1421
Chapter 42 The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
This 46-year-old woman presented with combined deflated and ptotic facial features.
There was a discrete ptosis of the eyebrow tail, with significant hollowing of the up-
per eyelid. The lower eyelid was empty, without significant laxity. The midface was de-
flated and ptotic, resulting in a heavy nasolabial fold. The corners of the mouth con-
tinued into an incipient marionette groove. The definition of the jawline was disturbed
by marked jowling. She also requested a reduction rhinoplasty.
Analysis of her photograph in her late twenties reveals a general oval shape of her
face. The youthful fullness of the upper eyelids and midface is striking compared
with the empty look in her forties. Note the absence of nasojugal and nasolabial
folds and marionette grooves in her earlier photo.
1422
Part VIII Face Lift and Neck Lift
Surgical Plan
Extended MACS-lift
Short-scar temporal lift
Microfat grafting of the medial upper eyelid hollow (1.5 cc), the malar and infraorbital
area (10 cc), the nasolabial fold with subcision (3 cc), the marionette groove (2.5 cc); in
total, 34 cc of fat grafted
Pinch lower blepharoplasty
Open rhinoplasty
The results after 1 year show a replenishment of her eyelids and midface, with a gen-
eral triangularization of her face as a result of the cranial shift of soft tissue volumes.
The nasolabial folds, marionette grooves, and jowls have corrected. Note the re-
semblance to her youthful photo.
1423
Chapter 42 The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
This 49-year-old man requested facial rejuvenation. He had thick, heavy skin and
generalized facial sagginess. He has some fatty infiltration of the submental area and
ptotic jowls, with deep nasolabial folds and heavy overlying grooves. The midface
had descended, and there was a distinct crease between the cheek and lower eyelid,
which bulged from the eyelashes to the infraorbital rim. His upper eyelids were hol-
low, and the eyebrows were heavy and low set. The tail of the eyebrow had dropped,
causing lateral crowding, with two to three deep horizontal creases in the paracan-
thal area. The patient also had deep frontal wrinkles.
1424
Part VIII Face Lift and Neck Lift
Surgical Plan
Submental liposuction
An extended MACS-lift
Pinch lower blepharoplasty with transconjunctival resection of fat
Short-scar temporal lift with galeopexy (this procedure was done under local anesthe-
sia with intramuscular midazolam 4.5 mg and took 2 hours 40 minutes)
The patient, shown 9 months and 3 years later, demonstrates correction of the cer-
vicomental angle, definition of the mandibular border, and improvement of the jowls,
with suspension of the submandibular glands by vertical tightening of the platysma
muscles. The nasolabial groove has been reduced, and the midface shows almost
complete rejuvenation of the lid-cheek junction. The malar volume is enhanced; this
effect can be best appreciated on the oblique view, where the effect of the temporal lift
can also be seen. The tail of the eyebrow has been raised about 1 cm. The beard and
sideburn remain in an anatomic position.
Today we would add microfat grafting in the midface and nasolabial folds to en-
hance the long-term stability of this patient’s result.
1425
Chapter 42 The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
Preoperative
9 months postoperatively
3 years postoperatively
This 56-year-old patient, described earlier (p. 1388), presented with general sagging
of the lower part of the face with a marked nasojugal groove and demarcation of
the inferior orbital rim, pronounced nasolabial folds, marionette grooves, jowling,
and a fatty, infiltrated neck. Correction was performed under local anesthesia with
intramuscular midazolam sedation.
1426
Part VIII Face Lift and Neck Lift
Surgical Plan
Extended MACS-lift
Submental liposculpture
Lower pinch blepharoplasty
Her results, seen 18 months postoperatively, reveal a nice redistribution of facial vol-
umes with augmentation of the zygomatic region, shortening of the vertical height
of the lower eyelid, reduction of the skeletonized aspect of the orbital region, and a
better transition between the lower eyelid skin and the cheek skin. There is visible
softening of the nasolabial fold and the marionette grooves, better definition of the
jawline, and correction of cervical skin laxity. The patient’s general facial shape now
appears less square and is more triangular and youthful looking.
1427
Chapter 42 The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
This 60-year-old man presented with the stigmata of facial aging in the submental
area and a total absence of cervicomental angularity and jawline definition. His jowl-
ing, marionette grooves, and nasolabial folds were pronounced. There was general
sagging of the midface, with skeletonization of the lower orbital region. Correction
was performed with the patient under general anesthesia (his preference), with a
1-day hospital stay.
1428
Part VIII Face Lift and Neck Lift
Surgical Plan
Extended MACS-lift
Transconjunctival fat removal
Submental liposculpture
Pinch lower blepharoplasty
His results, seen 1 year postoperatively, reveal a stable correction of the aging facial
features. The cervicomental angle has been reconstructed without opening the neck.
Correction of the jowling is evident, with better definition of the jawline. The down-
ward slant of the corners of the mouth was also corrected, and a general triangu-
larization of his square face can be seen on frontal view. Four millimeters of lower
eyelid skin was removed in the paracanthal region. This, together with the removal of
transconjunctival fat, resulted in a natural, rejuvenated lower eyelid without chang-
ing the shape of the palpebral fissure.
In oblique and profile views, the inconspicuous preauricular and temporal hairline
scar can be noted as well as the unaltered position of the sideburns because of the
purely vertical redraping of the skin. This also resulted in a hair-free tragus, a natu-
ral male sideburn, and normal position of beard growth. A short haircut, as usually
worn by men, is perfectly possible with the MACS-lift technique.
1429
Chapter 42 The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
This 58-year-old patient presented with obvious signs of facial aging after a 60 kg
(132-pound) weight loss as a result of a Scopinaro bowel reduction procedure. She
showed significant general sagginess of the total facial skin envelope, with marked
jowling, obvious platysmal bands, and very noticeable perioral rhytids. Surgery was
performed with a local anesthetic with intramuscular midazolam sedation.
1430
Part VIII Face Lift and Neck Lift
Surgical Plan
An extended MACS-lift
Perioral erbium:YAG laser resurfacing
Submental liposuction
Posterior cervicoplasty
The 1-year postoperative view shows a very natural correction of the sagging facial
features in a cranial direction. Correction of the submental area, with restoration of
the cervicomental angle, was accomplished without opening the neck. A posterior
cervicoplasty was necessary, not for the effect on the submental area, but for removal
of unaesthetic skin folds at the end of the procedure. Jowls and marionette grooves
were corrected, as were perioral rhytids. The skeletonized aspect of the orbital re-
gion was corrected by upward movement of the malar soft tissues and a subsequent
lower pinch blepharoplasty.
1431
Chapter 42 The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
Clinical Caveats
A short-scar face lift is not a classic face lift with a short scar.
The only rejuvenating vector is the vertical one. The horizontal vector does not re-
juvenate the face, but puts the face under tension and causes flattening of the face.
The vertical vector should work on the deep tissues and on the skin.
Purse-string sutures strongly anchored to the deep temporal fascia are not the same
as cable sutures from one point to another. A cable suture gives traction between
two points. Purse-string sutures, as used in the MACS-lift, are a facial sculpturing
technique that causes multiple microimbrications in the subcutaneous tissue.
After vertical redraping of the skin flap, the skin is resected in the temporal region.
This skin resection will act as a lock of the microimbrication result on the subcu-
taneous facial tissues.
Skin suturing starts from superior to inferior to prevent and treat dog-ear forma-
tion in the temporal area.
Only when residual skin folds are visible in the infraauricular region at the end of
the skin suturing is a posterior cervicoplasty carried out. This is done only for re-
draping of unacceptable skin folds and will have no effect on the submental region.
1432
Part VIII Face Lift and Neck Lift
Annotated Bibliography
Baker DC. Minimal incision rhytidectomy (short-scar face lift) with lateral SMASectomy:
evolution and application. Aesthet Surg J 21:14-26, 2001.
This article describes a large series of short-scar face lifts using lateral SMASectomy on
the deep tissues and provides a classification of indications for short-scar face lifting.
Camirand A, Doucet J. A comparison between parallel hairline incisions and perpendicular
incisions when performing a face-lift. Plast Reconstr Surg 99:10-15, 1997.
This article provided us with the tools to optimize the quality of the temporal prehair-
line incision and to reduce dog-ear formation at the superior end of the incision.
Connell BF, Semlacher RA. Contemporary deep layer facial rejuvenation. Plast Reconstr Surg
100:1513-1523, 1997.
Comprehensive article on rhytidectomy by one of the masters of facial rejuvenation surgery.
Hamra ST. Composite Rhytidectomy. St Louis: Quality Medical Publishing, 1993.
Breakthrough textbook initiating the concepts of vertical vectors and midface rejuve-
nation, incorporating the lower eyelid into the rhytidectomy procedure.
Little JW. Three-dimensional rejuvenation of the midface: volumetric resculpture by malar
imbrication. Plast Reconstr Surg 105:267-285; discussion 286-289, 2000.
Pioneering article that established volumetric procedures as a key to facial rejuvenation.
Owsley JQ, Fiala TG. Update: lifting the malar fat pad for correction of prominent nasolabial
folds. Plast Reconstr Surg 100:715-722, 1997.
Inspiring article about the possibilities of malar fat suspension to correct the midface
and nasolabial fold.
Saylan Z. The S-lift: less is more. Aesthetic Surg J 19:406-409, 1999.
This article started our thinking in the direction of short scars and purse-string suture
suspension.
Verpaele A, Tonnard P, Gaia S, et al. The third suture in MACS-lifting: making midface-lift-
ing simple and safe. J Plast Reconstr Aesthet Surg 60:1287-1295, 2007.
The minimal access cranial suspension (MACS)-lift exists in a simple and extended ver-
sion. The simple MACS-lift achieves a vertical lifting of neck and lower half of the face
with two purse-string sutures. The action of a third, malar suture gives additional cor-
rection of the middle third of the face, and results in the extended MACS-lift. It pro-
duces a natural midface lifting through a short scar, with adequate softening of the na-
solabial fold and good support of the lower eyelid.
Suggested Readings
Baker DC. Commentary on: Marchac D. Against the “visible” short scar face lift. Aesthet
Surg J 28:200-208; comment 209-210, 2008.
Baker DC. Lateral SMASectomy. Plast Reconstr Surg 100:509-513, 1997.
Byrd HS, Andochick SE. The deep temporal lift: a multiplanar, lateral brow, temporal, and
upper face lift. Plast Reconstr Surg 97:928-937, 1996.
Carniol PJ, Ganc DT. Is there an ideal facelift procedure? Curr Opin Otolaryngol Head Neck
Surg 15:244-252, 2007.
Coleman SR, Mazzola RF. Fat Grafting: From Filling to Regeneration. St Louis: Quality Med-
ical Publishing, 2009.
Donofrio LM. Fat distribution: a morphologic study of the aging face. Dermatol Surg
26:1107-1112, 2000.
Feldman JJ. Necklift. St Louis: Quality Medical Publishing, 2006.
Finger ER. A 5-year study of the transmalar subperiosteal midface lift with minimal skin and
superficial musculoaponeurotic system dissection: a durable, natural-appearing lift with
less surgery and recovery time. Plast Reconstr Surg 107:1273-1283; discussion 1284,
2001.
Fulton JE, Saylan Z, Helton P, et al. The S-lift facelift featuring the U-suture and O-suture
with skin resurfacing. Dermatol Surg 27:18-22, 2001.
Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 83:11-16, 1989.
Furnas DW. Strategies for nasolabial levitation. Clin Plast Surg 22:265-278, 1995.
Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane.
Plast Reconstr Surg 102:1646-1657, 1998.
Hester TR, Codner MA, McCord CD. The “centrofacial” approach for correction of facial
aging using the transblepharoplasty subperiosteal cheek-lift. Aesthetic Surg Q 16:51-58,
1996.
1433
Chapter 42 The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
Hunstad JP. A systematic approach to MACS-lift operative techniques. In Tonnard PL, Ver-
paele AM, eds. Short-Scar Face Lift: Operative Strategies and Techniques. St Louis: Qual-
ity Medical Publishing, 2007.
Jewell ML. The MACS-lift short-scar face lift: technical and strategic considerations. In Ton-
nard PL, Verpaele AM, eds. Short-Scar Face Lift: Operative Strategies and Techniques.
St Louis: Quality Medical Publishing, 2007.
Karam AM, Nayak LM, Lam SM. Short-scar purse-string facelift. Facial Plast Surg Clin
North Am 17:549-556, 2009.
Kestemont P. [Description and critical analysis of the “Tonnard and Verpaele’s” technique
for malar suspension] Ann Chir Plast Esthet 54:421-424, 2009.
Knize DM. Limited incision submental lipectomy and platysmaplasty. Plast Reconstr Surg
101:473-481, 1998.
Matarasso A, Elkwood A, Rankin M, et al. National plastic surgery survey: face lift tech-
niques and complications. Plast Reconstr Surg 106:1185-1195; discussion 1196, 2000.
Nahai F. Short-scar face lift: indications and technical considerations. In Tonnard PL, Ver-
paele AM eds. Short-Scar Face Lift: Operative Strategies and Techniques. St Louis: Qual-
ity Medical Publishing, 2007.
Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional
stereolithography, with reference to the pathogenesis of midfacial aging, scleral show,
and lateral suborbital trough deformity. Plast Reconstr Surg 106:479-488; discussion
489-490, 2000.
Pessa JE. The potential role of stereolithography in the study of facial aging. Am J Orthod
Dentofacial Orthop 119:117-120, 2001.
Pitman GH. Commentary on Baker DC: Minimal incision rhytidectomy (short scar face lift)
with lateral SMASectomy: evolution and application. Aesthet Surg J 21:14, 2001.
Ramirez OM. Subperiosteal minimally invasive laser endoscopic rhytidectomy: the SMILE
facelift. Aesthetic Plast Surg 20:463-470, 1996.
Stuzin JM, Baker TJ, Gordon HL. Extended SMAS dissections: an approach to midface re-
juvenation. Clin Plast Surg 22:295-311, 1995.
Tonnard P, Verpaele A. 300 MACS-lift shortscar rhytidectomies: analysis of results and com-
plications. Eur J Plast Surg 28:198-205, 2005.
Tonnard P, Verpaele A. The MACS-lift short scar rhytidectomy. Aesthet Surg J 27:188-198,
2007.
Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial suspension lift: a modified
S-lift. Plast Reconstr Surg 109:2074-2086, 2002.
Tonnard PL, Verpaele AM, eds. The MACS-Lift: Short-Scar Rhytidectomy. St Louis: Qual-
ity Medical Publishing, 2004.
Tonnard PL, Verpaele AM. Refining the MACS-lift technique and defining its limits. In Ton-
nard PL, Verpaele AM, eds. Short-Scar Face Lift: Operative Strategies and Techniques.
St Louis: Quality Medical Publishing, 2007.
Tonnard PL, Verpaele AM, eds. Short-Scar Face Lift: Operative Strategies and Techniques.
St Louis: Quality Medical Publishing, 2007.
Verpaele A, Tonnard P. Lower third of the face: indications and limitations of the minimal
access cranial suspension lift. Clin Plast Surg 35:645-659, 2008.
1434
Part VIII Face Lift and Neck Lift
Short-Scar Rhytidectomy
DANIEL C. BAKER
CHAPTER 43
1436
Part VIII Face Lift and Neck Lift
R
hytidectomy is a procedure that continues to evolve as surgeons seek to offer
patients natural rejuvenation with reduced morbidity. Over the years I have
witnessed an evolution of techniques ranging from basic skin lifts to superficial mus-
culoaponeurotic system (SMAS) procedures to even more complex, deep plane op-
erations in search of an operation that reliably restores facial form with minimal
morbidity. More recently, the need for extensive incisions for rhytidectomy has also
been questioned. It has become increasingly clear that not all patients require the
full classic temporal preauricular and retroauricular incisions. The incisions, as well
as the planes or levels of facial dissection, should be individualized for each patient,
in keeping with the physical changes related to aging and the desired result. As more
patients seek facial rejuvenation at an earlier age, the need for surgical solutions that
are less invasive and that involve less downtime is becoming increasingly important.
My approach to rhytidectomy has evolved over time. During my plastic surgery res-
idency in the late 1970s, the rhytidectomy that I was taught was a combination of
extensive defatting of the neck with complete platysma muscle transection, plicating
the medial borders and pulling laterally. This was presented as the only way to achieve
the “best results.” However, after many years of patient complaints, complications,
and overoperated necks, I decided to abandon most of these techniques in favor of
my current approach—a short-scar rhytidectomy with lateral SMAS ectomy or SMAS
plication in selected cases.
Today there are a variety of rhytidectomy techniques that produce excellent results.
Each surgeon must adopt a technique that serves his or her patients well and ideally
is safe, consistent, and applicable to a variety of anatomic problems. For me, the
short-scar rhytidectomy is a versatile technique that provides the solution I have been
seeking for a wide range of problems for patients of various ages, without the down-
side of more traditional procedures. With this approach I am confident of obtaining
consistently good results with shorter scars, minimal risk of complications, reduced
morbidity, and speedy postoperative recovery. It is a quick, safe, and reproducible
operation that combines the versatility of traditional SMAS flap undermining with
the safety and rapidity of SMAS plication or lateral SMASectomy.
Evolution of Technique
SMAS
In 1976 the work of Mitz and Peyronie helped to popularize the SMAS. With this
approach, the lateral SMAS was dissected directly overlying the parotid gland. I per-
formed this type of SMAS dissection in the late 1970s and continued to do so into
the mid-1980s. Generally I was disappointed with the effects of a simple elevation
and tightening of the lateral superficial fascia, because I saw little appreciable dif-
ference in overall facial contour, regardless of whether a lateral SMAS dissection had
been performed.
1437
Chapter 43 Short-Scar Rhytidectomy
Increasing experience with SMAS dissection convinced me that the mobile SMAS
anterior to the parotid gland would have to be elevated if the superficial fascia were
to effect a change in facial contour. However, this more extensive SMAS dissection
places the facial nerve branches in greater jeopardy. Additionally, the superficial fas-
cia tends to thin out as it is dissected more anteriorly, making the SMAS more prone
to tears. Because thinning and tearing after SMAS flap elevation was a common oc-
currence, compounded when significant tension placed on the SMAS flap during su-
turing resulted in additional tears, I concluded that extensive SMAS dissection was
not warranted in most patients and offered little long-term benefit in comparison
with SMAS plication.
Lateral SMASectomy
In 1992 I discovered the benefits of the lateral SMASectomy as an alternative to for-
mally elevating the superficial fascia. With this approach, a portion of the SMAS is
removed in the region directly overlying the anterior edge of the parotid gland at the
interface of fixed and mobile SMAS. Excision of the superficial fascia in this region
secures the mobile anterior SMAS to the fixed portion of the superficial fascia over-
lying the parotid gland. The SMASectomy is performed in a direction parallel to the
nasolabial fold to ensure that the vectors of elevation after SMAS closure will lie per-
pendicular or more vertical to the nasolabial fold, thereby producing improvement in
this fold as well as in the jowl and jawline.
Thus lateral SMASectomy became the foundation for my evolving face-lift technique.
This was then combined with a short-scar approach, which addressed patient con-
cerns about scarring and morbidity. The lateral SMASectomy also served as a de-
bulking in full faced patients, but in thin faces I continued to perform SMAS plication.
SMAS resection
parallel to
nasolabial fold
Platysma flap sutured to
periosteum of mastoid,
defining jawline
Vector of elevation
(vertical)
Width of SMAS
resection depends
on degree of laxity;
in thin faces
plication only
1438
Part VIII Face Lift and Neck Lift
Short-Scar Rhytidectomy
The short-scar rhytidectomy with lateral SMASectomy or plication developed out
of the demands of younger female patients (mostly in their forties) who sought fa-
cial rejuvenation but were adamantly opposed to any scarring behind the ears. These
patients objected to the posterior hairline distortion, hypertrophic scars, and hy-
popigmentation that they often observed in their friends or mothers who had un-
dergone face lifts. They were embarrassed to wear their hair up or in a ponytail with
such scars visible.
Although most classic face-lift incisions heal well and patients are happy,
hairline disruptions like these are deforming and difficult to correct.
The concept of mini-lifts or reduced-incision face lifts is not new. Mini-lifts have been
performed for almost a century; the first description of such a procedure was by Pas-
sot in 1919. These early operations were usually preauricular skin excisions with
minimal undermining, resulting in minimal, short-lived improvement. More recently,
the S-lift concept and the MACS-lift techniques with suspension sutures have gained
popularity.
My first experience with short-scar rhytidectomy was in 1990, when I operated on a
young woman who had submental and submandibular fat and early jowling but
good cervical skin elasticity. I performed lipoplasty of the neck and jowls with wide
subcutaneous undermining in the face, detaching the malar and masseterocutaneous
ligaments. A pure skin lift was done, with no retroauricular scars. The result was ex-
cellent, and this experience prompted me to adopt this procedure for all of my
younger patients with similar anatomic features.
In 1992 I began to incorporate the lateral SMASectomy technique into the face-lift
operation for women in their forties. I noticed that vertical elevation of the face had
a beneficial effect on the cervical skin. Lax cervical skin was tightened because the
soft tissues of the face and neck are linked anatomically. Between 1990 and 1998
I performed this operation, which had no retroauricular scars, on a total of 204 young
female patients. The results were “ponytail friendly” for these young, active women.
As I gained experience with this operation and its potential benefits, I extended its
application to older patients who demonstrated greater degrees of jowling and cer-
vi cal laxity. With these patients, more extensive undermining was required in the
neck and over the sternomastoid and submandibular regions and usually required
a short retroauricular incision. This undermining exposed the platysma muscle in
the neck, thereby facilitating elevation at the posterior muscle, continuous with the
SMAS ectomy.
Between 1990 and 2009 I performed more than 2400 short-scar rhytidectomies with
lateral SMASectomy or SMAS plication in patients ranging in age from 40 to 74.
These patients exhibited a variety of facial aging changes and neck deformities. To-
day I can safely say that this procedure is as reliable and safe as other face-lift pro-
cedures. It is also reproducible by most plastic surgeons with generally consistent
results in properly selected patients. However, it is not applicable to all patients, par-
ticularly those with excessive cervical laxity and poor skin elasticity. As I have gained
more experience, my criteria for the best candidates have become more stringent.
Today I rarely compromise the result for a shorter scar.
1439
Chapter 43 Short-Scar Rhytidectomy
Advantages and Disadvantages
Lateral SMASectomy
Lateral SMASectomy has several advantages over traditional SMAS elevation. Be-
cause the procedure does not require traditional SMAS flap elevation, there is less
concern about tearing of the superficial fascia. The potential for facial nerve injury is
reduced because most of the deep dissection is over the parotid gland. If the SMAS -
ectomy is performed anterior to the parotid gland, the deep fascia will similarly pro-
vide protection for the facial nerve branches as long as resection of the superficial
fascia is done precisely and the deep facial fascia is not violated. Because SMAS flaps
have not been elevated, they tend to hold suture fixation more strongly, and thus the
potential for postoperative dehiscence and relapse of contour is decreased.
1440
Part VIII Face Lift and Neck Lift
A lateral SMASectomy or SMAS plication is performed at the interface of the su-
perficial fascia fixed by the retaining ligaments and the more mobile anterior super-
ficial facial fascia.
SMAS resection begins over parotid, extends to lateral canthus
Resection at interface of fixed and mobile SMAS
Width of SMAS resection depends on laxity
On closure, this brings the mobile SMAS up to the junction of the fixed SMAS, pro-
ducing a durable elevation of both superficial fascia and facial fat. In thin-faced in-
dividuals, no SMAS or fat is removed; instead, the lax SMAS is imbricated and pli-
cated to recontour atrophic areas in the face and to correct the midface and nasolabial
folds.
Short-Scar Face Lift
The primary advantage of a short-scar rhytidectomy is that it allows patients who
wear their hair pulled up or back to do so. Any retroauricular scarring or disruption
of the posterior hairline makes such patients unhappy. In addition, the operation in-
volves less dissection and is less invasive; presumably this causes less pain and results
in a shorter healing time. In patients who develop hematomas, evacuation is easier
with less morbidity.
1441
Chapter 43 Short-Scar Rhytidectomy
There are disadvantages as well. This technique is not suitable for all patients, espe-
cially those with severe cervical skin laxity. Because the technique requires a signifi-
cant vertical lift, strict attention must be paid to minimizing temporal hairline shifts.
In certain patients an anterior hairline incision must be used. Fitting dog-ears into
the temporal and earlobe areas can be a challenge, and these areas take more time
to soften and flatten. Exposure of the neck with the short-scar technique is limited,
sometimes making the operation technically more difficult.
However, I do not use this technique in every patient, and there is still the occasional
patient (usually with a very thin face) who has an excellent result with only a skin
undermining and redraping procedure. There are other patients with severe cervico-
facial laxity and loss of elasticity who benefit from a classic rhytidectomy operation
with retroauricular scars. Most classic rhytidectomy incisions, if well placed and
closed without tension, will heal well with minimal scarring.
Preoperative Assessment
Patient Profiles
Based on my surgical experience with this procedure, I have classified candidates for
this procedure into four types as follows.
1442
Part VIII Face Lift and Neck Lift
Advantages and Disadvantages of Minimal-Incision Rhytidectomy
Advantages
Less dissection
Less invasive
Less scarring
Avoids posterior hairline
distortion
Allows easier hematoma
evacuation
Neck exposure
Ponytail friendly
Disadvantages
Requires more vertical skin lift
Difficult to fit in “dog-ears” in temporal and
earlobe areas
Requires time for temporal hairline scar to smooth
Requires time for retroauricular sulcus/earlobe scar
to smooth
Occasionally causes skin fold at base of earlobe
Is not applicable to patients with severe cervical
laxity and poor skin elasticity
1443
Chapter 43 Short-Scar Rhytidectomy
Early jowls
Submental fat
Slight cervical
laxity
Characteristics
Surgical Plan
Age early to late forties
Suction-assisted lipoplasty (neck)
Aging primarily facial
SMASectomy or plication
Early jowling
Plication only in a thin face
Slight cervical skin laxity
Chin implant if indicated
May have submental fat
May have microgenia
Good skin elasticity
Ideal candidates for a short-scar rhytidectomy are usually in their early to late for-
ties, with signs of aging primarily in the face. Although they may have slight cervi-
cal laxity, skin elasticity is still good. They have early jowling, often with submental
and submandibular fat. Microgenia may also be present.
These patients can be effectively treated with closed lipoplasty of the neck and jowls,
wide subcutaneous skin undermining, and lateral SMASectomy or plication. No
retroauricular incision is necessary to improve the neck and face. If indicated, a chin
implant will enhance the result.
Type I: The Ideal Candidate
This woman is an example of a type I patient. She underwent a short-scar rhytidec-
tomy and is shown 8 months postoperatively as well as 10 years postoperatively,
when she returned for a secondary rhytidectomy.
1444
Part VIII Face Lift and Neck Lift
Preoperative: 47 years old
8 months postoperatively
10 years postoperatively: 57 years old
1445
Chapter 43 Short-Scar Rhytidectomy
Preoperative: 47 years old
8 months postoperatively
10 years postoperatively: 57 years old
Scars 10 years postoperatively
This 48-year-old woman had early jowling and cervicofacial laxity. Her face was
thin and her body fat was low. At work she always wore her hair in a ponytail and
was greatly concerned about retroauricular scars and posterior hairline disruption.
Her presentation made her a type I (“ideal”) candidate for short-scar rhytidectomy.
Her thin face and hollow cheeks were best treated with plication and imbrication to
augment and recontour her face. Her 1-year postoperative results demonstrate an
overall change in her facial shape to oval, with correction of the jowls and midface
and enhancement of her cheekbones. The lateral view shows correction of the neck,
with preservation of the hairline and imperceptible scars.
1446
Part VIII Face Lift and Neck Lift
1447
Chapter 43 Short-Scar Rhytidectomy
These patients are usually in their late forties to late fifties with moderate jowling
and cervical skin laxity. Submandibular and submental fat is usually present, and
they may have microgenia. Medial platysma bands are not present on normal ani-
mation. (I do not evaluate the platysma on forced animation or on the basis of static
photographs; often what may appear to be significant platysma bands represents lax-
ity only, which can be corrected with a lateral pull.)
Moderate jowls
Submental fat
Moderate cervical
laxity
Characteristics
Surgical Plan
Age late forties to late fifties
Suction-assisted lipoplasty (neck)
Moderate jowls
SMASectomy/platysma resection
Moderate cervical skin laxity
Plication only in a thin face
Submental/submandibular fat
Chin implant if indicated
May have microgenia
No active platysma bands
Type II: The Good Candidate
Closed lipoplasty of the neck and jowls along with lateral SMASectomy or plication
produces a good result in these patients. If indicated, a chin implant will enhance
the result. Usually a retroauricular incision is not required. However, if a dog-ear is
present at the earlobe, it can be corrected with a short retroauricular incision.
1448
Part VIII Face Lift and Neck Lift
This 55-year-old woman had moderate jowling and cervicofacial laxity with mini-
mal submental fat. Excess skin and fat of the upper and lower eyelids was present.
She represented a type II (“good”) candidate for short-scar rhytidectomy. To maintain
facial fat and restore facial fullness, plication of the SMAS and platysma was per-
formed. Her 1-year postoperative result demonstrates reestablishment of a youthful,
oval facial shape, enhancement of the submalar region and cheekbones, and correc-
tion of the oral commissures. The lateral view demonstrates correction of the cervi-
cal laxity and jawline, with preservation of the hairline.
1449
Chapter 43 Short-Scar Rhytidectomy
1450
Part VIII Face Lift and Neck Lift
Fair candidates are usually in their late fifties, sixties, or early seventies. They exhibit sig-
nificant jowling, moderate cervical laxity, and submental and submandibular fat. Sig-
nificant medial platysma bands, active on natural animation, may also be present.
The approach to type III patients is via an open submental incision connecting sub-
cutaneous undermining with the face and lateral neck. Open lipoplasty of submen-
tal and submandibular fat is performed to expose the platysma muscle. A 4 to 5 cm
wedge of platysma is removed at the level of the hyoid. The medial borders of the
platysma muscle are approximated to define the cervicomental angle. Lateral sutur-
ing of the platysma to the mastoid periosteum enhances the jawline. If redundant
skin is present at the earlobe after redraping, it can be removed with a short retroau-
ricular incision. It must be emphasized that in a type III patient the neck improve-
ment and its longevity are usually not as successful as when a classic rhytidectomy
with retroauricular scars is performed.
Significant jowls
Moderate cervical laxity
Active platysma bands
Characteristics
Surgical Plan
Age late fifties, sixties, early seventies
Open submental suction-assisted lipoplasty
Significant jowls
Platysma approximation at hyoid with wedge excision
Moderate cervical skin laxity
SMASectomy or plication
Submental/submandibular fat
Usually extension of incision into retroauricular sulcus
Platysma bands on animation
Chin implant if indicated
May have microgenia
Some secondary rhytidectomy
Type III: The Fair Candidate
This 59-year-old woman had significant jowling and cervicofacial laxity with mi-
crogenia. She had excess skin and fat of her upper eyelids and represented a type III
(“fair”) candidate for short-scar rhytidectomy. A lateral SMASectomy was performed
to reduce jowl and cheek fullness. An upper blepharoplasty was also performed, and
a chin implant placed. Her 1-year postoperative results demonstrate improvement in
the facial shape and midface, with enhancement of the cheekbones. Neck improve-
ment resulted from midline platysma approximation and a chin implant. No sub-
platysmal work was done. A rhytidectomy cannot eliminate deep rhytids from the
commissures and jowl area.
1451
Chapter 43 Short-Scar Rhytidectomy
This 53-year-old woman had always had submental fullness and lacked cervico-
mental definition. She represented a type III (“fair”) candidate for short-scar rhytidec-
tomy. Her 1-year postoperative results demonstrate improvement in the neck and
jowls and reshaping of the face. Despite the fact that no subplatysmal work was
done, the lateral view demonstrates overresection of subcutaneous fat, leaving a slight
submental hollow and a prominent, ptotic chin.
1452
Part VIII Face Lift and Neck Lift
1453
Chapter 43 Short-Scar Rhytidectomy
Poor candidates are usually in their sixties and seventies, with significant jowling and
active, lax platysma bands. Skin folds and deep creases below the cricoid cartilage
are often present, and cervical skin elasticity is poor. Although these patients are not
good candidates for a short-scar rhytidectomy, this operation can be offered to them
as a compromise solution that keeps open the option of extending the retroauricular
incision if necessary. Laterally and posteriorly, it is usually necessary to undermine
over the mastoid and sternocleidomastoid muscles to obtain proper skin redraping.
Excess cervical skin must be tailored into the retroauricular sulcus.
The short-scar technique is a compromise in these patients, and the improvement in
the neck is rarely as good as would be obtained with a classic rhytidectomy with
wide anterior and posterior cervical undermining and redraping.
Significant jowls
Active platysma bands
Cervical skin folds below cricoid
Deep cervical creases
Poor skin elasticity
Characteristics
Surgical Plan
Age late sixties and seventies
A significant compromise
Significant jowls
Open submental suction-assisted lipoplasty
Poor cervical skin laxity
Platysma approximation at hyoid with wedge excision
Skin folds below cricoid
SMASectomy/platysma resection
Submental/submandibular fat
Removal of dog-ear in retroauricular sulcus
Platysma bands on animation
Chin implant if indicated
Deep cervical creases
Requires more extensive undermining for skin redraping
Poor skin elasticity
Retroauricular incision can always be extended
Type IV: The Poor Candidate
This 60-year-old woman is an example of a type IV patient. She underwent a short-
scar rhytidectomy with a temporal hairline incision. She is shown 1 year postoper-
atively with no posterior hairline incision.
1454
Part VIII Face Lift and Neck Lift
This 60-year-old woman demonstrated cervical laxity below the cricoid, extending
to the sternal notch. She was a poor candidate for a short-scar face lift, which would
have compromised the improvement of her cervical laxity. Although the patient has
a nice improvement after undergoing a short-scar rhytidectomy, the postoperative
result demonstrates persistent cervical laxity extending to the sternal notch. The pa-
tient was not happy and required neck revision with a classic retroauricular incision.
This much cervical laxity can only be corrected with wide through-and-through un-
dermining and removal of excess skin through the retroauricular occipital incision.
1455
Chapter 43 Short-Scar Rhytidectomy
Operative Technique
Anesthesia
In virtually all of the face lifts I perform, the patient is under monitored intravenous
propofol sedation. Patients are given oral clonidine, 0.1 to 0.2 mg, 30 minutes be-
fore surgery to control their blood pressure. The face and neck are infiltrated with
local anesthetic, 0.5% lidocaine with 1:200,000 epinephrine, through a 22-gauge
spinal needle. I inject the face before I scrub to provide the requisite 10 minutes for
vasoconstriction to occur.
Incisions
When the temporal hairline shift is minimal, the preferred incision is placed well
within the temporal hair. With this incision it is often necessary to excise a triangle of
skin below the temporal sideburn at the level of the superior root of the helix.
1456
Part VIII Face Lift and Neck Lift
When a larger skin shift is anticipated (frequently the lift is more vertical with a short-
scar rhytidectomy) or the distance between the lateral canthus and the temporal hair-
line is greater than 5 cm, the incision is made a few millimeters within the temporal
hairline. Although this is a compromise, the alternative of a receding temporal hair-
Optional temporal
hairline incision
for recessed hairlines
Subcutaneous undermining
into neck allows exposure
of platysma and skin redraping
Optional submental incision;
undermining connects laterally
with platysma approximation
Closed or open
liposuction
Usual extent of subcutaneous
undermining to lateral canthus
and release of malar ligaments
Preferred incision
line is rarely acceptable to female patients. When the incisions are executed properly
(it is essential to bevel the incision at least 45 degrees through the hair follicles as
well as the redraped flap so hair can grow through the incision), these scars heal well
and are easy to revise or camouflage. The only exception might be in a patient with
deeply pigmented skin in whom the scar will contrast and appear as a white line.
The choice of preauricular incision is left to the surgeon. When executed properly,
all of these incisions heal well and are imperceptible. I usually prefer a curved inci-
sion anterior to the helix and continue inferiorly anterior to the tragus in a natural
skinfold. This preserves the thin, pale, hairless tragal skin and its demarcation from
the cheek skin, which is usually coarser, thicker, darker, and has lanugo hairs. I per-
form intratragal incisions in patients in whom the cheek and tragal skin is similar
and the tragal cartilage is not sharp or prominent. Closure must be without tension
and the flap overlying the tragus defatted to the dermis.
In a short-scar rhytidectomy, I try to end the incision at the base of the earlobe. This
is usually possible in type I or II patients, but in type III or IV patients a shorter
retroauricular incision is often necessary to correct a dog-ear after the facial flap
rotation.
Skin Flap Elevation
All skin flap undermining is carried out under direct visualization with scissors dis-
section to minimize trauma to the subdermal plexus and preserve a significant layer
of subcutaneous fat on the undersurface of the flap. I prefer subcutaneous dissection
in the temporal region, because the skin seems to redrape better. I believe that hair
loss results primarily from tension rather than superficial undermining. Subcuta-
neous dissection in the temporal region must be performed carefully to avoid pene-
trating the superficial temporal fascia that protects the frontal branch of the facial
nerve. All dermal attachments between the orbicularis oculi muscle and the skin are
separated up to the lateral canthus.
Dissection extends across the zygoma to release the zygomatic ligaments but stops
several centimeters short of the nasolabial fold. I have never believed that further dis-
section provides significant benefits; on the contrary, the only result is increased bleed-
ing. In the cheek, dissection releases the masseteric-cutaneous ligaments and, if nec-
essary, the mandibular ligaments.
Subcutaneous dissection continues over the angle of the mandible and sternocleido-
mastoid for 5 to 6 cm into the neck. This exposes the posterior half of the platysma
muscle. If a submental incision has been made, the facial and lateral neck dissection
is connected through and through to the submental dissection.
1457
Chapter 43 Short-Scar Rhytidectomy
1458
Part VIII Face Lift and Neck Lift
Defatting the Neck and Jowls
The extent of subcutaneous undermining in the temporal area, cheek, and lateral
neck is shown. If excess fat is present, closed or open liposuction superficial to the
platysma is performed in the submental and submandibular areas. When necessary,
medial platysma approximation is done through the submental incision.
Whenever possible, I prefer closed suction–assisted lipoplasty in the neck and jowls.
A 2.4 mm Mercedes-tip cannula is used; it is kept under constant, steady motion in
the subcutaneous space. A 3 to 5 mm layer of subcutaneous fat is left on the under-
surface of the cervical skin. If the jowls are suctioned, this is always done conserva-
Preferred incision
Optional preauricular
or intratragal incision
Subcutaneous undermining
into neck allows exposure of
platysma and skin redraping
Usual lower border
of undermining
Submental incision in normal
skin crease; undermining
connects laterally
Usual extent of subcutaneous
undermining to lateral canthus
and release of malar ligaments
Optional temporal incision
for recessed hairlines; bevelled
tively. Subplatysmal fat is rarely suctioned or removed, because the facial nerves run
just beneath the platysma. Additionally, any patient with significant subplatysmal
fat probably has a fat, round face, so removing subplatysmal fat could create an over-
operated look. This, of course, is a personal aesthetic surgical judgment.
Lipoplasty is usually performed before elevating the skin flaps, taking care not to
oversuction the portion of the SMAS-platysma that will be elevated over the mandible
with the lateral SMASectomy.
Open Submental Incision With Medial Platysma
Approximation
After many years, I now only open the neck when prominent active platysma bands
are present. I have found that I can achieve excellent results with closed lipoplasty
and a strong lateral platysma vector. Therefore, in type III and IV patients with active
platysma bands on animation, the medial approximation provides another vector to
enhance the cervicomental recontouring.
I prefer to make the submental incision in the submental crease. The subcutaneous
dissection is performed with the patient’s neck hyperextended. Undermining is usu-
ally to the level of the thyroid cartilage and the angle of the mandible. Suction-
assisted lipoplasty is then performed with a large, single-hole cannula under direct
vision. Direct fat excision is carried out, if necessary, but to avoid creating depres-
sions, subplatysma fat is rarely removed.
The medial borders of the platysma muscle are identified and elevated for several
centimeters. To break the continuity of the bands, a wedge of muscle is removed at the
level of the hyoid bone. The medial borders of the muscle are then sutured together
with interrupted buried 3-0 PDS sutures.
The submental incision is left open to allow a final confirmation hemostasis and re-
contouring after communication with the facial dissection and completion of the lat-
eral SMASectomy.
1459
Chapter 43 Short-Scar Rhytidectomy
Lateral SMAS Plication
1460
Part VIII Face Lift and Neck Lift
In the SMAS-platysma resection, the level of resection is superficial to the parotid
masseteric fascia that overlies the facial nerve branches. The outline of the SMAS -
ectomy is marked on a tangent from the lateral malar eminence to the angle of the
mandible, essentially in the region along the anterior edge of the parotid gland. In
most patients this involves a line of resection extending from the lateral aspect of the
malar eminence toward the tail of the parotid gland. Frequently, orbicularis oculi
muscle fibers are exposed at the superior limit of the excision. Usually a 2 to 4 cm
segment of superficial fascia is excised, depending on the degree of SMAS-platysma
laxity and debulking required.
In a SMAS resection, I like to pick up the superficial fascia in the region of the tail
of the parotid gland, extending the resection from inferior to superior in a controlled
fashion. When SMAS resection is being performed, it is important to keep the dis-
section superficial to the deep fascia and avoid dissection into the parotid parenchyma.
The size of the parotid gland varies from patient to patient; consequently, the amount
of protection needed for the underlying facial nerve branches will also vary. Despite
this, as long as the dissection is carried superficial to the deep facial fascia, ensuring
that only the superficial fascia is resected, facial nerve injury as well as parotid in-
jury will be prevented. In essence, this is a resection of the superficial fascia in the
same plane of dissection in which one would normally raise a SMAS flap.
Danger zone behind
parotid gland:
resect at same level as
SMAS flap elevation
Lateral SMASectomy
extends from tail of
parotid to lateral canthus
1461
Chapter 43 Short-Scar Rhytidectomy
SMAS resection
parallel to
nasolabial fold
Vector of elevation
perpendicular to
nasolabial fold
SMAS and platysma
plication suspension;
suture is just beneath SMAS
First suture from submandibular
platysmal SMAS to anterior
tympano-mastoid fascia
(vertical vector)
Platysma flap sutured
to mastoid periosteum
(lateral oblique vector)
Medial and lateral platysma vectors
create a muscular hammock
to support and define the jawline
Malar fat pad
vector
Facial vectors
Submandibular
vertical vector
Wedge excision of
platysma to disrupt band
The following vectors are illustrated: (1) vectors of elevation of the SMAS-platysma
and (2) vectors of superolateral elevation of the SMAS-platysma and medial ap-
proximation of the anterior platysma in the submental area above the hyoid bone.
The various vectors accomplish corrections of the anterior neck, cervicomental
angle, jowls, and nasolabial folds. The first key suture grasps the platysma at the an-
gle of the mandible and advances it in a posterosuperior direction; it is secured with
figure-of-eight 2-0 Maxon sutures to the fixed lateral SMAS overlying the parotid
gland. This lifts the cervical platysma and cervical skin, helps to define the jawline,
and improves contouring in the submandibular region.
Vectors
1462
Part VIII Face Lift and Neck Lift
The lines of closure of the lateral SMAS–platysma in the cheek and the lateral neck
and medial platysma approximation in the submental area are depicted. Excess fat
in the mastoid and submandibular areas is removed by liposuction. After SMAS re-
section, interrupted 3-0 and 4-0 PDS buried sutures are used to close the SMASec-
tomy; the fixed lateral SMAS is evenly sutured to the more mobile anterior superficial
fascia. The last suture lifts the malar fat pad, securing it to the malar fascia. It is im-
portant to obtain a secure fixation to prevent postoperative dehiscence and relapse
of the facial contour.
Plication of mobile SMAS
to fixed SMAS
Zygomatic arch
Last suture lifts
malar fat pad
Temporalis fascia
If firm monofilament sutures are used, such as PDS or Maxon, the sutures should
be buried and the sharp ends on the knot trimmed. Final contouring of any SMAS
or fat irregularities along the suture line is completed with scissors. Fat can also
be trimmed at the sternomandibular trough; final contouring is accomplished with
liposuction.
Skin Closure, Temporal Fascia, and Earlobe Dog-Ears
After SMAS and platysma approximation, some tethering of the skin might appear
at the anterior extent of the subcutaneous dissection because of the pull of the un-
derlying SMAS. This can also occur in the lower eyelid with elevation of the malar
fat pad. Further subcutaneous undermining is necessary to free these tethers, allow-
ing the skin to redrape.
Facial skin redraping is done with a less-vertical vector than with the SMAS. The
first key skin suture rotates the facial flap posteriorly to redrape the midface, jowls,
and submandibular skin. Suture fixation is at the level of the insertion of the supe-
rior helix. I like to use a buried 3-0 PDS suture through the temporal fascia with a
generous bite of dermis on the skin flap. The closure is performed with minimal ten-
sion. Staples are used to close any incisions in the hair. A wedge is usually removed
at the level of the sideburn to preserve the hairline. If an anterior hairline incision
has been made, I like to close it with buried 5-0 Monocryl sutures and 5-0 nylon su-
tures. Extra time and attention must be spent on this closure to eliminate any dog-
ears and obtain the finest scar. Bevelling the facial flap will enhance hair growth
through the scar.
Excess skin is then trimmed from the facial flap so that there is no tension on the
preauricular closure. Wound edges should be “kissing” without sutures. Trimming
at the earlobe must also be without tension, and the skin flap is tucked under the
lobe with 4-0 PDS sutures, taking a bite of earlobe dermis, cheek flap dermis, and
conchal perichondrium to minimize any tension. A small dog-ear might be present
behind the earlobe; this is easily trimmed and tailored into a short incision in the
retroauricular sulcus. A closed suction drain is usually brought out through a sepa-
rate stab wound in the retroauricular sulcus to drain the neck, and a Penrose drain is
placed through the temporal incision to drain the face.
1463
Chapter 43 Short-Scar Rhytidectomy
This patient underwent a lateral SMASectomy via short-scar rhytidectomy with an
anterior hairline incision. She is shown postoperatively at the conclusion of surgery
before dermabrasion (A), after dermabrasion (B), in frontal and lateral views 1 week
after dermabrasion (C and D), and in a retroauricular view at 2 weeks (E). The bunch-
ing around the earlobe will smooth with the passage of time; the retroauricular crease
and occipital hairline are undisturbed. The preauricular and temporal hairline inci-
1464
Part VIII Face Lift and Neck Lift
1 week after
dermabrasion
1 week after
dermabrasion
A
B
C
D
E
F
sion is shown 2 weeks postoperatively (F). Ancillary procedures included an upper
lid blepharoplasty, rasping of the nasal dorsum, insertion of an extended chin im-
plant, perioral and glabellar dermabrasion, and lower lid laser resurfacing.
Complications
The table summarizes the complications of short-scar rhytidectomy in my series,
which are consistent with those of other standard face-lift operations. Despite spe-
cial attention to blood pressure control in the postoperative period, the hematoma
rate is still 1.5%. The most common problems are the need for minor revisions of
the earlobe and temporal hairline scars, but these are far less significant than when
I was revising retroauricular scars or trying to repair posterior hairlines.
1465
Chapter 43 Short-Scar Rhytidectomy
Complications of the Short-Scar Face Lift
Complication
Frequency (%)
Hematoma
1.5
Facial paralysis (all resolved in 2 months)
0.3
Infection (abscess)
0.8
Skin slough (minor)
1.0
Hypertrophic scars
2.0
Suture granuloma (PDS)
3.5
Earlobe deformity
0.8
Retroauricular pleating
2.0
Temporal hairline scar revision
3.0
Cervical tightening/platysmaplasty in
2.0
poorly selected patients
Outcomes
In properly selected patients, the results and duration seem similar to what is achieved
with classic rhytidectomies. Type I and II patients who have returned at 8 to 10 years
for secondary lifts were very pleased with the results of the first operation. The short-
scar technique was used for all secondary lifts. For type III and IV patients, the re-
sult in the neck will not be as good when classic retroauricular incisions are made.
This category of patients is more likely to require some type of neck revision. The
limitations must be discussed preoperatively.
Of the short-scar rhytidectomies I performed from 1990 to 2009, all but 15 were
performed on women. Because a man’s neck usually has a thicker layer of skin and
muscle, few male patients are candidates for this procedure.
1466
Part VIII Face Lift and Neck Lift
After 20 years and 2400 short-scar rhytidectomies, I implemented stricter indications:
Young
Good skin elasticity
Minimal cervical laxity
Open neck for platysma
Rarely compromise the result for a short scar
Results
This 44-year-old woman exhibited the signs of a typical type II patient. She under-
went a short-scar rhytidectomy with a SMASectomy and an upper eyelid blepharo-
plasty. We also inserted a chin implant. She is shown 21⁄2 years postoperatively, with
an absence of retroauricular and occipital incision scars.
This 68-year-old woman underwent a short-scar rhytidectomy. A 35% trichloroacetic
total facial peel and perioral and glabellar dermabrasion were performed at the time
of surgery. A small, extended chin implant was also inserted. This woman was a
heavy smoker, so the submental area was not opened. She is shown 5 months post-
operatively.
1467
Chapter 43 Short-Scar Rhytidectomy
1468
Part VIII Face Lift and Neck Lift
Concluding Thoughts
The short-scar rhytidectomy is an excellent face-lift technique for younger patients
with good skin elasticity and minimal cervical laxity. Older patients with excessive
cervical laxity and poor skin elasticity do not get optimal results from this technique,
so it is a compromise for them. Rarely will I sacrifice the result for a shorter scar.
Clinical Caveats
When the temporal hairline shift is assessed as minimal, the preferred incision is
well within the temporal hair.
The temporal hairline incision allows a more vertical elevation of the facial flap
while preserving the hairline.
All skin flap undermining is carried out under direct vision (with scissors dissec-
tion) to minimize trauma to the subdermal plexus and preserve a significant layer
of subcutaneous fat on the undersurface of the flap.
Subcutaneous dissection in the temporal region must be performed carefully to
avoid penetrating the superficial temporal fascia that protects the frontal branch
of the facial nerve.
Whenever possible, I prefer to use closed section-assisted lipoplasty in the neck
and jowls.
I usually perform lipoplasty before elevating the skin flaps. In doing so, I am care-
ful not to oversuction the portion of the SMAS-platysma that will be elevated over
the mandible with the lateral SMASectomy.
When SMAS resection is being performed, it is important to keep the dissection
superficial to the deep fascia and avoid dissection into the parotid parenchyma.
Because the size of the parotid gland varies from patient to patient, the amount
of protection for the underlying facial nerve branches will also vary.
After SMAS resection, interrupted 3-0 PDS buried sutures are used to close the
SMASectomy, the fixed lateral SMAS being evenly sutured to the more mobile an-
terior superficial fascia. The last suture lifts the malar fat pad, securing it to the
malar fascia. It is important to obtain a secure fixation to prevent postoperative
dehiscence and relapse of facial contour.
Annotated Bibliography
Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Plast Reconstr Surg
64:781-795, 1979.
The authors present a detailed anatomy of the muscular branches of the facial nerve and
discuss how to prevent injuries to them during rhytidectomy, and how to manage in-
juries when they do occur.
Connell BF. Contouring the neck in rhytidectomy by lipectomy and a muscle sling. Plast Re-
constr Surg 61:376-383, 1978.
Accurate diagnosis of the cause of the objectionable contour problems is necessary for
the execution of appropriate and adequate surgical technique for correction. The au-
thor discusses adequate lipectomy combined with deep support provided by a sling made
from full-width platysma muscle flaps for improving neck contour.
Marchac D, Brady JA, Chiou P. Face lifts with hidden scars: the vertical U incision. Plast Re-
constr Surg 109:2539-2551, 2002.
The authors present their development of a strictly vertical retroauricular incision to
minimize visible scarring.
Mitz V, Peyronie M. The superficial musculoaponeurotic 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 using anatomic dis-
sections, radiographs, and histologic sections. They reported that the SMAS may be
helpful in corrective surgery for facial palsy and during face-lifting operations if a retro-
fascial approach is used. This procedure, while safe in the parotid area, can become dan-
gerous in the area anterior to the parotid gland.
Suggested Readings
Alpert BS, Baker DC, Hamra ST, et al. Identical twin face lifts with differing techniques: a
10-year follow-up. Plast Reconstr Surg 123:1025-1033; discussion 1034-1036, 2009.
Baker DC. Complications of cervical rhytidectomy. Clin Plast Surg 10:543-562, 1983.
Baker DC. Deep dissection rhytidectomy: a plea for caution. Plast Reconstr Surg 93:1498-
1499, 1994.
Baker DC. Lateral SMASectomy. Plast Reconstr Surg 100:509-513, 1997.
Baker DC. Lateral SMASectomy. Semin Plast Surg 16:417-422, 2002.
Baker DC. Lateral SMASectomy, plication and short scar facelifts: indications and techniques.
Clin Plastic Surg 35:533-550, 2008.
Baker DC. Short scar facelift. In Aston S, Steinbrech D, Walden J, eds. Advances in Aesthetic
Surgery. London: Elsevier Ltd, 2009.
Baker DC, Aston SJ, Guy CJ, Rees TD. The male rhytidectomy. Plast Reconstr Surg 4:514-
522, 1977.
1469
Chapter 43 Short-Scar Rhytidectomy
Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas. Plast Re-
constr Surg 115:2119-2122; discussion 2123, 2005.
Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematomas requiring surgical
evacuation following male rhytidectomy: a thirty year review of 985 cases. Plast Recon-
str Surg 116:1973-1985; discussion 1986-1987, 2005.
Connell B. Cervical lift: surgical correction of fat contour problems combined with full width
platysma muscle flap. Aesthetic Plast Surg 1:355-365, 1978.
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Part VIII Face Lift and Neck Lift