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
Long, thin faces often benefit from an enhancement of malar
volume. SMAS dissection and facial fat repositioning anteriorly
over the zygomatic eminence allow the surgeon to restore malar
volume, thereby increasing bizygomatic diameter. :hen malar
volume is enhanced, the face appears wider. Volume augmenta-
tion to the deep malar compartment is often helpful in improving
facial shape in the long thin face (Fig. 48.20).
Convexity of the Malar Region Juxtaposed
with the Concavity of the Submalar Region
In youth, facial fat is situated over the malar and preparotid
region. Malar fullness is juxtaposed to a concavity in the subma-
lar region overlying the buccinator muscle. As patients age, the
relationship between the malar and submalar regions changes,
and facial shape changes with it. In most patients, the lateral
malar region deflates with aging while the submalar region
radially expands outward, resulting in little differential noted
between lateral malar highlights and submalar fullness. As the
aesthetic relationship between the malar and submalar region
changes, there is a loss of the angular, tapered shape of youth,
making middle-aged faces appear oval, square, or bottom heavy.
Preoperatively, the face of the patient shown in Fig. 48.21 is
oval as a result of malar deflation. Evaluating the relationship
between the malar and submalar regions on the front view, for
me, is an essential component of aesthetic treatment planning.
For many patients, restoring this relationship by increasing malar
highlights and malar volume and reconstructing the concavity
in the submalar region by internal fat repositioning becomes a
central component of improving facial shape.
Fig. 48.20 (a,c) Long, thin faces often benefit from an enhancement
of malar volume. (b,d) Superficial musculoaponeurotic system
dissection and facial fat repositioning anteriorly over the zygomatic
eminence enable the surgeon to restore malar volume, thereby
increasing bizygomatic diameter. When malar volume is enhanced, the
face appears wider. (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.)
Fig. 48.21 (a) Oval face due to malar deflation. Evaluating the rela-
tionship between the malar and submalar regions on the front view is
an essential component of aesthetic treatment planning. (b) For many
patients, restoring this relationship by increasing malar highlights and
malar volume and reconstructing the concavity in the submalar region
by internal fat repositioning become a central component of improving
facial shape. (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.)
Fig. 48.22 (a) Preoperatively, this patient shows a blunting of
the relationship between the malar and submalar regions. (b)
Postoperatively, enhancing malar volume and the bizygomatic
diameter and restoring the concavity within the submalar region
have made her face appear more angular as well as shorter vertically.
(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
a
b
b
a
c
b
d

48 Extended SMAS Technique in Facial Rejuvenation
625
Preoperatively, the patient shown in Fig. 48.22 shows a blunt-
ing of the relationship between the malar and submalar regions.
Postoperatively, enhancing malar volume and the bizygomatic
diameter, and restoring the concavity within the submalar region
have made her face appear more angular as well as shorter
vertically.
Vertical Height of the Mandibular Ramus and
Horizontal Length of the Mandibular Body
The vertical height of the mandibular ramus and the horizontal
length of the mandibular body provide skeletal support for the
lower two-thirds of the face. Patients who present with a normal
mandibular ramus height, as well as adequate horizontal length
of the mandibular body, usually have excellent skeletal support
for soft tissue repositioning and are, therefore, less of a surgical
challenge. Patients with a short mandibular ramus, an open man-
dibular plane angle, and a short length of the mandibular body
typically have poor skeletal support for midface and perioral
soft tissue repositioning. These patients are a greater surgical
challenge for restoring facial shape, and they often benefit from
volumetric augmentation, either alloplastic or autogenous, to
enhance skeletal support.
48.4 'i̵erenWiDO 9eFWRrV IRr
Redraping SMAS Dissection
and Skin Flap
Dermal elastosis and skin laxity in an aging face often do not
occur in the same direction or at the same rate as the descent
of fat and other factors affecting the superficial fascia. The main
advantages of performing skin dissection separate from SMAS
dissection is that it allows these two layers to be draped along
vectors that are independent of one another. Another advantage
of a two-layer SMAS facelift is that the contouring tension is
placed on the superficial fascia, thereby allowing the surgeon
to use less tension for skin closure. This also improves control
over scar perceptibility. In my experience, facial fat is usually
repositioned in a more vertical vector than skin flap redraping.
Strong vertical shifting of the cervicofacial flap is traditional in
many facelift techniques and is required in short scar facelifts
that lack a postauricular incision. Although skin tightening can
produce a dramatic improvement in facial laxity, the aesthetic
effects of vertical skin vectoring, unfortunately, have been poorly
defined. Specifically, when skin is shifted in a cephalad direction,
the effect of skin tension commonly produces an accentuation of
flatness in the preparotid region, an area that typically deflates
with aging. In my opinion, vertical skin shift often produces an
unnatural tightness, accounting for the typical surgical appear-
ance associated with rhytidectomy. If the surgeon has been
successful in repositioning descended facial fat, strong vertical
skin tension is neither desirable nor required to enhance the
postoperative result (Fig. 48.23).
The two patients shown in Fig. 48.24 show the effect of vertical
rotation of the cervicofacial flap associated with hairline distor-
tion. A skin flap that is overrotated in a cephalad direction not only
can compromise the temporal hairline but also tends to produce
flatness in the lateral midface overlying the masseter and parotid.
This imparts a tight, unnatural appearance to the face. The effect
of scar perceptibility is evident when strong skin tension is used
in an attempt to contour the face.
48.4.1 Surgical Technique:
Extended SMAS Dissection
Most patients who have enough laxity to justify a facelift will
benefit from tightening the superficial fascial layer. Restoring
support to the underlying deeper facial soft tissues has become
a key part of my approach to improve facial aging. If the SMAS is
thin and tenuous, plication of this layer is an alternative to formal
SMAS elevation. However, in my opinion, better contouring, more
aesthetic control and longer-lasting results are obtained after a
formal dissection of the superficial fascia from the restraint of
the retaining ligaments.
In skin flap dissection, it is important to develop uniform
skin flaps during the subcutaneous undermining, taking care to
leave some intact fat along the superficial surface of the SMAS,
especially where the SMAS is to be dissected. If the skin flaps are
dissected so that no fat is left along the superficial surface of the
Fig. 48.23 Vectors for redraping superficial musculoaponeurotic
system dissection and skin flap.
Fig. 48.24 Effect of vertical rotation of the cervicofacial flap associated
with hairline distortion.

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VIII Surgical Rejuvenation of the Face and Neck
SMAS, then the SMAS becomes more difficult to raise, being thin,
tenuous, and prone to tearing. In a SMAS-type facelift, much of
the contouring is obtained by elevation and fixation of the SMAS
layer. The more substantial the SMAS flap, the better the surgical
and aesthetic control in the result.
I carry the subcutaneous skin flap dissection into the malar
region just past the restraint of the lateral zygomatic ligaments.
This represents the subcutaneous junction between the superior
middle and malar fat compartments. Caudally, the subcutaneous
undermining carries the skin flap dissection from the middle into
the lower malar and jowl fat compartments, just anterior to the
restraint of the masseteric ligaments. From an anatomic perspec-
tive, this skin flap dissection is carried anteriorly to the junction
between the fixed and mobile regions of the cheek.
Accuracy in the degree of subcutaneous dissection provides
more aesthetic control, and overdissection of the skin flap should
be avoided, as it is unnecessary to recruit skin and increases
the morbidity of the procedure. Limiting skin flap elevation just
past the restraint of the retaining ligaments provides adequate
flap release as well as better aesthetic control by preserving the
attachments that go from SMAS to the facial skin via the reti-
nacula cutis anteriorly. The preservation of these attachments,
followed by adequate release of the SMAS, enables the surgeon
to reposition anteriorly displaced fat and skin as a composite unit
through SMAS rotation. Preserving the medial retinacular fibers
by limiting overdissection of the skin flap provides for more con-
trol in correction of radial expansion through internal fat and skin
repositioning via the SMAS.
48.4.2 SMAS Elevation
The dissection of the superficial fascia allows the surgeon to
reelevate the jowl and descended malar fat upward into the
face as well as internally reposition fat closer to the deep fascia
and facial skeleton. The aesthetic basis of an extended SMAS
dissection, a variation of high SMAS techniques, is that both the
anterior and lateral cheek are repositioned as a unit, independent
of skin flap redraping.
The incision design for the extended SMAS dissection rep-
resents an extension of a standard lateral SMAS dissection. The
malar aspect of the dissection allows for the repositioning of facial
fat along the infraorbital and lateral orbital rim, as well as restor-
ing lateral malar volume. The SMAS dissection just lateral to the
zygomatic eminence provides access to the masseteric ligaments
to allow jowl fat elevation and to restore submalar concavity. The
dissection laterally in the cheek frees the SMAS from the parotid
and sternocleidomastoid, improving mandibular border contour
(Fig. 48.25).
The incisions for the extended SMAS dissection begin in the
preauricular region approximately 1 cm inferior to the zygomatic
arch, caudal to the path of the frontal branch. This horizontal
incision is continued several centimeters forward to the region
where the zygomatic arch joins the body of the zygoma. At this
point, the malar extension of the SMAS dissection begins with the
incision angling superiorly over the malar eminence toward the
lateral canthus for a distance of 3 to 4 cm. On reaching the edge
Fig. 48.25 The incision design for the extended superficial muscu-
loaponeurotic system (SMAS) dissection represents an extension of a
standard lateral SMAS dissection.
Fig. 48.26 To obtain mobility of the superficial fascia in an extended
superficial musculoaponeurotic system (SMAS) dissection, the surgeon
must mobilize the SMAS peripheral to the restraint of the retaining
ligaments. To ensure adequate flap mobility, the SMAS needs to be
completely dissected from the underlying parotid gland including the
accessory lobe, from the superior masseteric ligaments, and from the
lateral zygomatic ligaments. (Left figure 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.)

48 Extended SMAS Technique in Facial Rejuvenation
627
of the subcutaneous skin flap in the region of the lateral orbit, the
incision is carried inferiorly at a 90ƒ angle toward the superior
aspect of the nasolabial fold. The malar incision design parallels
the cephalad boarder of the lateral malar pad, which is usually
apparent overlying the malar eminence. A vertical incision is
designed along the preauricular region, extending along the lat-
eral border of the platysma, carrying the incision 6 to 8 cm below
the mandibular border.
To obtain mobility of the superficial fascia in an extended SMAS
dissection, the surgeon must mobilize the SMAS peripheral to
the restraint of the retaining ligaments. To ensure adequate flap
mobility, the SMAS needs to be completely dissected from the
underlying parotid gland, including the accessory lobe, from the
superior masseteric ligaments, and from the lateral zygomatic
ligaments (Fig. 48.26).
The SMAS in the malar region is elevated in continuity with
the SMAS of the cheek. In elevating the malar portion of the
SMAS dissection, the fibers of the orbicularis oculi, as well as the
zygomaticus major and minor, are usually evident, and the flap
is elevated directly along the superficial surface of these muscles.
It is important to carry the dissection directly external to these
muscle fibers, where a natural plane exists, remembering that
the facial nerve branches lie deep to these muscular bellies. The
malar SMAS is elevated until the flap is freed from the underlying
zygomatic eminence.
Completely freeing the SMAS from the lateral zygomatic attach-
ments is an important technical point in obtaining the mobility
necessary to reposition the malar soft tissue superiorly. Similarly,
to obtain adequate SMAS mobility of the lower cheek and jowl
requires a division of the stout fibers of the upper masseteric
ligaments. Dissection the SMAS from the parotid and ligaments
along the anterior boarder of the sternocleidomastoid completes
the SMAS release. Once free from ligamentous attachments, the
SMAS dissection becomes less fibrous and traction of the SMAS
demonstrates unrestricted cheek movement.
In terms of technical difficulty, elevating the SMAS just lateral
to the zygoma is the most difficult aspect of an extended SMAS
dissection, as the SMAS is thin in this region and the nerve
branches are close.
From an anatomic perspective, in dissecting the SMAS over the
parotid, accessory lobe of the parotid, or lateral zygoma, the nerve
branches are deep and protected. -ust lateral to the zygoma, in
the region of the upper masseteric ligaments, the nerve branches
are relatively less protected. Proceed carefully in this region and
stop the dissection as soon as the upper masseteric ligaments are
divided and the SMAS becomes mobile. I prefer to perform this
segment of an extended SMAS dissection last, after I have elevated
the SMAS both laterally and medially. I find it best to perform flap
dissection in regions where the depth of dissection is more easily
clarified before extending flap elevation lateral to the zygoma.
Proceed carefully in this portion of the SMAS elevation.
Repositioning and closure of the SMAS is then performed. The
malar SMAS flap is advanced superolaterally over the zygomatic
prominence in a direction perpendicular to the nasolabial fold
and usually paralleling the zygomaticus major muscle.
Once the malar flap is secure, the cheek–SMAS flap is typically
repositioned vertically. I prefer vertical vectors of the lateral
SMAS, as this produces a more defined contour along the jaw-
line and jowl. If the SMAS has been freed from the parotid and
ligaments along the anterior border of the sternocleidomastoid,
a suture placed in the preauricular region will typically vertically
elevate the lateral SMAS 5 to 7 cm. The SMAS flap is then carefully
secured with multiple interrupted buried sutures. Occasionally
skin dimpling is noted after securing the SMAS flap; this results
from the forces of SMAS rotation on resuspended facial skin. Skin
dimpling is treated by simply performing a bit more subcutaneous
undermining before skin flap redraping.
As I have gained more experience with this procedure, I realize
that the most important aspect of an extended SMAS facelift is
not the SMAS dissection but rather the suturing of the SMAS.
Dissecting the SMAS free from the restraint of the retaining liga-
ments is a permissive factor, providing the surgeon more control
in fat repositioning. How the SMAS is sutured determines both
the location and volume of fat repositioned (this volume is located
adjacent to the suture line) and affects the internal repositioning
of fat and correction of radial expansion. I spend as much time
suturing the SMAS accurately as I do dissecting it.
After proper contouring of the SMAS, the facial skin flaps are
rotated and closed in the direction decided based on preoperative
evaluation. In general, I prefer more lateral vectors in redraping
the skin, with most of the redundant skin removed over the ear
and the temporal hairline not shifted cephalically. The skin flaps
are inset with a minimum degree of tension placed along the key
sutures, and then the skin flaps are trimmed with a degree of
redundancy between the key sutures to minimize tension along
the incision sites. I favor restoring contour facelifting through
deep layer support, placing the tension on the SMAS and platysma
closure, and minimizing the tension on skin flap closure to obtain
consistency in terms of scar perceptibility. Stated in other terms,
facial contouring is restored through deep layer support rather
than through tension in skin flap redraping.
To summarize, the key points in mobilizing the superficial
fascia from the restraint of the retaining ligaments of the cheek
are as follows:
• The SMAS overlying the parotid gland and malar eminence tends
to be substantial and easy to dissect, with both the parotid and
zygomaticus major and minor muscles protecting the underly-
ing facial nerve branches. These areas are very safe regions to
begin SMAS elevation and delineate the sub-SMAS plane.
• The thinnest fascial component of an extended SMAS dissec-
tion is in the region just lateral to the zygomatic eminence,
where the SMAS splits to invest the elevators of the upper lip.
Dissecting the skin flap thinly in this region leaves a substan-
tial amount of subcutaneous fat intact along the surface of the
superficial fascia, providing greater ease of SMAS dissection
and minimizing the possibility of tearing at this location.
• The most difficult portion of an extended SMAS dissection is
freeing the superficial fascia from the restraint of the superior
masseteric ligaments, which are lateral to the zygomatic
eminence. If these ligaments are not mobilized, restricted
movement is noted in the portion of superficial fascia that
affects contouring along the lower cheek and anterior jowl.
The zygomatic branches of the facial nerve are in close prox-
imity to the upper masseteric ligaments. At times it can prove
difficult to differentiate between ligaments and facial nerve
branches. Caution is essential in this region of dissection; if
the anatomy is unclear, limit dissection in this region.

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VIII Surgical Rejuvenation of the Face and Neck
48.4.3 Vectors of Fat Elevation:
Facial Asymmetry
All patients exhibit some degree of facial asymmetry. Commonly,
one side of the face is vertically longer, and the short side of the
face is usually wider than the long side. Malar highlights are typ-
ically more superiorly located on the long side of the face, and,
with age, facial fat tends to descend in a more vertical direction
on the long side. As facial asymmetry and facial skeletal config-
uration are asymmetric in most individuals, it follows that the
vectors of fat elevation (SMAS repositioning) should be specific
for the right and the left side of the face.
The vector in which the SMAS is repositioned has a significant
impact on the location and volume of elevated facial fat, thereby
influencing facial shape. Decisions regarding the direction of
SMAS vectoring for the right and left sides of the face are best
determined preoperatively, as it is very difficult to make aesthetic
vector judgments intraoperatively with the patient recumbent.
SMAS vectors influence postoperative facial shape. Vertical
SMAS repositioning typically provides a larger amount of fat
for enhancing the malar eminence and allows for a reduction in
fullness within the submalar region as fat is forced vertically along
the concavity of the buccinator. For this reason, vertical SMAS
vectors are often indicated to reshape round, full faces, allowing
them to appear more tapered and thinner postoperatively. In the
patient shown in Fig. 48.27, a small amount of jowl defatting
through needle aspiration was also performed.
If the SMAS is vectored more obliquely, there is less volume of fat
brought into the malar region and a greater volume of fat repositioned
into the submalar region. Oblique SMAS repositioning is therefore
helpful in elderly patients who appear gaunt over the buccal recess,
as it allows the surgeon to enhance the submalar region volumet-
rically. Volume addition to augment the submalar region is helpful
in these type of deflated faces to blend the cheek with the perioral
region and prevent occurrence of cross-cheek depressions.
The patient shown in Fig. 48.28 exhibited asymmetry in the
submalar region preoperatively. The area appeared hollow and
concave on the right and fuller on the left side. For this reason, the
SMAS was vectored obliquely on the right to enhance the subma-
lar region volumetrically; it was vertically vectored on the left to
restore submalar hollowing and balance the two sides of her face.
48.4.4 SMAS Fixation
In a two-layer SMAS-type facelift, the tension of contouring is
placed on the superficial fascia rather than on the skin envelope.
Thus the fascial quality and tensile strength of the superficial
fascia have an influence on both the longevity of the result and
the volume of fat, which can be repositioned intraoperatively and
maintained postoperatively. In other words, soft tissue quality
influences long-term contour and is the primary reason facelifts
in young patients are more predictable.
I have come to realize that the predominant factor in improving
shape is the method in which the superficial fascia is secured, as
well as how the SMAS is sutured affects facial shape:
• Adding more sutures enables the surgeon to stack volume along
the suture line, which is located in the lateral cheek and along
the lateral malar eminence, both regions that deflate in aging.
• As the superficial fascia is sutured, facial fat is not only repo-
sitioned vertically but also repositioned internally, forcing the
soft tissue to conform to the underlying deep facial structures.
This provides the surgeon greater control in improving radial
expansion, something especially evident in the submalar region.
The excess SMAS, rather than being excised, is typically rolled
onto itself to form a double layer of SMAS thickness so as to aid in
secure fixation. An added benefit of preserving the excess SMAS
is that it allows stacking of vascularized fat over the zygomatic
eminence, highlighting the malar region and serving as an autoge-
nous malar augmentation (Fig. 48.29).
Fig. 48.27 In this patient, a small amount of jowl defatting through
needle aspiration was also performed as well as superficial muscu-
loaponeurotic system 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 reposi-
tioning. Plast Reconstr Surg. 2007; 119:362-376.)
Fig. 48.28 (a) Patient with preoperative asymmetry in the submalar
regions, which appeared hollow and concave on the right and fuller on
the left side. (b) For this reason, the superficial musculoaponeurotic
system was vectored obliquely on the right to enhance the submalar
region volumetrically; it was vertically vectored on the left to
restore submalar hollowing and balance the two sides of her face.
(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

48 Extended SMAS Technique in Facial Rejuvenation
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48.4.5 Correction of Platysma Bands
and Cervical Obliquity
The best approach to the anterior platysma is through a sub-
mental incision placed just caudal to the submental skin crease.
If this crease is deep, the skin cephalad is elevated toward the
base of the chin pad and along the caudal mandibular border to
free the crease from the mandibular ligaments. This softens the
appearance of the submental crease and allows better blending
between the chin and the neck. The cervical skin is carefully
elevated, and the dissection is carried inferiorly in the neck.
:hen the platysma muscle is exposed anteriorly, most patients
exhibit a decussation of platysmal fibers across the midline, at
least for a few centimeters below the mentum. If platysma band
surgery is planned, these decussating fibers should be sharply
divided with scissor dissection in the midline. Then the medial
edge of the platysma is mobilized from the mentum inferiorly,
typically as low as the skin flap dissection. Mobilization, usually
performed using a combination of sharp and blunt dissections,
separates the platysma from the underlying subplatysmal fat,
the anterior belly of the digastric muscle, and the strap muscles
overlying the thyroid cartilage. At times numerous small venules
are encountered within the subplatysmal fat, and careful hemo-
stasis must be obtained. After mobilization of the medial edges
of the platysma, the subplatysmal fat is contoured according to
preoperative planning. I typically am conservative in subplatysma
fat removal and most commonly resect fat at the level of the hyoid
to deepen the cervical mental angle.
Following mobilization, the medial edge of the platysma
muscle is grasped on either side and overlapped in the midline
to estimate the amount of excess muscle present. Muscle excess
varies from patient to patient. A portion of the medial edge can be
excised to remove redundancy within the platysma. A conserva-
tive resection is performed to avoid undue tension at the time of
suture plication (Fig. 48.30).
Muscular plication consists of edge-to-edge approximation
using multiple interrupted sutures at the mentum and extending
at least to the level several centimeters caudal to the hyoid. This
longer plication enhances the surgeon’s ability to contour the
platysma so that it conforms to the floor of the mouth and the
thyroid cartilage. Suture placement back from the leading edge
of the muscle, in areas of intact muscular fascia, is an important
technical point in preventing suture pull-through postoperatively
(Fig. 48.31).
After edge-to-edge approximation of the platysma, some
form of muscular release is performed. This muscular release
commonly involves a partial transection of the platysma muscle,
with the myotomy performed inferiorly within the neck. This
usually consists of a horizontal cut extending from the midline a
distance of 5 to 7 cm, until the platysmaplasty appears to conform
to the floor of the mouth without tension. Division of not only the
muscle, but also the SMAS lining the posterior surface of the pla-
tysma, is an important technical point in adding the prevention of
band recurrence (Fig. 48.32).
Platysma transection is an effective technique for treating
platysma bands and obtaining improved cervical contour. This
procedure must be performed meticulously. Early experience
with transection was fraught with complications; specifically,
if the transection was performed at a high level, it could cause
unveiling of the submaxillary glands and denervation of the
platysma, leading to lower lip dysfunction. Also, obvious contour
depressions associated with divided muscular edges could occur
in an overly thin neck.
The key to platysma transection is that the transection be
performed low in the neck, where the muscle tends to be thin,
often as inferior as the midthyroid cartilage. Preservation of pre-
platysmal fat overlying where the transection is performed is an
important factor in preventing surface irregularities in the region
where the muscle is divided.
Fig. 48.29 Excess superficial musculoaponeurotic system tissue, rather
than being excised, is typically rolled onto itself to form a double layer
of fascia thickness so as to aid in secure fixation. (Left figure 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. 48.30 Following mobilization, the medial edge of the platysma
muscle is grasped on either side and overlapped in the midline to
estimate the amount of excess muscle present. Muscle excess varies
from patient to patient. A portion of the medial edge can be excised to
remove redundancy within the platysma. A conservative resection is
performed to avoid undue tension at the time of suture plication.

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VIII Surgical Rejuvenation of the Face and Neck
The muscular release after platysma transection serves many
purposes:
• It alleviates tension along the medial portion of the platysma
transection following plication.
• It allows the platysma to shift superiorly, producing a deeper
cervicomental angle.
• It prevents the conversion of two platysmal bands to a single
band after edge-to-edge approximation, which can be visible
when the neck is extended.
48.4.6 Sequence of SMAS Fixation
versus Platysmaplasty
Because the SMAS and the platysma lie in the same anatomic
layer, if platysmaplasty is performed before the SMAS dissection,
it can adversely affect facial contour. :hen the platysmaplasty is
performed first, the descended jowl fat is locked down into the
neck, and movement of the superficial fascia diminishes follow-
ing elevation of the SMAS. This diminished movement tends to
lessen the surgeon’s ability to modify facial shape. If the SMAS
fixation is performed before the platysmaplasty, descended jowl
fat is repositioned cephalad into the cheek, which improves
laxity along both the jawline as well as the neck. After the SMAS
has been securely sutured bilaterally, the mandibular border
will appear more defined, making cervical contouring less
demanding. :hen performing platysmaplasty subsequent to
Fig. 48.33 How facial fat reelevation influences cervical appearance.
(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. 48.34 Result after extended superficial musculoaponeurotic
system repositioning and platysmaplasty. (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. 48.32 After edge-to-edge approximation of the platysma,
some form of muscular release is performed. This muscular release
commonly involves a partial transection of the platysma muscle, with
the myotomy performed inferiorly within the neck.
Fig. 48.31 Muscular plication, consisting of edge-to-edge approximation
using multiple interrupted sutures at the mentum and extending at
least to the level several centimeters caudal to the hyoid, enhancing the
surgeon’s ability to contour the platysma so that it conforms to the floor
of the mouth and the thyroid cartilage. Suture placement back from the
leading edge of the muscle, in areas of intact muscular fascia, is an import-
ant technical point in preventing suture pull-through postoperatively.

48 Extended SMAS Technique in Facial Rejuvenation
631
SMAS fixation, the surgeon will notice less redundancy along the
medial borders of the platysma; there is also less need to resect
muscle at the time of platysmaplasty. The enhanced contour
effects of extended SMAS dissection, associated with precise
platysmaplasty, tend to diminish the need to remove cervical fat.
In general, the neck and jawline appear softer if preplatysmal fat
is preserved when contouring the neck.
The patient shown in Fig. 48.33 illustrates how facial fat reele-
vation influences cervical appearance. Sequencing errors can lead
to loss of contour; I prefer to perform SMAS elevation and fixation
before performing platysmaplasty. As the facial fat and skin are
reelevated upward into the midface through SMAS rotation, the
mandibular border becomes more distinct, making cervical con-
touring more predictable.
The woman shown in Fig. 48.34 demonstrates the result after
extended SMAS repositioning and platysmaplasty.
The patient in Fig. 48.35 is shown before and after an extended
SMAS dissection. By reelevating descended facial fat back up toward
the malar region and lateral midface and securing it there intraop-
eratively, her facial shape is improved. The mandibular border has
been enhanced through SMAS repositioning and platysmaplasty.
48.4.7 Incisions
The importance of incision quality cannot be overemphasized
in diminishing signs that the patient has undergone a surgical
procedure. One of the major advantages of a two-layer facelift is
that the tension of contouring is along the superficial fascia, and
thus there is less need to redrape the skin flap with great force.
Decreased tension on the key sutures in both the preauricular
and postauricular region provides greater control over scar per-
ceptibility. If the incisions are artistically designed, patients can
typically wear their hair up off their ears without the obvious
stigma that a facelift has been performed.
Many authors have described the salient factors regarding
incision design; these main points should be emphasized:
• Tragal incisions, placed at the margin of the tragus rather
than preauricularly, are preferable, because the color differ-
ence between the pale skin of the ear and the blush skin of
the cheek is usually better camouflaged when the incision is
brought internally into the ear.
• Tragal incisions are more demanding than preauricular
incisions, requiring precise design and placement so that the
tragus is not distorted. The aesthetic unit of the tragus is rect-
angular, as opposed to semilunar. If the surgeon designs the
tragal incision properly, respecting the incisura of the tragus,
the tragus will appear normal in its shape postoperatively,
exhibiting both a visual beginning at its junction with the
helix and a visual ending along the preserved incisura.
• Detached earlobes tend to appear more natural than attached
earlobes. If a small cuff of cheek skin is left attached to the
earlobe, it will allow surgical rotation of the skin up under the
earlobe during skin flap redraping, with suturing of the ear-
lobe distinct from the cheek flap. The earlobe should be inset
in an axis posterior to the axis of the pinna, thereby avoiding
a pixie deformity.
The intraoperative photograph in Fig. 48.36 illustrates the
standard tragal incision with preservation of the incisura of the
tragus. The incision is carried around the earlobe approximately 1
to 2 mm caudal to the junction of the earlobe with the cheek skin.
In Fig. 48.37, a preauricular incision is shown at left, 2 months
postoperatively. Again, the problem with preauricular incisions is
Fig. 48.35 Patient (a) before and (b) after an extended superficial
musculoaponeurotic system (SMAS) dissection. By reelevating
descended facial fat back up toward the malar region and lateral
midface and securing it there intraoperatively, her facial shape is
improved. The mandibular border has been enhanced through SMAS
repositioning and platysmaplasty.
Fig. 48.36 Standard tragal incision with preservation of the incisura of
the tragus. The incision is carried around the earlobe approximately 1
to 2 mm caudal to the junction of the earlobe with the cheek skin.
a
b

632
VIII Surgical Rejuvenation of the Face and Neck
that the difference in color between the skin of the cheek and the
skin of the ear is more visible in this anterior incision location.
In the center, a tragal incision is seen 5 months postoperatively;
this incision was patterned after the methods shown in Fig. 48.36.
At right, a well-designed and inset tragal incision should produce
an imperceptible, normal-appearing tragus that exhibits both a
visual beginning and end and a detached-appearing earlobe.
There is an increasing public demand for facial rejuvenation at
earlier ages, when facial laxity is often minimal. This places the
onus on the surgeon to create incisions that are imperceptible if
these procedures are to be justified. 1o matter how well deep-
layer support is obtained and facial contour improved by SMAS
elevation and platysmaplasty, if the incision is obvious, the scar
quality poor, the hairline disturbed, or the earlobe deformed, the
overall result will be disappointing.
48.5 Concluding Thoughts
From a personal perspective, after close to three decades of
striving to improve techniques in facial rejuvenation, it is
my firm conviction that improving technical control when
contouring the superficial facial fascia and platysma provides
a more consistent, aesthetically pleasing result that is natural
in appearance. To perform a successful two-layer SMAS-type
facelift, the surgeon must not only understand facial soft tissue
anatomy but also perform a procedure that demands technical
precision. A two-layer SMAS-type facelift is a time-consuming
operation, with both the skin flap elevation and the dissection of
the SMAS requiring meticulous, accurate dissection. Obtaining
consistency with this procedure is challenging because of the
variability among individuals in the thickness of subcutaneous
fat and the SMAS and the variability of facial shape that must
be contoured. After precise dissection, secure fixation of both
the SMAS and platysma is essential to maintain the desired
postoperative shape. Ensuring meticulous hemostasis, followed
by careful skin flap inset, are required to minimize postoperative
scar perceptibility and ensure a rapid postoperative recovery.
Despite these demands, I have found the extended SMAS tech-
nique to be rewarding, with a high degree of patient satisfaction. All
techniques have advantages and disadvantages. For me, the biggest
advantage of the extended SMAS technique remains its aesthetic
versatility, allowing the surgeon to vary the contouring aspects of
the procedure according to the aesthetic needs of the patient.
Clinical Caveats
• Patient selection is probably the most critical factor in deter-
mining the success of a proposed aesthetic procedure.
• The anatomic arrangement of the facial soft tissues as a
series of concentric layers is key to the safety of rhytidectomy
procedures. This concentric arrangement allows dissection
within one anatomic plane to proceed completely indepen-
dent of structures lying within another anatomic plane.
• Improving technical control when contouring the superficial
facial fascia and platysma provides a more consistent, aes-
thetically pleasing, nonsurgical-looking result.
• The surgical significance of the deep facial fascia is that all the
facial nerve branches within the cheek lie deep to the deep
facial fascia.
• Although aging is a complex process, many of the stigmata
developing in the aging face involve a change in the relation-
ship between the superficial and deep facial fascia, with the
superficial unit of the facial soft tissue descending inferiorly in
relation to the fixed deeper structures of the face.
• The importance of the zygomatic ligaments lies in their abil-
ity to suspend malar soft tissue superiorly over the zygomatic
eminence. With aging, malar support commonly attenuates,
leading to an inferior migration of malar soft tissue. Dermal
elastosis and attenuation of support from retaining ligaments,
associated with both deflation and radial expansion, are the
Fig. 48.37 (a) Preauricular incision 2 months postoperative. (b) Tragal incision 5 months postoperative, patterned after the methods shown in the
Fig. 48.36. (c) Well-designed and inset tragal incision producing an imperceptible, normal-appearing tragus that exhibits both a visual beginning and
end and a detached-appearing earlobe
a
b
c

48 Extended SMAS Technique in Facial Rejuvenation
633
main components that must be addressed to reconstruct the
anatomic changes resulting from aging.
• The principal advantage of performing skin undermining
separately from SMAS dissection is that it allows these two
layers to be redraped along vectors that are independent of
one another.
• The significance of the retaining ligaments is their location,
which determines the degree of surgical dissection necessary
in face lifting.
• In facelifting, it would seem that wide mobilization and
aggressive dissection would improve contour, but my expe-
rience with wide dissection has led me to a contrary view. I
have found that wide dissection peripheral to the restraint of
the retaining ligaments is counterproductive in an extended
SMAS facelift technique.
• A facelift can be considered an aesthetically reconstructive
procedure in that facial soft tissue anatomy is restored to a
state resembling its structure before the degenerative effects
of aging occurred.
• More than any other factors, skin quality and elasticity
have perhaps the greatest influence on outcome after a
rhytidectomy.
• Buccal fat removal tends to reduce facial fullness, but rarely
does it improve prominent jowls.
• In most patients, jowling can be improved through SMAS
rotation. In some patients jowl fat removal is helpful.
• The prominent nasolabial fold requires restoration of malar
support to produce a lasting change in contour. In my expe-
rience, extending the cheek SMAS dissection into the malar
region to restore malar support has been helpful in improving
prominent nasolabial folds. Volume addition medial to the
fold is helpful in blending the cheek with the perioral region.
• Correction of the obtuse neck involves restoration of skin
tone, contouring of regional lipodystrophy, and restoration
of platysma support.
• One of the major advantages of a two-layer facelift is that the
tension of contouring is along the superficial fascia, and thus
there is less need to redrape the skin flap with great force.
• The importance of incision quality cannot be overemphasized
in diminishing the signs that the patient has undergone a
surgical procedure.
• The postauricular incision extends along the postauricular
groove, not up onto the conchal surface.
• Because the SMAS and platysma represent the same ana-
tomic layer, if platysmaplasty is performed before the SMAS
dissection, it can adversely affect facial contour. Contouring
the platysma after SMAS fixation leads to more control in
shaping both the cheek and neck.
• In skin flap dissection, it is important to develop uniform skin
flaps during the subcutaneous undermining, taking care to
leave some fat intact along the superficial surface of the SMAS,
especially in the regions where the SMAS is to be dissected.
• The SMAS overlying the parotid gland and malar eminence
tends to be substantial and easy to dissect, with both the
parotid and zygomaticus major and minor muscles protect-
ing the underlying facial nerve branches. These areas are
very safe regions to begin SMAS elevation and delineate the
sub-SMAS plane.
• Because the SMAS and platysma are in the same layer, what
the surgeon does in the face influences the contour in the
neck.
Suggested Reading
[1] Aston S-. Face lift with FAME technique. Presented at the Thirty-Second Annual
Baker Gordon Symposium on Cosmetic Surgery, Miami, FL, 1998
>2@ Aston S-. Platysma muscle in rhytidoplasty. Ann Plast Surg 1979;3(6):529–539
>3@ Baker T-, Gordon HL, Stuzin -M. Surgical Rejuvenation of the Aging Face, 2nd ed.
St. Louis, MO: CV Mosby; 1995
>4@ Barton FE -r. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg
1992;90(4):601–607
>5@ Connell BF. Cervical lifts: the value of platysma muscle flaps. Ann Plast Surg
1978;1(1):32–43
>6@ Connell BF. 1eck contour deformities. The art, engineering, anatomic diagnosis,
architectural planning, and aesthetics of surgical correction. Clin Plast Surg
1987;14(4):683–692
[7] Connell BF, Marten T-. The trifurcated SMAS flap: three-part segmentation of the
conventional flap for improved results in the midface, cheek, and neck. Aesthetic
Plast Surg 1995;19(5):415–420
[8] Feldman JJ. Neck Lift. St. Louis, MO: 4uality Medical Publishing; 2006
[9] Gierloff M, St|hring C, Buder T, Gassling V, Aoil <, :iltfang -. Aging changes of the
midface fat compartments: a computed tomographic study. Plast Reconstr Surg
2012;129:263–273
>10@ Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg 1990;86(1):53–61,
discussion 62–63
[11] Lambros V. Fat contouring in the face and neck. Clin Plast Surg
1992;19(2):401–414
>12@ Lambros V, Stuzin -M. The cross-cheek depression: surgical cause and effect
in the development of the ´joker lineµ and its treatment. Plast Reconstr Surg
2008;122(5):1543–1552
>13@ Lemmon ML, Hamra ST. Skoog rhytidectomy: a five-year experience with 577
patients. Plast Reconstr Surg 1980;65(3):283–297
>14@ Little -:. Three-dimensional rejuvenation of the midface: volumetric resculp-
ture by malar imbrication. Plast Reconstr Surg 2000;105(1):267–285, discussion
286–289
>15@ Marten T-. Facelift. Planning and technique. Clin Plast Surg 1997;24(2):269–308
>16@ Mendelson BC. Surgery of the superficial musculoaponeurotic system: principles
of release, vectors, and fixation. Plast Reconstr Surg 2001;107(6):1545–1552,
discussion 1553–1555, 1556–1557, 1558–1561
[17] Mendelson BC. Correction of the nasolabial fold: extended SMAS dissection with
periosteal fixation. Plast Reconstr Surg 1992;89(5):822–833, discussion 834–835
[18] Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the
parotid and cheek area. Plast Reconstr Surg 1976;58(1):80–88
[19] Owsley -4. Lifting the malar fat pad for correction of prominent nasolabial folds.
Plast Reconstr Surg 1993;91(3):463–474, discussion 475–476
>20@ Owsley -4 -r. SMAS-platysma facelift. A bidirectional cervicofacial rhytidectomy.
Clin Plast Surg 1983;10(3):429–440
>21@ Rogers BO. A brief history of cosmetic surgery. Surg Clin North Am
1971;51(2):265–288
>22@ Rohrich R-, Pessa -E. The fat compartments of the face: anatomy and clinical
implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219–2227,
discussion 2228–2231
>23@ Rohrich R-, Stuzin -M, Dayan E, Ross EV, eds. Facial Danger Zones: Staying Safe
with Surgery, Fillers, and Non-Invasive Devices. 1ew >24@ Skoog T. 3ODVWLF 6XUJHU\ 1HZ 0HWKRGV DQG 5HfiQHPHQWV. Philadelphia, PA: :B
Saunders; 1974
>25@ Stuzin -M. Restoring facial shape in face lifting: the role of skeletal support
in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg
2007;119(1):362–376, discussion 377–378
>26@ Stuzin -M, Baker T-, Baker TM. Refinements in face lifting: enhanced facial
contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg
2000;105(1):290–301
>27@ Stuzin -M, Baker T-, Gordon HL. The relationship of the superficial and deep
facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg
1992;89(3):441–449, discussion 450–451
>28@ Stuzin -M, Baker T-, Gordon HL, Baker TM. Extended SMAS dissection as an
approach to midface rejuvenation. Clin Plast Surg 1995;22(2):295–311

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VIII Surgical Rejuvenation of the Face and Neck
49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the
Midface, Cheek, and Jawline
Timothy Marten and Dino Elyassnia
Abstract
The traditional ´lowµ cheek superficial musculoaponeurotic
system (SMAS) flap, elevated below the zygomatic arch, suffers
the drawback that it cannot, by design, exert an effect on tissues of
the midface and infraorbital region. Low designs target the lower
cheek and jowl only and produce no improvement in the upper
anterior cheek and midface area. Planning the flap higher, along
the zygomatic arch, and extending the dissection medially in an
´extended SMASµ fashion to mobilize midface tissue overcomes
this problem and allows a combined, simultaneous single-flap
lifting of the jawline, cheek, and midface. An improved outcome
is obtained, and no separate midface lift procedure is needed.
Keywords
facelift, superficial musculoaponeurotic system, high SMAS,
midface lift, extended SMAS, lamellar dissection, bidirectional
facelift, SMAS vector, trifurcated SMAS, postauricular trans-
position flap, facelift incisions, concealed-incision facelift,
retrotragal incision, earlobe reconfiguration, earlobe reduction,
earlobe insetting, Marten facelift marker, Ristow’s triangle,
aging face, facelift anesthesia, short-scar facelift, lateral sweep,
hairline displacement, ´chopped-offµ tragus, retracted tragus,
pixie ear
49.1 Introduction
Traditional facelift techniques have relied upon the tightening
of thin flaps of aging skin to elevate and support sagging, deeper
facial tissue. Although initial results from these procedures
often appeared good, early recurrence of the original problems
was common, and poor scars and healing problems were fre-
quently seen as a result of obligatory wide flap undermining and
unavoidable skin flap tension. These procedures also typically
produced an easily recognized tight or ´faceliftedµ look, which
was usually exacerbated by subsequent similarly performed
procedures.
As plastic surgeons have pursued more natural-appearing
and long-lasting outcomes, our understanding of the facial aging
process and the underlying anatomy responsible for the associ-
ated changes has improved and facelift techniques have evolved.
Experience has since confirmed that an attractive and natural-
appearing result is not possible without diverting tension from
the skin to the superficial musculoaponeurotic system (SMAS)
and platysma and without addressing other deep-layer structures
and the aging midface.
49.2 Fundamental Concepts in
Rejuvenation of the Face
49.2.1 Recognizing the Aging Changes
of the Face
Recognizing the components of the aging changes of the face
and appreciating the underlying anatomic abnormalities is
essential to properly advising patients and fundamental to the
planning of any surgical repair. Careful analysis will reveal that
most patient problems will fall into three broad categories: (1)
aging and breakdown of the skin and skin surface; (2) facial
sagging, skin redundancy, and loss of youthful facial contour;
and (3) facial wasting, atrophy, and/or age-related lipodystro-
phy. Proper treatment will depend upon the types of problems
present, the patient’s priorities, and the time, trouble, and
expense the patient is willing to invest to obtain the desired
improvement.
Patients primarily concerned with surface aging of their face
may not require formal surgical procedures and may achieve the
type of improvement they desire through salon care and derma-
tologic surface treatments of the skin. These treatments include
skin peels, skin resurfacing, chemodenervation (neurotoxin injec-
tions), and various forms of cutaneous laser and other treatments
designed to remove or reduce age spots, telangiectasias, wrinkles,
and other age-related skin surface imperfections.
Patients primarily concerned with facial sagging, skin excess,
and loss of facial contour will achieve minimal ultimate improve-
ment, however, if only surface treatments are employed, and
they will require formal surgical lifts, in which sagging tissue is
repositioned and redundant tissue is excised, if these problems
are to be properly corrected and an attractive and natural-
appearing improvement is to be obtained. The misapplication
of surface treatments of the skin to the sagging face with excess
tissue will produce little more than a smooth but saggy face
with no improvement in contour. This sort of smooth-saggy
look, typically seen in older patients who have undergone laser
resurfacing or deep skin peels, is inconsistent with a natural
appearance, as patients with loss of facial contour generally
also have concomitant skin surface aging. It is arguably more
attractive and natural appearing to have a well-contoured face
with a few wrinkles and surface imperfections than a smooth
but saggy one.
Similarly, the misapplication of filler or fat injections to the
sagging face with excess skin and an overly large skin envelope
may produce a smoother face but at the same time an objection-
ably large, heavy, and unfeminine-appearing one. One must also
keep in mind that despite industry efforts to make us believe

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
635
otherwise, fillers ´liftµ radially³that is, in an outward direction³
not vertically. Suggesting that fillers lift the face vertically may
be one of the most deceptive and most thoughtlessly repeated
mischaracterizations we make to ourselves and our patients.
Many if not most of the changes associated with loss of facial
contour, however, represent primarily “deep-layer” problems that
will not be adequately corrected with traditional ´skin onlyµ or
´low-SMASµ techniques. Regrettably, many surgeons unfamiliar
with deep-layer techniques, and other physicians insufficiently
trained to perform them, often perform ´skin-onlyµ facelifts or
´mini-liftsµ and resort to misguided and misapplied ancillary
procedures in an ultimately futile effort to overcome the short-
comings of these methods.
Patients with significant facial atrophy and age-related
facial wasting will generally achieve suboptimal improvement
from both surface treatments of facial skin and surgical lifts.
Smoothing skin will not hide a drawn appearance caused by
loss of facial volume, and it is difficult to create natural and
attractive contours by lifting and repositioning tissues that have
abnormally thinned with age. Restoring lost facial volume with
autologous fat grafting is a powerful technique that has gained
widespread acceptance and is now acknowledged by most plastic
surgeons and other physicians engaged in treating the aging face
as ´the missing linkµ in facial rejuvenation and it comprises the
most important advance in aesthetic surgery in several decades
or more. Properly performed, the addition of fat to areas of the
face that have atrophied as a result of age or disease can produce
a significant and sustained improvement in appearance unob-
tainable by other means. In addition, autologous fat grafting may
represent the first true antiaging therapy that plastic surgeons
have to offer, in that there is a growing body of evidence that
adult stem cells transferred with fat exert a regenerative effect
on tissues in areas adjacent to areas where fat is injected, includ-
ing overlying skin.
Age-related facial atrophy rarely exists as an isolated event in
the healthy patient, however, and thus patients troubled by it are
not always logically or appropriately treated by fat grafting alone.
Isolated fat grafting is also arguably of questionable benefit to
the patient troubled by significant facial sagging and skin redun-
dancy. Although aggressive filling of the sagging face with fat can
produce improved contour and a smoother appearance, it gen-
erally results in an unusually large, overfilled face that appears
both unnatural and unfeminine. Such an overfilled face is hard
to correct in an attractive manner at a later date, and it is both
more logical and practical to perform fat grafting in conjunction
with formal surgical lifts if needed, or after ptotic tissue has been
repositioned and redundant tissue has been removed. :hen a
high-SMAS technique is used in conjunction with fat grafting,
both loss of facial contour and facial atrophy can be corrected,
and optimal improvement in the patient’s appearance can be
obtained.
49.2.2 Panfacial Rejuvenation
Rarely does isolated aging occur in the lower face and neck, and
many patients requesting primary facelift procedures often
need to undergo some sort of forehead and eyelid surgery, and
often procedures to improve the appearance of their mouth as
well, if they have not already done so. Many are confused by the
term facelift, however, and take it to imply that improvements
will be made comprehensively in all areas. These patients must
be counseled carefully, as the facelift itself will produce little if
any improvement in upper face and neck problems (or perioral
wrinkling and deflation) but rather tends to unmask and draw
attention to them.
It is not uncommon for patients concerned with aging in their
lower face and neck to question the need to undergo forehead
surgery. Many unconsciously optimize their forehead appearance
when looking in a mirror by raising their eyebrows, or they try to
conceal forehead ptosis by aggressive plucking of their lateral eye-
brows or the wearing of forehead-concealing hairstyles. Although
chemodenervation with botulinum toxin injections can smooth
forehead expression lines and, in some cases, be used to produce
some lateral brow elevation, it cannot correct advanced brow
ptosis or compensate for temporal tissue compression resulting
from raising the upper cheek during a facelift. Failure to recognize
forehead ptosis and properly advise patients regarding its signif-
icance and perform forehead surgery when needed can result
in a disharmonious appearance often referred to as the ´young
face³old foreheadµ deformity.
It is also not uncommon for patients to request that surgery be
performed upon their neck only. Although such a plan is accept-
able for some men, failure to restore attractive cheek contour and
lift sagging jowls concomitantly in women generally results in an
unnatural and unfeminine appearance. In addition, if an aggres-
sive “corset” platysmaplasty is performed as part of an isolated
neck lift, sagging in the cheeks and jowl area can be accentuated,
as platysma tightening exerts a downward pull on tissue in these
areas.
Facelift surgery can unmask other existing age-related problems
and create a need to perform additional procedures. This is com-
monly seen in the lower eyelid area, where the ptotic cheek often
smooths the lower lid skin preoperatively by dragging it inferiorly.
A properly executed repositioning of the midface and malar fat will
often result in some lower lid wrinkling and redundancy not present
before surgery. This can be demonstrated prior to the procedure to
the patient by elevating the cheek to the predicted postoperative
position while the patient holds a hand mirror, pointing out to
the patient the resulting wrinkling in the lower lid area. In these
cases some excision of lower lid skin must be made (or resurfacing
performed), even if the lid appears smooth before surgery, if lower
lid wrinkling is to be avoided postoperatively. It is also for this
reason that lower blepharoplasty should arguably be performed
after facelift surgery is complete, and not at the beginning of the
procedure.
49.2.3 Why Use the SMAS?
The fundamental flaw in ´skin-onlyµ facelifts (´mini-lifts,µ
“franchise facelifts,” “infomercial facelifts,” and similar limited
and predictably problematic “one-layer” procedures) is the
fact that skin was meant to serve a covering function and not a
structural or supporting one. Skin is an inherently elastic tissue
and was intended to stretch and move as we eat, speak, emote,
and express ourselves. It was not intended to support sagging
muscle, fat, and other structures lying underneath it that pre-
dictably descend with age. Attempts to use skin as the vehicle
to lift sagging deep-layer tissues by removing and tightening it

636
VIII Surgical Rejuvenation of the Face and Neck
corrupts its covering function and results in abnormal skin ten-
sion and related secondary problems including, but not limited
to, poor scars, tragal retraction, earlobe malposition, and a tight
and unnatural appearance. Skin tension also flattens contour,
rather than restoring it, and because skin stretches as tension
is applied, objectionable temple, sideburn, and occipital hairline
displacement is common when ´skin-onlyµ techniques are used.
In addition, because skin is inherently elastic and not capable of
providing a sustained support of deep facial tissues, the results
of most ´skin-onlyµ facelifts and similar ´mini-liftsµ are usually
short-lived.
Using the SMAS to lift sagging facial tissues and to restore lost
facial contour circumvents the problems associated with skin-only
lifts, as it is an inelastic structural fascial layer that is attached to
and envelops facial tissues sagging with age, and it is capable of
providing sustained foundational support to them. Although skin
is excised in SMAS procedures, and proper excision will provide
an improved result, only skin that is truly redundant is removed,
and closure can be made under normal skin tension. Facial skin so
treated will distribute itself naturally over new contours created
by SMAS repositioning and is capable of some self-repair and
contraction. This averts a tight, ´pulled,µ or ´liftedµ appearance,
provides for optimal wound healing and inconspicuous scars, and
adds further to the end result.
Using the SMAS provides a means by which sustained support
can be obtained from a structural tissue layer and one in which
tension can be transferred away from the skin. This results in a
soft, natural facial appearance with high-quality scars, and it often
triples or even quadruples the life span of improvement obtained.
Diverting tension to the SMAS and platysma and away from the
skin also preserves natural preauricular contours and minimizes
displacement of temporal and sideburn hairlines. In addition,
unlike skin-only facelifts, in which subsequent procedures worsen
skin tightness and problems associated with it, SMAS facelifts,
if skillfully performed, can be repeated as often as needed and
desired by the patient without producing skin tightness and
abnormal appearances. This removes the “two-facelift limit” set
by many surgeons performing one-layer skin-only procedures,
and it allows patients to undergo procedures at an earlier age and
more frequently, if desired.
Experience has shown that sustained and attractive support
of the deep layers of the face cannot be predictably obtained by
the placement of “suspension” and “cable” sutures, even if soft,
partially elastic, and absorbable materials are used, and the list of
failed products and techniques of these kinds is now quite long.
These ´suture liftµ procedures have led to a variety of significant
problems for many patients including suture extrusion, traction
dimples, visible bowstringing, ´puppet lines,µ ´joker lines,µ nerve
injuries, facial dyskinesias, chronic pain syndromes, and a wide
variety of abnormal appearances during animation. Suspension
sutures and implantable straps placed in the neck can also create
bunching and tissue irregularities and a tight or choking feeling
that is disturbing to patients and can result in difficulties in speak-
ing and swallowing. In at least one instance a cervical suspension
suture placed by an unknown surgeon precipitated lightheaded-
ness and syncope in a patient when her head was turned and her
neck flexed, necessitating its removal. In addition, if large, stiff,
permanent sutures or strap-type devices are used, the suture
knots and the sutures and straps themselves can often be felt
beneath the skin. In some cases the suture knots or implantable
straps can erode overlying skin or scalp, again necessitating their
removal.
The fundamental flaw in suture lifts and the use of suspension
sutures and implantable facial straps is that they rely on a small,
rigid thread or strap to support a large area of delicate, inherently
soft, mobile facial tissue. Over time these sutures or devices typi-
cally ´cheese-wireµ through tissues they were intended to support
and can injure important neuromuscular structures. Suspension
sutures and implantable straps also prevent natural depression
and downward movement of facial tissues, impeding certain
expressions, creating unnatural appearances, and precipitating
disturbing sensations.
Unlike suspension suture placement, SMAS elevation enables
a balanced and secure elevation of facial tissues without dis-
ruption of their natural relationships or facial muscle action.
Tissue anchoring is achieved through direct tissue contact and
healing, not distant point suspension by a suture, barbed thread,
or purported ´microplicationµ of facial tissues. SMAS elevation
also allows natural gliding and depression of tissue and more
natural appearances in animation that these other, ill-conceived
techniques do not.
The periosteum has been advocated by some as the layer
beneath which facelift dissection should be performed and the
vehicle by which sagging deep facial tissues should be elevated.
:hen properly performed, such procedures divert some tension
away from the skin and avoid many of the problems associated
with skin-only procedures. Improvement in the infraorbital and
upper midface areas may also be obtained in some cases when
the procedures are properly designed. The periosteal layer is a
conceptually illogical choice for overall rejuvenation of the face,
however, in that it is densely adherent to the facial skeleton and
does not significantly descend as part of the aging process. It is
also not closely associated with the intermediate layers of the
face, where most of the aging is known to occur, and its dissec-
tion typically results in prolonged swelling and induration and
generally portends a longer period of recovery for the patient
after the procedure. In addition, many subperiosteal facelift
techniques rely on the concomitant use of suspension sutures
and thus often share many of the problems related to these pro-
cedures. Unlike the periosteum, the SMAS is closely associated
with tissues that descend as the face ages and actually envelops
many, if not most, of those of concern. It is thus arguably a more
logical layer to use to restore facial tissues to a more youthful
position.
49.2.4 Why Use a SMAS Flap?
Despite the significant and time-tested advantages the SMAS
flap has made available to surgeons performing facial rejuve-
nation procedures, and the breakthrough in improvement in
appearance and longevity it has provided, as plastic surgeons
have sought to simplify the SMAS technique with the goal of
obtaining the benefits, or at least some of the benefits, of SMAS
flap surgery without the need to formally raise a SMAS flap. In
these procedures the SMAS is variously plicated, folded upon
itself, gathered with sutures, ´microplicatedµ with purse-string
suspension sutures, or strip-excised (´SMASectomyµ), and
no flap is dissected. Although these procedures are appealing

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
637
in their ostensible simplicity, experience has shown that the
placement of the multiple sutures now known to be necessary
in many of these procedures typically encompasses almost as
much time as that required to raise and suspend a SMAS flap. It
has also been seen that suture plication and SMAS strip excision
do not avert risk to facial nerves and other important structures
such as the parotid duct, as these structures have been injured
in plication procedures and other non–SMAS flap techniques.
As a practical matter, the biggest problem with plication and
SMAS strip excision procedures may rest in the fact that they are
destructive to the SMAS layer and compromise it, or even render
it useless for future use as a formal flap, and we have encountered
a number of patients who have suffered this problem. Typically
such patients are younger and have been convinced that they did
not need formal SMAS flap dissection and that SMAS plication
or microplication would suffice, but they have not obtained the
outcome and/or longevity they had hoped for. :hen a secondary
procedure is then performed in these patients, the SMAS layer
is often compromised or unusable for a formal SMAS flap proce-
dure. The patient’s only option under such situations is another
plication, and each successive such procedure further disrupts
and compromises the SMAS layer. In contrast, experience has
shown that a SMAS flap, when skillfully performed, can be read-
ily raised in secondary and tertiary procedures in many patients
and that SMAS flap elevation does not limit a patient’s future
options for treatment. This arguably is particularly important
to younger patients, who, predictably, will be undergoing future
facelift procedures.
49.2.5 SMAS and the Midface
The midface is generally defined as an inverted triangular area
situated over the anterior upper cheek that is bounded by the
zygomaticus major muscle laterally, the nasolabial fold medi-
ally, and the infraorbital rim/orbitomalar ligament superiorly.
In healthy, youthful-appearing individuals, this area is full and
is confluent with the adjacent cheek and lower eyelid. As one
ages, however, and as men and women enter their early midlife
and beyond, there is generally a descent of midface tissues and
a loss of volume, resulting in hollowing and flattening of this
area. Over time this results in a loss of the smooth and youthful
transition from the lower eyelid to cheek and, eventually, an ill,
haggard, and elderly appearance. :hile atrophy often plays a
dominant role in this process, this change is often mistakenly
referred to by many surgeons as midface ´ptosis.µ As the mid-
face descends and cheek volume diminishes, normal orbital fat
may appear to have ´grownµ (pseudoherniation) and may mis-
takenly be targeted for removal by a blepharoplasty procedure
(Fig. 49.1).
The recognition of midface ´ptosisµ as a significant component
of the changes occurring in the aging face, combined with the
realization that the traditional SMAS facelift produces little
or no improvement in the midface region, has led to a variety
of procedures designed to specifically target the midface area.
Many of these techniques were popular in the past as isolated
procedures or were performed in conjunction with lower eyelid
surgery. Although there is merit in the idea of rejuvenating the
midface, a consensus of opinion as to how and when it should
best be performed has never been reached, and routine isolated
midface lift procedures have been largely abandoned. Most
midface lift procedures have a steep learning curve and have
been fraught with complications, especially those performed
through a blepharoplasty incision. These complications include
lid retraction, ectropion, canthal displacement, and related
corneal exposure and dry eye problems. As a result, many mid-
face lift techniques came necessarily to incorporate potentially
problematic aggressive adjunctive surgical maneuvers, including
canthotomies, canthoplasties, and orbicularis oculi muscle
suspensions to reduce the likelihood these problems will occur.
However, these maneuvers are technically demanding and often
result in a ´changed lookµ that is disturbing to many patients. In
addition, they carry a high risk of significant and troublesome
complications of their own.
Many other arguments can be made against the use of isolated
midface lift procedures, including the fact that attractive rejuve-
nation of the face is possible without complete elimination of the
nasolabial fold. Most patients with nasolabial folds can be seen to
have had them when they were young, and their presence reflects
the patient’s anatomic makeup and not a specific age-related
undesirable change. In such cases it is neither necessary nor
desirable to efface these folds completely, as they are an inherent
and appropriate feature of the patient’s face. As a practical matter,
however, it is now acknowledged by most surgeons still perform-
ing midface lifts, or having had experience with them, that most
of the improvement obtained by the procedure consists only of
elevation of the lid–cheek junction, not ´correctionµ of the naso-
labial fold. Midface lifts also produce a subtle improvement not
always noticed or appreciated by the patient. Because of this, time
in the operating room is often arguably better spent on lower-risk
maneuvers that result in more noticeable improvement of higher
priority to patients.
Careful evaluation of most patients who need or request
a midface lift will show that they also need a facelift. It is rare
to encounter a patient with midface aging who does not also
Fig. 49.1 Treating cheek “ptosis” and pseudoherniation of lower
eyelid fat. As the cheek atrophies and descends with age, the lower
eyelid fat “bags” become more exposed and prominent in a process
known as “pseudoherniation.” (a) Patient with ptotic and atrophic
cheek. The lower lid fat, while actually normal is size, is exposed and
appears ostensibly as a large “bag.” Removing this fat by performing
a traditional blepharoplasty procedure would lower the lid–cheek
junction and create a hollow and elderly appearance. (b) Same patient
seen after high–SMAS facelift and fat injections to the cheeks but no
blepharoplasty or fat removal from the lower eyelid. Pseudoherniated
lower eyelid fat has been disguised by lifting, filling, and reconstituting
the cheek. This produces a more youthful, fit, and attractive appear-
ance than removing lower lid fat would have. Note that the upper orbit
has been replenished with fat injections as well. (Procedure performed
by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
a
b

638
VIII Surgical Rejuvenation of the Face and Neck
have sagging in the cheek and jowl, and midface lifts are as a
result arguably more logically performed in conjunction with
a formal facelift procedure. :hen they are performed together,
improvement is more balanced and comprehensive, and a more
harmonious and natural appearing result is usually obtained.
Healing is also faster and complications are less likely if midface
improvement can be obtained through the facelift incision rather
than through a blepharoplasty or intraoral approach.
Analysis of the aging face will also show that midface lifts
are also generally conceptually flawed in that they erroneously
assume the problem seen in the anterior upper cheek to be solely
one of tissue sagging and ptosis. Failure to acknowledge the fact
that atrophy is present to a significant degree in most cases has
led to general disappointment for both patients and surgeons
following many procedures once initial swelling has subsided, and
this realization has resulted in the addition of dermis fat grafts,
orbital fat transposition, “septal resets,” and similar maneuvers
to midface ´liftµ procedures. It is questionable and remains to
be answered, however, whether these procedures can produce a
restoration of lost volume as simply, naturally, and effectively as
can be obtained with autologous fat grafting. The current trend
increasingly seems to strongly favor a ´fillingµ rather than a ´lift-
ingµ approach.
49.2.6 Why Use a “High SMAS”?
The conventional ´lowµ cheek SMAS flap, elevated below the
zygomatic arch, suffers from the drawback that it cannot, by
design, have an impact on tissues of the midface and infraor-
bital region. Low designs target only the lower cheek and jowl
and produce little if any improvement in the upper anterior
cheek area. Planning the flap ´higher,µ along the border of the
zygomatic arch, and extending the dissection medially in an
´extended SMASµ fashion to mobilize midface tissue overcomes
this problem and produces an improved result (Fig. 49.2). This is
the fundamental concept behind the high-SMAS idea: planning
the flap ´higherµ provides the biomechanical means by which a
combined and simultaneous lift of the midface, lower cheek, and
jowl can be obtained with a single flap and avoids the need to
perform a separate midface lift procedure.
More specifically, benefits of a high-SMAS plan include resto-
ration of youthful upper cheek contour, an aesthetically signifi-
cant fill of the infraorbital region, increased support of the lower
eyelid, improved posture of the mouth, and improved correction
of the nasolabial fold that cannot be obtained when a traditional
low-SMAS procedure is performed. High-SMAS procedures are
also readily combined with midface fat grafting, since midface
and infraorbital tissue planes are not opened or dissected. This
averts the need to perform complex and potentially problematic
procedures in which orbital fat is transposed, the orbital septum
´reset,µ or free grafts placed.
At least part of the past popularity of low-SMAS designs can
be attributed to concerns regarding anatomic constraints about
the zygomatic arch and laudable and well-intended efforts to
design flaps that could be dissected safely without risk of injury
to the frontal branch of the facial nerve. Published studies and a
reappraisal of the assumption of the need for a low dissection,
along with a careful consideration of the actual anatomy of the
nerve over the arch, has shown, however, that a high dissection
is anatomically sound and clinically safe. For many if not most
patients, the repositioning of midface tissues obtained with a
high SMAS flap will be satisfactory, and no additional or separate
midface lift procedure will be required (Fig. 49.3).
49.2.7 The Extended SMAS Concept
The extended SMAS concept is integral to the high-SMAS tech-
nique and the means by which midface tissues are liberated
and allowed to be elevated in an integrated fashion when a high
SMAS flap is raised (Fig. 49.4).
The extended SMAS concept, however, as set forth by Stuzin, is
not synonymous and should not be confused with the “extended
SMASµ facelift technique, the latter being the name Stuzin gave
to his personal facelift technique in which a low SMAS flap is
dissected but a more medially situated tab of SMAS tissue is
created over the lateral zygoma as part of the low SMAS flap that,
he asserts, can be used to lift midface tissues.
Fig. 49.2 “High”- and “low”–superficial musculoaponeurotic system
(SMAS) techniques compared. (a) Plan for low-SMAS procedure.
Note that the upper border of the flap lies below the zygomatic
arch. (b) Low SMAS flap after dissection and suspension. Area of flap
effect (green solid circle) is limited to the lower cheek and jowl, and
no improvement is obtained in the midface, infraorbital, or perioral
regions (black dashed circle). (c) Plan for high-SMAS procedure. Note
that the upper border of the flap lies over the zygomatic arch. (d) High
SMAS flap after dissection and suspension. Area of flap effect (green
solid circle) includes not only both the cheek and jowl but the midface,
infraorbital, and perioral regions (black dashed circle) is well. (Copyright
© Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
639
Stuzin’s extended SMAS concept was a groundbreaking one that
clarified certain anatomic realities that had gone unrecognized by
other surgeons employing SMAS techniques, and it comprised a
new and important approach in treatment of the midface during
facelift procedures that remains germane to this day.
Traditional SMAS dissections targeted largely the lower-cheek
SMAS and platysma and focused on releasing more inferiorly situ-
ated masseteric–cutaneous ligaments restraining the lower cheek
and posterior jaw line areas (Fig. 49.4a). These types of dissections
were likely undertaken in large part because they were relatively
easier to perform as compared with dissecting more superiorly,
and perhaps due to the hyperfocus on the jaw line, and lack of
awareness of the need to reposition the midface as well, that was
prevalent at that time.
In the extended SMAS approach, dissection is limited in the
lower cheek to the release of the masseteric–cutaneous liga-
ments that are situated along the anterior border of the parotid,
in recognition of the fact that a more extensive dissection serves
no purpose and does not provide an improved release, and focus
is instead directed more superiorly to release the zygomatic
ligaments situated near the origin of the zygomaticus major
muscle and their confluence with upper masseteric–cutane-
ous ligaments situated just inferior to them, as was not done
in traditional, ´nonextendedµ SMAS dissections (Fig. 49.4b).
Extending the SMAS flap dissection up onto the zygoma and
into this area and releasing these more superiorly situated
ligaments restraining the upper SMAS, while perhaps more
tedious, resulted in a release of the upper cheek and midface
that provided a more comprehensive effect of the SMAS flap
and a more balanced and complete lift of the face. :ithout an
extended SMAS dissection, the full potential of a high SMAS flap
will not be realized.
49.2.8 Lamellar Dissection and
Bidirectional Tissue Shifts
A number of specific strategies that have been devised for uti-
lization of the SMAS that merit consideration (Fig. 49.5). These
include “deep-plane” and “composite” one-layer dissections,
in which the SMAS and skin are elevated as a single unit and
advanced along the same vector (Fig. 49.5c), and “lamellar”
dissections, in which skin and SMAS are elevated as two separate
lamellae, or layers, and advanced bidirectionally along different
vectors and under different tension loads (Fig. 49.5a,b).
Deep-plane and composite-type dissections have the potential
advantage that they are quicker to perform and result in a com-
paratively thicker, arguably more durable and better vascularized
flap composed of both skin and SMAS. These dissections have
the distinct disadvantage, however, that they constitute unidi-
rectional lifts, in which the skin and SMAS must be advanced
the same amount in the same direction (along the same vector)
and suspended under more or less the same amount of tension.
Because skin and SMAS age at different rates and along some-
what different vectors, however, optimal treatment of each layer
is generally not possible when these types of dissections are
performed, and skin overshifting, skin overtightening, temporal
hairline displacement, ´wrinkle shiftµ from the neck to the cheek,
and other objectionable occurrences and unnatural appearances
can result. In addition, if the orbicularis oculi is included in a
composite flap as delineated in the procedure design, the muscles’
motor nerve supply can be compromised and lid dysfunction,
nerve cross-regeneration, and other disturbing and objectionable
abnormalities can occur.
Two-layer, lamellar dissections offer the distinct advantage that
skin and SMAS can be advanced different amounts, along separate
vectors, and suspended under different amounts of tension in
Fig. 49.3 High–SMAS facelift. (a) Woman aged 47 before surgery.
Note loss of youthful contour. (b) Same patient 1 year and 3 months
after high-SMAS facelift, neck lift, forehead lift, upper and lower eye
lifts, and fat injections. Sagging tissues have been repositioned, youth-
ful jaw line contour restored, and redundant skin excised without a
tight or pulled appearance. (Procedure performed by Timothy Marten,
MD, FACS. Copyright © Timothy Marten.)
Fig. 49.4 The “extended SMAS” concept. (a) Traditional (but incorrect)
area of SMAS undermining (brown shaded area). A lack of understand-
ing of the presence and location of the ligaments restraining the SMAS
layer led to an unnecessary overdissection of the SMAS-platysma
inferiorly well into the neck, where no ligaments are present, and an
underdissection in the upper cheek, where the zygomatic ligaments
restrain the upper cheek and midface (red arrow). (b) Extended SMAS
dissection. Dissection is limited in the inferior SMAS–platysma to the
release of the masseteric–cutaneous ligaments (small black squares
along the anterior border of the parotid) and extended into the upper
cheek and midface to release the zygomatic ligaments (small black
circles located near the origin of the zygomaticus major muscle at tip of
red arrow). Although more tedious, the release of the upper cheek and
midface obtained when an extended dissection is performed gives the
SMAS flap a more comprehensive effect and provides a more balanced
and complete lift of the face. (Copyright © Timothy Marten.)
a
b

640
VIII Surgical Rejuvenation of the Face and Neck
pursuit of optimal artistic and aesthetic goals. This ´bidirectional
lift” allows each of these layers to be addressed individually,
and overly vertical skin shifts, counterproductive skin tension,
unwanted and objectionable hairline displacement, and ´wrinkle
shifts” can be better avoided. This, in turn, results in a more nat-
ural appearance, a more comprehensive rejuvenation, and fewer
secondary irregularities.
Two-layer lamellar techniques suffer the potential drawbacks
that the skin and SMAS flaps are thinner, arguably more fragile,
and less well vascularized and that the dissection is technically
more demanding and time-consuming to perform.
49.2.9 Lateral Sweep
Traditional skin-only facelifts and low-SMAS procedures
typically result in overtightening of the lateral cheek skin and
provide little support to the midface, lateral perioral, and jowl
areas. Over time, these unsupported tissues continue to descend
in a disproportionate fashion while the lateral face remains tight,
resulting in a characteristic and unnatural-appearing underreju-
venated mouth and objectionable tight and ´swept-upµ appear-
ance on the jawline and lateral face, often pejoratively referred to
as ´lateral sweepµ (Fig. 49.6).
Although unsupported tissue in the lateral perioral and jowl
areas largely responsible for this problem is actually anteriorly
situated, and perhaps the problem would be more correctly
thought of anatomically as an ´anteriorµ phenomenon, this
objectionable-appearing occurrence has nonetheless come to
be known as ´lateralµ sweep due to the adjacent and abnormal
preauricular tightness. Lateral sweep is generally most apparent
in the lateral view when the patient looks down. In this position
lateral facial tightness is increased by the better tissue fixation
and exaggerated SMAS support in the preauricular area, and the
“sweep” appearance on the lateral face is accentuated by the com-
paratively poor or nonexistent support of the more anteromedial
midface and lateral perioral areas.
Lateral sweep is an unavoidable and inevitable consequence of
all traditional skin-lift and low-SMAS deep-plane and composite-
type procedures that are not designed and carried out in a way that
supports the midface and lateral perioral area. These skin-only
and low deep-layer procedures are incapable of providing uniform
support to both the anterior and lateral cheek and are biogeomet-
rically inclined to produce an unbalanced and unnatural appear-
ance. Lateral sweep is also typically seen when a vertical vector
is used when shifting the skin flap in older patients with aging
inelastic skin or in younger patients who have had a remote facelift
in which a vertical skin flap vector was used. A high SMAS flap,
in contrast, provides simultaneous and uniform one-flap support
of the lateral facial, midface, and perioral areas, and this results
in a more balanced, comprehensive, and natural rejuvenation and
minimizes the chance the lateral sweep will occur.
Lateral sweep can result when a high-SMAS technique is used
if the lateral perioral region is overdissected subcutaneously and
ligamentous attachments between the SMAS and the skin in the
lateral perioral region are mistakenly and inappropriately divided.
These ligaments are the means by which the high SMAS flap sup-
ports the lateral perioral area, and overdissection of this sort is
a common error made by surgeons who mistakenly assume that
extended skin undermining will help improve the nasolabial fold
and/or allow the excision of more facial skin. This is not a flaw
in the high-SMAS concept or technique; it is merely a failure to
perform the procedure correctly.
49.2.10 Misapplication of
Ancillary Procedures
Many, if not most, of the changes associated with loss of facial
contour as one ages represent primarily deep-layer problems
that will be inadequately corrected with traditional skin-only
or low-SMAS techniques. Regrettably, surgeons unfamiliar with
deep-layer techniques, or insufficiently trained to perform them,
are increasingly performing skin-only facelifts or ´mini-liftsµ in
Fig. 49.5 Lamellar dissection and bidirectional tissue shift. (a) Two-layer lamellar dissections, in which the skin and SMAS are dissected as two
separate layers, offer the distinct advantage over one-layer deep-plane and composite dissections in that each layer is advanced independently along
a separate vector and suspended under a different degree of tension. (b) When a lamellar dissection is performed, the SMAS can be advanced more
vertically along a vector parallel to the long axis of the zygomaticus major muscle (white arrow) while the skin can be allowed to flow more naturally
posteriorly more perpendicular to the nasolabial fold (solid black arrow). (c) When a deep-plane or composite dissection is made the skin and superfi-
cial musculoaponeurotic system (SMAS) can be moved only along the same vector and the same distance. (Copyright © Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
641
conjunction with misguided and misapplied ancillary procedures
to overcome the considerable shortcomings of such plans. These
procedures include facial liposuction, inappropriate extraction of
buccal fat, malarplasty (´cheek implantµ), submalarplasty (´sub-
malar implantµ), geniomandibular groove augmentation (´pre-
jowl implantµ), polytetrafluoroethylene (PTFE; e.g., Gore-Tex, :.
L. Gore and Associates, 1ewark, DE) implantation, and various
types of conceptually flawed suspension and/or ´barbedµ and
´cuppedµ suture placement. Although some of these procedures
are at times indicated and indeed of benefit to certain patients,
they will be unnecessary in the majority of cases if a high-SMAS
facelift and deep-layer rejuvenation is performed.
49.3 Preoperative Planning
It is not possible to design or use a ´universalµ facelift technique,
as each patient will present with a unique set of problems that
require precise anatomic diagnosis and an appropriately planned
and individualized surgical repair. Committed study, careful
planning, and avoidance of a ´formula techniqueµ will maximize
improvement, limit complications, and minimize secondary
irregularities commonly seen following ´one-size-fits-allµ
procedures.
49.3.1 Incision Planning
One of prospective facelift patients’ most commonly expressed
fears is having an obvious scar that can be seen by others. A poorly
concealed scar, or other stigmata related to imprudent incision
planning, can give rise to self-consciousness, embarrassment,
shame, humiliation, and social dysfunction. A poorly planned
incision can place strain on relationships, limit the potential for
future relationships, and even interfere with a patient’s potential
for professional advancement. Scar visibility, or the lack of it,
is part of our professional ´signatureµ and is often regarded as
a marker for how skillfully the rest of the procedure was per-
formed. If an otherwise well-performed facelift is accompanied
by a poorly concealed scar or other stigmata related to poor
incision planning, our patients will feel we have failed them.
Planning the Temple Incision
The temporal portion of the facelift incision has traditionally
been placed within the temporal scalp in a well-intended, but
all too often counterproductive attempt to hide the resulting
scar. :hen cheek skin redundancy is small and abundant temple
and sideburn hair is present, such a plan can be used without
producing objectionable sideburn elevation and temporal hair-
line displacement. Patients best suited for this incision plan are
usually younger and troubled only by mild to moderate cheek
laxity. In older patients, however, who typically experience
larger skin shifts and who typically have sparse temple hair, such
a plan can result in unnatural and telltale sideburn elevation and
displacement of the temporal hairline (Fig. 49.7).
Proper analysis, careful planning, and the use of an incision
along the hairline, when indicated, can avert this problem without
compromising the overall outcome of the procedure (Fig. 49.8).
In choosing the location of the temporal portion of the facelift
incision, it is important for the surgeon to estimate the skin
redundancy over the upper cheek along the vector of skin flap ele-
vation and, thus, the skin shift and superior displacement of the
temporal tuft of hair (´sideburnµ) that will occur when the facelift
flap is lifted. This can be gauged by simply pinching up redun-
dant skin along the predicted superolateral vector of skin shift
and assessing the amount present. The surgeon’s estimate of skin
redundancy over the cheek, when considered in conjunction with
the amount of existing temporal “skin show” and temple-sideburn
hair present, enables rational selection of the best site for placement
of the temporal incision.
In patients in whom minimal or modest skin shift is predicted
to occur and for whom lush temporal scalp and sideburn hair
is present, the temporal portion of the facelift incision can be
placed in the traditional location 4 to 5 cm within the temporal
scalp, extending superiorly up from the anterior superior aspect
of the ear (Fig. 49.9). :hile individual circumstances will vary
and the decision about where the incision be placed should be
based on the circumstances present and not arbitrarily based on
age, typically patients in whom this incision plan is indicated are
under 45 years old.
Fig. 49.6 Lateral sweep. Traditional skin-only facelifts and low–super-
ficial musculoaponeurotic system (SMAS) procedures typically result in
overtightening of the preauricular cheek skin and provide little support
to the lateral perioral and jowl areas. In time, these unsupported
tissues continue to descend in a disproportionate fashion, while the
lateral face remains tight, resulting in a characteristic and objection-
able “swept-up” appearance of the skin over the jawline, often referred
to as “lateral sweep. ” (Procedure performed by an unknown surgeon.
Copyright © Timothy Marten.)

642
VIII Surgical Rejuvenation of the Face and Neck
In patients in whom more significant temporal skin shift is
predicted to occur and in whom less abundant temporal-sideburn
hair is present and the sideburn is predicted to be displaced above
the level of the junction of the root of the helix with the cheek,
consideration should be given to placing the incision along the
hairline (Fig. 49.8, Fig. 49.10) rather than within the temporal
scalp. This incision plan will accommodate large posterior-
superior skin flap shifts and allows maximum improvement in the
upper lateral face to be made. If it is made with care and closed
under no tension, the resulting scar is usually inconspicuous and
far less troublesome for the patient or obvious to others (see Fig.
49.8) than is a displaced hairline (see Fig. 49.7).
:hile individual circumstances will vary and the decision as to
where the incision will be placed should be based on the circum-
stances present and not arbitrarily based on age, typically patients
in whom this incision plan is indicated are over 45 years old.
In light of the preceding discussion it can be seen that the plan
for the location of the temporal portion of the facelift incision
cannot be arbitrary and must be based on the patient’s individual
anatomy and tissue condition, and options for its placement should
be discussed with any patient in whom significant elevation of the
sideburn or displacement of the temporal hairline might occur.
Other but arguably less important considerations include the
patient’s skin type, eye color, ancestry, and age, as patients with
lighter complexions, light-colored eyes, who are over 50 years old
and of Northern European ancestry typically form better scars
than patients with darker complexions, darker eye color, who are
under 50 years old or of Mediterranean, Middle Eastern, Asian,
or African ancestry. In all, incision placement is best presented to
the patient as a choice between two imperfect alternatives, and it
is wise to leave the final decision as to where the incision will be
located to the patient after appropriate discussion has taken place.
Placing the incision in a traditional location within the temporal
Fig. 49.9 Plan for incision on temporal scalp. This plan should be
used for patients with modest skin excess and who have abundant
temporal-sideburn hair and thus are predicted to have minimal or
modest superior and posterior shift of sideburn and temple hair after
elevation of the facelift skin flap. It will not be appropriate for most
patients, especially older patients and patients undergoing secondary
or tertiary procedures. The dotted red line shows the incision location.
A small anterior protrusion should be made part of the design where
the ear joins the temporal scalp, as shown, to prevent the advance-
ment of skin into this area, which should consist of hair bearing scalp.
Black dotted line shows location of pre-auricular part of the facelift
incision. The incision should then extend superiorly along a vertical
line dropped through the auditory meatus (white line). In certain cases
the incision may extend higher or lower than shown, depending on the
amount of excess skin present in the upper lateral face. (Copyright ©
Timothy Marten.)
Fig. 49.7 Displacement of the sideburn and temple hair due to poor
incision planning. (a,b) The temporal portion of the facelift incision
was made in the temporal scalp in a well-intended but conceptually
flawed effort to hide the resulting scar. Because cheek flap redundancy
was large and skin elasticity poor, advancement of the cheek skin flap
has resulted in objectionable and telltale hairline displacement. An
incision along the hairline (black dotted line in c) would have prevented
this occurrence. (c) Deconstruction of the cause of the temporal
hairline displacement seen in parts a and b. The operating surgeon
made a well-intended effort to hide the temporal portion of the facelift
incision in the temporal scalp (red dotted line) but underestimated
or did not appreciate the amount of skin redundancy over the upper
lateral cheek. When the facelift skin flap was advanced (black arrow),
skin was moved into an area where scalp and hair should be present.
The black dotted line shows the incision plan that would have pre-
vented this occurrence. (Procedures performed by unknown surgeons.
Copyright © Timothy Marten.)
Fig. 49.8 (a–c) Healed incisions along the temporal hairline. The use of
an incision along the hairline, when indicated, can prevent hairline and
sideburn displacement without compromising the end result. Although
a fine scar is present along the hairline in each of these patients, it
is not evident upon casual inspection. Note the preservation of lush
temple hair and a full, youthful, natural-appearing sideburn (compare
with Fig. 49.7). (Procedures performed by Timothy Marten, MD, FACS.
Copyright © Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
643
scalp (see Fig. 49.9) will help conceal the scar, but often at the
expense of a large and objectionable displacement of the sideburn
and temporal hairline (see Fig. 49.7) and compromised improve-
ment over the upper lateral face. Inappropriate use of a temple
scalp incision inevitably results in an objectionable, unnatural, and
“facelifted” appearance that is immediately obvious, even upon a
casual glance and at a distance. An incision along the sideburn and
temporal hairline (see Fig. 49.10), however, will prevent hairline
elevation and displacement, and although a scar will be present
where the incision was made, it is usually inconspicuous and will
not be noticed by others if closed under no tension and otherwise
carried out technically correctly. In addition, although a subop-
timally healed incision along the hairline can be concealed with
makeup or revised, a significantly elevated and displaced hairline
is difficult to conceal and is a challenge to surgically correct. It
has been our experience that most patients are disturbed by the
prospect of elevation and displacement of their sideburn hair and
recognize such occurrences as objectionable and tell-tale signs
that a facelift has been performed. :hen counseled properly and
given the choice, most will readily consent to incision placement
along their hairline when indicated.
Planning the Preauricular Incision
Open to scrutiny, the preauricular region exists as a frequent
point of reference for those seeking to identify a facelift patient
and in essence arguably constitutes the signatureµ (or lack
thereof) of the surgeon’s work. Traditionally incisions in this
area are made well anterior to the anterior border of the helix
and continued inferiorly, anterior to the tragus, and anterior and
inferior to the lobular–facial junction (Fig. 49.11).
This design, however, works well only for the older or unusual
patient with cheek and tragal skin of similar characteristics
who, in addition, exhibits favorable healing. Unfortunately, most
patients have a marked gradient of color, texture, and surface
irregularities over these areas, and a telltale mismatch will be
evident, even in the presence of an inconspicuous scar. For these
reasons, and in all but the unusual case, the preauricular portion
of the facelift incision should be precisely placed along the posterior
margin of the tragus (in a “retrotragal” position) rather than in the
pretragal sulcus (Fig. 49.11b). In this location a mismatch of color,
texture, or surface irregularities will not be noticed and the scar, if
visible, will appear to be a tragal highlight (Fig. 49.12).
In addition, and despite some claims to the contrary, a properly
planned and executed incision along the margin of the tragus that
is closed under no tension will not produce tragal retraction or
other telltale anatomic irregularity (Fig. 49.13).
In the male patient a similar incision plan is used (Fig. 49.14).
In many cases, skin flap shifts will be modest and such that beard
hair will not be retroposteriorly displaced enough to be advanced
onto the tragus itself. In cases where larger skin flap shifts occur
(typically older men), the tragus can be kept free of beard hair
when a retrotragal incision is used by intraoperative destruction
of beard follicles from the underside of the tragal flap when
indicated.
The preauricular incision consists of three component inci-
sions: (1) a prehelical incision, (2) the tragal incision, and (3) a
prelobular incision. Careful attention to the planning of each must
be undertaken if a well-concealed scar and natural appearance is
Fig. 49.10 Plan for incision along the temporal hairline: female
vs. male patients. An incision along the temporal hairline should
be considered whenever the surgeon’s assessment predicts that
objectionable superior and posterior displacement of the sideburn and
temple hair will occur. This incision plan is usually indicated in older
patients and almost always indicated in patients undergoing secondary
or tertiary procedures. In certain cases the incision may extend more
superiorly or inferiorly than shown depending on the amount of excess
skin present in the upper lateral face (see also Fig. 49.37). (a) Temple
hairline incision plan for the female patient (dotted red line). Note that
incision is planned as a soft curve to evoke a feminine appearance
extending inferiorly to a point approximately half the height of the
anterior helix (solid white lines). Dotted black lines show typical posi-
tion of preauricular incision in the female patient. (b) Temple hairline
incision plan for the male patient (dotted red line). Note that incision is
planned with a more rectangular masculine shape extending inferiorly
to a point approximately half the height of the anterior helix (solid
white lines). Dotted black lines show typical position of preauricular
incisions in a male patient. An incision plan that sets the male sideburn
more inferiorly than shown may compromise the blood supply to the
prehelical part of the facelift skin flap. Such a plan also requires the
patient to wear a long sideburn from his surgery date forward if the
scar is not to show. (Copyright © Timothy Marten.)
Fig. 49.11 Traditional vs. “concealed” preauricular incision plans. (a)
The traditional (but generally incorrect) location of the preauricular
incision places the scar in an area open to inspection by others and
“brands” the patient as having had facelift surgery. Makeup will not
conceal a scar in this location, as the scar is smooth and the skin on
either side of it is not. Making the incision in this location will also
typically culminates in a difference of skin color on each side of the
resulting scar, which is an additional telltale tipoff that surgery has
been performed. (b) The “concealed” or “retrotragal” incision plan
places the incision along natural anatomic contours in the helical–facial
sulcus, along the margin of the tragus, and in the lobular facial sulcus,
concealing the preauricular scar and disguising differences in color and
skin texture on each side of it as natural anatomic interfaces. While
cheek skin is advanced onto the tragus, a better overall concealment
of the scar is obtained (see also Fig. 49.12, Fig. 49.13, Fig. 49.14).
(Copyright © Timothy Marten.)

644
VIII Surgical Rejuvenation of the Face and Neck
to be obtained. The superior, prehelical portion of the preauricu-
lar incision should be planned as a soft curve paralleling the curve
of the anterior border of the helix. This will result in a natural
appearing ´widthµ to the helix in keeping with the rest of the ear
and the resultant scar, if visible, will appear to be a helical high-
light and/or the natural anatomic transition from smooth pinker
skin of the helix to the paler, coarser skin of the cheek (Fig. 49.15,
Fig. 49.16).
If the prehelical portion of the preauricular incision is placed
too far anteriorly or is situated so that it encroaches on the helix
itself, the illusion of the scar as an anatomic interface and/or
reflected highlight is lost (Fig. 49.16).
As the tragus is approached, the mark for incision is carried
into the depression superior to it and then continued along its
posterior margin. In this location the scar, if visible, will appear as
a natural highlight (Fig. 49.17).
Although an incision along the posterior margin of the tragus
is often referred to as a ´retrotragal incision,µ it is unnecessary
and an error to place this incision in a true retrotragal position
on the inner surface of the tragus. This usually results in a bulky,
amorphous-appearing tragus and obliteration of tragal anatomy.
Fig. 49.12 Pretragal and concealed (retrotragal) scars compared.
(a) Pretragal incision has healed satisfactorily with an acceptable scar
but the scar is plainly visible due to differences of color and texture
on each side of it and exists as a telltale sign that a facelift has been
performed. (Surgery performed by an unknown surgeon.) (b) Same
patient after secondary facelift in which the incision was moved to the
posterior margin of the tragus (retrotragal position). Color and texture
differences, and the scar itself, are now hidden along natural anatomic
interfaces, and no telltale sign that a facelift has been performed is
present. (Surgery performed by Timothy Marten, MD, FACS. Copyright
© Timothy Marten.)
Fig. 49.13 (a–c) Healed retrotragal incisions. Close-up views of facelift
patients with preauricular incisions along the margin of the tragus in
a retrotragal position. Scars are well concealed, no tragal distortion is
present, and a normal pretragal sulcus can be seen. While cheek skin
has been advanced onto the tragus, a more natural appearance and
better concealed scar is present than if a pretragal incision had been
used (see also Fig. 49.12b). (Surgeries performed by Timothy Marten,
MD, FACS. Copyright © Timothy Marten.)
Fig. 49.14 (a–c) Healed retrotragal facelift scars in male patients.
A retrotragal placement of the preauricular portion of the facelift
incision has resulted in an inconspicuous and well-concealed scar. In
the upper third, the scar sits in the interface between the helix and the
cheek and the scar appears to be a reflected highlight of the anterior
helical border. In the middle third, the scar sits along the poster margin
of the tragus and cannot be seen. Some coarse and bearded skin has
been shifted up against and onto the tragus in b and c, but this is
less obvious than the presence of a pretragal scar with a gradient of
color and texture on each side of it. In the lower third, the scar sits in
a well-concealed location 2 to 3 mm outside the lobular–facial sulcus
but far enough away from it that shaving in that area is not difficult.
(Surgery performed by Timothy Marten, MD, FACS. Copyright ©
Timothy Marten.)
Fig. 49.15 Optimal position of prehelical part of the preauricular inci-
sion. The prehelical portion of the preauricular incision (red dotted line)
should be planned as a soft curve paralleling the curve of the anterior
border of the helix. This will result in a natural-appearing “width” to
the helix, in keeping with the rest of the ear (black dotted lines), and
the resultant scar, if visible, will appear to be a helical highlight and be
disguised as the natural transition between the smooth pinker skin of
the helix and the coarser, paler skin of the cheek. (Surgery performed
by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
645
At the inferior portion of the tragus the incision must turn ante-
riorly and then again inferiorly, into the crease between anterior
lobule and cheek. If a more relaxed plan is made, or if a straight
line or ´lazy Sµ incision plan is used, skin settling and scar con-
traction will result in crowding of the incisura, obliteration of the
inferior tragal border, and a telltale elongated or ´chopped- offµ
tragal appearance (Fig. 49.18).
Planning the Perilobular Incision
To obtain a natural perilobular appearance, it is essential, in
cases where a naturally shaped earlobe is present, to preserve
the natural sulcus between the earlobe and the cheek and to
avoid destruction or excision of this aesthetically important
anatomic subunit. This is accomplished by marking the incision
1 to 2 mm inferior to this junction in women and 2 to 3 mm
Fig. 49.17 Optimal position of the preauricular incision. (a) Placing the preauricular scar along natural anatomic interfaces (red dotted line) places
transitions of color and texture in locations where the eye is expecting to see them, and the scar itself, if seen, will appear as a reflected highlight (see
Fig. 49.12b). (b) Note that the scar, although hypopigmented and situated on darker skin and visible, appears to the eye to be a reflected highlight
along the anterior border of the helix and the posterior margin of the tragus, and elsewhere where the incision was made. Note also how gradients of
color and texture on each side of the scar appear expected and natural. A similar illusion and concealment would not be present had the incision been
placed in a pretragal location. (Copyright © Timothy Marten.)
Fig. 49.16 Improper and proper placement of prehelical scar. Often the prehelical portion of the preauricular scar is poorly situated, and the illusion
of it as an anatomic feature is lost. (a) The prehelical incision has been made too far anteriorly, and the illusion of the scar as an anatomic feature is
lost. (Surgery performed by unknown surgeon.) (b) The prehelical incision has been made too far posteriorly and has obliterated the helical facial
sulcus and has encroached on part of the helix itself. (Surgery performed by unknown surgeon.) (c) A patient with a properly planned and executed
prehelical incision. The scar has been placed directly in the helical–facial sulcus. In this location a transition of color and texture is expected, and the
scar appears to be a natural anatomic feature (see also Fig. 49.15). (Surgery performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

646
VIII Surgical Rejuvenation of the Face and Neck
inferior to it in men. Placing the incision slightly more inferiorly
in men facilitates shaving postoperatively should bearded skin
be shifted superiorly against the incision, as it commonly will be.
In both cases, when a naturally shaped lobule is present, all other
factors being equal, a superior result will be obtained when such
a plan is used, in comparison with any plan in which the incision
is placed directly in the sulcus and an attempt is subsequently
made to join thin, soft earlobe directly with coarse, thick cheek.
:hen a square, ´attached,µ or large lobule is present, consid-
eration should be given to earlobe reconfiguration or earlobe
reduction when the earlobe is reset into the cheek skin flap (see
discussion later in this chapter; Fig. 49.62, Fig. 49.63).
Planning the Postauricular Incision
The ´postauricularµ portion of the facelift incision (Fig. 49.19) is
actually composed of three component incisions:
(1) A concho-mastoid incision extending in and along the
concho-mastoid sulcus (Fig. 49.19d, gray-dotted line). (2) A
trans-mastoid incision traversing horizontally across the mastoid
to the occipital scalp (see Fig 49.19d, red line). (3) An occipital
incision extending into the occipital scalp or along the occipital
hairline (Fig. 49.19d, white dotted line). A careful consideration
of the design of each is important if an overall well-concealed and
inconspicuous scar is to be obtained.
Planning the Conchomastoid Portion of the
Postauricular Incision
Traditionally, the conchomastoid portion of the facelift incision
has been made up onto and over the posterior surface of the
concha. This was done as part of a well-intended but conceptually
flawed effort to offset inevitable descent of the postauricular skin
flap and inferior migration of the resulting scar, which occurred
when skin was forcefully advanced superiorly and suspended
under tension in a misguided attempt to improve neck contour by
skin flap tightening. Experienced surgeons have come to realize
that such a plan embodies numerous erroneous assumptions and
can result in many undesirable effects, including hypertrophic
scarring, postauricular webbing, and obliteration of the auricu-
lomastoid/conchomastoid sulcus.
The postauricular portion of the facelift incision should
instead be marked directly in the existing auriculomastoid
Fig. 49.19 Planning the position of the transmastoid part of the postauricular incision. Strategically placing the transmastoid part of the postauric-
ular incision conceals it and allows optimal excision of skin from the anterior neck. If it is placed too low, it is visible when the patient’s hair is worn
up or in a short hairstyle. If it is placed too high, the defect created will force an excessive vertical shift of the postauricular skin flap and compromise
improvement in the neck. (a) The point of divergence of the anterior and superior crura of the antihelix provides a useful guide for how high the
transmastoid part of the postauricular incision should be placed (red dot). (b) At this horizontal level (red line) the rim of the helix will typically “touch”
the occipital hairline in the lateral view. (c) A transmastoid scar placed at this level will cross over to the occipital scalp in a hidden location. Note that
if the incision were placed lower, the resulting scar would show. (d) Typical plan for the postauricular incision showing the transmastoid component
(red line) to be concealed. Gray dotted line shows location of the conchomastoid component incision hidden behind the ear and white dotted line the
occipital incision hidden along the occipital hairline. (Note: The patient shown has undergone a previous facelift, and it can be seen that his scars are
well concealed despite his very short “military-style” haircut. ) (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
Fig. 49.18 “Chopped-off” tragus. The unnatural and objectionable-
appearing, elongated tragus with an indistinct inferior border that
results from poor incision planning, improper excision of skin at
the time of incision closure, and failure to provide SMAS support of
deep-layer facial tissues. (Note also unaesthetic and objectionable
displacement of sideburn hair due to improper planning of the
temporal portion of the facelift incision as well; see also Fig. 49.7.
(Surgery performed by an unknown surgeon. Copyright © Timothy
Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
647
(conchomastoid) sulcus in women and 2 to 3 mm posterior to it
in men, with the ear in its resting position or slightly retracted.
Placing the incision 2 to 3 mm posterior to the sulcus in men
prevents advancement of bearded skin against the concha and
facilitates shaving in this area. Such a plan places the scar along
or near a natural anatomic interface, where it will be difficult to
detect, even on close inspection. Marking must be made with the
ear resting near its natural anatomic position. If the ear is pulled for-
ward while marks are made, mastoid skin will be pulled anteriorly
over the posterior surface of the concha and the incision will end up
posterior to its intended location and outside the auriculomastoid
(conchomastoid) sulcus. Incorrect marking in this manner is one
of the most common causes of a poorly situated postauricular
(conchomastoid) scar.
Planning the Transmastoid Portion of the
Postauricular Incision
Considerable confusion exists among surgeons performing
facelift procedures as to what level the transmastoid part of the
postauricular facelift incision should cross over to the occipital
scalp, and as a result, this part of the incision is often not placed
strategically and in a manner that best conceals it or allows
optimal excision of skin from the anterior neck. If it is placed too
low, it will be visible when the patient’s hair is worn up or if the
patient wears a short hairstyle. If it is placed too high, the defect
created will force an overly vertical shift of the postauricular
skin flap and compromise improvement in the anterior neck and
submental region. Fortunately, if one assesses the goals sought
and employs simple logic in meeting them, rational and effective
placement of the transmastoid incision becomes possible.
A useful guide in siting the transmastoid part of the postau-
ricular incision is to envision a horizontal line through the point
at which the anterior and superior crura of the antihelix diverge
(red dot in Fig. 49.19a). Typically, at that level the rim of the helix
extends posteriorly back to the occipital hairline to the so-called
´helix–hairline touch pointµ (Fig. 49.19b), and a transmastoid
incision placed at that level will be hidden behind the ear in the
lateral view (Fig. 49.19c).
Planning the Occipital Portion of the Postauricular
Incision
Planning the location for the occipital portion of the facelift
incision is conceptually similar to that of the temple region, and
the incision plan must take into account and address similar
concerns of avoiding hairline displacement and scar visibility.
Traditionally this incision is arbitrarily placed low transversely,
into the occipital scalp, in a well-intended but almost always
counterproductive attempt to hide the resultant scar (Fig.
49.20a).
Regrettably, many other similarly conceptually flawed incision
plans that do not recognize tissue biogeometry of the postauricu-
lar area or provide for skin excision along a useful vector have been
advocated and are commonly used. A thoughtful consideration of
what one is trying to accomplish, however, enables one to employ
incision plans that are effective and rational.
For patients in whom neck skin redundancy is small and shifting
and excision of postauricular skin is not necessary, a traditional
postauricular incision plan (as shown in Fig. 49.20a) is appropri-
ate if its transmastoid portion is situated superiorly enough to
be concealed behind the ear (see preceding discussion) and will
result in a well-concealed scar. Patients in this category are usu-
ally young and troubled only by mild neck skin redundancy, and
in these situations the incision is used for access to the lateral neck
only (and access to the lateral platysmal border), not as a means
Fig. 49.20 Traditional plan for the occipital portion of the postauricular incision. (a) The incision is placed low transversely across the mastoid
extending into the occipital scalp in a well-intended but usually counterproductive attempt to hide the resultant scar. This incision should be used
only in younger patients for access to the lateral neck only and cannot be used to remove excess neck skin without producing hairline notching if the
postauricular skin flap is shifted along a proper posterior-superior vector. (b,c) Examples of hairline displacement caused by inappropriate use of the
incision plan shown in part a. (Procedures performed by unknown surgeons. Copyright © Timothy Marten.)

648
VIII Surgical Rejuvenation of the Face and Neck
to remove any postauricular skin. Mistakenly using this incision
to excise skin along a posteriorly directed vector will predictably
result in the advancement of neck skin into the occipital scalp and
´notchingµ of the occipital hairline (Fig. 49.20b,c; Fig. 49.21a,b).
Similarly, using this incision to excise postauricular skin along a
superiorly directed vector will predictably result a wide transmas-
toid scar (Fig. 49.22). Skin excision along either vector using this
incision is conceptually flawed and the source of all-too-common
secondary facelift irregularities.
Although not all patients and their surgeons will recognize
these irregularities for what they are, most are nonetheless
aware that an unnatural appearance is present, especially those
patients who wear short hairstyles, wear their hair up or back,
or lead active lives and engage in activities that may displace
camouflaging wisps of remaining hair. Proper analysis, careful
planning, and the use of an incision along the hairline (Fig. 49.23),
when indicated and carried out in a technically correct manner,
will prevent this problem, and allow skin to be excised along a
correct posterosuperior vector, while simultaneously producing a
well-concealed scar (Fig. 49.24; see also Fig. 49.19a).
In logically designing and deciding upon the proper position
of the occipital portion of the facelift incision, the surgeon must
gauge the degree of skin redundancy present on the anterior neck
and along the predicted posterosuperior direction of skin flap
shift. This can be accomplished by pinching up tissue over the
upper lateral neck along the superolateral vector along which it
will be advanced and estimating the amount of excess present. If
2 cm or less of excess neck skin is present, a ´traditionalµ incision
across the mastoid extending posteriorly into the scalp at the level
of the mid–upper ear (Fig. 49.19a) will, in most cases, not result in
objectionable disruption of the occipital hairline and, if properly
designed and closed, should result in a scar no more visible than
in a ´short-scarµ procedure. As a practical matter, patients whose
tissue conditions are amenable to this incision plan are typically
under 40 years old. If more than 2 cm of neck skin redundancy is
present, however, the incision should be placed along the occipital
hairline but designed in such a manner that a telltale scar will
not be visible in front of the fine hair on the nape of the neck
(Fig. 49.23, Fig. 49.24). This can be accomplished by turning the
inferior portion of the incision back into the scalp at the junction
of thick and thin hair (Fig. 49.23b). This incision plan is typically
needed in patients over 40 years old if hairline displacement is
to be avoided and neck skin is to be excised along a proper and
useful vector.
The length of the occipital portion of the postauricular incision
will necessary vary depending on the quality of the patient’s
tissues and the amount of redundant skin present in the anterior
neck and submental area (size of ´wattleµ), and ´small,µ ´medium,µ
Fig. 49.23 Plan for incision along the occipital hairline. This incision
plan allows skin to be excised along a proper posterosuperior vector,
prevents hairline displacement, and results in a well-concealed scar
if carried out in a technically correct fashion. Note that the incision
is planned so that its inferior portion typically turns posteriorly into
the occipital scalp at the junction of thick and thin hair but will vary in
length in accord with the amount of skin redundancy present in the
anterior neck area. (see Fig. 49.25) (a) Schematic of occipital hairline
incision plan. (b) Occipital hairline incision plan marked on a typical
patient. (Copyright © Timothy Marten.)
Fig. 49.21 Understanding the cause of occipital hairline displacement.
(a) An example of avoidable notching and displacement of the occipital
hairline seen in a patient whose surgeon inappropriately used a tradi-
tional occipital incision plan (see also Fig. 49.20). (b) Deconstruction
of the occipital hairline displacement seen in part a. The surgeon made
a well-intended, but conceptually flawed attempt to hide the scar
in the occipital scalp (dotted red line) after underestimating the skin
redundancy in the upper lateral neck. Skin has been advanced (black
arrow) into a position where scalp hair should be and the hairline is
“notched.” The dotted black line shows the incision plan that would
have prevented the problem. (Procedure performed by unknown
surgeon. Copyright © Timothy Marten.)
Fig. 49.22 Understanding the cause of a wide and hypertrophic
postauricular scar. (a) An example of avoidable postauricular scar
widening and hypertrophy seen in a patient whose surgeon inappro-
priately excised skin along a superiorly directed vector. (red arrow in
b) (Procedure performed by unknown surgeon.) (b) Deconstruction
of the scar widening and hypertrophy seen in (a). The surgeon made
a well-intended, but conceptually flawed attempt to advance the
postauricular skin flap along a superiorly directed vector (red arrow),
typically in an effort to avoid occipital hairline displacement and recon-
stitute the occipital hairline. This erroneously assumed that excess
skin was present in the lower lateral neck (black circle) and produced a
false apparent redundancy of skin over the mastoid (skin shown in red
circle) due to the elevated position of the patient’s shoulder while lying
supine on the operating table. When the patient assumed an upright
position postoperatively and the shoulder dropped, a skin deficit was
created, and traction of the wound produced the wide and hypertro-
phic scar seen in (a). Gray circle shows actual area of neck skin excess,
and green arrow shows the proper vector of skin flap advancement if
optimal improvement in the anterior neck and submental region is
to be obtained. The green circle denotes the area where skin actually
should be excised (along an occipital hairline incision). No skin should
be excised in the area of the red circle. (Copyright © Timothy Marten.)
a
b

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
649
and ´longµ (length of incision along the occipital hairline) incision
plans are used as indicated (Fig. 49.25). In patients with good
tissue quality and minimal anterior neck and submental skin
excess (´small wattleµ), a ´shortµ incision along the hairline will
be indicated (Fig. 49.25a). In patients with modest loss of skin
quality and modest anterior neck and submental skin excess
(´medium wattleµ), a ´mediumµ-length incision is made along
the occipital hairline (Fig. 49.25b). In elderly patients with poor
skin elasticity and a large anterior neck and submental skin excess
(´large wattleµ), a ´longµ incision along the occipital hairline will
be needed (Fig. 49.25c).
As is the case with temporal incision placement, options for the
placement of the occipital portion of the facelift incision should
be discussed with the patient and presented as a choice between
imperfect alternatives. Although an incision along the occipital
hairline is usually inconspicuous, even on close inspection, if
designed and carried out in a technically correct fashion, a scar
will undeniably be present where it was made. Placing the incision
into the occipital scalp may ostensibly help conceal the scar but
will usually do so at the expense of objectionable displacement
of the occipital hairline, an overly superiorly directed shift of
the postauricular skin flap, and a compromise in the amount of
neck skin excised. :hile a suboptimally healed incision along
the occipital hairline can be revised or easily concealed with an
appropriate hairstyle, a significantly displaced hairline can be dif-
ficult to conceal and is a challenge to correct. Overall, it has been
our experience that most patients are disturbed by the prospect
of occipital hairline displacement and recognize it as a telltale sign
that a facelift has been performed. :hen properly counseled and
given the choice, most will readily consent to an incision along the
hairline when indicated.
From a practical standpoint it must be acknowledged that
the traditional incision into the occipital scalp should be used for
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will require an incision along the occipital hairline if skin is to be
Fig. 49.24 Healed scars along the occipital hairline. Proper analysis, careful planning, and the use of an incision along the hairline when indicated, will
allow skin to be excised along a correct posterosuperior vector, while simultaneously preventing hairline notching and producing a well-concealed
scar. (a,b) Healed scars along the occipital hairline in two women. (c,d) Healed scars along the occipital hairline in two men. (Surgery performed by
Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
Fig. 49.25 Plan for length of incision along the occipital hairline. The length of the occipital portion of the postauricular incision (red dotted line) will
vary depending on the quality of the patient’s tissues and the amount of redundant skin present in the submental area (size of the “wattle”). (a) In
patients with good tissue quality and minimal submental skin redundancy (“small wattle”), a “short” incision along the hairline will be indicated. (b)
In patients with modest loss of skin quality and modest submental redundancy (“medium wattle”), a “ medium” incision is made along the occipital
hairline. (c) In elderly patients with poor skin elasticity and a large submental skin excess (“large wattle”), a “long” incision along the occipital hairline
will be needed. (Copyright © Timothy Marten.)

650
VIII Surgical Rejuvenation of the Face and Neck
advanced and excised in a biogeometrically correct fashion and
hairline displacement is to be avoided.
Why Not Make the Postauricular Incision
Higher?
A variety of postauricular incision plans have been proposed and
published that utilize designs high up behind the ear, extending
in various patterns into the occipital scalp in a well-intended but
ultimately conceptually flawed attempt to better conceal the
resulting scar. These plans, however, do not recognize the tissue
biogeometry of the postauricular area and do not provide for
skin excision along a useful vector without resulting in hairline
displacement, and making the postauricular incision higher does
not ´hideµ the scar. A high postauricular incision plan, while
ostensibly a good idea, actually compounds the problem of
occipital hairline notching and displacement (Fig. 49.26).
The “Short-Scar” Facelift
The idea of shortening the incisions used to perform procedures
to rejuvenate the face is appealing to patients and surgeons alike.
Indeed, the first facelift procedures, performed some 100 years
ago, consisted of small excisions of skin near the ear and along
frontal and occipital hairlines. Regrettably, and despite the many
important advances in techniques to rejuvenate the face that
have been made over the past century, as nonplastic surgeons
have begun to perform aesthetic surgery procedures and market
their services, a new emphasis has been placed on arguably
ill-conceived ´short-scarµ procedures that are of questionable
benefit to patients but that are nonetheless appealing in concept
to almost anyone considering a facelift procedure. Although
some short-scar techniques, such as limited-incision forehead lift
and short-scar neck lift, have merit and have provided new and
better options for appropriate patients, skin redundancy remains
a consistent and undeniable problem for the surgeon seeking to
rejuvenate the face and neck, and, considered in conjunction
with overall failure of noninvasive ´skin-shrinkingµ technolo-
gies, shorter incision plans involve significant compromises in
the overall improvement that can thus be obtained. (Table 49.1)
Short-scar incision plans suffer the significant drawback that
they limit access to deep-layer structures, the modification of
which form the foundation of the modern facelift procedure, and
prevent redundant skin from being shifted along proper vectors
that produce the most improvement and most natural appear-
ance. Typically, manipulations of deep-layer tissues performed
through ´short-scarµ incisions plans are markedly compromised
and result more often in damage to the SMAS layer than in a
useful repositioning of it. Shorter incisions also require that skin
be gathered up when sutured and prevent it from being excised in
a smooth, well-tailored ´coutureµ fashion (Fig. 49.27).
A longer scar, conversely, provides proper access to the SMAS
and platysma, allows them to be used in an optimal manner,
and allows skin flaps to be shifted in a geometrically correct
fashion and skin to be excised in a well-tailored fashion without
objectionable puckering or gathering along incision lines (see Fig.
49.23, Fig. 49.24).
Ironically, most short-scar facelift procedures have placed
their focus on the postauricular area and seek to shorten the
postauricular portion of the facelift scar. This scar is situated in
a well-concealed area, and if tension is diverted to deep-layer
tissue, skin excision carefully planned and properly carried out,
and the incision closed under no tension, an inconspicuous scar
will almost always result. This scar is arguably less obvious, less
difficult to conceal, and less disturbing to the patient than is a
shorter but irregular and puckered postlobular scar. Shortening a
scar under these circumstances in a concealed area is of question-
able value to the patient.
Fig. 49.26 Making the postauricular incision higher does not prevent hairline displacement. (a) A surgeon has made a well-intended but conceptually
flawed attempt to hide the postauricular scar by making it high over the mastoid and extending transversely high into the occipital scalp (red dotted
line). (b) Cervical skin has been advanced into an area where scalp should be (black arrow). (c) Black dotted line shows the original position of the
hairline and the place where the incision should have been made. A large and objectionable displacement of the occipital hairline is evident. It can
be seen that placing the incision higher compounds rather than reduces the problem of hairline displacement. (Surgery performed by an unknown
surgeon. Copyright © Timothy Marten.)
Table 49.1 Drawbacks of “short-scar” procedures
• Scar shifted from concealed area behind ear to visible area in front of
temple hairline
• Skin flaps cannot be shifted in biogeometrically correct fashion of
maximum benefit to patient
• Compromised access to deep layers of the face
• Unaesthetic puckering and gathering of tissue common
• Amount of visible scar not really “shorter” than in properly performed
“long-scar” technique
• Reduced amount of redundant skin excised from face

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
651
Perhaps the most difficult-to-understand aspect of short-scar
incision plans is that to shorten the postauricular scar and min-
imize the resulting puckering and gathering behind the ear and
earlobe, the cheek skin flap is shifted along an overly superiorly
directed vector, necessitating a scar along the less well-concealed
sideburn and temporal hairline (Fig. 49.28).
Although an incision is often required in this area in many
patients to prevent temple hairline and sideburn displacement,
shortening a scar in a concealed area (the postauricular area) by
shifting it to a more visible area (the temple area) is arguably
of dubious value to the patient, who might not have required it.
Regrettably, and somewhat sadly, it is younger patients, whose
fears of ´longµ scars are preyed upon, who are typically desig-
nated as candidates for short-scar procedures. It is this group of
patients, however, who are disproportionately burdened by the
more visible scar along the temporal hairline, who likely would
not otherwise need it had a longer incision been made behind the
ear (Fig. 49.29).
Given the choice, it has been our experience that younger patients
are relieved to learn that a scar along the temporal hairline is not
always necessary and that it can be instead hidden in the temporal
scalp if an incision along the hairline behind the ear is made.
The ultimate fallacy about short-scar procedures involves the
notion of the length of the scar itself, and the fact that it is the
amount of visible scar that matters and whether the scar is con-
cealed. If the amount of scar present in potentially visible areas is
measured, there is no actual difference between that present in
typical short-scar and long-scar procedures (Fig. 49.30). In this
sense the ´shortµ and ´longµ scars are the same length, and a short
scar is not really shorter (Table 49.1).
49.3.2 3ODnning 0RdiÀFDWiRn RI WKe
SMAS and Platysma
All patients undergoing a facelift will benefit from a posterosupe-
rior advancement of the cheek SMAS, and this maneuver serves
as the fundamental step in natural-appearing and attractive reju-
venation of the face upon which all others are based (Fig. 49.3).
SMAS advancement provides a natural-appearing and long-last-
ing correction in the cheek and jowl, consolidates the lower face,
and provides a means to divert tension away from the skin. :hen
a ´high-SMASµ plan is used, improvement can be obtained in the
midface, infraorbital, and perioral areas without the need for
a separate midface lift procedure. For some patients SMAS flap
advancement alone will provide appropriate correction. Others,
however, will require additional maneuvers or modifications of
this step if their problems are to be adequately addressed.
49.4 Preoperative Preparations
All patients undergo a preoperative physical evaluation, and any
with significant medical problems must be cleared by their inter-
nist or personal physician before their procedure is performed.
Each patient is required to avoid agents known to cause platelet
dysfunction for 2 weeks prior to surgery, and a list of products
that contain aspirin and other medications and products that
have antiplatelet activity is provided.
Fig. 49.28 The short-scar facelift strategy and incision plan. (a) A typical early design of short-scar facelift incision plan (red dotted line). Note that
a postauricular incision is not used (pen mark on patient). When skin was shifted along an optimal vector for excising skin from the neck (blue arrow)
a dog-ear formed behind the lobule (see Fig. 49.27). (b) To avoid the postlobular dog-ear, the short-scar plan evolved to incorporate a superiorly
directed “vertical” shift of the cheek skin flap. When an incision hidden in the temporal scalp was used as shown (red dotted line), marked and objec-
tionable overelevation of the temple and sideburn hair occurred. (c) To avoid objectionable shift of temple and sideburn hair and to accommodate
large amounts of skin shifted into the temple area, the short-scar plan came to use an incision along the temple hairline (red dotted line). This in
essence resulted in shifting of the scar from the more concealed occipital hairline (mark on patient’s skin) to the more visible area on the temple
hairline (see also Fig. 49.29). (Copyright © Timothy Marten.)
Fig. 49.27 Puckering and pleating of skin behind the ear resulting
from “short-scar” facelift. (a) Arguably modest but unaesthetic
pleating behind lobule of a patient who has undergone a previous
“short-scar” facelift. Shortening the scar in the postauricular area has
prevented skin from being excised in a smooth, well-tailored fashion.
(b) Objectionable postauricular pleating as a result of an effort to
shorten the postauricular portion of the facelift incision. A longer
scar, even suboptimally healed, would arguably be far less obvious
and objectionable. (Procedures performed by unknown surgeons.
Courtesy of Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

652
VIII Surgical Rejuvenation of the Face and Neck
49.4.1 Smokers and Former Smokers
All patients who smoke are asked to quit 4 weeks before their
procedure and are required to avoid smoking and all secondhand
smoke for 2 weeks after. Patients who smoke, or have a signif-
icant history of smoking but have quit, are advised in writing
that their risk of serious complications, including poor healing,
flap necrosis, skin slough, and thromboembolic phenomena is
significantly higher than in nonsmokers. It is generally assumed,
however, that most patients will not cease smoking, and extra
care should be taken to be sure informed consent is complete in
this regard.
Fortunately, flap viability is dependent upon a variety of factors
other than smoking that are under the surgeon’s control and
that are minimized by the high-SMAS procedure design. These
factors include the amount of tissue trauma during dissection, the
extent of skin undermining, and the amount of tension of the skin
flap. Because the high-SMAS technique limits skin undermining,
preserves important cheek perforators, and avoids tension on
delicate cervicofacial skin flaps, a careful surgeon employing
proper technique can operate with acceptable risk on smokers.
Smokers should always be approached with caution, however, and it
should be recognized that these patients are suboptimal candidates
for surgery and are at increased risk for serious local and systemic
complications.
49.4.2 Ultrasonic and Radiofrequency
“Skin-Shrinking” Treatments
Patients should be questioned carefully about previous nonin-
vasive radiofrequency (RF) and ultrasonic ´skin-shrinkingµ pro-
cedures, as these treatments appear to damage skin subdermal
microcirculation and compromise superficial microlymphatic
vessels, and patients who have undergone these treatments seem
to be compromised candidates for facelift procedures. Similarly,
patients who are longstanding filler users, especially if they have
used more inflammatory fillers such as poly-L-lactic acid (PLLA),
are likely to have internal facial fibrosis and inflammatory
changes, rendering them more challenging candidates as well.
The patient who has undergone facial ultrasonic and RF
´skin-shrinkingµ treatments is part of a growing body of patients
who seem to sustain clinically significant compromise of their
skin microcirculation as a result of these and like treatments that
puts them at greater risk of slough and healing-related problems
following facelift procedures and suboptimal take when fat graft-
ing is performed. Unlike when laser resurfacing is performed,
in ´skin-shrinkingµ procedures energy is directed and dispersed
under the skin rather than on its surface, and energy meant to
´tightenµ the face appears to damage both subdermal microcir-
culation and adjacent superficial microlymphatic vessels. The
Fig. 49.30 A “short” scar is not really shorter. (a) Typical short-scar incision plan (dotted red line). The length of the scar is approximately 15 cm. (b)
Typical long-scar incision plan for a younger patient. A postauricular incision is present. The temporal portion of the incision (yellow dotted line) is
made within the temporal scalp and will result in a scar that is not visible and does not show. (c) Visible part of a “long”-scar plan when one does not
count the concealed temporal portion (dotted yellow line in part b). The visible scar is approximately 15 cm in length. There is no difference in the
amount of visible scar in most short- and “long”-scar plans. (Copyright © Timothy Marten.)
Fig. 49.29 Short-scar and long-scar facelift incisions compared. (a) Long-scar incision plan that would be used in a younger patient. The temporal
portion of the incision (yellow dotted line) is concealed within the temporal scalp, and the resulting scar is not visible and not a concern to the patient.
The postauricular incision (red dotted line) is in a relatively concealed area (inset photo: white arrow). (b) Short-scar incision plan. The postauricular
incision has been eliminated and the incision shifted to a more visible area along the sideburn and temporal hairline that would typically be of more
concern to a younger patient (inset photo: white arrow). (Copyright © Timothy Marten.)
a
b

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
653
incidence of problems seems to parallel the number and intensity
of treatments the patient has undergone, which one would expect
to parallel the degree of compromise to their tissues. These
patients also seem to experience prolonged edema and a longer
period of recovery following facelift surgery.
Consideration should be given to advising, in writing, patients
who have undergone previous ultrasonic and RF “skin-shrinking”
treatments that their risk of serious complications, including poor
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in patients who have not undergone these procedures, especially if
they have undergone multiple previous treatments. From the sur-
geon’s standpoint, these patients should be regarded, approached,
and treated as similar to smokers.
49.4.3 Chemical Treatment of Hair
All patients are instructed not to color, ´perm,µ ´relax,µ or other-
wise chemically treat their hair during the 2-week period before
and after surgery. Doing so can result in hair breakage and hair
loss.
49.4.4 Infection Prophylaxis
Patients are required to shampoo their hair and shower and
cleanse their skin with antibacterial soaps the night prior to
surgery, paying careful attention to the periauricular areas.
Consideration should also be given to preop chlorhexidine home
prep of the body if fat grafting is to be performed. Patients who
have a history of methicillin-resistant Staphylococcus aureus
(MRSA) infection, patients who are health care workers, and
other patients at risk of being MRSA carriers should be consid-
ered for MRSA testing and decolonization.
49.4.5 Allocating Operating Room Time
It is important that adequate OR time be allotted for contempo-
rary facelift procedures, as they are deceptively time-consuming
compared with traditional techniques. A high-SMAS facelift,
especially when performed in conjunction with forehead plasty,
eyelid surgery, fat injections, skin resurfacing, and other pro-
cedures, will often encompass up to 6 to 8 hours or more, even
when performed by a ´fastµ surgeon working with a well-orga-
nized and experienced OR team. Most surgeons we know who
perform these complicated combined procedures on a regular
basis have resigned themselves to this fact and have made
appropriate adjustments in their surgery schedules. Usually this
means allotting an entire day for the procedure. For difficult
procedures, or when additional surgery is requested (e.g., rhino-
plasty), it is recommended that the procedures be staged over 2
separate days.
It is prudent for any surgeon new to these techniques to consider
staging a full-face rejuvenation consisting of multiple procedures
over two separate days. This worked well for us early in our prac-
tices and is still recommended to certain patients with difficult or
unusual problems and those who request multiple ancillary pro-
cedures. Typically facelift, neck lift, and fat grafting are performed
the first day. The patient is then kept overnight and returned to
the OR the following day (or a few days later) for forehead plasty,
blepharoplasty, lip lift, otoplasty, skin resurfacing, and other like
requested procedures. Patient acceptance of this recommendation
will be high if it is presented to them as in their best interest and
part of the surgeon’s effort to ensure their safety and to provide
high-quality care.
49.5 Anesthesia
49.5.1 Anesthesia Considerations for
Facelift Procedures
:hile it is possible to perform a limited procedure that one can
technically call a “facelift” under local anesthesia, any such pro-
cedure necessarily encompasses significant compromises in the
treatment of the SMAS and platysma that form the foundation
of the modern facelift and will typically not allow the perfor-
mance of important related and ancillary procedures including
comprehensive fat grafting, deep neck lifting, and often-needed
forehead surgery due to limits on the amount of local anesthetic
that can be administered and on the patient’s and surgeon’s
tolerance for the procedures’ complexity and length. Adding
oral and/or intravenous (IV) sedation (´conscious sedationµ) to
procedures performed under local anesthesia can improve the
patient’s experience and facilitate the performance of more
comprehensive operations, but it negates many of the purported
advantages of a ´localµ technique. It also places the surgeon
in the role of anesthesiologist and in charge of monitoring the
patient and managing and treating intraoperative problems
(hypertension, arrhythmias, etc.).
Most modern facelift techniques, including the high-SMAS
procedure, are time-consuming and technically demanding and
arguably will test the patience and composure of almost any
surgeon. It is highly recommended that any surgeon new to these
techniques enlist the services of an anesthesiologist or competent
Certified Registered 1urse Anesthetist (CR1A) as part of a team
approach to patient care. This is particularly important when the
procedure is to be performed upon a patient whom is apprehen-
sive or has a history of anesthetic difficulties, hypertension, or
other significant medical problems. This will avert the frustration
and aggravation of trying to perform a technically demanding
procedure while simultaneously being shouldered with the
responsibility of supervising the administration of an anesthetic,
monitoring the patient, and managing intraoperative problems.
49.5.2 Our Preferred Facelift Anesthesia
Technique
1ot using local anesthesia does not automatically equate to
the need for general anesthesia, however, and formal general
anesthesia, in which patients are paralyzed, endotracheally
intubated, and placed on a ventilator, is not necessary and is
arguably not optimal for the performance of most facelift pro-
cedures. The majority of our facelifts are performed under deep
sedation administered by an anesthesiologist using a laryngeal
mask airway (LMA; Fig. 49.31).
The use of an LMA allows the patient to be heavily sedated
without compromise of their airway, but the patient need not

654
VIII Surgical Rejuvenation of the Face and Neck
receive muscle relaxants and can be allowed to breathe sponta-
neously. An LMA is also less likely to become dislodged during the
procedure than an endotracheal tube is, as well as less likely to
trigger coughing and bucking when the patient’s head is turned
or when the patient emerges from the anesthetic.
It is useful to modify the way in which the laryngeal mask is tra-
ditionally used when performing facelift procedures. Traditionally
the cuff of the LMA is inflated to create a seal so that a ventilator
can be used, positive pressure ventilation applied, and vapor
anesthetics administered. This is not necessary, however, when
patients are not paralyzed and are only heavily sedated, when
intravenous sedation is used rather than inhalation anesthetics,
and when the patient is allowed to breathe spontaneously. In such
cases the cuff of the LMA can be left uninflated or be minimally
inflated and the LMA left to function as simply a large oral airway.
1ot inflating the cuff limits pressure in the hypopharynx and
related postoperative discomfort that can occur in the throat.
Some surgeons have expressed concern that the LMA, especially
with the cuff inflated, will cause distortion of the neck that would
result in confusion in decision making when performing deep
neck and other neck lift procedure maneuvers. :e have found
this not to be the case, and while a bulge is often evident if the
LMA cuff is inflated, the surgeon can simply ignore it and carry out
all neck maneuvers as usual and as indicated. The bulge created
by the inflated cuff will not affect gauging the extent to which
deep-layer neck maneuvers are carried out (submandibular
gland reduction, subplatysmal fat resection, and digastric muscle
reduction) or interfere otherwise with the neck lift procedure
(platysmaplasty, platysmamyotomy, lateral platysma suspension
using a postauricular transposition flap, drain placement, etc.).
49.5.3 Preop Anesthesia Medications
Most patients receive preoperative medication tailored and
adjusted to their age, weight, height, personality, specific cir-
cumstances, and general health, and this regimen is modified
depending upon the type of anesthetic used. Typical preop
medications currently used for patients in good health without
contraindications and as appropriate for their weight and general
conditions include clonidine (1–3 mg orally), atenolol (12.5–25
mg orally), and midazolam 3 to 5 mg intramuscular (typically
deltoid injection). These medications should be administered
after all preop discussions have been made, patient questions
answered, and preoperative consents and other related paper-
work signed. Oral narcotics should not be given as part of the
premedication, as they commonly result in nausea and vomiting.
Cocaine, anticholinergics, and parasympathomimetics are also
avoided in our practices.
Antiemetics are given routinely in a preemptive fashion at the
beginning of each procedure and typically include ondansetron
(10 mg IV) and dexamethasone (3–5 mg IV). It should be noted
that dexamethasone is administered for its antiemetic properties
and not as a means to reduce swelling. Patients with a history
of motion sickness, perioperative nausea and vomiting, or other
risk factors are given medications to block the emetic reflex at
multiple levels that typically include aprepitant (Emend; 40 to 80
mg orally) and/or a scopolamine patch (placed on the upper inner
thigh).
49.5.4 Patient Monitoring During
Anesthesia
All patients are fully monitored with electrocardiography,
automatic sphygmomanometry, transcutaneous pulse oximetry,
and mainstream capnography. Perioperative blood pressure is
closely monitored and aggressively treated should it become
significantly elevated, especially in patients with existing hyper-
tension or a ´borderlineµ condition. The latter group of patients
should be watched closely and treated preemptively, as they
typically become hypertensive once the surgery and anesthesia
are begun.
49.5.5 Method of Intraoperative
Sedation
The current mainstay of patient sedation during our facelift pro-
cedures is achieved using propofol. Typically a bolus (1–2 mg/kg)
is administered by the anesthesiologist prior to LMA insertion,
followed by a drip infusion administered via an infusion pump
depending on the patient’s circumstances and titrated to the his
or her needs (75–200 —g/kg/min).
If fat grafting is being performed, fat harvesting is performed
at the beginning of the procedure and before the patient’s face
is prepped and draped, and the anesthesiologist may temporarily
inflate the cuff on the LMA so that an inhalation anesthetic (sevo-
flurane or similar) can be administered to provide a brief period of
Fig. 49.31 The flexible Laryngeal mask airway. An LMA maintains an
open airway during deep sedation but allows patients to breath spon-
taneously. When the flexible model shown is used and the breathing
circuit is draped separately, unobstructed access to the neck and
submental region can be obtained. (Copyright © Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
655
deep sedation during that part of the procedure. The cuff is then
deflated or its pressure reduced before the face is prepped and the
patient draped for the facelift procedure.
In most cases the IV anesthetic infusion is titrated to a deeper
level for a brief period once the patient has been prepped and
draped to give the surgeon a few minutes of deep sedation in
which to perform local anesthetic nerve blocks and infiltrate all
proposed sites for incision with local anesthetic solution.
49.6 Surgical Technique
The sequence of events in the facelift procedure is outlined in
Table 49.2.
49.6.1 Patient Positioning, Urinary
Catheter Insertion, and Patient
Marking
The patient is placed supine on a warmed and well-padded,
slightly flexed operating table, and a special effort is made to
ensure and document that the elbows, heels, and other potential
pressure points are well protected. The patient’s lower extrem-
ities are then elevated and antiembolic pedal compression
devices applied. An indwelling, balloon-tipped urinary catheter
(´Foley catheterµ) is placed after sedation is begun or general
anesthesia administered. During this time, the facelift incision
plan is marked with a fine-tipped surgical marker after skin to
be marked is degreased with isopropyl alcohol. If fat grafting is
to be performed, fat is harvested at this time, before the face is
prepped and draped, and typically entails turning the patient into
a right and left lateral decubitus position. A temperature probe
is then taped in the axilla or groin, and the patient sufficiently
covered or a patient warming device applied, to allow the room
to be cooled for the comfort of the scrubbed team members.
49.6.2 Patient Prepping and Draping
After anesthesia is begun, fat has been harvested, the patient has
been positioned on the table, the urinary catheter placed, and
the incision plan marked as just described, a sterile prep drape
is then placed beneath the patient’s head, and bland ophthalmic
ointments instilled into each eye. Each patient then receives a
full prep of the entire scalp, face, ears, nose, neck, shoulders,
and upper chest with full-strength (1:750) benzalkonium chlo-
ride (=ephiran, Sanofi, Bridgewater, 1-) solution. Care is taken
to ensure that prep solution does not pool in the eye areas or
otherwise get into the eyes. The patient’s head is placed through
the opening of a disposable sterile ´split sheet,µ or a split, adhe-
sive-backed disposable sterile transverse laparotomy sheet (tails
facing the patient’s feet), leaving the entire head and neck region
unobscured from the clavicles up.
The breathing circuit is subsequently draped separately from
the patient by wrapping it with a sterile paper drape sheet and
securing it with 1-inch Steri-Strips (3M, St. Paul, M1), or by cover-
ing it with a sterile stockingette. This allows it to be moved during
the procedure as the patient’s head is turned from side to side and
away from the submental area when working in the neck through
the submental incision. :hen drapes are applied in this manner,
it is not necessary to secure the LMA with tape or by other means
as long as its position is watched by the anesthesiologist and/
or other members of the OR team present. If an endotracheal
tube is used, it can be conveniently and effectively secured to
the upper lip skin with a TegaDerm (3M, St. Paul, M1) or similar
sterile adhesive-backed dressing. This method of prepping and
draping allows unimpaired examination of the cervical profile
in its entirety throughout the procedure and provides complete
access to all areas of the scalp. No head drapes are used, as they
will limit scalp access and make it difficult to determine hair shaft
inclination and make incisions properly.
After the general prep of the face is complete and drapes have
been applied, the posterior surface of the tragus and the auditory
canals are prepped with full-strength povidone-iodine using
cotton-tipped swabs by a scrubbed member of the surgical team.
Each nasal vestibule, the perioral area, and the gingivolabial sulci
are prepped with povidone–iodine as well. .ittner ´peanutµ
sponges are then placed in each auditory meatus, and these
are changed as necessary during the procedure to prevent the
accumulation of blood in the auditory canals. If the patient’s face
and ear canals are small, the .ittner sponges can be trimmed to
reduce their size slightly and obtain a better fit.
No hair is cut or shaved along any proposed site of incision.
Shaving or trimming hair will negate accurate assessment of hair
shaft inclination relative to the scalp and can result in incisions
that injure hair follicles. Tightly applied rubber bands, adhesive
tape, surgical lubricants, antibiotic ointment, and hair clips pro-
duce similar problems and should also be avoided for the same
reasons.
It is always an error to shave any area of the scalp before the
procedure, as this commits the surgeon to excision of the shaved
area, even if this is determined to be inappropriate intraopera-
tively. As a practical matter, in most well-planned facelifts, little if
any scalp tissue should actually be excised.
49.6.3 Administering Local Anesthesia
Local anesthetic is administered even if deep sedation or general
anesthesia is used. This limits stimulation of the patient and the
overall amount of anesthetic needed and significantly reduces,
or even often eliminates, the need for intraoperative narcotics.
A significant and helpful hemostatic effect is also obtained when
epinephrine/tranexamic acid–containing solutions are used.
Sensory nerve blocks are performed using 0.25 bupivacaine
with epinephrine 1:200,000 injected with a 25-gauge needle
attached to a 10-mL ring control syringe. Blocking major sensory
nerves allows the rest of the face to be injected with a reduced
degree of stimulation. Skin marked for incision is then infiltrated
with the same solution. If fat grafting is to be performed, it is
performed at this time in a ´dryµ field and prior to subcutaneous
infiltration of the face.
Once fat grafting is complete, areas where subcutaneous
dissection will be made are infiltrated with 0.1 lidocaine with
epinephrine 1:1,000,000) and tranexamic acid (1,000 mg per
500 mL of local anesthetic solution), taking care to ensure that
the total dose of lidocaine does not exceed 7 mg per kilogram
per 4 hours (Fig. 49.32). Infiltration of the preauricular cheek
and postauricular areas is carried out using a 22-gauge spinal
needle, as skin in these areas is typically adherent and resistant

656
VIII Surgical Rejuvenation of the Face and Neck
Table 49.2 Sequence of events in facelift procedure, overview
33. Raise and suspend superior margin of SMAS flap on oppo-
site side of face parallel to long axis of zygomaticus major
muscle.
34. Trim posterior margin of ipsilateral SMAS flap to match cut
edge beneath it; and close over parotid gland under no
tension.
35. Gauge platysma excess on medial platysmal borders and
excise.
36. Suture trimmed medial borders of platysma muscles edge
to edge in one layer with interrupted sutures from mentum
to mid–thyroid cartilage without invaginating tissue and
under normal muscle tension (perform platysmaplasty). Do
not tighten in corset fashion.
37. Suspend postauricular transposition flaps to mastoid fascia
on right and left side.
38. Perform chin augmentation if indicated.
39. Divide medial half of right and left platysma muscles at
level of midthyroid to cricoid cartilage through submental
incision (with electrocautery or Metzenbaum scissors).
40. Divide lateral half of right and left platysma muscles below
inferior aspect of postauricular transposition flaps through
postauricular incisions (with electrocautery or Metzenbaum
scissors).
41. Place subcutaneous and subplatysmal 10 French round
Jackson-Pratt drains.
42. Irrigate with antibiotic solution and make final check for
hemostasis.
43. Redrape skin on right side of face, gauge excess width in
supra-auricular area with facelift marker, and suspend under
normal skin tension at key point of anchoring above ear.
44. Anchor postauricular skin flap in apex of postauricular defect
at key point of anchoring behind ear without trimming
superior margin of skin flap.
45. Trim anterior edge of postauricular skin flap to match curve
of posterior concha and close with simple interrupted
sutures of 4–0 nylon.
46. Use facelift marker to gauge skin excess along occipital
portion of postauricular incision. Trim excess skin. Close
under no tension with a combination of half buried vertical
mattress sutures of 4–0 nylon and simple interrupted
sutures of 6–0 nylon.
47. Trim and close temporal incision under no tension.
48. Trim and close prehelical part of preauricular incision under
no tension.
49. Trim and close the prelobular part of preauricular incision
under no tension.
50. Trim and close the tragal incision under no tension and
maintaining skin to fill the pretragal sulcus.
51. Inset the lobule (perform earlobe reconfiguration or reduc-
tion if indicated).
52. Perform temple–forehead plasty as indicated.
53. Perform blepharoplasties as indicated.
54. Perform upper lip lift if indicated.
55. Close the submental incision.
56. Perform buccal fat reduction if indicated.
57. Perform perioral and/or lower eyelid laser resurfacing if
indicated (no lasering should be performed on cheek skin
that has been undermined).
1.
Induce anesthesia.
2.
Mark incisions while Foley catheter placed.
3.
Harvest fat.
4.
Position patient, prep face, drape.
5.
Perform nerve blocks and inject incision sites with 0.25%
bupivicaine with epinephrine.
6.
Inject fat.
7.
Infiltrate skin to be subcutaneously undermined with 0.1%
lidocaine with epinephrine solution.
8.
Raise skin flap on right side of face.
9.
Raise skin flap on left side of face.
10. Raise SMAS flap on right side of face.
11. Raise SMAS flap on left side of face.
12. Make submental incision, subcutaneously undermine submen-
tal skin, and join with undermined skin made in lateral neck.
13. Incise platysma midline.
14. Elevate platysma on right over anterior belly of digastric to
submandibular gland (SMG).
15. Incise capsule of right SMG and mobilize SMG inside capsule
(mobilize more than planned resection).
16. Identify anterior belly of right digastric muscle near mentum.
17. Dissect under lateral border of right side of subplatysmal fat
pad among inferior surface of digastric to insertion on lateral
hyoid and carry into SMG capsule (Metzenbaum scissors).
18. Divide lateral border of subplatysmal fat over anterior belly
of digastric (using cautery).
19. Dissect right side of subplatysmal fat pad off anterior belly
of digastric and deep fascia with cautery (do not include
interdigastric fat).
20. Inject approximate line of resection of mobilized SMG and
anterior belly of right digastric with 0.25% bupivicaine with
epinephrine.
21. Repeat elevation of platysma on left side.
22. Incise capsule of left SMG and mobilize SMG inside capsule
(mobilize more than planned resection).
23. Identify anterior belly of left digastric muscle near mentum.
24. Dissect under lateral border of left side of subplatysmal fat
pad along inferior surface of digastric to insertion on lateral
hyoid and carry into SMG capsule (Metzenbaum scissors).
25. Excise subplatysmal fat pad, leaving interdigastric fat
between anterior digastric bellies and in suprahyoid sulcus.
26. Inject approximate line of resection of mobilized left SMG
and anterior belly of left digastric muscle with 0.25% bupiv-
icaine with epinephrine.
27. Resect protruding portion of right SMG along plane tangent
to ipsilateral border of mandible and anterior belly of ipsilat-
eral digastric muscle using cautery.
28. Resect protruding portion of right anterior digastric belly.
29. Resect protruding portion of left SMG along plane tangent
to ipsilateral border of mandible and anterior belly of ipsilat-
eral digastric muscle using cautery.
30. Resect protruding portion of left anterior digastric belly.
31. Raise and suspend superior margin of SMAS flap on side of
face that sags most, parallel to long axis of zygomaticus
major muscle.
32. Trim posterior margin of ipsilateral SMAS flap to match
cut edge beneath it and close over parotid gland under no
tension.

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
657
to injection with a blunt cannula. Infiltration of the neck, sub-
mental, and anterior cheek regions are carried out with a 1.6-mm,
20-cm-long multihole blunt-tipped infiltration cannula. No direct
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of the procedure as just described. Approximately 150 to 200 cc of
dilute local anesthetic solution is infiltrated subcutaneously into
each side of the face and neck.
Maintenance of the local block is achieved by systematically
reinfiltrating the key areas (pre- and postauricular regions)
midway during the procedure and readministering nerve blocks
EHfRUH WKH ORFDO DQHVWKHWLF H̵HFW ZHDUV R̵. This prevents loss of
continuity of the local anesthetic effect and avoids stimulation
of the patient that would otherwise occur should reinjection be
delayed until after sensation has returned.
49.6.4 Making Incisions
Incising the skin is a key step in which the surgeon exercises
direct control over the quality of the resultant scar, and incisions
should not be made in a casual or careless manner. All incisions
on the scalp must be made precisely parallel to hair follicles to
avoid injury to them. A carelessly made incision will injure fol-
licles and can result in peri-incisional alopecia. Frequently this
is mistakenly attributed to the patient’s own poor healing and
erroneously regarded as a ´wide scar.µ
In most cases, follicles and hair shafts will be similarly inclined,
but this may not be true in the kinky- or curly-haired individual
or when a patient’s hair is wet, saturated with surgical lubricants,
or restrained with drapes, tape, or rubber bands. For this reason
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precisely parallel to hair follicles as it is made on the scalp. One
must also recognize that hair follicle inclination is not uniform
over the scalp and that follicles will be inclined differently at dif-
ferent areas along the planned incision. Because of this, the angle
of the scalpel blade with the scalp must change correspondingly
as the incision is made, and the completed incision will be beveled
to varying degrees and in different directions, if properly made.
Incisions made along skin-scalp interfaces should be beveled
slightly to the scalp side to leave one or two rows of hair follicles
beneath the sutured incision. An exaggerated bevel, advocated by
some surgeons, is not needed and is typically counterproductive,
as it usually results in regrowth of hair that is kinky and unruly
and thus of concern to the patient.
49.6.5 Cheek and Neck Skin Flap
Elevation
After incisions are made, skin flaps are elevated according to the
preoperative plan over the cheek and neck (see Fig. 49.31b, Fig.
49.34, Fig. 49.35). 3DUWLDO VHSDUDWLRQ Rf WKH VNLQ ÁDS fURP WKH 60$6
´ODPHOODU GLVVHFWLRQµ LV QHFHVVDU\ EHFDXVH VNLQ DQG 60$6 ÁDSV
QHHG WR EH DGYDQFHG LQ GL̵HUHQW GLUHFWLRQV Lf DQ RSWLPDO RXWFRPH
is to be obtained. This “bidirectional” tissue shift is not possible
if a ´deep-planeµ or ´compositeµ type dissection (elevation of a
combined skin–SMAS flap) is made.
Correct positioning of the operating room lights and proper
retraction by the assistant is required if proper dissection is to be
made and potentially harmful trauma to the flaps is to be avoided.
Light should be placed on both sides of any skin flap being dissected
to provide simultaneous direct and transmitted illumination, and
blind dissection should not be made. Light shone upon the skin
surface (transillumination) will help define flap thickness, while
light shone underneath the skin flap upon the site of dissection
(direct illumination) allows identification of important structures.
Too much direct illumination can obscure the transillumination
effect and must be avoided. This is particularly true of the bright
direct light emitted from fiberoptic headlights and fiberoptic
retractors. If they are to be used, their intensity should be reduced
so that a proper and balanced illumination effect is obtained and
Fig. 49.32 Local anesthetic solutions. (a) Nerve blocks and incision sites: 0.25% bupivacaine with epinephrine. Maximum safe doses of bupivacaine
with epinephrine in mg: patient’s weight in kg ð 3. For example, for a typical 60-kg female patient, maximum dose equals 70 mL of 0.25% bupivacaine
with epinephrine. Rule of thumb: 1 mL of 0.25% bupivacaine with epinephrine per kilogram of body weight. (b) Subcutaneous infiltration with 0.1%
lidocaine with 1:1,000,000 epinephrine. Solution mixture: 50 mL of 1% lidocaine, 10 mL 0.25% bupivacaine, 1 g tranexamic acid, 1 ampoule epineph-
rine, in 500 mL normal saline. Maximum safe dose of lidocaine with epinephrine in mg: patient’s weight in kg ð 7. For 60-kg female patient, 150–200
mL of solution per side. (Copyright © Timothy Marten.)

658
VIII Surgical Rejuvenation of the Face and Neck
the transillumination effect is not lost while skin flaps are being
raised.
The circulating nurse or other unscrubbed team member
should be assigned the task of adjusting the overhead lights as
needed for the surgeon, and the importance of this assignment
should be emphasized. In time, a perceptive nurse or assistant will
need only watch the operative field to know when adjustment is
needed. If the circulating nurse is required to monitor the patient,
administer medication, leave the operating room frequently, or be
otherwise occupied, it is recommended that an additional staff
member be present.
Both surgeon and assistant should refrain from adjusting
overhead lights, as each will need both hands free for proper
retraction and dissection. Adjusting the lights with one hand while
retracting with the other is a common error that invariably results
LQ H[FHVVLYH WUDFWLRQ XSRQ WKH VNLQ ÁDS DQG XQQHFHVVDU\ WUDXPD WR
delicate cervicofacial tissue.
Proper care of the patient and effective functioning of the
operating room team will require that two team members be
scrubbed with the surgeon throughout most of the procedure. One
scrubbed team member will be necessary to act as a “full-time”
surgical assistant, providing tissue retraction and exposure. This
is a key role that precludes the simultaneous passing of instru-
ments, loading of sutures into needle holders, tracking of sharps,
and maintenance of the instrument stand. A second scrubbed
team member should be present to oversee and carry out these
latter important secondary functions. Regardless of experience, or
claims to the contrary, is not possible for one person to assume
both roles effectively without compromising her or his role as an
assistant, disrupting work flow, and otherwise slowing down the
surgical procedure.
The preauricular cheek flap dissection is begun using a
fine-tipped Adson forceps and a small .aye scissors or scalpel
to elevate skin off the tragus and the flap in the prehelical and
prelobular areas. Once the preauricular cheek flap edge has been
elevated, the forceps is set aside and gentle traction is applied by
the assistant with double-pronged skin hooks. A standard-pattern
medium Metzenbaum scissors is then used to establish the proper
plane further, and flap dissection is begun. Usually the preauricu-
lar scissors dissection is most easily begun, and the proper plane
most easily identified in the prelobular area.
Facelift skin flap dissection is most effectively performed when
surgeon and assistant work together as a carefully coordinated
team using a ´four-handedµ technique (Fig. 49.33). In this tech-
nique, the assistant applies gentle traction upon the skin flap
directed toward the surgeon with two 10-mm double-pronged
skin hooks. One skin hook retractor should be held in each hand,
as it is not possible for the assistant to provide proper retraction
using a ´one-handedµ technique (holding both retractors in one
hand). The surgeon then dissects while providing gentle counter-
traction toward the assistant with the fingertips of the opposite
(nondominant) hand on the skin surface.
As the dissection advances, one skin hook is exchanged for a
small Deaver, shaped 1-inch malleable, or similar retractor. The
remaining skin hook is used to drape the skin flap gently over the
retractor and keep it properly positioned upon it. This eliminates
the need for excessive traction force, minimizes tissue trauma,
and provides for optimal visualization under the skin flap.
The surgeon should always avoid retracting for her- or himself,
as this invariably leads to excessive tissue traction and rough
KDQGOLQJ Rf WKH ÁDS, especially when exposure is limited or dis-
section becomes difficult. Retracting should instead always be
performed by a conscientious assistant capable of focusing his or
her attention on providing proper exposure while simultaneously
protecting delicate facial skin flaps. This assistant must ignore his
or her natural urge to ´helpµ the surgeon by applying excessive
force when retracting. It must also be recognized that most hos-
pital and surgery center personnel are accustomed to assisting
surgeons in other specialties and have not been trained in proper
tissue-handling techniques. They are usually not aware that
improper retracting, excessive traction, and rough handling of the
ÁDS DUH KDUPfXO and can lead to flap compromise, tissue necrosis,
and skin slough. Time taken to teach them proper retracting and
tissue-handling techniques as just outlined is well spent.
Tissue trauma to skin flaps can be significantly reduced by
periodically moving the dissection from one area to another
and completing flap elevation in stages. This allows the tissue to
´breatheµ and avoids prolonged traction upon and compromise of
any one area. Traction should also be released before retractors
are moved, however. If traction is not released, tissue will be
injured and the flap microcirculation will be compromised as the
retractor is moved from side to side beneath the skin flap.
It should be the responsibility of all OR team members to ensure
WKDW ÁDSV DUH KDQGOHG FDUHfXOO\ DQG WKDW WKH\ DUH QRW VXEMHFWHG WR
excessive traction, pinching, folding beneath retractors, or other
potentially harmful actions. It is not possible for the surgeon, who
is usually preoccupied with other aspects of the procedure, to be
always diligent in this regard.
Skin flaps should be elevated sharply under direct vision and
blind dissections avoided in most areas. This is particularly
important in the ´great auricular corridor,µ the preauricular
region, and the upper medial cheek, where an inadvertent deep
Fig. 49.33 “Four-Handed” Technique. The assistant applies gentle
traction upon the skin flap towards the surgeon with two 10 mm
double pronged skin hooks with one retractor held in each hand. The
surgeon then dissects while providing gentle counter traction towards
the assistant with the fingertips of the opposite hand. Properly orga-
nized teamwork facilitates flap dissection and reduces tissue trauma.
Optimal dissection is not possible if the surgeon retracts for her or
himself, or if the assistant tries to retract with both retractors held in
one hand. (Copyright © Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
659
dissection can injure the great auricular nerve or the underlying
SMAS and compromise its use as a flap. It has been our observation
that many surgeons using non-SMAS facelift techniques engage in a
GHHSHU VNLQ ÁDS GLVVHFWLRQ WKDQ WKH\ UHDOL]H, and inspection of their
flaps after dissection often reveals that a portion of the SMAS
has been elevated as part of the ´skinµ flap. Adjustments to this
type of technique must be made if damage to the SMAS is to be
avoided and a SMAS flap to be used. It is also an error, however,
to dissect too close to the posterior surface of the skin flap, as this
can result in injury to subdermal microcirculation. Dissecting too
close to the underside of the skin flap is usually caused by using
aggressively patterned, pointed, serrated, and ´extra-sharpµ-type
surgical scissors. Meticulous attention to proper injection of
dilute local anesthetic solution into the subcutaneous plane with
a blunt-tipped injection cannula, as described in the preceding
section, preestablishes the proper plane of dissection and greatly
facilitates skin flap elevation in the proper plane.
Although subtle, some visual clues are helpful in determining
when the proper plane has been established and avoiding prob-
lems of a too-deep or too-superficial dissection. If skin flap dis-
section is made too deep and SMAS fibers are elevated with it, the
under surface of the skin flap will appear relatively smooth and
covered by streaks of fine white tissue. :hen transilluminated,
flaps dissected in this manner will have a ´cloudy skyµ appearance
and appear relatively ´thick.µ If dissection is made in the proper
plane, however, the undersurface of the flap will have a character-
istic rough, ´pebbled,µ or ´cobblestoneµ appearance and be more
yellow. Transillumination of a flap dissected in the correct plane
enhances this appearance.
Blind dissection made by pushing scissors, or blunt dissection
made using a scissors spreading technique, are unacceptably
traumatic to the subdermal microcirculation of the skin and
can result in flap compromise, damage to subdermal fat, and
unintended injury to the SMAS and platysma. This is particularly
likely when aggressively patterned, double-edged, serrated, or
´extra-sharpµ-type scissors are used. After experimenting with
many scissors patterns, experience has shown that none is as
good or as forgiving as the standard medium curved Metzen-
baum type.
Postauricular skin flap undermining is most easily begun infe-
riorly if the occipital incision has been made along the occipital
hairline, or posteriorly if the incision has been made onto the
occipital scalp, as more subcutaneous fat is usually present in
these areas and the correct plane of dissection is most easily
identified there. Beginning dissection in these areas also helps
one identify the proper plane more superiorly and anteriorly in
the postauricular area where less subcutaneous fat is present and
the skin and fascia lie in close proximity and can be more tightly
bound. Careful infiltration of dilute local anesthetic into the plane
of dissection, as previously described, also facilitates dissection in
these and other areas of the face.
Once the correct plane of dissection has been established
in the postauricular area, two 10-mm double-pronged skin
hook retractors are placed and held by the assistant toward
the surgeon’s forehead, and Metzenbaum scissors are used to
elevate the postauricular skin flap. Postauricular flap elevation
should be performed under direct vision aided by transillu-
mination. Dissection in the postauricular area is most easily
performed when an incision along the occipital hairline is used
in an inferior-to-superior direction rather than in a posterior-to-
anterior one.
As dissection progresses anteriorly and inferiorly from the
postauricular region to the upper lateral neck, care must be taken
to avoid injury to the great auricular nerve, and dissection of this
area should be made under direct vision. This nerve provides sen-
sation to the lower two-thirds of the ear and travels superficially
superiorly in the upper lateral neck over the sternocleidomastoid
muscle fascia. The most superficial portion of the nerve is ana-
tomically constant and lies approximately 6.5 cm inferior to the
auditory meatus midway between the anterior and posterior
borders of the sternocleidomastoid muscle. It is helpful to mark
that spot preoperatively to guide one during dissection. If the
dissection is performed correctly, however, the nerve will lie deep
to the plane of skin flap dissection and will be covered by a thin
layer of subcutaneous fat and fascia, and it is neither necessary
nor advisable to attempt to specifically identify or isolate this
nerve through additional dissection.
Patients with thin faces, elderly patients, or those undergoing
secondary facelifts will not uncommonly have little subcutaneous
fat between the superficially situated portion of the great auric-
ular nerve and the skin, however. For this reason, extra caution
must be taken in these patients when elevating the skin flap in
this area, and a clear knowledge of nerve anatomy is required.
As dissection is continued farther anteriorly into the cervical
region and anterior to the external jugular vein, subcutaneous
fat generally becomes more abundant and is less tightly bound to
underlying tissues, and the flap is easier to dissect. Care should be
taken to remain in a subcutaneous plane, however, and to leave
the majority of the preplatysmal fat on the platysmal surface. This
makes fat excision and sculpting easier later in the procedure, if
required, and precludes the need for difficult and tedious excision
of fat from the undersurface of the cervical skin flap. In contrast
to the dissection of the cheek skin flap, in which a conscious effort
must be made to prevent the flap from becoming too thick, a
slightly deeper dissection should be made in the neck to preserve
a slightly thicker layer of subcutaneous fat. Preservation of a
thicker layer of fat helps avoid a hard or overresected appearance
in the cervicosubmental area and objectionable overexposure of
underlying neck anatomy. In fact, in many necks, and especially
in secondary procedures, the goal will often be to preserve all
subcutaneous fat present at this point in the procedure and to
resect none at that time.
If a submental incision is planned, subcutaneous dissection
of the anterior neck skin flap will be more easily and effectively
completed through it, rather than through the postauricular
incisions. Undermining of the submental crease and releasing the
submental and mandibular ligaments will also be easier through
the submental incision as well, and bleeding in these areas that is
frequently encountered more easily controlled.
Although subcutaneous undermining is necessary to achieve
an optimal result, it should not arbitrarily include the entire face.
If a SMAS dissection is planned, preservation of the anterior
platysma–cutaneous ligaments will allow attractive and youthful-
appearing elevation of perioral tissue that cannot be obtained
with a ´skin-onlyµ technique or when wide skin undermining is
performed (Fig. 49.34, Fig. 49.35).
The platysma–cutaneous ligaments anchor the dermis of the
perioral cheek to the SMAS and upper platysma and provide a

660
VIII Surgical Rejuvenation of the Face and Neck
means of lifting and supporting the lateral perioral area without
overtightening the skin of the upper–lateral face. Preservation
of the platysma–cutaneous ligaments also preserves important
accompanying perforating vessels to the cheek flap. This reduces
the likelihood of skin slough and flap compromise.
If subcutaneous dissection is extended too far anteriorly and the
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significant portion of the benefit of SMAS elevation and advance-
ment will be lost. :ide cheek flap undermining and division of
the platysma–cutaneous ligaments are also the underlying cause
of the ´lateral sweepµ deformity (Fig. 49.6), as SMAS support of
sagging perioral tissues is lost when dissection is performed in
this manner.
49.6.6 Temple Dissection
The temple incision is made according to the preoperative plan
based on the redundancy present over the upper cheek and the
predicted degree of displacement of the sideburn and temporal
hairline (see preceding section).
:hen a traditional incision on the temporal scalp is indicated
(most typically in patients under 45 years old), it is made pre-
cisely parallel to hair follicles. This will generally require that the
incision be beveled to varying degrees and in different directions
along its length, as hair follicles are not uniformly inclined over
the temporal scalp. The dissection is then deepened and carried
down through the galea aponeurotica (´superficial temporal
fascia”) to the fascia of the temporalis muscle and the tempo-
ral hair-bearing fasciocutaneous flap anterior to the incision
undermined. This dissection is usually easy to perform bluntly
with closed Metzenbaum scissors or blunt Boies elevator and
should be extended anteriorly to the lateral orbit, inferiorly to
the midtemple, and superiorly to the temporal line. The bridge
of fascia lying inferiorly between the subgaleal dissection in the
temple and the subcutaneous dissection in the cheek (mesotem-
poralis) can then be safely and conveniently partially divided
in a curvilinear fashion posterior to the temporal hairline if the
anatomy of the frontal branch of the facial nerve is understood
and the division made thoughtfully and in the correct location
(Fig. 49.36).
This bridge of tissue contains the anterior branch of the super-
ficial temporal artery, and it must be divided and ligated when
encountered, or thoroughly cauterized if the mesotemporalis is
divided. This is of no clinical consequence in the nonsmoking
patient without vascular disease, and it is a routine part of the
dissection of this area when conditions indicate that the temporal
portion of the facelift incision be placed within the temporal
scalp. The frontal branch of the facial nerve lies well anterior and
inferior to this chosen point of transition between planes, and this
dissection, when executed as described, is anatomically sound
and clinically safe. Frontal branch anatomy can be confusing, how-
ever, and any surgeon who is uncertain of the exact relationships in
this region should review them carefully and made a detailed study
(Fig. 49.36; see also Fig. 49.41 in the following section on SMAS
dissection) before undertaking this dissection.
Fig. 49.34 Extent of subcutaneous undermining. Shaded (yellow) area
shows area of subcutaneous skin flap undermining in (a) traditional
(incorrect) and (b) contemporary “extended” (correct) plans. Note
that the platysma-cutaneous ligaments (black dots in (b) are not
undermined and are preserved in the extended plan. Preservation
of platysma-cutaneous ligaments and proper elevation and fixation
of the SMAS provide a lift and support of lateral perioral tissues that
is lost if the cheek is over-dissected as shown in (a). Note also in the
extended undermining plan the temple is released (1) to accommodate
upper cheek and mid-face tissue shift, the zygomatic ligaments (2) are
divided to release upper cheek and mid-face, the mandibular ligaments
(3; see also Fig. 49.35) are divided to optimize improvement in the
jowl and along the jawline, and the submental restraining ligaments (4;
see also Fig. 49.35) are divided to soften the “double chin” and allow
the fat of the chin and the submental region to be blended once deep
layer neck maneuvers have been completed. These releases were not
made in traditional (a) skin undermining plans. (Copyright © Timothy
Marten.)
Fig. 49.35 Plan for subcutaneous undermining shown on patient.
Shaded (yellow) area shows area of subcutaneous skin flap under-
mining. Note that skin undermining is limited in the perioral cheek
to preserve the platysma-cutaneous ligaments but extends up along
and onto the inferior border of the jawline to release the mandibular
ligaments that contribute to jowl and prejowl groove formation, and
superiorly up onto the anterior-inferior chin to release the submental
retaining ligaments that contribute to a “double-chin” appearance. The
transverse solid purple line marked on the skin of the submental area
is the site where the submental incision will be made. The transverse
solid purple lines low on the anterior neck mark the location of the
cricoid cartilage. (Copyright © Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
661
Partially dividing the bridge of tissue between the subgaleal
plane of the temple and the subcutaneous plane of the cheek
is an important maneuver that allows the two planes of dis-
section to be joined laterally. This, in turn facilitates exposure
in the upper cheek and lateral orbital area, dissection of the
SMAS, and redraping of the temporal portion of the facelift
flap. This strategy of dissection also protects hair follicles on
the undermined temporal scalp by moving the plane of dissec-
tion subgaleally and deep to them. Temporal skin can then be
undermined subcutaneously up to the lateral orbit, bringing
the dissections in the cheek and temple into wide continuity
(see Fig. 49.36b).
:hen an incision along the temporal portion of the anterior
hairline is indicated (most patients over 45 years old), it is made
a few millimeters within it as a straight line with a slight bevel
toward the scalp side. Although advocated by some surgeons,
it is unnecessary and typically counterproductive to make this
incision in a zigzag or wavy fashion. Properly trimmed and
closed under no tension, a straight-line incision will produce the
best-concealed scar.
The superior extent of temporal hairline incision will nec-
essarily vary depending upon the amount of cheek skin shift
predicted and whether a forehead lift is to be concomitantly
performed if puckering and gathering are to be avoided in this
area. Often small superior extensions beyond what was marked
preoperatively are needed if a smooth and well-tailored closure
is to be obtained. This incision should be made no higher than
the junction of the temporal hairline with the frontotemporal
hairline, however. If it is carried more superiorly, the resulting
scar will usually be visible, as hair tends to grow posteriorly in
that area (Fig. 49.37).
After an incision along the temporal hairline has been made,
the temporal skin flap is carefully undermined subcutaneously
and joined with the subcutaneous dissection in the cheek. 1o
transition between planes is necessary when this incision plan is
used, no hair-bearing flaps are raised, and the superficial temporal
vessels and frontal branch of the facial nerve are left undisturbed,
beneath the superficial temporal fascia (Fig. 49.38).
49.6.7 SMAS Dissection
Once skin flaps have been elevated, they are retracted and the
zygomatic arch palpated. A line is then traced ´highµ over its
midportion in water-soluble surgical ink (methylene blue) from a
point just lateral to the infraorbital rim to a point approximately
1 cm anterior to the superior aspect of the tragus. This line lies
´higherµ than the dissection made in ´deep-planeµ and other
low-SMAS techniques (and thus the origin of the name ´high-
SMASµ), and well above the malar origin of the zygomaticus
major muscle. The mark is then turned inferiorly and carried
over the preauricular portion of the parotid 1 to 1.5 cm anterior
to the ear. Inferior to the lobule, it is continued inferiorly and
slightly posteriorly to the anterior border of the sternocleido-
mastoid muscle to a point approximately 2 to 3 cm below the
mandibular border (Fig. 49.39).
A basic ´highµ flap of this type is used on most patients, and
several important advantages that arise from its design are worth
considering. First, SODQQLQJ WKH VXSHULRU PDUJLQ Rf WKH ÁDS RYHU
and along the zygomatic arch, rather than inferior to it, expands the
H̵HFW Rf WKH ÁDS WR LQFOXGH WKH XSSHU PLGfDFH DQG DOORZV D EHWWHU
vector to be applied to it. Carrying the incision posteriorly and
inferiorly over the tail of the parotid to the anterior border of the
sternocleidomastoid muscle in the upper lateral neck also main-
tains a “safety zone” between the incision and the mandibular
margin and moves the dissection away from the point at which
the marginal mandibular nerve exits the anterior border of the
inferior portion of the parotid (Fig. 49.40). Placing the remaining
portion of the incision along the anterior border of the sterno-
cleidomastoid muscle places the dissection in a relatively thin
and avascular area of the platysma and along a line where the cut
Fig. 49.36 (a,b) Dividing the mesotemporalis. When conditions dictate that the temporal portion of the facelift incision should be made within the
temporal scalp, the bridge of tissue situated between the subgaleal dissection in the temple and the subcutaneous dissection in the cheek (part a, white
arrow) can safely be divided posterior to the course of the frontal branch of the facial nerve (part b, dotted yellow line). This bridge of tissue contains the
anterior branch of the superficial temporal artery, which must be divided and cauterized or ligated (white arrows in part b). (Copyright © Timothy Marten.)
a
b

662
VIII Surgical Rejuvenation of the Face and Neck
edge, if visible through the skin after surgery, would appear to be
the anterior muscle border.
High SMAS flap elevation is begun by incising the SMAS layer
over the zygomatic arch. This is accomplished by grasping the
preauricular SMAS overlying the lateral arch with an Allis clamp
on each side of the marked line and lifting it up and away from
deeper tissues. An incision is then made with Metzenbaum scis-
sors or a needlepoint cautery, set on a low, ´eyelidµ coagulation
current setting, into the SMAS layer that has been lifted up and
continued medially 1 to 2 cm along the marked line in the tensed
plane. The Allis clamps are then released and reapplied incremen-
tally as the dissection proceeds further medially along the marked
line in the elevated and tensed plane in 1- to 2-cm segments in a
similar fashion using scissors or cautery. A considerable amount
of tissue lies over the lateral arch, and the frontal branch will be
safely concealed beneath half a centimeter or more of fibrous fat;
its path may be located using Pitanguy’s landmark (Fig. 49.41).
The margin for error may be reduced, however, in the thin, aged
patient with advanced facial atrophy and less soft tissue cover over
the arch or in a secondary procedure. Extra caution must be taken
under these circumstances.
Using a needle-tipped cautery set on the low ´eyelidµ coagula-
tion current setting to incise the SMAS layer can provide valuable
feedback and alert the surgeon when a motor nerve branch is
approached, as the cautery acts as a makeshift nerve stimulator.
:hen dissection is advanced into proximity to a nerve, soft facial
twitching will be seen, and this should be watched for by both
the surgeons and the surgical assistant (who typically has a better
view of the patient’s face).
The preauricular limb of the SMAS incision, defining the flap’s
posterior margin, is then made using a similar technique over
the posterior parotid along the marked line in the preauricular
region. The dissection is continued inferiorly and posteriorly to
the anterior border of the sternocleidomastoid muscle to a point
approximately 2 to 3 cm below the mandibular margin. These two
incisions define the superior and posterior margins of the ´highµ
SMAS flap to be elevated (see Fig. 49.39).
After initial SMAS incisions have been completed as described,
the preauricular tissue constituting the posterior superior corner
of the of the SMAS flap is grasped with two Allis forceps, and
flap elevation is then begun using careful scissors or low-current
needle-tipped cautery dissection technique.
Undermining should be limited in the preparotid cheek and
upper lateral neck and more extensive over the zygoma and
upper midface (Fig. 49.42; see also Fig. 49.2, traditional versus
extended SMAS). Use of a needle-tipped cautery device set
on low coagulation current settings to raise the SMAS flap is a
convenient way for less experienced surgeons to make this dis-
section, as it serves as a make-shift nerve stimulator and when a
motor nerve is approached movement will be noticed before the
nerve is encountered, as previously described. The needle-tipped
low-coagulation-current cautery technique of flap elevation is
also useful in secondary and tertiary facelifts in which the SMAS
layer has been previously dissected as anatomy can be less clear
in those situations.
The SMAS, though substantial, is thinner than many surgeons
imagine it to be, and it is decidedly thinner and less substantial
than many other tissue layers typically dissected in plastic surgery
procedures. SMAS flap elevation will also entail dissection just
superficial to the plane of the facial nerves in close proximity to
important motor branches. $OWKRXJK ÁDS HOHYDWLRQ RYHU WKH SDURWLG
is safe, great care must be taken when dissecting more medially and
over the zygoma and anterior to the anterior border of the parotid
gland in the cheek and over the masseter muscle.
Sharp (not vertical-spreading) scissors or cautery dissection of
the high SMAS flap is usually required posteriorly over the parotid,
where the plane between parotid fascia and SMAS is often indis-
tinct. Vertical spreading, while advocated by some who perform
deep-plane procedures, is unacceptably traumatic, as the SMAS
flap does not have the reinforcement and backing of the skin seen
when deep-plane and composite dissections (skin and SMAS dis-
sected as a monolayer) are made. In some instances a portion of
the parotid fascia may be incidentally and/or unavoidably raised
with the SMAS flap and part of the lobular surface of the gland
may be exposed. This is usually of no clinical consequence and
should be used by the surgeon as a road sign in identifying the
proper plane of dissection situated slightly more superficially.
A separate and distinct plane does exist, however, medial to
the anterior border of the parotid between the SMAS-platysma
and the parotidomasseteric fascia. This plane is most easily
identified and established in the lower cheek, where it can usu-
ally be entered by gentle blunt dissection with scissors tips, low-
coagulation-current needle tip cautery, a fingertip, or with a
.ittner (´peanutµ) sponge. The parotidomasseteric fascia will
be seen as a thin, shiny, transparent, mobile layer covering the
masseter muscle, parotid duct, buccal fat, and the branches of
the facial nerve. Careful dissection on top of this layer is safe
and will not result in nerve injury, but great caution must be
exercised when dissecting sharply or with cautery, or when
clamping or coagulating in this area. Frequently, motor nerve
branches accompany perforating vessels, and each bleeding point
Fig. 49.37 Length of the temple hairline incision. The superior
extent of the temporal hairline incision will vary depending upon the
amount of cheek skin shift predicted (and whether a forehead lift is
to be concomitantly performed) if puckering and gathering are to
be avoided in this area. Note that a male patient is shown; in female
patients the incision should have a more rounded feminine design as
in Fig. 49.10a. (a) Superior extent of temple hairline incision when
modest cheek skin displacement is predicted (white dotted line). (b)
Superior extent of temple hairline incision when moderate cheek
skin displacement is predicted (white dotted line). The incision must
be made higher to accommodate the cheek skin shift, but it still is
situated in a well-concealed location. (c) Superior extent of temple
hairline incision when large cheek skin displacement is predicted (white
dotted line). This incision should be made no higher than the junction
of the temporal hairline with the frontotemporal hairline, however
(point shown by white arrow). If it is carried more superiorly along the
frontotemporal hairline (area designated by red X), the resulting scar
will usually be visible, as hair tends to grow posteriorly in that area.
(Copyright © Timothy Marten.)
a
c
b

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
663
PXVW EH FDUHfXOO\ LGHQWLfiHG ZKHQ KHPRVWDVLV LV EHLQJ SHUfRUPHG
Blind clamping should not be performed, and low coagulation
current should always be used. The patient’s face should also be
carefully monitored whenever cauterization for bleeding is per-
formed and current discontinued immediately if facial twitching
is noted. Bleeding near a facial nerve branch, if encountered and
difficult to cauterize without facial twitching, is most safely
managed by applying a few minutes of direct pressure upon the
bleeding area.
Sub-SMAS dissection must generally be carried over the
anterior border of the parotid in the lower cheek to ensure that
masseteric–cutaneous ligaments tethering the SMAS are released
(region marked by small squares in Fig. 49.42) and if optimal
improvement is to be obtained in the lower cheek, jowl, and
jawline areas. These ligaments are often difficult to visualize
specifically and most easily identified by fingertip palpation along
the front of dissection. If these restraining attachments are not
released, an optimal SMAS effect will not be realized and minimal
overall benefit will be obtained.
As SMAS flap dissection is carried anteriorly and medially in
the upper cheek over the superior portion of the parotid and its
accessory lobe, the SMAS will be seen to thin and invest the lip
elevators. $W WKLV SRLQW WKH GLVVHFWLRQ PXVW EH ´H[WHQGHGµ VXSHUfiFLDO
to the superior portion of the zygomaticus major muscle, and the
muscle’s origin typically must be carefully exposed and partially
visualized if optimal improvement is to be obtained in the upper
cheek, infraorbital, and midface areas. -ust at the malar origin of
the zygomaticus major muscle the zygomatic ligaments will be
Fig. 49.38 Skin flap dissection with temporal hairline incision. When
an incision is made along the temporal hairline, all dissection is in a
subcutaneous plane and no transition between planes is necessary, no
hair-bearing flaps are raised, and the superficial temporal vessels are
left undisturbed. (Copyright © Timothy Marten.)
Fig. 49.39 Markings for the high SMAS flap. The superior margin
of the high SMAS flap (methylene blue ink line) is marked over the
zygomatic arch (black lines) and not below it, starting at the level
of the infraorbital rim and extending posteriorly to a point approxi-
mately 1 cm anterior to the superior margin of the tragus. It is then
turned inferiorly in front of the ear and extends inferiorly and slightly
posteriorly to the anterior border of the sternocleidomastoid muscle
approximately 2 to 3 cm below the mandibular border. (Copyright ©
Timothy Marten.)
Fig. 49.40 Plan for posterior margin of the high SMAS flap and the
marginal mandibular nerve branch. The marginal mandibular branch
of the facial nerve (yellow line) emerges from the anterior border
of the inferior portion of the parotid gland (black line) well anterior
to the SMAS incision over the posterior jawline/ upper lateral neck
region. Note that mark for posterior incision curves posteriorly to
the anterior border of the sternocleidomastoid muscle and extends
2 to 3 cm inferior to the mandibular border. (Copyright © Timothy
Marten.)
Fig. 49.41 Pitanguy’s landmark for the frontal branch of the facial
nerve (yellow dotted line) is a line extending from the inferior margin
of the tragus to a point 1.5 cm superior to the lateral eyebrow. It can
be seen that the nerve lies under the flap only at its upper lateral
most corner, where it is anatomically consistent at 9 mm deep and is
safely deep and posterior to all but the very first part of the SMAS flap
dissection. (Copyright © Timothy Marten.)

664
VIII Surgical Rejuvenation of the Face and Neck
encountered (region marked by small circles in Fig. 49.42). These
fibrous connections, extending between the periosteum and skin,
restrain the upper cheek and midface and must be divided in a
sub-SMAS plane. :hen completely released, a dramatic liberation
of the flap and the upper cheek and midface will be obtained. The
lateral-most ligaments are typically more substantial and gener-
ally require sharp or cautery dissection and formal transection.
The ligaments lying more medially are generally softer and can
often be disrupted bluntly with open scissors tips, a .ittner
sponge, or a fingertip.
Directly inferomedial to the origin of the zygomaticus major
muscle, and superomedial to the accessory lobe of the parotid and
the parotid duct, lies the zone of transition between the zygomatic
and masseteric–cutaneous ligaments, the most potentially dangerous
part of the SMAS dissection. Proper liberation and release of the
SMAS flap usually requires at least partial division of restraining
attachments in this area, but it moves the dissection into very close
proximity to the zygomatic branches of the facial nerve (Fig. 49.43).
Although experienced surgeons make this dissection appear
easy and frequently seem to minimize the risk involved, it is
often difficult for the less experienced surgeon to distinguish
between nerve branches and ligamentous attachments in this
area. Anatomic variations are also common in this region, and in
some cases nerves will penetrate the deep fascia early and travel
directly in a sub-SMAS plane or send a branch over the zygomat-
icus major to the orbicularis oculi. In these situations, traction
on the SMAS flap during dissection can tent up these branches,
placing them at even greater risk. It is highly recommended that
any surgeon uncertain of the anatomy of the facial nerve and its
variations or the exact relationships in this area review them and
study Fig. 49.43 carefully before undertaking this dissection.
A safe dissection of the submalar SMAS and proper release of
the zygomatic ligaments will require adequate light; an attentive
assistant; a well-organized surgical team; a dry field; and patience,
caution, and composure on the part of the surgeon. However, if
confusion is encountered or anatomy seems unclear, it is better to
limit dissection until additional experience and familiarity with this
anatomic region are obtained. No amount of improvement in facial
appearance is worth an injury to the facial nerve.
49.6.8 Techniques for SMAS Flap
Elevation
A helpful technique that we frequently use in making a safe sub-
SMAS dissection, as previously outlined, is to raise the SMAS flap
with a needle-tip cautery set on a low coagulation current setting
rather than scissors. :hen such a technique is used, a gentle sep-
aration of the tissue layers can be made and when proximity to
motor nerve branches occurs, soft facial twitching will be noted.
:hen dissection with cautery is brought into close proximity
to a motor nerve, a more marked twitching will be noted, and
additional caution should be exercised. If a question arises as to
whether an area of tissue contains a nerve branch or a ligament,
the surgeon can briefly apply a pulse of low cautery current near
the area in question. If it twitches, a nerve branch is likely pres-
ent and further dissection must be made with care. If no twitch
is seen, a nerve branch is not present and the dissection can be
continued further if indicated. :earing low loupe magnification
(2.5ð) also helps the surgeon follow the correct plane and stay
on top of the shiny parotidomasseteric fascia that overlies the
facial nerve branches as they emerge from the anterior border
Fig. 49.43 Completed SMAS flap dissection. An extensively dissected
SMAS flap showing important surgical anatomy. Inferior to the origin
of the zygomaticus major muscle, and superomedial to the accessory
lobe of the parotid, lies the zone of transition (red circles) between
the zygomatic ligaments (blue circles) and the masseteric–cutaneous
ligaments (black circles) and the most potentially dangerous part
of the SMAS dissection. Proper release of the SMAS flap usually
requires at least partial division of restraining attachments in this
area of transition, with the dissection coming into close proximity to
zygomatic branches of the facial nerve. Care should be taken when
dissecting in this area. Other important anatomy shown includes the
origin of the zygomaticus major muscle, the origin of the zygomaticus
minor muscle, the malar fat pad, and the platysma. (Copyright ©
Timothy Marten.)
Fig. 49.42 Extent of superficial musculoaponeurotic system (SMAS)
undermining. Complete release of the SMAS flap requires that both
the masseteric–cutaneous ligaments along the anterior border of
the parotid gland (small black squares) and the zygomatic ligaments
near the origin of the zygomatic major muscle (small black circles) be
released. Note that minimal undermining is needed inferiorly, because
there are no ligaments restraining the SMAS in that area, but a more
“extended” SMAS release is needed in the upper cheek and midface
area. The group of parallel lines shown in the cheek represents the
origin of the zygomaticus major muscle (see also Fig. 49.4). (Copyright
© Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
665
of the parotid and over the masseter muscle by providing the
surgeon better visualization of the tissue being dissected and the
structures that are present. Loupes and low-energy needle-tip
cautery dissection enable the surgeon to advance the front of
dissection incrementally by cutting only a thin veil of tissue at
a time and avoiding cutting a large amount that might contain
a nerve branch. The needle-tipped low-coagulation-current
cautery technique of flap elevation is also useful in secondary
and tertiary facelifts in which typically the SMAS layer has been
previously dissected and anatomy is less clear.
49.6.9 Assessing Completeness of SMAS
Flap Dissection
:hile anatomy and anatomic structures provide important
signposts to the surgeon, as clinicians we seek a clinical result
(lift of facial tissues), and dissection of the SMAS flap and release
of retaining ligaments is continued until gentle traction on the
superior flap margin produces motion at the cheek, nasal ala,
philtrum, and stomal angle, and elevation and compression of
infraorbital and lower eyelid region. This “traction test” clinically
FRQfiUPV DGHTXDWH ÁDS UHOHDVH DQG LV D PRUH LPSRUWDQW LQGLFDWRU
of a complete dissection than any arbitrary anatomic endpoint.
If flap release is incomplete, residual tethering fibers should be
identified and carefully divided, and the traction test repeated.
:hen dissection is complete, the malar pad and attached skin
will move freely as part of the ´highµ SMAS flap superiorly,
and no separate dissection of the malar pad (finger-assisted
malar elevation, ´FAMEµ), suture suspension of the midface
(minimal-access cranial suspension, ´MACSµ), or subperiosteal
dissection (´midface liftµ) is required.
49.6.10 SMAS Suspension and Proper
SMAS Vector
Once the SMAS flap has been elevated and adequately released
and all deep-layer neck maneuvers (subplatysal fat excision,
submandibular gland reduction, and partial digastric myectomy)
have been completed if indicated, the superior edge of the flap
is grasped and shifted variously to determine which direction
produces the best effect on the upper midface, cheek, and jowl.
In all but the unusual case this is along a posterosuperior vector
parallel to the long axis of the zygomaticus major muscle. If a ´ver-
ticalµ or posterior vector is used, the function of the zygomaticus
major muscle will be corrupted and abnormal appearances
during animation may result (Fig. 49.44).
Management of the superior margin of the SMAS flap and
the technique of flap suspension is not arbitrary and will vary
Fig. 49.44 Proper and improper vectors of SMAS shift. (a) The proper direction of shift of the SMAS is along a vector parallel to the long axis of the
zygomaticus major muscle (green arrow). (b) If the SMAS is shifted along a posteriorly directed vector (red arrow) and not along the long axis of the
zygomatic major muscle, the muscle is pulled off its axis and its function compromised. This can result in deepening of the nasolabial fold, abnormal
appearances during facial movement, and a pulled “clown mouth” appearance, as pull is applied to the risorius muscle (black arrow). (c) An analogous
problem is encountered when a vertical vector (red arrow) is used in a “vertical facelift” and the zygomaticus major muscle is pulled medially off its
axis of function. A vertical vector also applies pull to the zygomaticus minor muscles and can result in a sneering appearance to the mouth (black
arrow). (Copyright © Timothy Marten.)
a
b
c

666
VIII Surgical Rejuvenation of the Face and Neck
depending on the problems present, where the temporal incision
was made, and other considerations particular to the patient,
including sex, race, and overall facial morphology. Accordingly,
how the superior margin of the SMAS flap is suspended will
depend on the patient’s circumstances and the aesthetic outcome
desired, and it provides the surgeon an opportunity to improve
and optimize the patient’s appearance. There are three general
strategies used that allow facial shape and racial, ethnic, and
gender characteristics to be optimized.
SMAS Suspension in the Narrow Face
In many cases no trimming of the superior margin of the flap
is performed, as the overlapping tissue segment adds volume to
and restores lost projection over the lateral cheek and zygomatic
arch and ´ovalizesµ the Caucasian female face, restoring shape
lost with age.
SMAS Suspension When the Temporal Incision Is
on the Temporal Scalp
In situations where widening the interzygomatic distance and
´ovalizingµ the face is desired and when the temporal part of
the facelift incision has been made on the temporal scalp (Fig.
49.9), the superior edge of the SMAS flap is raised along a vector
parallel to the long axis of the zygomaticus major muscle (see
Fig. 49.44a), up over the zygomatic arch and is anchored with
interrupted sutures of 3–0 polyglycolic acid (PGA; Vicryl,
Ethicon, Somerville, 1-) or other suture of choice, well over
the zygomatic arch, directly to the temporalis muscle fascia,
superior to the divided mesotemporalis. Suspension in this
manner is facilitated if the inferior border of the divided meso-
temporalis is gently pushed inferiorly as sutures are placed.
This scheme solidly suspends the midface, upper cheek, and
jowl with no risk of injury to the frontal branch of the facial
nerve (Fig. 49.45).
Avoiding “Smile Block”
1o suturing is needed or should be performed over the zygoma
or along the infraorbital rim. These parts of the face are mobile
and need to move during animation and for natural expression.
Directly suspending the midface along the zygoma or infraorbital
rim can result in tissue tethering and dimpling upon animation,
often referred to as ´smile block.µ
If the mesotemporalis has been divided too high (above the
level of the helical–facial junction) and direct anchoring of the
SMAS flap to the temporalis muscle fascia is not possible even
when the mesotemporalis is pushed inferiorly, suspension can
still be made in this manner if sutures are allowed to bridge the
intervening gap or if a trifurcated SMAS flap is used (discussed
subsequently).
SMAS Suspension When the Temporal Incision
Is along Temporal Hairline
:hen an incision along the temporal hairline is indicated and
temporal dissection is made in a subcutaneous plane, a meso-
temporalis will not be present, temporalis muscle fascia will
not be exposed, and the SMAS flap, when elevated, will often
impinge on the sideburn area when advanced superiorly. In
these cases an incision through the galea aponeurotica (galeot-
omy) can be made at the inferior edge of the sideburn to expose
the temporalis muscle fascia. If this galeotomy incision is
thoughtfully planned and dissection is carefully performed, the
superficial temporal artery can typically be preserved; however,
it should be noted that this vessel is routinely divided when the
mesotemporalis is divided in cases where the temporal part of
the facelift incision is made on the temporal scalp, and it can
be divided and ligated in this situation without concern as well.
Once the galeotomy has been performed, SMAS flap suspension
can then be made to the temporalis muscle fascia as previously
described (Fig. 49.46). This comprises the second method of
management and suspension of the superior margin of the
SMAS flap.
SMAS Suspension with a Trifurcated SMAS Flap
A useful and convenient variation of overlapping the superior
margin of the SMAS flap over the zygomatic arch and suspend-
ing it to the temporalis muscle fascia described in the two
preceding scenarios that can optimize support transmitted
to the upper cheek and midface is the trifurcated SMAS flap
(Fig. 49.47). The name comes from the idea that the main body
of the SMAS flap can be divided into three component parts
to optimize its effectiveness: a superior segment to optimize
support for the upper cheek and midface (discussed here), the
main body of the flap to support the mid–lower cheek and jowl,
and a postauricular transposition flap to support the lateral
border of the platysma in the upper lateral neck and along the
cervicomental angle (discussed subsequently). This flap is best
used in circumstances when a sturdy and robust SMAS flap
has been raised, and it is particularly useful when the superior
SMAS flap margin does not easily reach the exposed temporalis
muscle fascia. Conversely, it is less useful when the flap is thin
and fragile, or when it is easily raised to the point of suspension
on the temporalis muscle fascia.
Fig. 49.45 High SMAS flap suspension when the temporal part of
the facelift incision has been made within the temporal scalp. (a) The
temporal portion of the facelift incision was made within the temporal
scalp (see Fig. 49.36, dividing the mesotemporalis). The SMAS flap has
been advanced superiorly, parallel to the long axis of the zygomaticus
major muscle (see Fig. 49.44, proper and improper vector of SMAS
shift), the mesotemporalis pushed inferiorly, and the flap is shown
being sutured directly to the temporalis muscle fascia. (b) Suspension
of the superior and posterior SMAS flap margins is complete (after the
posterior margin has been trimmed). Note that no suturing is required
over the anterior zygoma or along the infraorbital rim, as the midface
is included in the flap and rises with it. (Copyright © Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
667
To create a trifurcated SMAS flap, the SMAS flap, once dis-
sected and adequately released, is elevated parallel to the long
axis of the zygomaticus major muscle and an incision is made
2 to 3 cm into the posterior margin of the flap at the level from
which it was originally harvested, creating a tab of tissue that is
then rotated superiorly and anchored to the temporalis muscle
fascia. The cut edge from which the upper flap was separated is
then sutured to the cut edge overlying the zygomatic arch from
which the original flap was harvested (Fig. 49.48). Substantial
anchoring of the SMAS flap can be obtained in this manner,
and in many cases increased support of the anterior face can be
obtained.
SMAS Suspension When Interzygomatic
Widening Is Not Desired
:hile overlapping the SMAS in the upper lateral face is benefi-
cial and will improve the shape and contour of the faces of many
patients undergoing facelift procedures, in patients with wide
faces and a small mandible, in many men, and in many patients
of Asian or Slavic ancestry, enhancement of the upper cheek and
arch and the broadening of the face obtained by overlapping
the SMAS as just described may not be aesthetically appropri-
ate, necessary, or desired. In such cases the redundant tissue
along the superior flap margin can be excised and discarded
(rather than overlapped as in the previous two methods of flap
Fig. 49.46 (a) High SMAS flap suspension when the temporal portion of the facelift incision is made along the temporal hairline. A completed
high SMAS flap dissection in a patient who has a temporal hairline incision is shown. In this case the patient is male, and the incision has a more
masculine angular plan. For women, incisions should be planned with soft curves and made in a less angular fashion, as shown by dotted black
line. If the high SMAS flap were raised at this point, it would impinge on the sideburn area. (b) Temporal galeotomy to expose temporalis muscle
fascia for high SMAS flap anchoring. To avoid impingement on the sideburn and to facilitate firm anchoring of the high SMAS flap, the sideburn
is retracted with a double-pronged 10-mm skin hook, and the galea aponeurotica (superficial temporal fascia) is incised with electrocautery on
each side of the superficial temporal vessels to expose the temporalis muscle fascia. (c) Comparison of fascial exposure with temporal incision
within the temporal scalp vs. along the temporal hairline. (Left side) The superficial temporal fascia (galea) has been incised beneath the sideburn
and the sideburn reflected superiorly. This process exposes the temporalis muscle fascia, to which the SMAS will be anchored. Note that the
superficial temporal artery can often (but need not) be preserved as shown when this dissection is made. (Right side, above) Division of the meso-
temporalis when the temporal portion of the facelift incision (white dotted line) has been made in the temporal scalp (younger patients). (Right
side, below) Completion of division of the mesotemporalis (galeotomy). Note that the subgaleal plane in the temple and the subcutaneous plane
in the cheek have been united and the temporalis muscle fascia has been exposed, similarly to that shown at left, where the temporal portion
of the facelift incision is made along the temporal hairline. (d) Protection of the frontal branch of the facial nerve while performing temporal
galeotomy and exposing temporalis muscle fascia. The sideburn is retracted and the galeotomy completed with electrocautery on each side
of the superficial temporal vessels, preserving them to expose the temporal muscle fascia. Note that to avoid injury to the frontal branch of
the facial nerve (dotted orange line), the galeotomy must roughly follow the external contour of the sideburn and must not extend anteriorly to
the lateral canthus. (e) Anchoring the high SMAS flap to the temporalis muscle fascia exposed in steps a–d. The high SMAS flap has been raised
parallel to the long axis of the zygomaticus major muscle (see Fig. 49.43a) and its superior margin anchored to the temporalis muscle fascia
exposed in steps a through d with 3–0 Vicryl sutures (or other suture of choice). Black triangles represent approximate sites of suture placement.
Gently pushing the divided mesotemporalis inferiorly facilitates suture placement. “Trifurcating” the SMAS flap (see Fig. 49.47 and 49.48) also
facilitates high SMAS flap anchoring if the flap does not easily reach the galeotomy site. Note that no sutures are needed over the zygoma or
onto the anterior cheek, as the anterior portion of the flap and the midface ride up with the lateral part of the flap. (f) Completed anchoring
to the high SMAS flap. The SMAS flap has been advanced and its superior margin securely suspended to the temporalis muscle fascia. After
SMAS flap suspension, the reflected sideburn is returned to its original position (dotted black line) and reanchored there before skin trimming
and suturing in the temporal area is performed. Note that overlapping of SMAS widens the interzygomatic distance and “ovalizes” the face.
Dotted black line along the zygomatic arch shows where the high SMAS flap was harvested from and the degree of overlapping. (Copyright ©
Timothy Marten.)

668
VIII Surgical Rejuvenation of the Face and Neck
suspension) and the superior flap margin sutured edge to edge
to the superior margin of the initial incision made in the SMAS
over the zygomatic arch, where the SMAS flap was harvested
(Fig. 49.49). This constitutes the third method of management
and suspension of the superior margin of the SMAS flap.
Trimming and Management of the
Posterior Margin of the SMAS Flap
Regardless of how the superior margin of the flap is suspended,
some trimming of the posterior margin of the cheek SMAS flap is
invariably subsequently required when the SMAS flap is advanced
along a proper vector parallel to the long axis of the zygomaticus
major muscle to allow an edge-to-edge approximation to the
SMAS remnant in the preauricular region. Overlapping of the
SMAS in the preauricular area is functionally unproductive
and artistically inappropriate, as such arrangement lends no
additional support to the anterior face and obliterates natural
preauricular contours and the pretragal hollow.
Trimming of the posterior margin of the cheek SMAS flap should
be performed after the superior margin has been suspended
over the zygomatic arch by one of the three methods previously
outlined. Trimming is accomplished by carefully gauging the
redundancy present and tracing a line in marking ink over the cut
edge lying beneath it (Fig. 49.50a). The amount of tissue excised
will vary depending upon the size of a given face, the degree of
release of the flap and the chosen vector of advancement. It is
unproductive and an error, however, to place traction on the SMAS
in the preauricular region, and the posterior margin of the flap
should be trimmed carefully to avoid overexcision and a tight
closure. Posterior traction on the SMAS will result in pulling the
zygomaticus major muscle off its axis of function and subsequent
Fig. 49.47 Trifurcated high SMAS flap. (a) A high SMAS flap can be trifurcated into three component parts, the superior portion of which can
optimize support of the anterior face and facilitate suspension to the temporalis muscle fascia. The flap is raised superiorly after it has been dissected,
and an incision is made 2 to 3 cm into it as shown over the zygomatic arch (dotted red line). Black dotted line A shows the superior margin of the high
SMAS flap, black dotted line B shows the posterior margin of the flap, black dotted line C shows where the high SMAS flap will be trimmed to create the
postauricular transposition flap, and black dotted line D shows the approximate location of a partial platysma myotomy. (b) The three component
parts of the trifurcated SMAS flap are shown: (1) the superior portion, to be anchored to temporalis muscle fascia to suspend the midface; (2) the
main portion, to be anchored to the cut edges from which the flap was harvested, which suspends the lower cheek and jowl; and (3) the postauricular
transposition flap, created from excess tissue on the posterior margin of the flap that is left attached to the cervical platysma, which will be anchored
to mastoid fascia to suspend the lateral platysma border. (c) The trifurcated SMAS flap advanced and sutured. The red arrow shows the enhanced
vector of anchoring of the anterior face and midface that is provided by the superior segment of the flap. (Copyright © Timothy Marten.)
Fig. 49.48 Intraoperative example of trifurcated high SMAS flap. (a)
A high SMAS flap has been trifurcated into three component parts by
notching the superior part of the flap at the level from which it was
harvested over the zygomatic arch and excising the excess tissue on
the posterior margin of the flap but leaving it attached to the cervical
platysma. (b) The superior segment (1) has been sutured to temporalis
muscle fascia to suspend the midface, the middle segment (2) or main
portion has been sutured to the cut edge from which the flap was
harvested along the zygomatic arch to suspend the lower cheek and
jowl, and (3) the postauricular transposition flap, created from excess
tissue on the posterior margin of the flap that was left attached to
the cervical platysma and that has been sutured to mastoid fascia,
to suspend the lateral platysma border and define the cervicomental
angle. The white arrows show the component lift of each flap segment
on the face. (Copyright © Timothy Marten.)
Fig. 49.49 High SMAS flap suspension when facial widening is not
desired. (a) Close-up view of patient’s right face (head to the left
and chin to the right). The SMAS flap has been advanced superiorly,
the excess marked, and the excess tissue along the superior margin
of the SMAS flap is about to be excised. (b) Excision of the superior
and posterior SMAS flap margins is complete. Note that the trimmed
edge of superior margin of the SMAS flap can now be sutured to the
cut edge beneath it, from which the flap was harvested, avoiding any
increase in the interzygomatic distance or facial widening. (Copyright
© Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
669
irregularities in animation, traction of the risorius muscle and
perioral distortion, a ´pulled look,µ an objectionable ´clown
mouth appearance,” herniation of buccal fat, and other undesir-
able appearances (Fig. 49.44b). No pull need be or should be placed
posteriorly on the SMAS.
Volume-Sparing Management of the
Posterior Margin of the SMAS Flap
After trimming of the posterior margin of the SMAS flap, the
cut edge is approximated to the preauricular remnant with
multiple interrupted sutures of 3–0 PGA suture (or other suture
of choice). These sutures consolidate the cheek, reconstitute the
SMAS layer, restore SMAS cover of the parotid gland, and help
support the superior suture line, but they should not be used to
put posterior traction on the SMAS flap.
In situations in which lateral facial and preauricular atrophy
and hollowing are present, a ´volume-sparingµ management
of the posterior margin of the SMAS flap can be used. In this
technique the redundant portion of the posterior margin of the
SMAS flap is not excised but instead is isolated yet left attached
to the body of the SMAS flap and folded upon itself to add volume
to the lateral face. The segment of tissue to be enfolded in the
volume-sparing technique is formed by placing light traction on
the posterior margin of the SMAS flap and cutting into it at the
level of the mid-lobule and that point anchored under no tension
with 3–0 PGA (suture or other suture of choice). A small triangle
of SMAS is then excised superiorly to optimize the shape of the
tissue segment to be enfolded. The tissue segment so defined is
then folded under the main body of the SMAS flap and the folded
edge sutured to the preauricular SMAS remnant, created when the
SMAS (Vicryl) flap was initially elevated, with simple interrupted
3–0 PGA Vicryl sutures (or other suture of choice). Management of
the posterior margin of the SMAS flap in a volume-sparing manner
as described does not preclude the formation of a postauricular
transposition flap (discussed subsequently).
Upon completion of suturing of the cheek SMAS, improved
facial contour should be seen, and a faint smile in the anesthetized
patient’s face should be evident. Usually elevation of the lid–cheek
junction and compression of lower eyelid tissue will also be seen
if a complete high SMAS effect has been achieved (Fig. 49.51).
49.6.11 Suspension of the
Lateral Platysma Border
Trimming the posterior margin of the SMAS flap can be per-
formed in a way that will provide added support to the upper
lateral neck and along the cervicomental angle by leaving the
segment of tissue separated from the posterior SMAS border
attached to the cervical platysma, transposing it to the mastoid
process, and using it as a SRVWDXULFXODU WUDQVSRVLWLRQ ÁDS (PATF;
Fig. 49.52).
A PATF improves neck contour by correcting horizontal platysma
redundancy and increasing anterior neck support. Frequently
this cannot be accomplished by lateral platysmapexy alone, due
to mobility of the tissues in the upper lateral neck. Suturing the
transposed segment of cheek SMAS to the mastoid fascia, while
leaving it attached to the cervical platysma, circumvents this
problem and produces an improved result. In addition, an autolo-
gous dynamic sling is created that tightens the anterior neck and
submental region when the patient looks down. This tightening
is obtained because the mastoid moves superiorly during neck
flexion and away from the anterior neck, pulling the transposed
flap, and attached tissue, with it.
:hen a PATF is used, it must be carefully designed and its
effect tested intraoperatively. The SMAS must be incised and
the flap created in such a fashion that the flap exerts its effect
on the cervical platysma below the mandibular border and
along the cervicomental angle, and not more superiorly on the
SMAS in the cheek along the jawline (Fig. 49.53). PATF suspen-
sion is also best delayed until after anterior platysmaplasty is
completed, because if suspended first, the medial platysma
borders may be displaced to the extent that they cannot be
sutured together.
:hen combined with an anterior platysmaplasty, the use of
a PATF creates a mastoid-to-mastoid sling of autologous tissue
along the cervicomental angle to deepen and accentuate it. This is
Fig. 49.50 Management of the posterior margin of the flap. (a) The SMAS flap has been advanced along a vector parallel to the long axis of the
zygomaticus major muscle and suspended superiorly (in this case, the excess along the superior margin of the flap has been excised, and not
overlapped). Dotted black line shows the excess along the posterior edge of the flap to be separated from it. (b) The excess SMAS on the posterior
margin of the flap has been separated but left attached to the cervical platysma below the mandibular margin and transposed to the mastoid for use
as a postauricular transposition flap (PATF). (c) The posterior defect is closed edge to edge over the parotid gland with multiple interrupted sutures of
3–0 polyglycolic acid (PGA, Vicryl). If anterior platysmaplasty is performed, the PATF will be sutured to the mastoid after the platysmaplasty has been
completed. (Copyright © Timothy Marten.)

670
VIII Surgical Rejuvenation of the Face and Neck
a more natural and better strategy than any attempt to accentuate
neck contour by the placement of suspension sutures or straps.
49.6.12 Drain Placement
Drains are used routinely, and experience has shown that
they reduce postoperative eccymosis and seromas and enable
patients to return to their work and social lives sooner. As a
practical matter, drains are particularly needed when deep neck
maneuvers (subplatysmal fat excision and submandibular gland
reduction) are performed. It should be acknowledged that drains
will not substitute for poor hemostasis, however, and will not
prevent hematoma formation.
Drain placement should be performed prior to skin flap
anchoring and incision closure. A 10 French round, end-
perforated -ackson-Pratt-style closed-circuit suction drain is
placed subcutaneously across the anteroinferior neck through a
small stab incision on the occipital scalp 1 to 2 cm posterior to
the occipitomastoid incision. 1o drains are placed in the cheeks.
:hen extensive modifications have been made to the anterior
cervical and submental regions, when the patient’s face is large
and the drain will not reach completely across to the other side, or
when complete dissection across the neck is not made, one drain
is placed subcutaneously on each side.
If concomitant neck lift has been performed that included sub-
plastysmal fat excision, submandibular gland reduction, and/or
digastric muscle reduction, a subplatysmal drain is required, and
a 10 French -ackson-Pratt-style drain is placed in the subplatys-
mal space and exteriorized and anchored on the occipital scalp in
the postauricular area. Failure to place a subplatysmal drain when
deep-layer maneuvers (subplatysmal fat excision, submandibular
gland reduction, or partial digastric myotomy) are performed will
result in fluid collections (seromas, lymph fluid collections, and
sialomas) in the neck and submental regions in some patients,
and these in turn can result in prolonged cervical induration and
edema, delayed attainment of optimal neck contour, and perma-
nent lumps and other irregularities in the cervicosubmental area.
49.6.13 Skin Flap Repositioning and
Anchoring Suture Placement
:hen trimming and suturing the skin flap, it must be remem-
bered that in the contemporary facelift procedure, contour is
created by modifying the SMAS and deep layers of the face and
that the purpose and goal of skin excision is to remove redundancy,
QRW WR WLJKWHQ WKH VNLQ ÁDS Skin was meant to serve a covering
function, not a structural or supporting one. Trying to lift the face
by tightening the skin is a conceptually flawed concept that will
corrupt the skin’s intended covering function and is destined to
produce poor scars and unnatural “facelifted” appearances.
Skin flap repositioning and suture placement at key points
of suspension should be performed with the patient’s head in a
neutral position (no flexion or extension), as flexion or extension
of the neck will influence the amount of skin excised.
Skin must also be shifted along a vector that is compatible with
its covering function and does not result in secondary irregular-
ities. Shifting skin along an overly ´verticalµ vector, or trimming
skin flaps so that incisions are closed under tension, will result in
poor scars, a tight, unnatural appearance, and other objectionable
problems. Shifting skin too posteriorly can result in an insufficient
vertical repositioning of tissue, distortion of the mouth, and
typically results in a “pulled,” “wind-blown,” and objectionable
´pulled mouthµ look.
Cheek skin flaps should be shifted along a vector roughly per-
pendicular to the nasolabial fold and along a distinctly different
and somewhat more posteriorly directed vector than the SMAS
(see Fig. 49.5 and accompanying discussion). :hen this is done,
skin will lie more naturally over the tragal region once healing
is complete, and an improved effect will also be obtained in the
nasolabial area. The key concept to be kept in mind is that lift and
contour are created by SMAS repositioning and that only skin that
is truly redundant should be removed.
In the postauricular area, the postauricular skin flap should
be shifted along a vector parallel to the mandibular border. This
provides optimal improvement in the anterior neck and allows
maximum excision of skin flap redundancy without compromis-
ing the skin flap’s covering function. If the postauricular skin flap
is shifted along a more superiorly directed vector (parallel to the
long axis of the sternocleidomastoid muscle), improvement in
the anterior neck will be compromised, skin will be erroneously
excised over the apex of the occipitomastoid incision, and a wide
scar will be present once healing is complete (see Fig. 49.22).
Supra-auricular Skin Flap Anchoring
There are two points of initial skin flap anchoring that set the
stage for the remainder of the closure. The first point is located in
the supra-auricular area, where the most anterosuperior part of
Fig. 49.51 High superficial musculoaponeurotic system (SMAS) effect
seen on the operating table. The SMAS has been suspended on the
right side only and the skin has been laid back on the face but not
trimmed or sutured. The effect of high SMAS flap elevation can be
seen: the corner of the mouth on the right has been raised and the
posture of the mouth and perioral tissues on the right side improved;
the patient has upper dental show and appears to be smiling on the
right side (note that the patient is under anesthesia and that this is
purely the effect of SMAS flap elevation), the cheek on the right side
has been raised and is fuller and more projected than on the left,
and it can be seen that the lid–cheek junction has been raised on the
right side and that skin has been advanced into the right lower eyelid.
Compare these changes with the opposite (left) side, where the SMAS
flap has not yet been suspended. (Copyright © Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
671
the ear joins the scalp. To set this point, the cheek skin flap should
be shifted along a vector roughly perpendicular to the nasolabial
fold, and skin redundancy is then gauged with a Marten facelift
marker (Medicon eG, Tuttlingen, Germany) or similar implement
(Fig. 49.54). A T-shaped incision is then made into the flap at the
marked point in such a manner that only excess skin is removed
and the flap is anchored under normal skin tension. Making the
incision in a T shape facilitates suture placement and simplifies
subsequent trimming of adjacent skin. The flap is then anchored
at this point with a half-buried vertical mattress suture of 4–0
nylon, with the knot tied on the scalp side. 1o deep sutures are
necessary or used.
Postauricular Skin Flap Anchoring
The second point of initial skin flap anchoring is located in the
postauricular area at the anterosuperior aspect of the trans-
mastoid portion of the postauricular incision (black dot in Fig.
49.55). To set this point, the skin flap is placed over the ear and
shifted posteriorly and somewhat superiorly, roughly parallel to
transverse neck creases and the mandibular border, and in such
a manner that skin is anchored under minimal or no tension and
that little or no skin need be trimmed from the anterior border
Rf WKH SRVWDXULFXODU ÁDS This provides optimal improvement in
the anterior neck and submental region, where it is needed most,
and allows maximum excision of skin flap redundancy without
shifting cervical skin and wrinkle lines onto the lower face and
“lateral sweep” that occurs when a more vertical vector is used.
The flap is then secured at this second point with a simple inter-
rupted suture of 4–0 nylon. 1o incision into the flap is necessary
at this point of suspension, no skin should be excised, and no
deep suture is needed or used.
If the postauricular skin flap is anchored along a more superi-
orly directed vector, less skin will be removed from the anterior
neck and submental area (where it is needed most), improvement
in the anterior neck will be compromised, skin will be inappropri-
ately excised over the apex of the occipitomastoid incision, and a
wide scar will likely end up being present where the scar crosses
the mastoid area once healing is complete (see Fig. 49.22).
Fig. 49.52 A postauricular transposition flap (PATF) can be created from the posterior margin of a SMAS flap, and the PATF can be used to effect
improvement in the neck. (a) Schematic plan for PATF. (b) After separation of excess tissue on the posterior margin of the SMAS flap and transposition
to the postauricular area. Note that the flap is left attached to the cervical platysma. Note also that to be effective, the flap must be created so that
it pulls under the mandibular border and not higher up along it. (c) After elevation and suturing of a SMAS flap and suturing of a PATF to the mastoid
fascia (typically some shortening of the flap is performed). In combination with anterior platysmaplasty (dashed line), a mastoid-to-mastoid sling of
autologous tissue that accentuates the cervicomental angle is created. Note that platysmaplasty should be performed first and then the suspension
of PATF is made. (Copyright © Timothy Marten.)
a
b
c
Fig. 49.53 Improper and proper construction of the postauricular
transposition flap (PATF). (a) Improper design and construction of
the PATF. The flap has been designed and constructed too superiorly
and pulls along the lower face and lateral mandibular border. Such
an arrangement does little to improve the neck and accentuate the
jawline. (b) Correct design and construction of the PATF. The flap has
been designed and constructed more inferiorly so that its resultant
pull is below the mandible and along the cervicomental angle. Such
a design optimizes cervicosubmental contour. (Copyright © Timothy
Marten.)
a
b

672
VIII Surgical Rejuvenation of the Face and Neck
Exteriorizing the Lobule
Once the two key anchoring sutures have been placed as just
described, the flap overlying the inferior portion of the ear
should be cautiously divided and the lobule exteriorized.
This is a key step in the procedure that must be performed with
great care if a visible perilobular scar, lobular malposition, and
objectionable secondary earlobe deformities are to be avoided.
Gauging the depth at which the incision should be made into
the flap is greatly facilitated by the use of a facelift marker (Fig.
49.54), and the incision should follow the rim of the helix to the
superior portion of the incisura intertragica (intertragal notch).
If the incision is made correctly, the apex of it should rest snugly
against the inferiormost portion of the conchal cartilage when
the lobule is subsequently exteriorized. If the incision into the
cheek flap is made too far anteriorly or inferiorly, however, artis-
tically appropriate resetting of the lobule will not be possible,
and the outcome of the overall procedure will be significantly
compromised.
49.6.14 Skin Flap Trimming and Closure
Trimming and Closure along the
Conchomastoid/Auriculomastoid Sulcus
Skin flap trimming and incision closure is typically begun in the
postauricular area along the conchomastoid/auriculomastoid
sulcus behind the ear after key anchoring sutures have been
placed and the lobule exteriorized, and it is usually performed
before trimming and closure of the preauricular and occipital
portion of the incision and insetting of the lobule. It is per-
formed by conservatively trimming the anterior border of the
postauricular skin flap into a soft curve to match the curve of
the incision made in the conchomastoid/auriculomastoid sulcus.
1o attempt should be made to excise large amounts of tissue
from this area, as that would require and force a counterpro-
ductive and overly superiorly directed vector of advancement
of the postauricular skin flap. The incision is then closed with
several interrupted sutures of 4–0 nylon. The closure need not be
´watertight,µ and no deep suture is needed or used.
Little if any skin should be trimmed from the anterior margin of
WKH SRVWDXULFXODU ÁDS DORQJ WKH conchomastoid/auriculomastoid
sulcus. If it appears that a large amount of skin needs to be excised
from this area, the postauricular flap has been shifted incorrectly
both too far anteriorly and superiorly. In such instances, the
previously placed anchoring sutures should be removed and the
flap readvanced along a more appropriate, and more posteriorly
directed, vector.
Closure of the Transmastoid Incision
It is an error to excise any skin over (superior to) the apex of the
transmastoid portion of the postauricular incision and to shorten
WKH SRVWDXULFXODU ÁDS DORQJ WKH ORQJ D[LV Rf WKH VWHUQRFOHLGRPDV-
toid muscle (see red arrow in Fig. 49.22b, Fig. 49.55), as is com-
monly practiced, and closure of the transmastoid portion of the
postauricular incision should be made without trimming any skin.
Despite an apparent redundancy in this area when the patient is
supine on the operating table, there is not a true skin excess at this
location. This pseudoexcess of skin results only from the patient’s
elevated shoulder position in the supine position. It will vanish
when the patient sits up and the shoulders drop to a normal posi-
tion. Skin along the long axis of the sternocleidomastoid muscle
Fig. 49.54 The facelift marker by Medicon. The use of a facelift flap
marker provides a reliable means for appropriate excisions of facial skin to
be made. The lower jaw of the instrument is designed to be placed with its
tip at the edge of the scalp side of the incision, where the tooth will hold it
in place. The skin flap is then pulled over the lower jaw of the instrument,
and when normal resting skin tension has been set, the instrument is
closed. On closing, the upper jaw of the instrument marks the precise
position of the edge of the scalp flap beneath it. (Top) Close-up view
of the instrument tip design. (Bottom) The instrument in use. (Marten
Marker, Copyright © Timothy Marten.)
Fig. 49.55 Incorrect trimming of postauricular skin flap. It is an error
to excise any skin over (superior to) the apex of the occipitomastoid
incision and shorten the postauricular flap along the long axis of the
sternocleidomastoid muscle. There is no true excess of skin along this
vector, nor any aesthetic benefit from shifting skin in this direction.
Excision of skin in this fashion is the underlying cause of hypertrophic
healing in the postauricular area and of a wide postauricular scar.
(Copyright © Timothy Marten.)