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

S
urgical rejuvenation of the aging face has become one of the most frequently
performed surgical procedures in the United States. Face lifting, introduced as a
skin tightening procedure in the early 1900s, has technically matured during the past
quarter-century. This evolution is directly related to scientific investigation of facial
soft tissue anatomy, resulting in a better understanding of the changes that occur
with aging. Over the past 30 years, a number of procedures have been developed
with a variety of technical approaches to reconstruct aging-related anatomic changes.
When the face lift was first developed, both patients and surgeons focused on the
laxity that occurs with facial aging, and efforts were directed to tightening what was
loose rather than to restoring the shape of the face—hence the term face lift (rather
than facialplasty), a mechanical term that implies a procedure to lift what has fallen.
Unfortunately, this mechanical approach often produced a tight, operated look—the
wind-tunnel appearance that has so often been associated with surgical rejuvenation
of the aging face. Today, based on a better understanding of facial soft tissue anatomy
and the anatomic changes that occur during aging, face lifting has developed into
both a reconstructive procedure (to reconstruct the anatomic changes from aging)
and a more artistically defined technique that attempts to enhance facial appearance
while minimizing any signs that a surgical procedure has been performed.
There are many treatment goals for face lifting other than simply correcting the hall-
marks of the aging face, including improvement of the nasolabial folds, jowls, and
cervical contour. A face lift must also address the aesthetic concepts of improving
shape and bringing out the beauty of the face that existed during youth. The sur-
geon attempting to meet these goals must have a thorough understanding of facial
soft tissue anatomy, the anatomic changes that occur from aging, and the ideal fa-
cial shape that can be obtained for a particular patient. The design of the surgical
access incisions must minimize scar perceptibility and avoid hairline distortion to
prevent surgical stigmata.
Aging in the face is complex and multifactorial, and plastic surgeons may encounter
a number of problems during midface rejuvenation, including the following:
 The dermal component of aging related to intrinsic and extrinsic skin changes
(dermal elastosis)
 Descent of facial fat
 Facial deflation, which tends to be regionally specific
 Radial expansion as facial fat becomes centrifugally situated away from the
facial skeleton
All of these factors influence facial shape with aging. Individual patients exhibit var-
ious degrees of all these problems, and each component of the aging face should be
addressed according to a patient’s specific needs.
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Patient photos taken during youth and as the individual has grown older are very
helpful in determining how a patient has aged. Youthful photos usually reveal the lo-
cation of the volumetric highlights present, document areas that have deflated over
time, and indicate both the position and vector of facial fat descent. These factors il-
lustrate patient-specific changes in facial shape and clarify the possible methods for
repositioning facial fat to improve and restore shape. From my perspective, restoring
facial shape is a more worthy aesthetic goal than attempting to tighten a loose face.
Pertinent Anatomy
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation
The anatomy that allows a rhytidectomy to be performed safely is the arrangement
of the facial soft tissue in concentric layers. This arrangement allows dissection within
one anatomic plane to proceed completely separate from structures lying within an-
other anatomic plane. The layers of the face are the skin; subcutaneous fat; superficial
facial fascia (superficial musculoaponeurotic system [SMAS]); mimetic muscles;
parotidomasseteric fascia (deep facial fascia); and the plane of the facial nerve, parotid
duct, buccal fat pad, and facial artery and vein.
Buccal fat pad
SMAS
Parotidomasseteric fascia
Mimetic muscle
SMAS
Mimetic muscle (platysma)
Subcutaneous layer
Skin
Subcutaneous layer
Parotidomasseteric fascia
Plane of facial nerve

A surgeon attempting to master sub-SMAS dissection must understand the follow-
ing anatomic components of facial soft tissue anatomy.
ANATOMIC CONSISTENCY
Although the thickness of the various layers differ from
patient to patient, structures within each layer are anatomically consistent. Consid-
ered two-dimensionally, the facial nerve exhibits a variety of branching patterns, but
on a three-dimensional basis, the facial nerve always lies within a specific anatomic
plane. This arrangement allows the surgeon to perform extensive sub-SMAS dissec-
tion safely, as long as the dissection proceeds at a level superficial to the plane of the
facial nerve.
SMAS THICKNESS
The thickness of the SMAS may vary significantly from patient
to patient as well as from one region of the face to another. Overlying the parotid
gland, within the temporal region (temporoparietal fascia), and within the scalp
(galea), the SMAS is a substantial, discrete layer. As the SMAS is traced anteriorly
in the face, overlying the masseter and buccal fat pad and into the malar region, it
tends to become thinner and less substantial. Elevating the SMAS in these areas re-
quires precise dissection so the flap is thick enough to be useful in facial contouring.
MUSCLE LAYERS
The muscles of facial expression are arranged in four overlapping
anatomic layers. The muscles that are encountered during a face lift procedure in-
clude the platysma, orbicularis oculi, zygomaticus major and minor, and risorius
muscles, which are all superficial mimetic muscles. The deeply situated mimetic mus-
cles are the buccinator and mentalis muscles. Most of the muscles of facial expres-
sion lie superficial to the plane of the facial nerve and therefore receive their inner-
vation along their deep surfaces. The only muscles within the facial soft tissue
architecture that lie deep to the plane of the facial nerve are the mentalis, buccina-
tor, and levator anguli oris muscles; they receive their innervation along their su-
perficial surfaces.
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Part VIII  Face Lift and Neck Lift
Courtesy J.K. Terzis, MD
In this cadaver dissection of the facial nerve, it can be
seen that the area directly overlying the zygomatic but-
tress is devoid of motor branches, and the only nerves
in this region are sensory branches. For this reason,
dissection in the malar area is quite safe—the malar
eminence represents a watershed between the frontal
branches of the facial nerve lying superiorly and the
zygomatic branches of the facial nerve that lie just in-
ferior to the zygomatic buttress.

This cadaver dissection shows the path of the marginal mandibular nerve. The de-
pressor anguli oris muscle has been divided so that the nerve can be seen lying along
the deep surface of this muscle. The depressor anguli oris and the depressor inferi-
oris muscles are typical of facial muscles that lie superficial to the plane of the facial
nerve and receive their innervation along their deep surfaces.
ANATOMIC FACIAL UNITS
The muscles of facial expression that are situated su-
perficially within the facial soft tissue architecture are invested by the superficial fas-
cia. By invested, I mean that the superficial fascia lines both the superficial and deep
surfaces of these muscles. This SMAS–mimetic muscle complex thus forms a single
anatomic and functional unit that moves facial skin during animation.
FACIAL FASCIA
Deep to the SMAS–mimetic muscle complex lies the deep facial fas-
cia. The deep facial fascia is a continuation of the superficial layer of the deep cer-
vical fascia cephalad into the face. Where this fascial layer is identified, it is given
specific nomenclature. Overlying the parotid gland, the deep fascia is called the
parotid fascia or parotid capsule; overlying the masseter muscle, it is called the mas-
seteric fascia; and in the temporal region, it is called the deep temporal fascia.
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The cadaver dissection on the left is seen after SMAS-platysma elevation within the
cheek; the underlying parotid gland, the anterior border of the parotid (marked in
ink), and the parotidomasseteric fascia (held in forceps) are exposed. The signifi-
cance of the deep facial fascia is that all the facial nerve branches within the cheek lie
deep to this layer. Typically, these nerve branches course deep to the deep fascia un-
til they reach the muscles of facial expression, at which point they penetrate the deep
fascia to innervate these mimetic muscles along their deep surfaces. In the cadaver
dissection on the right, the parotidomasseteric fascia has been elevated to expose the
underlying masseter muscle and the marginal mandibular nerve as it crosses the fa-
cial artery and vein.
The essential point regarding the architectural arrangement of the facial soft tissue
is that there is a superficial component of the facial soft tissue that is defined by the
superficial facial fascia and includes the SMAS and those components that move fa-
cial skin (including superficially situated mimetic muscle invested by the SMAS, the
subcutaneous fat, and skin). This is in contrast to the deeper component of the fa-
cial soft tissue, which is defined by the deep facial fascia and the structures related
to the deep fascia, including the relatively fixed structures of the face, such as the
parotid gland, masseter muscle, periosteum of the facial bones, and facial nerve
branches. As the face ages, many of the typical changes seen are associated with a
change in the anatomic relationship between the superficial and deep facial fascia.
With age, facial fat descends in the plane between superficial and deep facial fascia,
thereby justifying reelevation of fat through sub-SMAS dissection to improve facial
shape.
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Mandibular ligaments
Zygomatic ligaments
Masseteric cutaneous ligaments
Parotid cutaneous
ligaments
Zygomaticus minor muscle
Zygomaticus major muscle
Risorius muscle
Retaining Ligaments
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation
Communication between the superficial and deep facial fascia occurs at the level of
the retaining ligaments. These structures fix facial soft tissue in a normal anatomic
position, resisting gravitational forces. Retaining ligaments exist in specific locations
of the face, including (1) the malar area, where they are called zygomatic ligaments,
(2) along the anterior border of the masseter muscle, forming the masseteric cuta-
neous ligaments, (3) over the parotid gland, forming the parotid cutaneous liga-
ments, and (4) in the parasymphysial and symphysial region of the mandible, where
they are called mandibular ligaments.
There are two types of retaining ligaments, as defined by their origins. The osteocu-
taneous ligaments are a series of fibrous bands that run from periosteum to dermis.
The zygomatic and mandibular ligaments are examples of these structures.
The second system of supporting ligaments is formed by a coalescence of the super-
ficial and deep facial fascia in certain regions of the face (the parotid-cutaneous lig-
aments and the masseteric cutaneous ligaments). These fascial connections, which
fix both superficial and deep fascia to underlying facial structures, such as the parotid
gland and masseter muscle, similarly lend support against gravitational forces through
fibrous septa that extend into the dermis. Attenuation of support from the retaining
ligaments is responsible for many of the features of facial aging.
In the evolution of midface aging, the zygomatic and masseteric cutaneous ligaments
are particularly important. The zygomatic ligaments originate from the periosteum
of the malar region as a series of fibrous septa that begin laterally in the region where
the zygomatic arch joins the body of the zygoma and permeate the malar pad (fi-
brous McGregor’s patch). A particularly stout ligament originates along the me-
dialmost portion of the zygoma, medial to the zygomaticus minor. The zygomatic
ligaments fix the malar pad to the underlying zygomatic eminence in a youthful face.

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Part VIII  Face Lift and Neck Lift
Attenuation of the zygomatic ligamentous support suspending the malar pad and
the medial cheek leads to an inferior migration of these soft tissues adjacent to the
line of the muscular fixation of the nasolabial fold. The fold not only deepens with ag-
ing, but an accumulation of cheek soft tissue lateral to the nasolabial line also ac-
counts for fold prominence.
Soft tissue support in the medial cheek is provided by a series of fibrous bands that
extend along the entire anterior border of the masseter muscle. These fibers, called
masseteric cutaneous ligaments, are identified superiorly in the malar area, where
they mingle with the zygomatic ligaments and extend along the anterior border of
the masseter as far inferiorly as the mandibular border. These fibers represent coales -
cence between the superficial and deep fascia, extending from the masseter muscle
vertically to insert into the overlying dermis. When an individual is young, the mas-
seteric ligaments support the soft tissues of the medial cheek superiorly above the
mandibular border.
Attenuation of support from the masseteric cuta-
neous ligament allows the soft tissues of the medial
cheek to descend inferiorly, leading to the forma-
tion of the facial jowl.

Because of the anatomic relationships of the retaining ligaments, the jowl has con-
stant borders. Anteriorly, the jowl is bordered by the mandibular ligaments. Posteri-
orly, the jowl complex is positioned along the anterior border of the masseter muscle.
Aesthetic Analysis and Treatment Planning
As the face ages, facial shape changes multifactorially. Some of these changes can be
addressed in a straightforward manner, whereas others present difficult technical
challenges. A paradox for me has always been that facial anatomy (in terms of ba-
sic soft tissue architecture) is essentially unchanged from youth to middle age, but
facial appearance changes greatly over time and is patient specific. Although each
face ages differently, there are common features in all of them.
Descent of Facial Fat
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation
As the face ages, facial fat descends. As seen in a photograph taken at age 25, this
woman has a youthful face full of well-supported facial fat, typically overlying the
malar eminence and along the lateral cheek, which overlies the parotid gland and
masseter muscle. In addition, there is generally a concavity or depression overlying
the buccal recess just anterior to the masseter muscle. The combination of fullness
in the malar region and lateral cheek and a concavity overlying the buccal recess ac-
counts for the angular, tapered appearance of the youthful face. In the same woman
at age 55, 30 years later, the aesthetic effect of facial fat descent becomes obvious.

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Typically, faces in middle age are square, with little differential between malar high-
light and midfacial fat. As facial fat becomes more inferior in the face, the face ap-
pears visually longer. The aesthetic consequences of loss of facial angularity with ag-
ing are as important as the depth of the nasolabial fold and jowling. For me, an
improvement of facial shape is one of the primary goals of facial rejuvenation.
Volume Loss and Facial Deflation
Youthful faces are full of well-supported fat. Deflation occurs over time, soft tissue
becomes less supported and appears lax, and it tends to be most apparent in areas
of the face that have a high density of retaining ligaments (the malar pad, preparotid
area, lateral and infraorbital rim, and the lateral chin). Youthful faces have a smooth
contour between the aesthetic subunits. Middle-aged faces, as a result of both de-
flation and fat descent, develop lines between the regions. An appropriate aesthetic
treatment plan requires repositioning of the descended soft tissue into areas of facial
deflation to improve shape, not only to restore the volume of youth, but also to blunt
the lines between aesthetic subunits. Volumetric augmentation through autologous
fat injection or other injectable soft tissue fillers is an ancillary procedure that can
be useful for augmenting areas of deflation.
Deflation is a complex process that tends to be regional and age specific. A break-
through in understanding how deflation occurs came with a discovery by Rohrich
and Pessa. These investigators realized that the subcutaneous fat of the cheek, rather
than being homogeneous, is broken into compartments, each with an independent
perforator blood supply and surrounded by specific septal membranes. The aesthetic
significance of fat compartmentalization is that deflation tends to occur within a spe-
cific region of the cheek, rather than deflating homogeneously.
At the risk of oversimplification, one key to understanding facial deflation is the lo-
cation of the zygomaticus major muscle, which traverses from the malar eminence
to the oral commissure. Deflation of the cheek lateral to the zygomaticus major mus-
cle tends to occur independent of deflation in the malar region, medial to the zygo-
maticus major. For many patients, lateral cheek deflation develops at a younger age
than malar pad deflation, and it often appears in patients in their forties.

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Chapter 44  Extended SMAS Technique in Facial Rejuvenation
This 42-year-old patient has early facial aging resulting primarily from deflation. She
has a hollowing effect in the lateral cheek and preparotid region. Deflation has oc-
curred in the fat compartments lateral to the zygomaticus major muscle. She is seen
before and after a face and neck lift. Anteriorly situated fat was brought into the up-
per lateral midface, where it filled the areas of deflation, thereby blunting the lines
between aesthetic subunits. The change in facial shape is evident; her face appears
more structured and supported after facial fat repositioning.
Medial cheek and malar pad deflation tends to occur later in life and is responsible
not only for the loss of volumetric support within the anterior cheek, but also for
the development of the infraorbital V deformity. Deflation in this region results in
an apparent increase in the vertical length of the lower lid as the lid cheek junction
visually descends inferiorly into the poorly supported anterior cheek.
An interesting region of deflation develops in some patients in the submalar region
lateral to the oral commissure. In these patients, deflation can result in accentuation
of the submalar concavity, which can become more obvious after the vertical soft
tissue shifts associated with face lifts. An accentuation of the submalar depression
lateral to the oral commissure can result in the development of joker lines, or cross-
cheek depressions, which may appear in patients who have undergone a face lift.
Avoidance of vertical soft tissue repositioning in conjunction with volume addition
in the submalar recess lateral to the oral commissure can help prevent the accentu-
ation of postoperative cross-cheek depressions.

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Part VIII  Face Lift and Neck Lift
Radial Expansion
Not all facial aging is vertical; one major challenge in facial rejuvenation is the ra-
dial expansion of facial soft tissue that occurs in the midface. In youth, the skin and
underlying subcutaneous fat are densely attached to the deep facial fascia by reti-
nacular fibers running through skin, subcutaneous fat, and superficial fascia that
insert into the deep fascia and facial musculature. Over time, with prolonged ani-
mation such as smiling, the skin along the nasolabial line is forced deep to the sub-
cutaneous fat, positioned lateral to the nasolabial fold, which attenuates these reti-
nacular attachments. Animation forces the skin and fat lateral to the nasolabial fold
to expand radially and prolapse outward from the facial skeleton, accounting for
much of the nasolabial fold prominence in an aging face. Radial expansion lateral
to the oral commissure and marionette line similarly accounts for the prominence
of the jowl in many patients, making older faces appear square and bottom-heavy.
Radial expansion is technically difficult to correct, because there are few surgical so-
lutions for reestablishing the retinacular attachments between skin, subcutaneous
fat, and deep fascia. Nevertheless, repositioning facial fat through some form of sup-
port to the superficial fascia not only repositions fat vertically, but also provides in-
ternal repositioning so that the facial soft tissues lie closer to the facial skeleton. As
the soft tissues become situated closer to the underlying deeper structures of the face,
facial morphology tends to be restored to a more youthful configuration. Because of
the technical difficulty of completely treating radial expansion in many faces, in-
complete correction of both the jowl and nasolabial fold is common postoperatively,
despite efforts to reposition descended facial fat.
This cadaver dissection illustrates the muscular in-
sertions into the oral commissure and modiolus. The
small arrow overlies the facial portion of the platysma
and points to the risorius muscle; the large arrow
points to the depressor anguli oris muscle, where it
merges with the platysma. Superiorly, the insertion of
the zygomaticus major into the lateral commissure
can be seen, with a slip of muscle inserting inferiorly
into the modulus. After deflation in this area, the me-
dial component of the cross-cheek depression devel-
ops in the area between the elevator and the depres-
sors of the lip.

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Chapter 44  Extended SMAS Technique in Facial Rejuvenation
This 59-year-old man lost 41 kg (90 pounds) after a gastric bypass procedure. There
are areas of deflation along the infraorbital rim, lateral orbital rim, and malar re-
gion. Also noticeable is the apparent length of the lower lid from the infraorbital
V deformity in association with malar pad deflation. The radial expansion of skin
and fat lateral to the nasolabial fold is most marked on the right side. Not only does
the malar fat deflate and descend, but also attenuation of the retinacular connections
between skin, fat, and deep facial fascia lateral to the nasolabial line allows cen-
trifugal prolapse of soft tissue, which accentuates the nasolabial prominence. This
patient’s postoperative results show that the deflated areas have been improved by
repositioning fat into them. The nasolabial folds are improved after malar pad repo-
sitioning, but the correction is incomplete, especially on the right. Malar pad eleva-
tion helps flatten the prominent nasolabial fold and improve the infraorbital V de-
formity, but it does little to correct radial expansion, with the skin lateral to the
nasolabial line remaining prolapsed from its attachments to the facial skeleton.

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Part VIII  Face Lift and Neck Lift
The Role of Skeletal Support in Formulating a Surgical
Treatment Plan
Facial shape and contour are intuitively evaluated when the surgeon analyzes a patient
for facial rejuvenation. Often the two-dimensional considerations seen in photo-
graphs are the easiest aspects of aging to identify, and factors such as nasolabial fold
depth, jowl prominence, and cervical contour become the primary focus for im-
proving the appearance of a middle-aged face. Although these factors are certainly
important for treatment planning, the more subtle, three-dimensional qualities of
facial shape are equally important and are greatly influenced by underlying skeletal
support.
When evaluating facial shape during preoperative analysis, there are several major
factors that I have found helpful to consider.
FACIAL WIDTH, BIZYGOMATIC DIAMETER, AND MALAR VOLUME
The emphasis of
face lifting over the last 20 years has been on malar pad elevation. Although malar
pad elevation and restoration of malar highlights is important for improving facial
shape, it needs to be patient-specific. Many patients present preoperatively with wide
faces, strong malar eminences, and large malar volume with little evidence of malar
fat descent. In these individuals it is necessary to evaluate preoperatively the degree
of malar pad elevation required to improve facial shape.
Facial width and bizygomatic diameter reflect the underlying degree of skeletal sup-
port. Patients who exhibit strong malar eminences and wide bizygomatic diameter
often benefit from having malar highlights restored but usually do not require sig-
nificant enhancement of malar volume, because that causes a wide face to appear
even wider postoperatively. Shaping in these faces usually focuses on improving the
lower two thirds of the cheek, specifically addressing jowl fat repositioning as well
as creating submalar hollowing to improve the aesthetic relationship between malar
and submalar regions.

FACIAL LENGTH AND THE RELATIVE VERTICAL HEIGHTS OF THE LOWER AND MID-
DLE THIRD OF THE FACE
Compared with wide faces, patients who present with
vertical maxillary excess often have long, thin faces on the front view. As facial fat
descends, it becomes situated anteriorly and inferiorly, making the face appears even
longer.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation
Long, thin faces often benefit from an enhancement of malar volume. SMAS dissec-
tion and facial fat repositioning anteriorly over the zygomatic eminence allow the
surgeon to restore malar volume, thereby increasing bizygomatic diameter. When
malar volume is enhanced, the face appears wider.
CONVEXITY OF THE MALAR REGION JUXTAPOSED WITH THE CONCAVITY OF THE
SUBMALAR REGION
In youth, facial fat is situated over the malar and preparotid
region. Malar fullness is juxtaposed with a concavity in the submalar region over-
lying the buccinator muscle. As patients age, the relationship between the malar and
submalar regions changes, and facial shape changes with it. As facial fat descends
and facial deflation occurs, there is less volume overlying the malar eminence, and
there is an associated fullness increase in the submalar region. As the aesthetic rela-

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Part VIII  Face Lift and Neck Lift
tionship between the malar and submalar region changes, there is a loss of the an-
gular, tapered shape of youth, making middle-aged faces often appear oval. With
even greater facial fat descent and an increase in submalar fullness, older faces ap-
pear square.
Preoperatively, this patient’s face is oval as a result of malar deflation. Evaluating the
relationship between the malar and submalar regions on the front view, for me, is
an essential component of aesthetic treatment planning. For many patients, restor-
ing this relationship by increasing malar highlights and malar volume and recon-
structing the concavity in the submalar region becomes a central component of im-
proving facial shape.
Preoperatively, this patient shows a blunting of the relationship between the malar
and submalar regions. Postoperatively, enhancing malar volume and the bizygomatic
diameter, and restoring the concavity within the submalar region have made her face
appear more angular as well as shorter vertically.

The Vertical Height of the Mandibular Ramus and the
Horizontal Length of the Mandibular Body
The vertical height of the mandibular ramus and the horizontal length of the
mandibular body provide skeletal support for the lower two thirds of the face. Pa-
tients who present with a normal mandibular ramus height, as well as adequate hor-
izontal length of the mandibular body, usually have excellent skeletal support for
soft tissue repositioning and are, therefore, less of a surgical challenge. Patients with
a short mandibular ramus, an open mandibular plane angle, and a short length of
the mandibular body typically have poor skeletal support for midface and perioral
soft tissue repositioning. These patients are a greater surgical challenge for restoring
facial shape, and they often benefit from volumetric augmentation, either alloplas-
tic or autogenous, to enhance skeletal support.
Differential Vectors for Redraping SMAS Dissection
and Skin Flap
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation
Dermal elastosis and skin laxity in an aging face often do not occur in the same di-
rection nor at the same rate as the descent of fat and other factors affecting the su-
perficial fascia. The main advantages of performing skin dissection separate from
SMAS dissection is that it allows these two layers to be draped along vectors that
are independent of one another. Another advantage of a two-layer SMAS face lift is
that the contouring tension is placed on the superficial fascia, thereby allowing the
surgeon to use less tension for skin closure. This also improves control over scar per-
ceptibility. In my experience, facial fat is usually repositioned in a more vertical vec-

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Part VIII  Face Lift and Neck Lift
tor than skin flap redraping. Strong vertical shifting of the cervicofacial flap is tra-
ditional in many face lift techniques. Although skin tightening can produce a dra-
matic improvement in facial laxity, the aesthetic effects of vertical skin vectoring un-
fortunately have been poorly defined. Specifically, when skin is shifted in a cephalad
direction, the effect of skin tension commonly produces an accentuation of flatness
in the preparotid region, an area that typically deflates with aging. In my opinion,
vertical skin shifting often produces an unnatural tightness, producing the typical
effects associated with rhytidectomy. If the surgeon has been successful in reposi-
tioning descended facial fat, strong vertical skin tension is neither desirable nor re-
quired to enhance the postoperative result.
These two patients show the effect of vertical rotation of the cervicofacial flap as-
sociated with hairline distortion. A skin flap that is overrotated in a cephalad direc-
tion not only can compromise the temporal hairline, but also tends to produce flat-
ness in the lateral midface overlying the masseter and parotid. This imparts a tight,
unnatural appearance to the face. The effects of scar perceptibility is evident when
strong skin tension is used in an attempt to contour the face.
Surgical Technique: Extended SMAS Dissection
Most patients who have enough laxity to justify a face lift will benefit from tighten-
ing the superficial fascial layer. Restoring support to the underlying deeper facial soft
tissues has become a key part of my approach to improve facial aging. If the SMAS
is thin and tenuous, plication of this layer is an alternative to formal SMAS eleva-
tion. However, in my opinion, better contouring and longer-lasting results are ob-
tained after a formal dissection of the superficial fascia.
In skin flap dissection, it is important to develop uniform skin flaps during the sub-
cutaneous undermining, taking care to leave some intact fat along the superficial sur-
3
44-1 Face lift with
extended SMAS
Vicryl mesh fixation

face of the SMAS, especially where the SMAS is to be dissected. If the skin flaps are
dissected so that no fat is left along the superficial surface of the SMAS, then the
SMAS becomes more difficult to raise, being thin, tenuous, and prone to tearing. In
a SMAS-type face lift, much of the contouring is obtained by elevation and fixation
of the SMAS layer. The more substantial the SMAS flap, the better long-term results
that can be obtained.
I carry the subcutaneous skin flap dissection well into the malar region and usually
undermine the skin overlying the lateral two thirds of the zygomatic eminence. I pre-
fer to stop undermining the skin several centimeters lateral to the nasolabial fold, be-
cause this preserves some of the attachments that go from SMAS to the facial skin. The
preservation of these attachments, followed by adequate undermining of the SMAS,
allows the surgeon to reelevate anteriorly displaced fat and skin through SMAS ro-
tation rather than by redraping the superficial fascia completely independent of skin
flap redraping. In my opinion, this maneuver produces a more pleasing aesthetic re-
sult in most patients and preserves some of the peripheral vascularity to the facial
skin flap.
SMAS Elevation
The dissection of the superficial fascia allows the surgeon to reelevate the jowl and
descended malar fat upward into the face. In patients with prominent nasolabial
folds and significant extraorbital hollowing, the SMAS dissection should extend into
the malar region to reelevate the malar fat pad over the zygomatic eminence. An
added benefit of performing a more extensive anterior dissection of the SMAS is that
it frees this layer from the restraint of both the zygomatic and masseteric ligaments,
and this anterior release provides for a more complete elevation of the facial fat be-
low the oral commissure and along the anterior portion of the jowl.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation
The incision design for the extended SMAS dissection is an
extension of a standard lateral SMAS dissection. The malar
aspect of the dissection allows for the repositioning of fa-
cial fat along the infraorbital and lateral orbital rim, as well
as restoring malar volume. The SMAS dissection just lateral
to the zygomatic eminence provides access to the masseteric
ligaments to allow jowl fat elevation and restoring submalar
concavity. The dissection laterally in the cheek frees the
SMAS from the parotid, providing for repositioning de-
scended platysma, thereby improving mandibular border
contour.

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Part VIII  Face Lift and Neck Lift
The incisions for extended SMAS dissection begin approximately 1 cm inferior to
the zygomatic arch to ensure that the frontal branch of the facial nerve is preserved.
This horizontal incision is continued several centimeters forward to the region where
the zygomatic arch joins the body of the zygoma. At this point, the malar extension
of the SMAS dissection begins with the incision angling superiorly over the malar
eminence toward the lateral canthus for a distance of 3 to 4 cm. On reaching the
edge of the subcutaneous skin flap in the region of the lateral orbit, the incision is
carried inferiorly at a 90-degree angle toward the superior aspect of the nasolabial
fold. A vertical incision is designed along the preauricular region, extending along
the posterior border of the platysma to a point 5 to 6 cm below the mandibular bor-
der. In essence, the malar extension of the SMAS dissection simply represents an ex-
tension of a standard SMAS dissection into the malar region in an attempt to obtain
a more complete form of deep layer support.
To obtain mobility of the superficial fascia in an extended SMAS dissection, the sur-
geon must mobilize the SMAS peripheral to the restraint of the retaining ligaments.
To ensure adequate flap mobility, the SMAS needs to be completely dissected from
the underlying parotid gland and from the superior aspect of the masseteric liga-
ments and the zygomatic ligaments.
The SMAS in the malar region is then elevated in continuity with the SMAS of the
cheek. When elevating this flap, the fibers of the orbicularis oculi, as well as the zy-
gomaticus major and minor, are usually evident and the flap is elevated directly along

the superficial surface of these muscles. It is important to carry the dissection directly
external to these muscle fibers, where a natural plane exists, remembering that the
facial nerve branches lie deep to these muscular bellies. The malar SMAS is elevated
until the flap is freed from the underlying zygomatic prominence.
Completely freeing the SMAS from the zygomatic attachments is an important tech-
nical point in obtaining the mobility necessary to reposition the malar soft tissue su-
periorly. To obtain this mobility usually requires a division of the upper fibers of the
masseteric cutaneous ligaments, which will expose the underlying body of the buc-
cal fat pad. The cheek portion of the SMAS dissection is performed beginning di-
rectly overlying the parotid gland and then extending this dissection anterior to the
parotid utilizing a combination of sharp and blunt dissection toward the anterior
border of the masseter.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation
It is often necessary to extend the malar SMAS dissection more peripherally than the
subcutaneous dissection to obtain adequate flap mobility of the soft tissues lateral
to the nasolabial fold. This portion of the dissection is easily performed by simply
inserting the scissors in the plane between the superficial surface of the elevators of
the upper lip and the overlying subcutaneous fat. Once the scissors are inserted in
the proper plane, the surgeon bluntly dissects in a series of passes toward the na-
solabial fold (green area). The scissors must remain superficial to the elevators of
the upper lip to prevent motor nerve injury. Usually three or four passes are required
to obtain adequate flap mobility.

In most patients, after extended SMAS dissection of the cheek and malar regions,
mobility of the soft tissues lying lateral to the nasolabial fold remains restricted un-
less the dissection is carried more medially. This restriction in movement results from
the undivided retaining ligaments that originate medial to the zygomaticus minor.
To improve mobility, I commonly continue malar pad elevation medially in an area
where I have not subcutaneously undermined the skin. This dissection is carried di-
rectly in the plane between the malar fat and the superficial surface of the elevators
of the upper lip. It is usually quite easy to delineate this level of dissection after the
malar SMAS elevation is complete, and the superficial surface of the elevators of the
upper lip visualized. The scissors are then inserted directly superficial to the eleva-
tors of the upper lip, and blunt dissection is quickly performed by pushing the scis-
sors in a series of passes bluntly toward the nasolabial fold. I find that when we in-
sert the scissors in the proper plane, the dissection quickly glides through the malar
soft tissues, and I usually feel a “snap” as we dissect through the remaining retain-
ing ligaments. Once these structures are divided, greater mobility can be felt when
traction is applied to the malar portion of the SMAS flap, translating into greater
movement along the uppermost portion of the nasolabial fold.
Repositioning and closure of the SMAS is then performed. The malar SMAS flap is
advanced superolaterally over the zygomatic prominence in a direction perpendicu-
lar to the nasolabial fold, and usually paralleling the zygomaticus major muscle. Af-
ter superior and lateral advancement, if a malar augmentation is not planned, the
excess tissue can be excised and the flap securely fixated to the zygomatic periosteum
with interrupted sutures.
Once the malar flap is secure, the cheek-SMAS flap is rotated superiorly perpendic -
ular to the mandibular border. This portion of the SMAS flap is used to contour jaw-
line and jowl. The SMAS overlying the preauricular region and ear is then treated as
a transposition flap and carried posteriorly behind the ear, helping to restore tone
to the submental region and neck. After trimming, the SMAS flap is carefully secured
with multiple interrupted sutures. Occasionally skin dimpling is noted after secur-
ing the SMAS flap; this results from the forces of SMAS rotation on resuspended fa-
cial skin. Skin dimpling is treated by simply performing a bit more subcutaneous un-
dermining before skin flap redraping.
That the SMAS has been adequately mobilized can be determined by observing the
effect of facial contouring when traction on the SMAS is applied. In general, freeing
the SMAS past the restraint of the retaining ligaments provides the mobility neces-
sary to obtain consistent facial contouring through SMAS redraping.
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Part VIII  Face Lift and Neck Lift

After proper contouring of the SMAS dissection, the facial skin flaps are rotated and
closed in the direction decided on based on preoperative evaluation. In general, these
skin flaps are inset with a minimum degree of tension placed along the key sutures
and then the skin flaps are trimmed with a degree of redundancy between the key
sutures to minimize tension along the incision sites. I favor restoring contour face
lifting through deep layer support, placing the tension on the SMAS and platysma
closure, and minimizing the tension on skin flap closure to obtain consistency in
terms of scar perceptibility. Stated in other terms, facial contouring is restored through
deep layer support rather than through tension in skin flap redraping.
To summarize, the key points in mobilizing the superficial fascia from the restraint
of the retaining ligaments of the cheek are as follows:
 The SMAS overlying the parotid gland and malar eminence tends to be sub-
stantial and easy to dissect, with both the parotid and zygomaticus major and
minor muscles protecting the underlying facial nerve branches. These areas are
very safe regions to begin SMAS elevation and delineate the sub-SMAS plane.
 The thinnest fascial component of an extended SMAS dissection is in the re-
gion just lateral to the zygomaticus major muscle, where the SMAS splits to
invest the elevators of the upper lip. Dissecting the skin flap thinly in this re-
gion leaves a substantial amount of subcutaneous fat intact along the surface
of the superficial fascia, providing greater ease in SMAS dissection and mini-
mizing the possibility of tearing this layer.
 The most difficult portion of an extended SMAS dissection is freeing the su-
perficial fascia from the restraint of the superior masseteric ligaments, which are
lateral to the zygomaticus major muscle. If these ligaments are not mobilized,
restricted movement is noted in the portion of superficial fascia that affects
contouring along the lower nasolabial fold, oral commissure, and anterior
jowl. The zygomatic branches of the facial nerve are in close proximity to the
upper masseteric ligament. At times it can prove difficult to differentiate be-
tween ligaments and facial nerve branches. Caution is essential in this region
of dissection.
Variations in Extended SMAS Technique to Effect
a Restoration in Facial Shape
The biomechanics of SMAS repositioning have been previously described and are
influenced by the degree of release, vector of fat repositioning and how the superfi-
cial fascia is fixated. As postoperative contour is dependent on each of these factors,
preoperative planning needs to be patient specific in terms of the degree of SMAS
release required, the vectors in which facial fat is repositioned, and the location and
method for SMAS fixation.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation

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Part VIII  Face Lift and Neck Lift
Release
The incision design of an extended SMAS dissection allows for complete release of the
SMAS from its underlying retaining ligamentous attachment in the lateral midface. As
surgeons, there is a tendency to believe that a greater degree of SMAS dissection
equates with a better result, but this has not been my experience. Rather, precision
in the degree of SMAS dissection and its release from the retaining ligaments as dic-
tated by the aesthetic needs of a patient increases surgical control and consistency
in while minimizing morbidity.
How much to release the SMAS, and how high and anterior to carry the SMAS dis-
section, needs to be decided preoperatively. In patients who present with adequate
malar volume, wide bizygomatic diameter and little evidence of malar pad descent,
it is usually unnecessary to carry the SMAS dissection medial to the lateral orbital
rim (although I usually carry the dissection high within the malar eminence to al-
low fat repositioning along the infraorbital and lateral orbital rims). Most commonly,
these types of patients require only a restoration of malar highlight and not signifi-
cant anterior malar volume enhancement. Limiting the SMAS dissection to the lateral
aspect of the malar eminence will not increase facial width on the front view. Typi-
cally, the shaping considerations for these patients is focused on reducing fullness in
the submalar region. Sub-SMAS dissection along the lateral aspect of the zygomatic
eminence provides exposure to the juxtaposed masseteric ligaments, allowing the
submalar fat to be repositioned superiorly along the concavity of the underlying buc-
cinator, thereby restoring submalar hollowing.
Long faces often benefit from carrying the malar portion of the extended SMAS dis-
section anteriorly, medial to the lateral orbital rim so that malar volume restoration
is performed along the anterior aspect of the zygomatic eminence. Carrying the SMAS
dissection more medially allows the surgeon to enhance malar volume and restore
malar highlights anteriorly over the zygomatic eminence, thereby increasing facial
width on the front view.

Patients with wide bizygomatic diameters and good underlying skeletal support typ-
ically do not require a significant anterior malar dissection to improve facial shape.
Most commonly, the SMAS dissection in these patients, while kept high, is extended
only as medial as the lateral orbital rim, so that malar volume restoration is limited
to the lateral aspect of the zygomatic eminence. The shaping considerations for these
types of faces usually emphasize reducing fullness within the submalar area, as well
as jowl fat elevation. Postoperatively, the patient’s face appears more tapered and
thinner in morphology through facial fat repositioning without removal of facial fat.
Vectors of Fat Elevation: Facial Asymmetry
All patients exhibit some degree of facial asymmetry. Commonly, one side of the face
is vertically longer, and the short side of the face is usually wider than the long side.
Malar highlights are typically more superiorly located on the long side of the face
and, with age, facial fat tends to descend in a more vertical direction on the long
side. As facial asymmetry and facial skeletal configuration are asymmetric in most
individuals, it follows that the vectors of fat elevation (SMAS repositioning) should
be specific for the right and the left side of the face.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation

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Part VIII  Face Lift and Neck Lift
The vector in which the SMAS is repositioned has a significant impact on the loca-
tion and volume of elevated facial fat, thereby influencing facial shape. Decisions re-
garding the direction of SMAS vectoring for the right and left side of the face are
best determined preoperatively, as it is very difficult to make aesthetic vector judg-
ments intraoperatively with the patient recumbent.
SMAS vectors influence postoperative facial shape. Vertical SMAS repositioning typ-
ically provides a larger amount of fat for enhancing the malar eminence, as well as al-
lowing for a reduction in fullness within the submalar region as fat is forced verti-
cally along the concavity of the buccinator. For this reason, vertical SMAS vectors
are often indicated to reshape round, full faces, allowing them to appear more ta-
pered and thinner postoperatively. In this patient, a small amount of jowl defatting
through needle aspiration was also performed.
If the SMAS is vectored more obliquely, there is less volume of fat brought into the
malar region and a greater volume of fat repositioned into the submalar region.
Oblique SMAS repositioning is therefore helpful in elderly patients who appear gaunt
over the buccal recess, as it allows the surgeon to volumetrically enhance the sub-
malar region.

This patient exhibited asymmetry in the submalar region preoperatively. The area
appeared hollow and concave on the right and fuller on the left side. For this rea-
son, the SMAS was vectored obliquely on the right to volumetrically enhance the
submalar region; it was vertically vectored on the left to restore submalar hollowing
and balance the two sides of her face.
SMAS Fixation
In a two-layer SMAS-type face lift, the tension of contouring is placed on the su-
perficial fascia rather than on the skin envelope. Thus the fascial quality and tensile
strength of the superficial fascia has an influence on both the longevity of result and
the volume of fat, which can be repositioned intraoperatively and maintained post-
operatively. In other words, soft tissue quality influences long-term contour and is
the primary reason that face lifts in young patients are more predictable.
In an effort in improve fascial quality in a SMAS face lift, for over a decade I incor-
porated Vicryl mesh into the SMAS fixation. It was my initial observation that in-
corporating Vicryl mesh into fixation improved not only longevity of result, but also
provided greater aesthetic control. However, for the past 2 years I have stopped us-
ing Vicryl mesh, because I have come to realize that the predominant factor in im-
proving fixation is the method in which the superficial fascia is secured. Obtaining
a secure fixation using multiple sutures placed deep within the superficial fascia al-
lows the surgeon greater control in postoperative shape. Suturing the SMAS under
moderate tension affects facial shape:
 Adding more sutures allows the surgeon to stack volume in specific areas of
the midface, which is useful in augmenting areas of deflation, as well as aug-
menting volume along the malar eminence.
 As the superficial fascia is sutured under tension, facial fat is not only reposi-
tioned vertically, but also repositioned internally, forcing the soft tissue to con-
form to the underlying deep facial structures. This gives the surgeon greater
control in improving radial expansion.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation

The excess SMAS, rather than being excised, is rolled onto itself to form a double
layer of SMAS thickness. It is then fixated to the periosteum of the zygomatic emi-
nence. An added benefit of preserving the excess SMAS rather than excising it is that
as the thickened SMAS layer is secured to the zygomatic eminence, it highlights the
malar region, serving as an autogenous malar augmentation. Highlighting the malar
area tends to enhance angularity in facial contour.
Correction of Platysma Bands and Cervical Obliquity
The best approach to the anterior platysma is through a submental incision, placed
just caudal to the submental skin crease. If this crease is very deep, the skin cepha-
lad is elevated toward the base of the chin pad and along the caudal mandibular bor-
der to free any retaining mandibular ligaments, which tend to accentuate the crease.
After this, the cervical skin is carefully elevated. The cervical skin is usually under-
mined at least to the level of the cricoid.
When the platysma muscle is exposed anteriorly, most patients exhibit a decussa-
tion of platysmal fibers across the midline, at least for a few centimeters below the
mentum. If platysma band surgery is planned, these decussating fibers must be
sharply divided with scissor dissection directly in the midline. Then the medial edge
of the platysma is mobilized from the mentum inferiorly at least to the hyoid and
commonly as caudal as the cricoid cartilage. Mobilization, usually performed using
a combination of sharp and blunt dissection, separates the platysma from the un-
derlying subplatysmal fat, the anterior belly of the digastric muscle, and the strap
muscles overlying the thyroid cartilage. At times numerous small venules are en-
countered within the subplatysmal fat and careful hemostasis must be obtained. Af-
ter mobilization of the medial edges of the platysma, the subplatysmal fat is con-
servatively contoured according to preoperative planning.
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Part VIII  Face Lift and Neck Lift

Following mobilization, the medial edge of the platysma muscle is grasped on either
side and overlapped in the midline to estimate the amount of excess muscle present.
Muscle excess varies from patient to patient. A portion of the medial edge can be
excised to remove redundancy within the platysma. A conservative resection is per-
formed to avoid undue tension at the time of suture plication.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation
Muscular plication consists of edge-to-edge approximation using multiple interrupted
sutures at the mentum and extending at least to the level of the hyoid. This longer
plication enhances the surgeon’s ability to tighten and contour the platysma so that
it adheres to the floor of the mouth and the thyroid cartilage. This produces a bet-
ter foundation for redraping of cervical skin. Suture placement back from the lead-
ing edge of the muscle, in areas of intact muscular fascia, is an important technical
point in preventing suture pull-through postoperatively.

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Part VIII  Face Lift and Neck Lift
In most patients, the edge-to-edge suturing below the hyoid is continued inferiorly
toward the cricoid cartilage. A low plication joining a widely separated platysma
over a prominent thyroid cartilage tends to blunt a prominent larynx and produce
a rounder, more feminine appearance to the neck.
After edge-to-edge approximation of the platysma, some form of muscular release
is performed. This muscular release commonly involves a partial transection of the
platysma muscle, with the myotomy performed inferiorly within the neck. This usu-
ally consists of a horizontal cut extending from the midline to the anterior border
of the sternocleidomastoid muscle.
Platysma transection is an effective technique for treating platysma bands and ob-
taining the desired cervical contour. This procedure must be performed meticulously.
Early experience with transection was fraught with complications; specifically, if the
transection was performed at a high level, it could cause unveiling of the submaxil-
lary glands and denervation of the platysma, leading to lower lip dysfunction. Also,
obvious contour depressions associated with divided muscular edges could occur in
an overly thin neck.

The key to platysma transection is that the transection of the muscle must be per-
formed lower in the neck, often as inferior as the level of the cricoid cartilage. The
disadvantage of horizontal transection at this level is that a depression in the neck can
develop if preplatysmal fat has been removed at the level at which the transection is
performed. Preservation of preplatysmal fat lower in the neck where the transection
is to be performed is obviously an important factor in preventing this problem.
In most patients, only partial division is required. The myotomy is performed from
the midline laterally until the tension is completely released from the platysmaplasty
closure (approximately the anterior border of the sternocleidomastoid muscle in most
patients).
The muscular release seen after platysma transection serves many purposes:
 It alleviates tension along the medial portion of the platysma transection fol-
lowing plication.
 It allows the platysma to shift superiorly, producing a deeper cervicomental
angle.
 It prevents the conversion of two platysmal bands to a single band after edge-
to-edge approximation, which can be visible when the neck is extended.
Sequence of SMAS Fixation Versus Platysmaplasty
Because the SMAS and the platysma lie in the same anatomic layer, if platysmaplasty
is performed before the SMAS dissection, it can adversely affect facial contour. Con-
touring the neck before the midface can also present problems. When the platysma -
plasty is performed first, the descended jowl fat is locked down into the neck, and
movement of the superficial fascia diminishes after elevation of the SMAS. This di-
minished movement tends to lessen the surgeon’s ability to modify facial shape; it
also produces a less aesthetic contour. If the SMAS dissection is performed before
the platysmaplasty, descended jowl fat is brought cephalad to the mandibular bor-
der and is easily repositioned. After the SMAS has been securely sutured bilaterally,
the mandibular border appears more distinct, making cervical contouring less de-
manding. When performing platysmaplasty subsequent to SMAS fixation, the sur-
geon will notice less redundancy along the medial borders of the platysma; there is
also less need to resect muscle at the time of platysmaplasty. The enhanced contour
effects of extended SMAS dissection, associated with precise platysmaplasty, tend to
diminish the need to remove cervical fat. In general, the neck and jawline appear
softer if preplatysmal fat is preserved when contouring the neck.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation

This patient illustrates how facial fat reelevation influences cervical appearance. Se-
quencing errors can lead to loss of contour; I prefer to perform SMAS elevation and
fixation before performing platysmaplasty. As the facial fat and skin are reelevated
upward into the midface through SMAS rotation, the mandibular border becomes
more distinct, making cervical contouring more predictable.
1502
Part VIII  Face Lift and Neck Lift
This woman demonstrates the result after extended SMAS repositioning and platys -
maplasty.

This patient is shown before and after an extended SMAS dissection. By reelevating
descended facial fat back up toward the malar region and lateral midface and se-
curing it there intraoperatively, her facial shape is improved. The mandibular border
has been enhanced through SMAS repositioning and platysmaplasty.
Incisions
The importance of incision quality cannot be overemphasized in diminishing signs
that the patient has undergone a surgical procedure. One of the major advantages
of a two-layer face lift is that the tension of contouring is along the superficial fas-
cia, and thus there is less need to redrape the skin flap with great force. Decreased
tension on the key sutures in both the preauricular and postauricular region pro-
vides greater control over scar perceptibility. If the incisions are artistically designed,
patients can typically wear their hair up off their ears without the obvious stigma
that a face lift has been performed.
Many authors have described the salient factors regarding incision design, these main
points should be emphasized:
 Tragal incisions, placed at the margin of the tragus rather than preauricularly,
are preferable, because the color difference between the pale skin of the ear
and the blush skin of the cheek is usually better camouflaged when the inci-
sion is brought internally into the ear.
 Tragal incisions are more demanding than preauricular incisions, requiring
precise design and placement so that the tragus is not distorted. The aesthetic
unit of the tragus is rectangular, as opposed to semilunar. If the surgeon de-
signs the tragal incision properly, respecting the incisura of the tragus, the tra-
gus will appear normal in its shape postoperatively, exhibiting both a visual
beginning at its junction with the helix and a visual ending along the preserved
incisura.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation

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Part VIII  Face Lift and Neck Lift
 Detached earlobes tend to appear more natural than attached earlobes. If a
small cuff of cheek skin is left attached to the earlobe, it will allow surgical rota-
tion of the skin up under the earlobe during skin flap redraping, with sutur-
ing of the earlobe distinct from the cheek flap. The earlobe should be inset in
an axis posterior to the axis of the pinna, thereby avoiding a pixie deformity.
This intraoperative photograph illustrates the standard tragal incision with preser-
vation of the incisura of the tragus. The incision is carried around the earlobe ap-
proximately 1 to 2 mm caudal to the junction of the earlobe with the cheek skin.
Left: A preauricular incision is shown 2 months postoperatively. Again, the problem
with preauricular incisions is that the difference in color between the skin of the
cheek and the skin of the ear is more visible in this anterior incision location. Center:
A tragal incision is seen 5 months postoperatively; this incision was patterned after the

methods described in the preceding figure. Right: A well-designed and inset tragal
incision should produce an imperceptible, normal-appearing tragus that exhibits
both a visual beginning and end and a detached-appearing earlobe.
There is an increasing public demand for facial rejuvenation at earlier ages, when
facial laxity is often minimal. This places the onus on the surgeon to create incisions
that are imperceptible if these procedures are to be justified. No matter how well
deep-layer support is obtained and facial contour improved by SMAS elevation and
platysmaplasty, if the incision is obvious, scar quality poor, the hairline disturbed,
or the earlobe deformed, the overall result will be disappointing.
Concluding Thoughts
From a personal perspective, after close to two decades of striving to improve tech-
niques in facial rejuvenation, it is my firm conviction that improving technical con-
trol when contouring the superficial facial fascia and platysma provides a more con-
sistent, aesthetically pleasing result that is nonsurgical in appearance. To perform a
successful two-layer SMAS-type face lift, the surgeon must not only understand fa-
cial soft tissue anatomy, but also must perform a procedure that demands technical
precision. A two-layer SMAS-type face lift is a time-consuming operation, with both
the skin flap elevation and the dissection of the SMAS requiring meticulous, accu-
rate dissection. Obtaining consistency with this procedure is challenging because of
the variability among individuals in the thickness of subcutaneous fat and the SMAS.
After precise dissection, secure fixation of both the SMAS and platysma is essential
to maintain the desired postoperative contour. Ensuring meticulous hemostasis, fol-
lowed by careful skin flap inset, are required to minimize postoperative scar percep-
tibility and ensure a rapid postoperative recovery.
Despite these demands, I have found the extended SMAS technique to be rewarding,
with a high degree of patient satisfaction. All techniques have advantages and dis-
advantages. For me, the biggest advantage of the extended SMAS technique remains
its aesthetic versatility, allowing the surgeon to vary the contouring aspects of the
procedure according to the aesthetic needs of the patient.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation

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Part VIII  Face Lift and Neck Lift
Clinical Caveats
 Patient selection is probably the most critical factor when determining the success
of a proposed aesthetic procedure.
 The anatomic arrangement of the facial soft tissues as a series of concentric lay-
ers is key to the safety of rhytidectomy procedures. This concentric arrangement
allows dissection within one anatomic plane to proceed completely independent
of structures lying within another anatomic plane.
 Improving technical control when contouring the superficial facial fascia and
platysma provides a more consistent, aesthetically pleasing, nonsurgical-looking
result.
 The surgical significance of the deep facial fascia is that all the facial nerve branches
within the cheek lie deep to the deep facial fascia.
 Although aging is a complex process, many of the stigmata developing in the ag-
ing face involve a change in the relationship between the superficial and deep facial
fascia, with the superficial unit of the facial soft tissue descending inferiorly in re-
lation to the fixed deeper structures of the face.
 The importance of the zygomatic ligaments lies in their ability to suspend malar
soft tissue superiorly over the zygomatic eminence. With aging, malar support
commonly attenuates, leading to an inferior migration of malar soft tissue. Atten-
uation of support from retaining ligaments, dermal elastosis, and facial lipodys-
trophy are the three main components that must be addressed to reconstruct the
anatomic changes resulting from aging.
 The principal advantage of performing skin undermining separately from SMAS
dissection is that it allows these two layers to be redraped along vectors that are
independent of one another.
 The significance of the retaining ligaments is their location, which determines the
degree of surgical dissection necessary in face lifting.
 In face lifting, it would seem that wide mobilization and aggressive dissection
would improve contour, but my experience with wide dissection has led me to a
contrary view. I have found that wide dissection peripheral to the restraint of the
retaining ligaments to be counterproductive in an extended SMAS face-lift tech-
nique.
 Rhytidectomy can be considered a reconstructive procedure in that facial soft tis-
sue anatomy is restored to a state resembling its structure before the degenerative
effects of aging occurred.

 More than any other factors, skin quality and elasticity have perhaps the greatest
influence on outcome after a rhytidectomy.
 Buccal fat removal tends to reduce facial fullness, but rarely does it improve promi-
nent jowls.
 In most patients, jowling can be improved through SMAS rotation.
 The prominent nasolabial fold requires restoration of malar support to produce
a lasting change in contour. In my experience, extending the cheek SMAS dissec-
tion into the malar region to restore malar support has been helpful in improving
prominent nasolabial folds.
 Correction of the obtuse neck involves restoration of skin tone, contouring of re-
gional lipodystrophy, and restoration of platysma support.
 One of the major advantages of a two-layer face lift is that the tension of con-
touring is along the superficial fascia, and thus there is less need to redrape the
skin flap with great force.
 The importance of incision quality cannot be overemphasized in diminishing the
signs that the patient has undergone a surgical procedure.
 The postauricular incision extends along the postauricular groove, not up onto
the conchal surface.
 Because the SMAS and platysma represent the same anatomic layer, if platysma -
plasty is performed before the SMAS dissection, it can adversely affect facial con-
tour. Contouring the neck before the midface can also present problems.
 In skin flap dissection, it is important to develop uniform skin flaps during the
subcutaneous undermining, taking care to leave some fat intact along the super-
ficial surface of the SMAS, especially in the regions where the SMAS is to be dis-
sected.
 The SMAS overlying the parotid gland and malar eminence tends to be substan-
tial and easy to dissect, with both the parotid and zygomaticus major and minor
muscles protecting the underlying facial nerve branches. These areas are very safe
regions to begin SMAS elevation and delineate the sub-SMAS plane.
 Because the SMAS and platysma are in the same layer, what the surgeon does in
the face influences the contour in the neck.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation

Annotated Bibliography
Feldman JJ. Neck Lift. St Louis: Quality Medical Publishing, 2006.
Corset platysmaplasty is useful for all patients with visible paramedian muscle bands
and all patients who would benefit from having a decussated upper neck platysma
opened for submuscular defatting, including patients with oblique, palpably firm necks
that suggest a vertically short platysma muscle or low-lying hyoid bone.
Mendelson BC. Correction of the nasolabial fold: extended SMAS dissection with periosteal
fixation. Plast Reconstr Surg 89:822-833; discussion 834-835, 1992.
The nasolabial fold has defied satisfactory correction with the face-lift operation despite
variations of the SMAS technique over the past 20 years. In this study, the nasolabial
fold is shown to be part of the overall aging deformity that affects the cheek and peri-
oral region. The relevant anatomy is reviewed and the safety of the procedure is assessed
in a personal series of 135 patients. It is concluded that the two principles of this tech-
nique, that is, complete SMAS release and reattachment to the zygoma, safely and ef-
fectively achieve a natural-appearing rejuvenation of the cheek and nasolabial fold.
Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS dissection as an approach to
midface rejuvenation. Clin Plast Surg 22:295-311, 1995.
The objective in rhytidectomy is to rejuvenate and improve facial appearance. To ob-
tain consistent results, face lifting should be approached not just as a tightening or lift-
ing procedure but also as a reconstructive procedure, reversing the anatomic changes
that occur in aging. The authors discuss the blending of surgical technique, anatomic
knowledge, and artistic sensitivity to individualize the surgical approach for patients.
Furthermore, the authors stress that obtaining surgical rejuvenation while minimizing
signs of surgical distortion should be the ultimate goal of face-lifting procedures.
Suggested Readings
Aston SJ. Face lift with FAME technique. Presented at the Thirty-second Annual Baker Gor-
don Symposium on Cosmetic Surgery, Miami, 1998.
Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast Surg 3:529-539, 1979.
Baker TJ, Gordon HL, Stuzin JM. Surgical Rejuvenation of the Aging Face, 2nd ed. St Louis:
CV Mosby, 1995.
Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg 90:601-607, 1992.
Connell BF. Cervical lifts: the value of platysma muscle flaps. Ann Plast Surg 1:32-43, 1978.
Connell BF. Neck contour deformities: the art, engineering, anatomic diagnosis, architec-
tural planning, and aesthetics of surgical correction. Clin Plast Surg 14:683-692, 1987.
Connell BF, Marten TJ. The trifurcated SMAS flap: three-part segmentation of the conven-
tional flap for improved results in the midface, cheek, and neck. Aesthetic Plast Surg
19:415-420, 1995.
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Part VIII  Face Lift and Neck Lift

Hamra S. The deep plane rhytidectomy. Plast Reconstr Surg 86:53-61; discussion 62-63,
1990.
Lambros V. Fat contouring in the face and neck. Clin Plast Surg 19:401-414, 1992.
Lambros V, Stuzin JM. The cross-cheek depression: surgical cause and effect in the develop-
ment of the “joker line” and its treatment. Plast Reconstr Surg 122:1543-1552, 2008.
Lemmon ML, Hamra ST. Skoog rhytidectomy: a five-year experience with 577 patients. Plast
Reconstr Surg 65:283-297, 1980.
Little JW. Three-dimensional rejuvenation of the midface: volumetric resculpture by malar
imbrication. Plast Reconstr Surg 105:267-285; discussion 286-289, 2000.
Marten TJ. Face lift planning and technique. Clin Plast Surg 24:269-308, 1997.
Mendelson BC. Surgery of the superficial musculoaponeurotic system: principles of release,
vectors, and fixation. Plast Reconstr Surg 107:1545-1552; discussion 1553-1561, 2001.
Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and
cheek area. Plast Reconstr Surg 58:80-88, 1976.
Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Re-
constr Surg 91:463-474; discussion 475-476, 1993.
Owsley JQ Jr. SMAS-platysma face lift: a bidirectional cervicofacial rhytidectomy. Clin Plast
Surg 10:429-440, 1983.
Rogers BO. A brief history of cosmetic surgery. Surg Clin North Am 51:265-288, 1971.
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.
Skoog T. Plastic Surgery: New Methods and Refinements. Philadelphia: WB Saunders, 1974.
Stuzin JM. Restoring facial shape in face lifting: the role of skeletal support in facial analy-
sis and midface soft tissue repositioning. Plast Reconstr Surg 119:362-376; discussion
377-378, 2007.
Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting: enhanced facial contour using
Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg 105:290-301, 2000.
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.
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Chapter 44  Extended SMAS Technique in Facial Rejuvenation

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High SMAS Face Lift
With Orbicularis Redraping and
Septal Reset

FRITZ E. BARTON, JR.
CHAPTER 45

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Part VIII  Face Lift and Neck Lift
T
he traditional method of soft tissue facial rejuvenation has been segmental, skin-
based surgery. Most commonly, early signs of aging have been addressed with
initial blepharoplasty, followed later by correction of the cheek and/or neck and oc-
casionally, rejuvenation of the forehead. This approach was and still is popular for
several reasons. First, the patient views it as logical to do multiple, small, stepwise
procedures. The patient assumes that if less is done, the less likelihood that he or she
will look “operated on.” Second, it seems less threatening when the procedures can
be done with a local anesthetic and sedation, rather than with a general anesthetic.
Third, the procedures are quick for the surgeon, and recovery is quick for the pa-
tient. Limited skin-based procedures, with or without superficial plication sutures
in the SMAS, are simple in concept as well as in application.
In this chapter, I will present an approach that challenges most of those tenets.
I believe that paramount to the maintenance of facial beauty in aging is the mainte-
nance of facial harmony. At any age, one of the requirements for looking natural is
for all segments of the facial aesthetic complex—from the hairline to the clavicles—
to match. Generalized laxity looks natural; generalized firmness looks natural. But
a lax segment juxtaposed against a firm segment looks unnatural. As I explain to pa-
tients, no matter how skillfully you shorten two legs of a chair, it never looks in bal-
ance. Not only is this disharmony important initially, but as aging progresses, dishar-
mony often becomes more apparent.
It is my firm belief that at the time of the initial facial rejuvenation surgery, changes
that are present throughout should be treated simultaneously and comprehensively.
I think that the subunits of the face and neck overlap. Thus mobilizing only one unit
is restricted by the attachments of the adjacent units. Mobilizing and repositioning
all of the subunits simultaneously allows a harmonious blending. Nowhere is this
more important than in the lower eyelid and the cheek.
Pertinent Anatomy
Several surgical principles are incorporated in surgical planning. First, the cheek unit
is dealt with as a single composite unit. Although some faces have significant facial at-
rophy with volume loss, descent is not only a prominent factor, but it is also the most
correctable factor. The facial soft tissues, skin and subcutaneous fat, are attached to
the facial skeleton by osteocutaneous fibrous connections—“ligaments” and fascias.
Over time these supporting fibrous attachments relax, allowing descent, particularly
of the superficial subcutaneous fat and skin. Just as the skin was not holding the soft
tissues in place initially, it is not a useful layer for resupport. Skin is a viscoelastic
structure, designed to be flexible and expansile. By definition, an elastic structure is

not a good choice for bearing the load of suspension. Dense collagenous structures,
fascia and tendon, are designed to carry load. Therefore retightening the deep fascia
is the best way to resuspend the facial fatty mass and skin.
Critics of this load-bearing suspension concept argue that any tension in a face lift
creates flattening of the facial contours and should be avoided. I agree that any ten-
sion in the skin is to be avoided to avoid stress relaxation and a stretched look. Skin
will not support even its own weight, much less the weight of the cheek mass. It is
the skin tension from skin-based procedures that has produced the large number of
stretched, distorted faces that have given face-lift surgery a bad name.
However, vertical repositioning of the subcutaneous facial mass by means of fascial
(SMAS) advancement does not flatten contour or create skin tension.
The second principle in my approach is to leave skin attached to the SMAS and sub-
cutaneous fatty mass, so the entire cheek moves as a whole. This approach is a mod-
ification of the original Skoog procedure.
Our previous studies have shown that the platysma/SMAS serves as a myocutaneous
unit. After transection of the anterior branch of the superficial temporal artery with
the surgical dissection, the branches of the anterior facial artery supply the midcheek
skin via the platysma. Moreover, the SMAS sends fibrous connections through the
overlying subcutaneous fat to the dermis. Therefore elevation of the subcutaneous
mass through the SMAS indirectly advances the skin without causing direct dermal
tension.
Some have criticized advancing the cheek as a composite of skin and SMAS, con-
tending that the skin and SMAS cannot be redraped in different directions. I do not
believe this opinion to be valid. First, as has recently become accepted, the best di-
rection for redraping both the skin and the SMAS in the cheek is vertical. However,
the neck often requires more horizontal (or oblique) redraping. Thus the skin and
platysma are dissected as separate layers in the neck below the mandible.
The third principle is that advancement is facilitated by release. As previously dis-
cussed, the subcutaneous fatty mass and SMAS are fixed by retaining ligaments and
fascial attachments. The fatty mass is secured by the zygomatic retaining ligament.
The SMAS is restricted by its attachment to the parotid capsule as well as its invest-
ment of the superficial layer of the facial mimetic muscles. Advancement vertically
is restricted by these attachments. Conversely, I believe that advancement is facili-
tated by release of these attachments. This approach is central to the debate over
whether plication (infolding without undermining) is as effective as imbrication (un-
dermining, advancement, and overlapping) in long-term maintenance of cheek sus-
pension. Having performed both techniques for many years, I think that imbrica-
tion is more long lasting.
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Chapter 45  High SMAS Face Lift With Orbicularis Redraping and Septal Reset

A wide variety of methods have been described for using the SMAS to elevate the
subcutaneous facial fat. Early attempts at SMAS advancement were timid dissections
only over the parotid gland. Because the SMAS is broadly laminated to the parotid
capsule, the SMAS is immobile in this area. As a result, these initial experiences were
disappointing, and the value of the SMAS was questioned.
With extended dissection, however, the restriction of the parotid capsule is released,
and the areolar gliding plane over the buccal area is entered. With this maneuver, the
cheek mass over the buccal and mandibular area is well mobilized. This step in the
evolution of SMAS dissection I regard as a low SMAS technique, in that its effect is
limited to below the zygomatic arch. The upper subcutaneous mass, or malar pad,
is left unsuspended.
It was my goal to suspend the entire cheek subcutaneous mass, mandibular and
malar, as a single unit to provide pansupport. In 1984, after several years of anatomic
dissections and experience with sub-SMAS dissections in reconstructive cheek flaps,
I performed my first high SMAS procedure. Other than several variations of the ex-
tent of anterior dissection, I have persisted with the original technique. As with any
procedure, the application subtleties vary with each patient, but I have found the
high SMAS face lift to deliver consistent, predictable, long-lasting benefits. Although
the cheek mass suspension method remained rather constant, what I have added is the
approach to the lower orbit and lid-cheek junction.
As with surgery of the cheek and neck, early lower blepharoplasty techniques fo-
cused on skin excess. I initially performed skin flap elevation and excision, in asso-
ciation with selective fat removal, for many years. In some patients, it was and re-
mains an adequate technique. However, I began to observe that the result in many
patients was not of the highest quality.
One group that failed with the skin flap technique was patients with so-called malar
bags. It was not until the sentinel publications of Furnas describing festoons and
Hamra observing the orbicularis crescent that I came to understand, and look for,
the importance of orbicularis ptosis in lower eyelid surgery. Like many unnoticed
deformities, the more you look for it, the more prevalent you realize it is. I am now
convinced that orbicularis ptosis is present in essentially every aging eyelid. Thus or-
bicularis suspension in the lower eyelid is comparable to SMAS suspension in the
cheek.
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Part VIII  Face Lift and Neck Lift

It is imperative to understand the partitioning of the orbit from the cheek to under-
stand how to safely deal with the lid-cheek junction. Extending from the lacrimal
bone medially to the inner orbit laterally, the fibrous sling encases the lower lid tarsal
plate and soft tissue. The lower eyelid is a rather slight and fragile structure, so the
suspensory apparatus can be delicate.
The cheek mass, by contrast, is much more massive, and accordingly, it is heavier.
Unopposed, the weight of the cheek would overwhelm the fragile lid suspensory sys-
tem and pull the lid down into ectropion. However, the eyelid is protected by two
barriers.
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Chapter 45  High SMAS Face Lift With Orbicularis Redraping and Septal Reset
Orbicularis retaining
ligament
Zygomaticocutaneous
ligament
Lateral canthal
tendon
The orbicularis retaining ligament (or orbitomalar ligament) extends from just be-
low the orbital rim to the junction between the preseptal and periorbital orbicularis
oculi. Originating medially at the orbital rim and extending obliquely downward
through the cheek at the lower border of the periorbital orbicularis oculi is the zy-
gomaticocutaneous ligament (or malar membrane). In combination, these two os-
teocutaneous ligaments serve as “check rein” partitions from which the weight of
the cheek is partially suspended. As long as they are intact, the lower eyelid is pro-
tected. Procedures developed to blend the lid-cheek junction, however, frequently
disrupt these barriers. To avoid potential ectropion of the lower eyelid with release
of the barriers, protective independent suspension of the cheek should be done. This
protection gains in importance as patients with increasingly negative-vector orbits
are treated.

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Part VIII  Face Lift and Neck Lift
Operative Technique
To begin a high SMAS face lift, a preauricular skin incision is usually brought post-
tragally. The mastoid extent of the incision is determined by the degree of neck skin
excess.
A limited subcutaneous dissection is carried out in the preauricular area to the ex-
tent of the estimated skin excision. The goal is to leave minimal undermined skin at
the completion of the procedure. The subcutaneous dissection is continued above
the zygomatic arch in a tunnel over to the lateral border of the orbicularis oculi.
The SMAS is then initially incised from the top of the tragus to the bottom of the
earlobe to establish the proper plane over the parotid. It is at this location that the
SMAS is thickest and the facial nerve is the deepest within the parotid gland.
With the sub-SMAS plane established, dissection is continued anteriorly to the bor-
der of the parotid, where it becomes areolar in nature. It is at this point that the fa-
cial nerves exit the parotid gland, and the dissection is switched from sharp to blunt
spreading. With vertical spreading, the buccal dissection is carried into the area of
the mobile SMAS. It is imperative to leave the translucent buccal fascia intact as a
protection over the facial nerve branches.
At the lower extent of the sub-SMAS dissection, approximately 4 cm below the
mandibular border, a small horizontal backcut is made to allow the SMAS to dis-
place upward without restriction from the investing fascia.
Subcutaneous tunnel
superior to arch
Subgaleal dissection
if simultaneous open
forehead lift is to be done
Only skin expected to be
removed is undermined
Subcutaneous
dissection 4 to 5 cm
Subcutaneous dissection
of neck from mastoid to midline
superficial to platysma muscle

Next the upper border of the SMAS is transected above the zygomatic arch over to
the lateral border of the orbicularis oculi muscle. It is this maneuver that facilitates
upward repositioning of the upper malar fat. It has also been the most controversial
portion of the technique. Traditional teaching has been that transection of the SMAS
at this level would sever the frontal branch of the facial nerve. However, that anatomic
dictum is incorrect. In fact, the facial nerve branch courses deeper over the zygomatic
arch, and the SMAS can be safely elevated and separated from it.
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Chapter 45  High SMAS Face Lift With Orbicularis Redraping and Septal Reset
Temporal branch
of facial nerve
SMAS
incision
Upper lateral corner of SMAS
remains attached to skin
Dissection from beneath SMAS
over zygomaticus major muscle, thus
releasing restraint of investing fascia
Marginal mandibular
branch of facial nerve
Once the upper SMAS is released above the zygomatic arch, it is severed from the
zygomatic retaining ligaments and its investment of the zygomaticus major muscle.
Using the visible border of the orbicularis oculi as a point of origin, the surgeon can
identify the path of the zygomaticus major muscle. A thin layer of fat should be left
on the muscle to protect the motor branch to the lateral orbicularis, which courses
over the external surface of the zygomaticus major muscle origin. The plane of dis-
section is continued from beneath the SMAS over the external surface of the zygo-
maticus major muscle and into the subcutaneous plane, releasing the investing fas-
cia connection of the SMAS.
The cheek mass is then relocated in a vertical direction and secured to the deep tem-
poral fascia above the auricle. The periauricular SMAS is then reapproximated to
provide a broad, secure closure. This vertical suspension of the cheek mass not only
supports the cheek mass, but also provides something of a shelving support below
the orbital tissues.

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Part VIII  Face Lift and Neck Lift
Orbicularis Suspension
The first step in orbicularis suspension is to perform a subciliary incision. The skin is
then elevated over the pretarsal and preseptal orbicularis muscle. The lateral half of
the orbicularis muscle is incised, leaving a pretarsal strip intact. Dissection is carried
beneath the orbicularis muscle down to the level of the orbital rim. At this point the
orbicularis retaining ligament and attachment over the zygomatic body are freed to
allow mobilization. Without release of these attachments, the orbicularis muscle can-
not be adequately mobilized superiorly.
A laterally based interpolation flap is then formed from the redundant upper edge
of the orbicularis muscle. This muscular pennant is then tunneled beneath the su-
perficial head of the lateral canthal raphe to be secured to the lateral orbital rim peri -
osteum above. Tarsal protection during the healing phase is accomplished by either
canthopexy or canthoplasty of the lateral canthal tendon. Redundant skin is then
conservatively trimmed.
In patients with vector-positive orbits, only orbicularis redraping is necessary to
smooth a prominent arcus marginalis.
Septal Reset
In patients with a negative-vector orbit, a prominent tear-trough configuration may
be present consisting of malar bone deficiency, deep set arcus marginalis, and her-
niation of orbital fat. A septal reset procedure may be beneficial in addition to the
orbicularis suspension and skin removal.

After elevation and release of the orbicularis muscle, the orbital septum is divided
along the arcus marginalis. The orbital fat is extruded over the orbital rim. The or-
bital septum and orbital fat are then sutured together to the periosteum of the ante-
rior orbital rim.
The remainder of the procedure of orbicularis suspension is then completed as pre-
viously described.
Benefits of the Combined Procedures
Although any of the aforementioned procedures can be performed alone, I think they
are much more effective and much safer when performed together.
Effectiveness
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Chapter 45  High SMAS Face Lift With Orbicularis Redraping and Septal Reset
Repair septal hernia
Advance arcus marginalis
(septum plus fat)
Orbicularis
retaining
ligament
Malar
membrane
The vertical elevation of the malar fat partially effaces the visible depression along
the arcus marginalis, but it also transfers skin into the eyelid, usually necessitating
lower lid skin removal. In addition, the malar fat elevation undercuts the redundant
lower border of the orbicularis oculi, creating or accentuating a malar crescent.

1520
Part VIII  Face Lift and Neck Lift
Suspension of the orbicularis corrects this problem. In negative-vector patients with
fat herniation, release of the orbital septum and reset of the orbital fat with the sep-
tum to the anterior orbital rim enhances the procedure.
Safety
From a safety viewpoint, independent suspension of the cheek protects the eyelid
suspensory mechanism. To redrape the orbicularis oculi to correct orbicularis pto-
sis, release of the orbicularis retaining ligament is necessary. Furthermore, release of
the malar membrane softens the oblique depression sometimes present across the
cheek. The release of these osseocutaneous ligaments removes the protective parti-
tion between the lower eyelid and cheek. Independent vertical cheek elevation not
only removes the weight of the cheek from the eyelid, but it also creates a “shelving”
sling to support the eyelid.
For both reasons, when presented with a patient with aging in both the eyelid and
cheek, I prefer to redrape them simultaneously, rather than sequentially.
Fascial suspension of
cheek supports eyelid