undergone a SMAS elevation during the primary procedure, which
can distort the landmarks during sub-SMAS dissection. Nonetheless, with careful
attention to detail during dissection, most secondary rhytidectomy patients will
bene t from a formal undermining and tightening of the SMAS layer during the
reoperative procedure.

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MIMETIC MUSCULATURE
Deep to the SMAS and intimately associated with it are the mimetic muscles, or
muscles of facial expression. Rather than all being situated within the same layer
within the facial soft tissue architecture, these muscles are arranged in four anatomic
layers that overlap one another.4 The mimetic muscles that might be encountered
during rhytidectomy—platysma, orbicularis oculi, zygomaticus major, and zygo-
maticus minor—are super cially situated in relation to the plane of the facial nerve
and thus receive their innervation along their deep surfaces. In contrast, the bucci-
nator, mentalis, and levator anguli oris muscles, which are the most deeply situated
mimetic muscles within the facial soft tissue architecture, lie posterior to the plane
of the facial nerve and therefore are innervated along their super cial surfaces.The
surgical signi cance of this anatomic relationship is that when SMAS elevation is
being performed, as long as the dissection is carried along the super cial surface of
the facial muscles, injury to muscular innervation cannot occur. For example, ele-
vation of the SMAS within the malar region will expose bers of the underlying
zygomaticus major and zygomaticus minor muscles, but their innervation will not
be injured as long as the integrity of these muscles is not violated.
Facial nerve branches
Nasalis muscle
Masseter muscle
Occipitofrontalis muscle
Orbicularis oculi muscle
Zygomaticus minor muscle
Risorius muscle
Levator labii superioris muscle
Orbicularis oris muscle
Temporalis muscle
Buccinator muscle
Platysma muscle
Sternocleidomastoid muscle
Galea aponeurotica
Platysma muscle
Zygomaticus major muscle
Levator anguli oris muscle
Depressor anguli oris muscle
Depressor labii inferioris muscle
Mentalis muscle

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Reoperative Rhytidectomy
DEEP FACIAL FASCIA (PAROTIDOMASSETERIC FASCIA)
Because the face and neck are contiguous, it makes sense that the fasciae of the
neck continue cephalad into the face. Just as the SMAS represents a continuation
of the super cial cervical fascia into the face, the corresponding deeper layer of
cervical fascia (super cial layer of the deep cervical fascia) continues into the face.
This layer has been termed the parotidomasseteric fascia.
The relevance of this fascia to facial anatomy is infrequently discussed,
but it is extremely important: within the cheek, the facial nerve
branches and the parotid duct always lie deep to the parotidomasse-
teric fascia.5,6
This cadaver dissection (left) following SMAS-platysma elevation within the cheek
has exposed the underlying parotid gland, the anterior border of the parotid gland
(marked in ink), and the parotidomasseteric fascia (held in forceps).The facial nerve
branches within the cheek are always deep to the parotidomasseteric fascia. The
cadaver dissection (right) following elevation of the parotidomasseteric fascia has
exposed the underlying masseter muscle and the marginal mandibular nerve as it
crosses the facial artery and vein.
Within the neck, the super cial layer of the deep cervical fascia is found along the
super cial surface of the strap muscles. Superior to the hyoid bone, this fascial layer
overlies the mylohyoid and can be traced superiorly over the mandibular body.7

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This deep fascia extends into the face and overlies the parotid gland, at this point
becoming the parotid capsule or investing parotid fascia. More anteriorly, the deep fa-
cial fascia overlies the masseter muscle and is called the masseteric fascia. Medial to the
masseter muscle, the deep facial fascia lines the super cial surface of the buccal fat
pad and parotid duct.This fascia extends into the malar region, lying deep to the el-
evators of the upper lip. An extension of deep facial fascia superior to the zygomatic
arch, within the temporal region, has been called the deep temporal fascia.
FACIAL NERVE
Facial nerve injury is the most feared complication in rhytidectomy.When the sur-
geon fully understands the facial anatomy and performs careful anatomic dissection,
the chances of facial nerve injury are greatly lessened.
The facial nerve is encompassed by the parotid gland in the lateral aspect of the
face. Medially it emerges from the parotid gland and traverses the super cial surface
of the masseter muscle immediately deep to the parotidomasseteric fascia. Medial
to the masseter muscle, the facial nerve overlies the buccal fat pad. The buccal fat
pad, parotid duct, facial artery and vein, and facial nerve lie within the same
anatomic plane within the cheek. As the facial nerve courses peripherally, it sends
branches to the overlying mimetic muscles.
Buccal fat pad
Zygomatic ligaments
Masseteric cutaneous
ligaments
Skin
Parotid cutaneous
ligaments
Parotid gland
Parotidomasseteric
fascia
Deep temporal fascia
Parotid duct
Platysma invested by
superficial facial fascia (SMAS)
Superficial temporal artery (divided)
Frontal branch of facial nerve (divided)
Superficial temporal
artery (divided)
Temporoparietal fascia
Frontal branch of
facial nerve (divided)
Facial artery

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Reoperative Rhytidectomy
The frontal branch of the facial nerve is an anomaly. Unlike other
nerve branches that lie deep to the deep facial fascia, once the frontal
branch crosses the zygomatic arch, it traverses the temporal region
along the undersurface of the temporoparietal fascia, invested in sub-
SMAS fat, and then peripherally penetrates this layer to innervate the
occipitofrontalis muscle along its deep surface.
In this illustration, a cross section of the temporal region demonstrates the contin-
uation of the SMAS cephalad to the zygomatic arch where it is called temporopari-
etal fascia. The temporal region therefore represents one area of the facial anatomy
where a complete violation of the SMAS layer can produce direct injury to a mo-
tor branch. For a motor branch injury to occur during undermining within the
cheek during rhytidectomy, the dissection must penetrate not only the SMAS but
also the deep facial fascia. However, because of the more super cial course of the
frontal branch in the temporal region, this motor nerve is at risk of injury if just the
temporoparietal fascia is violated at this site during dissection.8
Buccal fat
Temporalis muscle
Posterior masseteric fascia
Zygomatic arch
ß Line of fusion
Parotidomasseteric fascia
Deep temporal fascia
Masseter muscle
Temporal fat pad
Loose areolar tissue
Temporoparietal fascia
Frontal branch of facial nerve
SMAS
ß Superficial layer
ß Deep layer

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R ETAINING LIGAMENTS
Facial soft tissue is supported over bony prominences by a series of retaining liga-
ments that run from deep, xed facial structures to the overlying dermis.9 On ca-
daver dissection there appear to be two types of retaining ligaments. First, there are
true osteocutaneous ligaments, which are a series of brous bands that run from the
periosteum and insert directly into the dermis.The zygomatic and mandibular lig-
aments are examples of osteocutaneous ligaments. The masseteric cutaneous liga-
ment and the parotid cutaneous ligaments are formed as a condensation between
the super cial and deep facial fasciae. Rather than originating from periosteum,
these ligaments originate from relatively xed facial structures such as the parotid
gland and the anterior border of the masseter muscle. Attenuation of support from
the retaining ligaments is responsible for many of the stigmata that occur in the
aging face. Second, there is a system of supporting ligaments formed by coales-
cences that occur between the super cial and deep facial fasciae in certain regions
of the face (for example, parotid cutaneous ligaments and masseteric cutaneous lig-
aments).These fascial connections xate both super cial and deep facial fasciae to
underlying xed structures, such as the parotid gland and anterior border of the
masseter muscle, and support facial soft tissue with brous septa that extend into the
dermis.
The zygomatic ligaments exist as a series of brous septa that originate laterally
from the periosteum of the malar region where the zygomatic arch joins the body
of the zygoma. Similar bers are observed overlying the malar eminence. A partic-
ularly stout ligament is noted to originate along the most medial portion of the zy-
goma near the zygomaticomaxillary suture. The zygomatic ligaments extend
through the malar pad (McGregor’s patch) and insert into the overlying malar skin;
they x the malar pad to the underlying zygomatic eminence.
Mandibular cutaneous
ligament
Zygomatic ligaments
Masseteric cutaneous
ligaments
Parotid cutaneous
ligaments
Masseter
muscle
Zygomaticus minor muscle
Zygomaticus major muscle

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Chapter 11
Reoperative Rhytidectomy
In this cadaver dissection, the mandibular ligaments are identi ed in the parasym-
physeal region of the mandible just lateral to the chin pad and extend from bone
into the overlying skin.The mandibular ligaments tend to be the thickest and most
discrete of the retaining ligaments, forming a series of sturdy brous bands that se-
curely xate the parasymphyseal dermis to the underlying mandible.
Masseteric cutaneous ligaments support the soft tissues of the medial cheek supe-
riorly over the mandibular body.These ligaments consist of a series of brous bands
that originate along the entire anterior border of the masseter muscle from the
malar region to the mandibular border and extend vertically from the masseter
muscle through the platysma and subcutaneous fat to insert into the overlying der-
mis. These bers are easily identi ed in sub-SMAS dissection. Once the SMAS is
elevated anterior to the parotid gland, an areolar plane, extending from the anterior
border of the parotid gland to the anterior border of the masseter muscle, can be vi-
sualized between the super cial and deep facial fasciae. On reaching the anterior
border of the masseter muscle, this areolar plane ends as the brous septa of the
masseteric ligaments are encountered.
In summary, there appear to be two systems of retaining ligaments supporting fa-
cial soft tissue in a superior position. First, true osteocutaneous ligaments exist,
which are brous structures running from bone through the facial soft tissue to in-
sert into the overlying dermis. Second, a system of ligamentous support is formed
by a coalescence between the super cial and deep facial fasciae, xating facial skin
to underlying structures such as the parotid gland and masseter muscle. Although
tending to be ner in appearance than osteocutaneous ligaments, these attachments
between super cial and deep fasciae similarly function to support facial soft tissues
in normal anatomic position.

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ANATOMIC CHANGES THAT OCCUR W ITH AGING
Although arranged within anatomic layers, the individual structures composing fa-
cial soft tissue relate to one another anatomically to form a cohesive, working struc-
ture, producing facial movement while providing resistance to gravitational change.
Precise knowledge of the anatomic relationships existing between these layers is
useful in understanding the changes that occur in the aging face, allowing the sur-
geon to formulate a rational approach to correct various deformities during
rhytidectomy.
The retaining ligaments of the face support the facial soft tissue in normal anatomic
location. As stated earlier, two types of ligamentous support exist. As this ligamen-
tous system becomes attenuated with age and dermal elastosis occurs, the stigmata
of the aging face develop.
The importance of the zygomatic ligaments lies in their ability to suspend malar
soft tissue over the zygomatic eminence. This 26-year-old patient is shown after a
full-face chemical peel; she is shown again at 57 years of age.With aging, attenua-
tion of malar support commonly occurs, leading to an inferior migration of malar
soft tissue. This soft tissue ptosis occurs adjacent to the line of muscular xation
along the nasolabial fold. It is not that the fold deepens with aging; instead, malar
soft tissue lateral to the nasolabial line descends, which accounts for the fold promi-
nence in the aging face.Therefore attempts at diminishing the prominent nasolabial
fold should be directed at restoration of malar support and repositioning of malar
soft tissue.10,11

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The bers of the masseteric cutaneous ligament originate along the anterior bor-
der of the masseter muscle, extend vertically through the platysma and subcuta-
neous fat, and insert into the dermis of the cheek. The importance of these bers
lies in their support of the soft tissue of the cheek superiorly above the mandibu-
lar border. In our opinion, attenuation of support from masseteric cutaneous liga-
ments leads to an inferior migration of cheek soft tissue below the mandibular bor-
der and is largely responsible for the formation of jowls in elderly patients. Because
of the anatomic arrangement existing between the retaining ligaments, if one ex-
amines a patient with prominent jowling, it is apparent that the jowl complex has
anatomically constant borders. Anteriorly the jowl is bordered by the tethering
mandibular ligaments, whereas posteriorly the jowl complex is located along the
anterior border of the masseter muscle. Attempts to diminish the prominent jowl
should therefore be directed at restoring cheek support and repositioning the soft
tissue of the jowl complex superiorly above the mandibular border.
Aging is not skin deep; the deep facial soft tissues are also involved.
Attenuation of support from retaining ligaments, dermal elastosis, and facial lipodys-
trophy are the three main factors that must be addressed to reverse the anatomic
changes that occur with aging. In general, the dermal aspects of aging are treated
through the redraping of the skin ap in rhytidectomy. Lipodystrophy, which com-
monly occurs in the submental and cervical regions of the face but can also in-
volve the jowls and nasolabial folds, must also be dealt with through the contour-
ing of fat. To address the problems of attenuation of support from the retaining
ligaments, some form of deep layer support is mandated, usually involving SMAS-
platysma contouring.

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PLATYSMA BANDS
Similar to the retaining ligaments within the face, retaining ligaments within the
neck tightly support the platysma against the deep cervical fascia overlying the
floor of the mouth and thyroid cartilage. These fibers exist along the caudal
mandibular border, course throughout the brous subplatysmal fat that lines the
submental triangle, and extend from the hyoid bone and superior aspect of the thy-
roid cartilage into the overlying platysma.The arrangement of these ligaments ac-
counts for the acute cervicomental angle associated with a youthful appearance.
With aging, attenuation of the cervical support for the platysma occurs, allowing
the anterior edges of the platysma muscle to descend inferiorly and causing the
platysma bands to become prominent. As the platysma muscle slips from its cervi-
cal support and descends inferiorly, cervical obliquity blunts the previously acute
cervicomental angle. Muscular hypertrophy with age and shortening of the bow-
stringed platysma also contribute to platysma band prominence in the aging face.
Therefore attempts to correct platysma banding and cervical obliquity must center
on restoring the platysma to its normal anatomic location and contour. Any teth-
ering within the platysma that has occurred over time as the result of the platysma
muscle residing in a bow-stringed position must also be dealt with through some
form of transection myotomy to release and lengthen the muscle.

Early Complications Following Primary
and Secondary Rhytidectomy
James C. Grotting
The face-lift operation, like any other aesthetic procedure, is at risk for early com-
plications.The most common of these is hematoma, although skin slough and in-
fection can also interfere with recovery. Nerve injuries, both sensory and motor,
continue to occur and may lead to serious morbidity if they do not resolve spon-
taneously. Other early complications of primary and secondary rhytidectomy are
dysphagia and emotional issues.
Hematoma following face lift is a signi cant source of morbidity.Various authors
report the incidence among all patients at 1% to 12.9%.12-18 The risk factors for
hematoma include hypertension, especially when it is uncontrolled preoperatively;
male sex;bleeding disorders;and the use of various medications that interfere with
coagulation.19,20 Clearly, prevention is paramount in reducing the incidence of post-
operative hematoma. Blood pressure control pays the highest dividends in this ef-
fort.The incidence of hematoma among patients having facial rejuvenation under
local anesthesia with sedation may be a bit lower than those undergoing general
anesthesia. However, with either group it is crucial that blood pressure be normal-
ized before the start of the procedure. If the patient’s blood pressure remains greater
than 180 systolic or 90 diastolic after initial sedation, we do not proceed until the
blood pressure is diminished. Persistent elevation is an indication for referral and
workup by the patient’s primary physician. Clonidine has been recommended as a
useful agent for preoperative control of blood pressure at doses of 0.1 to 0.2 mg
orally the morning of surgery.17
Men have a higher incidence than women of bleeding during face-lift procedures
and more frequently develop postoperative hematomas (between 3.97% and 12.9%
of cases).21 The cause of this phenomenon is likely from increased sebaceous glands
and more hair follicles, each of which is surrounded by a more extensive capillary
network. As a result, the vascularity of the male skin is increased leading to greater
sources of blood vessel disruption. In light of this phenomenon, more limited un-
dermining in men as well as a conservative closed approach to the neck can de-
crease the surface area at risk for postoperative bleeding.
We ask our anesthetists to avoid spikes in blood pressure as the patient emerges
from general anesthesia, because this is the time of great risk for the development
of a hematoma. Drains are useful as a monitoring mechanism for the amount of
bleeding, but it is well accepted that they do not prevent hematoma. Head eleva-
tion, cool compresses, pain control, and continued sedation are all useful in main-
taining the blood pressure at an acceptable level.
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MANAGEMENT OF HEMATOMAS
Hematomas following a face-lift procedure can fall into two categories:small ones
that can be drained at the bedside without returning to the operating room, and
large ones where the cheek and/or neck must be reopened and explored to control
the bleeding source.
Bedside Management of Hematomas
The key to successful management of hematomas is early detection.
When detected early, a hematoma is more likely to be able to be managed without
return to the operating room.17 Bedside management is accomplished by removal
of enough sutures or staples to be able to remove clots and fresh blood. Preparation
for this procedure should include some oral pain medication or sedation if the pa-
tient is overly anxious. Blood pressure must be under good control. Thorazine or
nitropaste are useful agents for decreasing blood pressure by vasodilation. Towels
or “chucks” are spread beneath the patient’s head, and the area is prepared with a so-
lution such as Betadine. A Yankauer suction tip or red Robinson catheter is help-
ful for evacuating all the clots, and the surgeon can then assess ongoing bleeding.
The area is irrigated profusely with saline solution until the return is clear.Then 20
to 30 ml of 0.4% lidocaine with 1:200,000 epinephrine solution are injected un-
der the ap. Compression is held for 5 to 10 minutes, and a supportive circumfer-
ential dressing is applied.
Operative Treatment of Hematomas
If the hematoma is large and seems to involve both cheeks and the
neck, a return to the operating room is indicated.
Other factors that should sway the surgeon toward the operating room are:
An uncooperative patient
An overly anxious patient
A large, delayed hematoma
Labile blood pressure
Bilateral hematomas
A compromised airway

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If the patient is having dif culty breathing, immediate removal of sutures and de-
compression are essential. Since intubation and airway control in the presence of a
large hematoma can be exceedingly dif cult, I prefer to initially get control of the
situation under local anesthesia with a little sedation. Often, very little is needed, be-
cause the tissues are often still numb from the initial procedure, and antianxiety
and pain medications may already have been given.The surgeon must try to locate
the primary source of fresh bleeding and pack that area while evacuating the re-
mainder.With large hematomas, I usually remove the majority of sutures to make
absolutely certain that all sources of bleeding have been controlled, because the
worst scenario is to think one has control of the bleeding source only to nd that
the hematoma has recurred after the patient has already left the operating room.
Profuse irrigation with saline solution and dilute hydrogen peroxide will usually re-
veal the bleeding source. Of course, one feels most confident when a single
“pumper” is found. When multiple bleeding points are encountered, I prefer to
keep the patient in the operating room under observation a bit longer until I am
sure no further bleeding is going to occur. Drains should always be replaced and
their proper function con rmed.
Four hours after undergoing a face lift, an endoscopic brow lift, and a lower bleph-
aroplasty, this 59-year-old patient developed an obvious hematoma involving both
cheek pockets and the neck. Exploration revealed two arterial bleeding points in the
neck that were controlled. All regions were washed out and the skin was reclosed.

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The 4-month postoperative result shows near complete resolution of the sequelae
of this complication.