The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Part VIII  Face Lift and Neck Lift
Fascial Layers, Adhesions, and Ligaments of the Face
Knowledge of the fascial layers, adhesions, and ligaments of the face contributes to
surgeons’ understanding of the changes resulting from the aging process and enables
us to precisely prepare surgical procedures, not only within the appropriate layer of
the face, but also in planning the release of adhesions and ligaments to mobilize the
tissues and easily reposition them. Adequate mobilization and repositioning of fa-
cial tissues depends on complete release of the adhesions and ligaments before mo-
bilization. An understanding of the layers of the face clarifies the anatomic relation-
ships and defines the planes of dissection for mobilization of tissues in facial
rejuvenation.
If the facial soft tissues are conceptualized as a series of concentric layers, as pro-
posed by Stuzin, Baker, and Gordon, the aesthetic surgeon will understand that dis-
section within one anatomic plane can proceed without disturbing the other layers.
From superficial to deep, these layers include skin, subcutaneous tissue, superficial
facial fascia (SMAS), premasseter space, mimetic muscles, and deep facial fascia
(parotideomasseteric fascia); the deepest plane contains the facial nerve, parotid duct,
buccal fat pad, and facial vessels. These layers and various structures, although
Skin
Temporal fascia
Subcutaneous tissue
Parotid gland
Muscle
Deep facial fascia
(parotideomasseteric fascia)
Superficial facial fascia
(temporoparietal fascia SMAS)

anatomically distinct, function as one unit to convey facial expression. Changes within
each layer and the effects that these changes have on the other layers produce the
visible signs of facial aging.
Subcutaneous Layer
The thickness of the subcutaneous layer varies not only from individual to individ-
ual but within different areas of the same face. There is scant, if any, subcutaneous
fat overlying the zygoma; it is most plentiful over the cheek, jowl, and submental ar-
eas. Fullness and descent in these areas causes cheek flattening, accentuation of na-
solabial folds, jowl formation, and fullness of the central neck.
Superficial Facial Fascia, Superficial Musculoaponeurotic System
Anatomic Features
The SMAS is considered to be a well-defined portion of the superficial facial fascia.
This superficial facial fascia is a discrete fascial layer forming a continuous sheath
through the face and neck and extending into the malar region, the lip, and even the
nose. It extends into the forehead, temporal area, and scalp as the temporoparietal
fascia. This layer separates the subcutaneous tissues from the underlying muscles and
the deep facial fascia and facial nerves.
The SMAS represents an upward extension of the superficial cervical fascia into the
face, and the temporoparietal fascia can be considered an extension of the SMAS
into the temporal and scalp regions. This layer varies in thickness. It is very thick
over the parotid gland (SMAS), the temporal region (temporoparietal fascia), and
the scalp (galea); it is much thinner over the masseter muscle and becomes thinnest
in the malar region. Just like the subcutaneous fatty tissues, it will vary in thickness
from individual to individual.
The attachment of the SMAS throughout the face is not uniform. It has areas of tight
adherence to the underlying structures in some areas, whereas in others it separates
with less difficulty making a SMAS elevation possible even with blunt dissection.
In surgical terms, we often divide the SMAS into the fixed and mobile portions. The
fixed portion lies over the parotid gland; it is firmly adherent to the gland and is im-
mobile. The mobile portion, beyond the parotid gland, lies directly over the mimetic
muscles, facial nerves, and parotid duct. It is not adherent to the structures and is
highly mobile. It is mobilization and traction on this part that results in movement of
the midface and lower face.
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Chapter 40  Applied Anatomy of the Face and Neck

Functional Significance
The muscles of facial expression, the mimetic muscles, are bound by the superficial
fascial layer and arranged in four layers, as described by Freilinger et al. The muscles
most likely to be visualized during rhytidectomy—the orbicularis oculi, platysma,
and zygomaticus major and minor—are all superficially located and all innervated
by the facial nerve on the deep surface.
Only the deepest muscles—the buccinator, mentalis, and levator anguli oris—lie deep
to the plane of the facial nerve and are innervated on their superior surface. Clini-
cally, this is significant in that SMAS elevation can be performed safely as long as
the plane of dissection stays above these muscles. In deep plane rhytidectomy, dis-
section along the anterior surface of the zygomaticus major muscle can be performed
safely, since this dissection is superficial to the nerve branches and the muscle is inner-
vated on its deep surface.
It is only through mobilization and traction on the mobile SMAS that the facial tis-
sues can be effectively mobilized, elevated and repositioned.
Premasseter Space
Anatomic Features
The soft tissues overlying the masseter can be divided into two separate areas. An
oblique line that goes from the inferior edge of the tragus to just below the oral com-
missure separates the upper masseteric area form the lower masseteric area. The up-
per area contains the zygomatic branch of the facial nerve, the accessory lobe of the
parotid and parotid duct, and the upper buccal trunk of the facial nerve.
The lower area contains what is referred to as the premasseter space. This is an avas-
cular cleavage plane that contains no facial nerves, where the SMAS is easily ele-
vated. This space underlies the SMAS and platysma and is superficial to the masseter
fascia. It is a true space with a rhomboid shape and defined boundaries where the
SMAS separates with less difficulty, making a safe SMAS elevation possible even with
blunt dissection.
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Part VIII  Face Lift and Neck Lift

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Chapter 40  Applied Anatomy of the Face and Neck
The floor of the premasseter space is made up of the masseter fascia. No facial nerve
branches are at risk while dissecting through this space as the branches course be-
neath the fascia of the masseter. The roof of the premasseter space is formed by the
superficial fascia that encloses the upper aspect of the platysma. This fascia is strongly
adherent to the platysma fibers. The platysma continues up from the neck in an
oblique fashion over the premasseter space. At the anterosuperior border of the space,
the platysma has a strong deep fixation to a key masseteric cutaneous ligament. There
are no facial nerve branches within the roof of the premasseter space.
The superior border of the premasseter space is limited by a strong septum that is
tightly bound by a posterior ligament and an anterior key masseteric cutaneous lig-
ament. The location of this septum is represented by a line that crosses the surface
of the masseter from the inferior edge of the tragus to the oral commissure. This is
the line that bisects the masseter into an upper and a lower area. The lower area
(premasseter space) is the safe area where sub-SMAS dissection can be performed
with ease.
Zygomatic branch of facial nerve
Parotid duct
Lower buccal branch of facial nerve
Upper buccal branch of facial nerve
Upper mandibular branch
of facial nerve
Premasseter space
Mandibular ligament
Masticator space
Key masseteric cutaneous ligaments

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Part VIII  Face Lift and Neck Lift
30 mm
15 mm
The posterior border of the premasseter space starts 25 to 30 mm anterior to the
tragus and extends down to about 15 mm above the angle of the mandible. The area
between the ear and the posterior border of the space is lined by immobile SMAS
that is tightly adherent to the underlying structures, particularly the parotid capsule.
The posterior border of the premasseter space (25 to 30 mm anterior to the tragus,
just anterior to the edge of the parotid) represents the end of these dense attachments,
and the beginning of the mobile SMAS. When a sub-SMAS dissection is planned, it
should be started 25 to 30 mm anterior to the tragus where the premasseter space
begins. The presence of a defined space under the SMAS makes this dissection eas-
ier and safer. When in the space, further dissection of the SMAS should be blunt and
atraumatic which further reduces the chances of nerve injury. There is no advantage
in performing this dissection in the tightly adherent immobile SMAS. An additional
benefit that comes from not dissecting the immobile SMAS is that a segment of firm
adherent tissue remains to anchor the newly surgically repositioned mobile SMAS.
The inferior border of the space is made up of a thin membrane that extends from
the previously described posterior border, approximately 15 mm superior to the an-
gle of the mandible, all the way to the mandibular ligament at the labiomandibular
crease. The upper mandibular branch of the facial nerve crosses the posterior bor-
der of the masseter approximately 8 mm above the angle of the mandible then con-
tinues below the inferior border of the premasseter space. This makes the inferior

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Chapter 40  Applied Anatomy of the Face and Neck
The anterior border of the premasseter space is defined by the anterior border of the
muscle. The forward prolongation of the muscle’s lower anterior part for 20 to 25 mm
is the basis for the jowl recess at the anteroinferior corner of the premasseter space.
Medial to the anterior membrane is a sheet of masseteric ligaments that provide
structural support and form a “picket fence”-like reinforcement of the border. This
ligamentous support extends from the key masseteric cutaneous ligament at the an-
terosuperior border of the space down to the mandibular ligament. The mandibular
ligament is located immediately in front the jowl recess and it demarcates the transi-
tion between the jowl and the labiomandibular fold. The more the jowl descends,
the more apparent this demarcation becomes.
Anterior to the premasseter space, on the medial side of the ligaments, course several
branches of the facial nerve that came from beneath the floor of the space. Further
medial to the premasseter space, between the masseteric ligaments and the oral com-
missure, is the masticator space which contains the buccal fat pad. In youth, the in-
ferior border of the masticator space is at the oral commissure, separate from the jowl
recess. With significant aging changes and ligament laxity, this space, along with the
buccal fat, can extend down so low as to contribute to the heaviness of the jowls and
labiomandibular folds. Adequate rejuvenation of the jowls and labiomental folds may
sometimes require management of the buccal fat pad. Surgical access to the buccal
fat can be obtained through the attenuated anterior border of the premasseter space.
border of the premasseter space cephalad to the mandibular branch, which remains
outside the operative field at all times. Clinically, there is no advantage to be gained
in extending the sub-SMAS dissection to the rim of the mandible. Except for the
mandibular ligament anteriorly, there are no ligamentous fixations along the infe-
rior septum. This makes the inferior boundary of the space more predisposed to in-
ferior displacement when there is descent of the tissues with age.
25 mm
Mandibular ligament

Functional Significance
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Part VIII  Face Lift and Neck Lift
The jowl and labiomandibular fold are classical signs of aging. Correction of the
jowls and labiomandibular folds are two of the most essential elements for a suc-
cessful face-lift. The SMAS and the jowls seem to be closely related since the manip-
ulation of the SMAS during a face lift achieves improvement of the jowl. The pre-
masseter space is implicated in the formation of jowls. With aging, a progressive
attenuation of the masseteric ligaments causes laxity of the anterior and inferior bor-
der allowing the roof to slide down. The changes along the anterior border are not
uniform. There is less laxity above where there is a stronger fixation by the thick key
masseteric ligaments, and there is more laxity below in the jowl recess. With liga-
ment laxity, there is descent of tissues into the anteroinferior area of the premasseter
space extending below the mandible rim, resulting in the development of the jowl.
Improvement in the laxity of the jowls and labiomandibular folds can be obtained
Mandibular ligament
Platysma muscle
(premasseter space roof)
Masticator space
Premasseter space
Tight masseteric
ligaments
Mandibular ligament
Platysma muscle
(premasseter space roof)
Masticator space
Premasseter space
Jowl
Loose masseteric
ligaments

through a posterosuperior pull of the mobile roof (SMAS) of the premasseter space.
Sub-SMAS dissection through this avascular space is easy and safe since it contains
no vital structures. The amount of pull possible increases in older patients because
of the laxity of the masseteric cutaneous ligaments. If a SMASectomy is required, it
becomes an effective and safe technique since a strip of SMAS is being resected from
the roof of the space without any risk of nerve damage. The nearest facial nerve
branches (buccal) are under the floor of the space.
Deep Facial Fascia
Parotideomasseteric Fascia
The superficial layer of the deep cervical fascia continues onto the face as the deep
facial fascia. In the area overlying the parotid it is referred to as the investing fascia
of the parotid and over the masseter it is called the masseteric fascia. The deep fa-
cial fascial layer extends to the malar region lying deep to the lip elevators, and its
extension above the zygomatic arch is the deep temporal fascia. The clinical signifi-
cance of this layer is that the facial nerve branches within the cheek all lie deep to
it. The superficial fascia and deep facial fascia are separated by loose areolar tissue
typical of the usual arrangement between fascial layers elsewhere in the body. How-
ever, these two layers are firmly attached to each other in certain anatomic locations.
In the temporal region there is an areolar plane between the temporoparietal (super-
ficial facial fascia) and the deep temporal fascia (deep facial fascia). In the areolar
tissue between them lie the temporal artery and the frontal branch of the facial nerve.
A similar plane is found in the cheek between the SMAS (superficial facial fascia)
and the parotideomasseteric fascia (deep facial fascia) over the masseter muscle and
between the platysma and the strap muscles in the neck. The two facial fascial lay-
ers are firmly attached to each other along the zygomatic arch over the parotid gland
and along the anterior border of the masseter.
The Deepest Plane
The deepest plane lying deep to the deep facial fascia or parotideomasseteric fascia
contains the zygomatic and buccal branches of the facial nerve, the buccal pad, the
parotid duct, and the facial artery and vein.
Functional Significance
The clinical significance of these four facial layers involves their relationship to the
branches of the facial nerve and their preservation during rhytidectomy. Any dissec-
tion superficial to the SMAS is obviously well away from the underlying nerves. Be-
low the SMAS and above the deep facial fascia, dissection within the cheek will pro-
tect the buccal and zygomatic branches. However, the frontal branch requires special
attention once it crosses the zygoma and assumes a superficial course. Since the zy-
gomaticus muscles are innervated on their deep surface, deep plane rhytidectomy su-
perficial to the zygomaticus muscles does not place the facial nerve branches at risk.
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Chapter 40  Applied Anatomy of the Face and Neck

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Part VIII  Face Lift and Neck Lift
Skin
Temporal fascia proper
Frontal branch of facial nerve
Parotid gland
Galea
Deep layer of deep temporal fascia
Superficial temporal fascia
(temporoparietal fascia)
(continuous with galea)
Subcutaneous fat
Periosteum
Areolar (subgaleal) fascia
(fuses with superficial fat pad)
Superficial layer of deep temporal fascia
Superficial fat pad
Deep fat pad (buccal fat pad)
Temporalis muscle
Periosteum
Zygomatic arch
Parotid fascia
SMAS
Masseter muscle
Path of dissection
Continued path of dissection
Variation

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Chapter 40  Applied Anatomy of the Face and Neck
Retaining Ligaments and Adhesions
of the Face and Neck
Temple and Periorbital Region
Temporal Ligamentous Adhesions
Proper elevation and rejuvenation of the periorbital area, specifically the lateral brow
and lower lid-cheek junction depends on appropriate release of a variety of adhe-
sions and ligamentous attachments. There are numerous adhesions and attachments
in this area. They have been given different names and described as different types
of structures by various authors. Some of the adhesions and ligaments in this area
have been referred to as tendons, though no real tendons in the anatomic sense are
present in the region.
Temporal
ligamentous adhesion
Supraorbital
ligamentous adhesion
Lateral brow
thickening of
periorbital septum
Lateral orbital
thickening of
periorbital septum
Periorbital septum
Zygomatic branch
of facial nerve
Temporal branches
of facial nerve
Adhesions
Thickenings
Septum
Inferior
temporal septum
Zygomaticotemporal nerve
Sentinel vein
Temporalis muscle

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Part VIII  Face Lift and Neck Lift
The medial and lateral third of the eyebrow above the orbit is held in position by the
temporal ligamentous adhesions. These extend posteriorly along the temporal crest as
the superior temporal septum or the temporal line of fusion. These adhesions extend
medially toward the medial orbit as the supraorbital ligamentous adhesions. Laterally
from the supraorbital rim the adhesion extends toward the posterior and upper bor-
der of the zygoma in the form of the inferior temporal septum. More anteriorly, di-
rectly over the orbital rim—starting medially and extending counterclockwise around
the orbit—are the periorbital septum superiorly, extending laterally to the lateral
brow thickening of the periorbital septum, farther down laterally along the orbital
rim to the lateral orbital thickening of the periorbital septum, and then around the
lower lateral portion of the orbit and along its inferior border as the lower extent or
continuation of the periorbital septum. As described by Moss, Mendelson, and Tay-
lor, essentially the periorbital septum extends around the orbit from the upper medial
area of the orbit to the lower medial portion covering three quarters of the circum-
ference of the orbit.
Periorbital Ligaments
Functional Significance
Complete division of these adhesions and septa is essential for repositioning of the lat-
eral brow and periorbital tissues. These adhesions are usually very easily dissected with
a periosteal elevator. However, sometimes the lateral brow thickening of the perior-
bital septum may require division using the scissors rather than a periosteal elevator.
Remembering and recounting the names of these various adhesions and attachments
is not as important as remembering that it is essential to divide all of them to allow
adequate mobilization of the lateral brow and periorbital tissues.
Lower lid bulge
Malar bag
Zygomaticocutaneous
ligament
Orbitomalar
ligament
Suborbicularis
oculi fat
Orbitomalar
ligament
Zygomatico-
cutaneous
ligament

Midlateral Face
Anatomic Features
Retaining ligaments of the midlateral face run from underlying fixed bony origins
into the overlying dermis. The ligaments serve to support the facial skin in its nor-
mal anatomic position. Based on their anatomic studies, Stuzin and colleagues de-
scribed two types of retaining ligaments. The first, or true osseocutaneous ligaments,
run from the periosteum to the dermis (for example, the zygomatic and mandibular
ligaments). The second system is formed by the coalescence of the superficial facial
fascia and the deep facial fascia that fixes the facial layers to underlying structures
such as the parotid and masseter and are attached to the overlying dermis by fibrous
septa. The parotid cutaneous and masseteric cutaneous ligaments are examples of
this second system. These much finer structures also serve to maintain facial soft tis-
sue in its normal position. The zygomatic ligaments take origin from the body of the
zygoma and the zygomatic arch and extend through the malar fat pad to the over-
lying dermis. The mandibular ligaments originate in the parasymphyseal region of
the mandible and extend to the overlying dermis. Masseteric cutaneous ligaments
are located along the entire anterior border of the masseter, where the superficial fa-
cial fascia and deep facial fascia are firmly adherent. A series of fibrous bands ex-
tends vertically up to the dermis to support the cheek skin. The parotideocutaneous
ligaments lie along the parotid gland, where the superficial facial fascia and the deep
facial fascia are firmly adherent to each other and similar septa anchor the overly-
ing skin down to the fascia.
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Chapter 40  Applied Anatomy of the Face and Neck
Inferior temporal adhesion
SMAS plane
Zygomatic ligament
Masseteric ligament
Periorbital septum
Subgaleal plane
Galeal plane
Sub-SMAS plane
Temporal ligamentous adhesion
Superior temporal adhesion
Adhesion
Septa
Orbicularis muscle
Ligament
Skin
Bone
Periosteum
Deep fascial plane
Sub-SMAS plane
SMAS plane

Functional Significance
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Part VIII  Face Lift and Neck Lift
These ligaments are essentially fixed structures extending from underlying bone to
dermis. Facial tissue, especially fat pads, can pivot around them, producing creases
such as the marionette grooves of the lower face. With age, these ligaments attenu-
ate and relax. This, combined with the loss of skin elasticity and soft tissues, will
lead to the stigmata of aging. The zygomatic ligaments suspend the malar soft tis-
sues and fat pad over the zygomatic prominence. As this support weakens, the malar
soft tissues gradually migrate downward, and redundant skin hangs over the fixed
nasolabial sulcus. Rather than the nasolabial sulcus deepening with age, it is the
downward migration of the soft tissues against the fixed nasolabial sulcus that ac-
counts for the observed changes. Surgical correction of the prominent nasolabial fold
should concentrate on repositioning the malar soft tissues and restoring malar sup-
port. In a similar fashion, attenuation and weakness of the masseteric cutaneous lig-
aments will allow a downward shift of the cheek tissues below the mandibular mar-
gin, where tethering by the mandibular ligament will lead to the formation of jowls.
Surgical correction of jowls should include a rearrangement and resuspension of the
deep tissues. These ligaments that extend from bone to dermis must be released dur-
ing a face lift to achieve the desired result. Left intact, they limit mobility.
Deep temporal fascia
Masseteric
cutaneous
ligament
Parotid gland
Zygomatic ligament
Platysma
(in SMAS)
Superficial temporal artery
Deep temporal fascia
Masseteric
cutaneous
ligament
Parotid gland
Zygomatic ligament
Platysma
(in SMAS)
Superficial temporal artery

Malar and Buccal Fat Pads
Malar Fat Pad
Anatomic Features
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Chapter 40  Applied Anatomy of the Face and Neck
A youthful appearance with the associated cheek prominence is related to the promi-
nence of the underlying zygoma as well as the position and fullness of the malar fat
pad. Owsley noted that the malar fat pad is an area of increased thickening of the
subcutaneous tissues extending from the malar region to the nasolabial crease. This
fat pad is located superficial to the SMAS and mimetic muscles. It is roughly trian-
gular in shape, with the base along the nasolabial fold and the apex toward the zy-
gomatic prominence. When the malar fat pad descends, it adds fullness to the na-
solabial fold and deepens it.
Functional Significance
The malar fat pad must be repositioned to improve midfacial appearance. This may
be accomplished with subperiosteal, deep plane, and composite face-lift techniques.
With the deep plane lift, the fat pad remains attached to the overlying skin and ten-
sion on the skin elevates the cheek.
With age, not only is there descent of the malar fat pad, but also loss of volume. The
recent work of Lambros has demonstrated that volume loss may be clinically more
relevant than descent. Currently, our approach to facial rejuvenation includes a com-
bination of malar fat pad elevation as well as volume replacement.
Malar fat pad

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Part VIII  Face Lift and Neck Lift
Buccal Fat Pad
Anatomic Features
The buccal fat pad lies deep to the deepest of the facial layers and contributes to
cheek and facial contour. This specialized type of fat, called syssarcosis, enhances
muscular motion. It resembles orbital fat in color, function, and form.
The buccal fat pad is intimately related to the temporalis, masseter, and buccinator
muscles, the zygomatic and buccal branches of the facial nerve, and the parotid duct.
The space that is occupied by the buccal fat pad is called the masticatory space. The
buccal fat pad within this space separates the muscles of mastication from each other
and from the mandible, maxilla, and zygoma.
The buccal fat pad weighs approximately 8 to 12 g and consists of a central body
and three extensions. The temporal extension extends superiorly deep to the zygoma,
the pterygoid extension extends backward deep to the ramus of the mandible, and
the buccal extension, which is the most superficial extension, lies within the cheek.
The body and buccal extensions are clinically significant and contribute to cheek
contour.
Buccal fat pad

The central body is located above the parotid duct and extends along the upper an-
terior border of the masseter muscle. It lies deep to the masseter muscle and over the
upper fibers of the buccinator extending to the maxilla where it lies over the second
maxillary molar. Posteriorly it is wrapped around the maxilla.
The buccal extension lies below the parotid duct, which separates it from the cen-
tral body. Deep to it lie the buccinator and oral mucosa and the facial vessels; the zy-
gomatic and buccal branches of the facial nerve lie superficial to it. The parotid duct
passes through the fat pad and buccinator into the oral mucosa opposite the second
maxillary molar. The pterygoid portion passes downward and backward on the deep
medial surface of the ramus of the mandible lying on the lateral surface of the me-
dial and lateral pterygoid muscles. The deep temporal portion extends upward deep
to the zygoma lying directly over the temporalis muscle and its tendon.
Functional Significance
In selected cases removal of the buccal fat pad will reduce cheek fullness and enhance
the malar eminence. It is essentially the central body and buccal portion or exten-
sion that is clinically removed, effecting contour changes of the cheek.
The buccal fat pad has a distinct yellow color and is easily distinguished from subcu-
taneous fat. Because of its intimate relationship with the facial vessels, parotid duct,
and branches of the facial nerve, the fat should be gently teased and removed. Sharp
dissection should be avoided. The buccal fat pad resembles an egg yolk in color as
well as in size and consistency; removing this pad from the masticatory space is also
reminiscent of separating egg yolk from egg white.
Stuzin et al described the intraoral approach, in which a longitudinal incision is made
in the buccal sulcus at the level of the second upper molar, dissection continuing
through the buccinator. The buccal fat is enveloped in a fascial layer. This fascial layer
is opened and the buccal fat pad is as easily identified and delivered as an egg yolk.
Alternatively, during open or endoscopic face lift the buccal fat pad is approached
along the anterior border of the masseter muscle. Careful dissection and spreading
are recommended to avoid injury to the facial nerve branches. Longitudinal spread-
ing will provide easy access to the buccal fat pad.
The buccal fat pad does change with age. It is most prominent in infants and young
children. As the surrounding tissues grow with age, this fat pad becomes less promi-
nent during adulthood. With old age, the buccal fat pad undergoes involution, is far
less prominent, and can descend, contributing to the heaviness of the jowls.
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Chapter 40  Applied Anatomy of the Face and Neck

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Part VIII  Face Lift and Neck Lift
The Submental or Digastric Triangle
With greater interest in subplatysmal procedures to improve neck contouring, the
anatomy of the submental triangle has gained importance. Two sides of the submen-
tal triangle are made up of the anterior belly and posterior belly of the digastric and
ramus; the mandible makes up the third side. Within this triangle deep to the platysma
lie the subplatysmal fat, the submandibular gland, the facial artery and vein, the lin-
gual nerve, and the marginal mandibular branch of the facial nerve. There are also
a number of lymph nodes within this triangle.
Facial artery and vein
Facial nerve
Marginal mandibular nerve
Submandibular gland
Superficial thyroid vein
Thyroid gland
Omohyoid muscle
Sternohyoid muscle
Parotid gland
Greater auricular nerve
Accessory nerve
Internal jugular vein
Ansa cervicalis nerve
Sternomastoid muscle
Posterior belly
of digastric muscle
Anterior belly
of digastric muscle

Mylohyoid Muscle
The mylohyoids are a pair of flat triangular sheets of muscle originating from the
mylohyoid line of the mandible. The fibers run forward and downward toward the
insertion, posteriorly into the hyoid and anteriorly into a fibrous raphe that extends
from the mentum to the hyoid. These paired muscles compose the muscular support
of the floor of the mouth and constitute the medial side of the submental or digas-
tric triangle.
Submandibular Gland
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Chapter 40  Applied Anatomy of the Face and Neck
The submandibular gland is a bilobed structure with a large superficial lobe and a
much smaller deep lobe. The lobes are attached to each other along the posterior
border of the mylohyoid muscle. The bulk of the gland lies under the body of the
mandible and extends down to the tendinous junction between the two bellies of the
digastric. The gland is encased in a connective tissue capsule. The relations of the su-
perficial part of the gland are as follows:
 Anterior lies the anterior belly of the digastric muscle
 Posterior lie the posterior belly of the digastric and the stylohyoid muscles
 Medial lie the mylohyoid, hyoglossus, and the lingual and hypoglossal nerves
 Lateral lie the body of the mandible, the platysma, and the cervical branch of
the facial nerve
 The facial artery crosses the posterior and superior aspect of the gland
Digastric muscle
Mylohyoid muscle
Submandibular gland

Functional Significance
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Part VIII  Face Lift and Neck Lift
The contents of the submental or digastric triangle all lie deep to the platysma and
in neck contouring or rejuvenation constitute the deepest layer of the neck. Removal
of subplatysmal fat, partial tangential or complete excision of the anterior belly of
the digastric muscle, and partial excision of the superficial lobe of the submandibu-
lar gland all constitute deep plane neck procedures and contribute to neck recon-
touring.
Although fat and digastric muscle excision is relatively straightforward, the excision
of the superficial lobe of the submandibular gland may cause concern because of the
intimate relationship of the gland to the facial artery, cervical and marginal mandibu-
lar branches of the facial nerve, and the lingual nerve. However, since the gland is
encased in a sheath or capsule, intracapsular dissection of the gland is relatively safe.
Concluding Thoughts
My fascination with anatomy first began in medical school, when I recognized the
beauty and complexity of the body’s anatomic structures. I well remember one of
my professors telling me that I would learn anatomy three times and forget it four
times. Little did I know how true that statement was. Over the span of my career,
I have not only learned and relearned my anatomy, but also have grown to recognize
that this is a topic that requires frequent revisiting if one is to gain familiarity with
anatomic structures, their relationships, and the intricacies of their vasculature and
innervation. Perhaps it was this fascination with anatomy that led me into a career
as a surgeon. Regardless, it is knowledge of anatomy that is the foundation of all of
the surgical procedures that I perform today.
Anterior belly
of digastric muscle
Superficial lobe of
submandibular gland
Mylohyoid
muscle

A detailed knowledge of the anatomy of the face is essential to appreciate the aging
process and the resulting changes in facial appearance. Armed with this understand-
ing, we can successfully develop strategies for rejuvenation. Understanding of the
planes of the face and the contents of each of these planes enables the surgeon to
satisfactorily and confidently operate on facial tissues to restore a youthful appearance
while minimizing morbidity.
Dissecting with confidence while ensuring the safety of important nerve and vascu-
lar structures is the hallmark of an experienced surgeon. With experience, the sur-
geon also recognizes the fact that variation in anatomy is the rule rather than the ex-
ception. Two sides of the same face will vary in symmetry and anatomy, just as the
facial anatomy will vary from one individual to another. In addition to naturally oc-
curring anatomic variations, the surgeon must also be prepared to address those re-
sulting from trauma and from previous surgical interventions.
Although anatomy is seemingly static, we would be mistaken to assume that we know
all there is to know about this topic. New anatomic insights and details are regularly
being described as our understanding of facial anatomy continues to evolve.
Annotated Bibliography
Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 83:11-16, 1989.
This article discusses anatomic features and functions of the retaining ligaments of the
cheek. With a thorough knowledge of this anatomy, surgical landmarks can be identi-
fied and anatomic disorientation during facial dissection can be avoided.
Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Recon-
str Surg 97:1321-1333, 1996.
The development of eyebrow ptosis with aging is commonly attributed to progressive
laxity of scalp and forehead soft tissues. However, if change in eyebrow position resulted
entirely from tissue stretching, uniform lowering of the medial and lateral eyebrow seg-
ments should occur. Clinical observations show that the lateral eyebrow segment usu-
ally becomes ptotic earlier than the medial segment, indicating that a more complex
mechanism exists. To clarify the development of eyebrow ptosis, the author performed
anatomic and histologic studies on 20 (40 half-head) fresh cadaver specimens. The stud-
ies confirmed that the mechanism producing eyebrow ptosis has a relatively greater ef-
fect on the lateral eyebrow segment. The interaction of structures and forces contribut-
ing to the mechanism producing eyebrow ptosis is also discussed. Derived concepts can
be applied to the execution of the forehead lift procedure.
1341
Chapter 40  Applied Anatomy of the Face and Neck

Knize DM. Reassessment of the coronal incision and subgaleal dissection for foreheadplasty.
Plast Reconstr Surg 102:478-489; discussion 490-492, 1998.
The subgaleal plane is the most commonly used dissection plane for foreheadplasty to-
day. However, some surgeons have begun to advocate using the subperiosteal plane,
and controversy surrounds the question of which dissection plane is more surgically
sound for raising a forehead flap. On the basis of 25 fresh cadaver dissections and more
than 20 years of clinical experience with foreheadplasty, the author concludes that dis-
section done at the subperiosteal rather than the subgaleal plane provides greater ben-
efit to the patient.
Mendelson BC, Freeman ME, Wu W, et al. Surgical anatomy of the lower face: the premas-
seter space, the jowl, and the labiomandibular fold. Aesthetic Plast Surg 32:185-195,
2008.
The authors describe the premasseter space, an avascular cleavage plane that contains
vital structures through which sub-SMAS dissection can be performed safely and easily.
They conclude that the premasseter space should be considered the preferred dissection
plane for lower (cervicofacial) face lifts.
Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the midcheek and malar
mounds. Plast Reconstr Surg 110:885-896; discussion 897-911, 2002.
The authors describe the anatomy of the midcheek to explain midcheek aging and malar
mounds. Their cadaver study located a glide plane space overlying the body of the zy-
goma. The function of this space, together with the anatomic boundaries and anatomic
features of this area, determine the characteristic aging changes that occur in this region
and explain malar mounds. The authors also discuss the surgical implications of this
anatomy.
Meyer DR, Linberg JV, Wobig JL, et al. Anatomy of the orbital septum and associated eye-
lid connective tissues. Ophthal Plast Reconstr Surg 7:104-113, 1991.
The authors examine the anatomy of the orbital septum and associated eyelid connective
tissues and review embryologic development of the eyelid connective tissues. Recom-
mendations for ptosis surgery based on the anatomic principles discussed are provided.
Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and
cheek area. Plast Reconstr Surg 58:80-88, 1976.
The authors investigated the SMAS in the parotid and cheek areas by anatomic dissec-
tions, radiographs, and histological sections. They conclude that the SMAS may be help-
ful in corrective surgery for facial palsy and during face-lift operations if a retrofascial
approach is used. However, this procedure, safe in the parotid area, can become danger-
ous in the area anterior to the parotid gland.
Moss JC, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the
temple and periorbital regions. Plast Reconstr Surg 105:1475-1490; discussion 1491-
1498, 2000.
This study documents the anatomy of the deep attachments of the superficial fasciae
within the temporal and periorbital regions. Knowledge of these relationships allows
the surgeon to use the tissue planes and soft tissue ligaments as intraoperative landmarks
for the vital neurovascular structures. This results in improved efficiency and safety for
aesthetic procedures in these regions.
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Part VIII  Face Lift and Neck Lift

Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications
for cosmetic surgery. Plast Reconstr Surg 119:2219-2227; discussion 2228-2231, 2007.
The authors investigated the partitioning of subcutaneous fat of the face in multiple in-
dependent anatomic compartments by performing 30 hemifacial cadaver dissections.
They found that the nasolabial fold is a discrete unit with distinct anatomic boundaries.
What has been referred to as malar fat is composed of three separate compartments:
medial, middle, and lateral temporal–cheek fat. The forehead is similarly composed of
three anatomic units, including central, middle, and lateral temporal–cheek fat. They
concluded that the concept of separate compartments of fat suggests that the face does
not age as a confluent or composite mass. Shearing between adjacent compartments may
be an additional factor in the causes of soft tissue malposition.
Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal
boundaries of the subcutaneous fat compartments. Plast Reconstr Surg 121:1804-1809,
2008.
The authors studied the histology of the septal boundaries between several adjacent fat
compartments. They found that fibrous condensation of connective tissue formed diffu-
sion barriers. These septa originated from underlying fascia and inserted into the der-
mis of the skin. A septal barrier originated from the fascia of the frontalis muscle, so
these septal barriers are not necessarily related to the superficial musculoaponeurotic
system but can occur anywhere between superficial fascia and skin. Their findings sup-
port the concept that subcutaneous fat is compartmentalized, specifically by fascial con-
densations that travel from superficial fascia to dermis. These septa form an intercon-
necting framework that limits shearing forces on the face. This framework provides a
“retaining system” for the human face. Implicit in this concept is the suggestion that the
face ages three-dimensionally, with separate compartments changing relative to one an-
other by both position and volume.
Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and deep medial fat compartment. Plast
Reconstr Surg 121:2107-2112, 2008.
This article explores the concept of pseudoptosis as a mechanism of midfacial aging: di-
minished volume of a specific deep fat compartment leads to an excess skin envelope
and the illusion of a more prominent nasolabial fold. The anatomy of this deep fat com-
partment, and of two others, is described.
Schaverien MV, Rohrich RJ, Pessa JE. Vascularized membranes determine the anatomical
boundaries of the subcutaneous fat compartments. Plast Reconstr Surg 123:695-700,
2009.
The authors demonstrate that superficial fat in the face exists in distinct anatomic com-
partments. These fat compartments are separated by fascial septa that arise from the su-
perficial fascia and insert into the dermis. Perforating vessels arising from deep arteries
travel through these septa to supply the skin and define the overlying vascular territo-
ries or angiosomes.
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Chapter 40  Applied Anatomy of the Face and Neck

Whetzel TP, Mathes SJ. Arterial anatomy of the face: an analysis of vascular territories and
perforating cutaneous vessels. Plast Reconstr Surg 89:591-603; discussion 604-605, 1992.
The authors investigated the cutaneous arterial circulation of the face and scalp by using
multiple anatomic techniques in fresh cadaver specimens. They defined 11 vascular ter-
ritories of the face and scalp and observed three distinct patterns of arterial vasculariza-
tion. The results of this study provided the anatomic framework to potentially revise or
improve reconstructive or aesthetic procedures of the face based on known arteries.
Suggested Readings
Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Plast Reconstr Surg
64:781-795, 1979.
Baker TJ, Gordon HL, Stuzin JM. Surgical Rejuvenation of the Face, 2nd ed. St Louis: Mosby,
1995.
Boyd B. Personal communication, 2005.
de Castro CC. The anatomy of the platysma muscle. Plast Reconstr Surg 66:680-683, 1980.
Costas PD, Heatley G, Seckel BR. Normal sensation of the human face and neck. Plast Re-
constr Surg 93:1141-1145, 1994.
DiFrancesco L, Codner MA, McCord CD, et al. EMG and video studies of patients before
and after subciliary blepharoplasty incisions. Presented at the Thirty-fourth Annual Meet-
ing of the American Society for Aesthetic Plastic Surgery, Boston, May 2003.
Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve
based on the dissection of 100 facial halves. Plast Reconstr Surg 29:266-272, 1962.
Dubin B, Jackson IT, Hahm A, et al. Anatomy of the buccal fat pad and its clinical signifi-
cance. Plast Reconstr Surg 83:257-264, 1989.
Duchenne de Boulogne GB. The Mechanism of Human Facial Expression. New York: Cam-
bridge University Press, 1990.
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
80:686-690, 1987.
Gosain AK, Yousif NJ, Madiedo G, et al. Surgical anatomy of the SMAS: a reinvestigation.
Plast Reconstr Surg 92:1254-1263; discussion 1264-1265, 1993.
Grotting JC, Stuzin JM. Reoperative rhytidectomy. In Grotting JG, ed. Reoperative Aesthetic
and Reconstructive Plastic Surgery, 2nd ed. St Louis: Quality Medical Publishing, 2007.
Jost G, Levet Y. Parotid fascia and face lifting: a critical evaluation of the SMAS concept.
Plast Reconstr Surg 74:42-51, 1984.
Lambros V. Goals in achieving true rejuvenation of the upper eyelid/brow complex bleph -
aroplasty. Panel at the New Horizons in Cosmetic Surgery Symposium, Indian Wells,
CA, Jan 2004.
Lowery JC, Bartley GB, Litchy WJ. Electromyographic studies of the reconstructed lower
eyelid after a modified Hughes procedure. Am J Ophthalmol 119:225-228, 1995.
1344
Part VIII  Face Lift and Neck Lift

McCord CD, Coles W, Shore JW, et al. Treatment of essential blepharospasm. II. A modifi-
cation of exposure for the muscle stripping technique. Arch Ophthalmol 102:269-273,
1984.
McCord CD, Shore J, Coles W, et al. Treatment of essential blepharospasm. I. Comparison
of facial neurectomy vs. muscle stripping. Arch Ophthalmol 120:260-268, 1984.
Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the ligamentous attachments
of the lower lid and lateral canthus. Plast Reconstr Surg 110:873-884; discussion 897-
911, 2002.
Nemoto Y, Sekino Y, Kaneko H. Facial nerve anatomy in eyelids and periorbit. Jpn J Oph-
thalmol 45:445-452, 2001.
Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Re-
constr Surg 91:463-474; discussion 475-476, 1993.
Pessa JE, Brown F. Independent effect of various facial mimetic muscles on the nasolabial
fold. Aesthetic Plast Surg 16:167-171, 1992.
Peterson RA, Johnston DL. Facile identification of the facial nerve branches. Clin Plast Surg
14:785-788, 1987.
Ramirez O. Spatial orientation of motor innervation to the lower orbicularis oculi. Aesthet
Surg J 20:107-113, 2000.
Rubin LR, Mishriki Y, Lee G. Anatomy of the nasolabial fold: the keystone of the smiling
mechanism. Plast Reconstr Surg 83:1-10, 1989.
Rudolph R. Depth of the facial nerve in face lift dissections. Plast Reconstr Surg 85:537-544,
1990.
Ruess W, Owsley JQ. The anatomy of the skin and facial layers of the face in aesthetic surgery.
Clin Plast Surg 14:677-682, 1987.
Seckel BR. Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery, 2nd ed. St
Louis: Quality Medical Publishing, 2010.
Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias:
Relevance to rhytidectomy and aging. Plast Reconstr Surg 89:441-449; discussion 450-
451, 1992.
Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical applications of the
buccal fat pad. Plast Reconstr Surg 85:29-37, 1990.
Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy of the frontal branch of the facial
nerve: the significance of the temporal fat pad. Plast Reconstr Surg 83:265-271, 1989.
Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an important reference point for sur-
gery in the temporal region. Plast Reconstr Surg 101:27-32, 1998.
Yousif NJ, Gosain A, Matloub HS, et al. The nasolabial fold: an anatomic and histologic
reappraisal. Plast Reconstr Surg 93:60-69, 1994.
Yousif NJ, Gosain A, Sanger JR, et al. The nasolabial fold: a photogrammetric analysis. Plast
Reconstr Surg 93:70-77, 1994.
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Clinical Decision-Making
in Face Lift and Neck Lift

FOAD NAHAI
CHAPTER 41

Evaluation
Not all faces age in the same way, nor do they require the same procedures for reju-
venation. The degree of volume loss, tissue descent, and skin changes will vary. Each
face ages individually, with some areas remaining more youthful than others. I eval-
uate the entire face, assessing skin quality, volume, and descent. For descriptive pur-
poses, I think of the face in terms of the three zones: periorbital, perioral, and neck.
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Part VIII  Face Lift and Neck Lift
Periorbital zone
(upper third)
Perioral zone
(middle third)
Neck zone
(lower third)
Periorbital zone
(upper third)
Perioral zone
(middle third)
Neck zone
(lower third)
The forehead, brow, and upper midface make up the periorbital zone; the lower part
of the face—nasolabial folds, lips, jowls, and chin—is called the perioral area; and
the jawline, submental area, and neck are referred to as the neck zone. I also think of
these three zones as dividing the face and neck into upper, middle, and lower thirds.
Ideally, I prefer to rejuvenate all three zones simultaneously to restore a youthful ap-
pearance with a harmonious transition from zone to zone. Most of the time, how-
ever, patients request improvement in one zone or only one component of a given
zone. Many patients who would be excellent candidates for full facial rejuvenation
say, “I just want my eyes or my neck done.” Another typical request is, “I know
I could use a face lift, but I just want to get rid of my baggy eyelids.” These patients
require an explanation of the aging process so they will understand that it is best to

In this 56-year-old patient, aging affected all three of the facial zones. She underwent
an endoscopic brow lift, upper and lower blepharoplasty, and face and neck lift. Her
postoperative result demonstrates harmonious rejuvenation of all three facial zones.
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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift
address an entire zone rather than individual components of a zone. It is even better
to address all three face and neck zones rather than only one. Nevertheless, some pa-
tients truly need rejuvenation of only one zone rather than of the full face. In these
patients, the aging process has advanced more rapidly in one zone than in the others.

The signs of aging are not as far reaching in this 48-year-old patient. Her facial ag-
ing was confined mostly to the upper third, or periorbital zone. She underwent an
endoscopic brow lift and upper lid blepharoplasty with transpalpebral midfacial re-
juvenation. Her postoperative result also demonstrates harmonious facial rejuvena-
tion, even though the surgical correction was far more limited.
When a patient expresses interest in a procedure involving only one zone, I advise
her or him about how the overall result could be enhanced by adding procedures in-
volving adjacent zones. Doing so avoids a patchwork effect in which a rejuvenated
periorbital area leads into an aging lower face and neck. The patient’s motivation
for seeking less rather than more may be financial, or could be related to a fear of
surgery and anesthesia, or the patient may have a genuine lack of concern about the
rest of the face compared with the area in question. The surgeon should initiate an
open discussion of the patient’s wishes, concerns, and fears so the patient will be
pleased rather than disappointed with the results. When examining a candidate for
face-lift surgery, I first determine which zones require intervention and whether the
aging process has affected the face equally. For example, is the most striking feature
of this aging face the neck, the midface, or the brow? Or are they all equally involved?
Facial aging involves more than sagging, wrinkling skin with shifting soft tissue; most
of these patients have also lost volume. An aging face in a thin patient looks much
older than an equally aged full face in an overweight patient. This is obviously re-
lated to loss of volume. After my initial impression, I evaluate the skin, each zone,
and the components of each zone according to my mental checklist.
Facial Skin
The evaluation includes an assessment of skin quality and skin excess, along with
the presence of rhytids at rest and on animation. I look for signs of photoaging and
sun-related dyschromia. I assess the skin’s thickness and elasticity and make a men-
tal note of where the excess skin is and whether the excess is real or apparent.
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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift
Checklist for Evaluating the Aging Face—Facial Skin
Quantity
 Visible skin excess
This 50-year-old woman has facial aging in all three zones. Her skin quality is rather
poor, showing real and apparent excess skin, significant photoaging, and deep rhytids
at rest and on animation.
Quality
 Thickness
 Elasticity
 Photoaging
Rhytids
 At rest
 On animation
This 51-year-old patient also demonstrates facial aging in all three zones but has bet-
ter skin quality. Her full, heavy face has more apparent than real excess skin, nor-
mal elasticity, and minimal photoaging. No rhytids are visible at rest.

Middle Third of the Face: The Perioral Zone
The perioral area, or middle third, is evaluated next. The nasolabial folds and mar-
ionette grooves are categorized by noting their depth at rest and when smiling (see
Chapter 9). The angle of the mouth is noted. The lips are evaluated for volume and
length of the upper lip. With aging, the lips lose a significant amount of volume and
the distance from the nose to the upper lip vermilion lengthens, leading to a loss of
definition of the philtral columns. Lip lines are noted. I specifically look at the depth
of the chin crease for chin ptosis and evaluate the jowls. I also evaluate the role of
the mandibular ligament in the aging appearance in this area. The nose, especially
the tip, often becomes ptotic with aging.
Upper Third of the Face: The Periorbital Zone
Evaluation of the periorbital zone begins with an analysis of the medial and lateral
brow position and the relationship of the brow to the upper eyelid. I look at the
glabella for lines as well as active and passive rhytids. The temporal brow junction,
with the upper cheek–zygomatic area, is evaluated for the presence of deep rhytids
(crow’s-feet) and excess skin (see Chapters 27 and 35). I evaluate the upper and lower
lids, assessing the skin, muscle, and fat in the lids. After noting the relationship of
the upper lid to the brow, I move to the lower lid, noting the relationship of the lower
lid to the cheek and the transition from the periorbital to the perioral zone. Lower
lid tone is assessed. The volume of the cheek and midface area is also noted.
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Part VIII  Face Lift and Neck Lift
Checklist for Evaluating the Upper Third of the Face/Periorbital Zone
Brow position
Lower eyelid
 Lateral
 Skin
 Medial
 Muscle
Glabella
 Fat
 Depth of rhytids
 Lid-cheek junction
 Muscle activity
 Lid tone
Upper eyelid
Nasolabial folds
 Skin
Transition to perioral zone
 Muscle
Soft tissue volume
 Fat
 Relationship to brow

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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift
Checklist for Evaluating the Middle Third of the Face/Perioral Zone
Nasolabial folds and marionette grooves
Lower lip
Angle of the mouth
 Volume
 Downward
 Lip lines
 Neutral
Chin
 Upward
 Chin crease
Upper lip
 Chin ptosis
 Volume
Jowls
 Length
Nose
 Philtral columns
 Tip ptosis
 Lip lines
Lower Third of the Face: The Neck Zone
In assessing the quality and quantity of the neck skin, I look for excess skin below
the thyroid cartilage and over the sternocleidomastoid muscle. A judgment is made
as to whether the submental skin excess is real or apparent. I then look at the jaw-
line, submental area, and neck-jaw angle and their relationship to each other. As-
sessment of the submental and neck fat includes the subcutaneous fat and the sub-
platysmal fat. I differentiate between subcutaneous and subplatysmal fat by pinching
the submental area at rest and then after contraction of the platysma muscles.
Checklist for Evaluating the Lower Third of the Face/Neck Zone
Skin
Fat
 Quality
 Subcutaneous/preplatysmal
 Quantity
 Subplatysmal
– Real excess
 Platysma bands
– Apparent excess
 Jawline
 Neck/jaw angle
 Digastric muscles
 Submandibular gland

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Part VIII  Face Lift and Neck Lift
Evaluation of excess skin of the neck and platysma bands with the patient at rest
Evaluation of the location of submental fat,
pinching the submental area at rest
Subcutaneous versus platysma fat is
assessed by pinching the submental
area during contraction
The platysma bands are evaluated. The submandibular gland and digastric muscles
are assessed by looking for a bulge below the mandibular rim within the sub-
mandibular triangle, especially on neck flexion.
Evaluation of platysma bands on animation

Facial Adhesions and Retaining Ligaments
Determining whether the facial ligaments and adhesions should be released is an im-
portant step in planning surgical rejuvenation of the face.
Proper elevation and rejuvenation of the periorbital area depends on the appropri-
ate release of a number of temporal adhesions and attachments, regardless of the de-
gree of brow ptosis or facial aging. In contrast to the face, these temporal adhesions
and attachments are not visible and cannot be assessed clinically.
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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift
Orbitomalar
ligaments
Fixed
nasolabial
sulcus
Masseteric
cutaneous
ligaments
Mandibular
ligament
Zygomatic
ligaments
Orbitomalar
ligaments
Fixed
nasolabial
sulcus
Masseteric
cutaneous
ligaments
Mandibular
ligament
Zygomatic
ligaments
Retaining ligaments of the midlateral face can be assessed clinically. These ligaments
maintain the facial skin in its normal anatomic position. Stuzin et al described two
types of retaining ligaments: a true osteocutaneous ligament running from a fixed
bony origin to the dermis (such as zygomatic and mandibular), and a second system
made up of a coalescence of superficial and deep facial fascia fixing the fascial lay-
ers to the underlying structures, such as the parotid and masseter, and then attaching
superficially to the skin (the parotid cutaneous and masseteric cutaneous ligaments).
These ligaments are essentially fixed structures so that facial tissue, especially fat
pads, can pivot around them, producing creases such as the marionette lines of the
lower face. With age, the ligaments attenuate and relax. This relaxation, along with
loss of skin elasticity and soft tissue, causes some of the stigmata of aging. The zy-
gomatic ligaments suspend the malar soft tissues and fat pad over the zygomatic

prominence. As this support weakens, the malar soft tissues gradually migrate down-
ward, and redundant skin hangs over the fixed nasolabial sulcus. Rather than deep-
ening with age, it is the downward migration of the soft tissues against the fixed na-
solabial sulcus that accounts for the observed changes. Similarly, attenuation and
weakness of the masseteric cutaneous ligaments allow a downward shift of the cheek
tissues below the mandibular margin. Tethering by the mandibular ligament forms
the jowls.
Clinical evaluation of the face should take note of these ligaments and the role they
play in the aging face. Ligaments extending from bone to dermis must be released
during a face lift to achieve the desired results. Leaving the masseteric ligaments in-
tact limits lateral mobility. An evaluation of the relevance of these ligaments to the
observed aging changes allows the surgeon to plan appropriately for ligament re-
lease. Although release of these ligaments is required in most older individuals, it is
not always necessary to divide them in younger individuals and in those undergoing
limited rejuvenation procedures.
TREATMENT OPTIONS
The Face
I do not believe that there is a face lift for all seasons. However, all described face-
lift techniques have five things in common:
1. An incision
2. Flap elevation
3. Vectors
4. Fixation
5. Ancillary procedures
Evaluation of the face leads to selection of the procedure including length and loca-
tion of the scars, level and extension of dissection or flap elevation, management of
the superficial musculoaponeurotic system (SMAS), vectors, volume management,
and ancillary procedures. These decisions are based on analysis of the patient’s de-
gree of aging, morphology, skin quality and quantity, and, most important, the pa-
tient’s expectations and my understanding of the anticipated result.
The options include a variety of incisions, different levels of dissection, varying extent
of skin undermining, different vectors, and repositioning of the subcutaneous tissues
through a number of suspension or plication techniques.
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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift
Incisions
The length of the incisions varies from liposuction and endoscopic access incisions to
the classic full-length face-lift incision. The purpose of skin incisions is to gain ac-
cess to deeper tissues, resect excess skin, or both.
If the purpose of the skin incision is to allow access to the deeper tissues, and the
deep tissue rearrangement renders the desired result without skin excision, these ac-
cess incisions can be kept to a minimum, as in liposuction and endoscopic proce-
dures. If the desired result cannot be attained through the rearrangement of the deeper
tissue without skin excision, a longer skin incision is necessary, and the length of
that skin incision will reflect the location of the excess skin to be removed. For ex-
ample, endoscopic face lifting is achieved without removing any facial skin, whereas
short-scar face-lift techniques eliminate the postauricular scar in patients who have
no excess skin below the level of the cricoid and posterior to the sternomastoid. How-
ever, the success of endoscopic and short-scar procedures depends not only on the
location of excess skin but also on the quality and elasticity of the skin. These pro-
cedures rely on redraping and redistribution of the skin, especially in the neck.
Stretched, inelastic skin, regardless of location—face, breast, or abdomen—will not
redrape, redistribute, or retract and must be excised.
The short-scar techniques have increased in popularity as patients demand mini-
mally invasive procedures, with less down time and reduced morbidity. Patient se-
lection is the key, because unless a less-invasive procedure with a shorter scar pro-
duces a result comparable to that of standard procedures, is not in the best interest
of the patient and may result in loss of the surgeon’s credibility. In selecting patients
for the short-scar technique, I assess the quality of the neck skin and then evaluate
the patient with what I call the “vertical simulation” test. I place my hand on the
Treatment Options for the Face
Incisions
Extent of skin undermining
 Length
SMAS management
 Location
 Plication
Levels of dissection
 Resection and plication
 Subcutaneous
 Mobilize, resect, and plicate
 Subfascial
Vectors
 Subperiosteal
 Vertical
 Combination
 Diagonal
Suspension sutures

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Part VIII  Face Lift and Neck Lift
side of the patient’s face in front of the tragus and pull vertically upward, simulat-
ing the vertical vectors of the short-scar face lift. While my hand is elevating this tis-
sue, I observe the junction of the earlobe and neck skin. If there are no folds of excess
skin extending posteriorly beyond that area, the patient is an excellent candidate for
a short-scar face lift. If there is excess skin or if a fold develops there, the patient is
best suited for a full-scar procedure. Additionally, this test also enables me to evalu-
ate the neck and submental area and determine whether I will make a submental in-
cision or not by observing the neck during the vertical simulation test.
For example, these images depict an ideal candidate for a short-scar face lift. The
vertical vector, as demonstrated by the examiner’s hand, does not result in any folds
of excess skin behind the earlobe, and the improvement seen in the submental area
obviates the need for a submental incision.

In contrast, these images show an individual who would not be a candidate for a
short-scar face lift, because the vertical vector demonstrated by the examining hand
results in folding of excess skin beyond the earlobe, and the lack of improvement in
the submental area and jawline indicates the need for a submental incision and a
central approach to neck recontouring.
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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift

Location
The scar location depends on the patient’s facial structure, including the hairline,
sideburns, skin color, and ear topography.
Temple Incision
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Part VIII  Face Lift and Neck Lift
Incision behind the temporal hairline
Prehairline incision
The options include placement of the incision 2 to 3 cm behind the temporal hair-
line or right at the temporal hairline. This decision is based on the distance between
the lateral canthus and the anterior part of the temporal hairline, which ideally should
be 3 to 5 cm. To maintain this ideal distance, the excess skin over the upper cheek is
assessed. This excess skin will be recruited and rotated upward when the face-lift flap
is elevated. If resection of excess cheek skin through the incision behind the tempo-
ral hairline would widen the distance between the hairline and lateral canthus, I pre-
fer a prehairline incision to maintain a natural 3 to 5 cm distance. Widening beyond
5 cm results in an unnatural or “operated-on” appearance. When resection of the ex-
cess cheek skin would not shift the temporal hairline posteriorly or widen the dis-
tance between the hairline and lateral canthus, the incision can safely be placed be-
hind the hairline. This placement is of more significance in men than in women.

In patients with short sideburns, I prefer the prehairline incision to avoid elevation or
elimination of the sideburns through the vertical shift of facial skin. In secondary
face lifts I make a prehairline incision, because most of these patients already have
shortened sideburns.
Preauricular Incision
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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift
Incision behind the temporal hairline
Prehairline incision
To mask this difference, a curved incision along the curve of the anterior border of the
helix is made to the upper border of the tragus. At this juncture, the incision may be
curved in front of the tragus or along the posterior border of the tragus; then it fol-
The incision in the preauricular area is made in
the anatomic margin between the ear and the
face rather than in front of it. Not only the color
but also the texture and thickness of the ear skin
vary from that of facial skin.

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Part VIII  Face Lift and Neck Lift
I used to make retroauricular incisions only in patients with inelastic or stretched
neck skin with excess skin below the cricoid and posterior to the sternomastoid, but
now I rely on the vertical simulation test to determine the need for a retroauricular
incision. This incision is best placed within the retroauricular sulcus. The upward
length is not only a matter of personal preference but of practical importance. I vary
it according to my estimate of the amount of skin to be removed. The less skin that
is being removed, the longer I make this retroauricular incision before taking it trans-
versely across into the occipital hairline. In patients with an excessive amount of re-
dundant skin, I take this incision across to the occipital hairline and then follow it
downward. I discuss these options with patients so they understand the incisions are
being altered to achieve a better result.
lows the sulcus between the earlobe and the cheek. My preference is for the intra-
tragal incision along its posterior border but not behind the tragus. A well-executed
intratragal incision is imperceptible compared with a pretragal incision. In the rare
patient who has little color difference between the facial and tragal skin, the pretra-
gal incision may serve as well. For a tragal incision to be imperceptible, the tragus
has to have a beginning and an end and not blend into the cheek at the lower bor-
der. The inferior tragal border must be preserved. The prominence of the tragus plays
a role in selecting the intertragal incision. The more prominent the tragus, the bet-
ter the rest will be. A flat tragus may retract forward and lead to enlargement of the
external auditory meatus. Special attention must be paid in men, whose facial skin
may be ruddier than the ear skin. In these patients a pretragal incision is preferred.
Retroauricular Incision
A high retroauricular incision crossing
to the hairline—best suited to individuals
with modest redundancy of neck skin
with normal skin elasticity
A lower retroauricular incision crossing
to the hairline—best suited to individuals
with modest to excessive redundancy of
neck skin with some loss of skin elasticity
An occipital hairline incision—best suited
to individuals with excessive or massive
skin redundancy, especially in the lower
neck with stretched, inelastic skin

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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift
Face Lift: Incision Options
Prehairline With
Temporal
Discontinuous
Continuous With
Features
Prehairline
Temporal Incision
Preauricular Incision
Sideburns
High or short


Low or long

Hairline
Anterior: Lateral canthus


to hairline distance 3 to 5 cm
Posterior: Lateral canthus
to hairline distance 5 cm


Secondary Face Lift


Choosing the Best Option
I personally do not perform a subcutaneous face lift and believe that few surgeons
do. The subcutaneous dissection serves two purposes: access to deeper tissues (SMAS)
and skin resection. All modern face-lift techniques include various degrees of skin
undermining. Extensive skin undermining to release the nasolabial fold and mandibu-
lar retaining ligaments, although effective, can increase the risk of vascular compro-
mise and hematoma.
Levels of Dissection
Subcutaneous

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Part VIII  Face Lift and Neck Lift
Subfascial
Infraorbital
nerve
Periosteal
elevator
Most modern face lifts include some form of sub-
fascial or sub-SMAS dissection. The extent of this
dissection varies from technique to technique. The
vectors and methods of plication also vary from
surgeon to surgeon. I rely heavily on SMAS mo-
bilization and a vertical vector for improvement of
the perioral area, jowls, and jawline.
Low dissections of the SMAS have a limited effect
on the upper midface and periorbital area. High
SMAS dissections dramatically improve the upper
midface and periorbital area.
The advantage of the subperiosteal approach to
the midface is its relative ease, speed, and safety.
The facial nerve branches are less at risk with this
approach; however, it is limited in its effects on
the lower face, jawline, and jowls. The sub peri -
osteal approach depends on suspension sutures to
maintain the result.
In thin faces, I try to preserve the SMAS; in heavy faces, I resect it. I plicate the SMAS
or undermine and plicate as necessary. My preference is to incise the SMAS not im-
mediately preauricular, as in some described techniques, but at the junction of the
mobile and fixed SMAS. This avoids dissecting the very thin SMAS in the preauricular
area. My decision to plicate or to mobilize and plicate the SMAS depends on its mo-
bility. I pick the SMAS up at the junction of the fixed and mobile SMAS and pull it
superiorly while observing the effect on the jawline and perioral area. If the pull pro-
vides the desired effect, I simply plicate (in thin faces), or resect and plicate (in heavy
faces). However, if pulling without mobilization does not produce the desired effect,
I incise and mobilize the SMAS until the desired effect is observed.
Subperiosteal

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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift
Combinations
The subperiosteal and subfascial or subperiosteal and subcutaneous levels of dis-
section can be combined in a variety of ways. Examples include a subperiosteal ap-
proach to the periorbital area and midface and a sub-SMAS approach to the peri -
oral area and jawline.
Vectors
SMAS deep
tissue vector
Skin vector
SMAS deep
tissue vector
Skin vector
Most modern face lifts include a separate vector for the skin and deeper tissues. The
deeper tissues are elevated in a more vertical or diagonally vertical vector and the
skin in a more posterior and vertical direction. The vertical vector on the SMAS im-
proves the jawline, the perioral area, and, with the high SMAS technique, the midface.
The more diagonal vector on the platysma improves on the neck and submental area.
With a short-scar face lift, the skin vector is vertical, but the vector on the SMAS
and platysma can be varied.

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Part VIII  Face Lift and Neck Lift
Subfascial
Face Lift: Levels of Dissection
Suspension
Standard
High
Extended
Sutures and
Regional Effects
Subcutaneous
SMAS
SMAS
SMAS
SMASectomy
Subperiosteal
Devices
Periorbital







Cheek and nasolabial folds







Jowls and jawline







Neck





Vectors
Diagonal
Vertical
Vertical
Vertical
Vertical
Vertical
Diagonal
Diagonal
Diagonal
Diagonal
Diagonal
Diagonal
Risks
Skin flap viability





Facial nerve





Choosing the Best Option
Degree of effectiveness indicated by the number of pluses.
Most endoscopic and subperiosteal midface techniques require suspension sutures
or other devices to elevate and hold the soft tissues in the desired position. Although
usually effective, these sutures are not risk free; a disadvantage is that the fixation
point is far removed from the tissue being fixed.
Suspension
suture
Subperiosteal
undermining
Sutures
Suspension
Suspension
suture
Subperiosteal
undermining

Ancillary Procedures
Ancillary procedures include volume management and resurfacing. These are per-
formed almost routinely in all of my facial rejuvenation procedures to enhance the
overall result. Although in the past the actual face lift was the end result, today many
of us feel that the face lift lays the foundation, and the ancillary procedures that are
performed concomitantly represent the finishing touches that result in true rejuve-
nation rather than simply the rearrangement of soft tissues.
Volume Management
Although volume management usually includes augmentation of tissues, in selected
patients I also remove excess volume, especially in the neck and jowls. Alloplastic
implants, autologous fat, and fillers are available for volume enhancement. By far
the most popular material of choice for volume enhancement is autologous fat. In
some patients, volume enhancement with fat transfer has become routine. Alloplas-
tic materials such as chin and cheek implants may be preferable to fillers or autolo-
gous fat in selected patients. Fillers are also an acceptable alternative to autologous
fat for volume enhancement.
The buccal fat pad is very prominent in some heavy faces and must be addressed to
recontour the perioral area and jawline. The buccal fat pad can be approached ei-
ther through the face-lift incision deep to the platysma or through an intraoral inci-
sion. I have resected the buccal fat pad as an isolated procedure in heavy, youthful
faces (those that present a cherubic appearance) and in primary as well as second-
ary face lifts for recontouring. Despite the intimate relationship of the superficial por-
tions of the buccal fat pad with the facial nerve, I have found this procedure to be
both safe and effective. Although I rarely resect the buccal fat pad, in the right pa-
tient it has a dramatic effect in recontouring the lower face and managing volume.
It is rare and only in a heavy face that I resect fatty tissue. When I do so, it is limited
to the jowls. However, in all but the thinnest of necks I resect some fat below the
skin, between the platysma or deep to the platysma, depending on the volume of the
neck and distribution of the fat in these three layers.
Resurfacing
Rearranging the deep tissues and resecting excess skin does not always result in im-
provement of the quality of the skin. Sun-damaged, inelastic, wrinkled skin is usu-
ally dealt with through resurfacing, concomitant with the face lift. This includes der-
mabrasion, peels (croton oil or TCA), and lasers. These procedures, when combined
with a face lift, are not only effective but also safe if limited to the areas where there
has been no skin undermining. The undermined skin may also be treated with der-
mabrasion, peel, or laser, but cautiously and very superficially. Judgment must be
exercised on an individual basis when resurfacing over face-lift flaps.
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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift

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Part VIII  Face Lift and Neck Lift
The Neck
Treatment Options for the Neck
Incisions
Extent of skin undermining
 Length
Vectors
 Location
 Vertical
Levels of dissection
 Diagonal
 Subcutaneous
Suspension sutures
 Subplatysmal
Plication sutures
Incisions
Length
Incisions for rejuvenation and recontouring of the neck range from liposuction ac-
cess incisions to submental incisions and preauricular and retroauricular incisions.
Incision length is dictated by the anatomic and morphologic findings as well as the
planned procedure. The submental incision allows access to the medial platysma and
subplatysmal structures. The retroauricular incision allows access to the lateral
platysma and affords the opportunity for skin resection.
Location
SUBMENTAL
My preference for the submental incision, varying in length from 3 to
5 cm, is to place it just posterior to the submental crease. Others prefer to place the
incision within the crease. I believe placement within the crease further deepens the

crease and attracts attention to the scar. Posterior placement affords better access to
the submental area and allows dissection anteriorly to eliminate or render the sub-
mental crease less shallow. This incision also allows access to the chin for correc-
tion of the ptotic or “witch’s” chin.
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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift
RETROAURICULAR
In the isolated neck lift without a face lift, it is sometimes nec-
essary to begin the incision at or below the level of the tragus, continuing around
the earlobe and into the retroauricular area to prevent earlobe distortions and im-
prove access to the jawline and neck. In the past I typically reserved retroauricular
incisions for patients with inelastic or stretched neck skin with excess skin below the
cricoid and posterior to the sternomastoid, but now I rely much more on the vertical
simulation test. The best placement is within or just above the retroauricular sulcus.
Upward length should be varied according to the amount of skin removal required.
The less skin to be removed, the longer I make this vertical component before cross-
ing to the hairline. If neck skin is excessive, I place the incision along the occipital
hairline in a downward and backward direction rather than extending it into the
hair. These incisions are all planned preoperatively, and their location and alterna-
tives are fully discussed with the patient. I emphasize the benefits of a lower incision
in terms of tightening the lower neck skin.

Levels of Dissection
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Part VIII  Face Lift and Neck Lift
Neck Lift: Incision Options
Long to Just
Longer
Long to
Below Level
Above Level
Level of
of Tragus
Short in
of Tragus
Tragus
Then Crossing
Retroauricular
Crossing
Crossing
Down Along
Features
Preauricular
Submental
Sulcus Only
Into Hair
Into Hair
Occipital Hairline
Skin Quality
Normal elasticity


Inelastic, stretched,
sun damaged





Skin Quantity
No skin excess



Apparent skin excess



Real skin excess





Planes of Intervention
Superficial


Deep to platysma





Choosing the Best Option
Planes of the Neck
 Superficial plane
 Intermediate plane
 Deep plane
I think of the neck as having three planes: superficial (skin and subcutaneous fat),
intermediate (platysma and interplatysmal fat), and deep (subplatysmal structures).