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

Clinical Caveats
 Faces age in all areas; therefore all aged areas should be addressed simultaneously
to preserve facial harmony.
 Skin undergoes stress relaxation. Therefore, to avoid a stretched look, skin should
not be placed under tension.
 The SMAS is the best “handle” with which to reposition the subcutaneous facial
mass.
 Leaving the SMAS attached to the skin allows the skin to be repositioned without
tension.
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Part VIII  Face Lift and Neck Lift
Annotated Bibliography
Barton FE Jr. Facial Rejuvenation. St Louis: Quality Medical Publishing, 2008.
This text offers a more complete explanation of office organization, patient consulta-
tion, variations in panfacial rejuvenation, and skin surface care.
Furnas DW. Festoons of orbicularis muscle as a cause of baggy eyelids. Plast Reconstr Surg
61:540-546, 1978.
This classic article brought clarity and attention to orbicularis ptosis and the cause of
“malar bags.” Surgical resuspension is described.
Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 83:11-16, 1989.
This classic article first defined the osteocutaneous ligaments of the face. Release of these
ligaments is necessary to completely mobilize the SMAS and subcutaneous cheek mass.
Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid
and cheek area. Plast Reconstr Surg 58:80-88, 1976.
These young surgeons, working with Tessier, published the first detailed anatomic de-
scription of the subcutaneous fascia in the face, which they called the superficial mus-
culoaponeurotic system (SMAS).
Skoog T. Plastic Surgery—New Methods. Philadelphia: WB Saunders, 1974.
Although the superficial subcutaneous fascial had been noted by earlier anatomists and
surgeons, it was Tord Skoog who conceived using the subcutaneous fascia to mobilize a
composite cheek flap.

Suggested Readings
Barton FE Jr. Rhytidectomy: the anatomical basis for complete dissection. Presented at the
Annual Meeting of the American Society for Aesthetic Plastic Surgery, Los Angeles,
1992.
Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg 90:601-607, 1992.
Barton FE Jr. The SMAS and the nasolabial fold. Plast Reconstr Surg 89:1054-1057; dis-
cussion 1058-1059, 1992.
Barton FE Jr, Ha R, Awada M. Fat extrusion and septal reset in patients with tear trough
triad: a critical appraisal. Plast Reconstr Surg 113:2115-2121; discussion 2122-2123,
2004.
Barton FE Jr, Hunt J. The high-superficial musculoaponeurotic system technique in facial
rejuvenation: an update. Plast Reconstr Surg 112:1910-1917, 2003.
Flowers RS. The tear trough deformity and its correction. Presented at the Annual Meeting
of the California Society of Plastic Surgeons, Monterey, 1970.
Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation.
Plast Reconstr Surg 96:354-362, 1995.
Hamra ST. Repositioning the orbicularis oculi muscle in composite rhytidectomy. Plast
Reconstr Surg 90:14-22, 1992.
Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic
system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast
Reconstr Surg 12:77-88, 1996.
Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the ligamentous attach-
ments of the lower lid and lateral canthus. Plast Reconstr Surg 110:873-884; discussion
897-911, 2002.
Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the midcheek and malar
mounds. Plast Reconstr Surg 110:885-896; discussion 897-911, 2002.
Pessa JE, Garza JR. The malar septum: the anatomical basis of malar mounds and malar
edema. Aesthetic Surg J 17:11-17, 1997.
Pessa JE, Zadoo VP, Adrian EK, et al. Anatomy of a “black eye”: a newly described fascial
system of the lower eyelid. Clin Anat 11:157-161, 1998.
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Chapter 45  High SMAS Face Lift With Orbicularis Redraping and Septal Reset

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Lamellar High SMAS Face
and Midface Lift:
A Comprehensive Technique for
Natural-Appearing Rejuvenation of the Face

TIMOTHY J. MARTEN
CHAPTER 46

T
raditional face-lift techniques have relied on the tightening of thin flaps of ag-
ing skin to elevate and support sagging deeper facial tissue. Although initial re-
sults from these procedures often appeared good, early recurrence of the original de-
formity was common, and poor scars and healing problems were frequently seen as
a result of the obligatory wide flap undermining and unavoidable skin flap tension.
These procedures also typically produced an easily recognized tight or face-lifted
look that was usually exacerbated with subsequent procedures.
As plastic surgeons have pursued an improved outcome, our understanding of the
aging process has improved, and face-lift techniques have evolved. Experience has
since confirmed that an attractive, natural-appearing result is not possible without
diverting tension away from the skin to the superficial musculoaponeurotic system
(SMAS) and platysma and unless other deep layer structures and the aging midface
are addressed. For many patients, an improved result is obtained if age-related facial
atrophy is concomitantly corrected with fat injections or by other means (see Chap-
ter 47).
Fundamental Concepts
Why Use the SMAS?
The fundamental flaw in “skin-only” face lifts, mini-lifts, and similar procedures is
the fact that skin was meant to serve a covering function—not a structural or sup-
porting one. Skin is inherently elastic and was intended to stretch and move as we
express ourselves; it is not structurally capable of supporting sagging muscle, fat,
and other structures that lie beneath it. Using skin as a vehicle to support sagging
deep-layer tissue corrupts its covering function and results in abnormal skin tension
and related secondary problems, including poor scars, tragal retraction, earlobe mal-
position, and a tight, unnatural appearance. Skin tension also flattens contour rather
than restoring it, and because skin stretches as tension is applied, objectionable tem-
ple, sideburn, and occipital hairline displacement is common when skin-only tech-
niques are used. In addition, because skin is inherently elastic and not capable of
providing sustained support of deep facial tissues, the improvements achieved through
most skin-only face lifts and mini-lifts are usually short lived.
Using the SMAS to lift sagging facial tissues and restore facial contour circumvents
the problems associated with skin-only lifts as it is an inelastic structural layer ca-
pable of providing meaningful and sustained support. Although skin must be excised
in SMAS procedures and proper excision will produce an improved result, only re-
dundant tissue is sacrificed, and closure can be made under normal skin tension. Fa-
cial skin so treated will distribute itself naturally over new contours and is capable
of some self-repair and contraction. This averts a tight or lifted appearance and fur-
ther enhances the result.
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Part VIII  Face Lift and Neck Lift

Using the SMAS and platysma to elevate sagging facial tissues and to create an at-
tractive face and neck contour provides a means by which sustained support can be
obtained from nonelastic, structural tissue layers, and tension can be transferred away
from the skin. This results in a soft, natural facial appearance, high-quality scars,
and often doubles or triples the lifespan of the improvement. Diverting tension to the
SMAS and platysma and away from the skin also preserves delicate preauricular con-
tours and minimizes displacement of temporal and sideburn hairlines. In addition,
unlike skin-only face lifts and mini-lifts in which subsequent procedures worsen skin
tightness and problems associated with it, SMAS face lifts, at least in theory, can be
repeated as often as needed without producing skin tightness and an abnormal ap-
pearance. This removes the “two face-lift limit” set by many surgeons performing
skin-only procedures and allows patients to undergo procedures at an earlier age
and more frequently, if desired.
Sustained and attractive support of the deep layers of the face cannot be predictably
obtained by the placement of long “suspension” and “cable” sutures, even if soft,
partially elastic materials are used. These “suture lift” procedures have led to a va-
riety of problems for many patients, including suture extrusion, traction dimples,
visible bowstringing, nerve injuries, facial dyskinesias, chronic pain syndromes, and
an abnormal appearance on animation. Suspension sutures placed in the neck can
also create a tight or choking feeling that is disturbing to patients, and can result in
difficulties in speaking and swallowing. In addition, if large, stiff, permanent sutures
are used, the suture knots and the sutures themselves can often be felt beneath the
skin. In some cases these suture knots can erode overlying skin, necessitating their
removal.
The fundamental flaw in “suture lifts” and the use of suspension sutures is that one
must rely on a small, rigid thread to support a large area of delicate, inherently soft,
mobile facial tissue. Over time, these sutures “cheese-wire” through the tissues they
were intended to support and can injure important neuromuscular structures. Sus-
pension sutures also prevent natural depression and downward movement of facial
tissues, impeding certain expressions and creating an unnatural appearance.
Unlike suspension suture placement, SMAS elevation allows secure, balanced eleva-
tion of facial tissues without disruption of their natural relationships. Tissue an-
choring is achieved through direct tissue contact and healing, not distant point sus-
pension by a suture. SMAS elevation also allows natural gliding and depression of
tissue and a more natural appearance on animation.
The periosteum has been advocated by some as the layer beneath which face-lift dis-
section should be performed and the layer by which sagging deep facial tissues should
be elevated. When properly performed, such procedures divert some tension away
from the skin and avoid many of the problems associated with skin-only procedures.
1527
Chapter 46  Lamellar High SMAS Face and Midface Lift

Improvement in the infraorbital and upper midface areas may also be obtained in
some cases when the procedures are properly designed. However, this layer is a con-
ceptually illogical choice for overall rejuvenation of the face in that it is densely ad-
herent to the facial skeleton and does not significantly descend as part of the aging
process. It is also not closely associated with the intermediate layers of the face, where
most of the aging is known to occur, and its dissection results in prolonged swelling
and induration and generally portends a longer recovery period for the patient. In
addition, many subperiosteal face-lift techniques rely on the concomitant use of sus-
pension sutures; thus these procedures often share many of the related problems. Un-
like the periosteum, the SMAS is closely associated with tissues that sag as the face
ages and actually envelopes many, if not most, of those of concern. It is thus arguably
a more logical layer to use to restore them to a more youthful position.
The SMAS and the Midface
The midface is generally defined as an inverted triangular area situated over the an-
terior upper cheek that is bounded by the zygomaticus major muscle laterally, the
nasolabial fold medially, and the infraorbital rim superiorly. In healthy, youthful-
appearing individuals this area is full and confluent with the adjacent cheek and lower
eyelid. As men and women age, however, and enter their early midlife and beyond,
there is a general wasting of and loss of volume from this area. Over time, this re-
sults in a loss of the smooth, youthful transition from the lower eyelid to the cheek
and eventually leads to an ill, haggard, elderly appearance. Midface atrophy is felt
by some surgeons to also be accompanied by descent of midface tissues, and the ag-
ing change seen in the upper cheek area is thus often referred to as midface ptosis.
The recognition of midface ptosis as a significant component of the changes occur-
ring in the aging face, combined with the realization that the traditional SMAS face
lift produced little or no improvement in the midface region, has led to the develop-
ment of a variety of procedures designed to specifically target the midface area. Many
of these techniques are now being performed as isolated procedures or in conjunc-
tion with lower eyelid surgery.
Although there is merit in the idea of rejuvenating the midface, isolated midface lift
procedures are still evolving and have not been perfected. Most procedures have a
steep learning curve and have been fraught with complications, especially when per-
formed through a blepharoplasty incision. These complications include lid retrac-
tion, ectropion, canthal displacement, and dry-eye problems. As a result, many mid-
face lift techniques have come to incorporate potentially problematic aggressive
adjunctive surgical maneuvers, including canthotomies, canthoplasties, and orbicu-
laris oculi muscle suspensions to prevent these problems from occurring. These ma-
neuvers often result in a “changed look” that is disturbing to many patients and carry
a high risk of significant and troublesome complications of their own.
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Part VIII  Face Lift and Neck Lift

Many other arguments can be made against the use of isolated midface procedures,
including the fact that attractive rejuvenation of the face is possible without com-
plete elimination of the nasolabial fold. Most patients with nasolabial folds had them
when they were young, and their presence reflects the patient’s anatomic makeup,
not necessarily an age-related, undesirable change. In such cases it is neither necessary
nor desirable to completely eliminate them, because they are an inherent and ap-
propriate feature of the patient’s face. As a practical matter, however, most of the
improvement obtained by midface lifts consists only of elevation of the lid-cheek
junction, not correction of the nasolabial fold. Midface lifts also produce a subtle
improvement that is not always noticed or appreciated by the patient. Because of
this, time in the operating room is often arguably better spent on lower-risk maneu-
vers that result in more noticeable improvement that is of higher priority to the
patient.
Careful evaluation of most patients who request a midface lift will show that they
also need a face lift. It is rare to encounter a patient with midface aging who does
not also have sagging in the cheek and jowl, and midface lifts are arguably more log-
ically performed in conjunction with a formal face-lift procedure. When this is done,
improvement is more balanced and comprehensive, producing a more harmonious
and natural-appearing result. Healing is also faster and complications are less likely
if midface improvement can be obtained through the face-lift incision rather than
through a blepharoplasty or intraoral approach.
Most midface lifts are also generally conceptually flawed in that they are based on
the erroneous assumption that the problem seen in the anterior upper cheek is solely
one of tissue sagging. Failure to acknowledge the fact that atrophy is present to a
significant degree in most cases has led to general disappointment following many
procedures for both patients and surgeons and has resulted in the addition of der-
mal fat grafts, orbital fat transposition, and “septal resets” to midface lift procedures.
However, it remains to be answered whether these procedures can restore lost vol-
ume as simply, naturally, and effectively as with fat injections.
The High SMAS Lift
The conventional low cheek SMAS flap elevated below the zygomatic arch suffers
the drawback that it cannot by design have an impact on tissues of the midface and
infraorbital region. Low designs target the lower cheek and jowl only and produce
little if any improvement in the upper anterior cheek area. Planning the flap “higher,”
along the superior border of the zygomatic arch, and extending the dissection me-
dially to mobilize midface tissue overcomes this problem and produces an improved
result.
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Chapter 46  Lamellar High SMAS Face and Midface Lift

1530
Part VIII  Face Lift and Neck Lift
Low SMAS. A, Plan for a low SMAS procedure. Note that the upper border of the flap lies
below the zygomatic arch. B, Low SMAS flap after dissection and suspension. The area
of flap effect (green circle) is limited to the lower cheek and jowl, and no improvement is
obtained in the midface, infraorbital, or perioral regions (black circle).
High SMAS. C, Plan for a high SMAS procedure. Note that the upper border of the flap lies
over the zygomatic arch. D, High SMAS flap after dissection and suspension. The area
of flap effect (green circle) includes not only the cheek and jowl, but also the midface, infra-
orbital, and perioral regions (black circle).
D
C
B
A

Benefits include restoration of a youthful upper cheek contour, an aesthetically sig-
nificant fill of the infraorbital region, increased support of the lower eyelid, and cor-
rection of the nasolabial fold, all without the need to perform a separate or distinct
midface lift. High SMAS procedures are also readily combined with midface fat in-
jections, because midface and infraorbital tissue planes are not opened or dissected.
This averts the need to perform complex and potentially problematic procedures in
which orbital fat is transposed, the orbital septum “reset” or free grafts are placed.
At least part of the popularity of low SMAS designs can be attributed to perceived
anatomic constraints about the zygomatic arch and laudable efforts to design flaps
that could be dissected safely without jeopardizing the frontal branch of the facial
nerve. However, careful reappraisal of this assumption has shown that high dissection
is anatomically sound and clinically safe. For many if not most patients, the reposi-
tioning of midface tissue obtained with a high SMAS flap is satisfactory, and no ad-
ditional or separate midface lift procedure is required.
Lamellar Dissection and Bidirectional Tissue Shifts
A number of specific strategies that merit review have been devised for use of the
SMAS. These include composite dissections in which the SMAS and skin are elevated
as a single unit and advanced in the same direction, and “lamellar” dissections in
which skin and SMAS are elevated as separate layers and advanced bidirectionally
along different vectors. Composite-type dissections have the potential advantage of be-
ing quicker to perform, and they result in a comparatively thicker, arguably more
durable flap composed of both skin and SMAS. However, these dissections have the
distinct disadvantage that skin and SMAS must be advanced the same amount, in
the same direction, and suspended under more or less the same amount of tension.
Because skin and SMAS age at different rates and along somewhat different vectors,
optimal treatment of each layer is generally not possible when these techniques are
employed, and skin overshifting, skin overtightening, hairline displacement, “wrin-
kle shift” from the neck to the cheek, and other objectionable occurrences and un-
natural appearances can result. In addition, if the orbicularis oculi is included in a
composite flap, the muscle’s motor nerve supply can be compromised and lid dys-
function, nerve cross-regeneration, and other disturbing and objectionable abnor-
malities can result.
Lamellar dissections offer the distinct advantage that skin and SMAS can be ad-
vanced different amounts, along separate vectors, and can be suspended under dif-
ferential tension. This allows each of these layers to be addressed individually, avoid-
ing skin tension, hairline displacement, and objectionable wrinkle shifts. This in turn
results in a more natural appearance, a more comprehensive rejuvenation, and fewer
secondary deformities. Lamellar techniques have the potential drawbacks that the
SMAS flap is thinner and more fragile and that the dissection is technically more de-
manding and time consuming to perform.
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Chapter 46  Lamellar High SMAS Face and Midface Lift

Lateral Sweep
Traditional skin-only face lifts and low SMAS procedures typically resulted in over-
tightening of the lateral cheek skin and provided little support of the perioral area
and jowl. In time, these unsupported tissues continued to descend in a dispropor-
tionate fashion, resulting in a characteristic and objectionable “upswept” appear-
ance. Although the unsupported tissue responsible for this problem is actually ante-
riorly situated, and it is perhaps more correctly referred to anatomically as an anterior
phenomenon, this unattractive occurrence has come to be known as lateral sweep.
Lateral sweep is generally most apparent in the lateral view when the patient looks
down. In this position, lateral facial tightness is increased as a result of better tissue
fixation in the preauricular area, and the “sweep” appearance is accentuated because
of the comparatively poor support and fixation in the perioral and jowl areas.
Lateral sweep is an unavoidable eventual consequence of all traditional skin-lift, low
SMAS, and low composite procedures. These skin-only and low deep-layer proce-
dures are not capable of providing uniform support to both the anterior and lateral
cheek and are biogeometrically inclined to produce an unbalanced, unnatural ap-
pearance. A high SMAS flap, in contrast, provides simultaneous uniform support of
the lateral facial, midface, and lateral perioral areas. This results in a more balanced,
comprehensive, and natural rejuvenation.
Lateral sweep can result when a high SMAS technique is used if the lateral perioral
region is overdissected subcutaneously and ligamentous attachments between the
SMAS and the skin are mistakenly and inappropriately divided. These ligaments are
the means by which the high flap supports the lateral perioral area, and overdissec-
tion of this sort is a common error made by surgeons who erroneously assume that
extended skin undermining will help improve the nasolabial fold. This is not a flaw
in the technique; it is merely a failure to perform the procedure correctly.
Recognizing the Aging Deformity
Recognizing the elements of the aging deformity and appreciating the underlying
anatomic changes are essential to properly advising patients and fundamental to the
planning of any surgical repair.
Many if not most of the changes associated with loss of facial contour represent pri-
marily deep-layer problems that will be inadequately corrected with traditional skin-
only or low SMAS techniques. Regrettably, surgeons unfamiliar with deep-layer tech-
niques often employ skin-only face lifts or mini-lifts and resort to misguided and
misapplied ancillary procedures to overcome the shortcomings of these methods.
These procedures include facial liposuction, buccal fat extraction, malarplasty, sub-
malarplasty, geniomandibular groove augmentation (a prejowl implant), PTFE (Gore-
1532
Part VIII  Face Lift and Neck Lift

1533
Chapter 46  Lamellar High SMAS Face and Midface Lift
High SMAS face lift. A, This 47-year-old woman is shown before surgery. Note the loss
of youthful contour. B, She is shown following a high SMAS face lift, neck lift, forehead lift,
upper and lower blepharoplasties, and fat injections. Sagging tissues have been reposi-
tioned, her youthful jawline contour restored, and redundant skin has been excised without
producing a tight or pulled appearance.
Tex) implantation, and various types of suspension suture placement. Although some
of these procedures are sometimes indicated, they will be unnecessary in most cases
if a high SMAS face lift and deep-layer rejuvenation are performed.
Patients with significant facial atrophy and age-related facial wasting will generally
achieve suboptimal improvement from both surface treatments of facial skin and
surgical lifts. Smoothing the skin will not hide a drawn appearance caused by the
loss of facial volume, and it is difficult to create natural, attractive contours by lift-
ing and repositioning tissues that have abnormally thinned and deflated with age.
Restoring lost facial volume using fat injections is a powerful technique that has
gained increased acceptance by plastic surgeons and other physicians who treat the
aging face. When properly performed, the addition of fat to areas of the face that
have atrophied from age or disease can produce a significant, sustained improvement
in appearance that is unobtainable by other means. However, age-related facial
atrophy rarely exists in isolation in a healthy individual; thus patients troubled by it
are not always appropriately or logically treated by fat injections alone. Isolated fat
injections are also of questionable benefit to a patient with significant facial sagging
and skin redundancy. Although aggressive filling of the sagging face with fat can im-
prove the facial contour, it generally results in an unusually large, overfilled face that
appears both unnatural and unfeminine. Such an overfilled face is hard to correct at-
tractively at a later date. It is both more logical and practical to perform fat injec-
tions in conjunction with formal surgical lifts if needed, or after ptotic tissue has
been repositioned and redundant tissue has been removed. When a high SMAS tech-
A
B

nique is used in conjunction with fat injections, both loss of contour and facial
atrophy can be corrected and optimal improvement can be obtained.
Panfacial Rejuvenation
Rarely does isolated aging occur in the lower face and neck, and nearly all patients
who request face-lift surgery need to undergo some sort of forehead and eyelid sur-
gery as well. Many are confused, however, by the term “face lift” and take it to im-
ply correction will be made in all areas. These patients must be counseled carefully,
because the face lift itself will produce little if any improvement in upper facial de-
formities and in fact tends to unmask and draw attention to them.
It is not uncommon for patients concerned with aging in their lower face and neck to
question the need to undergo forehead surgery. Many unconsciously optimize their
forehead appearance when looking in a mirror by raising their eyebrows, or they try
to conceal the signs of forehead ptosis by aggressive plucking the lateral eyebrows
or by futilely trying to hide dense transverse forehead wrinkles with hairstyles that
conceal the forehead. Although chemodenervation with botulinum toxin injections
(such as Botox or Dysport) can smooth forehead expression lines by relaxing hyper -
active muscles and in some cases can be used to produce some lateral brow eleva-
tion, these injections cannot correct advanced brow ptosis. Failure to properly advise
patients and perform forehead surgery can result in the disharmonious appearance
often referred to as the young face–old forehead deformity.
It is also not uncommon for patients to request that surgery be performed on their
neck only. Although such a plan is acceptable for some men, failure to concomitantly
restore attractive cheek contour and lift sagging jowls in women generally results in
an unnatural and unfeminine appearance. In addition, if an aggressive “corset”
platysmaplasty is performed as part of an isolated neck lift, sagging in the cheeks
and jowl area can be accentuated, because platysma tightening exerts a downward
pull on tissue in these areas.
Face-lift surgery can unmask other existing deformities and create a need to perform
additional procedures. This is commonly seen on the lower eyelid, where the ptotic
cheek often smoothes lower lid skin preoperatively by dragging it inferiorly. Prop-
erly executed repositioning of the midface and malar fat pad will usually result in
some lower lid wrinkling and redundancy that was not present before surgery. This
can be demonstrated before the procedure to the patient by elevating the cheek to
the predicted postoperative position while the patient holds a hand mirror and point-
ing out the resulting wrinkling in the lower lid area. In these cases some excision of
lower lid skin must be made (or resurfacing performed), even if the lid appears
smooth before surgery, if lower lid wrinkling is to be avoided postoperatively. It is
also for this reason that lower blepharoplasty should be performed after face-lift sur-
gery is complete, not at the beginning of the procedure.
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Part VIII  Face Lift and Neck Lift

Preoperative Planning
It is not possible to design or use a universal face-lift technique, and this is the funda -
mental flaw of all formulaic, “franchise,” “infomercial,” and other “cookie-cutter”
types of face-lift procedures. Each patient has a unique set of problems that require
precise anatomic diagnosis and an appropriately planned and individualized surgi-
cal repair. Committed study and careful planning will maximize improvement, limit
complications, and minimize the secondary deformities commonly seen after an ill-
conceived and inappropriate “one-size-fits-all” procedure.
Planning the Temple Incision
The temporal portion of the face-lift incision has traditionally been placed within
the temporal scalp in a well-intended but often counterproductive attempt to hide
the resulting scar. When cheek skin redundancy is small and abundant temple and
sideburn hair is present, such a plan can be used without producing objectionable
sideburn elevation and temporal hairline displacement. Patients best suited for this
incision plan are usually young, with mild cheek laxity only. In many other situa-
tions, however, larger skin shifts and the presence of sparse temple hair can result in
unnatural, telltale shifting and displacement of the temporal hairline and sideburn.
1535
Chapter 46  Lamellar High SMAS Face and Midface Lift
Displacement of the sideburn and temple hair as a result of poor incision planning.
In this woman the temporal portion of the face-lift incision was made in the temporal scalp
in a well-intended effort to hide the resulting scar. Because the cheek flap redundancy
was large and skin elasticity was poor, advancement of the cheek skin flap resulted in
objectionable hairline displacement. An incision along the hairline would have prevented
this deformity. Proper analysis, careful planning, and the use of an incision along the hair-
line, when indicated, can avert this problem without compromising the overall outcome of
the procedure.

In choosing the location of the temporal portion of the face-lift incision it is impor-
tant to note the distance between the lateral orbit and the anterior aspect of the tem-
poral hairline as this distance is aesthetically significant and increases with age.
1536
Part VIII  Face Lift and Neck Lift
Healed incisions along the temporal hairline. The use of an incision along the hairline,
when indicated, can prevent hairline and sideburn displacement without compromising the
result. Although a fine scar is present along the hairline in each of these patients, it is not
evident on casual inspection. Note the preservation of lush temple hair and a full, youthful,
natural-appearing sideburn (compare with the patients shown on p. 1535).
Assessing temporal skin show. The distance
between the lateral orbit and the temporal hairline
and how it will change with skin flap shift must be
considered when planning the temple portion of
the face-lift incision.

In healthy, youthful-appearing individuals the distance between the lateral orbit and
temporal hairline usually measures no more than 4 to 5 cm, but in older patients or
in those who have had a prior face lift, it will often be seen to be considerably more.
Equally important as this distance is the surgeon’s estimate of the skin redundancy
over the upper cheek, and thus the skin shift that will occur when the face-lift flap
is lifted. This can easily be assessed by simply pinching up redundant skin and mea-
suring it. Skin redundancy over the cheek, when considered in conjunction with the
amount of existing temporal “skin show,” allows rational selection of the best site
for placement of the temporal incision.
In patients in whom minimal or modest temporal skin shift is predicted to occur us-
ing the preceding method of analysis and for whom the temporal hairline will re-
main within 5 cm of the lateral orbit, the temporal portion of the face-lift incision
can be placed in the traditional location 4 to 5 cm within the temporal scalp, ex-
tending superiorly from the anterior-superior aspect of the ear.
1537
Chapter 46  Lamellar High SMAS Face and Midface Lift
Plan for incision on temporal scalp. This plan is used for patients predicted to have mini-
mal or modest shift of sideburn and temple hair after elevation of the cheek flap. It will not
be appropriate for all patients.

1538
Part VIII  Face Lift and Neck Lift
When analysis of the amount of temple and sideburn hair present and the degree of
redundant cheek skin that exists suggests the temporal hairline will be shifted more
than 5 cm away from the lateral orbit and/or the sideburn hair shifted above the junc-
tion of the ear with the scalp, one should consider placing the incision along the hair-
line rather than within the temporal scalp.
This incision will accommodate large posterior-superior skin flap shifts and allows
maximal improvement in the upper lateral face to be made without objectionable
displacement of the temple and sideburn hair. If it is made with care and closed un-
der no tension, the resulting scar is usually inconspicuous and far less troublesome for
the patient than a displaced hairline would be (see p. 1535).
In light of the preceding discussion it can be seen that the position of the temporal
portion of the face-lift incision cannot be arbitrary and must be based on the pa-
tient’s individual anatomy, and options for the placement of the temporal portion
of the face-lift incision should be discussed with any patient in whom significant dis-
placement of the temporal hairline or elevation of the sideburn might occur. Inci-
sion placement is best presented as a choice between two imperfect alternatives and
it is wise that the final decision as to where the incision will be located be left to pa-
tient after appropriate discussion has been made. Placing the incision in a traditional
location within the temporal scalp (see p. 1537) will help conceal the scar, but often
Plan for incision along the temporal hairline.
An incision along the temporal hairline should be
considered whenever objectionable displacement
of the sideburn and temple hair is predicted.

at the expense of a large and objectionable displacement of the temporal hairline
and sideburn, and compromised improvement over the temporal face. Inappropri-
ate use of a temporal scalp incision inevitably results in an old and unnatural ap-
pearance that is usually immediately obvious, even on a casual glance and at a dis-
tance. An incision along the hairline, however, will prevent hairline displacement,
and although a scar will undeniably be present where the incision was made, it is
usually inconspicuous and will not be noticed by others. In addition, although a sub-
optimally healed incision along the hairline can be concealed with makeup or tat-
tooed or revised, a significantly displaced hairline is difficult to conceal and a chal-
lenge to correct. It has been my experience that most patients are disturbed by the
prospect of temple and sideburn hair displacement and recognize this occurrence as
a telltale sign that a face lift has been performed. When counseled properly and given
the choice, most will readily consent to incision placement along their hairline.
Planning the Preauricular Incision
Open to scrutiny, the preauricular region exists as a frequent point of reference for
those seeking to identify a face-lift patient. Traditionally, incisions here are made well
anterior to the anterior border of the helix and continued inferiorly, anterior to the
tragus.
1539
Chapter 46  Lamellar High SMAS Face and Midface Lift
Traditional location of the preauricular incision. This plan places the scar in an area
open to inspection by others and “brands” the patient as having had face-lift surgery.
Makeup will not conceal a scar in this location, because the scar is smooth and the skin
on either side of it not. Placing the incision in this location will also typically result in a differ-
ence of skin color on each side of the resulting scar—an additional telltale sign that surgery
has been performed.

1540
Part VIII  Face Lift and Neck Lift
This design, however, works well only for the unusual patient with cheek and tra-
gal skin of similar characteristics who also exhibits favorable healing. Unfortunately,
most patients have a marked gradient of color, texture, and surface irregularities over
these areas, and a telltale mismatch will be evident on each side of the scar, even if
the scar itself heals inconspicuously. For these reasons, and in all but the unusual
case, the preauricular portion of the face-lift incision should be precisely placed along
the posterior margin of the tragus, rather than in the pretragal sulcus.
In this location a mismatch of color, texture, or surface irregularities will not be no-
ticed (or will appear appropriate), and the scar, if visible, will appear to be a tragal
highlight.
Marginal tragal (“retrotragal”) plan for the
preauricular portion of the face-lift incision.
Placing the incision along natural anatomic contours
conceals the scar and disguises differences in color
and skin texture on each side of it. Note that the
preauricular incision is composed of a prehelical,
pretragal, and prelobular component incision.
Comparison of pretragal and marginal tragal (retrotragal) incisions. Left, In this patient
the pretragal incision has healed satisfactorily, but the resulting scar is visible because of
differences of color and texture on each side of it. Right, The same patient is seen after a
secondary face lift in which the incision was moved to the posterior margin of the tragus
(the retrotragal position). Color and texture differences, and the scar itself, are now hidden
along natural anatomic interfaces.

In addition, and despite some claims to the contrary, a properly planned and exe-
cuted incision along the margin of the tragus will not produce tragal retraction or
other anatomic irregularity.
1541
Chapter 46  Lamellar High SMAS Face and Midface Lift
Healed retrotragal incisions. Close-up views of face-lift patients with preauricular inci-
sions along the margin of the tragus. Scars are well concealed, and no tragal distortion
is present.
In a man, the tragus can be kept free of beard hair by intraoperative destruction of
beard follicles from the underside of the tragal flap.
Retrotragal incisions in male patients. In these men, the incision has been made along
the posterior margin of the tragus in the same general plan as was used for the female pa-
tients shown above. This avoids a pretragal scar that is typically difficult for a man to con-
ceal. The tragus is kept free of beard hair by intraoperative destruction of beard follicles
from the underside of the tragal flap. This is accomplished by folding the tragal skin flap
over the index fingertip of the surgeon’s nondominant hand using small skin hooks and ap-
plying low electrocautery current to exposed beard follicles with a needle-tipped cautery in-
strument. Loupe magnification facilitates accurate destruction of individual follicles.

The superior (prehelical) portion of the preauricular incision should be planned as a
soft curve paralleling the curve of the anterior border of the helix. This will result in
a natural-appearing width to the helix in keeping with the rest of the ear, and the
resultant scar, if visible, will appear to be a helical highlight. As the tragus is ap-
proached, the mark for incision is carried into the depression superior to it and then
continued along the posterior tragal margin. In this location the scar, if visible, will
appear as a natural highlight. It is unnecessary and an error to place this incision in
a retrotragal position on the inner surface of the tragus. This usually results in a
bulky, amorphous-appearing tragus and obliteration of tragal anatomy.
At the inferior portion of the tragus, the incision must turn anteriorly and then again
inferiorly, into the crease between anterior lobule and cheek. If a more relaxed de-
sign is used, or if a straight line incision is made, skin settling and scar contraction
will result in crowding of the incisura, obliteration of the inferior tragal border, and
a telltale elongated and chopped-off tragal appearance.
1542
Part VIII  Face Lift and Neck Lift
Planning the Perilobular Incision
To obtain a natural perilobular appearance, it is essential to preserve the natural sul-
cus between the earlobe and cheek and to avoid destruction of or excision of this
and aesthetically important anatomic subunit. This is accomplished by marking the
incision 1 to 2 mm inferior to this junction. All other factors being equal, a superior
result will be obtained when such a plan is used, in comparison to any plan in which
the incision is placed directly in the sulcus and an attempt is subsequently made to
directly join a thin, soft earlobe with a coarse, thick cheek.
“Chopped-off” tragus. An unnatural-appearing,
elongated tragus with an indistinct inferior border
results from poor incision planning and improper
excision of skin during incision closure.

Planning the Postauricular Incision
Traditionally, the postauricular portion of the face-lift incision has been made over
the posterior surface of the concha. This was done as part of a well-intended effort
to offset the inevitable descent of the postauricular flap and inferior migration of the
resulting scar that occurred when the skin was tightened in an attempt to improve
neck contour. Many surgeons have come to realize that such a plan embodies erro-
neous assumptions and can result in undesirable effects, including hypertrophic scar-
ring, postauricular webbing, and obliteration of the auriculomastoid crease. In ad-
dition, a scar on the posterior surface of the concha will not migrate inferiorly if the
flap has been shifted and trimmed correctly and is suspended under minimal or no
tension. It may thus be visible to those sitting behind the patient in some settings.
The postauricular portion of the face-lift incision should be marked directly in the
existing auriculomastoid groove and the mark turned posteriorly at the approximate
level of the anterior crus of the antihelix. Marking must be made with the ear resting
near its natural anatomic position. If the ear is pulled forward while the marks are
made, mastoid skin will be pulled anteriorly over the posterior surface of the con-
cha, and the incision will end up posterior to its intended location. Incorrect mark-
ing in this manner is one of the most common causes of a poorly situated postauric -
ular scar.
Planning the Occipital Incision
Planning the location for the occipital portion of the face-lift incision is conceptu-
ally similar to that for the temple region, and the incision plan must address similar
concerns of hairline displacement and scar visibility. Traditionally this incision is ar-
bitrarily placed transversely, high on the occipital scalp, in a well-intended but usu-
ally counterproductive attempt to hide the resultant scar.
1543
Chapter 46  Lamellar High SMAS Face and Midface Lift
Traditional plan for the occipital portion of the
face-lift incision. The incision is made transversely
into the occipital scalp in a well-intended but usually
counterproductive attempt to hide the resultant
scar. This incision plan should be used for access
to the upper lateral neck only in younger patients
and patients with minimal neck skin excess as it
does not allow skin to be excised without notching
of the occipital hairline (see p. 1544).

1544
Part VIII  Face Lift and Neck Lift
For patients with a minor redundancy of neck skin for whom excision of postauricu -
lar skin is unnecessary, such a plan is appropriate and will result in a well-concealed
scar. Patients in this category are usually young and have only a mild neck deformity.
In these cases the incision is used for access to the lateral neck only, not as a means
to remove postauricular skin. Skin excision using this incision plan will result in the ad-
vancement of neck skin into the occipital scalp and notching of the occipital hairline.
Although not all patients will recognize this deformity for what it is, most are none -
theless self-conscious about it, especially if they wear their hair up or back or lead
active outdoor lives where activities, wind, and water may displace camouflaging
wisps of remaining hair. Proper analysis, careful planning, and the use of an incision
along the hairline, when indicated, can avert this problem without compromising
the result.
Notching of the occipital hairline.
Notching of the occipital hairline is
seen in these two patients, whose sur-
geons inappropriately used traditional
occipital incision plans.
Healed incisions along the occipital
hairline. Both of these patients are
seen after surgery in which an incision
along the occipital hairline was used.
If this incision is planned carefully and
properly closed, notching of the hair-
line is averted and an inconspicuous
scar will result.

In choosing the location of the occipital portion of the face-lift incision, the surgeon
must estimate the skin redundancy along the predicted posterior-superior direction
of flap shift. This can be accomplished by pinching up tissue over the upper-lateral
neck and measuring it. If 2 cm or less of excess neck skin is present, a “traditional”
incision over the mastoid extending posteriorly into the scalp at the level of the midear
(see p. 1544) will not, in most cases, result in an objectionable disruption of the oc-
cipital hairline. If more than 2 cm of neck skin redundancy is present, however, the
incision should be placed along the occipital hairline but be designed so that a tell-
tale scar will not be visible in front of the fine hair on the nape of the neck. This can
be accomplished by turning the inferior portion of the incision back into the scalp
at the junction of thick and thin hair. From a practical standpoint, the traditional
incision on the occipital scalp should be used for access to the neck only and closed
without skin flap shift or advancement. Any patient with significant neck skin re-
dundancy will require an incision along the occipital hairline if skin is to be advanced
and excised in a biogeometrically correct fashion and hairline displacement is to be
avoided.
1545
Chapter 46  Lamellar High SMAS Face and Midface Lift
As is the case with temporal incision placement, options for placement of the oc-
cipital portion of the face-lift incision should be discussed with the patient and pre-
sented as a choice between two imperfect alternatives; it is wise to let the patient
make the final decision after the advantages and disadvantages of each location have
been discussed. Although an incision along the hairline is usually inconspicuous,
even on close inspection, a scar will undeniably be present. Placing the incision within
the scalp may help conceal the scar but will usually do so at the expense of objec-
tionable displacement of the occipital hairline. Although a suboptimally healed in-
cision along the hairline can be revised, tattooed, or easily concealed with an ap-
propriate hairstyle, a significantly displaced hairline is difficult to conceal and a
challenge to correct. It has been my experience that most patients are disturbed by
the prospect of occipital hairline displacement and recognize it as a telltale sign that
a face lift has been performed. When properly counseled and given the choice, most
patients will readily consent to an incision along the hairline.
Plan for an incision along the occipital
hairline. The incision is planned so that its
inferior portion turns posteriorly into the
occipital scalp at the junction of thick and
thin hair. This incision plan allows excess
neck skin to be excised biogeometrically,
prevents hairline displacement, and pro-
duces a well-concealed scar.

1546
Part VIII  Face Lift and Neck Lift
Short-Scar Face Lift
The idea of shortening the incisions used for facial rejuvenation procedures is ap-
pealing to patients and surgeons alike. Indeed, the first face-lift procedures performed
some 100 years ago consisted of small excisions of the skin near the ear and along
the frontal and occipital hairlines. Ironically, and despite the many important ad-
vances in techniques to rejuvenate the face that have been made over the past cen-
tury, as non–plastic surgeons have begun to perform aesthetic surgery procedures
and market their services, a new emphasis has been placed on ill-conceived “short-
scar” procedures of questionable value and that are nonetheless deceptively appeal-
ing to almost any patient. Although some short-scar techniques, such as a limited-
incision forehead lift, have merit and have provided new and better options for many
patients, skin redundancy remains a consistent and undeniable problem for the sur-
geon seeking to rejuvenate the face and neck, and shorter incision plans involve sig-
nificant compromises in the overall improvement that can thus be obtained.
Short-scar incision plans suffer the significant drawbacks that they limit access to
deep-layer structures and prevent redundant skin from being shifted along proper
vectors that produce the most improvement and the most natural appearance. Typ-
ically, manipulations of deep-layer tissues performed through short-scar incision
plans are ineffectual at best, and more often result in damage to or mutilation of the
SMAS. Shorter incisions also require that skin be gathered up when sutured and pre-
vent it from being excised in a smooth, well-tailored manner.
A longer scar, conversely, allows skin flaps to be shifted in a geometrically correct
fashion (see p. 1544, bottom) and skin to be excised without objectionable pucker-
ing or gathering, as seen above.
Interestingly and somewhat perplexingly, most short-scar procedures focus on the
postauricular area and seek to shorten the postauricular scar. This scar is situated
in a well-concealed area, however, and if tension is diverted to deep-layer tissue and

skin excision is carefully planned and properly executed, an inconspicuous scar will
usually result. A scar in the postauricular area is arguably less obvious, easier to con-
ceal, and overall less disturbing to the patient than is a shorter but irregular, puckered
scar. Shortening a scar under these circumstances in a concealed area defies logic and
is of questionable value to the patient.
Perhaps the most difficult to understand aspect of short-scar incision plans is that
to minimize puckering and gathering behind the earlobe, the cheek skin flap is shifted
along a vector that is directed too superiorly, necessitating a scar along the far less
well concealed sideburn and temporal hairline. Although an incision is sometimes
required in this area in certain patients to prevent hairline displacement, as previ-
ously discussed, shortening a scar in a concealed area by shifting it to a more visible
area is of dubious value to a patient who might not have required it.
Ironically, it is younger patients, whose fears of longer scars can easily be played to,
who are typically thought of and said to be the best candidates for short-scar pro-
cedures. It is this group of patients, however, who are disproportionately burdened
by a more visible scar along the temporal hairline that would typically heal more fa-
vorably and be of less concern to an older patient. When the patient is properly coun-
seled and given the choice, I find that younger patients are relieved to learn that a
scar along the temporal hairline is not necessary in most cases and that it can be in-
stead hidden in the temporal scalp and along the hairline behind the ear.
1547
Chapter 46  Lamellar High SMAS Face and Midface Lift
Comparison of long- and short-scar face-lift incision plans. Left, Most short-scar plans
seek to shorten the incision in the postauricular area. To avoid puckering and gathering
behind the lobule (see p. 1546), a vertical vector is applied to the cheek skin flap, neces-
sitating an incision along the temple hairline as shown. Total scar length is approximately
12 cm. Right, A typical “long-scar” plan. The temporal part of the incision (white dashed
line) is hidden in the temporal scalp and if properly closed will be difficult to find. The total
length of visible scar (red dashed line) is 12 cm—no different from the short-scar plan.
However, no scar is present in the highly visible area along the temporal hairline.
“Short” scar plan
“Long” scar plan
12 cm
12 cm

The final misconception about short-scar procedures involves the idea of the length
of the scar itself and the fact that it is the amount of visible scar that matters, and
whether the scar is concealed or not. If the amount of scar present in potentially vis-
ible areas is measured, there is no actual difference between that present in typical
short-scar and long-scar procedures. In this sense, the term short-scar is a misnomer,
because the visible scars from short- and long-scar incision plans are in reality the
same length.
When asked what motivated them to adopt a short-scar face-lift technique, many
surgeons cite poor healing in the postauricular area as the overriding impetus. In-
herent in such a claim, however, is the notion that the postauricular area somehow
heals in a different way from the other areas of the face and in a consistently aber-
rant manner. In reality, their answer reveals that they have simply been performing
the procedure incorrectly. Two avoidable problems are typically put forth as the rea-
son for avoiding a postauricular scar: hairline displacement and wide (or irregular
and hypertrophic) postauricular scars. Hairline displacement results from inappro-
priate use of a traditional postauricular incision plan made into the occipital scalp.
Wide, irregular, and hypertrophic scars are the result of ill-conceived attempts to cre-
ate contour in the neck by tightening neck skin. Both these problems are readily avoid-
able, as discussed earlier and later in this chapter.
Ultimately, the purported advantages of short-scar procedures rest largely in their
appeal to patients—and their allure and marketability on that basis. This, coupled
with the growing demand for simplified face lifts, will likely ensure that such short-
scar procedures will be with us in some form for some time to come. Nonetheless,
the onus is on all physicians engaging in facial rejuvenative surgery to act in the best
interest of the patient and to plan incisions to best suit each patient’s circumstances.
We must not simply do what is convenient, easily marketed, and quickly performed.
1548
Part VIII  Face Lift and Neck Lift
Drawbacks of Short-Scar Procedures
 Shortening the scar can result in puckers and folds in the perilobular area.
 Shortening the scar compromises access to deep layers of the face.
 Skin flaps cannot be shifted in the biogeometrically correct fashion that is of most ben-
efit to the patient.
 The scar is shifted from a concealed area behind the ear to visible area in front of the
temple hairline.
 A visible scar may not actually be shorter than that in a long-scar procedure.

Planning the Submental Incision
Most face-lift patients require modification and repair of the neck and submental re-
gions that can only be performed through a submental incision, and optimal im-
provement in the neck generally cannot be obtained unless a submental incision is
made. Traditionally, this incision is placed directly in and along the submental crease
in a well-intended but counterproductive attempt to conceal the resulting scar.
1549
Chapter 46  Lamellar High SMAS Face and Midface Lift
Traditional but incorrect plan for the sub-
mental incision. The incision should not be
placed directly along the submental crease
(arrow), because this will reinforce the submen-
tal retaining ligaments and accentuate the
double-chin appearance. The typical plan of
skin undermining (yellow area) also promotes
a double-chin appearance, because the crease
is not undermined, retaining ligaments are not
released, and the fat of the chin and neck
cannot be readily sculpted to create a smooth
transition between them.
This incision plan should be avoided, however, because it will surgically reinforce
the crease and accentuate a double-chin or witch’s-chin deformity. Exposure of the
submental region will also be compromised, and the surgeon will encounter diffi-
culty when suturing or dissecting low in the neck. A more posterior placement of
this incision will eliminate these problems but will still result in an inconspicuous
and well-concealed scar.
Correct location for the submental incision.
Placing the submental incision 1.5 cm posterior
to the submental crease prevents accentuation
of the “double chin” and witch’s chin deformities
and provides for easier dissection and suturing
in the anterior neck (compare with the illustra-
tion above). This incision plan allows the sub-
mental crease to be undermined and submen-
tal retaining ligaments to be released, and the
fat of the chin pad and neck can be sculpted
to create a smooth transition between them
(see p. 1550, top).

1550
Part VIII  Face Lift and Neck Lift
The submental incision should be placed well within the mandibular shadow and
well posterior but parallel to the submental crease at a point lying roughly half the
distance between the mentum and hyoid. This usually corresponds to a site 1 to
2 cm posterior to the crease.
Correction of the double-chin deformity. Left, This patient, seen preoperatively, had a
double chin. Right, The patient is shown after a face and neck lift. The submental incision
was made posterior to the submental crease to allow undermining and release on the sub-
mental retaining ligaments and blending of chin and neck fat.
Plan for a submental incision. The submental
portion of the face-lift incision (solid line) should
be placed well within the mandibular shadow
and well posterior but parallel to the submental
crease (dotted line), approximately half the dis-
tance between the mentum and hyoid (arrows).
Usually this corresponds to a point about 1 to
2 cm posterior to the submental crease.

The incision should be approximately 3 to 3.5 cm in length but may be made longer
if necessary, as long as neither end will be advanced up on a visible portion of the
face when skin flaps are shifted. Healing will be best, and the scar will be best con-
cealed, if it is made as a straight, not curved, line.
1551
Chapter 46  Lamellar High SMAS Face and Midface Lift
Planning Modification of the SMAS and Platysma
All patients undergoing a face lift will benefit from posterior-superior advancement
of the cheek SMAS; this maneuver is the fundamental step in a natural-appearing,
attractive rejuvenation of the face on which all others are based.
High SMAS flap. Left, Plan for a basic high SMAS flap. The superior margin of the flap
is planned at the level of the zygomatic arch, not inferior to it. Right, High SMAS flap after
advancement and suturing. Unlike traditional low SMAS procedures, the superior margin
of the flap is suspended above the zygomatic arch to the innominate deep temporal fascia,
and a broad effect across the entire hemiface is obtained that includes the midface, infraor-
bital, and perioral regions.
Healed submental incisions. Placement of the
submental incision posterior to the submental
crease will still result in an inconspicuous, well-
concealed scar (arrows) as well as provide better
access and exposure when working in the deep
layers of the neck. The incision location is the
same for a male or a female patient. Left, Close-
up view of a healed submental scar in a female
patient. Right, Close-up view of a healed sub-
mental scar in a male patient.

SMAS advancement provides a natural-appearing and long-lasting correction in the
cheek and jowl and will strengthen, secure, stabilize, and reinforce the lower face. A
high SMAS plan can be used to improve the midface and infraorbital and perioral
areas without the need for a separate midface lift. For some patients, a simple SMAS
flap advancement alone will provide appropriate correction. Others, however, will
require additional maneuvers or modifications of this step to adequately address their
problems.
Assessment of the Cervicosubmental Region
Each patient’s cervicosubmental region must be carefully examined both at rest and
during platysma activation to completely assess platysma deformity. The surgeon
asks the patient to “push your jaw forward and tighten your neck,” demonstrating this
maneuver first so the patient can perform it correctly. Frequently an insignificant-
appearing deformity at rest will be obvious when the muscles are clenched. Failure to
recognize and appropriately correct these dynamic deformities is the reason too many
face-lift patients appear improved in repose but unnatural or bizarre during conversa -
tion, animation, and other activities that require activation of the platysma muscle.
1552
Part VIII  Face Lift and Neck Lift
Dynamic assessment of the cervicosubmental
region. The neck is examined as the platysma is
contracted. Dynamic platysma muscle irregulari-
ties are often called platysma bands.
Examination of the cervicosubmental region with and without platysma activation
allows one to distinguish between “soft” and “hard” cervical bands. Soft bands
change little during platysma activation and are predominantly a problem of skin
laxity. Hard bands are tight or become exaggerated when the platysma muscle is ac-
tivated, indicating a problem of platysmal origin.

1553
Chapter 46  Lamellar High SMAS Face and Midface Lift
It is important to distinguish between soft and hard platysma bands, because treat-
ment will vary, depending on the type of bands present. Patients with hard bands re-
quire a transverse platysma myotomy. The result of a platysma myotomy is imme-
diate, dramatic, long-lasting, and superior to any suture, suture suspension, or corset
technique. The length of the transection required will vary, depending on the con-
figuration of bands present, and will thus differ from patient to patient. However,
patients with soft bands can usually be adequately treated with skin excision, skin
excision plus platysmaplasty (suturing of the medial muscle borders together, or lat-
eral platysmapexy alone; see p. 1554).
Platysma bands generally lie in medial and lateral locations. Each band is situated
near the medial and lateral platysma muscle borders but does not usually correlate
precisely with them. For patients with anterior platysma bands only, a transverse
platysma myotomy is planned from jugular vein to jugular vein at the level of the
cricoid cartilage. The muscles need not be completely transected under these cir-
cumstances; just the region where the platysma band is present.
Plan for treatment of anterior platysma bands. Transverse platysma myotomy is
performed in the region of the platysma muscle where the platysma band is present.
Left, The anterior neck is illustrated after a platysmaplasty but before an anterior platysma
myotomy. Right, After an anterior platysma myotomy at the level of the cricoid cartilage.
(NOTE: Myotomy is most easily and effectively performed after the platysmaplasty has been
completed.) Dividing the platysma at the level of the cricoid keeps the incision in an area
where the muscle is thin and is less likely to bleed and show. Dividing the platysma in the
cervicomental angle will result in an unnatural, harsh transition from the submental region
to the neck and can cause lower lip dysfunction.

1554
Part VIII  Face Lift and Neck Lift
If lateral as well as anterior bands are present, the myotomy is carried more later-
ally to include them as well. If definition is poor over the lateral mandibular border,
in addition to anterior and lateral neck bands, platysma myotomy is planned to con-
tinue full-width superolaterally up to the anterior border of the sternocleidomastoid
muscle to join the incision in the SMAS. A similar full-width myotomy of this type
is also indicated in an individual with a firm, obtuse neck with a short platysma and
poor definition over the mandibular angle, but no bands.
In many necks, only a subtotal myotomy need be performed. As a practical matter,
however, complete transection of the platysma is performed in most patients to en-
sure the best contour possible and to limit the potential of band recurrence or that
residual platysma bands will be present. Despite assertions to the contrary, a full-
width platysma myotomy will not result in a neck that appears to thin or reduced
support of the submandibular glands. Medial wedge resections of platysma at the
hyoid and vertical excisions of platysma bands are not effective and usually result
in secondary deformities. These procedures are not recommended, and experience
has shown that they should not be performed.
Plan for treatment of anterior and lateral platysma bands. If lateral bands are present,
the myotomy is carried more laterally to include them. Left, The anterior neck is illustrated
after a platysmaplasty but before an anterolateral platysma myotomy. Right, After an an-
terolateral myotomy at the level of the cricoid cartilage. (NOTE: Myotomy is most easily and
effectively performed after the platysmaplasty has been completed.)

If submental support is poor and/or optimal improvement in the anterior neck is de-
sired, anterior platysmaplasty is planned. Anterior platysmaplasty helps consolidate
the neck and optimizes improvement in neck contour but is not adequate or effec-
tive in the treatment of platysma bands.
1555
Chapter 46  Lamellar High SMAS Face and Midface Lift
Plan for full-width platysma transection. A full-width myotomy corrects not only anterior
and lateral bands, but also provides improved definition over the lateral mandibular border.
Left, The anterior neck is illustrated after a platysmaplasty but before a full-width platysma
myotomy. Right, After a full-width platysma myotomy at the level of the cricoid cartilage.
(NOTE: Myotomy is most easily and effectively performed after the platysmaplasty has been
completed.)
Anterior platysmaplasty. Repair of platysma diastasis improves submental support and
helps consolidate the neck. However, it is not an adequate or effective treatment of pla -
tysma bands.

1556
Part VIII  Face Lift and Neck Lift
When mild horizontal platysma muscle redundancy is present in the neck, a lateral
platysmapexy is planned. A lateral platysmapexy ensures that the platysma is draped
smoothly and snugly along the cervicomental angle and helps to further improve
and consolidate the neck, especially when the patient looks down. It is usually ef-
fective only when suturing is performed in the firm, dense tissue in the perilobular
areas and over the upper fourth of the sternocleidomastoid muscle, where its fascia
is immobile. In thin necks, the cut muscle edges can be overlapped. In fuller necks,
redundant muscle can be trimmed and the muscle segments sutured edge-to-edge.
When a patient’s horizontal platysma muscle redundancy is large or optimal im-
provement in cervicomental contour is desired, a postauricular transposition flap of
cheek SMAS is planned. The postauricular transposition flap is created by splitting
off redundant tissue from the posterior margin of the cheek SMAS flap, but leaving
it attached inferiorly to the cervicosubmental platysma. If properly constructed and
secured, this flap will provide dynamic reinforcement of the upper neck and sub-
mental areas when the patient looks down. When used in conjunction with an an-
terior platysmaplasty, postauricular transposition flaps result in a continuous mastoid-
to-mastoid sling of muscle across the upper neck along the cervicomental angle.
Lateral platysmapexy. Left, Before a lateral platysmapexy. Right, After a lateral platysma -
pexy. The lower lateral border of the SMAS flap is sutured to the dense fascia in the peri -
lobular area and over the upper sternocleidomastoid muscle. (NOTE: The lateral platysma-
pexy should be performed after the anterior platysmaplasty.)

From a practical standpoint, the final decision about how to manage horizontal
platysma redundancy and whether platysmapexy or postauricular transposition flaps
should be used is best deferred until the day of surgery, when the effects of SMAS
advancement and anterior platysmaplasty can be determined.
1557
Chapter 46  Lamellar High SMAS Face and Midface Lift
Plan for postauricular transposition flap. Top, Plan for postauricular transposition flap.
Bottom left, Elevation and transposition of flap to postauricular area. Bottom right, After
SMAS elevation and suturing. To be effective and produce the best accentuation of the
jawline, the flap must be fashioned so that it pulls posteriorly on the cervical platysma be-
low the mandibular border, not on the lower cheek SMAS above it. (NOTE: From a technical
standpoint, it is best to raise the entire SMAS flap and suspend it by its superior margin
first. The postauricular transposition flap can then most easily be separated from its poste -
rior margin.)

Planning the Modification of the Submental Region
Traditional face-lift techniques do not adequately address many aspects of aging in the
submental region, and it is not enough in most situations to limit treatment of the
neck to preplatysmal lipectomy and postauricular skin excision. For many patients
subplatysmal fat accumulation, submandibular salivary gland “ptosis,” and digas-
tric muscle hypertrophy will contribute significantly to their neck deformity, neces-
sitating additional treatment.
In many patients a significant portion of cervical fat accumulation will be present
in a subplatysmal location, and little if any fat will need to be removed from the pre-
platysmal layer. Indeed, as patients age, fat stores generally shift from preplatysmal
to subplatysmal, and the small amount of subcutaneous fat present in a typical pa-
tient presenting for a face lift is necessary and must be preserved to maintain a soft,
youthful, attractive appearance.
Abnormal collections of subplatysmal fat can be identified by preoperative palpa-
tion of the neck with and without platysma activation. Fat lying predominantly in a
preplatysmal position will generally feel soft and will remain in the examiner’s grasp
when the platysma muscle is activated. Fat lying in a subplatysmal position, how-
ever, will have a firmer feel, and will tend to be pulled superiorly out of the exam-
iner’s grasp when the platysma is contracted.
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Part VIII  Face Lift and Neck Lift
Assessing the location of cervicosubmental fat. Left, The patient’s submental “wattle” is
grasped with the face and neck in repose. Right, The patient is then asked to activate the
platysma muscle. In this example, the fat is pulled superiorly from the examiner’s grasp, in-
dicating a predominantly subplatysmal position. Fat lying predominantly in a subcutaneous,
preplatysmal position would tend to remain within the examiner’s grasp when the platysma
is contracted.

Subplatysmal fat accumulations are typically present in patients with firm, obtuse
necks who have had lifelong cervicomental fullness. In these individuals, partial sub-
platysmal lipectomy will be productive, but complete removal of all subplatysmal
fat is rarely indicated. The final decision about performing a subplatysmal lipectomy
is best made after the subplatysmal space has been explored.
The submandibular glands must be assessed preoperatively because they often con-
tribute to the appearance of a full, “lumpy” neck. Large submandibular glands are
most easily seen in a secondary face-lift patient who has had a prior aggressive cer-
vicosubmental lipectomy. Large glands are frequently hidden by submental fat or a lax
platysma muscle in a patient with a full neck presenting for a primary procedure,
and a plan that does not recognize this fact will lead to disappointing and unexpected
bulges in the lateral submental regions postoperatively.
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Chapter 46  Lamellar High SMAS Face and Midface Lift
Submandibular glands are usually palpable as firm, smooth, discrete, mobile masses
in the lateral submental triangle, lateral to the anterior belly of the digastric muscle
and medial to the inner aspect of the ipsilateral mandibular border. Submandibular
glands lying deep to the plane tangent to the inferior border of the mandible and the
ipsilateral anterior belly of the digastric muscle do not disrupt neck contour and will
usually not require treatment. However, glands protruding inferior to this plane are
likely to be problematic if excess cervical fat is removed and redundant skin is excised.
Despite some claims to the contrary, experience has shown that prominent sub-
mandibular glands are actually large, not ptotic, and that the platysma contributes
little to their position or support. Attempts at tightening the platysma when a promi-
Prominent submandibular glands. Submandibular glands are usually evident as protrud-
ing masses in the lateral submental triangle, lateral to the anterior belly of the ipsilateral
digastric muscle and mandibular border. Left, This patient had residual prominent subman -
dibular glands after a face lift with submental liposuction. His prior procedure made the
prominent glands more obvious. Right, This patient had residual prominent submandibular
glands after a “weekend neck lift.” Aggressive resection of subcutaneous fat had exposed
the prominent gland.

nent gland is present usually results in a modest, short-lived improvement. Careful
sculpting of the periglandular fat will sometimes disguise small glands, but for large,
prominent glands, the protruding portion must be resected to achieve a sustained,
optimal improvement.
The decision to perform submandibular gland resection should be made in con-
junction with the patient after appropriate discussion of the advantages and disad-
vantages of the procedure. Patients should know that the procedure may prolong
submental induration and edema and carries a small theoretical (but unlikely) risk
of bleeding, sialoma, salivary fistula, and dry-mouth symptoms.
A small subgroup of patients will have digastric muscles with large, bulky anterior
bellies that are evident as linear paramedian submental fullness. Large anterior bel-
lies of the digastric muscles are most easily seen in a secondary face-lift patient who
has had prior aggressive cervicosubmental lipectomy. As in the case with large sub-
mandibular glands, large digastric muscles are frequently hidden by excess submen-
tal fat or lax platysma muscle in a patient presenting for pri mary procedures, and
failure to identify them may lead to unexpected and objectionable submental bulges
postoperatively. In these individuals, subtotal superficial digastric myectomy should
be considered. The final decision to perform partial digastric muscle resection is best
deferred until the day of surgery, when the improvements produced by other modi-
fications of the submental region can be evaluated.
Preoperative Preparations
All patients undergo a preoperative physical evaluation, and any with significant
medical problems must be cleared by their internist or personal physician before their
procedure is performed. Patients are required to avoid agents known to cause platelet
dysfunction for 2 weeks before surgery; they are given a list of products such as as-
pirin, ibuprofen, ketoprofen, naproxen, nonsteroidal antiinflammatory drugs, vita-
min E, and other prohibited products.
Patients who smoke are asked to quit 4 weeks before their procedure and are re-
quired to avoid smoking and all secondhand smoke for 2 weeks after surgery. Pa-
tients who smoke or have a significant history of smoking but have quit are advised
in writing that their risk of serious complications, including poor healing, flap necro-
sis, skin slough, and thromboembolic phenomena, is significantly higher than in non-
smokers. It is generally assumed, however, that most patients will not cease smok-
ing, and extra care should be taken to ensure that informed consent is complete in
this regard. Fortunately, flap viability depends on a variety of factors other than
smoking that are under the surgeon’s control or are minimized by the high SMAS
procedure design. These factors include tissue trauma, the extent of skin undermin-
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Part VIII  Face Lift and Neck Lift

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Chapter 46  Lamellar High SMAS Face and Midface Lift
ing, and the amount of skin tension. Because the high SMAS technique limits skin
undermining, preserves important cheek perforators, and avoids tension on delicate
cervicofacial skin flaps, a careful surgeon employing proper technique can operate
safely on smokers. Indeed, some surgeons allow patients who smoke to do so in the
perioperative period and have observed no increase in complications. Smokers should
always be approached with caution, however, and every surgeon should recognize
that these patients are at high risk for serious local and systemic complications.
All patients are instructed not to color their hair, have a permanent, or otherwise
chemically treat their hair during the 2-week period before and after surgery, be-
cause this may result in hair breakage and loss. Patients are instructed to shower and
shampoo with antiseptic soaps the night before surgery, paying careful attention to
the periauricular areas.
It is important that adequate operating room time be allotted for contemporary face-
lift procedures, since they are deceptively time consuming compared with traditional
or more limited techniques. A high SMAS face lift, when performed in conjunction
with a foreheadplasty, eyelid surgery, fat injections, dermabrasion, and other proce-
dures, may often encompass 6 to 8 hours or more, even when performed by a “fast”
surgeon working with a well-organized and experienced operating room team. Most
surgeons I know who regularly perform these complicated combined procedures
have resigned themselves to this fact and have made appropriate adjustments in their
surgery schedules. Usually this means allotting an entire day for the procedure. For
difficult procedures, or when additional surgery is requested (such as rhinoplasty),
it is recommended that the procedures be staged over two separate (consecutive or
nonconsecutive) days.
It is strongly recommended that any surgeon new to these techniques consider stag-
ing a full-face rejuvenation over 2 days. This worked well for me early in my prac-
tice and is still recommended for certain patients with difficult or unusual problems
and those who request multiple ancillary procedures. Typically, face and neck lifts
are performed the first day. The patient is then usually returned to the operating room
the following day or a few days later for foreheadplasty, blepharoplasty, and other
procedures. Patient acceptance of this recommendation will be high if it is presented
to them as being in their best interest and that it is part of the surgeon’s efforts to
ensure their safety and provide high-quality care.
Anesthesia
The majority of face lifts I perform are now done with the patient under deep seda-
tion administered by an anesthesiologist using a laryngeal mask airway (LMA).
A laryngeal mask technique allows the patient to be heavily sedated without com-

promise of their airway, but the patient need not be given muscle relaxants and can
be allowed to breathe spontaneously. A laryngeal mask is also less likely to become
dislodged during the procedure than an endotracheal tube, and it is less likely to trig-
ger coughing and bucking when the patient emerges from the anesthetic. However,
any skillfully administered anesthetic is adequate for performing the procedure.
Most modern, comprehensive face-lift techniques, including the high SMAS proce-
dure, are time consuming, technically demanding, and will test the patience and com-
posure of the surgeon. It is highly recommended that any surgeon new to these tech-
niques enlist the services of an anesthesiologist or competent CRNA. This is particularly
important when the procedure is to be performed on a patient who is apprehensive,
has a history of difficulties with anesthesia, hypertension, or other significant med-
ical problems. This will avert the frustration and stress of trying to master a techni-
cally demanding procedure while bearing the responsibility of supervising the ad-
ministration of an anesthetic, monitoring the patient, and managing intraoperative
problems.
Most patients receive preoperative medication tailored and adjusted to their age,
weight, height, personality, specific circumstances, and general health; this regimen
is modified depending on the type of anesthetic used. Oral narcotics should not be
given as part of the premedication, because they commonly result in nausea and
vomiting. Cocaine, anticholinergics, and parasympathomimetics are also avoided.
We administer antiemetics preemptively at the beginning of each procedure, and pa-
tients with a history of perioperative nausea are usually given several agents to block
the emetic reflex at multiple levels. All patients are fully monitored with electrocar-
diography, automatic sphygmomanometry, transcutaneous pulse oximetry, and main-
stream capnography. Perioperative blood pressure is closely monitored and fluctua-
tions are aggressively treated, especially in patients with existing hypertension or a
borderline condition. The latter group of patients should be watched closely and
treated preemptively, because they typically become hypertensive once the surgery
and anesthesia is begun.
Surgical Technique
The patient is placed supine on a well-padded operating table, with a special effort
to ensure that the elbows, heels, and other potential pressure points are well pro-
tected. The patient’s lower extremities are elevated and antiembolic pedal compres-
sion devices applied. An indwelling balloon-tipped urinary catheter is placed after
sedation is begun or general anesthesia administered. A temperature probe is taped
in the axilla or groin, and the patient is sufficiently covered or a patient-warming
1562
Part VIII  Face Lift and Neck Lift

device is applied to allow the room to be cooled for the comfort of the scrubbed
team members.
Each patient receives a full surgical scrub of the entire scalp, face, ears, nose, neck,
shoulders, and upper chest with full-strength (1:750) benzalkonium chloride (Zephi-
ran) solution the day of surgery after a bland ophthalmic ointment is instilled in each
eye. The patient’s head is then placed through the opening of an adhesive-backed
disposable transverse laparotomy sheet, leaving the entire head and neck region un-
obscured from the clavicles up. This allows unimpaired examination of the cervical
profile in its entirety throughout the procedure and provides complete access to all
areas of the scalp. No head drapes are used, because they will limit scalp access and
make it difficult to determine hair shaft inclination and make incisions properly.
The breathing circuit is draped separately from the patient by wrapping it with a
sterile sheet or covering it with a sterile stockinette. This allows it to move during
the procedure as the patient’s head is turned from side to side. When set up in this
manner, it is not necessary to secure the LMA with tape or by other means, as long
as its position is watched by the anesthesiologist and/or other members of the oper-
ating room team present. If an endotracheal tube is used, it can be conveniently se-
cured to the perioral skin with Tegaderm or similar sterile, adhesive-backed dressing.
After the general preparation of the face is complete and drapes have been applied,
the posterior surface of the tragus and the auditory canals are prepared with full-
strength povidone-iodine (Betadine) using cotton-tipped swabs by a scrubbed mem-
ber of the surgical team. Each nasal vestibule, the perioral area, and the gingivolabial
sulci are prepared with povidone-iodine as well. Peanut sponges are placed in each
auditory meatus, and these are changed as necessary during the procedure to pre-
vent the accumulation of blood in the auditory canals.
No hair is cut or shaved along any proposed site of incision. Shaving or trimming
hair will prevent accurate assessment of hair shaft inclination relative to the scalp
and can result in incisions that injure hair follicles. Tightly applied rubber bands, ad-
hesive tape, surgical lubricants, antibiotic ointment, and hair clips produce similar
problems and should also be avoided. It is always an error to preshave any area of
the scalp before the procedure, because this commits the surgeon to excision of these
areas, even if this is determined to be inappropriate intraoperatively. As a practical
matter, in a well-planned face lift, little if any scalp tissue should actually be excised.
Administering Local Anesthesia
A local anesthetic is administered, even if deep sedation or general anesthesia is used.
This limits stimulation of the patient and the overall amount of anesthetic needed.
A significant hemostatic effect is also obtained when solutions containing epineph-
rine are used.
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Chapter 46  Lamellar High SMAS Face and Midface Lift

Sensory nerve blocks are performed using 0.25% bupivacaine (Marcaine) with epi -
nephrine 1:200,000. This allows the rest of the face to be injected with a reduced de-
gree of stimulation. Skin marked for incision is then infiltrated with the same solution.
Areas of subcutaneous dissection are infiltrated with 0.1% lidocaine (Xylocaine)
with epinephrine 1:1,000,000 using a 22-gauge spinal needle in the cheek and postau-
ricular areas and a blunt infiltrator in the neck and submental regions. Care is taken
to ensure that the total dose of bupivacaine does not exceed 3 mg/kg of body weight
and lidocaine does not exceed 7 mg/kg of body weight per 4 hours. No direct infil-
tration of the SMAS or platysma is necessary if the overlying subcutaneous tissues
are infiltrated generously at the beginning of the procedure, as described. It is not
necessary to inject local anesthetic in a tumescent fashion.
The local block is maintained by systematically reinfiltrating the key areas (preau-
ricular and postauricular) during the procedure and readministering nerve blocks
before the local anesthetic effect wears off. This prevents loss of continuity of the lo-
cal anesthetic effect and stimulation of the patient that would otherwise occur if rein-
jection were delayed until after sensation returned.
Making Incisions
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Part VIII  Face Lift and Neck Lift
Incising the skin and scalp is a key step in which the surgeon exercises direct control
over the quality of the resultant scar, and incisions should not be made casually or
carelessly. All incisions on the scalp or along scalp-skin interfaces must be made pre-
cisely parallel to the hair follicles to avoid injury to them, which can result in peri-
incisional alopecia. Frequently this is mistakenly attributed to the patient’s own poor
healing characteristics and is erroneously regarded as “a wide scar.”
In most cases, follicles and hair shafts will be similarly inclined, but this may not be
true in a kinky-haired or curly-haired individual or when the patient’s hair is wet,
saturated with surgical lubricants, or restrained with drapes, tape, or rubber bands.
For this reason it is important to confirm by direct observation that the incision is
precisely parallel to the hair follicles as it is made. One must also recognize that hair
All incisions on the scalp must be made
precisely parallel to the hair follicles to avoid
injury to them, and it is important to confirm
by direct observation that this is true as the
incision is made.

follicle inclination is not uniform over the scalp: follicles will be inclined differently
at different areas along the planned incision. Because of this, the angle of the scalpel
blade with the scalp must change correspondingly as the incision is made, and the
completed incision will be beveled to varying degrees and in different directions, if
properly performed.
Skin Flap Elevation
After incisions are made, skin flaps are elevated according to the preoperative plan
over the cheek and neck. Partial separation of the skin flap from the SMAS (lamellar
dissection) is necessary because skin and SMAS flaps need to be advanced in differ-
ent direction to achieve an optimal outcome. This “bidirectional” tissue shift is not
possible if a “composite” type of dissection (elevation of a combined skin-SMAS
flap) is done.
Correct positioning of the operating room lights and proper retraction by the assis-
tant is essential for proper dissection, and unnecessary trauma to the flaps must be
avoided. Light should be placed on both sides of any flap being dissected to provide
simultaneous direct and transmitted illumination; blind dissection must be avoided.
Shining a light on the skin surface (transillumination) will help define flap thickness,
while lighting the site of dissection (direct illumination) allows identification of im-
portant structures. However, too much direct illumination can obscure the transil-
lumination effect and must be avoided. This is particularly true of the bright direct
light emitted from fiberoptic headlights and retractors. If they are used, their intensity
should be reduced to produce proper, balanced illumination.
The circulating nurse or other unscrubbed team member should be assigned the task
of adjusting the overhead lights as needed and the importance of this assignment
emphasized. In time, a perceptive nurse need only watch the operative field to know
when adjustment is needed. If the circulating nurse is required to monitor the pa-
tient, administer medication, or frequently leave the operating room, it is recom-
mended that an additional staff member be present for adjusting lighting.
The surgeon and assistant should refrain from adjusting the overhead lights, because
each will need both hands free for proper retraction and dissection. Adjusting the
lights with one hand while retracting with the other is a common error that invari-
ably results in excessive traction on the flap and unnecessary trauma to delicate cer-
vicofacial tissue.
Proper care of the patient and effective functioning of the operating room team re-
quires that two team members be scrubbed with the surgeon throughout most of
the procedure. One scrubbed team member will be necessary to act as a full-time
surgical assistant. This is a key role that generally precludes passing instruments,
loading sutures into needle holders, tracking sharps, and maintaining the instrument
1565
Chapter 46  Lamellar High SMAS Face and Midface Lift

1566
Part VIII  Face Lift and Neck Lift
stand. A second scrubbed team member should be present to oversee and carry out
these important secondary functions. Regardless of experience or claims to the con-
trary, it is not possible for one person to effectively assume both roles without com-
promising her or his role as an assistant and otherwise slowing down the surgical
procedure.
Cheek flap dissection is begun using an Adson forceps and a small Kaye scissors or
scalpel, grasping only tissue edges that will later be excised. Once the flap edge has
been elevated, the forceps are set aside and gentle traction is applied by the assistant
with double-pronged skin hooks. A standard patterned medium curved Metzenbaum
scissors is then used to establish the proper plane.
Flap dissection is most effectively performed when the surgeon and assistant work
together as a carefully coordinated team using a four-handed technique in which the
assistant applies gentle traction on the skin flap directed toward the surgeon with
two large double-pronged skin hooks. One skin hook retractor should be held in
each hand, because it is not possible for the assistant to provide proper retraction
using a one-handed technique (holding both retractors in one hand). The surgeon
then dissects while providing gentle countertraction toward the assistant with the
fingertips of the opposite hand.
As the dissection advances, one skin hook is exchanged for a small Deaver, malleable,
or similar retractor. The remaining skin hook is used to drape the flap over the re-
tractor and keep it properly positioned on it. This eliminates the need for excessive
traction and minimizes trauma to the flap.
Four-handed technique. The assistant applies gentle traction on the skin flap toward the
surgeon with two large double-pronged skin hooks with one retractor held in each hand.
The surgeon then dissects while providing gentle countertraction toward the assistant with
the fingertips of the opposite hand.

The surgeon should not retract for herself or himself, because this invariably leads to
rough handling of the flap, especially when exposure is limited or dissection becomes
difficult. Retracting should instead always be performed by a conscientious assistant
capable of focusing his or her attention on providing proper exposure and protect-
ing delicate facial flaps. This assistant must ignore his or her natural urge to “help”
the surgeon by applying excessive force when retracting. It must also be kept in mind
that most hospital and surgery center personnel are accustomed to assisting surgeons
in other specialties and have not been trained in proper tissue-handling techniques.
They are usually not aware that improper retracting, excessive traction, and rough
handling of the flap are harmful and can lead to flap compromise, tissue necrosis,
and skin slough, and time taken to teach them proper retracting techniques is well
spent.
Tissue trauma to skin flaps can be significantly reduced by periodically moving the
dissection from one area to another and completing flap elevation in stages. This al-
lows the tissue to “breathe” and avoids prolonged compromise of any one area. Trac-
tion should also be released before retractors are moved. If traction is not released,
the flap’s microcirculation will be compromised as the retractor is moved from side
to side.
All operating room team members should be responsible for ensuring that flaps are
handled carefully and that they are not subjected to excessive traction, pinching, fold-
ing beneath retractors, or other potentially harmful actions. It is not possible for the
surgeon, who is usually preoccupied with other aspects of the procedure, to always
be diligent in this regard.
Skin flaps should be elevated sharply under direct vision, avoiding blind dissection.
This is especially important in the preauricular region and over the cheek, where a
deep dissection can injure and compromise the underlying SMAS or render it use-
less as a flap. I have observed that many surgeons using non-SMAS face-lift tech-
niques dissect deeper than they realize, and inspection of their flaps after dissection
often reveals that SMAS fibers have been elevated as part of the “skin” flap. It is also
an error to dissect too close to the posterior surface of the skin flap, because this can
result in injury to the subdermal microcirculation.
Although subtle, some visual clues are helpful in avoiding these problems and de-
termining when the proper plane has been established. If skin flap dissection is made
too deep and SMAS fibers are elevated, the flap’s undersurface will appear relatively
smooth and covered by streaks of fine white tissue. When transilluminated, flaps dis-
sected in this manner will appear cloudy and relatively thick. If dissection is made
in the proper plane, however, the undersurface of the flap will have a characteristic
1567
Chapter 46  Lamellar High SMAS Face and Midface Lift

rough pebbled or cobblestone appearance and will be more yellow. Transillumina-
tion of a flap dissected in the correct plane enhances this appearance.
Blind dissection done by pushing scissors or blunt dissection using a scissors-spread-
ing technique is unacceptably traumatic to the subdermal microcirculation of the
skin and can result in flap compromise, damage to subdermal fat, and unintended
injury to the SMAS and platysma. This is particularly likely when aggressively pat-
terned, doubled-edged, serrated, and extra-sharp scissors are used. After experi-
menting with many scissors patterns, I have found none as good as the standard Met-
zenbaum type.
Postauricular skin flap undermining is most easily begun inferiorly if the occipital
incision has been made along the occipital hairline, or posteriorly if the incision has
been made over the occipital scalp, because more subcutaneous fat is usually pres-
ent in these areas. Beginning dissection in these areas helps the surgeon identify the
proper plane more superiorly and anteriorly in the postauricular area, where less
subcutaneous fat is present and the skin and fascia lie in close proximity. Careful in-
filtration of dilute local anesthetic into the plane of dissection also facilitates dissec-
tion in these areas, but large-volume tumescent injections should be avoided, because
these can injure delicate postauricular skin.
Once the correct plane of dissection has been established in the postauricular area,
two 10 mm double-pronged skin hook retractors are placed and held by the assis-
tant, and Metzenbaum scissors are used to elevate the postauricular skin flap. Postau-
ricular flap elevation should be done under direct vision aided by transillumination.
Dissection is most easily performed in a posterior-to-anterior direction rather than
in a superior-to-inferior one.
As dissection progresses anteriorly and inferiorly from the postauricular region to
the upper lateral neck, the surgeon must be careful to avoid injury to the great au-
ricular nerve. This nerve provides sensation to the lower two thirds of the ear and
travels superficially superiorly in the upper lateral neck over the sternocleidomastoid
muscle fascia. The most superficial portion of the nerve is anatomically constant, ly-
ing approximately 6.5 cm inferior to the auditory meatus midway between the an-
terior and posterior borders of the sternocleidomastoid muscle. In most patients,
however, it will lie deep to the plane of skin flap dissection and is covered by a thin
layer of subcutaneous fat. In these cases, it is neither necessary nor advisable to at-
tempt to specifically identify or isolate this nerve through additional dissection.
1568
Part VIII  Face Lift and Neck Lift

Patients with thin faces or those undergoing secondary face lifts will not uncom-
monly have little subcutaneous fat between the superficially situated portion of the
great auricular nerve and the skin. For this reason, extra caution must be taken in
these patients when elevating the skin flap in this area, and a clear knowledge of
nerve anatomy is required.
As dissection continues anteriorly into the cervical region, subcutaneous fat gener-
ally becomes more abundant, and the flap is easier to dissect. The surgeon must be
careful to remain in a subcutaneous plane and to leave the majority of the pre-
platysmal fat on the platysmal surface. This makes fat excision and sculpting easier
later in the procedure, if required, and precludes the need for tedious excision of fat
from the undersurface of the cervical skin flap. Unlike dissection of a cheek skin flap,
in which a conscious effort must be made to prevent the flap from becoming too
thick, a slightly deeper dissection should be made in the neck to preserve a slightly
thicker layer of subcutaneous fat. Preserving a thicker layer of fat helps to avoid a
hard or overresected appearance in the cervicosubmental area and objectionable
overexposure of underlying neck anatomy.
If a submental incision is planned, completing subcutaneous dissection of the ante-
rior neck skin flap will be more easily performed through it, rather than through the
postauricular incisions. Undermining the submental crease and releasing the sub-
mental and mandibular ligaments will also be easier when performed through the
submental incision.
The submental incision should be made 1 cm or more posterior to the submental
crease, approximately halfway between the mentum and hyoid. Placing the incision
in this location helps conceal it in the shadow of the mandible and avoids surgical
reinforcement of the crease and accentuation of a double-chin and witch’s-chin de-
formity. The surgeon should stand at the head of the table during dissection of the
submental region while the assistant retracts the edges of the submental incision with
a pair of 10 mm double-pronged skin hooks. The skin is undermined using Met-
zenbaum scissors, and the dissection should be made subcutaneously, leaving the
majority of the preplatysmal fat on the platysma surface. Submental dissection is
continued inferiorly and laterally until it is joined with the dissection made previ-
ously in the lateral neck.
On completion of subcutaneous undermining of the anterior neck and submental
regions, the submental restraining ligaments should be divided and the submental
crease released from its bony attachments. Some bleeding is usually encountered dur-
ing this maneuver, but this should not prevent the surgeon from completing this im-
portant step.
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Chapter 46  Lamellar High SMAS Face and Midface Lift

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Part VIII  Face Lift and Neck Lift
Although in most patients’ necks subcutaneous undermining is necessary, this should
not arbitrarily include the entire face. If a SMAS dissection is planned, preserva-
tion of the anterior platysma-cutaneous ligaments will allow attractive, youthful-
appearing elevation of perioral tissue that cannot be obtained with a skin-only tech-
nique or when wide skin undermining is performed.
These ligaments anchor the dermis of the perioral cheek to the SMAS and upper
platysma and provide a means of lifting and supporting the lateral perioral area with-
out overtightening the skin of the upper-lateral face. Preservation of the platysma
cutaneous ligaments also preserves important accompanying perforating vessels to
the cheek flap. This reduces the likelihood of flap slough, swelling, and compromise.
If subcutaneous dissection is extended too far anteriorly and the platysma-cutaneous
ligaments are divided, the SMAS effect on the superficial tissues of the perioral cheek
and jowl will be negated, and a significant portion of the benefit of SMAS elevation
and advancement will be lost. Wide cheek flap undermining and division of the
platysma-cutaneous ligaments is also the underlying cause of the lateral sweep de-
formity, since SMAS support of sagging perioral tissues is lost when dissection is
performed in this manner.
Temple Dissection
The temple incision is made according to the preoperative plan based on the redun-
dancy present over the upper cheek and the predicted degree of displacement of the
sideburn and temporal hairline (see the preceding section).
Extent of subcutaneous undermining. The shading indicates the area of subcutaneous
undermining. Note that the platysma-cutaneous ligaments (red dots) are not undermined
and are preserved. Preservation of platysma-cutaneous ligaments and proper elevation
and fixation of the SMAS provides support of lateral perioral tissues and prevents the
“lateral sweep” deformity.