The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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VIII Surgical Rejuvenation of the Face and Neck
third of the face (cervicomental angle, jowls, and marionette
grooves)
• 7KH H[WHQGHG 0$C6 OLIW ;0$C6, in which a supplementary
third purse-string suture was placed to suspend the malar fat
pad; this suture had an added impact on the nasolabial groove,
midface, and lower eyelid
1owadays, we strongly believe that MACS lift, combined with
midfacial fat grafting to replace the third purse-string suture by
augmentation of the deflated areas with fat graft, gives better
results regarding the harmonious full-face rejuvenation aspect.
46.3 MACS Lift
:ith the MACS lift approach, the incision begins at the lower
limit of the earlobe, extends preauricularly to the temporal hair-
line, and traces the temporal hairline along the sideburn up to the
level of the lateral canthus. The skin is undermined at a subcuta-
neous level over 5 to 6 cm in an anterior direction. The inferior
limit of undermining goes as caudal as necessary to visualize the
lateral border of the platysma muscle. Usually the undermining is
marked 2 to 3 cm below the mandibular angle (Fig. 46.3).
The first purse-string suture is anchored to the deep temporal
muscle fascia 1 cm in front of the helical rim and 1 cm above the
zygomatic arch. It runs downward toward the mandibular angle,
as care is taken to incorporate 2 to 3 firm bites in the craniolateral
border of the platysma muscle, and then it turns upward as a
narrow U-shaped loop toward the original anchor point. The suture
is firmly woven into the SMAS tissue, which is not undermined.
:hen this purse-string suture is tightened, the lateral portion of
the platysma is pulled upward. This suture, when combined with
a closed-suction lipectomy, produces a dramatic correction of the
cervicomental angle and contour of the upper neck.
The second purse-string suture starts at the same anchor point
on the deep temporal muscle fascia, extends more obliquely toward
the jowls (“ 30ƒ from the first suture), and follows the borders of
the undermining as a more open, O-shaped, purse-string loop. It
ends at the original anchor point. :hen this suture is tightened,
the SMAS is placed under concentric tension, producing a lifting
to the jowl, the marionette groove, and the oral commissure.
Fig. 46.2 Different ways of skin excision (a) in a classical facelift and
(b) in a minimal-access cranial suspension (MACS) lift.
Fig. 46.3 (a) Incision on simple minimal-access cranial suspension
(S-MACS) lift. (b) The different areas where the two purse strings have
effect during the surgical procedure.

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
575
The short-scar MACS lift will adequately treat 90 of our
patient population. :hen the limits of the MACS lift procedure
are reached, ancillary procedures will supplement this procedure.
Care is taken not to overtreat any patient.
46.3.1 Indications and Contraindications
The ideal patient for a surgeon’s initial MACS lift case is a 45- to
50-year-old woman whose main complaint is a moderate submen-
tal laxity with a blunted cervicomental angle but without obvious
platysmal bands. -owls, marionette grooves, and nasolabial folds
are developing but disturb the patient mainly when she bends
forward. This is a frequent complaint in middle-aged women who
discover these signs of aging in the lower third of the face. This
type of patient is ideally suited for treatment with MACS lift.
Nevertheless, patients in the sixth decade or older are also
benefiting from the safety and the low complication rate of the
MACS lift technique. In this category, additional measures can be
indicated to enhance the effect on platysmal bands or important
skin excess. The vertical vector warrants the preservation of a
natural appearance.
The mild jowling and central anterior neck laxity shown by the
patient in Fig. 46.4 make her an ideal candidate for correction by
a MACS lift.
Combination of a MACS lift with fat grafting is particularly
appropriate for a patient who needs correction of the upper half
of the nasolabial folds and the midface or other areas that appear
deflated. The need for the adjunctive fat grafting is determined not
only by age but also by the bony anatomy of the face (Fig. 46.5).
A person with a poorly developed malar eminence will be subject
to earlier midfacial aging than one with strong malar relief. This is
also often related to poor lower lid support.
In classic teaching, smoking is considered an absolute contrain-
dication for facelift surgery. Because of the limited subcutaneous
dissection and the absence of multiplanar dissection in a MACS
lift, we consider smoking to be a relative contraindication. For
the same reason, combining the MACS lift with skin resurfacing
techniques is safe and well tolerated.
As a general rule, only patients with no major medical history of
disease or cardiovascular risk factors are selected for outpatient,
office-based surgery. The decision whether to perform the MACS
lift with local or with general anesthesia depends on the surgeon’s
and patient’s preferences.
46.3.2 Pertinent Anatomy
Two permanent purse-string sutures (three in the former
extended MACS lift) are woven into the deep subcutaneous
tissues, which consist of parotid fascia and SMAS in the preau-
ricular and cheek area (Fig. 46.6). The sutures are anchored into
the deep temporalis muscle fascia to ensure a strong hold.
The main danger zone in the placement of sutures is located
on the zygomatic arch, halfway between the ear and the lateral
orbital rim. This zone is completely avoided, because no suture
crosses the zygomatic arch (Fig. 46.7). The anchor point of the
two sutures is located posterior to the frontal branch of the facial
nerve. The first loop is directed vertically downward and reaches
the lateral edge of the platysma muscle in the region of the man-
dibular angle. The marginal mandibular branch of the facial nerve
is out of danger for entrapment by the purse-string suture, since
it runs more anteriorly.
The second purse-string suture loop runs at an angle of 25 to
30ƒ and reaches to 1 fo 2 cm above the mandibular border.
46.3.3 Preoperative Assessment and
Planning
Communication with the Patient
Generally, it is very important to listen carefully to the patient’s
wishes in the first clinical consultation. :e start by inquiring
what bothers the patient and what has prompted this visit.
Fig. 46.4 Preoperative pictures of an ideal candidate for minimal-access cranial suspension (MACS) lift.

576
VIII Surgical Rejuvenation of the Face and Neck
:hen asked what they are seeking, most patients consulting
for facial rejuvenation demonstrate a maneuver that they have
repeatedly executed before their mirrors: they push the skin of
the mandibular angle upward. This maneuver has a beneficial
effect on the neck and on the jowling (Fig. 46.8). A MACS lift
acts primarily on the lower half of the face, the upper neck and
submental areas, jowls, marionette grooves, and lower cheeks.
It is important to explain the concept of MACS lift intervention
to the patient. To do this, it is helpful to simulate the feasible
correction on the facial features with the patient looking in the
mirror and the physician standing behind. This will give the
patient an idea of the possibilities and limitations of the tech-
nique. The patient will learn that the MACS lift is a lifting pro-
cedure that addresses the neck and lower two-thirds of the face,
without having an influence on the forehead. The patient will also
understand that the main goals are to restore the facial volume;
to get rid of most of the facial laxity; and, in combination with
fat grafting, to restore the correct, balanced proportion involving
facial deflation phenomenon.
Fig. 46.6 Representation of the direction and the anchorage in the
deep subcutaneous tissue.
Fig. 46.5 Benefits of combination of minimal-access cranial suspen-
sion (MACS) lift with malar fat grafting. (a) For a younger patient, it will
correct the malar insufficiency and flattening of the lateral cheek. (b)
In an older patient, it will also correct the nasolabial folds and midfacial
hollowing.
a
b
Fig. 46.7 Representation of the major danger zone for the frontal
branch of the facial nerve.
Fig. 46.8 Upward pushing maneuver that patients usually show when
they try to explain the desired result in the lower half of the face.

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
577
In some cases, ancillary procedures to the eyelids and peri-
oral and neck areas can be proposed, but the patients must be
informed of the cumulative morbidity to be expected. Once the
surgeon understands the patient’s expectations, a treatment plan
can be designed and customized to meet patient goals.
All patients are fully informed of the details of the proposed
procedure, including the benefits, limitations, risks, time of
surgery, expected morbidity and recovery, and potential for prob-
lems and complications. This informed consent is provided both
verbally and in written documents given to the patient.
Photography
A standardized series of six pictures of the patient is taken:
frontal (Fig. 46.9), lateral (Fig. 46.10), oblique (Fig. 46.11), lateral
with neck flexed (Fig. 46.12), and closeups of the lower and upper
halves of the face (Fig. 46.13).
46.3.4 Operative Technique
Preoperative Markings
On the day of surgery, any makeup is removed by the nurse, and
a new set of pictures is taken as previously described. The patient
sits upright in front of the surgeon for the initial markings.
Submental liposuction is planned for almost every patient. Fat
tends to accumulate in this area, so even in slim patients, lipo-
suction in this region helps enhance the cervicomental angle.
The patient is asked to make a double chin, and the area where
excess fat is palpated is marked with a pencil. Care is taken to
include the lateral ´wingsµ of the submental fat, which go as far as
the infralobular area, and the lower pole of the jowls.
Anesthesia and Surgical Setting
:e prefer to perform the MACS lift with the patient under gen-
eral anesthesia. This procedure can also be performed using a
local anesthetic with sedation.
The MACS lift is designed to be performed in a private surgical
office by one surgeon and one nurse.
Markings and Incisions
:ith the patient supine on the operating table, marking starts
at the lower limit of the lobule, extending up in the preauricular
crease. At the level of the incisura intertragica, the marking
makes a 90ƒ turn backward to preserve the integrity of this ana-
tomic landmark. Markings then follow the posterior edge of the
tragus, ascending toward the helical root. Because there is a dis-
tinct color difference between the cheek skin and the auricular
skin, it is essential that the markings precisely follow this line of
Fig. 46.9 The frontal view shows the face from the top of the head
down to the sternal notch. (Reproduced with permission from Tonnard
PL, Verpaele AM, Bensimon RH. Centrofacial Rejuvenation. New York,
N<: Thieme Medical Publishers, 2018.)
Fig. 46.10 Perfect perpendicular lateral view should show only one
eyebrow, with the patient gazing straight forward.

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VIII Surgical Rejuvenation of the Face and Neck
demarcation. At the superior limit of the ear, the marking traces
the small hairless recess between the sideburn and the auricle
and then turns downward to follow the inferior implantation of
the sideburn (Fig. 46.14).
The horizontal marking then continues forward in a zigzag
pattern 2 mm within the lower and anterior implantation of the
sideburn. This zigzag pattern increases the length of the temporal
incision for better congruence with the length of the cheek flap
(Fig. 46.15). The total length of the incision will not exceed 7 to 9
cm, depending on the dimensions of the auricle (vertical branch
of the incision) and the width of the sideburn (horizontal branch
of the incision).
The surgeon palpates the mandibular angle with an index
finger and marks it as the lowest point of the undermining. The
extent of the undermining is marked starting from the lowest
point of the incision at the lobule, directed toward the marking of
the mandibular angle, then curving anteriorly to a point 5 to 6 cm
in front of the ear. 1ext, the marking is directed toward the upper
end of the incision (Fig. 46.16).
:hen adjunctive procedures are planned (such as an upper/
lower blepharoplasty, fat grafting, short-scar temporal lifting,
or anterior/posterior cervicoplasty), they are marked together
with the MACS lift markings. (For detailed descriptions, see the
individual adjunctive procedures later in this chapter.)
The subcutaneous plane is infiltrated with the preferred
solution of local anesthetic. 1ormally 30 to 40 mL of solution is
Fig. 46.11 The oblique view has the tip of the nose just within the
contour of the opposite cheek to demonstrate the distribution of the
facial volumes.
Fig. 46.12 An extra side view picture is taken with the patient looking
down at the knees, producing a double chin. We refer to this as the
“Bruce Connell view,” because he has pointed out its importance.
Fig. 46.13 (a) A close-up view of the lower face is taken to focus on the
contour of the jaw line, marionette grooves, and nasolabial folds and to
demonstrate any perioral rhytids (the “bar code”). (b) A close-up view
of the upper half of the face reveals detailed information about the
upper and lower eyelids; tear troughs; and periorbital fold, grooves,
and wrinkles.
a
b

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
579
injected per cheek and in the submental area, which gives a mod-
erate degree of tumescence. At the end of the cheek infiltration,
a distinct blanching is visible in the previously infiltrated areas.
Suction Lipectomy
:e prefer to use a 3-mm spatula cannula with one opening. The
opening is always directed downward, not toward the skin, to
avoid dermal damage. Two or three incisions are used to criss-
cross the marked area optimally. The lipectomy is performed in
a preplatysmal plane under tactile guidance of the nondominant
hand. The endpoint is a skin flap of 3 to 4 mm thickness, not less,
to preserve the softness of the cervical contours.
Incision
The incision starts at the lobule and continues along the previ-
ously described markings. The surgeon carefully respects the
incisura intertragica by making a distinct 90ƒ step at the begin-
ning of the tragus.
The tragal incision is made exactly on the edge of the tragus. An
incision placed too anterior to the tragus will leave a visible color
difference between the pale tragus skin and the slightly darker
cheek skin.
At the sideburn, the blade is inclined to an angle of 30ƒ to
the skin so that the incision goes obliquely through the dermis,
perpendicular to the hair shafts. The incision follows the marked
zigzag pattern 2 mm within the hairline (Fig. 46.17).
An oblique incision within the hairline will allow hair to grow
through the scar. After hair regrowth, the final scar will be hidden
a few millimeters within the hairline and become virtually invis-
ible (Fig. 46.18).
Fig. 46.14 Marking for minimal-access cranial suspension (MACS) lift
surgical project. Note the zigzag marking on the temporal area.
Fig. 46.15 =igzag pattern within lower anterior border of sideburn.
Fig. 46.16 Marking of the dissection of the deep subcutaneous tissue
on the skin.
Fig. 46.17 (a,b) Incision of the markings previously done; note the
inclination of the blade.
a
b

580
VIII Surgical Rejuvenation of the Face and Neck
Flap Creation
Blind undermining of the skin is performed with Freeman–.aye
facelift scissors, and the dissection proceeds in a subcutaneous
plane (Fig. 46.19). The scissors points are directed toward the
skin to ensure that the surgeon has visual and palpable control
over the thickness of the cheek flap. Most of the dissection is
accomplished by spreading maneuvers with the scissors. Care is
taken to create a flap sufficiently thick to mask small irregulari-
ties of the underlying layer.
After the flap is created, hemostasis is achieved by direct coag-
ulation with microneedle cautery under direct illumination by a
lighted retractor or a headlight.
First Purse-String Suture: The Vertical Loop
The initial purse-string suture will be fixed to the deep tem-
poralis fascia at a point 1 cm above the zygomatic arch and 1
cm in front of the helical rim. (The zygomatic arch is marked in
Fig. 46.20 for demonstration purposes.) An extra dose of local
anesthetic is injected at the anchor point (note the dot) down to
the temporal bone; then the needle is withdrawn, and all layers
of tissues are infiltrated.
:ith the Stevens scissors in the spreading mode, a 0.5-cm-
diameter window is made in the SMAS/parotid fascia to visualize
the deep temporal muscle fascia (Fig. 46.21). It should be iden-
tified as a distinct, white, shiny layer. A 0 polydioxanone suture
(PDS) on a big C3 needle is used to perform the suspension of the
sagging facial and neck soft tissues.
The first bite starts in the window where we visualize the deep
temporal fascia and goes down to the temporal bone (Fig. 46.22).
The needle is oriented toward the tragus, so there is no danger of
damaging any facial nerve branch. The frontal branch of the facial
nerve runs deep in this region and becomes superficial several
centimeters more anteriorly. Firm bites approximately 1 to 1.5
cm long and 0.5 cm deep are taken in the SMAS tissue/parotid
fascia in the upper two-thirds and platysma in the lower third.
:ith every bite, it is essential to confirm that the needle enters
Fig. 46.18 Illustrative representation of the angle of the incision along the hairline.
Fig. 46.20 Markings of the zygomatic arch. Note the dot that indicates
the exact anchor point of deep temporalis fascia.
Fig. 46.19 Undermining from the short-scar preauricular incision.

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
581
a substantial part of the SMAS tissue so that the suture will not
pull through.
The suturing goes down toward the region of the mandibular
angle to the lower limit of the undermining. In this region, direct
visualization by means of a headlight or a lighted retractor is help-
ful. It is essential to identify the cranial border of the platysma and
to place two or three firm bites in this structure before inverting
the direction of the suture.
:hen the cranial platysma is included in the flap, the suturing
is turned upward and continued toward the starting point.
This procedure creates a narrow U-shaped purse-string loop
about 1 cm wide and results in a vertical suspension of the
platysma and a restoration of the cervicomental angle. After the
first purse-string suture is tied, some obvious skin dimples might
occur at the mandibular angle. Most of these will disappear with
the vertical redraping of the skin, but some will have to be freed
with scissors (Fig. 46.23).
Second Purse-String Suture: The Oblique Loop
The second suture originates from the same location on the deep
temporal fascia. This purse-string suture forms a wider loop,
directed toward the jowls, at an angle of “ 30ƒ with the vertical.
This loop is more O-shaped than the U-shaped vertical loop
in order to prevent linear traction on the subcutaneous tissue,
which could be visible through the skin.
The loop follows the borders of the anterior undermining in the
lower part of the cheek. Short bites of 1 cm maximum are taken
in the parotid fascia and the SMAS tissue (Fig. 46.24). The second
loop is also tied under maximal tension. It results in a concentric
lifting of the jowls, the lower cheek, and the oral commissures.
Sometimes bulging is unavoidable after pulling the two purse-
string sutures. To correct this issue, we mold the deep subcuta-
neous tissue with resorbable 4–0 Vicryl sutures, and we remove
with scissors the caudal excess part (Fig. 46.25).
Skin Redraping and Resection
One of the most important features in the short-scar facelift is
the vertical redraping of the skin. This provides a ´lockµ to the
subcutaneous sculpturing work in the cheek. Because the vector
of the subcutaneous lifting is almost purely vertical, the redrap-
ing and resection of the skin in the same direction will seal the
underlying suspension effect. Vertical redraping also prevents
Fig. 46.21 Opening with Stevens scissors to the deep plane where the
suture is to be anchored.
Fig. 46.22 Demonstration of first bites in the deep temporal muscle
fascia.
Fig. 46.23 (a) Representation of the marked first purse-string suture.
(b) Limits of the dissection in the mandibular area (on the right).
a
b

582
VIII Surgical Rejuvenation of the Face and Neck
formation of dog-ears at the lobule region. The earlobe is pulled
upward by the suspension sutures and will have to be set back in
the cheek flap, taking the place of any dog-ears.
:hen vertical redraping of the skin is performed, the need for
retroauricular skin redraping will be avoided or limited to the few
cases with extreme neck skin laxity.
The skin flap is put under moderate vertical tension, and the skin
excess is determined with the help of the Pitanguy or D’Assumpcao
forceps (Fig. 46.26). The skin marking is incised with the knife,
and the excess is excised with the scissors. The skin resection on
the cheek flap is carried out in linear fashion and will be sutured
to the zigzag border of the temporal hairline incision. The zigzag
incision will now open up when coapting with the linear cheek
flap, thereby compensating for the incongruence in length of both
borders and reducing possible dog-ears. Closure with interrupted
4–0 Vicryl buried sutures is started from the superior end of the
incision backward to avoid dog-ears in this section.
The lateral part of the cheek flap is trimmed only minimally just
to coapt with the preauricular incision (Fig. 46.27). Absolutely no
traction is exerted on this part of the incision. The skin is incised
with the knife, and the flap is resected with the scissors. The
earlobe is pulled upward by the action of the suspension sutures
and the redraping of the skin in the vertical direction. To put the
earlobe back into its natural position, a small segment of skin has
to be excised anterior to the earlobe. It is preferable to underre-
sect rather than to overresect in this area to avoid postoperative
position changes of the earlobe. The earlobe should be angled 15ƒ
posteriorly for a natural appearance.
The horizontal limb of the incision is sutured with a running
5–0 nylon horizontal mattress suture, taking bigger bites on the
cheek flap side than on the temporal side to compensate for the
final incongruence in length between the two sides (Fig. 46.28).
A 10-gauge soft silicone drain is inserted for active drainage
and directed toward the frontoparietal area covered by hair (Fig.
46.29). In earlier years, we exteriorized it in the retroauricular
area. The disadvantage of that was that at the time of the drain
removal, the cheek flap could be degloved, as happened a few
times. For this reason, we now prefer to exteriorize the drain in the
temporal area and place the drain completely vertical. :hen the
drain is removed, the cheek flap stays attached and the chances
of hematoma are reduced. The rest of the suturing is done with
running and separated 6–0 nylon sutures.
Fig. 46.24 Second purse-string suture in a surgical view.
Fig. 46.25 (a,b) Shaping and correction of the bulge after pulling the
two purse-string sutures.
a
b
Fig. 46.26 Marking and excision of the skin in the temporal region.

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
583
46.3.5 Case Study
The 46-year-old woman shown in Fig. 46.30a presented with
combined deflated and ptotic facial features. There was a dis-
crete ptosis of the eyebrow tail, with significant hollowing of the
upper eyelid. The lower eyelid was empty, without significant
laxity. The midface was deflated and ptotic, resulting in a heavy
nasolabial fold (Fig. 46.31a,c,e,h). The corners of the mouth
continued into an incipient marionette groove. The definition of
the jawline was disturbed by marked jowling. She also requested
a reduction rhinoplasty.
Analysis of her photograph in her late 20s (Fig. 46.30b) revealed
a general oval shape of her face. The youthful fullness of the upper
eyelids and midface was striking compared with the empty look
in her 40s. 1ote the absence of nasojugal and nasolabial folds and
marionette grooves in her earlier photo.
Surgical Plan
• MACS lift
• Short-scar temporal lift
• Microfat grafting of the medial upper eyelid hollow (1.5 mL),
the malar and infraorbital area (10 mL), the nasolabial fold
with subcision (3 mL), and the marionette groove (2.5 mL); in
total, 34 mL of fat grafted
• Pinch lower blepharoplasty
• Open rhinoplasty
Results
The results after 1 year (Fig. 46.31b,d,f,h) show a replenishment
of her eyelids and midface, with a general triangularization of
her face as a result of the cranial shift of soft tissue volumes. The
nasolabial folds, marionette grooves, and jowls are corrected.
Note the resemblance to her youthful picture.
46.3.6 Postoperative Care
The patient is instructed to take the following medications:
• Oral ampicillin 500 mg every 6 hours, beginning the morning
of surgery and continuing for 4 days
• Continue any home medication
The patient is instructed to respect the following guidelines:
• Stay in the company of a friend or relative for the first 24 hours
• Relax in a quiet environment
• Avoid stressful activities
• Avoid bending forward and Valsalva maneuvers
• Sleep with the head slightly elevated
• A soft diet is recommended, since mouth opening is painful
the first 5 days because of traction on the temporalis muscles
The patient is also informed about normal postoperative dis-
comfort, swelling, and ecchymosis, especially in the eyelids. The
Fig. 46.27 Removal of the skin excess in the preauricular region.
Fig. 46.29 Insertion of 10-gauge soft silicone drain placed in frontopa-
rietal region.
Fig. 46.28 Horizontal mattress suture on the limb of temporal region
where the skin was resected.

584
VIII Surgical Rejuvenation of the Face and Neck
patient is instructed to contact the surgeon if any of the following
conditions develop:
• Rapidly increasing swelling and/or pain in the cheek area,
which could indicate a postoperative hematoma
• Pain or increasing discomfort in the resurfaced area
• A temperature greater than 38ƒC (100.4ƒF)
• Any visual impairment
46.3.7 Problems and Complications
As any surgery, facelift involves specific potential complications.
Usually, the most frequent complication is hematoma, which
usually does not cause permanent damage but is disturbing
for both the patient and the surgeon because it requires
reintervention.
The occurrence of paralysis of a facial nerve branch depends
on the technique. Avoiding dissection in proximity of facial nerve
branches makes the procedure less likely to cause nerve damage.
Skin slough as consequence of skin ischemia can have several
causes: the extent of skin undermining, the thickness of the skin
flap, the amount of traction on the skin, external or internal pres-
sure, and heavy smoker.
Bad scarring is not always controllable by the surgeon. Scarring
problems can involve hypertrophy, hypotrophy, or dystrophy, but
most of the time they are a result of poor design of the placement
of the incision or an incorrect insetting of the earlobe.
Fig. 46.30 (a) Woman aged 46 presenting facial aging due to sagging
and deflation. (b) The same patient in her 20s.
Fig. 46.31 (a,c,e,g) Preoperative and (b,d,f,h) 1-year postoperative picture series of 46-year-old woman who underwent minimal-access cranial
suspension (MACS) lift, temporal lift, open rhinoplasty, and other ancillary procedures as described in the text.

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
585
Infection is not so common but can lead to terrible conse-
quences, such as hypertrophic scars and alopecia.
As far as our experience is concerned, we have not encountered
major complication such as skin slough, permanent facial palsy, or
unacceptable scarring.
Our incidence of hematoma was 1.1, mostly in patients under
anticoagulant therapies. Among our early cases with the former
extended MACS lift, we experienced a case of temporary paralysis
of the frontal branch of the facial nerve, from which the patient
promptly recovered after 6 weeks.
Other minor problems, such as palpability of the knot, were
encountered in few cases.
46.4 Ancillary Procedures
46.4.1 Anterior Neck
Preoperatively, the surgeon assesses the patient’s facial and cer-
vical redundancy by digitally lifting the facial skin upward at the
mandibular angle region. If this maneuver produces correction
of visible platysma bands, one can be confident that the MACS
lift will adequately tackle this problem. If platysma muscle is
not easily visualized with the standard dissection, it is possible
to dissect the flap under the mandibular angle further and grab
more distal bites proceeding ventrally. The shape of the loop will
resemble a hockey stick. Usually this little modification of the
technique is very useful to improve mild platysmal banding.
If the platysmal bands are not corrected with this preoperative
maneuver, an anterior cervicoplasty is added at the end of the
MACS lift procedure. Because suturing together platysmal bands
on the midline counteracts the lifting effect on the cheeks, the
neck work is delayed until the facelift procedure is completed. At
the end of a MACS lift procedure, the lateral parts of the platysma
are so tightly pulled upward by the vertical purse-string sutures
that it is virtually impossible to bring the medial borders of the
platysma together to the midline. Therefore, we perform open
resection of the medial bands of the platysma at the end of the
procedure. A resection of about 1 cm of medial muscle border is
carried out, with or without a horizontal relaxation incision at the
level of the hyoid. Conservative open resection of subplatysmal fat
is done when indicated.
46.4.2 Posterior Neck
The limits of MACS lifting depend on the amount of skin excess
in the neck as well as on the quality of the skin. Problems can
arise when dealing with thin, sun-damaged neck skin with a
significant number of wrinkles down to the clavicular region. In
these cases, after vertical skin redraping, vertical skin folds will
begin to appear in the infralobular neck region. These folds are
aesthetically unacceptable and need to be corrected at the end
of the procedure with a posterior cervicoplasty. This maneuver
consists of tension-free redraping of the skin in an occipital
direction from a prehairline posterior neck incision. A 5-cm
incision is designed in a zigzag pattern at the occipital hairline.
The area of skin undermining is designed to reach 1 cm beyond
the anterior most infralobular skin fold. The skin flap is created
by blind scissors dissection in a superficial subcutaneous level.
The skin is redraped in an occipital direction, and the skin
excess is resected. The skin is approximated with buried 4–0
Vicryl sutures and finished with a running 4–0 nylon horizontal
mattress suture.
In a case with important subplatysmal fat accumulation, an
open anterior neckplasty can be performed. This includes a sub-
platysmal fat resection under direct vision, followed when needed
by an approximation of the preplatysmal edges. In cases with
important platysmal banding or neck laxity, a neck lift according
to Dr. Mario Pelle Ceravolo is added to the MACS lift procedure.
46.4.3 Forehead
Indications for brow lifting are very surgeon-dependent. Some
surgeons believe that everyone needs one; others³and we fall
into this category³are more conservative in their approach and
do not routinely elevate every patient’s eyebrows.
Many procedures are available for forehead correction, ranging
from open foreheadplasty to endoscopic brow lift or limited-
incision temporal lifting techniques. :ith the introduction of
botulinum toxin A into our practice, our indications for surgical
brow lifting have diminished impressively. Almost every patient
is offered botulinum toxin treatment before or after surgery.
It completes the treatment, optimizes the result, and leads to
improved patient satisfaction. Furthermore, temporal lift usually
can address the problem in the lateral part of the brows.
46.4.4 Short-Scar Temporal Lift
:hen we analyze patients’ photographs in their 20s and 30s,
the vast majority of photos show full upper eyelids, with only a
minimal show of the eyelid above the cilia. The medial part of the
eyebrow usually is relatively low, and the lateral third is at the
same level or even higher than the medial third.
:ith aging, the tail of the eyebrow descends to a variable
degree, depending on the underlying anatomy of the frontalis
muscle. The part of the population that has a frontalis muscle
insertion extending to the tail of the eyebrow will have less
descent of this part of the eyebrow and often will respond very
well to a chemodenervation with botulinum toxin of the temporal
portion of the orbicularis oculi muscle.
However, most people do not have good support of the lateral
third of the eyebrow and develop a degree of temporal hooding
with time. It is this deformity that we aim to correct with the
short-scar temporal lift. Additionally, when a vertical facelift of
any kind is performed, the problem of temporal hooding is aggra-
vated by a gathering of skin in the paracanthal region. If too much
skin redundancy appears in the paracanthal area when simulating
the vertical lift, the patient is counseled about the necessity of a
temporal lift.
To address these problems, a modified Fogli’s temporal lift by
fasciapexy is performed. The principle of this operation is basi-
cally the same as for a subcutaneous forehead lift, limited to the
lateral third of the forehead, in which the galea is used as a vehicle
to suspend the ptotic temporal tissue and provide a tension-free
skin closure in the temporal hair-bearing skin.

586
VIII Surgical Rejuvenation of the Face and Neck
Technique
The subcutaneous part of the temporal undermining is per-
formed from the MACS lift incision in continuity with the subcu-
taneous cheek skin undermining. It stops at a level at least 2 cm
above the tail of the eyebrow.
The temporal lift is done after the loop sutures are placed, but
before the final redraping and resection of the cheek and lower
eyelid skin, to reduce dog-ear formation in the temporal and
paracanthal region.
Markings
:hen a temporal lift is planned in combination with a MACS lift,
the markings are adapted so that the subcutaneous dissection of
the cheek is extended over the temporal region to a level at least
2 cm above the tail of the eyebrow. The skin incision is marked
horizontally in the temporal hair-bearing skin (Fig. 46.32).
From here a subgaleal undermining is performed downward to
a level about 2 cm above the tail of the eyebrow (Fig. 46.33).
Here the galea is transected with the tip of the scissors from
deep to superficial, to fall into the previously undermined subcu-
taneous tissue. This maneuver protects against possible damage to
the frontal branch of the facial nerve, which runs the undersurface
of the temporoparietal fascia, about 2 cm cranial to the tail of the
eyebrow.
Two U-shaped Vicryl 2–0 sutures are placed between the cra-
nial edge of the transected galea and the galea at the site of the
skin incision.
Tying these knots will produce a bulging of skin, which will
disappear after 6 to 8 weeks when the Vicryl sutures lose their
strength. After the knots are firmly tied, a few millimeters of skin
are resected to minimize skin bulges, and the incision is closed
with 3–0 running nylon suture.
For the medial part of the forehead, botulinum toxin therapy
is recommended, because it is an effective way of treating gla-
bellar and frontal grooves without the need for further surgical
procedures.
46.4.5 Microfat Grafting
Deflation through loss of subcutaneous fat is a recognized caus-
ative factor in facial aging. Guided by early patient photographs
(age 20–30), we decide which areas need volumetric restoration
by additional fat grafting. Experience has taught us that almost
every patient loses volume in the nasojugal and nasolabial folds
and marionette grooves. About 50 of these individuals will
benefit from adding volume to the malar area and the medial
upper eyelid.
Technique
Fat grafting is performed before the MACS lift. This minimizes
the cold ischemia time of the prepared fat grafts. At this stage,
there is also no distortion of the face by edema resulting from
the surgery.
The fat is usually harvested by the assistant at the time of
infiltration of local anesthetic to the face. The abdomen is the pre-
ferred donor site because of its ease of access. A multiholed grater
cannula (Tulip Medical, San Diego, CA) with 1-mm sharp holes is
used for fat harvesting (Fig. 46.34). The fat parcels harvested this
way are small enough to be placed with a 0.9-mm or even 0.7-mm
grafting cannula.
The fat is then strained through a sterile nylon cloth and rinsed
with normal saline solution. Then the fat is collected in 10-mL
syringes for final transfer to 1-mL Luer lock syringes.
Fig. 46.32 Planning and marking of temporal lift with a minimal-ac-
cess cranial suspension (MACS) lift: the upper line within the temporal
area is the skin incision. The lower line marks the galea transection.
Fig. 46.33 Subgaleal undermining during surgery and a visual
representation of the correct plane of dissection toward deep adipose
tissue.
Fig. 46.34 (a) Multiholed cannula used for harvesting the fat. (b)
Rinsing technique.

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
587
The fat is injected using 0.9- to 0.7-mm-diameter blunt cannu-
las with one small hole on the side. No incision is needed to insert
the cannula. A puncture with an 18-gauge needle works well. The
puncture hole need not be closed.
46.4.6 Augmentation Blepharoplasty
The concept of augmentation blepharoplasty is based on the
hypothesis that periorbital aging is essentially a deflation phe-
nomenon. This has led to a paradigm shift from resection toward
filling in periorbital rejuvenation (Fig. 46.35; Fig. 46.36).
46.4.7 Sharp-Needle Intradermal Fat
Grafting
:rinkles can be treated by filling subdermal or intradermal
planes. Filling in the subdermal plane is used to treat folds or
deep wrinkles that result from underlying volume depletion.
Conversely, fine wrinkles are treated with intradermal injections
because they result from changes in the skin itself.
The quest to find the ideal dermal filler is ongoing. In 2008 we
started using fine-particle microfat for intradermal injection into
facial rhytids with the intent of achieving a permanent correction
without the perils of a synthetic permanent filler. This sharp-
needle intradermal fat injection method was published under
the acronym S1IF.
Indications and Contraindications
:hether the targeted wrinkle is treatable with S1IF depends
on the skin thickness, mobility, and quality. Dynamic wrinkles
in the glabella will primarily need chemodenervation by botu-
linum toxin. Residual rhytids can later be additionally treated
with S1IF.
Atrophic craquelp of the skin of the lower eyelids is usually not
a good indication for a filler nor for S1IF. Deep folds such as the
nasolabial folds and marionette grooves are more amenable to
blunt-cannula microfat grafting with or without subcision.
Thus the gross indications for S1IF are quite similar to those for
superficial resorbable synthetic filler treatment. S1IF is typically a
technique for correcting superficial dermal damage or deformities
such as rhytids, acne scars, and atrophic scars, but not for deep
volume correction.
The amount of microfat required for intradermal fat injections
is very small (ranging from 0.1 to 0.5 mL according to the length of
the rhytid). If intradermal fat transfer is performed without deep
lipofilling, harvesting the fat is not time consuming (2.5–25 mL of
lipoaspirate is sufficient in most cases).
However, S1IF is usually applied as a supplementary and final
act after blunt-cannula microfat grafting of the deep folds (such
as nasolabial folds) or in conjunction with any surgical facial
rejuvenation procedure. In some cases, intradermal fat injection is
combined with laser resurfacing or croton oil peeling during the
same procedure.
Contraindications for S1IF are atrophic skin conditions (such
as result from steroid use and diabetes), bleeding disorders and
anticoagulant use, and smoking.
Fat Harvesting Technique
In the S1IF procedure the material injected is actually microfat,
harvested and prepared in the same manner as for deep volu-
metric blunt-cannula microfat grafting.
Injection Technique
Injection must be performed in a superficial dermal plane. The
skin rhytid is pinched parallel between the thumb and index
finger. Linear thread injection of the fat is performed as the
needle is withdrawn.
Blanching of the skin over the injected wrinkle is the endpoint
of injection. A slight overcorrection is advised, because blanch-
ing and overcorrection will normalize within a few hours after
resorption of the interstitial fluid. In thinner skin such as the neck,
the overcorrection may remain visible for more than a week but
always subsides eventually.
Deep wrinkles, sharp folds, or acne scars may require a subci-
sion maneuver for separating the skin from its deep attachments
to achieve an optimal result. Subcision is performed with an
18-gauge needle.
Results
As in any microfat grafting procedure, after S1IF a variable
resorption of the injected fat occurs, which stabilizes after 4
Fig. 46.35 Markings of microfat grafting of the infrabrow area and
malar in green.
Fig. 46.36 Marking and guideline for volume distribution of malar
augmentation.

588
VIII Surgical Rejuvenation of the Face and Neck
months. The degree of resorption varies from patient to patient
and is also correlated with the mobility of the treated area.
Perioral wrinkles usually show a higher resorption rate than a
glabella that has been immobilized with botulinum toxin.
The result seen after 4 months can be considered as consolidated.
The simplicity of the surgery and the easy recovery convinces
most patients of the possibilities of the procedure, and the thresh-
old for them to come back for treatment of any new rhytids is low.
Case Study: SNIF in Anterior Neck Rhytids
The 44-year-old woman in Fig. 46.37 presented for neck rejuve-
nation. She was treated solely with 6.5 mL of S1IF into the hor-
izontal rhytids and 18 mL of nanofat in the whole anterior neck
region. 1o surgical lifting was performed. The ridges of the S1IF
injections and the edematous aspect of the whole anterior neck
skin are common and disappear within the following weeks. At 6
months follow-up, she has a marked reduction of the horizontal
rhytids and an improvement of the general neck skin quality.
Problems and Complications
Very few, minimal problems (redness, swelling, and bruising)
have been encountered with S1IF; bruising is most common.
1o surface irregularities such as lumpiness or unevenness were
observed in this series. 1o hypertrophy of the fat graft resulted
from weight gain. Although one patient lost a significant amount
of body weight, her results remained stable. The problems that
are possible with classic nonmicrofat grafting, such as palpable
nodules, firmness, fat necrosis, and fat cysts, were not seen in the
S1IF population.
Contrary to popular belief, intradermal fat grafting can be
performed safely with a sharp needle, as long as it is done in a
superficial dermal plane upon needle withdrawal, epinephrine
infiltration, and low-pressure injection together with pinching
of the skin. The harvesting and injection techniques should be
performed with precision to achieve optimal results and prevent
complications.
46.4.8 Nanofat
:ith the nanofat grafting technique, we inject regenerative cells
and elements in the clinical setting after processing adipose
tissue with a very simple mechanical manipulation. This tech-
nique destroys the mature adipocytes and leaves the complex
mixture of perivascular smaller-sized cellular components intact
and in their native paracrine environment. 1anofat grafting may
open possibilities of adipose tissue as a primary source of mes-
enchymal cells and stromal vascular fraction (SVF) in biocellular
therapies in the future.
Indications and Contraindications
1anofat is not a soft tissue filler; hardly any viable adipocytes
are present in the injectable substance. Nanofat is applicable in a
wide range of indications to improve the skin quality.
There are three categories of indications for the use of nanofat:
1. Trophic skin changes caused by age and sun damage
2. Pigmentary skin conditions
3. Scarring and atrophic skin conditions
Fig. 46.37 (a,d,f) Preoperatively at age 47 years. (b) The immediate intraoperative result. (c) At 6 days postoperative. (e,g) At 6 months postopera-
tive. (Reproduced with permission from Tonnard PL, Verpaele AM, Bensimon RH. Centrofacial Rejuvenation. New 2018.)

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
589
Presently nanofat is an integral component of our facial reju-
venation strategy, and we offer it to all of our patients. 1onfacial
areas such as the neck, the dpcolletp area, and the hands can also
greatly benefit from the use of nanofat grafting, sometimes in
combination with microfat or S1IF.
Because of the simplicity and safety of the procedure, nanofat
grafting has no specific contraindications.
Preoperative Planning and Preparation
Microfat is harvested with the multiholed microcannulas and
processed as described previously in the chapter. The rinsed and
filtered microfat is then transferred into 10-mL Luer lock syringes
and mechanically emulsified. Emulsification of the fat is achieved
by vigorously shifting the microfat between two 10-mL syringes,
connected to each other by a 2.4-mm-diameter (purple) female-
to-female Luer lock connector (Fig. 46.38). After 30 passes the
fat becomes more liquid and whitish. This number of passes is
arbitrary but has proven to be effective in our experience. This
process is then repeated with the 1.2-mm-diameter (green) con-
nector, also for 30 passes. This ensures that even the most fibrous
fat can be emulsified and that no viable adipocytes remain in the
resulting nanofat. The change in color is a result of the emulsifi-
cation of the grafted material. After the emulsification process
the fatty liquid is passed through a strainer cartridge with a dual
400/600-micron filter. This maneuver removes connective tissue
remnants that could block the fine 27-gauge needle. The ȩuent
is the end product, nanofat. It is transferred from the 10-mL Luer
lock syringes into 1-mL syringes for injection.
Technique
Because nanofat grafting is a very superficial treatment, topical
anesthesia is usually sufficient for treatment of the periorbital
skin, the neck, or the dpcolletp. Alternatively, a local nerve block
or infiltration anesthesia can be applied. If general anesthesia
is used, typically no extra infiltration for vasoconstriction is
necessary.
1anofat was designed to be injectable through fine (27-gauge)
needles. This allows very superficial skin injection in the super-
ficial reticular and papillary dermis. The zones marked for treat-
ment are injected with a threading technique upon withdrawal
of the needle. This further reduces the risk of an intravascular
injection, which is very unlikely in these superficial skin layers.
The needle is inserted with the bevel up and may be bent 60ƒ
to facilitate the ease of manipulation. The nanofat is injected in
adjacent fan-shaped patterns.
Results
As mentioned previously, nanofat is not a soft tissue filler.
1anofat is applicable in a wide range of indications in which
improvement of the skin quality is desired, including generalized
facial skin improvement, repairing craquelpd periorbital and
perioral skin, atrophic lip mucosa enhancement, removing lower
eyelid dark circles, correcting sun-damaged skin of the dpcolletp,
improvement of the dorsum of the hands, and scar improvement.
Case Study: Full-Face Nanofat Treatment
The 41-year-old woman in Fig. 46.39 requested noninvasive facial
rejuvenation. :e proposed an upper and lower augmentation
blepharoplasty with chemical browlift by botulinum toxin and
full-face nanofat grafting. The upper blepharoplasty consisted
of resection of skin and microfat grafting of the medial hollow
(1.5 mL per side). Tear trough and orbitomalar groove correction
consisted of microfat grafting of the orbitomalar area (7 mL per
side). Botulinum toxin was injected into the corrugator and pro-
cerus muscle (21 Dysport units per side) and frontal muscle (31.5
Dysport units). Full-face nanofat grafting was performed in an
immediately subdermal level (different from the classic nanofat
injection described previously). A total of 22 mL of nanofat was
injected.
Case Study: Neck Nanofat Treatment
The 71-year-old woman in Fig. 46.40 attended a consultation
for facial rejuvenation. She had a MACS lift with centrofacial
rejuvenation by microfat grafting and erbium laser resurfacing.
The laxity of the skin was corrected by the lifting procedure,
but the enhancement of the quality of the skin is a result of the
nanofat injection. The disappearance of the solar keratosis in the
postoperative images and the long-term stability after 3 years
are notable. For the neck correction, 6 mL of S1IF (see Fig. 46.37)
was injected through a 23-gauge needle into the horizontal
rhytids, and the whole anterior neck area was injected with 15
mL of nanofat through a 27-gauge needle.
Problems and Complications
There are very few complications with nanofat grafting. However,
one in particular deserves discussion: in our early series of dark
circle treatment, we had four patients who experienced a per-
sistent yellow discoloration at the injection site. This problem
Fig. 46.38 Tools used for nanofat processing. Luer-to-Luer connectors,
2.4- and 1.2-mm diameter, for emulsification. Tulip Nanotransfer for
straining emulsified fat through a 400/600-micron filter.

590
VIII Surgical Rejuvenation of the Face and Neck
has occurred only in the lower eyelid, not in any of the other
areas treated.
To prevent this problem, we developed the two-stage sequen-
tial emulsification process, which involves 30 passes through a
2.4-mm Luer-to-Luer connector, followed by a second 30 passes
through a 1.2-mm Luer-to-Luer connector, as described previ-
ously. The persisting adipose show has not reoccurred with this
method.
Obviously, all precautions recommended for preventing intra-
vascular injection should be taken, such as infiltration with local
anesthetic with epinephrine, injection upon withdrawal only,
injection under low pressure, and small aliquots per passage. This
is valid for any injectable.
46.5 Putting It All Together
46.5.1 Case Study
The 51-year-old woman in Fig. 46.41, a smoker, presented for
a facial rejuvenation procedure (Fig. 46.41a). After the consul-
tation, she decided to postpone the surgery and underwent a
gastric bypass procedure because she felt slightly overweight.
She lost 20 kg in 3 years, and the result of the weight loss on
her facial appearance was evident: she appeared to have aged
15 years in the 3-year period (Fig. 46.41b). At that time, at the
age of 54, she again presented for facial rejuvenation. Compared
with her appearance at the age of 28 years (Fig. 46.41c), the
Fig. 46.39 A 41 -year-old woman who had upper and lower augmentation blepharoplasty, botulinum toxin injection, and full-face nanofat injection.
(a,d) Preoperative. (b,e) At 6 months postoperative. (c,f) At 24 months postoperative. (Reproduced with permission from Tonnard PL, Verpaele AM,
Bensimon RH. Centrofacial Rejuvenation. New a
d
b
e
c
f

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
591
centrofacial deflation is obvious in her upper eyelids, midface,
and perioral area. Sagging of the peripheral area is visible, with
drooping of the tail of the eyebrow, loss of definition of the jowl
line, and neck laxity with platysmal bands, especially on the left
side. Fine wrinkles in the frontal, glabellar, and perioral areas
appear together with a lengthening of the vertical height of the
upper lip and loss of definition of the lip contours.
Nonsurgical Plan
The nonsurgical treatment plan consisted of the following:
• Smoking cessation
• A Retin-A skin care program
• Botulinum toxin in the glabellar and frontal area
Surgical Plan
The surgical treatment involved the following:
• Simple MACS lift with retroauricular incision
• Open neck procedure with platysmarrhaphy and partial tran-
section of the platysma at the level of the hyoid
• Short-scar temporal lift
• Upper augmentation blepharoplasty with skin-only resection
• Lower skin-pinch blepharoplasty
• Microfat grafting, 80 mL, harvested from the abdomen
̑ Infrabrow: 2 mL/side
̑ Malar: 13 mL/side
̑ 1asolabial fold: 1.5 mL (including 0.25 mL after subcision)
̑ Marionette grooves: 2.5 mL/side
• S1IF, 21-gauge needle:
̑ Upper white roll: 1.3 mL
Fig. 46.40 A 71-year-old woman who had a minimal-access cranial sus-
pension (MACS) lift with centrofacial rejuvenation by microfat grafting
and erbium laser resurfacing for facial rejuvenation. (a) Preoperative.
(b) At 3 months postoperative. (c) At 3 years postoperative. (d) At 4
years postoperative. (Reproduced with permission from Tonnard PL,
Verpaele AM, Bensimon RH. Centrofacial Rejuvenation. New Thieme Medical Publishers, 2018.)
Fig. 46.41 Preoperative views of patient in case study. (a) At age 51 years, before gastric bypass surgery. (b) At age 54 years, after losing 20 kg. (c)
At age 28 years for comparison. (Reproduced with permission from Tonnard PL, Verpaele AM, Bensimon RH. Centrofacial Rejuvenation. New Thieme Medical Publishers, 2018.)

592
VIII Surgical Rejuvenation of the Face and Neck
̑ Lower white roll: 1.0 mL
̑ Philtrum: 0.4 mL
• S1IF, 23-gauge needle:
̑ Barcode (upper lip): 1.2 mL
̑ Frontal wrinkles: 2.0 mL
̑ Glabella: 0.5 mL
̑ Cheek rhytids: 2.3 mL
̑ 1asolabial rhytids: 2.0 mL
• 1anofat in the anterior neck area (17 mL)
• Lip lift
Postoperative Result
The 1-year postoperative result demonstrates the correction
of the neck laxity with restoration of the cervicomental angle
(Fig. 46.42). Mandibular definition is restored by correction
of the jowling. The degree of platysmal banding required a
platysmarrhaphy and consequently a full facelift incision. Most
important was the correction of the volumetric deflation of
the centrofacial area. Compared with her appearance at age
28 years, the rejuvenation is very natural, with the essential
replenishment of the upper eyelids, the malar area, and the
perioral area. The effect of the lip lift is seen by the shortening
of the vertical height of the upper lip. The S1IF to the white
roll and the philtral columns restores the definition of the lip
contours to her younger appearance. The glabellar and frontal
rhytids are eradicated by the synergistic effect of botulinum
toxin and S1IF. In the profile view in downward gaze (the Bruce
Connell view), the restoration of the cervicomental angle and
the stable correction of the platysmal banding are evident. The
improvement in the quality of the neck skin is a result of the
microfat in the horizontal rhytids and nanofat in the whole
anterior surface of the neck.
:hen the effect of the lifting procedure in the peripheral
part of the face is compared with the effect of the centrofacial
rejuvenation, the centrofacial rejuvenation is clearly much more
important than the actual lifting procedure (Fig. 46.43). Both
techniques work synergistically toward a total natural facial
rejuvenation.
Fig. 46.43 (a,b) Effect of the peripheral lifting procedure, which
is limited to the definition of the jawline and the lower neck. The
centrofacial area has been masked in black. (c,d) Effect of the
centrofacial rejuvenation (augmentation blepharoplasty and perioral
replenishment), which clearly has more rejuvenating power than
mere lifting. The peripheral facelifting areas have been masked in
black. (Reproduced with permission from Tonnard PL, Verpaele AM,
Bensimon RH. Centrofacial Rejuvenation. New Publishers, 2018.)
Fig. 46.42 (a,d,f) Preoperative views. (b,e,g) At 1 year postoperative.
(c) The top right photo is a comparison of the patient at age 28 years.
a
d
b
e
c
f
g

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
593
Clinical Caveats
• Synergy between fat grafting and lifting is a powerful tool to
correct facial aging.
• Facial aging is the result of sagginess and deflation and the
quality of the soft tissues.
• A short-scar facelift is not a classic facelift with a short scar.
• The only rejuvenating vector is the vertical one. The hori-
zontal vector does not rejuvenate the face but puts the face
under tension and causes flattening of the face.
• The vertical vector should work on the deep tissues and on
the skin.
• Purse-string sutures strongly anchored to the deep tempo-
ral fascia, as used in the MACS lift, are a facial sculpturing
technique that cause multiple microimbrications in the
subcutaneous tissue.
• After vertical redraping of the skin flap, the skin is resected
in the temporal region. This skin resection will act as a lock
of the microimbrication result on the subcutaneous facial
tissues.
• Skin suturing starts from superior to inferior to prevent and
treat dog-ear formation in the temporal area.
• Lipofilling can be frequently implemented in all its different
techniques: microfat grafting for volume restoration of the
facial tissues, SNIF as correction of deep rhytides, and nanofat
as regenerative tool for skin quality.
Suggested Reading
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>2@ Baker DC. Lateral SMASectomy. Plast Reconstr Surg 1997;100(2):509–513
>3@ Byrd HS, Andochick SE. The deep temporal lift: a multiplanar, lateral brow, tem-
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>4@ Carniol P-, Ganc DT. Is there an ideal facelift procedure" Curr Opin Otolaryngol
Head Neck Surg 2007;15(4):244–252
>5@ Coleman SR, Mazzola RE. Fat Grafting: From Filling to Regeneration. St Louis, MO:
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>6@ Donofrio LM. Fat distribution: a morphologic study of the aging face. Dermatol
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[7] Feldman JJ. Necklift. St Louis, MO: 4uality Medical Publishing; 2006
[8] Finger ER. A 5-year study of the transmalar subperiosteal midface lift with
minimal skin and superficial musculoaponeurotic system dissection: a durable,
natural-appearing lift with less surgery and recovery time. Plast Reconstr Surg
2001;107(5):1273–1283, discussion 1284
[9] Fulton -E, Saylan =, Helton P, Rahimi AD, Golshani M. The S-lift facelift featuring
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>10@ Furnas D:. The retaining ligaments of the cheek. Plast Reconstr Surg
1989;83(1):11–16
[11] Furnas D:. Strategies for nasolabial levitation. Clin Plast Surg 1995;22(2):265–
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>12@ Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal
midface plane. Plast Reconstr Surg 1998;102(5):1646.1657
>13@ Hester TR, Codner MA, McCord CD. The ´centrofacialµ approach for correction of
facial aging using the transblepharoplasty subperiosteal cheek-lift. Aesthet Surg J
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>14@ Hunstad -P. A systematic approach to MACS-lift operative techniques. In:
Tonnard PL, Verpaele AM, eds. Short-Scar Face Lift: Operative Strategies and Tech-
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minimal access cranial suspension lift. Clin Plast Surg 2008;35(4):645–659, vii

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VIII Surgical Rejuvenation of the Face and Neck
47 Short-Scar Rhytidectomy
Daniel C. Baker
Abstract
A review of the surgeon’s 25-year experience with short-scar
rhytidectomy is presented. The main advantage is avoiding
retroauricular scars, which disrupt the posterior hairline. This
technique is mainly applicable for younger women with good
skin elasticity and minimal cervical laxity. The indications and
limitations as well as long-term results are presented.
Keywords
rhytidectomy, less invasive, shorter incisions, preserves hair-
lines, ponytail-friendly
47.1 Introduction
Rhytidectomy is a procedure that continues to evolve as surgeons
seek to offer patients natural rejuvenation with reduced morbidity.
Over the years I have witnessed an evolution of techniques ranging
from basic skin lifts to superficial musculoaponeurotic system
(SMAS) procedures to even more complex deep-plane procedures
in search of an operation that reliably restores facial form with min-
imal morbidity. More recently, the need for extensive incisions for
rhytidectomy has also been questioned. It has become increasingly
clear that not all patients require the full classic temporal preauric-
ular and retroauricular incisions. The incisions, as well as the planes
or levels of facial dissection, should be individualized for each
patient, in keeping with the physical changes related to aging and
the desired result. As more patients seek facial rejuvenation at an
earlier age, the need for surgical solutions that are less invasive and
that involve less downtime is becoming increasingly important.
My approach to rhytidectomy has evolved over time. During my
plastic surgery residency in the late 1970s, the rhytidectomy that
I was taught was a combination of extensive defatting of the neck
with complete platysma muscle transection, plicating the medial
borders and pulling laterally. This was presented as the only way
to achieve the “best results.” However, after many years of patient
complaints, complications, and overoperated necks, I decided
to abandon most of these techniques in favor of my current
approach³a short-scar rhytidectomy with lateral SMASectomy or
SMAS plication in selected cases.
Today there are a variety of rhytidectomy techniques that pro-
duce excellent results. Each surgeon must adopt a technique that
serves his or her patients well and that ideally is safe, consistent,
and applicable to a variety of anatomic problems. For me, the
short-scar rhytidectomy is a versatile technique that provides
the solution I have been seeking for a wide range of problems for
patients of various ages, without the downside of more traditional
procedures. :ith this approach I am confident of obtaining con-
sistently good results with shorter scars, minimal risk of compli-
cations, reduced morbidity, and speedy postoperative recovery.
It is a quick, safe, and reproducible operation that combines the
versatility of traditional SMAS flap undermining with the safety
and rapidity of SMAS plication or lateral SMASectomy.
47.2 Evolution of Technique
47.2.1 SMAS
In 1976 the work of Mitz and Peyronie helped popularize the
concept of the SMAS. :ith this approach, the lateral SMAS was dis-
sected directly overlying the parotid gland. I performed this type of
SMAS dissection in the late 1970s and continued to do so into the
mid-1980s. Generally I was disappointed with the effects of a simple
elevation and tightening of the lateral superficial fascia, because I
saw little appreciable difference in overall facial contour, regardless
of whether a lateral SMAS dissection had been performed.
Increasing experience with SMAS dissection convinced me that
the mobile SMAS anterior to the parotid gland would have to be
elevated if the superficial fascia were to effect a change in facial
contour. However, this more extensive SMAS dissection places
the facial nerve branches in greater jeopardy. Additionally, the
superficial fascia tends to thin out as it is dissected more anteri-
orly, making the SMAS more prone to tears. Because thinning and
tearing after SMAS flap elevation was a common occurrence, com-
pounded when significant tension placed on the SMAS flap during
suturing resulted in additional tears, I concluded that extensive
SMAS dissection was not warranted in most patients and offered
little long-term benefit in comparison with SMAS plication.
47.2.2 Lateral SMASectomy
In 1992 I discovered the benefits of the lateral SMASectomy as an
alternative to formally elevating the superficial fascia. :ith this
approach, a portion of the SMAS is removed in the region directly
overlying the anterior edge of the parotid gland at the interface of
the fixed and mobile SMAS (Fig. 47.1). Excision of the superficial
fascia in this region secures the mobile anterior SMAS to the fixed
portion of the superficial fascia overlying the parotid gland. The
SMASectomy is performed in a direction parallel to the nasolabial
fold to ensure that the vectors of elevation after SMAS closure will
lie perpendicular or more vertical to the nasolabial fold, thereby
producing improvement in this fold as well as in the jowl, jawline,
and midface (Fig. 47.2).
47.2.3 Twenty-First Century: Less
Invasive Techniques, Short-Scar
Facelifts, and Return to Plication
Thus lateral SMASectomy became the foundation for my evolv-
ing facelift technique. This was then combined with a short-scar
approach, which addressed patient concerns about scarring and
morbidity. The lateral SMASectomy also served as a debulking

47 Short-Scar Rhytidectomy
595
in full-faced patients, but in thin faces I continued to perform
SMAS plication.
47.2.4 Short-Scar Rhytidectomy
The concept of mini-lifts or reduced-incision facelifts is not
new. Mini-lifts have been performed for almost a century; the
first description of such a procedure was by Passot in 1919.
These early operations were usually preauricular skin excisions
with minimal undermining, resulting in minimal, short-lived
improvement. More recently, the S-lift concept and the MACS lift
techniques with suspension sutures have gained popularity.
Although most classic facelift incisions heal well and patients
are happy, hairline disruptions like those shown in Fig. 47.3 are
deforming and difficult to correct.
My first experience with short-scar rhytidectomy was in
1990, when I operated on a young woman who had submental
and submandibular fat and early jowling but good cervical skin
Fig. 47.1 Lateral SMASectomy. A portion of the superficial muscu-
loaponeurotic system (SMAS) is removed in the region directly overly-
ing the anterior edge of the parotid gland at the interface of the fixed
and mobile SMAS. (Adapted with permission from Baker DC. Minimal
incision rhytidectomy (short-scar face lift) with lateral SMASectomy:
evolution and application. Aesthet Surg J. 2001; 21:14-31.)
Fig. 47.2 The SMASectomy is performed in a direction parallel to the nasolabial fold to ensure that the vectors of elevation after superficial muscu-
loaponeurotic system (SMAS) closure will lie perpendicular or more vertical to the nasolabial fold, thereby producing improvement in this fold as well
as in the jowl, jawline, and midface.

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VIII Surgical Rejuvenation of the Face and Neck
elasticity. I performed lipoplasty of the neck and jowls with wide
subcutaneous undermining in the face, detaching the malar and
masseterocutaneous ligaments. A SMAS plication was done, with
no retroauricular scars. The result was excellent, and this experi-
ence prompted me to adopt this procedure for all of my younger
patients with similar anatomic features.
In 1992 I began to incorporate the lateral SMASectomy tech-
nique into the facelift operation for women in their 40s. I noticed
that vertical elevation of the face had a beneficial effect on the
cervical skin. Lax cervical skin was tightened because the soft tis-
sues of the face and neck are linked anatomically. Between 1990
and 1998 I performed this operation, which had no retroauricular
scars, on a total of 204 young female patients. The results were
´ponytail-friendlyµ for these young, active women.
As I gained experience with this operation and its potential
benefits, I extended its application to older patients who demon-
strated greater degrees of jowling and cervical laxity. :ith these
patients, more extensive undermining was required in the neck
and over the sternocleidomastoid and submandibular regions and
usually required a short retroauricular incision. This undermining
exposed the platysma muscle in the neck, thereby facilitating ele-
vation at the posterior muscle, continuous with the SMASectomy.
Between 1990 and 2009 I performed more than 3,000 short-
scar rhytidectomies with lateral SMASectomy or SMAS plication
in patients ranging in age from 35 to 84. These patients exhibited
a variety of facial aging changes and neck deformities. Today I can
safely say that this procedure is as reliable and safe as other facelift
procedures. It is also reproducible by most plastic surgeons with
generally consistent results in properly selected patients. However,
it is not applicable to all patients, particularly those with excessive
cervical laxity and poor skin elasticity. As I have gained more
experience, my criteria for the best candidates have become more
stringent. Today I rarely compromise the result for a shorter scar.
47.3 Advantages and Disadvantages
47.3.1 Lateral SMASectomy
Lateral SMASectomy has several advantages over traditional
SMAS elevation. Because the procedure does not require tradi-
tional SMAS flap elevation, there is less concern about tearing
of the superficial fascia. The potential for facial nerve injury is
reduced because most of the deep dissection is over the parotid
gland. If the SMASectomy is performed anterior to the parotid
gland, the deep fascia will similarly provide protection for the
facial nerve branches as long as resection of the superficial
fascia is done precisely and the deep facial fascia is not violated.
Because SMAS flaps have not been elevated, they tend to hold
suture fixation more strongly, and thus the potential for postop-
erative dehiscence and relapse of contour is decreased.
A lateral SMASectomy or SMAS plication is performed at the
interface of the superficial fascia fixed by the retaining ligaments
and the more mobile anterior superficial facial fascia.
On closure, this brings the mobile SMAS up to the junction of
the fixed SMAS, producing a durable elevation of both superficial
fascia and facial fat. In thin-faced individuals, no SMAS or fat is
removed; instead, the lax SMAS is imbricated and plicated to
recontour atrophic areas in the face and to correct the midface
and nasolabial folds.
47.3.2 Short-Scar Facelift
The primary advantage of a short-scar rhytidectomy is that it allows
patients who wear their hair pulled up or back to do so. Any retro-
auricular scarring or disruption of the posterior hairline makes such
patients unhappy. In addition, the operation involves less dissection
and is less invasive than traditional procedures; presumably this
causes less pain and results in a shorter healing time. In patients
who develop hematomas, evacuation is easier with less morbidity.
There are disadvantages as well. This technique is not suitable
for all patients, especially those with severe cervical skin laxity.
Because the technique requires a significant vertical lift, strict
attention must be paid to minimizing temporal hairline shifts. In
certain patients an anterior hairline incision must be used. Fitting
dog-ears into the temporal and earlobe areas can be a challenge,
and these areas take more time to soften and flatten. Exposure
of the neck with the short-scar technique is limited, sometimes
making the operation technically more difficult.
These advantages and disadvantages are summarized in Table
47.1. I do not use this technique in every patient, and there is still
the occasional patient (usually with a very thin face) who has an
excellent result with only a skin undermining and redraping pro-
cedure. There are other patients with severe cervicofacial laxity
Fig. 47.3 Hairline disruptions after facelift.

47 Short-Scar Rhytidectomy
597
and loss of elasticity who benefit from a classic rhytidectomy
operation with retroauricular scars. Most classic rhytidectomy
incisions, if well placed and closed without tension, will heal well
with minimal scarring.
47.4 Preoperative Assessment
47.4.1 3DWienW 3rRÀOeV
Based on my surgical experience with this procedure, I have clas-
sified candidates for this procedure into four types as follows.
Type I: The Ideal Candidate
Ideal candidates for a short-scar rhytidectomy are usually in
their early to late 40s, with signs of aging primarily in the face.
Although they may have slight cervical laxity, skin elasticity is
still good. They have early jowling, often with submental and
submandibular fat. Microgenia may also be present (Fig. 47.4).
These patients can be effectively treated with closed lipoplasty
of the neck and jowls, wide subcutaneous skin undermining, and
lateral SMASectomy or plication. 1o retroauricular incision is nec-
essary to improve the neck and face. If indicated, a chin implant
will enhance the result (Fig. 47.5).
The 48-year-old exercise trainer shown in Fig. 47.6 had early
jowling and cervicofacial laxity. Her face was thin and her body fat
was low. At work she always wore her hair in a ponytail and was
greatly concerned about retroauricular scars and posterior hairline
disruption. Her presentation made her a type I (´idealµ) candidate for
short-scar rhytidectomy. Her thin face and hollow cheeks were best
treated with plication and imbrication to augment and recontour her
face. Her 1-year postoperative results demonstrate an overall change
in her facial shape to oval, with correction of the jowls and midface
and enhancement of her cheekbones. The lateral view shows correc-
tion of the neck, with preservation of the hairline and imperceptible
scars. Her 10-year postop demonstrates face longevity.
Type II: The Good Candidate
These patients are usually in their late 40s to late 50s with mod-
erate jowling and cervical skin laxity (Fig. 47.7). Submandibular
and submental fat is usually present, and they may have
microgenia. Medial platysma bands are not present on normal
animation. I do not evaluate the platysma on forced animation or
on the basis of static photographs; often what may appear to be
significant platysma bands represent laxity only, which can be
corrected with a lateral pull.
Closed lipoplasty of the neck and jowls along with lateral
SMASectomy or plication produces a good result in these patients.
Table 47.1 Advantages and disadvantages of minimal-incision
rhytidectomy
Anatomical region
Cranial nerve innervations
• Less dissection
• Less invasive
• Less scarring
• Avoids posterior
hairline
distortion
• Allows easier
hematoma
evacuation
• Neck exposure
• Ponytail-friendly
• Requires more vertical skin lift
• Difficult to fit in “dog-ears” in temporal and
earlobe areas
• Requires time for temporal hairline scar to
smooth
• Requires time for retroauricular sulcus/earlobe
scar to smooth
• Occasionally causes skin fold at base of earlobe
• Is not applicable to patients with severe
cervical laxity and poor skin elasticity
Fig. 47.4 Types of patients for short-scar rhytidectomy. Type I: the ideal candidate. (Adapted with permission from Baker DC. Minimal incision
rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)

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VIII Surgical Rejuvenation of the Face and Neck
Fig. 47.5 Closed lipoplasty of the neck and jowls, wide subcutaneous
skin undermining, and lateral SMASectomy or plication. No retroauric-
ular incision is necessary to improve the neck and face. If indicated, a
chin implant will enhance the result.
Fig. 47.6 Long-term follow-up. Plication only, closed neck. (a) Anterior
views. (b) Lateral views.
Fig. 47.7 Types of patients for short-scar rhytidectomy. Type II: the good candidate. (Adapted with permission from Baker DC. Minimal incision
rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)

47 Short-Scar Rhytidectomy
599
If indicated, a chin implant will enhance the result. Usually a
retroauricular incision is not required. However, if a dog-ear is
present at the earlobe, it can be corrected with a short retroauric-
ular incision (Fig. 47.8).
This 59-year-old woman had moderate jowling and cervico-
facial laxity with minimal submental fat. Excess skin and fat of
the upper and lower eyelids was present. She represented a type
II (´goodµ) candidate for short-scar rhytidectomy. To maintain
facial fat and restore facial fullness, plication of the SMAS and
platysma was performed. Her 5-year postoperative result
demonstrates reestablishment of a youthful, oval facial shape,
enhancement of the submalar region and cheekbones, and cor-
rection of the oral commissures. The lateral view demonstrates
correction of the cervical laxity and jawline, with preservation
of the hairline. Her 13-year follow-up demonstrates the lon-
gevity of her first short-scar lift and 2-year postop secondary
short-scar lift.
Type III: The Fair Candidate
Fair candidates are usually in their late 50s, 60s, or early 70s.
They exhibit significant jowling, moderate cervical laxity, and
submental and submandibular fat. Significant medial platysma
bands, active on natural animation, may also be present (Fig.
47.9).
The approach to type III patients is via an open submental
incision connecting subcutaneous undermining with the face and
lateral neck. Open lipoplasty of submental and submandibular fat
is performed to expose the platysma muscle. A 4- to 5-cm wedge
of platysma is removed at the level of the hyoid. The medial
borders of the platysma muscle are approximated to define the
cervicomental angle. Lateral suturing of the platysma to the
mastoid periosteum enhances the jawline. If redundant skin is
present at the earlobe after redraping, it can be removed with a
short retroauricular incision. It must be emphasized that in a type
III patient the neck improvement and its longevity are usually not
as successful as when a classic rhytidectomy with retroauricular
scars is performed.
The 60-year-old woman shown in Fig. 47.10 had significant
jowling and cervicofacial laxity with microgenia. She had excess
skin and fat of her upper eyelids and represented a type III (´fairµ)
candidate for short-scar rhytidectomy. A lateral SMASectomy
was performed to reduce jowl and cheek fullness. An upper
Fig. 47.8 Closed lipoplasty of the neck and jowls along with lateral SMASectomy or plication produces a good result in these patients. If indicated, a
chin implant will enhance the result. (a) Anterior views. (b) Anteroinferior views. (c) Lateral views. (d) In life.

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VIII Surgical Rejuvenation of the Face and Neck
Fig. 47.9 Types of patients for short-scar rhytidectomy. Type III: the fair candidate. (Adapted with permission from Baker DC. Minimal incision
rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)
Fig. 47.10 (a,c,e) This 60-year-old woman with significant jowling and cervicofacial laxity with microgenia, and with excess skin and fat of her upper
eyelids, represented a type III (“fair”) candidate for short-scar rhytidectomy. After lateral SMASectomy, upper blepharoplasty, and chin implant
placement, her 1-year postoperative results demonstrate improvement (b) in the facial shape, (d) midface, and (e) neck.
a
d
b
e
c
f

47 Short-Scar Rhytidectomy
601
blepharoplasty was also performed and a chin implant placed.
Her 1-year postoperative results demonstrate improvement in the
facial shape and midface, with enhancement of the cheekbones.
1eck improvement resulted from midline platysma approxima-
tion and a chin implant. 1o subplatysmal work was done. A rhyt-
idectomy cannot eliminate deep rhytids from the commissures
and jowl area.
The 53-year-old woman shown in Fig. 47.11 had always had
submental fullness and lacked cervicomental definition. She rep-
resented a type III (´fairµ) candidate for short-scar rhytidectomy.
Her 1-year postoperative results demonstrate improvement in the
neck and jowls and reshaping of the face. Despite the fact that no
subplatysmal work was done, the lateral view demonstrates over-
resection of subcutaneous fat, leaving a slight submental hollow
and a prominent, ptotic chin.
Type IV: The Poor Candidate
Poor candidates are usually in their 60s and 70s, with signif-
icant jowling and active, lax platysma bands. Skin folds and
deep creases below the cricoid cartilage are often present, and
cervical skin elasticity is poor. Although these patients are not
good candidates for a short-scar rhytidectomy, this operation
can be offered to them as a compromise solution that keeps open
the option of extending the retroauricular incision if necessary.
Laterally and posteriorly, it is usually necessary to undermine
over the mastoid and sternocleidomastoid muscles to obtain
proper skin redraping. Excess cervical skin must be tailored into
the retroauricular sulcus (Fig. 47.12).
The short-scar technique is a compromise in these patients,
and the improvement in the neck is rarely as good as would be
obtained with a classic rhytidectomy with wide anterior and
posterior cervical undermining and redraping.
The 60-year-old woman shown in Fig. 47.13 demonstrated
cervical laxity below the cricoid, extending to the sternal notch.
She was a poor candidate for a short-scar facelift, which would
have compromised the improvement of her cervical laxity.
Although the patient had a nice improvement after undergoing
a short-scar rhytidectomy, the postoperative result demon-
strated persistent cervical laxity extending to the sternal notch.
The patient was not happy and required neck revision with a
classic retroauricular incision. This much cervical laxity can be
corrected only with wide through-and-through undermining
and removal of excess skin through the retroauricular occipital
incision.
Fig. 47.11 (a,c,e) This 53-year-old woman, who had always had submental fullness and lacked cervicomental definition, represented a type III (“fair”)
candidate for short-scar rhytidectomy. (b,d,f) Her 1-year postoperative results demonstrate improvement in the neck and jowls and reshaping of the
face, with overresection of subcutaneous fat, leaving a slight submental hollow and a prominent, ptotic chin.
a
d
b
e
c
f

602
VIII Surgical Rejuvenation of the Face and Neck
Fig. 47.12 Types of patients for short-scar rhytidectomy. Type IV: the poor candidate. (Adapted with permission from Baker DC. Minimal incision
rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)
Fig. 47.13 This 60-year-old woman, with cervical laxity below the cricoid extending to the sternal notch, was a poor candidate for a short-scar
facelift, which would have compromised the improvement of her cervical laxity. Postoperative result after short-scar rhytidectomy showed improve-
ment, but the cervical laxity persisted. Patient required neck revision with a classic retroauricular incision. (Reproduced with permission from Baker
DC. Lateral SMASectomy, Plication and Short Scar Facelifts: Indications and Techniques. Clin Plast Surg. Facelifts II. 2008; 35(4):533-550.)

47 Short-Scar Rhytidectomy
603
47.5 Operative Technique
47.5.1 Anesthesia
In virtually all of the facelifts I perform, the patient is under
monitored intravenous propofol sedation. Patients are given oral
clonidine, 0.1 to 0.2 mg, 30 minutes before surgery to control
their blood pressure. The face and neck are infiltrated with local
anesthetic, 0.5 lidocaine with 1:200,000 epinephrine, through a
22-gauge spinal needle. I inject the face before I scrub to provide
the requisite 10 minutes for vasoconstriction to occur.
47.5.2 Incisions
:hen the temporal hairline shift is minimal, the preferred
incision is placed well within the temporal hair. :ith this inci-
sion it is often necessary to excise a triangle of skin below the
temporal sideburn at the level of the superior root of the helix
(Fig. 47.14).
:hen a larger skin shift is anticipated (frequently the lift is
more vertical with a shortscar rhytidectomy) or the distance
between the lateral canthus and the temporal hairline is greater
than 5 cm, the incision is made a few millimeters within the tem-
poral hairline. Although this is a compromise, the alternative of a
receding temporal hairline is rarely acceptable to female patients.
:hen the incisions are executed properly (it is essential to bevel
the incision at least 45ƒ through the hair follicles as well as the
redraped flap so that hair can grow through the incision), these
scars heal well and are easy to revise or camouflage. The only
exception might be in a patient with deeply pigmented skin, in
whom the scar will contrast and appear as a white line.
The choice of preauricular incision is left to the surgeon.
:hen executed properly, all of these incisions heal well and are
imperceptible. I usually prefer a curved incision anterior to the
helix and continue inferiorly anterior to the tragus in a natural
skinfold. This preserves the thin, pale, hairless tragal skin and
its demarcation from the cheek skin, which usually is coarser,
thicker, and darker and has lanugo hairs. I perform intratragal
incisions in patients in whom the cheek and tragal skin is similar
and the tragal cartilage is not sharp or prominent. Closure must
be without tension and the flap overlying the tragus defatted to
the dermis.
In a short-scar rhytidectomy, I try to end the incision at the base
of the earlobe. This is usually possible in type I or II patients, but
in type III or IV patients a shorter retroauricular incision is often
necessary to correct a dog-ear after the facial flap rotation.
47.5.3 Skin Flap Elevation
All skin flap undermining is carried out under direct visualization
with scissors dissection to minimize trauma to the subdermal
plexus and preserve a significant layer of subcutaneous fat on
the undersurface of the flap. I prefer subcutaneous dissection in
the temporal region, because the skin seems to redrape better. I
Fig. 47.14 When the temporal hairline shift is minimal, the preferred incision is placed well within the temporal hair. With this incision it is often
necessary to excise a triangle of skin below the temporal sideburn at the level of the superior root of the helix. (Adapted with permission from Baker
DC. Minimal incision rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)

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VIII Surgical Rejuvenation of the Face and Neck
believe that hair loss results primarily from tension rather than
superficial undermining. Subcutaneous dissection in the tempo-
ral region must be performed carefully to avoid penetrating the
superficial temporal fascia, which protects the frontal branch of
the facial nerve. All dermal attachments between the orbicularis
oculi muscle and the skin are separated up to the lateral canthus.
Dissection extends across the zygoma to release the zygomatic
ligaments but stops several centimeters short of the nasolabial
fold. I have never believed that further dissection provides signif-
icant benefits; on the contrary, the only result is increased bleed-
ing. In the cheek, dissection releases the masseteric–cutaneous
ligaments and, if necessary, the mandibular ligaments.
Subcutaneous dissection continues over the angle of the man-
dible and sternocleidomastoid for 5 to 6 cm into the neck. This
exposes the posterior half of the platysma muscle. If a submental
incision has been made, the facial and lateral neck dissection is
connected through and through to the submental dissection
(Fig. 47.15).
47.5.4 Defatting the Neck and Jowls
The extent of subcutaneous undermining in the temporal area,
cheek, and lateral neck is shown. If excess fat is present, closed or
open liposuction superficial to the platysma is performed in the
submental and submandibular areas. :hen necessary, medial
platysma approximation is done through the submental incision.
:henever possible, I prefer closed suction-assisted lipoplasty
in the neck and jowls. A 2.4-mm Mercedes-tip cannula is used;
it is kept under constant, steady motion in the subcutaneous
space. A 3- to 5-mm layer of subcutaneous fat is left on the
undersurface of the cervical skin. If the jowls are suctioned, this is
always done conservatively. Subplatysmal fat is rarely suctioned
or removed, because the facial nerves run just beneath the pla-
tysma. Additionally, any patient with significant subplatysmal fat
probably has a fat, round face, so removing subplatysmal fat could
create an overoperated look. This, of course, is a personal aesthetic
surgical judgment.
Fig. 47.15 Subcutaneous dissection continues over the angle of the mandible and sternocleidomastoid for 5 to 6 cm into the neck, exposing the
posterior half of the platysma muscle. If a submental incision has been made, the facial and lateral neck dissection is connected through and through
to the submental dissection.

47 Short-Scar Rhytidectomy
605
Lipoplasty is usually performed before elevating the skin
flaps, taking care not to oversuction the portion of the SMAS-
platysma that will be elevated over the mandible with the lateral
SMASectomy.
47.5.5 Open Submental Incision with
Medial Platysma Approximation
After many years, I now open the neck only when prominent
active platysma bands are present. I have found that I can
achieve excellent results with closed lipoplasty and a strong
lateral platysma vector. Therefore, in type III and IV patients
with active platysma bands on animation, the medial approx-
imation provides another vector to enhance the cervicomental
recontouring.
I prefer to make the submental incision in the submental crease.
The subcutaneous dissection is performed with the patient’s neck
hyperextended. Undermining is usually to the level of the thyroid
cartilage and the angle of the mandible. Suction-assisted lipoplasty
is then performed with a large, single-hole cannula under direct
vision. Direct fat excision is carried out, if necessary, but to avoid
creating depressions, subplatysma fat is rarely removed.
The medial borders of the platysma muscle are identified and
elevated for several centimeters. To break the continuity of the
bands, a wedge of muscle is removed at the level of the hyoid
bone. The medial borders of the muscle are then sutured together
with interrupted buried 3–0 polydioxanone sutures (PDS).
The submental incision is left open to allow a final confirmation
of hemostasis and recontouring after communication with the facial
dissection and completion of the lateral SMASectomy (Fig. 47.16).
Fig. 47.16 The submental incision is left open to allow a final confirmation hemostasis and recontouring after communication with the facial dissec-
tion and completion of the lateral SMASectomy. Abbreviation: SMAS, superficial musculoaponeurotic system. (Adapted with permission from Baker
DC. Minimal incision rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)

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VIII Surgical Rejuvenation of the Face and Neck
47.5.6 Lateral SMAS Plication
In the SMAS–platysma resection, the level of resection is super-
ficial to the parotid masseteric fascia, which overlies the facial
nerve branches. The outline of the SMASectomy is marked on
a tangent from the lateral malar eminence to the angle of the
mandible, essentially in the region along the anterior edge of the
parotid gland. In most patients this involves a line of resection
extending from the lateral aspect of the malar eminence toward
the tail of the parotid gland. Frequently, orbicularis oculi muscle
fibers are exposed at the superior limit of the excision. Usually
a 2- to 4-cm segment of superficial fascia is excised, depending
on the degree of SMAS–platysma laxity and debulking required
(Fig. 47.17).
In a SMAS resection, I like to pick up the superficial fascia in
the region of the tail of the parotid gland, extending the resection
from inferior to superior in a controlled fashion. :hen SMAS
resection is being performed, it is important to keep the dissec-
tion superficial to the deep fascia and avoid dissection into the
parotid parenchyma. The size of the parotid gland varies from
patient to patient; consequently, the amount of protection needed
for the underlying facial nerve branches will also vary. Despite
this, as long as the dissection is carried superficial to the deep
facial fascia, ensuring that only the superficial fascia is resected,
facial nerve injury as well as parotid injury will be prevented. In
essence, this is a resection of the superficial fascia in the same
plane of dissection in which one would normally raise a SMAS
flap (Fig. 47.18).
47.5.7 Vectors
The following vectors are illustrated: (1) vectors of elevation of
the SMAS–platysma and (2) vectors of superolateral elevation of
the SMAS–platysma and medial approximation of the anterior
platysma in the submental area above the hyoid bone. The
various vectors accomplish corrections of the anterior neck, cer-
vicomental angle, jowls, and nasolabial folds. The first key suture
grasps the platysma at the angle of the mandible and advances
it in a posterosuperior direction; it is secured with figure-of-
eight 2–0 Maxon sutures to the fixed lateral SMAS overlying
the parotid gland. This lifts the cervical platysma and cervical
skin, helps define the jawline, and improves contouring in the
submandibular region (Fig. 47.16).
The lines of closure of the lateral SMAS–platysma in the cheek
and the lateral neck and medial platysma approximation in
the submental area are depicted. Excess fat in the mastoid and
submandibular areas is removed by liposuction. After SMAS
resection, interrupted 3–0 and 4–0 PDS buried sutures are used
Fig. 47.17 In the superficial musculoaponeurotic system (SMAS)-platysma resection, the level of resection is superficial to the parotid masseteric
fascia, which overlies the facial nerve branches. The outline of the SMASectomy is marked on a tangent from the lateral malar eminence to the angle
of the mandible, essentially in the region along the anterior edge of the parotid gland. In most patients this involves a line of resection extending
from the lateral aspect of the malar eminence toward the tail of the parotid gland. Frequently, orbicularis oculi muscle fibers are exposed at the
superior limit of the excision. Usually a 2- to 4-cm segment of superficial fascia is excised, depending on the degree of SMAS–platysma laxity and
debulking required.

47 Short-Scar Rhytidectomy
607
to close the SMASectomy; the fixed lateral SMAS is evenly sutured
to the more mobile anterior superficial fascia. The last suture lifts
the malar fat pad, securing it to the malar fascia. It is important to
obtain a secure fixation to prevent postoperative dehiscence and
relapse of the facial contour.
If firm monofilament sutures are used, such as PDS or Maxon,
the sutures should be buried and the sharp ends on the knot
trimmed. Final contouring of any SMAS or fat irregularities along
the suture line is completed with scissors. Fat can also be trimmed
at the sternomandibular trough; final contouring is accomplished
with liposuction.
47.5.8 Skin Closure, Temporal Fascia, and
Earlobe Dog-Ears
After SMAS and platysma approximation, some tethering of the
skin might appear at the anterior extent of the subcutaneous
dissection because of the pull of the underlying SMAS. This can
also occur in the lower eyelid with elevation of the malar fat pad.
Further subcutaneous undermining is necessary to free these
tethers, allowing the skin to redrape.
Facial skin redraping is done with a less vertical vector than
with the SMAS. The first key skin suture rotates the facial flap
posteriorly to redrape the midface, jowls, and submandibular
skin. Suture fixation is at the level of the insertion of the superior
helix. I like to use a buried 3–0 PDS through the temporal fascia
with a generous bite of dermis on the skin flap. The closure is
performed with minimal tension. Staples are used to close any
incisions in the hair. A wedge is usually removed at the level of
the sideburn to preserve the hairline. If an anterior hairline inci-
sion has been made, I like to close it with buried 5–0 Monocryl
sutures and 5–0 nylon sutures. Extra time and attention must
be spent on this closure to eliminate any dog-ears and obtain
the finest scar. Beveling the facial flap will enhance hair growth
through the scar.
Excess skin is then trimmed from the facial flap so that there is
no tension on the preauricular closure. :ound edges should be
´kissingµ without sutures. Trimming at the earlobe must also be
without tension, and the skin flap is tucked under the lobe with
4–0 PDS, taking a bite of earlobe dermis, cheek flap dermis, and
conchal perichondrium to minimize any tension. A small dog-
ear might be present behind the earlobe; this is easily trimmed
and tailored into a short incision in the retroauricular sulcus. A
closed suction drain is usually brought out through a separate
stab wound in the retroauricular sulcus to drain the neck, and a
Penrose drain is placed through the temporal incision to drain the
face (Fig. 47.5).
47.6 Complications
Table 47.2 summarizes the complications of short-scar rhytid-
ectomy in my series, which are consistent with those of other
standard facelift operations. Despite special attention to blood
pressure control in the postoperative period, the hematoma rate
is still 1.5. The most common problems are the need for minor
revisions of the earlobe and temporal hairline scars, but these
Fig. 47.18 When superficial musculoaponeurotic system (SMAS) resection is being performed, it is important to keep the dissection superficial to the
deep fascia and avoid dissection into the parotid parenchyma. The size of the parotid gland varies from patient to patient; consequently, the amount
of protection needed for the underlying facial nerve branches will also vary. (Adapted with permission from Baker DC. Minimal incision rhytidectomy
(short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)

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VIII Surgical Rejuvenation of the Face and Neck
are far less significant than when I was revising retroauricular
scars or trying to repair posterior hairlines.
47.7 Outcomes
In properly selected patients, the results and longevity are
similar to what is achieved with classic rhytidectomies. Type I
and II patients who have returned at 8 to 13 years for secondary
lifts were very pleased with the results of the first operation. The
shortscar technique was used for all secondary lifts. For type
III and IV patients, the result in the neck will not be as good as
when classic retroauricular incisions are made. This category of
patients is more likely to require some type of neck revision. The
limitations must be discussed preoperatively (Fig. 47.19).
Of the short-scar rhytidectomies I performed from 1990 to
2017, all but 30 were performed on women. Because a man’s neck
usually has a thicker layer of skin and muscle, few male patients
are candidates for this procedure.
After 25 years and 3,000 short-scar rhytidectomies, I have
implemented stricter indications:
Table 47.2 Complications of the short-scar facelift
Complication
Frequency (%)
Hematoma
1.5
Facial paralysis (all resolved in 2 months)
0.3
Infection (abscess)
0.8
Skin slough (minor)
1.0
Hypertrophic scars
2.0
Suture granuloma (PDS)
3.5
Earlobe deformity
0.8
Retroauricular pleating
2.0
Temporal hairline scar revision
3.0
Cervical tightening/platysmaplasty in poorly selected
patients
2.0
Fig. 47.19 Short-scar face and neck lift, plication only. Pre- and postoperative. (a) Anterior views. (b) Anteroinferior views. (c) Lateral views.

47 Short-Scar Rhytidectomy
609
• • Good skin elasticity
• Minimal cervical laxity
• Open neck for platysma
• Rarely compromise the result for a short scar
47.8 &RrreFWing WKe 'iffiFuOW 1eFN
Still the Biggest Challenge
“You are only as young as your neck.µ The goal of neck-contouring
surgery should be a graceful-looking neck, attractive by virtue of
its simplicity rather than its complexity.
:hy many surgeons prefer not to open the neck is obvious: less
dissection, less bleeding, less complications such as hematomas.
But in my hands, trying to correct platysma bands and thick
necks only by suturing the platysma laterally usually results in
suboptimal neck contouring, recurrent platysma cords, and early
recurrence of neck deformities. Undercorrected necks are the
most common complaint from patients who consult with me after
having surgery from another plastic surgeon. They usually say,
´My doctor did not correct my neck.µ For 35 years this has been
the most common mistake requiring a major revision after 1–1.5
years. I have not yet found an effective, long-lasting technique to
correct neck deformities without a submental incision and direct
platysmaplasty with neck sculpting. Today I continue to open the
neck on all patients with active platysma cords that contribute to
the neck deformity.
47.9 Facelift Longevity
Patients often ask, ´Doctor, how long will my face- and neck lift
last"µ
:hen I see patients with good skin elasticity, I usually tell them
the facelift I perform will last 10 to 15 years. Over that period of
time they will get a certain amount of relaxation, but having done
this for more than 35 years (over 8,000 facelifts), I have a good
idea of the longevity a particular patient will get. Many patients
have returned to me for a second facelift, and some for a third
facelift (Fig. 47.20).
Patients usually come back because they have some skin
relaxation, but when I compare their appearance 10 to 15 years
after the original facelift surgery, they still show improvements in
the facial, jowl, and neck areas compared with their preoperative
photos. They want to maintain how they have looked for the pre-
vious 10 to 15 years, so they often have a second facelift and get
another 10 to 15 years looking their best. I have a group of patients
who have had three facelifts and are well into their 80s. They do
not look perpetually 40 to 50, but they look younger than their
age, and naturally so. :e all live much longer today, and this group
of patients remains active well into their late 80s (Fig. 47.21).
Today I restore the facial foundation with SMAS flaps and plica-
tion. I sculpt the neck with platysma muscle flaps and defatting.
I restore facial volume with autologous fat grafting and fillers. All
this is accomplished before redraping and removing excess skin.
Simultaneously I can do full face resurfacing with peels and lasers
and utilize botulinum toxin for wrinkles previously resistant to
treatment. I usually combine all these procedures with the facelift
surgery to obtain the maximum facial improvement with a natural
appearance. One of the most common compliments my patients’
hear from their friends is ´47.10 Unnatural Results
Today most of the patients I see who look unnatural are not the
result of bad plastic surgery. These patients present with over-
filled, overtoxined, overpeeled, overlasered, distorted faces that
the lay population mistakes for bad plastic surgery. They have
lips like guppies and faces shaped like Avatar. Their faces are so
overfilled that their smile is restricted. This is not the result of
surgery Many patients have had these noninvasive treatments,
spending years and great amounts of money for disappointing,
poor, unnatural results. Their cost and recovery downtime are
Fig. 47.20 Short-scar face and open-neck platysmaplasty. (a) Anterior views. (c) Lateral views.

610
VIII Surgical Rejuvenation of the Face and Neck
often significantly greater than having a surgical face- and neck
lift, which gives superior, longer-lasting results.
47.11 The Gold Standard for Facial
Rejuvenation
I tell my patients that a well performed face- and neck lift, com-
bined with fat grafting or fillers and skin resurfacing, will last
between 10 and 15 years, giving them a more natural look, and
will be far less expensive than fillers, botulinum toxin, and laser
treatments over the same period.
:e as plastic surgeons have the ability to accomplish a superior
natural facial rejuvenation in a more economical way than our
nonsurgical colleagues. The fillers and laser and ´noninvasiveµ
techniques are good adjuncts to our surgery and are certainly
beneficial, prolonging our results and postponing surgery, but
they are not a substitute for well-performed surgery.
47.12 Concluding Thoughts
The short-scar rhytidectomy is an excellent facelift technique for
younger patients with good skin elasticity and minimal cervical
laxity. Older patients with excessive cervical laxity and poor
skin elasticity do not get optimal results from this technique, so
it is a compromise for them. Rarely will I sacrifice the result for
a shorter scar.
Although the debate continues about which rhytidectomy
technique yields the best results, there is no single technique
that is ´best.µ Most techniques are variations on a basic theme.
:hat has clearly evolved in the 21st century is the trend toward
less invasive procedures with low morbidity, short recovery,
and minimal scars. Most patients are happy with these new
simpler techniques. I believe that deeply invasive, more rad-
ical techniques do not give better or longer-lasting results.
Results and longevity are more surgeon-dependent than
technique-dependent.
Fig. 47.21 Short-scar face- and neck lift, closed neck, plication; upper and lower blepharoplasty. (a) Anterior and (b) lateral views pre- and 10 years
postoperative and pre–secondary facelift; (c) anterior and (d) lateral views preoperative and 3 years post secondary facelift; (e) face and neck scars.

47 Short-Scar Rhytidectomy
611
Clinical Caveats
• When the temporal hairline shift is assessed as minimal, the
preferred incision is well within the temporal hair.
• The temporal hairline incision allows a more vertical elevation
of the facial flap while preserving the hairline.
• All skin flap undermining is carried out under direct vision
(with scissors dissection) to minimize trauma to the subder-
mal plexus and preserve a significant layer of subcutaneous
fat on the undersurface of the flap.
• Subcutaneous dissection in the temporal region must be
performed carefully to avoid penetrating the superficial tem-
poral fascia, which protects the frontal branch of the facial
nerve.
• Whenever possible, I prefer to use closed suction-assisted
lipoplasty in the neck and jowls.
• I usually perform lipoplasty before elevating the skin flaps. In
doing so, I am careful not to oversuction the portion of the
SMAS-platysma that will be elevated over the mandible with
the lateral SMASectomy.
• When SMAS resection is being performed, it is important to
keep the dissection superficial to the deep fascia and avoid
dissection into the parotid parenchyma. Because the size of
the parotid gland varies from patient to patient, the amount
of protection for the underlying facial nerve branches will
also vary.
• After SMAS resection, interrupted 3–0 PDS buried sutures are
used to close the SMASectomy, the fixed lateral SMAS being
evenly sutured to the more mobile anterior superficial fascia.
The last suture lifts the malar fat pad, securing it to the malar
fascia. It is important to obtain a secure fixation to prevent
postoperative dehiscence and relapse of facial contour.
Suggested Reading
[1] Alpert BS, Baker DC, Hamra ST, Owsley -4, Ramirez O. Identical twin face
lifts with differing techniques: a 10-year follow-up. Plast Reconstr Surg
2009;123(3):1025–1033, discussion 1034–1036
>2@ Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg
1983;10(3):543–562
>3@ Baker DC. Deep dissection rhytidectomy: a plea for caution. Plast Reconstr Surg
1994;93(7):1498–1499
>4@ Baker DC. Lateral SMASectomy. Plast Reconstr Surg 1997;100(2):509–513
>5@ Baker D. Rhytidectomy with lateral SMASectomy. Facial Plast Surg
2000;16(3):209–213
>6@ Baker DC. Lateral SMASectomy, plication and short scar facelifts: indications and
techniques. Clin Plast Surg 2008;35(4):533–550, vi
[7] Baker DC. Short scar facelift. In: Aston S, Steinbrech D, :alden -, eds. Advances in
Aesthetic Surgery. London, U.: Elsevier Ltd; 2009
[8] Baker DC, Aston S-, Guy CL, Rees TD. The male rhytidectomy. Plast Reconstr Surg
1977;60(4):514–522
[9] Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas.
Plast Reconstr Surg 2005;115(7):2119–2122, discussion 2123
>10@ Baker DC, Stefani :A, Chiu ES. Reducing the incidence of hematoma requiring
surgical evacuation following male rhytidectomy: a 30-year review of 985 cases.
Plast Reconstr Surg 2005;116(7):1973–1985, discussion 1986–1987
[11] Baker DC, Conley -. Avoiding facial nerve injuries in rhytidectomy. Anatomical
variations and pitfalls. Plast Reconstr Surg 1979;64(6):781–795
>12@ Connell BF. Contouring the neck in rhytidectomy by lipectomy and a muscle
sling. Plast Reconstr Surg 1978;61(3):376–383
>13@ Connell BF. Cervical lift: Surgical correction of fat contour problems combined
with full-width platysma muscle flaps. Aesthetic Plast Surg 1976;1(1):355–362
>14@ Marchac D, Brady -A, Chiou P. Face lifts with hidden scars: the vertical U incision.
Plast Reconstr Surg 2002;109(7):2539–2551, discussion 2552–2554
>15@ Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the
parotid and cheek area. Plast Reconstr Surg 1976;58(1):80–88
>16@ Passot R. La chirurgie esthptique des rides du visage. Presse Med 1919;27:258–262
[17] Saylan =. The S-lift: less is more. Aesthetic Surg J 1999;19:406–409
[18] Tonnard L, Verpaele AM. The MACS-Lift: Short-Scar Rhytidectomy. St. Louis, MO:
4uality Medical Publishing; 2004
[19] Tonnard L, Verpaele AM. Short-Scar Face Lift: Operative Strategies and Techniques.
St. Louis, MO: 4uality Medical Publishing; 2007

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VIII Surgical Rejuvenation of the Face and Neck
48 Extended SMAS Technique in Facial Rejuvenation
James M. Stuzin
Abstract
There are many options for the surgical rejuvenation of the face.
Superficial musculoaponeurotic system (SMAS) management
is an integral part of most if not all techniques. In this chapter
I describe my extended SMAS technique, including anatomic
considerations, volume management, and ancillary procedures.
Keywords
facial aging, facial anatomy, facial ligaments, facial fat com-
partments, facial muscles, facelift, facial shaping, high SMAS
techniques
48.1 Introduction
Surgical rejuvenation of the aging face has become one of the
most frequently performed surgical procedures in the United
States. Facelifting, introduced as a skin-tightening procedure
in the early 1900s, has technically matured during the past
quarter-century. This evolution is directly related to scientific
investigation of facial soft tissue anatomy, resulting in a better
understanding of the changes that occur with aging. Over the
past 40 years, a number of procedures have been developed with
a variety of technical approaches to reconstruct aging-related
anatomic changes.
:hen the facelift was first developed, both patients and
surgeons focused on the laxity that occurs with facial aging, and
efforts were directed to tightening what was loose rather than
to restoring the shape of the face³hence the term facelift (rather
than facialplasty), a mechanical term that implies a procedure to
lift what has fallen. Unfortunately, this mechanical approach often
produced a tight, operated look³the wind-tunnel appearance
that has so often been associated with surgical rejuvenation of the
aging face. Today, based on a better understanding of facial soft
tissue anatomy and the anatomic changes that occur during aging,
facelifting has developed into both a reconstructive procedure
(to reconstruct the anatomic changes from aging) and a more
artistically defined technique that attempts to enhance facial
appearance while minimizing any signs that a surgical procedure
has been performed.
There are many treatment goals for facelifting other than simply
correcting the hallmarks of the aging face, including improvement
of the nasolabial folds, jowls, and cervical contour. A facelift
must also address the aesthetic concepts of improving shape and
bringing out the beauty of the face that existed during youth. The
surgeon attempting to meet these goals must have a thorough
understanding of facial soft tissue anatomy, the anatomic and
aesthetic changes that occur from aging, and the ideal facial shape
that can be obtained for a particular patient. The design of the
surgical access incisions must minimize scar perceptibility and
avoid hairline distortion to prevent surgical stigmata.
Aging in the face is complex and multifactorial, and plastic
surgeons may encounter a number of challenges, including the
following:
• The dermal component of aging related to intrinsic and extrin-
sic skin changes (dermal elastosis)
• Descent of facial fat
• Facial deflation, which tends to be compartment-specific
• Radial expansion as facial fat becomes centrifugally situated
away from the facial skeleton
• Cervical and jawline contour
All of these factors influence facial shape with aging. Individual
patients exhibit various degrees of all these problems, and each
component of the aging face should be addressed according to a
patient’s specific needs.
Patient photos taken during youth and as the individual has
grown older are very helpful in determining how a patient has
aged. highlights present, document areas that have deflated over time,
and indicate both the position and vector of facial fat descent.
These factors illustrate patient-specific changes in facial shape and
clarify the possible methods for repositioning facial fat to improve
and restore shape. From my perspective, restoring facial shape is a
more worthy aesthetic goal than attempting to tighten a loose face.
48.2 Pertinent Anatomy
The anatomy that allows a facelift to be performed safely is the
arrangement of the facial soft tissue in concentric layers. This
arrangement allows dissection within one anatomic plane to pro-
ceed completely separate from structures lying within another
anatomic plane. The layers of the face are the skin; subcutaneous
fat; superficial facial fascia, or superficial musculoaponeurotic
system (SMAS); mimetic muscles; parotidomasseteric fascia
(deep facial fascia); and plane of the facial nerve, parotid duct,
buccal fat pad, and facial artery and vein (Fig. 48.1).
A surgeon attempting to master sub-SMAS dissection must
understand the following anatomic components of facial soft
tissue anatomy.
48.2.1 Anatomic Consistency
Although the thickness of the various layers differ from patient
to patient, structures within each layer are anatomically consis-
tent. Considered two-dimensionally, the facial nerve exhibits a
variety of branching patterns, but on a three-dimensional basis,
the facial nerve always lies within a specific anatomic plane. This
arrangement allows the surgeon to perform extensive sub-SMAS
dissection safely, as long as the dissection proceeds at a level
superficial to the plane of the facial nerve.

48 Extended SMAS Technique in Facial Rejuvenation
613
48.2.2 SMAS Thickness
The thickness of the SMAS may vary significantly from patient
to patient as well as from one region of the face to another.
Overlying the parotid gland, within the temporal region (tem-
poroparietal fascia), and within the scalp (galea), the SMAS is a
substantial, discrete layer. As the SMAS is traced anteriorly in
the face, overlying the masseter and buccal fat pad and into the
malar region, it tends to become thinner and less substantial.
Elevating the SMAS in these areas requires precise dissection so
the flap is thick enough to be useful in facial contouring.
48.2.3 Muscle Layers
The muscles of facial expression are arranged in four overlap-
ping anatomic layers. The muscles that are encountered during
a facelift procedure include the platysma, orbicularis oculi,
zygomaticus major and minor, and risorius muscles, which are
all superficial mimetic muscles. The deeply situated mimetic
muscles are the buccinator and mentalis muscles. Most of the
muscles of facial expression lie superficial to the plane of the
facial nerve and therefore receive their innervation along their
deep surfaces. The only muscles within the facial soft tissue
architecture that lie deep to the plane of the facial nerve are
the mentalis, buccinator, and levator anguli oris muscles; they
receive their innervation along their superficial surfaces.
In the cadaver dissection of the facial nerve shown in Fig. 48.2, it
can be seen that the area directly overlying the zygomatic buttress
is devoid of motor branches, and the only nerves in this region are
sensory branches. For this reason, dissection in the malar area is
quite safe³the malar eminence represents a watershed between
the frontal branches of the facial nerve, lying superiorly, and the
zygomatic branches of the facial nerve, which lie just inferior to
the zygomatic buttress.
The cadaver dissection shown in Fig. 48.3 shows the path of the
marginal mandibular nerve. The depressor anguli oris muscle has
been divided so that the nerve can be seen lying along the deep
surface of this muscle. The depressor anguli oris and the depressor
inferioris muscles are typical of facial muscles that lie superficial
to the plane of the facial nerve and receive their innervation along
their deep surfaces.
48.2.4 Anatomic Facial Units
The muscles of facial expression that are situated superficially
within the facial soft tissue architecture are invested by the
superficial fascia. ´Investedµ means that the superficial fascia
lines both the superficial and deep surfaces of these muscles. This
SMAS–mimetic muscle complex thus forms a single anatomic
and functional unit that moves facial skin during animation.
48.2.5 Facial Fascia
Deep to the SMAS–mimetic muscle complex lies the deep facial
fascia. The deep facial fascia is a continuation of the superficial
layer of the deep cervical fascia cephalad into the face. :here
Fig. 48.1 Facial anatomy. Abbreviation: SMAS, superficial musculoaponeurotic system.

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VIII Surgical Rejuvenation of the Face and Neck
this fascial layer is identified, it is given specific nomenclature.
Overlying the parotid gland, the deep fascia is called the parotid
fascia or parotid capsule; overlying the masseter muscle, it is
called the masseteric fascia; and in the temporal region, it is
called the deep temporal fascia.
The cadaver dissection shown in Fig. 48.4 on the left is seen after
SMAS and platysma elevation within the cheek; the underlying
parotid gland, the anterior border of the parotid (marked in ink),
and the parotidomasseteric fascia (held in forceps) are exposed.
7KH VLJQLfiFDQFH Rf WKH GHHS fDFLDO fDVFLD LV WKDW DOO WKH fDFLDO QHUYH
branches within the cheek lie deep to this layer. Typically, these
nerve branches course deep to the deep fascia until they reach
the muscles of facial expression, at which point they penetrate the
deep fascia to innervate these mimetic muscles along their deep
surfaces. In the cadaver dissection on the right, the parotidomas-
seteric fascia has been elevated to expose the underlying masseter
muscle and the marginal mandibular nerve as it crosses the facial
artery and vein.
The essential point regarding the architectural arrangement
of the facial soft tissue is that there is a superficial component of
the facial soft tissue that is defined by the superficial facial fascia
and includes the SMAS and those components that move facial
skin (including superficially situated mimetic muscle invested by
the SMAS, the subcutaneous fat, and skin). In contrast, the deeper
component of the facial soft tissue is defined by the deep facial
fascia and the structures related to the deep fascia, including the
relatively fixed structures of the face, such as the parotid gland,
masseter muscle, periosteum of the facial bones, and facial nerve
branches. As the face ages, many of the shape changes noted are
associated with a change in the anatomic relationship between the
superficial and deep facial fascia. :ith age and loss of ligamentous
support, facial fat descends in the plane between superficial and
deep facial fascia, thereby justifying reelevation of fat through
sub-SMAS dissection to improve facial shape. Similarly, a loss of
ligament support allows the mobile superficial unit of facial soft
tissue to expand radially outward from the deep fascia, accounting
for the loss of angularity in facial shape noted from youth to middle
age. The forces of facial expression remain the primary agent for
radial expansion as the superficial fat loses its deep attachments,
and radial expansion often dominates the shape changes noted
within the submalar region, jowl, and jawline in the aging face.
48.2.6 Facial Fat Compartments
As described by Rohrich and Pessa in 2007, facial fat is not a
homogenous but rather is separated into specific compartments,
with each compartment having specific septal boundaries. Facial
fat compartments exist both superficial and deep to the SMAS.
The superficial facial fat, which lies within the subcutaneous
plane, is superficial to the SMAS and can be manipulated and
repositioned in a SMAS facelift. Deep fat compartments are sit-
uated more anteriorly in the cheek and overly the periosteum of
Fig. 48.2 Cadaver dissection of the facial nerve.
Fig. 48.3 Cadaver dissection showing the path of the marginal
mandibular nerve.

48 Extended SMAS Technique in Facial Rejuvenation
615
the orbit and midface (maxilla, zygoma, and piriform aperture)
lying deep to the mimetic muscles. The deep fat of the cheek
is contiguous with the deep fat of the lower lid, known as the
sub–orbicularis oculi fat (SOOF), and blends the lower lid with
the cheek in youth. Deep malar fat along the anterior maxilla
and zygoma contributes to anterior malar projection in youth.
Of note, both the superficial and deep fat compartments deflate
over time and are responsible for many features of the aging face.
48.2.7 7Ke SuSerÀFiDO )DFiDO )DW
Compartments
Superficial facial fat is separated into specific compartments
by the extension of the deeper retaining ligaments through the
cheek to insert into the skin. Rather than being diffuse in their
penetration of the SMAS, the retaining ligaments form specific
fibrous septa between compartments. These junctional boundar-
ies are also the location of vascular perforators. Clinically, while
performing subcutaneous dissection of the cheek, encountering
numerous perforators during dissection indicates an anatomic
transition from one superficial fat compartment to the next.
:hile there are many superficial fat compartments, the five
compartments that the plastic surgeon encounters in a facelift
are the (1) lateral compartment, (2) middle compartment, (3)
superficial malar compartment, (4) jowl compartment, and (5)
nasolabial fold compartment. If the dissection is performed under
direct visualization aided by transillumination, it is possible for the
surgeon to recognize which compartment is being dissected as well
as when the transition between compartments occurs (Fig. 48.5).
Lateral Compartment
The lateral compartment is located in the preauricular region,
tends to be narrow and thin, and follows the superficial temporal
artery cephalically. Typically the lateral compartment is only 3
to 5 cm in width and consists of dense, vascular, and fibrous fat.
This compartment directly overlies the parotid gland, and as the
dissection proceeds anterior to the parotid, the middle compart-
ment is encountered and the dissection becomes less fibrous.
Middle Compartment
The middle fat compartment lies medial to the parotid and
lateral to the anterior boarder of the masseter. This compart-
ment typically is thicker, less fibrous, and less vascular than the
lateral compartment and is the compartment where most of the
subcutaneous dissection of the cheek is performed in a facelift.
Because this large compartment is thick and avascular, it tends
to be easy to dissect. The anterior border of the middle compart-
ment is bounded by the masseteric ligaments and superiorly
by the zygomatic ligaments, such that the anterior boundary is
adjacent to the lateral malar and jowl compartments. In dissect-
ing between the middle, malar, and jowl compartments, fibrous
terminal ligamentous fibers separating these compartments
are encountered, and the dissection is frequently vascular as
the surgeon encounters the ascending perforators between
compartments. Once the dissection proceeds anteriorly into the
malar and jowl compartments, the surgeon again encounters,
thick easily dissected fat. The transition between the middle,
malar, and jowl compartments anatomically demarcates the
transition between the fixed and mobile regions of the cheek.
Fig. 48.4 (Left) Cadaver dissection after SMAS and platysma elevation
within the cheek, exposing the parotid gland and the parotidomasse-
teric fascia. (Right) After elevation of parotidomasseteric fascia, expos-
ing masseter muscle and marginal mandibular nerve. (Reproduced
with permission from Stuzin JM, Baker TJ, Gordon HL. The
relationship of the superficial and deep facial fascias: relevance to
rhytidectomy and aging. Plast Reconstr Surg. 1992; 89:441-449.)
Fig. 48.5 The superficial facial fat compartments are situated in the
subcutaneous plane, partitioned by the terminal extensions of the
retaining ligaments. The five superficial compartments of the cheek
from lateral to medial are (1) lateral, (2) middle, (3) malar, (4) jowl,
and (5) nasolabial. Each compartment has its own septal boundaries,
a separate perforator blood supply, and its own tendency to deflation
in aging.

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VIII Surgical Rejuvenation of the Face and Neck
Typically, I terminate my subcutaneous dissection once the
undermining proceeds anterior to the transition between the
middle, malar, and jowl compartments. At this location the skin
flap has been released from the retaining ligaments of the lateral
cheek, and further dissection is unnecessary. Recognizing which
fat compartment is being dissected, as well as the location where
the transition between the fixed and mobile compartments of
the cheek is located during surgery, provides a patient-specific
anatomic landmark for the degree of subcutaneous dissection
required for skin flap release. I have found that increasing preci-
sion in terms of the degree of dissection required improves both
aesthetic control and lessens the morbidity of the procedure,
leading to a quicker recovery and an overall more consistent result
(Fig. 48.6).
SuSerÀFiDO 0DODr &RmSDrWmenW
The superficial malar compartment is situated along the lateral
aspect of the zygomatic eminence and extends anteriorly toward
the paranasal region, providing volume to the anterior cheek.
This compartment is situated superficial to the orbicularis oculi
and elevators of the upper lip. In dissecting from the lateral cheek
(middle compartment), the malar compartment is identified as
the surgeon encounters numerous perforators from the trans-
verse facial artery as well as dense fibrous zygomatic ligaments
(termed McGregor’s patch). The upper masseteric ligaments are
similarly encountered along the inferior aspect of the zygoma,
and the combination of dense fibrous fat with vascularity can
make it difficult to identify the subcutaneous plane accurately
in this region. As the zygomatic branches of the facial nerve
are superficially positioned just deep to the SMAS lateral to the
zygoma, accurate plane identification is an important safety
consideration (Fig. 48.7).
Jowl Compartment
The jowl compartment consists of fluffy, thick fat and is situated
between the mandibular ligaments and the masseteric ligaments
overlying the facial portion of the platysma. -owl fat tends to be
avascular and easy to dissect. In aging, attenuation of support
from the masseteric ligaments allows the platysma and overlying
jowl fat to descend into the neck, which obscures the definition
of the mandibular border. As the jowl compartment tends not to
deflate in aging, jowl descent accompanied by adjacent perioral
deflation is responsible for this fat compartment becoming more
apparent in middle age and elderly patients.
Nasolabial Fold Compartment
The nasolabial fold compartment sits just lateral to the naso-
labial fold and anterior to the malar compartment. This fat
compartment typically consists of thick dense fat and rarely
deflates in aging. For this reason, the nasolabial compartment
typically becomes more obvious in aging as the adjacent malar
compartment and perioral regions deflate.
Fig. 48.6 The middle fat compartment (dark color) is situated between
the lateral, malar, and jowl compartments. This compartment consists
of thick, less vascular fat and is the compartment where most of the
subcutaneous dissection is performed in a facelift. Once the skin flap
dissection proceeds into the malar and jowl compartments, the flap is
released from the retaining ligaments of the lateral cheek and further
dissection is unnecessary.
Fig. 48.7 Cadaver dissection at the junction between the middle
and malar compartments along the lateral zygoma. When transiting
compartments, retaining ligaments are encountered as well as vascular
perforators. The scissors in this photograph are situated where the
zygomatic ligaments inset into the skin (separating the superior aspect
of the middle compartment from the lateral malar compartment).
The density of ligaments in this region can obscure proper plane
identification, and it is safer to dissect superficially along the transition
point between the middle and malar compartments, as the zygomatic
motor branches lie directly deep to the superficial musculoaponeurotic
system (SMAS) in this location. Notice the numerous vascular perfo-
rators present at this location, typical of vascular perforators located
along transition points between compartments. Once the subcuta-
neous dissection proceeds anterior to the middle compartment, the
mobile region of the cheek is encountered.

48 Extended SMAS Technique in Facial Rejuvenation
617
48.2.8 Deep Facial Fat Compartments
The deep compartments of the cheek lie deep to mimetic muscles
and overlie the periosteum of the orbit, midface, and piriform
aperture. The deep facial fat compartment (SOOF), which affects
lower lid morphology, is situated deep to the orbicularis oculi
and is divided into a lateral and medial component. The anterior
cheek is supported by the deep malar fat pad, which similarly has
a medial and lateral component. The medial component of deep
malar fat is situated along the piriform aperture and blends the
perioral region with the cheek in youth. The lateral component
of deep malar fat contributes to anterior malar projection and
blends the anterior cheek with the lateral cheek where it abuts
the buccal extension of the buccal fat pad. This lateral compo-
nent also abuts the orbit, blending the eyelid and cheek in youth
(Fig. 48.8).
The surgical importance of differentiating between superficial
and deep deflation is that superficial deflation can be improved by
repositioning superficial fat via the SMAS, while deep deflation
requires volumetric augmentation for correction.
48.2.9 Retaining Ligaments
Communication between the superficial and deep facial fascia
occurs at the level of the retaining ligaments. These structures
fix facial soft tissue in a normal anatomic position, resisting grav-
itational forces. Retaining ligaments exist in specific locations
of the face, including (1) the malar area, where they are called
zygomatic ligaments; (2) along the anterior border of the masse-
ter muscle, forming the masseteric–cutaneous ligaments; (3) over
the parotid gland, forming the parotid–cutaneous ligaments; and
(4) in the parasymphysial and symphysial region of the mandible,
where they are called mandibular ligaments (Fig. 48.9).
Fig. 48.8 The deep malar compartment overlies the periosteum of
the anterior cheek, deep to the mimetic muscles. The deep malar
compartment exhibits a medial and lateral component and abuts
the sub–orbicularis oculi fat (SOOF) compartment of the lower lid.
The medial component abuts the piriform aperture and provides
volumetric blending between the perioral region and anterior cheek in
youth. Similarly, the lateral component abuts the lower lid and SOOF,
providing volumetric blending across the lid–cheek junction in youth.
Fig. 48.9 Retaining ligaments. (Adapted with permission from Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting: enhanced facial
contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg. 2000; 105:290-301.)

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VIII Surgical Rejuvenation of the Face and Neck
There are two types of retaining ligaments, as defined by their
origins. The osteocutaneous ligaments are a series of fibrous
bands that run from periosteum to dermis. The zygomatic and
mandibular ligaments are examples of these structures.
The second system of supporting ligaments is formed by a
coalescence of the superficial and deep facial fascia in certain
regions of the face (the parotid–cutaneous ligaments and the mas-
seteric–cutaneous ligaments). These fascial connections, which
fix both superficial and deep fascia to underlying facial structures,
such as the parotid gland and masseter muscle, similarly lend
support against gravitational forces through fibrous septa that
extend into the dermis. Attenuation of support from the retaining
ligaments is responsible for many of the features of facial aging.
In the evolution of midface aging, the zygomatic– and masse-
teric–cutaneous ligaments are particularly important. The zygo-
matic ligaments originate from the periosteum of the malar region
as a series of fibrous septa that begin laterally in the region where
the zygomatic arch joins the body of the zygoma and permeate the
malar pad (fibrous McGregor’s patch). The zygomatic ligaments tend
to be stout laterally and weaken medially. The zygomatic ligaments
fix the malar pad to the underlying zygomatic eminence in a youth-
ful face, providing volumetric highlights in a youthful angular face.
The malar region is predominantly affected by deflation in
aging, leading to loss of volume overlying the lateral zygoma.
Additionally, attenuation of the zygomatic ligamentous support
suspending the malar pad and the medial cheek leads to an infe-
rior migration of these soft tissues adjacent to the line of the mus-
cular fixation of the nasolabial fold. 1ot only does the fold deepen
with aging, but an accumulation of cheek soft tissue lateral to the
nasolabial line also accounts for fold prominence. As noted, the
nasolabial fat compartment rarely deflates in aging (Fig. 48.10).
The masseteric–cutaneous ligaments are a series of fibrous
bands that extend along the entire anterior border of the masseter
muscle and provide soft tissue support in the submalar region of
the cheek. These fibers are identified superiorly in the malar area,
where they mingle with the zygomatic ligaments and extend
along the anterior border of the masseter as far inferiorly as the
mandibular border. These fibers represent coalescence between
the superficial and deep fasciae, extending from the masseter
muscle vertically to insert into the overlying dermis. :hen an
individual is young, the masseteric ligaments support the soft
tissues of the medial cheek superiorly above the mandibular
border and internally to conform to the deep fascia overlying the
buccinators.
Fig. 48.10 Attenuation of the zygomatic ligamentous support
suspending the malar pad and the medial cheek leads to an inferior
migration of these soft tissues adjacent to the line of the muscular
fixation of the nasolabial fold. This deepens with aging, and an
accumulation of cheek soft tissue lateral to the nasolabial line also
contributes to fold prominence. The nasolabial fat compartment rarely
deflates in aging. (Reproduced with permission from Stuzin JM,
Baker TJ, Gordon HL. The relationship of the superficial and deep
facial fascias: relevance to rhytidectomy and aging. Plast Reconstr
Surg. 1992; 89:441-449.)
Fig. 48.11 Attenuation of support from the masseteric ligaments allows
the soft tissues of the lower cheek and the facial portion of the platysma
to descend inferiorly, leading to the formation of the facial jowl.
(Reproduced with permission from Stuzin JM, Baker TJ, Gordon HL.
The relationship of the superficial and deep facial fascias: relevance
to rhytidectomy and aging. Plast Reconstr Surg. 1992; 89:441-449.)

48 Extended SMAS Technique in Facial Rejuvenation
619
Attenuation of support from the masseteric ligaments allows
the soft tissues of the lower cheek and the facial portion of the
platysma to descend inferiorly, leading to the formation of the
facial jowl. In addition, loss of this ligamentous support allows the
submalar fat and jowl fat to radially expand outward from the deep
fascia and mandible, obscuring jawline definition (Fig. 48.11).
48.2.10 Facial Nerve Danger Zones
Facial nerve injury is a feared complication in performing facial
aesthetic and reconstructive procedures. :hile most facial
nerve branches are protected, as they are situated deep to the
deep fascia as they traverse the cheek, there are specific regions
of the cheek where facial nerve branches are superficially posi-
tioned and more prone to injury. These danger zones are typically
located at regions of transition between facial fat compartments
and are characterized by nerve branches situated in the sub-
SMAS plane between superficial and deep fascia. Recognition of
the plane of dissection when dissecting within the danger zones
remains a key element in preventing inadvertent motor branch
injury (Fig. 48.12).
Frontal Branch
After exiting the parotid, the frontal branch overlies the peri-
osteum of the zygomatic arch. Cephalad to the zygomatic arch
the frontal branch travels in the plane between the SMAS (tem-
poroparietal fascia) and deep temporal fascia, invested in sub-
SMAS fat.
The frontal branch becomes more superficial as it traverses the
temporal region and approaches the frontalis, where this mimetic
muscle receives its innervation. As the frontal branch lies just
deep to the SMAS as it approaches the frontalis, dissection deep
to the SMAS in this region can produce a motor branch injury.
Zygomatic Branch
After exiting the parotid, the zygomatic branch lies deep to the
deep fascia and overlies the masseter. As it approaches the zygo-
maticus major muscle, the zygomatic branch typically pene-
trates the deep fascia and becomes situated in the plane between
superficial and deep fascia just inferolateral to the zygomatic
eminence. In subcutaneous undermining of the cheek, the region
lateral to the zygomatic eminence is both fibrous and bloody, as
zygomatic ligaments, upper masseteric ligaments, and perfora-
tors from the transverse facial artery traverse this region. For this
reason the proper plane of dissection can be difficult to identify.
As the zygomatic branch is superficially situated in this location,
inadvertent dissection, deep to the SMAS in this location, can
produce a motor branch injury resulting in upper lip weakness.
Proper plane identification is essential in this region of the cheek,
and it is often helpful to dissect the less fibrous areas of the cheek
both superior and inferior to the zygomatic eminence to ensure
accurate plane identification prior to dissecting in this danger
zone (Fig. 48.13).
Marginal and Cervical Branches
The cervical branch exits the tail of the parotid and almost
immediately is situated in the plane between superficial and
Fig. 48.12 (a) In this cadaver dissection, the areas of facial nerve
danger zones representing the superficially situated frontal branch,
zygomatic branch, and cervical branch are noted (black X). Cephalical
red dots represent the path of the parietal and frontal branches of
the superficial temporal artery. The red dots anteriorly in the cheek
represent the junction between the fixed and mobile regions of the
cheek, demarcated by the position of the lateral zygomatic ligaments
and masseteric ligaments. In terms of danger zones, the frontal branch
is superficially positioned within the temporal region as it approaches
the frontalis. The zygomatic branch is at greatest jeopardy just lateral
to the zygomatic eminence, where it is juxtaposed to the merging
of the zygomatic and upper masseteric ligaments. The cervical
branch is at greatest jeopardy along the mandibular angle, where
it is juxtaposed to the caudal masseteric ligaments. Proper plane
identification and inadvertent dissection deep to the superficial mus-
culoaponeurotic system (SMAS) should be avoided in these regions.
(b) Artist’s illustration of the facial nerve danger zones of the lateral
cheek. Danger zones represent regions where facial nerve branches
are superficially positioned, in the plane between the SMAS and deep
fascia. Inadvertent dissection deep to the SMAS in these areas may
result in motor branch injury.
a
b

620
VIII Surgical Rejuvenation of the Face and Neck
deep fascia. It typically traverses the lower cheek deep to both
SMAS and platysma before innervating this muscle along its
deep surface. The cervical branch is at greatest risk of injury
adjacent to the mandibular angle and caudal mesenteric lig-
aments. The caudal mesenteric ligaments tend to have stout
fibers and typically form a firm attachment between the skin of
the lower cheek, the platysma, and the underlying periosteum.
As a result of this adherence along the angle of the mandible,
the region of the caudal masseter represents a danger zone, as
inadvertent dissection deep to the platysma will result in cervi-
cal branch injury. The key to safety in subcutaneous dissection
when transiting from the cheek to the neck is accurate plane
identification to ensure that the dissection is carried superficial
to the platysma.
The marginal branch exits the tail of the parotid and is situated
deep to the deep fascia, typically invested in sub-SMAS fat. The
marginal branch remains deep to the deep fascia as it crosses
the facial artery and vein and becomes superficial only when it
reaches the depressors of the lower lip, which are innervated
along their deep surfaces. Because of the deep position of the
marginal branch as it transits across the cheek, it is infrequently
injured in subcutaneous dissection. The marginal branch is at
greater risk in sub-SMAS dissection if the dissection is carried
anteriorly as far forward as the facial artery and vein (which is not
necessary for adequate SMAS release). In this location, the caudal
masseteric ligaments are dense, and the proper plane of dissection
can appear obscure. Accurate release of the SMAS anterior to the
tail of the parotid and utilizing blunt dissection once the SMAS
has been freed from the parotid tail will protect the underlying
marginal branch (Fig. 48.14).
48.3 Aesthetic Analysis and
Treatment Planning
As the face ages, facial shape changes. Some of these changes
can be addressed in a straightforward manner, whereas others
present difficult technical challenges. A paradox for me has
Fig. 48.14 (a) Cadaver dissection illustrating the relationship of
the marginal and cervical branches adjacent to the caudal border
of the masseter. Note that the cervical branch (lower arrow) is more
superficial than the marginal branch and lies just deep to the platysma
(between superficial and deep fasciae) before innervating this muscle.
The marginal branch (upper arrow) lies deep to the deep fascia as it
crosses the facial artery and vein, and it tends to stay deep until it
reaches the depressor anguli oris and inferioris, which are innervated
along their deep surfaces. (b) Artist’s illustration demonstrating the
depth relationship between the marginal and cervical branches along
the caudal border of the masseter. At this location, the cervical branch
lies just deep to the platysma in the plane below the superficial mus-
culoaponeurotic system, while the marginal branch is situated deep to
the deep fascia. Because of its more protected position, the marginal
branch is rarely injured in a facelift.
Fig. 48.13 This cadaver photograph shows both the zygomatic and
buccal branches as they traverse the cheek. The lower black arrow
points to the major buccal branch, which parallels the parotid duct
and lies deep to the deep fascia in this location. The upper arrow points
to the zygomatic branch, which innervates the zygomaticus major
(held by forceps) just lateral to the zygomatic eminene. Note that this
branch penetrates the deep fascia in close proximity to the transverse
facial artery and lies in the plane between superficial and deep fascia
in this location. As this region tends to be fibrous (zygomatic and
upper masseteric ligaments) and bloody (from perforators from the
transverse facial artery), plane identification can be difficult. When in
doubt, dissect superficially to avoid inadvertent dissection below the
superficial musculoaponeurotic system within this danger zone.

48 Extended SMAS Technique in Facial Rejuvenation
621
always been that facial anatomy (in terms of basic soft tissue
architecture) is essentially unchanged from youth to middle
age, but facial appearance changes greatly over time and is
patient-specific. Although each face ages differently, there are
common features in all of them.
48.3.1 Descent and Radial Expansion
of Facial Fat
As the face ages, facial fat descends as well as becoming situated
outward from the facial skeleton and deep fascia, in what is
termed radial expansion. Facial fat descent predominantly affects
the lower cheek and jowl, while radial expansion is noted along
the nasolabial fold, submalar region, and jowl. Fat descent as
well as the outward migration of fat produces the bottom-heavy
square shape noted in middle age. As an example, in the photo-
graph taken at age 25 in Fig. 48.15, the patient exhibits a youthful
face full of well-supported facial fat, situated overlying the malar
eminence and along the lateral cheek as well as the preparotid
region. In addition, there is a concavity or depression overlying
the buccal recess just anterior to the masseter muscle as the
superficial fat and skin of the submalar region are bound to the
deep fascia and buccinator in youth. The combination of fullness
in the malar region and lateral cheek and a concavity overlying
the buccal recess accounts for the angular, tapered appearance
of the youthful face. In the same woman at age 55, the aesthetic
effect of facial fat descent and radial expansion of the submalar
region and jowl becomes obvious.
Typically, faces in middle age are square, with little differential
between malar highlights (which deflate) and midfacial fat. As
facial fat becomes situated more inferiorly in the face, the face
appears visually longer. The aesthetic consequences of loss of
facial angularity with aging are as important as the depth of the
nasolabial fold and jowling. For me, an improvement of facial
shape is one of the primary goals of facial rejuvenation.
48.3.2 9ROume /RVV Dnd )DFiDO 'eÁDWiRn
over time, and it tends to be most apparent in areas of the face
that have a high density of retaining ligaments (the lateral malar
eminence, preparotid area, lateral and infraorbital rim, and
lateral chin). aesthetic subunits. Middle-aged faces, as a result of both defla-
tion and radial expansion, develop demarcation lines between
adjacent regions of the cheek. An appropriate aesthetic treat-
ment plan requires repositioning of the descended soft tissue
into areas of facial deflation to improve shape, not only to restore
the volume of youth but also to blunt the demarcation lines
between aesthetic subunits. Volumetric augmentation through
autologous fat injection or other injectable soft tissue fillers is an
ancillary procedure that can be useful for augmenting areas of
deflation not corrected by fat repositioning via the SMAS.
Deflation is a complex process that tends to be regional and
age-specific. The aesthetic significance of fat compartmentaliza-
tion is that deflation tends to occur within a specific compartment
of the cheek, rather than homogeneously across the entire cheek
with age.
At the risk of oversimplification, deflation tends to occur earli-
est within regions of high ligamentous density, which are situated
predominantly in the lateral cheek. The lateral cheek tends to
show signs of deflation in the fourth decade, while malar deflation
is more apparent in the fifth to sixth decade. From a fat compart-
ment perspective, the lateral and middle fat compartments tend
to deflate a decade earlier than the malar compartment, while the
jowl and nasolabial compartments rarely deflate with age.
The 42-year-old patient shown in Fig. 48.16 has signs of early
facial aging resulting primarily from lateral cheek deflation and
Fig. 48.15 Descent and radial expansion of facial fat. (Adapted with
permission from Stuzin JM, Baker TJ, Baker TM. Refinements in face
lifting: enhanced facial contour using Vicryl mesh incorporated
into SMAS fixation. Plast Reconstr Surg. 2000; 105:290-301.)
Fig. 48.16 Patient aged 42 with signs of early facial aging resulting
primarily from lateral and middle compartment deflation and radial
expansion along the jawline but little evidence of malar deflation. She
is seen (a) before and (b) after a face- and neck lift. Anteriorly situated
fat was brought into the upper lateral midface, where it filled the areas
of deflation, thereby blunting the demarcation lines between aesthetic
subunits. The change in facial shape is evident; her face appears more
structured and supported after facial fat repositioning. (Reproduced
with permission from Stuzin JM. Restoring facial shape in face
lifting: the role of skeletal support in facial analysis and midface
soft-tissue repositioning. Plast Reconstr Surg. 2007; 119:362-376.)
a
b

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VIII Surgical Rejuvenation of the Face and Neck
radial expansion along the jawline. Deflation has occurred in the
lateral and middle compartments but she exhibits little evidence
of malar deflation. She underwent a face- and neck lift. Anteriorly
situated fat was brought into the upper lateral midface, where
it filled the areas of deflation, thereby blunting the demarcation
lines between aesthetic subunits. The change in facial shape is
evident; her face appears more structured and supported after
facial fat repositioning.
Medial cheek and malar deflation (both superficial and deep
compartments) tends to occur later in life and is responsible
not only for the loss of volumetric support within the anterior
cheek but also for the development of the infraorbital V deformity
(resulting primarily from deep malar deflation). Deflation in this
region results in an apparent increase in the vertical length of the
lower lid as the lid–cheek junction visually descends inferiorly
into the anterior cheek. The correction of deep malar deflation
requires volume augmentation, while superficial malar deflation
can be improved through the repositioning of fat via the SMAS.
A variant of deflation develops in some faces in the submalar
region lateral to the oral commissure. In these type of patients,
deflation results in an accentuation of submalar concavity, which
becomes more obvious after the vertical soft tissue shifts associ-
ated with a facelift. The accentuation of the submalar deflation
lateral to the oral commissure can result in the development of
joker lines, or cross-cheek depressions, which visually appear as if
the lateral commissure has been pulled into the cheek. Avoidance
of vertical soft tissue repositioning in conjunction with volume
addition in the submalar recess lateral to the oral commissure can
help prevent the creation of postoperative cross-cheek depres-
sions. Preoperative recognition of this form of submalar deflation
and the tendency to develop cross-cheek depressions is the key in
preventing this unattractive but all too common surgical stigma
associated with facelifting.
The cadaver dissection shown in Fig. 48.17 illustrates the mus-
cular insertions into the oral commissure and modiolus. The small
arrow overlies the facial portion of the platysma and points to the
risorius muscle; the large arrow points to the depressor anguli oris
muscle, where it merges with the platysma. Superiorly, the inser-
tion of the zygomaticus major into the lateral commissure can be
seen, with a slip of muscle inserting inferiorly into the modulus.
Fig. 48.17 Cadaver dissection illustrating the muscular insertions into
the oral commissure and modiolus. (Reproduced with permission
from Lambros V, Stuzin JM. The cross-cheek depression: surgical
cause and effect in the development of the “joker line” and its
treatment. Plast Reconstr Surg. 2008; 122:1543- 1552.)
Fig. 48.18 Man aged 59 who lost 41 kg (90 pounds) after a gastric
bypass procedure. There are areas of deflation along the infraorbital
rim, lateral orbital rim, and malar region. Also noticeable is the
apparent length of the lower lid from the infraorbital V deformity in
association with deep malar deflation. (Reproduced with permission
from Stuzin JM. Restoring facial shape in face lifting: the role of
skeletal support in facial analysis and midface soft-tissue reposi-
tioning. Plast Reconstr Surg. 2007; 119:362-376.)