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

Partially dividing the bridge of tissue between the deep plane of the temple and the
subcutaneous plane of the cheek allows the two planes of dissection to be joined lat-
erally; this in turn facilitates exposure in the upper cheek and lateral orbit, dissec-
tion of the SMAS, and redraping of the temporal portion of the face-lift flap. This
method of dissection also protects hair follicles on the undermined temporal scalp
by moving the plane of dissection deep to them. Temporal skin can then be under-
mined subcutaneously up to the lateral orbit, bringing the dissections in the cheek
and temple into wide continuity.
When an incision along the temporal portion of the anterior hairline is indicated, it
is made a few millimeters within it with a slight bevel, or parallel to the hair folli-
cles. This incision should be made no higher than the junction of the temporal hair-
line with the frontotemporal hairline; if it is carried more superiorly, the resulting
scar will usually be visible, since hair tends to grow posteriorly in this area.
After the incision is made along the hairline, the temporal skin flap is carefully un-
dermined subcutaneously and joined with the subcutaneous dissection in the cheek.
No transition between planes is necessary under these circumstances, and no hair-
bearing flaps are raised; the superficial temporal vessels and frontal branch of the fa-
cial nerve are left undisturbed beneath the superficial temporal fascia.
1572
Part VIII  Face Lift and Neck Lift
Subcutaneous
plane
Flap dissection with a hairline incision. When an incision along the temporal hairline is
used, all dissection will be in a subcutaneous plane and no transition between planes will
be necessary, no hair-bearing flaps are raised, and the superficial temporal vessels are left
undisturbed beneath the superficial temporal fascia.

SMAS Dissection
Once the skin flaps have been elevated, they are retracted and the zygomatic arch is
palpated. A line is then traced high over its midportion with water-soluble surgical
ink (methylene blue) from the infraorbital rim to a point approximately 1 cm ante-
rior to the superior portion of the tragus. This line lies higher than the dissection
made in most other techniques, and well above the malar origin of the zygomaticus
major muscle. The mark is then turned inferiorly and carried over the preauricular
portion of the parotid 1 to 2 cm anterior to the ear. Inferior to the lobule, it is carried
inferiorly and posteriorly to the anterior border of the sternocleidomastoid muscle.
1573
Chapter 46  Lamellar High SMAS Face and Midface Lift
A basic high flap of this type is used on most patients. There are several important
advantages in its design worth considering. First, planning the superior margin of
the flap over and along the zygomatic arch, rather than inferior to it, expands the
effect of the flap to include the upper midface and allows a better vector to be ap-
plied to it. Carrying the incision posteriorly and inferiorly over the tail of the parotid
to the anterior border of the sternocleidomastoid muscle in the upper-lateral neck
also maintains a safety zone between the incision and the mandibular margin and
moves the dissection away from the marginal mandibular nerve. Placing the remaining
portion of the incision along the anterior border of the sternocleidomastoid muscle
places the dissection in a relatively thin and avascular area of platysma and along a
line where the cut edge, if visible through the skin after surgery, would appear to be
the muscle border.
SMAS incision marked
Frontal branch of
facial nerve
Superficial
temporal fascia
Sternocleidomastoid
muscle
Plan for high SMAS flap. The superior margin of flap is planned over the zygomatic arch
and not below it. The frontal branch of the facial nerve (yellow dotted line) lies safely poste-
rior and deep to the majority of the dissection.

Flap elevation is begun by incising the SMAS over the zygomatic arch. This is accom -
plished by grasping the preauricular tissue overlying the lateral arch with an Allis
clamp on each side of the marked line and having the surgical assistant apply gentle
posterior traction on them to tense the SMAS layer. The surgeon then makes an inci -
sion with Metzenbaum scissors and continues it medially 1 to 2 cm along the marked
line in the tensed plane. Allis clamps are then released and reapplied incrementally
as the dissection proceeds farther medially along the marked line in the tensed plane
in 1 to 2 cm segments in a similar fashion. A considerable amount of tissue lies over
the arch, and the frontal branch will be safely concealed beneath several millimeters
of fibrous fat. The margin for error may be reduced in a thin, aged patient with ad-
vanced facial atrophy and less soft tissue cover over the arch or in a secondary pro-
cedure; therefore extra caution must be exercised under such circumstances.
The preauricular limb of the SMAS incision is then made using a similar technique
over the posterior parotid along the marked line in the preauricular region. It is con-
tinued inferiorly and posteriorly to the anterior border of the sternocleidomastoid
muscle. These two incisions define the high SMAS flap to be elevated.
After initial SMAS incisions have been completed, preauricular tissue comprising the
posterior-superior corner of the SMAS flap is grasped with Allis clamps and flap el-
evation is then begun using careful scissors technique. Undermining should be lim-
ited in the preparotid cheek, more extensive over the zygoma and upper midface.
1574
Part VIII  Face Lift and Neck Lift
Marginal mandibular branch
of facial nerve
Parotid gland
Accessory lobe of
parotid gland
Plan for
high SMAS flap
Plan for high SMAS flap. The marginal mandibular branch of the facial nerve (black
dotted line) emerges from the anterior border of the parotid gland well anterior to the SMAS
incision in the preauricular region. The mark for the posterior incision curves posteriorly to
the anterior border of the sternocleidomastoid muscle.

The SMAS, although substantial, is thinner than many surgeons imagine it to be,
and it is decidedly thinner and less substantial than other tissue layers that are typ-
ically dissected in plastic surgery procedures. SMAS flap elevation also entails dis-
section in the plane of the facial nerve, in close proximity to important motor
branches. Although flap elevation over the parotid is safe, great care must be taken
when dissecting more medially and over the zygomatic arch.
Sharp scissors dissection of the high SMAS flap is usually required posteriorly over
the parotid, where the plane between parotid fascia and SMAS is often indistinct. In
some instances a portion of the parotid fascia may be incidentally and/or unavoid-
ably raised with the SMAS flap, and part of the lobular surface of the gland may be
exposed. This is of no clinical consequence and should be used by the surgeon as an
aid in identifying the proper plane of dissection, situated slightly more superficially.
A separate and distinct plane does exist medial to the parotid between the SMAS-
platysma and the parotidomasseteric fascia. This plane is most easily identified and
established in the lower cheek, where it can usually be entered by gentle blunt dis-
section with scissors tips, a fingertip, or with a Kitner (peanut) sponge. The parotido-
masseteric fascia will be seen as a thin, shiny, transparent layer covering the mas-
seter muscle, parotid duct, buccal fat, and the branches of the facial nerve. Blunt
dissection on top of this layer is safe and will not result in nerve injury, but great
caution must be exercised when dissecting sharply or when clamping or coagulat-
ing in this area. Frequently motor nerve branches accompany perforating vessels,
1575
Chapter 46  Lamellar High SMAS Face and Midface Lift
Approximate extent of SMAS undermining. Complete release of the SMAS flap will
require that both the zygomatic ligaments (blue squares) and the parotidomasseteric liga-
ments (red dots) be released.
Zygomatic ligaments
SMAS incision
Parotidomasseteric
ligaments

and each bleeding point must be carefully identified when ensuring hemostasis. Blind
clamping should not be performed, and a low coagulation current should always be
used. The patient’s face should also be carefully watched during cauterization and
the current discontinued immediately if facial twitching is noted.
Sub-SMAS dissection must generally be carried over the anterior border of the parotid
in the lower cheek to ensure that parotidomasseteric ligaments tethering the SMAS
are released. These are most easily identified by fingertip palpation along the front of
dissection. If these restraining attachments are not released, the SMAS effect in the
lower cheek and jowl will not be optimal, and the overall benefit will be minimal.
As SMAS flap dissection is made anteriorly and medially in the upper cheek over the
superior portion of the parotid and its accessory lobe, the SMAS will be seen to thin
and invest the lip elevators. At this point the dissection must be taken superficial to
the superior portion of the zygomaticus major muscle and its upper 1 to 2 cm care-
fully exposed. The zygomatic ligaments will be encountered just at the malar origin
of the zygomaticus major muscle. These fibrous connections between the periosteum,
SMAS, and skin must be divided and when completely released, produce a dramatic
liberation of the flap. The lateralmost ligaments are typically more substantial and gen-
erally require sharp dissection and formal transection. The ligaments lying more me-
dially are generally softer and can often be disrupted bluntly with open scissors tips.
Directly inferomedial to the origin of the zygomaticus major muscle and supero-
medial to the accessory lobe of the parotid and the parotid duct lies the zone of tran-
sition between the zygomatic and parotidomasseteric ligaments—and potentially
the most dangerous part of the SMAS dissection. Proper liberation and release of the
SMAS flap usually requires at least partial division of restraining attachments in this
area, but this moves the dissection into very close proximity to the zygomatic branch
of the facial nerve.
1576
Part VIII  Face Lift and Neck Lift
Zygomaticus major muscle
Completed SMAS flap dissection. Inferior to the origin
of the zygomaticus major muscle and superomedial to the
accessory lobe of the parotid lies the zone of transition
between the zygomatic and masseteric-cutaneous liga-
ments (red dots)—potentially the most dangerous part
of the SMAS dissection. Proper liberation and release of
the SMAS flap usually requires at least partial division of
restraining attachments in this area, but this moves the
dissection into very close proximity to the zygomatic
branch of the facial nerve.

Although experienced surgeons make this dissection appear easy and often seem to
minimize the risk involved, it can be difficult for a less-experienced surgeon to dis-
tinguish between nerve branches and ligamentous attachments in this area. Anatomic
variations are common in this area, and in some cases nerves will penetrate the deep
fascia early and travel directly in a sub-SMAS plane or send a branch over the zy-
gomaticus major to the orbicularis oculi. In these situations, traction on the SMAS
flap during dissection can tent up these branches, placing them at even greater risk.
It is highly recommended that any surgeon uncertain of the anatomy of the facial
nerve and its variations or the exact relationships in this area review them carefully
before undertaking this dissection.
A safe dissection of the submalar SMAS and proper release of the zygomatic liga-
ments requires adequate light, an attentive assistant, a well-organized surgical team,
a dry field, and patience, caution, and composure on the part of the surgeon. Loupes
are very helpful in identifying important anatomic structures, and inexperienced sur-
geons should consider the use of a disposable battery-operated nerve stimulator to
aid in initial dissections. If the neophyte surgeon is confused or the anatomy seems
unclear, it is better to limit dissection until he or she gains additional experience and
familiarity with this anatomic region, because no amount of improvement in facial
appearance is worth an injury to the facial nerve.
Dissection of the SMAS flap and release of restraining ligaments is continued until
gentle traction on the flap produces motion at the nasal ala, philtrum, and stomal
angle, and elevation and compression of infraorbital and lower eyelid tissue. This
traction test clinically confirms adequate flap release and is a more important indi-
cator of a complete dissection than any arbitrary anatomic endpoint. If flap release
is incomplete, residual tethering fibers are identified are carefully divided, and the
traction test is repeated. When dissection is complete, the midface and malar pad
and attached skin will move freely as part of the high SMAS flap, and tissue ad-
vancement into the infraorbital area and compression of the lower eyelid skin will
be evident. No separate suturing or dissection of the midface is required.
1577
Chapter 46  Lamellar High SMAS Face and Midface Lift

SMAS Suspension
Once the SMAS flap has been elevated and adequately released, the superior edge of
the flap is grasped and shifted variously to determine which direction produces the
best effect on the upper midface, cheek, and jowl. In all but the unusual case, this is
along a posterior-superior vector parallel to the long axis of the zygomaticus major
muscle. If a vertical or posterior vector is used, the function of the zygomaticus ma-
jor muscle will be corrupted, and an abnormal appearance during animation may
result.
1578
Part VIII  Face Lift and Neck Lift
Correct
Incorrect
Incorrect
Management of the superior margin of the SMAS flap and the technique of flap sus-
pension will vary, depending on the problems present and considerations particular
to the patient, including sex, race, and his or her overall facial morphology. In most
cases no trimming of the superior margin of the flap is performed, because the over-
lapping tissue segments of the SMAS add volume to and restore lost projection over
the zygomatic arch. In these situations the superior edge of the flap is anchored with
multiple interrupted sutures of 3-0 Mersilene, well over the zygomatic arch, directly
to the deep temporal fascia, superior to the mesotemporalis.
Proper and improper vector of the SMAS shift. Left, The correct shift of the SMAS flap
is along the long axis of the zygomaticus major muscle. This allows natural muscle func-
tion. If the SMAS is shifted along a posteriorly directed vector (center), not along the long
axis of the zygomaticus major muscle, the muscle will be pulled off its axis and its function
compromised. This can result in deepening of the nasolabial fold and abnormal appear-
ances during animation. Right, An analogous problem occurs when a vertical vector is
used in a “vertical face lift.”

Suspension in this manner is greatly facilitated if the mesotemporalis is gently pushed
inferiorly as the sutures are placed. This solidly suspends the midface, upper cheek,
and jowl with little if any risk of injury to the frontal branch of the facial nerve. No
suturing is needed or should be performed more anteriorly over the zygoma or along
the infraorbital rim. These parts of the face are mobile and need to move during an-
imation and for natural expression. Directly suspending the midface along the zy-
goma or infraorbital rim, especially rigidly, can result in the tissue tethering and dim-
pling often referred to as a smile block. If direct anchoring of the flap to the temporal
muscle fascia is not possible, even when the mesotemporalis is pushed inferiorly, sus-
pension can still be made in this manner if the sutures are allowed to bridge the in-
tervening gap.
In patients with wide faces and small mandibles, in many men, and in many patients
of Asian or Slavic ancestry, enhancement of the upper cheek and arch obtained by
overlapping the SMAS may not be artistically appropriate, necessary, or desired. In
such cases the redundant tissue along the superior flap margin can be excised and
discarded and the superior flap margin sutured edge to edge to the superior margin
of the initial incision made in the SMAS over the zygomatic arch.
When an incision along the temporal hairline is used and temporal dissection is done
in a subcutaneous plane, temporal muscle fascia will not be exposed and a mesotem-
poralis will not be present. The redundant tissue along the superior flap margin can
1579
Chapter 46  Lamellar High SMAS Face and Midface Lift
High SMAS flap suspension with a temporal scalp incision. The SMAS flap has been
advanced superiorly, the mesotemporalis pushed inferiorly, and the flap secured to the
temporalis muscle fascia.
No sutures are
placed in this area

1580
Part VIII  Face Lift and Neck Lift
Sideburn retracted
Superficial temporal artery
Innominate temporal
fascia exposed
High SMAS flap suspension with a temporal hairline incision. Top left, To gain access
to the temporalis muscle fascia to suspend the SMAS, the sideburn is retracted and the
galea incised. Top right, The completed incision of the galea under the sideburn exposes
the temporalis muscle fascia. Once incised, a “mesotemporalis” (the transition from the
subcutaneous plane of the cheek to the subgaleal plane in the temple) is created. If this is
done carefully, the superficial temporal artery can be preserved, although it can be divided
and ligated without consequence. This establishes a situation for suspension of the SMAS
analogous to that shown on p. 1579. Bottom left, The suture has been placed through the
corner of the SMAS flap. Note that the mesotemporalis is being pushed inferiorly as the
suture is placed. Bottom right, Additional sutures have been placed between the superior
margin of the SMAS flap and the temporalis muscle fascia, securely anchoring the flap.
Although unnecessary, a few sutures have been placed and allowed to bridge anteriorly.
Once suspension of the SMAS is complete the sideburn is placed back in a proper ana -
tomic place and anchored down before the skin flap is trimmed and the incisions closed.
be excised and discarded, and the superior flap margin sutured edge to edge to the
superior margin of the initial incision made in the SMAS over the zygomatic arch.
Alternatively, the galea can be incised just inferior to the sideburn to expose the tem-
poralis muscle fascia (innominate fascia). The SMAS can then be anchored in a man-
ner analogous to the way in which the mesotemporalis has been divided.

Regardless of how the superior margin of the flap is secured, invariably some trim-
ming of the posterior margin of the cheek SMAS flap is subsequently required to al-
low an edge-to-edge approximation to the SMAS remnant in the preauricular region.
Overlapping of the SMAS in the preauricular area is functionally unproductive and
artistically inappropriate, because such an arrangement lends no additional support
to the anterior face and obliterates the natural preauricular contours and the pre-
tragal hollow.
The posterior margin of the cheek SMAS flap should be trimmed after the superior
margin has been suspended over the zygomatic arch. Tissue is excised by placing gen-
tle traction on it and tracing a line in marking ink over the cut edge lying beneath
it. The amount of tissue excised will vary depending on the size of the patient’s face,
the degree of release of the flap, and the chosen vector of advancement. It is unpro-
ductive and an error to place excessive traction on the SMAS in the preauricular re-
gion, and the posterior margin of the flap should be trimmed carefully to avoid
overexcision and a tight closure. Posterior traction on the SMAS will result in perioral
distortion, a “pulled” look, or other abnormal appearances.
After trimming of the posterior margin of the SMAS flap, the cut edge is approxi-
mated to the preauricular remnant with multiple interrupted sutures of 4-0 Mersi-
lene with the knots tied on the deep side. These sutures consolidate the cheek and
help support the superior suture line but should not be used to put posterior trac-
tion on the SMAS flap.
When the cheek SMAS is sutured, the facial contour should be improved and a faint
smile should be evident. Usually elevation of the lid-cheek junction and compression
of lower eyelid tissue will also be noted.
To provide additional support in the anterior neck and along the submental region,
the excess tissue along the posterior margin of the cheek SMAS flap can be left at-
tached to the cervical-submental platysma and used as a postauricular transposition
flap (see pp. 1556-1557). This flap improves neck contour by correcting horizontal
platysma redundancy and increasing submental support. Frequently this cannot be
accomplished by lateral platysmapexy (see p. 1556) alone because of the mobility of
the tissues in the upper lateral neck. Suturing the transposed segment of cheek SMAS
to the mastoid fascia while leaving it attached to the cervical platysma circumvents
this problem and improves the result. In addition, a dynamic sling is created that
tightens the submental region when the patient looks down. This tightening occurs be-
cause the mastoid moves superiorly during neck flexion and away from the anterior
neck, pulling the transposed flap and attached tissue with it.
1581
Chapter 46  Lamellar High SMAS Face and Midface Lift

When a postauricular transposition flap is used, it must be carefully designed and
its effect thoroughly tested intraoperatively. The SMAS must be incised in such a fash-
ion that the transposition flap exerts its effect on the cervical platysma below the
mandibular border, and not more superiorly on the SMAS in the cheek. Flap sus-
pension is also best delayed until after the anterior platysmaplasty is completed (see
the next section). A postauricular transposition flap, when used in conjunction with
anterior platysmaplasty, creates a mastoid-to-mastoid sling of autologous tissue. This
is a more natural and superior maneuver than any attempt to accentuate neck con-
tour by the placement of suspension sutures, alloplastic straps or bands, and simi-
lar measures.
Cervical Lipectomy
A cervical lipectomy is a technically demanding and conceptually difficult maneu-
ver that requires patience, perseverance, restraint, and artistic sensitivity. Success or
failure in neck rejuvenation will be largely determined by the surgeon’s proper or im-
proper handling of neck fat. Other maneuvers commonly performed to improve neck
contour, including platysmaplasty (a “corsetlike” tightening of the platysma), pla -
tysmapexy (Labbé sutures), placement of submental “hammock”-type suspension
sutures, and removal and repositioning of cervical skin, are far less important. Ac-
cepting this fact is an essential point of transition in most surgeons’ quest to provide
their patients with the optimal neck contour they desire.
Cervical fat is present in three distinct anatomic layers: preplatysmal, subplatysmal,
and deep cervicosubmuscular (intradigastric); understanding this distribution is the
key to attractive and successful outcomes in the neck. In almost all cases cervical
lipectomy should be limited to the two more superficially situated regions, and in a
contemporary neck lift the focus is placed predominantly on fat in the subplatysmal
layer. Lipectomy technique is not as important as the contours created, and it should
be the aim of the surgeon to produce a well-contoured and attractive neck, and not
simply one devoid of fat.
Contrary to what is traditionally practiced, preplatysmal cervicosubmental subcu-
taneous lipectomy should in most cases be performed after shifting and suturing of
the SMAS and platysma and excision of subplatysmal fat when indicated, and not
at the beginning of the procedure. If preplatysmal lipectomy is performed at the be-
ginning of the procedure, fat will be mistakenly excised from regions of the neck that
will be raised onto the face when SMAS flaps are advanced and suspended. This will
result in inadvertent creation of harsh or irregular mandibular contours.
1582
Part VIII  Face Lift and Neck Lift

Performing preplatysmal lipectomy at the beginning of the procedure also typically
results in erroneous removal of the fat necessary to a soft, youthful, healthy appear -
ance. Typically this overresection of subcutaneous fat will not be evident intraoper-
atively or for the first few months postoperatively because the error is masked by
swelling. Once the swelling has resolved, however, the cervicosubmental region will
have an unnatural, unhealthy, elderly, and overresected look.
Subcutaneous cervicosubmental fat should be thought of as the surgeon’s “artistic
clay”; it is my usual practice to leave this layer untouched in most necks until sub-
platysmal fat excision and deep-layer work have been performed (submandibular
gland reduction, partial digastric muscle myectomy), and all other maneuvers (platys -
maplasty and platysmamyotomy) have been completed. Once all other work in the
neck is complete and the optimal shape of the foundation of the face has been es-
tablished, only then is final contouring of the subcutaneous fat carefully and con-
servatively performed. Contouring preplatysmal cervicofacial fat as the last in the
sequence of steps used to improve the neck provides one important last opportunity
to optimize facial contour and finesse facial appearance that is lost if this fat is ar-
bitrarily sacrificed at an initial stage of the procedure.
1583
Chapter 46  Lamellar High SMAS Face and Midface Lift
Sequencing excision of preplatysmal fat. If preplatysmal fat is excised before the SMAS
is elevated, denuded areas that were formerly situated below the jawline will subsequently
be advanced onto the lower face. This can result in a harsh mandibular contour. To avoid
this problem, preplatysmal fat should be removed, if indicated, after the SMAS flap has
been raised. Left, Incorrect plan for preplatysmal fat excision (shaded area). Fat is excised
before the SMAS flap is raised. Right, After SMAS elevation, the denuded areas are moved
up onto the lower face, resulting in contour irregularities and depressions.

In full necks in which excessive subcutaneous fat deposits can be detected, pre-
platysmal lipectomy can be performed judiciously with a small suction cannula be-
fore needed deep-layer maneuvers are performed if care is taken to avoid injury to
the platysma muscles and to leave enough fat behind for final fat contouring later in
the procedure. This is an unusual circumstance, however; careful preoperative as-
sessment of the subcutaneous fat layer in the neck of most face-lift patients will show
that a paucity of fat is present.
In most cases cervicosubmental subcutaneous fat is removed after all other neces-
sary neck maneuvers have been performed. Fat can be removed in such circumstances
using an open suction technique with a one-holed cannula turned toward the
platysma. In thinner necks, simple excision is done with a scissors technique, or no
fat is removed. Preplatysmal lipectomy is usually easiest in the anterior and lateral
neck, where it is needed least, and is more difficult in the submental area and near
the mandibular border and chin, where it is needed most. Fat in the latter regions is
often firmly adherent to the platysma and is usually difficult to remove with a can-
nula alone. If preplatysmal lipectomy is performed with a suction cannula, fat should
be removed in a medial-to-lateral and inferior-to-superior direction, working through
both submental and postauricular incisions to prevent disruption of previously placed
sutures suspending the SMAS.
Although proper shift of the cheek SMAS often repositions ptotic jowl fat, partial
excision and contouring of this area may be necessary in some patients, particularly
those with round, full faces. It is also usually productive to examine the mandibular
contour while gently pushing inferiorly on the cheek. This simulates the effect of
gravity on the upright face and may reveal the need for additional fat excision from
this area.
Once skin and SMAS flaps have been elevated, but before the SMAS has been su-
tured and preplatysmal lipectomy is complete, the surgeon should examine the neck
intraoperatively to decide whether the subplatysmal space needs be explored.
Exploration may be indicated if a significant collection of subplatysmal fat was iden-
tified preoperatively or if large digastric muscles or submandibular glands are pres-
ent. Significant accumulations of subplatysmal fat can be demonstrated intraopera-
tively by placing gentle superior traction on the cheek flaps and flexing the neck. If the
neck appears full with this maneuver, the surgeon should consider exploring the sub-
platysmal space and removing redundant subplatysmal fat.
The subplatysmal region is explored through the submental skin incision, and the
subplatysmal space is entered by incising the superficially situated fascia between
the medial platysma muscle borders. A combination of blunt and sharp scissors tech-
1584
Part VIII  Face Lift and Neck Lift

nique is used to isolate each muscle edge. The muscle edge is then grasped and the
dissection carried laterally over the anterior belly of the anterior belly of the digastric
muscle hugging the underside of the platysma. If this dissection is carefully done, a
well-defined, relatively avascular plane can usually be identified. Small communi-
cating vessels are not infrequently encountered, especially near the medial muscle
borders; these should be carefully fulgurated and divided.
Subplatysmal fat should be left on the deep surface of the neck and not raised with
the platysma flap. This will facilitate fat removal, since it is technically difficult to re-
sect fat from the undersurface of the muscle.
The plane tangent to the anterior bellies of the digastric muscles should be used as
a landmark for the limit of subplatysmal fat removal. All fat lying superficial to this
plane should theoretically be removed to achieve an optimal contour. As a practical
matter, the overall neck contour must be considered, because it is the curvilinear
plane across the submental region tangent to the borders of the mandible and the
anterior bellies of the digastric muscles that ultimately determines an attractive neck
contour. If large submandibular glands and/or anterior bellies of the digastric mus-
cles are present but are not addressed, subplatysmal fat removal should be more con-
servative if accentuation of these problems is to be avoided. Fibrous fat in the pre-
hyoid region should not be arbitrarily removed, especially in women, to prevent
accentuation and masculinization of the larynx. If prominent submandibular glands
and digastric muscles are appropriately treated, however, subplatysmal fat can be
resected more aggressively, allowing optimal neck improvement.
Once the platysma muscles have been undermined, subplatysmal fat will be evident
as a triangular fat pad with its base lying at the hyoid and the tip near the mentum.
It should be removed incrementally, as appropriate, and as determined by the posi-
tion and size of the digastric muscles and the size of the submandibular glands. Fat
removal should not be arbitrary, and the surgeon must pay close attention to the new
contours created. Subplatysmal fat excision often results in the division of tributaries
of small pretracheal vessels, and a long, shielded cautery forceps and good suction
should be available to obtain adequate hemostasis when required.
Fat situated deep to the plane tangent to the anterior bellies of the digastric muscles
and beneath the deep cervical fascia (deep cervical or intradigastric fat) should rarely
be removed, and the overwhelming temptation to “clean out” the deep cervical space
must be resisted. Platysmaplasty and other maneuvers cannot compensate for
overzealous excision of deep fat, and in time, an objectionable submental depres-
sion will appear in the neck of a patient treated in this way.
1585
Chapter 46  Lamellar High SMAS Face and Midface Lift

Submandibular Gland Reduction
If a large submandibular gland is present, it can usually be seen and palpated lateral
to the ipsilateral belly of the anterior digastric muscle within its respective sub-
mandibular triangle, protruding inferiorly to a plane tangent to the digastric and the
mandibular border. The protruding portion can be incrementally resected through
the submental incision before the submental platysmaplasty is performed to improve
neck contour, if indicated.
Prominent submandibular glands will be encountered as subplatysmal dissection is
carried over the anterior belly of the digastric muscle. The prominent gland will ap-
pear as a smooth pink to tan mass covered by a smooth capsule. Reduction is begun
by incising the capsule overlying the gland inferomedially just lateral to the anterior
belly of the digastric muscle with Metzenbaum scissors. The submandibular gland
will be evident once exposed in this manner because of its distinctive lobulated ap-
pearance. Its inferior portion can be grasped and easily separated from adjacent tis-
sue inside its capsule with a gentle blunt scissors-spreading technique. Although all
vital structures are outside the glandular capsule, care should be taken when mobi-
lizing the gland superolaterally, because both the retromandibular vein and the mar-
ginal mandibular branch of the facial nerve are in close proximity in that area.
An examination of the gland, once separated from its capsule, will reveal it to be
large, not merely ptotic; this observation forms the basis of the recommendation that
partial resection be performed. In addition, examination of the exposed gland will
clearly demonstrate that attempts to reposition it more superiorly will ultimately be
fruitless.
The key to safe performing the procedure is adequate mobilization of the gland; mod-
est overmobilization will make both gland resection and the control of any intra -
glandular bleeding much easier. Once adequately mobilized inside its capsule, the
redundant, protruding portion of the submandibular gland is excised with an ex-
tended blade-tipped cautery and a long pair of insulated forceps. As in all surgery of
the neck and the submental region, a fiberoptic headlight or retractor is essential, as
is a competent assistant and a second scrubbed person to pass instruments and su-
tures as needed. One person cannot safely perform both these roles. A suction can-
nula or smoke-evacuating retractor should also be placed, and the position of the
cautery tip relative to vital adjacent structures must be known at all times during
the resection. If a smoke-evacuating retractor is used, a second Y-anchor suction setup
should be available in the event that bleeding is encountered during the resection.
The inferior portion of the gland is firmly grasped and pulled gently inferiorly and
medially out of its fossa, away from adjacent structures. The redundant portion is
1586
Part VIII  Face Lift and Neck Lift

subsequently incised incrementally under direct vision in a medial-to-lateral direc-
tion along the planned line of resection with coagulating current cautery. Gland ex-
cision should be performed so that the portion protruding inferior to the plane tan-
gent to the ipsilateral anterior belly of the digastric muscle and the ipsilateral
mandibular border will be resected. Usually the initial resection should be conser-
vative, and the gland is incrementally reduced thereafter, as required. It should never
be necessary and is not appropriate to remove an entire gland. This would most likely
result in a depression or other contour abnormality and could precipitate dry-mouth
symptoms.
Submandibular gland reduction must not be performed without good light, proper
instruments, suction, adequate exposure, sufficient personnel, and proper caution,
since intraglandular vessels may be encountered. These vessels are more commonly en-
countered when larger resections are necessary and are most easily managed by im-
mediate, thorough fulguration before further dissection is done. Typically bleeding
will occur from both the gland and the specimen side, and this is usually best con-
trolled by quickly moving the cautery back and forth between each end of the cut
vessel. If only the gland side is cauterized, bleeding will frequently continue from the
specimen side, obscuring the surgical field. If bleeding is brisk, the cut edge of the
gland should be compressed with forceps and the vessel isolated. It may then be
grasped with a second instrument and cautery applied. In these situations, the sur-
geon should consider placing a hemostatic suture of 3-0 chromic gut at the cauterized
site to prevent postoperative bleeding. In the unlikely event that bleeding cannot be
controlled by these means, the submandibular fossa should be packed with a gauze
sponge and digital pressure applied against the cut gland edge for several minutes.
In most cases, when the sponge is carefully removed, the bleeding will have stopped;
the bleeding point can be sought and any suspicious areas cauterized.
Once initial excision of the protruding portion of the gland is complete, the sub-
mental region is reconstructed, as indicated. It is not necessary or productive to at-
tempt to oversew the cut edge of the gland or close the glandular capsule. These
maneuvers are technically difficult and could precipitate intraglandular bleeding or
result in injury to nearby neurovascular structures. It is also not necessary or pro-
ductive to cauterize the cut edge of the gland in an attempt to shrink or seal it. This
typically results in more postoperative pain and swelling and prolonged submental
induration.
When submandibular gland reduction is performed, a drain should be placed in the
subplatysmal space and left in place for several days after the procedure. It is safest to
perform the platysmaplasty before the drain is placed and then to perforate the
platysma and thread the drain into place. If the drain is placed before the platysma -
plasty, the drain could be caught in one of the sutures, making its removal difficult.
1587
Chapter 46  Lamellar High SMAS Face and Midface Lift

Submandibular gland reduction, although important in the rejuvenation of many
necks, will not in and of itself result in attractive neck contour. Other problems must
be identified and addressed to achieve optimal results.
Submandibular reduction should be regarded as an advanced technique. It should
be undertaken by surgeons well versed in cervical anatomy and experienced in more
basic maneuvers used to rejuvenate the neck. It is highly recommended that any sur-
geon uncertain of the anatomy of the submental triangle or the exact relationships
of important structures in this area review them carefully before undertaking this
dissection.
Partial Digastric Myectomy
The surgeon will encounter a small subset of patients who have objectionably large
anterior digastric muscle bellies. Usually these are most easily identified after sub-
platysmal lipectomy and submandibular gland reduction has been performed, but
they may sometimes be evident preoperatively in patients seeking secondary surgery.
In these situations additional improvement in neck contour may be obtained by per-
forming superficial subtotal anterior digastric myectomy.
Superficial subtotal anterior digastric myectomy is performed under direct vision,
through the submental incision after the subplatysmal space has been opened, the
platysma muscle mobilized, and subplatysmal fat and protruding portions of the
submandibular gland resected, if indicated. The redundant portion of muscle is vi-
sually gauged and then simply picked up with forceps and tangentially resected with
Metzenbaum scissors. The neck is reexamined and the maneuver repeated until an
improved contour is obtained. Usually this entails the excision of 10% to 25% of
the total muscle mass. Occasionally 50% to 75% or more of each muscle will need
to be removed. Tangential muscle myotomy will typically result in variable amounts
of superficial oozing, which is easily controlled by grasping the bleeding areas and
applying cautery.
Superficial digastric myectomy, although important in the rejuvenation of many
necks, will not in and of itself result in attractive neck contour. Other problems must
be identified and addressed if optimal results are to be obtained.
Superficial digastric myectomy, although important in achieving attractive contour
in some necks, should be regarded as an advanced technique. It should be under-
taken by surgeons well versed in cervical anatomy and experienced in more basic
maneuvers used to rejuvenate the neck. It is highly recommended that any surgeon
uncertain of the anatomy of the submental region or the exact relationships of
important structures in this area review them carefully before undertaking this
dissection.
1588
Part VIII  Face Lift and Neck Lift

Anterior Platysmaplasty
Anterior platysmaplasty (see p. 1555, bottom) is performed in most patients and
provides an improved result in most necks, especially when the patient looks down
and flexes her or his neck. The purpose of platysmaplasty is to consolidate the neck.
It cannot create contour in and of itself, and it is not adequate treatment for platysma
bands in most patients. Typically platysmaplasty consists of suturing the medial mus-
cle borders together from the mentum to the thyroid cartilage in one or two layers
in conjunction with varying degrees of platysma transection (platysma myotomy)
low in the neck. If redundant muscle is present medially, it is excised and discarded
so that a smooth edge-to-edge approximation of the medial muscle borders can be
made. Experience has shown that this produces a better result and reduces the like-
lihood that objectionable midline fullness or bands will result after the tissues have
healed and relaxed than when excess muscle is invaginated and a multilayer “plica-
tion” is performed.
Platysmaplasty should be performed after checking the SMAS flap dissection and
suspension to prevent general accentuation of the effects of aging and gravity and
compromising rejuvenation of the face. Although this makes suture placement dur-
ing the platysmaplasty more difficult, it allows optimal repositioning of the cheek
and jowl. If platysmaplasty is performed first, the cheek SMAS and lower facial fat
will be pulled inferiorly and the improvements will be compromised.
Platysmaplasty is usually performed using a combination of multiple simple inter-
rupted and continuous sutures of 3-0 braided polyester sutures (or the surgeon’s su-
ture of choice) on a medium tapered needle beginning at the menton and working
inferiorly to the cricoid. Long instruments are needed and patience is required. Op-
timal improvement generally cannot be obtained if the repair is done in one layer or
if a running suture is initially used. If the first layer is performed using a running su-
ture, some gathering and a purse-string effect can occur. This will result in shorten-
ing along the line of repair and can cause bow-stringing and the formation of mid-
line bands. If the initial approximation is made with interrupted sutures, this problem
is averted.
Next, the line of repair can be oversewn and reinforced with a simple running su-
ture without a purse-string and shortening effect. The repair need only be snug, not
tight. If a permanent suture is used, each should be immersed in antibiotic solution
before placement, and care should be taken to bury all knots.
Platysmaplasty should be performed with the neck in a neutral position. If the clo-
sure is done with the neck extended, there may be excessive tightness when the patient
looks down. This is particularly true if the platysmaplasty is performed in conjunc-
tion with a postauricular transposition flap of cheek SMAS.
1589
Chapter 46  Lamellar High SMAS Face and Midface Lift

If postauricular transposition flaps are planned, suspension to the mastoid should
be performed after the anterior platysmaplasty is complete. If the transposition flaps
are suspended first, the platysma muscles can be shifted laterally, and it may be dif-
ficult or impossible to adequately join them in the midline. Suspension to the mas-
toid is performed with interrupted sutures of 4-0 Mersilene (or another suture of
choice). Usually the more proximal portions of the flap are secured with a simple
running suture of 4-0 Vicryl. This consolidates the deep-layer repair in the perilob-
ular area and prevents the flap from rolling on itself.
Transverse Platysma Myotomy
Although anterior platysmaplasty will often result in an attractive neck at rest and
on the operating table, objectionable platysma bands and muscle striations will of-
ten still be evident in conversation and during animation if additional steps are not
taken. These problems can be avoided by performing a transverse platysma myotomy
(see pp. 1553-1555). The extent of platysma transection will depend on the defor-
mities present and thus will vary from patient to patient.
Platysma myotomy should be performed after anterior platysmaplasty has been com-
pleted, when the platysma muscle is uniformly distributed over the anterior neck.
Myotomy should be performed low in the neck at the level of the cricoid cartilage. At
this level the muscle is thin and will bleed less, and the cut edges are less likely to be
visible postoperatively. In addition, a smooth transition across the cervicomental an-
gle is maintained. If transection is done higher, these benefits are lost and the larynx
will be masculinized. This is particularly true when a myotomy is performed along the
cervicomental angle or when wedges of platysma muscle are removed there.
An anterior platysma myotomy is best begun through the submental incision. The
medial platysma border is identified over the cricoid cartilage and grasped and lifted
away from the deep cervical fascia with a long DeBakey or similar type of forceps.
Myotomy is then done by nibbling through the muscle in small increments with long
Metzenbaum scissors. As the muscle is divided it usually separates a centimeter or
more, exposing the fascia beneath it. Serrated and supersharp scissors should not be
used, because they tend to pick up and cut adjacent tissue, and this can result in in-
jury to the anterior jugular vein, which usually leads to copious bleeding that can
be difficult to control. Gentle spreading with scissors tips before each cut helps sep-
arate the platysma from the underlying cervical fascia and facilitates dissection. The
myotomy is continued laterally according to the preoperative plan. If a full-width di-
vision of the platysma is planned, the lateralmost portion of the transection is com-
pleted through postauricular incisions by identifying the lateral muscle border, in-
cising it, and extending the incision to bring it into continuity with that made through
the submental incision.
1590
Part VIII  Face Lift and Neck Lift

Final Contouring of Cervicofacial Fat
Once SMAS suspension, platysmaplasty, platysma myotomy, and other modifica-
tions of deep-layer tissues have been completed, final contouring of superficial cer-
vicofacial fat can be performed. This should be done under direct vision using Met-
zenbaum scissors or a fine suction cannula. Final fat sculpting should be continued
until all contours are smooth and regular, but it is essential that not all fat be re-
moved to produce an attractive, natural appearance. Particular attention should be
paid to the jawline and jowl areas. In addition, if the patient has a double chin or
witch’s chin, extended dissection of the perimental area and chin pad should be done,
with fat contributing to these problems excised. Mental and submental fat should
then be sculpted and blended to ensure a smooth transition from the mentum to the
submental area.
Drain Placement
Drains are used routinely; experience has shown that they reduce postoperative ec-
chymosis and seromas and allow patients an earlier return to work and social ac-
tivities. However, drains will not substitute for poor hemostasis and will not prevent
hematoma formation. Drain placement should be performed before skin flap sus-
pension and incision closure. A 10 Fr round, end-perforated Jackson-Pratt style closed-
circuit suction drain is typically used in the neck. The drain is placed through a small
stab incision on the occipital scalp 1 to 2 cm superior to the apex of the occipito-
mastoid incision and anchored at its exit site with 4-0 nylon or a similar suture. The
perforated portion of the drain is then passed beneath the cervical skin across the
anterior neck to the opposite side of the face. When extensive modifications have
been made to the anterior cervical and submental regions, or when diffuse oozing is
encountered, one drain is placed one on each side. This provides overlapping drainage
of the anterior cervical area. Two drains are generally placed in most male patients as
well. As mentioned earlier, if submandibular gland resection is performed, a sepa-
rate drain is placed in the subplatysmal space.
Skin Flap Repositioning and Suspension Suture Placement
Skin flap repositioning and suspension suture placement should be performed with the
patient’s head in a neutral position, since flexion and extension of the neck will influ -
ence the amount of skin excised in the postauricular region. To avoid an unnatural
appearance, skin flaps must be shifted in a slightly more posterior, less superior di-
rection than with the SMAS. It must also be remembered the goal of skin excision
is to remove redundancy, not to tighten the skin flap. Shifting skin along an overly su-
perior vector or suspending skin flaps under tension will result in hairline displace-
ment, poor scars, and other secondary deformities and objectionable problems.
1591
Chapter 46  Lamellar High SMAS Face and Midface Lift

Cheek skin flaps should be shifted along a vector roughly perpendicular to the na-
solabial fold. When this is done sideburn elevation and displacement will be mini-
mized, and skin will lie more naturally over the tragal region once healing is com-
plete. An improved effect will also be obtained on the nasolabial area. In the neck
area, skin should be shifted along a vector parallel to the mandibular border. This
provides optimal improvement in the anterior neck and allows maximum excision
of skin flap redundancy without compromising the skin flap’s covering function. If
the postauricular skin flap is shifted along a more superiorly directed vector, im-
provement in the anterior neck will be compromised, skin will be erroneously ex-
cised over the apex of the occipitomastoid incision, and a wide scar will be present
once healing is complete.
There are two points of skin flap suspension that set the stage for the remainder of
the closure. The first point is located in the supraauricular area, where the anterior-
superiormost part of the ear joins the scalp. The cheek skin flap it is shifted along
a vector roughly perpendicular to the nasolabial fold and skin redundancy is then
gauged with a face-lift marker or similar implement. The skin flap should be held
under just greater than normal skin tension for marking, and a small T-shaped inci-
sion is made into the flap at the marked point. Making the incision in a T shape fa-
cilitates suture placement and simplifies subsequent trimming of the flap. The flap is
then anchored at this point with a half-buried vertical mattress suture of 4-0 nylon
with the knot tied on the scalp side. No deep sutures are necessary.
1592
Part VIII  Face Lift and Neck Lift
The face-lift marker. The use of a flap marker provides a reliable means for appropriate
excision of skin. The pin on the lower jaw of the marker is designed to be placed near the
edge of the incision. The skin flap is then pulled over the lower jaw of the instrument, and
when proper tension is set, the instrument is closed. Then the upper jaw of the instrument
marks the precise position of the edge of the scalp flap beneath it. This serves as a valu-
able guide to the degree of redundancy present and is particularly useful in gauging the
depth of “pilot” incisions initially made into the flap at points of initial flap suspension. The
marker is shown in use. Inset, Close-up view of the tip design.

The second point of suspension is located in the postauricular area at the anterior-
superior aspect of the occipitomastoid incision. The postauricular flap is shifted pos-
teriorly and somewhat superiorly, roughly parallel to transverse neck creases and the
mandibular border so that skin is suspended under minimal or no tension and that
little or no skin need be trimmed from the anterior (postauricular) flap border. Ex-
cessive trimming of skin from the anterior border of the postauricular skin flap will
require the flap to be shifted along an incorrect vector, and will compromise the re-
sult. The flap is then secured with a simple interrupted 4-0 nylon suture. No incision
into the flap is necessary, and no deep suture is used.
Once the two key suspension sutures have been placed, the flap overlying the infe-
rior portion of the ear should be carefully divided and the lobule exteriorized. This
is a key step in the procedure that must be performed incrementally and with great
care to avoid a visible scar, lobular malposition, and objectionable secondary de-
formities. If the incision to exteriorize the lobule is properly made, the apex of the
incision should rest snugly against the inferiormost portion of the conchal cartilage.
If the incision into the cheek flap is made too far anteriorly or inferiorly, however,
artistically appropriate resetting of the lobule will not be possible, and the outcome
of the overall procedure will be significantly compromised.
Skin Flap Trimming and Closure
Trimming of the skin flap and incision closure are conveniently begun in the postau-
ricular area after initial suspension sutures have been placed and the lobule exteri-
orized. Postauricular closure along the auriculomastoid sulcus should be completed
before trimming and closure of the occipital portion of the incision and resetting of
the lobule. It is begun by conservatively trimming the anterior border of the postau-
ricular skin flap into a soft curve to match the curve of the incision in the auriculo-
mastoid sulcus. The incision is then closed with several interrupted 4-0 nylon sutures.
No deep suture is used, and a watertight closure is not needed.
A small amount of skin only should be trimmed from the anterior margin of the
postauricular flap along the auriculomastoid sulcus. If it appears that a large amount
of skin needs to be excised from this area, the postauricular flap has been shifted in-
correctly, both too far anteriorly and superiorly. If this occurs, the previously placed
suspension sutures should be removed and the flap readvanced along a more ap-
propriate and more posteriorly directed vector.
1593
Chapter 46  Lamellar High SMAS Face and Midface Lift

It is also an error to excise any skin over (superior to) the apex of the occipitomastoid
incision and to shorten the postauricular flap along the long axis of the sternoclei-
domastoid muscle, as is commonly done. Despite an apparent redundancy in this
area when the patient is supine on the operating table, there is never any true skin
excess at this location. This pseudoexcess of skin is present only because of the pa-
tient’s high shoulder position in the supine position; it will vanish when she or he
sits up and the shoulders drop to a normal position. Skin along the axis of the ster-
nocleidomastoid muscle is also needed for side-to-side head tilt. Inappropriate exci-
sion of skin over the apex of the occipitomastoid defect is the ultimate underlying
cause of hypertrophic healing in the postauricular region and a wide postauricular
scar (see p. 1596, top).
Trimming and closure of the occipital portion of the incision should be performed
after closure of the postauricular area. If the occipital incision was made into the oc-
cipital scalp (see p. 1543), it should be closed without the excision of skin or scalp
in one layer with multiple simple interrupted 4-0 nylon sutures. This incision plan is
used to provide access to the lateral neck only and cannot by design accommodate
skin excision in this area without producing displacement and notching of the oc-
cipital hairline. Because this incision is usually beveled when properly done, staples
will not usually provide precise wound edge approximation. Sutures are generally
required to avoid malalignment and step-offs.
If the occipital incision has been made along the occipital hairline (see p. 1545), skin
only will be excised along the posterior border of the postauricular skin flap. A face-
lift marker should be used to gauge skin flap redundancy, and all points along the
flap should be intentionally trimmed with two to three millimeters of redundancy.
It must be remembered that the goal of skin excision is to remove redundancy, not
to tighten the cervical skin flap. If trimming is performed correctly, the wound edges
should abut one another and no gaps should be present before sutures are placed.
The incision is then closed in one layer with multiple half-buried vertical mattress
sutures of 4-0 nylon with the knots tied on the scalp side and simple interrupted su-
tures of 6-0 nylon (see p. 1596, bottom).
No deep sutures are required, and staples should not be used. This will provide pre-
cise wound edge alignment and prevent crosshatched scars (suture marks). In addi-
tion, if the incision is closed under no tension, as described, the scar will be an in-
conspicuous scar.
1594
Part VIII  Face Lift and Neck Lift

If the postauricular skin flap has been shifted along a proper vector and tissue dis-
tributed appropriately under no tension over the occipital area, a precise fit should
be obtained. If neck skin redundancy is large, or if the postauricular flap has been
suspended under tension, a dog-ear will often be present at the inferiormost portion
of the occipital incision. This should not be chased down the occipital hairline, be-
cause an obvious scar will result in the fine hair at the nape of the neck. A better re-
sult is obtained if the dog-ear is inset posteriorly into the occipital scalp, above the
junction of thick and fine hair, and secured with simple interrupted sutures of 4-0
nylon. This requires that a small ellipse of scalp be excised from the scalp side of the
incision but moves the end of the incision into dense hair where it is well concealed.
Skin flap redundancy should be carefully gauged using a face-lift marker while the pre-
tragal portion of the skin flap is held down into the pretragal hollow with an instru -
ment by the assistant. This ensures that enough skin will be present to fill the pre-
tragal sulcus and to provide natural and attractive preauricular contours once healing
is complete. This is also is a key step in avoiding a “retracted tragus” deformity.
Preauricular closure is performed next. Using marks made by the face-lift marker as
points of reference, the prehelical portion of the cheek skin flap is trimmed to form
a soft curve that matches the prehelical incision. If trimming is performed correctly,
wound edges that abut one another and no gaps should be present before sutures
are placed. The incision is then closed in one layer with multiple simple interrupted
sutures of 6-0 nylon or a simple running suture of 6-0 Prolene. No deep sutures are
necessary.
The prelobular (subtragal) portion of the cheek skin flap is trimmed next, guided by
marks made previously with the face-lift marker. If trimming is performed correctly,
wound edges will abut one another, and no gaps should be present before sutures
are placed. The incision is then closed in one layer with several simple interrupted
sutures of 6-0 nylon. No deep sutures are necessary.
Once the prehelical and prelobular areas have been closed, the tragal flap is trimmed.
This must be performed with great care while the assistant holds the pretragal por-
tion of the skin flap into the pretragal hollow. As elsewhere in the periauricular clo-
sure, the tragal flap should be trimmed with 2 to 3 mm of redundancy. Closure is
then made with simple interrupted 6-0 nylon sutures or a simple running suture of
6-0 Prolene. The tragal flap usually does not need to be thinned or defatted except
along its posterior margin, and no deep sutures are necessary. Trimming the tragal
skin flap too short is a serious artistic error that will result in tragal retraction and an
unnatural chopped-off tragal appearance.
1595
Chapter 46  Lamellar High SMAS Face and Midface Lift

1596
Part VIII  Face Lift and Neck Lift
Suturing incisions along hairlines. Left, Wound edges are approximated with interrupted
half-buried vertical mattress sutures of 4-0 nylon with the knots tied on the scalp side.
Right, Final approximation with simple interrupted 6-0 nylon sutures.
Incorrect trimming of the postauricular skin flap. It is an error to excise any skin over
(superior to) the apex of the occipitomastoid incision and shorten the postauricular flap
along the long axis of the sternocleidomastoid muscle. There is no true excess of skin
along this vector, nor any aesthetic benefit from shifting skin in this direction. Excision of
skin in this fashion is the underlying cause of hypertrophic healing in the postauricular area
and of a wide postauricular scar.

Insetting the Lobule
There is nothing as telltale and aesthetically objectionable as an abnormal position
of the earlobe. For this reason, the lobule should be inset into the cheek flap as the
last step in the closure of the periauricular area. Trimming the cheek flap to inset the
lobule must be performed with great care and should always be performed incre-
mentally in stages to prevent overexcision. The cheek flap should be trimmed and
the earlobe inset in such a manner that the lobule ends up situated in a natural and
aesthetic appearing posterior and somewhat superior position, even it if was in a
more anterior or inferior position before surgery. This is because the long axis of
the earlobe of an artistically ideal, nonsurgical-appearing ear sits approximately
15 degrees posterior to the long axis of the ear itself in the lateral view. As this an-
gle is reduced or shifted anteriorly, or if the lobule is mistakenly placed too far infe-
riorly, an elderly, unnatural, face-lift look is produced.
1597
Chapter 46  Lamellar High SMAS Face and Midface Lift
Proper insetting of the earlobe. In an artistically ideal, nonsurgical-appearing ear (left),
the long axis of the earlobe (dashed line) sits approximately 15 degrees posterior to the
long axis of the ear itself (solid line) in the lateral view. As this angle is reduced, or the axis
of the lobule shifted anterior to the long axis of the ear, an elderly, unnatural, face-lift look
is produced (right).
Insetting the lobule into the cheek so that its long axis sits posterior to the long axis
of the rest of the ear often requires that the lobule be released from tethering tissue.
It is then secured in two layers. The first layer consists of several deep dermal sutures
of 4-0 Monocryl. These sutures provide initial alignment and protect the incision
from disruption in the first few weeks after surgery when the patient pulls clothing,
jewelry, and other items off over the head. Final approximation is then made with a
simple running suture of 6-0 Prolene. A running polypropylene suture is usually eas-

ier to remove than a running or interrupted suture of 6-0 nylon, although either
method of suturing will suffice.
If the lobule has been inset correctly, there will often be redundant skin on the pos-
terior surface of the ear at the lobular-conchal junction. This is easily and conve-
niently managed by excising a triangle of skin corresponding to the tissue redun-
dancy in this area. Closure is done in one layer with several simple interrupted sutures
of 4-0 nylon or another suture of choice.
If foreheadplasty is to be performed as part of the procedure, closure of the tempo-
ral portion of the face-lift incision is delayed until after it is complete. This preserves
access to the upper lateral face and affords precise realignment of tissue in this area.
If the temporal portion of the face-lift incision has been made on temporal scalp (see
p. 1537), the incision is closed in one layer without excision of any hair-bearing tem-
poral tissue with multiple simple interrupted sutures of 4-0 nylon. A small amount
of cheek skin and scalp only will be excised immediately above the ear at the com-
pletion of the closure. Because a properly made incision on the temporal scalp is usu-
ally beveled, sutures, not staples, are generally required to avoid malalignment and
step-offs. It is clinically unproductive, a conceptual error, and a serious technical
mistake to excise scalp over the temple region in attempt to improve the forehead
or upper lateral face.
If the temporal portion of the face-lift incision has been made along the temporal
hairline (see p. 1538), skin only will be trimmed when it is closed. A face-lift marker
should be used to gauge temporal skin excess and the flap intentionally trimmed with
2 to 3 mm of redundancy. If trimming is performed correctly, wound edges should
abut one another and no gaps should be present before sutures are placed. The in-
cision is then closed in one layer with a combination of half-buried vertical mattress
sutures of 4-0 nylon, with the knots on the scalp side, and simple interrupted 6-0
nylon sutures (see p. 1596). Staples should not be used. This scheme will provide pre-
cise wound edge alignment and will prevent crosshatched scars (suture marks).
Once all other incisions have been sutured and all concomitantly performed proce-
dures have been completed, the submental incision is closed. Closure of the sub-
mental incision is usually delayed in this manner so that a final check for hemostasis
can be made. If closure is done earlier in the sequence of the procedure, subsequent
oozing in the neck can require that the incision be reopened to control it. The inci-
sion is closed in two layers to ensure precise approximation of subcutaneous fat and
skin. If a more casual closure is done, irregularities may result that will draw atten-
tion to the scar. The first layer of closure is accomplished using several deep dermal
sutures of 4-0 Monocryl. Final approximation is made with a simple running suture
of 6-0 Prolene.
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Chapter 46  Lamellar High SMAS Face and Midface Lift
Instrument Tray for a Face Lift
Number
Instrumentation
Scalpels
2
Scalpel handle (round) (Padgett P-650)
Skin Hooks
2
Double-pronged skin hook (10 mm) (P-5379)
Needle Holders
4
Needle holder long (7) (narrow carbide jaw, gold handled)
(V. Mueller CH2492)
4
Needle holder medium (carbide jaw, gold handled)
(Padgett P-2410)
3
Needle holder large (carbide jaw, gold handled) (Jarit 121-135)
4
Needle holder, Webster (smooth jaws) (Storz N5712)
Scissors
1
Tenotomy scissors (V. Mueller OP 5675) (forehead)
1
Kaye scissors (carbide jaw-gold handled) (P29065)
1
Metzenbaum scissors (med) (Padgett P-6468)
1
Suture scissors (small “baby Metz”)
1
Utility scissors (large straight Mayo) (Pilling LL3)
Forceps
1
Adson (carbide with fine w teeth) (P 2511)
1
Adson (carbide with medium w teeth)
1
DeBakey (8 fine-toothed jaws) (Codman 37-1011)
1
Coagulating forceps (black insulation) (SP 0531)
5
Allis forceps (Storz N-5600)
12
Mosquito hemostat (Storz)
2
Curved Kelly hemostat (for peanut sponges)
4
Straight Kelly hemostat
2
Snitz forceps (long)
1
Right-angle forceps (long)
Retractors
1
Malleable (small) (Padgett 4206)
1
Malleable (large) (Padgett P-4341)
1
Army (Codman 50-4071)
1
Freeman (Padgett P-491)
1
Freeman rake (four pronged) (Padgett P-509)
1
“Wound protector” (modified Des Marres retractor)
1
Ragnell retractor (double ended)
Miscellaneous
4
Towel clip (small)
4
Towel clip (large)
1
Obwegeser periosteal elevator (Padgett 7710)
1
Metal ruler
1
Metal comb
1
Marten flap marker
1
Yankauer suction (metal) (N7550)
1
Frazer suction and stylet (2 pieces)
2
Hair clip
1
Ring/sponge forceps
2
Zimmer blue plastic clip
1
Headlight joystick
1
Instrument retainer
1
Needle tip cautery
1
Cautery, long tip
1
Cautery, short tip

Completion of Concurrently Planned Procedures
When the face, neck, and forehead lifts are completed, attention is turned to upper
blepharoplasty, lower blepharoplasty, perioral dermabrasion, and other planned pro-
cedures, as indicated.
Dressings
After all planned procedures have been completed and all incisions closed, the pa-
tient’s hair is shampooed and rinsed with warm tap water that has been allowed to
stand for a few minutes with a few drops of povidone-iodine added. The sutured in-
cisions are given a final inspection. If poor alignment is found in any area, it is lo-
cally reprepared and sutures are removed and replaced, as required.
Once the patient’s hair has been shampooed and rinsed, conditioner is applied and
the hair is carefully detangled with a wide-toothed comb. Failure to adequately wash,
condition, and detangle the patient’s hair after completion of the procedure can re-
sult in matting and tangling that can be problematic in the postoperative period.
No dressings are required or applied. Dressings traditionally applied over the face
and neck after face-lift surgery create a tourniquet effect and accentuate swelling in
the face, regardless of how carefully they are applied. These dressings were needed
for two reasons. First, traditional face-lifts were usually closed over large Penrose-
type drains that were typically left protruding from a loosely closed postauricular
incision. A large, bulky, helmet type of dressing of mineral oil–soaked cotton secured
with a shell of rolled gauze was required to catch blood and serous fluid and prevent
it from soiling the patient’s clothing, belongings, and carpets. Second, a pressure
dressing was needed to hold undermined facial flaps against the underlying face and
to close down subcutaneous dead space. The use of closed suction drains has sim-
plified the management of these problems and eliminated the need for a dressing.
Every surgeon seeking the best result and the fewest complications should give care-
ful consideration to the need for a traditional face-lift dressing and its possible draw-
backs. Although those who use a face-lift dressing claim it prevents seromas and
hematomas and provides increased patient comfort, experience, simple logic, and
common sense all indicate otherwise. There are many compelling arguments against
the use of a face-lift dressing—perhaps the most compelling of which is the very real
danger of compromising circulation in delicate, widely undermined cervicofacial
skin flaps. Dressings also limit the ability to directly observe the face and neck and
may conceal an evolving or established problem. In addition, little about a face-lift
dressing is comfortable. Most are tight and confining; they obstruct hearing, com-
plicate facial hygiene, and needlessly attract unwanted attention. In my experience,
patients, when given the choice, almost always prefer to do without them. If the sur-
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Chapter 46  Lamellar High SMAS Face and Midface Lift
geon chooses to use a dressing, there should be a good reason for doing so, and it
should be confirmed that it does the patient no harm.
Patients are typically discharged with a hat, scarf, and sunglasses. If dermabrasion
or lip augmentation has been performed, a rigid disposable surgical mask that rests
off of the perioral area is also usually applied.
Postoperative Care
Performing the procedure itself fulfills only part of our obligation to the patient, and
the care they receive postoperatively is arguably as important as the surgery itself.
Diligent postoperative care will also ensure the best result and limit the likelihood
that problems and complications will occur.
All patients are discharged to an aftercare specialist with specific written instructions
as to how they are to care for the patient. I am always available to answer questions
and see any patient, if needed. Patients are asked to rest quietly and apply iced com-
presses to their eyes for 15 to 20 minutes of every hour they are awake for the first
3 days after surgery, even if they have not had eyelid surgery as part of the proce-
dure. For most patients, edema peaks at about this time. It is not necessary or pro-
ductive to apply ice compresses continually throughout the day or at night. It has
not proved necessary, and it is generally not well tolerated by the patient, to apply
iced compresses to the cheeks, neck, or forehead. If the patient has had lip augmen-
tation, ice compresses are applied to the perioral area in a similar manner and on a
similar schedule. Recently we have found that a commercially available water-cooled
face mask simplifies and improves the experience for many patients. Unlike tradi-
tional wet compresses, these masks apply continuous dry cooling that is well toler-
ated even when sleeping.
All patients are provided oral analgesics, sleep medications, antiemetic supposito-
ries, bland ophthalmic ointment, and preservative-free artificial tears solution with
specific instructions for their use. Patients are required to use ophthalmic ointment
each night for the first 3 weeks after surgery or until all signs of eye irritation have
abated. Artificial tears are used throughout the day, as needed. Patients are also in-
formed that eyedrops are not sufficient for night use.
All patients are instructed to sleep flat on their backs without a pillow. A small cylin-
drical neck roll is permitted if the patient requests it and/or requires it. This posture
ensures an open cervicomental angle and averts dangerous folding of the neck skin
flap and obstruction of regional lymphatic vessels that inevitably occurs if the pa-
tient is allowed to elevate the head on pillows, as is commonly recommended. In ad-

dition, swelling will drain to the back of the head instead of the neck in this posi-
tion, where it is not harmful and is less noticeable and more rapidly transmitted away
from the head and neck area when the patient sits upright.
All patients are shown an elbows-on-knees position that ensures an open cervico-
mental angle while sitting. This posture places the patient’s book, magazine, paper-
work, notebook computer, or meal in a position that allows reading, writing, eat-
ing, and TV watching in comfort and safety, with the patient’s chin up and the neck
extended. Other sitting postures typically result in unavoidable neck flexion and re-
lated problems.
All patients should be examined the morning after surgery, if possible. This visit, al-
though sometimes inconvenient, is important to identify incipient problems in an
early, treatable stage. All sutures should be checked and any appearing too tight
should be cut but left in place. Releasing potentially overtight sutures prevents necro-
sis and alopecia. Leaving the cut suture in place, rather than removing it, averts the
annoying bleeding from the suture site that inevitably occurs if the suture is com-
pletely removed at that time. All flaps should be carefully inspected. Whenever in-
cipient compromise is noted, one must be suspicious that a tight closure has resulted
in excessive tension over that area. If compromise is suspected, the offending sutures
should be removed, even if wound separation may result. Secondary healing of the
incision is always superior and easier to revise than is a large area of more anteri-
orly situated full-thickness skin slough.
Patients are allowed to take a soft diet as tolerated after surgery but are encouraged
to avoid salty, sour, dry, and difficult to chew foods. Patients are asked to abstain
from drinking alcoholic beverages for 2 weeks after surgery and until they are no
longer taking pain pills (acetaminophen included) or sleep medications.
Patients begin a daily routine of showering and shampooing no later than 3 days af-
ter their procedures. This helps remove crusting about the suture lines, keeps inci-
sions clean and bacteria counts down, and usually improves the patient’s general
overall sense of well-being. It also facilitates suture removal. Patients are instructed
that they need not be as thorough as usual when washing their hair after their pro-
cedure and that they need not attempt to remove all dried blood and crusts. They are
also assured that shower water, shampoo, and conditioners are not harmful and will
not cause infection. Showering and shampooing are permitted even when drains are
still in place.
Forehead drains are generally removed the morning after surgery by the aftercare
nurse or when the physician checks the patient. At lease one drain is usually left in
the neck until the first suture removal visit however. This is because drain output of-
ten quickly falls on the second or third day during the time the patient is mostly
supine and resting but then picks up again when the patient begins to spend more
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Part VIII  Face Lift and Neck Lift

time upright and starts to move her or his head about more. Leaving the neck drain
in for 4 to 5 days will reduce the likelihood that small collections will form and will
speed the overall resolution of edema and ecchymosis in the neck area.
Sutures are removed in two visits over 7 days. Fine sutures are removed on the first
visit 4 to 5 days after surgery. Half-buried vertical mattress sutures and scalp sutures
are removed on the second visit 7 days after surgery. It is usually not productive to
try to remove sutures hidden under dried blood or crusts along suture lines; these
are usually removed at a third visit approximately 2 weeks after surgery, at which
time crusts are gone and sutures are readily identified.
Patients should be warned that their scalp and parts of their face may be partially
numb after surgery and that they must be careful when bathing that shower water
is not too hot and that hairdryers are not used on high heat settings. Patients are also
instructed not to get a permanent or tint, dye, highlight, color, or otherwise chemi-
cally treat their hair for 2 weeks after surgery, because these treatments can result in
hair breakage or hair loss. Hot rollers and curling irons must be used with care for
several months, because the patient can unknowingly burn her forehead and scalp.
Determining when patients can return to work and their social lives depends on their
tolerance for surgery, their capacity for healing, the type of work they do, the activ-
ities they enjoy, and how they feel overall about their appearance. Patients are asked
to set aside 2 to 3 weeks to recover from surgery. Additional time off is recommended
before an important business presentation, family gathering, vacation, or other im-
portant event. If the patient is doing well and not experiencing problems, she or he
is allowed to return to light office work and casual social activity 9 to 10 days after
surgery. It is often wise to begin with a limited workday at first and to adjust their
schedules thereafter. If a patient’s job entails more strenuous activity or physical la-
bor, a longer period of convalescence may be required. Patients are advised not to
drive for the first 10 days after surgery until they are feeling well, their vision is clear,
and they have stopped taking pain medications.
Patients are advised to avoid all strenuous activity during the first few weeks after
surgery, including heavy lifting, stooping, straining, and bending forward, and are
informed that aerobic activities and exercise can result in internal bleeding and
hematoma formation. Two weeks after surgery, patients are allowed to begin light
exercise and gradually work up to their presurgical level of activity; 4 to 6 weeks af-
ter surgery, they are allowed to engage in more vigorous activities, including most
sports, as tolerated.
Patients are informed that it may take 2 to 3 months for them to look good in a pho-
tograph or to be seen at an important function. They are also advised to expect some
numbness and firmness in the face and submental areas for 6 to 9 months or more.
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Chapter 46  Lamellar High SMAS Face and Midface Lift

Results
Face Lift: Obtaining a Soft, Natural Appearance
Whenever prospective patients and the lay public discuss face-lift surgery, they will
inevitably express the most concern and dismay over the tight faces of various celebri-
ties and their friends and acquaintances that have undergone the procedure. Many
will unhesitatingly demonstrate what they see to be the problem by pulling force-
fully on their cheeks, eyes, and eyebrows, asking either not to look that way after
their surgery, or stating they will never undergo surgery for fear of ending up with
a similar appearance. This is reinforced by the numerous jokes and references in the
popular press to “masks,” “wind tunnels,” and “faces so tight they will crack” if the
individual smiles. Despite these expressed concerns and the frequent popular ridicule
of the typical outcome of skin-only face lifts, procedures based predominantly on
skin tightening continue to be performed.
The fundamental problem with the traditional skin-only face lift performed by many
surgeons is that skin is meant to serve as a covering function, not a structural, sup-
porting one. Most of the changes seen in the aging face are the result of an attenua-
tion of support and subsequent descent of deep layer facial tissues however, and not
sagging of skin. Any attempt to lift significant sagging of deep facial tissue with skin
will be short lived and destined to produce an overly tight appearance and other tell-
tale and objectionable problems.
The following patient example shows that when modern two-layer SMAS face-lift
techniques are used and tension is diverted to deeper layers of the face, a soft, natural
appearance with few telltale signs that surgery has been performed can be obtained.
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Part VIII  Face Lift and Neck Lift

This 42-year-old woman had a suboptimal eyebrow position and configuration, cheek
and jawline laxity, and hollowness in the cheeks and undereye area. Even when smil-
ing, she had a somewhat sad and melancholic appearance. She had had no prior plas-
tic surgery. The same patient is shown 13 months after a face lift, neck lift, a limited-
incision forehead lift, conservative upper and lower blepharoplasties, correction of
ptosis, fat injections, and an upper lip lift. A small nevus on her neck was also re-
moved. No skin resurfacing, facial implants, or other ancillary procedures were per-
formed. She now has soft, natural facial contours, with no tight, pulled, or face-lifted
appearance. Her improved eyebrow position gives her a more youthful, feminine,
alert appearance. The cheeks and jawline have been lifted and redundant skin re-
moved. Hollowness in the upper cheek and undereye area has been filled by lifting
sagging cheek tissue to a youthful position and by fat injections. She also had her
teeth whitened and straightened after the surgery was performed.
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Chapter 46  Lamellar High SMAS Face and Midface Lift

After surgery, improved eyebrow position and restoration of cheek fullness are evi-
dent, as well as an improved transition from the lower lid to the cheek, elevation of
the corners of the mouth, a smooth jawline, and improved neck contour. The lip lift
has shortened the distance from the bottom of her nose to the upper lip border and
improved the appearance of her mouth. The patient’s face has a lighter, fresher, more
alluring appearance.
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Part VIII  Face Lift and Neck Lift

In the preoperative lateral view, eyebrow ptosis, lower lid fullness, a tear trough, sag-
ging cheek and jowl, a “drool line,” and neck laxity can be seen. The patient ap-
peared tired and unfit, even though she was trim and in excellent overall health. Post-
operatively, her results are as described above. No scars are visible, there is no
distortion of the ear, and the earlobe is in normal position. In the down-tilted view,
her neck laxity and poor neckline could be seen preoperatively, presenting an el derly,
unfit appearance. Postoperatively, she now appears young, fit, and attractive.
1607
Chapter 46  Lamellar High SMAS Face and Midface Lift

Face Lift for Ethnic Patients
Hispanic patients, like Asian and black patients, often have elastic skin that stands
up comparatively well to the sun and as a result, typically ages well. Because these
patients often develop skin wrinkles comparatively late in life, they are thought by
many surgeons performing traditional skin-only face lifts to benefit minimally from
such procedures. In addition, people of ethnic ancestry with darker complexions are
also thought to form poor scars and are typically deemed to be poor candidates for
surgery on this basis.
A careful examination of the next patient’s face before surgery shows that although
minimal skin wrinkling and redundancy are present, there has been a loss of youth-
ful facial contour. This loss of shape and contour results from sagging tissues under
the skin; the improvement shown in the postoperative photo demonstrates the ef-
fectiveness of repositioning it by tightening the underlying SMAS layer. It is also ev-
ident that when tension is diverted away from the skin to deeper structural layers of
the face, healing will be excellent and scarring minimal. This patient demonstrates
the importance of addressing deep-layer aging, the effectiveness of the SMAS pro-
cedure, and that patients with good skin and minimal wrinkling can still benefit sig-
nificantly from a properly performed procedure. In addition, if tension is diverted
off the skin and transferred to deeper layers, healing of incisions will generally be
excellent and inconspicuous scars will result.
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Part VIII  Face Lift and Neck Lift

This 55-year-old Hispanic woman had sagging cheeks, heavy jowls, lower eyelid full-
ness, deep nasolabial lines, and thin lips. The patient has a somewhat stern and dis-
approving appearance. She has had no prior plastic surgery. The same patient is
shown 18 months after a face lift, neck lift, limited-incision forehead lift, upper and
lower blepharoplasties, chin augmentation, and fat transfer to the lips and cheeks.
No skin resurfacing or other ancillary procedures were performed. Postoperatively,
smooth facial contours and a more youthful facial shape are evident, with an ab-
sence of a pulled or a face-lifted appearance. There is a smooth transition between
the lower eyelid and cheek, and her lips and cheeks are fuller as a result of the fat
injections.
In the preoperative scowling view, it can be seen that the patient had strong corru-
gator muscles that produced deep creases and an intense, angry appearance. The pa-
tient is seen after surgery trying to frown; she is no longer able to do so because of
muscle modification performed as part of the forehead lift procedure.
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Chapter 46  Lamellar High SMAS Face and Midface Lift

In the oblique view her sagging cheeks and jowl and the hollow undereye areas are
evident. Postoperatively cheek fullness has been restored, the transition from the
lower eyelid to cheek is improved, the corners of her mouth have been elevated, and
she has a smooth jawline and an improved neck contour. The lateral and down-tilted
views show that her lower eye bag, tear trough, sagging cheek and jowl, thin lips,
drool line, poor neckline, and weak chin have been restored to a more attractive and
youthful appearance. The chin implant has produced a natural-looking profile that
is in better balance with the rest of her face. No scars are visible, there is no distortion
of the ear, and the earlobe is in normal position.
1610
Part VIII  Face Lift and Neck Lift

Face Lifts: Then and Now
Although skin tightening has been a traditional part of face-lift surgery since the in-
ception of such procedures, the assumption that it is logical and productive has come
under question in recent years. The reasons for this are numerous and are becoming
increasingly hard for less-experienced surgeons, and patients themselves, to ignore.
Contrary to past assumptions, facial aging is in reality predominantly a process of loss
of contour, rather than one of loosening and wrinkling of the skin. The skin, in large
part, merely descends with the sagging tissue beneath it and sags to a lesser degree on
its own. Skin is intended to serve a covering function, not a structural or supporting
one. It is inherently elastic and evolved to accommodate tissue shifting and dis-
placement associated with facial movement and expression. As such, skin cannot rea-
sonably be expected to provide sustained support for sagging deeper facial tissues.
It is now recognized by many surgeons performing procedures to rejuvenate the face
that skin tightening flattens facial contour rather than restoring it. Pulling on the skin
flattens the contours that make the face appear youthful and distinctive, much in the
way that stretching a rubber sheet or nylon stocking over it would. Skin tightness
looks unnatural; not even infants and children have tight skin. Instead, they have an
appropriate amount of skin to cover their youthfully contoured faces.
If skin is used as a vehicle for repositioning sagging deeper facial tissue, secondary
deformities including poor scars and earlobe malposition will occur. In addition, us-
ing skin to reposition sagging tissue requires it to shift unnaturally in an upward di-
rection. This can result in hairline and sideburn elevation, objectionable shifting of
neck wrinkles onto the face, and other unnatural appearances.
When the face is lifted using the deeper SMAS layer instead of skin, skin can be re-
draped under normal tension and in a more natural direction. When treated in such
a manner, skin appears to be capable of undergoing some degree of self-repair and
contraction, and this adds further to the improvement obtained. This concept forms
the basis of the lamellar (two-layer) and bidirectional (two-directional) maneuvers
used in modern face-lift techniques.
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Chapter 46  Lamellar High SMAS Face and Midface Lift

This 65-year-old woman had a high forehead, asymmetrical eyebrows, cheek and
jawline laxity, neck bands, deflated lips, and hollowness in the undereye area. De-
spite a bright smile, she had a somewhat tired and melancholic appearance. She had
previously undergone upper and lower blepharoplasties by another surgeon. She is
shown 13 months after a face lift, neck lift, forehead lift, upper and lower blepharo-
plasties, perioral dermabrasion, and fat transfer to the cheeks and lips. No skin resur-
facing, facial implants, or other ancillary procedures were performed. Note her soft,
natural, facial contours and the absence of a tight, pulled, face-lifted appearance.
Eyebrow asymmetry has been improved. The cheeks and jawline have been lifted and
redundant skin removed.
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Part VIII  Face Lift and Neck Lift

The patient had a large submandibular salivary gland, seen as fullness in the upper
neck area. Postoperatively the salivary gland has been reduced in size to obtain op-
timal neck contour. In the down-tilted view her neck laxity and poor neckline gave her
an elderly, unfit appearance. After surgery, her well-defined jawline and create a more
attractive, fit appearance.
1613
Chapter 46  Lamellar High SMAS Face and Midface Lift

The Concealed-Incision Face Lift
Considerable focus has recently been placed on shortening face-lift incisions as less-
experienced surgeons have begun performing procedures to rejuvenate the face. More
often than not, these short scars end up being wide, irregular, poorly positioned, or
otherwise visible, and the procedure is of questionable benefit to the patient. The real
goal in incision planning is to design incisions that provide the surgeon adequate ac-
cess to the deep layers of the face that are simultaneously well concealed and do not
result in hairline displacement. In properly performed face lifts, patients should be
free to wear their hair any way they wish afterward, and they should not need to
wear large earrings and heavy makeup to conceal the fact that they have had sur-
gery. It is evident that many surgeons are still struggling with concealing face-lift
scars when one notices that the area in front of the ear is typically hidden by hair or
large earrings or is cropped out of the picture in postoperative photos of face-lift pa-
tients shown in informational brochures, books, magazine articles, and websites.
The irony of misguided attempts to conceal face-lift incisions by shortening them is
that a well-trained surgeon employing proper technique can obtain inconspicuous
scars using a long-incision plan. The issue is not how long the scar is—it is whether
the scar can be seen and will be noticed by others, and this is the philosophy that
underlies the concealed-incision face-lift technique.
A fundamental principle of the concealed-incision face lift is that inconspicuous heal-
ing cannot occur if there is skin tension; that tension must be diverted to deeper struc-
tural layers of the face, such as the SMAS and platysma. This cannot be achieved if
the incision plan is too short, even if barbed suspension sutures are placed. It is
equally important that incisions be placed along natural anatomic interfaces where
the eye expects to see a natural line or a transition of skin color and texture. Scars
placed in these locations appear to be part of the patient’s natural anatomy or mimic
naturally reflected highlights.
Finally, the eye will not be looking for scars if the outcome of the face lift is soft and
natural appearing and there are no other telltale signs that surgery has been per-
formed. In many cases a patient’s friends and coworkers have refused to believe the
patient has had a face lift, even if she or he admits it, if the patient’s face is not tight
and a concealed-incision plan is used.
The following patient is a case in point. It is evident that a marked improvement in
the patient’s appearance has been obtained, but there are no telltale signs indicating
that surgery was performed. Her face has a soft, natural appearance, scars are con-
cealed, and no hairline displacement or other irregularities are present.
1614
Part VIII  Face Lift and Neck Lift

This 48-year-old woman had a heavy jowl, overall facial laxity, and deflation in her
cheek and undereye areas. She had had no previous plastic surgery. The same patient
is shown 2 years and 11 months after a face lift, neck lift, limited-incision forehead lift,
upper and lower blepharoplasties, fat transfer, and a shave excision of an unwanted
nevus on her right upper lip. No skin resurfacing, facial implants, or other ancillary
procedures were performed. Note the soft, natural facial contours and the absence
of a tight, pulled, or face-lifted appearance. The cheeks and jawline have been lifted
and redundant skin removed. Deflation in the upper cheek and undereye areas has
been corrected with fat transfer. An existing scar on the left anterior neck has been
released and fat grafted.
1615
Chapter 46  Lamellar High SMAS Face and Midface Lift

After surgery the patient’s neck and jawline have been lifted and redundant skin re-
moved. Note also that no distortion of the ear is present and the earlobe is in nor-
mal position. The patient appears fit, decisive, and more attractive.
1616
Part VIII  Face Lift and Neck Lift

1617
Chapter 46  Lamellar High SMAS Face and Midface Lift
Continued
Concluding Thoughts
The traditional “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 areas. Low designs target the lower cheek and jowl only and produce
little if any improvement in the upper anterior cheek region. Planning the flap
“higher,” along the zygomatic arch, and extending the dissection medially to mobi-
lize midface tissue overcomes this problem and results in a simultaneous lift of the
face and midface together. A separate midface lift procedure is not required, and more
comprehensive and natural-appearing improvement is obtained.
Clinical Caveats
 It is not possible to design a universal face-lift technique. Each patient will have a
unique set of problems that require precise anatomic diagnosis and an appropri-
ately planned and individualized surgical repair.
 Attractive, natural-appearing rejuvenation of the face is not possible without di-
verting tension away from the skin to the SMAS and platysma and unless other
deep-layer structures and the aging midface are addressed.
 Skin was meant to serve a covering function, not a structural or supporting one.
Using skin as the vehicle to support sagging deep-layer tissue corrupts its function
and results in abnormal tension and related secondary problems, including poor
scars, tragal retraction, earlobe malposition, and a tight, unnatural appearance.
 Using the SMAS to lift sagging facial tissues and restore facial contour circumvents
the problems associated with skin-only face lifts, because it is an inelastic struc-
tural layer capable of providing meaningful and sustained support. Although skin
must be excised in SMAS procedures, only redundant tissue is sacrificed, and clo-
sure can be done under normal skin tension.
 Careful evaluation of most patients who need a midface lift will show that they
also need a face lift. It is rare to encounter a patient with significant midface ag-
ing who does not also have sagging in the cheek and jowl, and a midface lift is ar-
guably more logically performed in conjunction with a formal face lift than as an
isolated, stand-alone procedure.
 A drawback of the conventional low cheek SMAS flap elevated below the zygo-
matic arch is that it does not by design have an effect on tissues of the midface,
perioral, and infraorbital regions. Planning the flap higher, along the superior bor-
der of the zygomatic arch, overcomes this problem and produces an improved
result.

Clinical Caveats—cont’d
 Lamellar dissections in which the skin and SMAS are dissected as two separate
layers offer the advantage that skin and SMAS can be advanced different amounts,
along separate vectors, and suspended under differential tension. This allows each
layer to be addressed individually as indicated and in turn results in a more com-
prehensive and natural-appearing improvement.
 Rarely does isolated aging occur in the lower face and neck, and nearly all patients
requesting face-lift surgery are also candidates for forehead and eyelid surgery. Pa-
tients do not always recognize this fact, however, and must be carefully counseled
in this regard.
 Proper analysis, careful planning, and the use of an incision along the hairline,
when indicated, can avert hairline notching and displacement without compro-
mising the overall outcome of the procedure. This is particularly true of patients
with marked skin redundancy and those undergoing secondary procedures.
 Anterior platysmaplasty helps consolidate the neck but is not adequate or effec-
tive for the treatment of platysma bands. Effective treatment of platysma bands
requires that a platysma myotomy be performed.
 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 ac-
cumulation, submandibular salivary gland ptosis, and digastric muscle hypertro-
phy will contribute significantly to their neck deformity and necessitate additional
treatment.
 Although subcutaneous undermining is usually necessary in most necks, it should
not arbitrarily include the entire face. If a SMAS dissection is planned, preserva-
tion of the anterior platysma-cutaneous ligaments will allow attractive and youth-
ful appearing elevation of perioral tissue that cannot be obtained with a skin-only
technique, or when wide skin undermining is performed.
 SMAS flaps should be advanced along a posterior-superior vector parallel to the
long axis of the zygomaticus major muscle. If a vertical or posterior vector is used,
the function of the zygomaticus major muscle will be corrupted and abnormal ap-
pearances during animation may result.
 Inappropriate excision of skin over the apex of the occipitomastoid defect is the
underlying cause of hypertrophic healing in the postauricular region and ultimately
of a wide postauricular scar. Although an apparent excess of skin will be present
in this area when the patient is supine on the operating table, this skin is neces-
sary once the patient’s shoulders drop in the upright position, and for side-to-side
head tilt.
1618
Part VIII  Face Lift and Neck Lift

 Rejuvenation of the face is a considerable undertaking, and its difficulty should
not be underestimated. The procedure must be carefully planned, meticulously car-
ried out, and the patient’s safety and well-being unfailingly ensured.
 Performing the procedure itself fulfills only part of our obligation to the patient,
and the care they receive perioperatively is arguably as important as the surgery
itself. Diligent perioperative care will ensure the best result and reduce the likeli-
hood that problems and complications will occur.
1619
Chapter 46  Lamellar High SMAS Face and Midface Lift
Annotated Bibliography
Connell BF, Marten TJ. Orbicularis oculi myoplasty: surgical treatment of the crow’s feet de-
formity. In Flowers R, ed. Operative Techniques in Plastic Surgery. Philadelphia: WB
Saunders, 1995.
A technique is described for surgical treatment of smile creases during a face-lift proce-
dure.
Marten TJ, ed. Facelift: State of the Art. Seminars in Plastic Surgery. New York: Thieme, 2002.
This book is a comprehensive collection of chapters on modern face-lift techniques. Au-
thors include Bruce Connell, Daniel Baker, John Owsley, Harvey Heinricks, Garth
Fisher, Timothy Marten, Sam Hamra, Steve Hoefflin, and Lawrence Robbins. Recom-
mended reading for all plastic surgeons interested in surgery to rejuvenate the face.
Marten TJ. Forehead aesthetics and preoperative assessment of the foreheadplasty patient.
In Knize D, ed. The Forehead and Temporal Fossa: Anatomy and Technique. Philadel-
phia: Lippincott Williams & Wilkins, 2001.
Textbook chapter on forehead aesthetics, evaluation of the patient requesting forehead
rejuvenation, and aesthetic goals in forehead surgery.
Marten TJ. Hairline lowering during foreheadplasty. Plast Reconstr Surg 103:224-236, 1999.
Scientific article on technique for lowering the hairline during a forehead lift procedure.
Marten TJ. Maintenance facelift: early facelift for younger patients. In Marten TJ, ed. Facelift:
State of the Art. Seminars in Plastic Surgery. New York: Thieme, 2002.
In-depth examination of controversies associated with management of the younger pa-
tient requesting facial rejuvenation, the advantages and disadvantages of commonly ad-
vocated techniques, and the author’s personal approach.
Marten TJ. Open foreheadplasty. In Knize D, ed. The Forehead and Temporal Fossa: Anatomy
and Technique. Philadelphia: Lippincott Williams & Wilkins, 2001.
Comprehensive textbook chapter on open forehead lift technique, including coronal and
hairline-lowering techniques.

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