The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

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Discussion by Donald S. Mowlds and Val Lambros
The addition of volume to the aging face is argu­
ably the most valuable adjunct to facelift surgery
since the introduction of the facelift itself. From a
paradigm and practice that revolved completely
around the surgical shortening of skin and removal
of fat, a new breadth of results became possible.
Suddenly, hollow cheeks and orbits could be filled,
temples leveled, and jawlines defined.1
The potential for complications is present in all
forms of surgery, and fat grafting is no exception. I (V.L.)
have injected fat since the 1980s, and over the past three
decades have gained perspective on both the benefits
and shortcomings of this treatment. This discussion ad­
dresses the complications of fat grafting.
By far the most common complication of facial
fat grafting is having too much of it where it should
not be. There are various explanations for how this
­situation ­occurs; some are technical and others ­biologic.
­Regardless of the cause, the common challenge ­facing
­clinicians ­attempting to treat this complication is
­removal of ­excess fat.
Variable Take of Grafted Fat
Though not a complication in and of itself, injected
fat is known to be highly variable in its ability to sur­
vive transfer. Estimates vary widely for the survival of
grafted fat in the face and span anywhere from 20 to
90%.2–6 This variability is a source of frustration for a
clinician who expects a reliable dose-dependent re­
sponse during treatment. Often multiple treatments
are necessary to achieve a particular result, and on
occasion the desired result may not be attainable be­
cause of grafted fat loss. Sometimes all the fat survives
or even grows, creating unexpected outcomes for the
clinician who lacks a reliable end point that tells him
or her when to stop injecting and must instead rely on
instinct and experience. The clinician is faced with the
dilemma of whether to inject in excess of the required
volume in anticipation of graft reabsorption, a mistake
in our opinion, or commit to performing multiple pro­
cedures, or both. If areas are underfilled they may be
corrected during subsequent fat grafting sessions or
more conveniently with off-the-shelf fillers. Some tol­
erance for ambiguity is a necessity in fat grafting.
Young full faces seem to have heartier fat and a bet­
ter bed for fat transfer: fat takes more efficiently in this
group, and as it happens this is also the group most
likely to gain weight in the future. Older, thin faces clin­
ically have a lower percentage of fat graft take. Some­
times all of the grafted fat in this group will simply
disappear, a frustration to both the clinician and the
patient. There is no easy solution to this situation. As
in other aspects of cosmetic surgery, those who need it
the most do the least well.
Fat grafting efficiency improves with subsequent
procedures, presumably because of an increase in vas­
cularized fat capable of supporting the newly grafted
tissue.7 Parenthetically, if the fat is centrifuged, an es­
timation of graft survival may be made based on the
oil present in the syringe. A high percentage of oil most
likely indicates fragility of the fat cells, which experi­
enced breakdown during harvesting. We believe that
there is a loose relationship between the ultimate take
of the graft and the quantity of oil present: The lower
the oil content, the higher the likelihood of survival.
Fat Overgrowth With Weight Gain
It is a classic teaching in plastic surgery that grafted
tissue retains the characteristics of its site of origin.
Dermal fat grafts from the abdomen to the face, for ex­
ample, are known to grow in proportion to increases
in abdominal adiposity.8–10 Grafted fat cells are not
exempt from this biologic principle. It is impossible to
predict with certainty the future of the grafted tissue.
For many, particularly in midlife, weight gain is difficult
to avoid, and fat grafted areas can enlarge to a degree
not anticipated by the doctor or patient. This almost
never looks good (Figs. 19D.1–19D.3). The well-inten­
tioned clinician may instigate a problem that will mani­
fest years after the original procedure. As more patients
in their 20s to 40s undergo fat grafting procedures, we
believe that there will be an increase in the numbers
of patients who will experience facial fat overgrowth
in the future. We have also seen this phenomenon in
patients who did not gain weight overall, but it is less
common and less dramatic.
A conservative approach is therefore recommended
in younger patients, because grafted fat may survive for
decades and is out the surgeon’s control.
Fat graft overgrowth after fat grafting in patients
with HIV has been observed. Controversy exists as to
whether this is intrinsic to the disease process or related
to antiviral therapy.11 In these patients, the grafted fat
can rapidly enlarge, requiring serial excisions.
Aesthetic Misjudgments
Plastic surgeons are influenced by their training, sur­
gical techniques, ritual, and their own aesthetic judg­
ment when anticipating a result. The adage “older faces

217
Chapter 19 Fat Grafting for Facial Rejuvenation
Fig. 19D.1 (a) A 50 year-old women who underwent a facelift with concurrent fat grafting. One year later she underwent further fat
grafting and reports doing well until gaining 8 pounds following menopause years later. (b) Eight years after her original surgery she
presented as pictured. Note the enlargement of fat in the cheeks and lips. (These images are provided courtesy of Dr. Val Lambros.)
a
b
Fig. 19D.2 (a) This 27-year-old female had a rhinoplasty and fat injection of the lips; injection consisted of 2 cc in the upper lip
and 2 cc in the lower lip. (b) At 4 months postoperatively. (c) Twelve years later after having gained weight. The size of the lips
has increased. (These images are provided courtesy of Dr. Val Lambros.)
a
b
c
Fig. 19D.3 (a) Preoperative view of a 27-year-old man who had 130 cc of fat placed into the face. He was 5 foot 11 inches tall and
weighed 155 lbs. (b) Only small changes were seen 1 year after fat grafting when he was at the same weight, leading the patient
and surgeon to wonder where all the grafted fat went. (c) Eight years later he has gained 15 lbs. The fat growth is obvious. He has
tear trough excesses, and the skin quality does not look better over the fat bulges. Fat was apparently used to define the chin and
jawline; fat does not do well in this role, because it looks blobby, not bonelike. The lips have also developed an odd look. His chief
complaint was, “I don’t look like my brothers.” (These images are provided courtesy of Dr. Val Lambros.)
a
b
c

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218
lose fat” has become universally brandished as a jus­
tification for volumizing the face with fat or fillers.7,12
In fact, the United States is in the midst of an obesity
epidemic, and the number of faces losing fat is probably
the minority.13
There are certain target areas that are technically
easy to fill and consequently overdone, sometimes to
the point of caricature. These include the lips, nasola­
bial folds, and cheeks. Overfilled faces are becoming in­
creasingly visible in blogs, advertisements, social media
posts, and popular conceptions of cosmetic treatments.
We believe that the contours of the individual face
should provide guidance for treatment. Formulaic treat­
ments based on generalized principles are best avoided.
In addition, surgeons are not trained in three-dimen­
sional visualization and manipulations of the face. It is
not uncommon to see doctors ill equipped for volume
procedures placing large volumes of fat without under­
standing the aesthetic consequences.
Attempts to improve projection and definition with
fat grafting may succeed in a petite female face. How­
ever, as a general rule, augmentation of the bony ar­
chitecture with fat does not achieve a bony look.14,15
Injected fat is soft tissue by definition and is not well
suited to simulating bony prominences. For example,
augmenting a weak chin or deficient cheekbone in a
male using fat produces an ill-defined mass of tissue,
which is emphatically a poor substitute for bone (see
Fig. 19D.3). A contention has been made that grafted fat
acquires the characteristics of the tissue adjacent to its
placement.16 This has neither been our experience, nor
is it supported by physical examination; fat is not bone.
Dynamic Deformities
Adding fat to the face clearly changes the amount of
fat mobilized with animation. Sometimes this is not
remarkable and sometimes it looks odd. Dynamic de­
formities are primarily observed in two locations: the
nasolabial fold and the lateral cheek. The volume of fat
required to efface the nasolabial crease may be substan­
tial, contributing significant mass to the cheek such that
the central cheek and nasolabial fold area become less
supple and do not move with smiling (Fig. 19D.4). This
area may be micro-liposuctioned as described later with
some improvement. Dynamic deformities in the upper
lateral cheek, however, are much more difficult to treat.
When smiling broadly, the action of the orbicularis oculi
muscle combined with translation of the cheek-fat mass
from zygomatic muscle contraction results in crow’s-
feet creases and expansion of the soft tissue over the
cheekbone, a normal facial expression in human beings
of all ages. This area is commonly fat grafted or treated
with fillers, because it may thin with age. When fat or
fillers are placed here they increase the amount of lo­
cal tissue acted upon with smiling; the cheek-fat mass
translocates and pushes the cheek and lower eyelid su­
periorly into the orbit, making the eyelid aperture ap­
pear smaller. Older patients are especially unhappy with
this look (Fig. 19D.5). In our experience, even if fat is
placed directly on the malar periosteum, the likelihood
of such a dynamic squint deformity persists. Further­
more, removal of fat from the lateral cheek in our experi­
ence rarely achieves the intended level of improvement.
Loss of Facial Identity
Fat grafting is powerful tool capable of making pro­
found changes in facial proportion. Though difficult to
study, clinical observation suggests that patients are
more sensitive to changes in self-perception after volu­
mization than with traditional traction and subtractive
surgery. We have seen patients dislike and complain
about traction deformities of the face or misplaced
Fig. 19D.4 The same patient as shown in Fig. 19D.3. He had concerns that after his fat grafts expanded, his smile changed. The
mass of fat that presumably is the cause for his smile asymmetry is visible on his right. (These images are provided courtesy of
Dr. Val Lambros.)

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Chapter 19 Fat Grafting for Facial Rejuvenation
Fig. 19D.5 (a) A 44-year-old patient after injection of 86 cc of fat into the face, notably 7 cc into the lower lip, 3 cc into the up­
per lip, 4 cc into each upper eyelid, and 3.8 cc into each lower eyelid. (b) Several years postoperatively she had visible overfill of
the upper eyelids, lips, and tear troughs. Her weight had not changed. This patient probably represents overinjection of fat with
more fat remaining than expected. There is always uncertainty about the degree of fat take. (c) Correction of brow overfill. The
dissection went from an upper lid incision, below the orbicularis oculi superiorly, and over the orbital rim, where the large visible
amount of fat was removed. The lips were liposuctioned with a 17-gauge injection needle. The tear troughs were treated as well.
(d) Four years postoperatively she has normalization of the upper lids. The tear troughs are improved. The lips remain problematic
and seem larger. Many fat grafting distortions of the face are amplified by excessive lips. (e) Fat grafting to the upper cheek com­
monly leads to soft tissue crowding of the lateral periorbital area with smiling. Although this is common in children, older patients
detest this look and tend to complain about it. (These images are provided courtesy of Dr. Val Lambros.)
a
b
c
d
e
wrinkles and creases, but they do not complain of not
looking like themselves. It is unclear which elements
of proportion and shape occupy the seat of facial iden­
tity, but patients who are unhappy with fat grafting
results have remarkably similar complaints. They have
concerns about not looking like themselves, of not rec­
ognizing themselves in the mirror; they say that their
friends do not recognize them. Sometimes these pa­
tients present with apparent lovely results. They report
not leaving their houses and reducing social interac­
tion. They are very self-conscious in public. They are
uniformly angry at their original surgeon, and though
desperate for improvement they will waver indecisively
before committing to corrective treatment (Fig. 19D.6).
In our experience, the resentment does not translate to
the subsequent treating surgeon.
Approach to the Preoperative Patient
Cosmetic surgery of the face is not an art form, nor is it
an anthropologic duplication of a youthful face (though
surgeons certainly do not mind if the postoperative re­
sult is interpreted as such). It is a way to make patients
happy.17 The surgical tools available to even the most
adept clinician are imperfect. Traction can be applied
across lax tissues and excess removed to impart defini­
tion to an aging face. Volume can be added and wrin­
kles improved in a modest way. With time the percep­
tive surgeon learns to appreciate the limitations of each
tool. In general the addition of volume is most success­
ful in an environment of tight skin, which is why fat
grafting is often combined with facelift surgery. Filling
lax facial skin with fat to the point of smoothness would

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Fig. 19D.6 (a) A 54-year-old woman just before fat grafting of a total of 130 cc into her face. (b) Approximately 6 months later.
Although her appearance has improved, she had a profound sense of loss of facial identity. She complained that she did not look
like herself and her friends did not recognize her. As many such patients do, she socially isolated herself. (c) After long discus­
sions with the surgeon, she decided that the hollowing of the cheek was the feature that she missed seeing. Using a fat injection
needle and syringe under local anesthesia, 5 cc of fat were removed from each lateral cheek to try to duplicate the look of the
preoperative cheek. Although a significant difference is not visible photographically, she is happy with this result. (These images
are provided courtesy of Dr. Val Lambros.)
a
b
c
result in a face the size of a basketball. Clinicians should
previsualize the face with a snugger skin envelope and
mentally fill it to the desired shape. Generally, cheeks
should have appropriate convexity, jawlines should
be straight, and the submalar area should not appear
sunken. Demarcation lines such as the lid–cheek inter­
face, the nasolabial crease, and marionette lines should
be smoothed. The superior aspect of the orbit should
not be visible, because this imparts an aged look.
Approach to the Overly Fat-Grafted
Patient
Patients who have had excess fat graft must be listened
to carefully even if their complaints might seem to be
out of proportion to the physical findings. They may be
emotionally fragile and desperate. An attempt must be
made to access preinjection and postinjection photo­
graphs, because patients sometimes do not know what
was done or misinterpret the results. Physical exami­
nation is important: The face should be carefully stud­
ied and palpated in repose and animation to ascertain
that the complaints are actually related to injected
fat, and if so, to understand the way that the fat has
altered the face in repose and animation. A common
complaint is that the cheeks are too full when smiling.
The treating physician must discuss candidly with the
patient that improving the appearance of the cheeks
during animation may result in a hollow and aged look
in repose. Most importantly, the limitations of current
procedures to remove facial fat in a controlled manner
must be firmly and thoroughly explained to these pa­
tients. More often than not, patients have envisioned
an end point that never existed or cannot be achieved
with surgery.
Unfortunately, removing grafted fat is challenging
and not currently possible at a level that allows for sim­
ple and effective treatment of these deformities. Both
clinicians and patients are frustrated by the inability to
correct overfilled facial contours.
The brow is the least difficult area of the face from
which to remove grafted fat and can easily be ap­
proached from an upper lid blepharoplasty incision.
Dissection proceeds to the orbital rim in the suborbicu­
lar plane, where the grafted fat becomes obvious as a
mass situated above the periosteum, allowing for exci­
sion under direct vision (see Fig. 19D.5). Liposuction of
this area is also effective.
By convention, grafted fat is placed in various tis­
sue planes to improve its odds of survival, thus making
targeted removal challenging. Scar tissue forms in areas
of fullness after each attempted removal, highlighting
the importance of accomplishing the desired correction
on the first attempt. It is said that “you can’t go home
again,” and the same seems to be true with removing
grafted fat. Although patients acknowledge that they are
improved, their expectations are rarely met and they
commonly request further treatments.
Micro-liposuction is our preferred tool for removal
of fat from the overly treated face. It is most effective in

221
Chapter 19 Fat Grafting for Facial Rejuvenation
the nasolabial folds and lower cheek and is technically
easy to perform. The areas to be treated are usually eas­
ily anesthetized, so these procedures are commonly per­
formed in an office treatment room. A small amount of
oral sedation might additionally be given to an anxious
patient, but for most, the slow application of local anes­
thetic is quite tolerable. We find it helpful to divide the
affected area into sections, and mark the skin as such, so
that fat removal can be performed in a systematic fash­
ion. A 17-gauge fat injection cannula attached to a 3-mL
syringe is typically passed through multiple access sites
to facilitate uniform removal. Larger or more aggressive
cannulas are more efficient; however, they can generate
some irregularities and are best used judiciously.
Aspiration is performed in a manner similar to fat
harvest. Grafted areas exhibit little resistance, whereas
areas that have been previously aspirated become in­
creasingly fibrotic, yielding less fat with each attempt.
To this point, it is important to accomplish as much as
possible during the first procedure. A visible change is
not always perceptible on the table; however, palpation
of the remaining fat demonstrates improvements in bulk
and mobility. Routine surgical swelling can be antici­
pated and is treated in the typical fashion. Four to six
months should be allowed for swelling to resolve and
a final result to become evident before repeat efforts
are pursued.
Lower Eyelid Injected Fat Deformities
The lower eyelid is the most difficult area of the face
to inject, and it is usually among the first targets of the
novice injector.
When shaded by dark circles and shadow, the lower
lid–cheek interface expresses tiredness, fatigue, and ill­
ness out of proportion to its small area. It seems obvi­
ous to try to fill in the tear troughs and to correct the
shadow caused by overhanging lower lid fat pads. In
the operating room, injecting the area with fat can look
wonderful, leading the injector to believe he or she had
achieved greatness. However, fat grafted to the lower lid
behaves in a unique way not seen in the rest of the face.
What begins as grafted fat innocently lying in tissues be­
comes a fibrofatty mass in either a bump or a toothpick-
like shape depending how it was placed. It is firm and
easily rolled under the fingers and unfortunately pro­
trudes and casts a shadow that is lower than the shadow
that it was intended to replace. It is extremely visible
and distressing to the patient and distracting to others.
This is a situation that is easy to generate, even among
expert injectors, and very difficult to correct.
Physical examination in these patients can locate
the extent but not the depth of the grafted fat. If discrete
masses are present in the lower lid, asking the patient to
squint may assist the injector in determining fat depth.
If the lower lid masses are effaced during this maneu­
ver, they are likely submuscular. Unfortunately, this test
is not always reliable.
Removal of Fat Grafted to the Lower
Eyelids
Although steroid injections have been tried, the con­
sensus is that they offer little benefit over the alter­
natives.9,10,18 A pretreatment injection of 5-flurouracil
and triamcinolone to soften the encapsulated fat fol­
lowed by micro-liposuction has been suggested.18 The
authors’ initial approach to these patients is to iden­
tify whether the problem is related to discrete bumps,
which may be camouflaged by the injection of fillers.
Injected fat is distinctly different from native fat in the
lower lids in that it is firm and fibrous. It is also much
more sensitive to trauma than native fat. Simply grasp­
ing and squeezing grafted fat with forceps or a hemo­
stat in the operating room will cause it to fall apart.
On the whole, we have not found micro-liposuction
of the tear trough to be very effective, especially for dis­
crete firm masses; in soft, puffier lids it may offer some
improvement. Exploration of the lower lid through a tra­
ditional blepharoplasty or transconjunctival approach
has been described.19 A critical variable in the success of
any intervention is the level of fat deposition. If it is ad­
jacent to the periosteum, direct exposure and removal is
preferred, because the fat is localized and circumscribed,
making removal fairly straightforward. Unfortunately,
this rarely seems to be the case in referred patients, in
whom fat placement in every plane of the lower lid from
the periosteum up to and including the skin seems to
be the prevailing practice. There seems to be a fond­
ness for placing the fat directly deep to the thin eyelid
skin, perhaps because it is said that fat grafts adjacent
to dermis have an effect on skin quality, an observation
that we do not share.16 It becomes necessary to dissect
and isolate each layer to remove the diffusely placed fat,
usually in the setting of a scarred lower lid. Some pleas­
ing results have been reported with the open removal
technique; however, in our experience the incidence of
postoperative irregularities is high, with one deformity
exchanged for another.
Consistently smoothing a scarred, lumpy lower lid is
a surgical challenge and very difficult to achieve; more­
over, the presence of any lingering irregularities seems
to bother patients as much as the presurgical deformity.
We have developed a healthy respect for the challenges
of this area and now rarely fat graft the lower lid. Exist­
ing options for the many patients with deformity are

SECTION IV AESTHETIC SURGERY
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flawed and unreliable. It is safe to say that advances in
treatment beyond what is currently available will be
welcomed.
Conclusion
There is no doubt that fat grafting is a powerful tool
for rehabilitating the aging face; however, as with any
surgical procedure, there are inherent shortcomings.
The most common complication of fat grafting is the
presence of fat in locations and quantities where one
does not want it. In younger patients, undertreatment
is preferred in anticipation of potential fat growth. We
believe that smaller staged treatment sessions will re­
sult in fewer complications than if total correction is
attempted in one large fat grafting procedure. Unfor­
tunately, the ability to remove grafted fat locally is
not equal to the challenges of fat misplacement or fat
growth. This is a circumstance that we fervently hope
will be improved in the future.
References
1. “2015 Cosmetic Surgery National Data Bank Sta­
tistics.” The American Society for Aesthetic Plastic
Surgery’s Cosmetic Surgery Statistics. The American
Society for Aesthetic Plastic Surgery, 2016. https://

1 July 2016.
2. Yu NZ, Huang JZ, Zhang H, et al. A systemic review
of autologous fat grafting survival rate and relat­
ed severe complications. Chin Med J (Engl) 2015;
128(9):1245–1251
3. Anderson OA, Tumuluri K, Francis ND, Olver JM. Peri­
ocular autologous Coleman fat graft survival and
histopathology. Ophthal Plast Reconstr Surg 2008;
24(3):213–217
4. Glasgold M, Glasgold R, Lam S. Autologous fat graft­
ing for midface rejuvenation. Clin Plast Surg 2015;
42(1):115–121
5. Meier JD, Glasgold RA, Glasgold MJ. Autologous fat
grafting: long-term evidence of its efficacy in mid­
facial rejuvenation. Arch Facial Plast Surg 2009;
11(1):24–28
6. Yoshimura K, Coleman SR. Complications of fat graft­
ing: how they occur and how to find, avoid and treat
them. Clin Plast Surg 2015;42(3):383–388, ix
7. Lambros V. Fat injection for aesthetic facial rejuvena­
tion. Aesthet Surg J 1997;17(3):190–191, 198
8. Lambros V. Fat injection for the aging midface. In:
Codner MA, Hester R, McCord CD, eds. Operative
techniques in plastic surgery. Amsterdam, Nether­
lands: Elsevier; 1998;5(2):129-137
9. Lam SM, Glasgold RA, Glasgold MJ. Limitations, com­
plications, and long-term sequelae of fat transfer. Fa­
cial Plast Surg Clin North Am 2008;16(4):391–399, v
10. Bucky LP, Kanchwala SK. The role of autologous fat
and alternative fillers in the aging face. Plast Reconstr
Surg 2007;120(6, Suppl)89S–97S
11. Teplica
D.
Discussion:
Autologous
fat
graft­
ing and injectable dermal fillers for human im­
munodeficiency
virus-associated
facial
lipo­
dystrophy: a comparison of safety, efficacy, and
long-term treatment outcomes. Plast Reconstr Surg
2013;131(3):507–509
12. Bass LS. Injectable filler techniques for facial rejuve­
nation, volumization, and augmentation. Facial Plast
Surg Clin North Am 2015;23(4):479–488
13. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD,
Ogden CL. Trends in obesity among adults in the Unit­
ed States, 2005 to 2014. JAMA 2016;315(21):2284–
2291
14. Yaremchuk MJ. Secondary malar implant surgery.
Plast Reconstr Surg 2008;121(2):620–628
15. Guerrerosantos J, Haidar F, Paillet JC. Aesthetic facial
contour augmentation with microlipofilling. Aesthet
Surg J 2003;23(4):239–247
16. Coleman SR.. Overview of placement techniques. In:
Coleman SR, ed. Structural Fat Grafting. St. Louis, MO:
Quality Medical Publishing; 2004:53-73
17. Ellenbogen R. Personal communication; 1989.
18. Taban M, Lee S, Hoenig JA, Mancini R, Goldberg RA,
Douglas RS. Postoperative wound modulation in aes­
thetic eyelid and periorbital surgery. In: Massry GG,
Murphy MR, Azizzadeh B, eds. Master Techniques in
Blepharoplasty and Periorbital Rejuvenation. New
York, NY: Springer; 2011:307-312
19. Massry GG, Azizzadeh B. Periorbital fat grafting. Fa­
cial Plast Surg 2013;29(1):46–57

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CHAPTER
20

The Forehead Lift: Open and Endoscopic
Cristiano Boneti and Luis O. Vasconez
Patients who present for an aesthetic facial improvement,
in many instances, are not aware of the factors that lead to
an aged or “tired” appearance. Most of the time they fo­
cus on the midface and periorbital changes. It is the clini­
cal responsibility of the surgeon to recognize forehead and
brow ptosis and demonstrate to the patient how it can be
improved.
A forehead lift procedure results in several improve­
ments to the aging face. It raises the eyebrows to a more
youthful level, ameliorates the transverse and vertical wrin­
kles, and opens up the eyes. These changes work very well
in complementing the facelift.
Wrinkles develop because the muscles insert into the
skin. Young skin is elastic and wrinkles are fleeting and tem­
porary; as the skin ages, it becomes inelastic, and wrinkles
become permanent.
Anatomy and Physiology of the
Forehead Muscles
The muscles of the face are unique. They do not have a bony
origin and bony insertion. They have no fascia. Thus they
do not have an all-or-none total contraction. They may con­
tract only portions of the muscle, which allows the multi­
tude of facial expressions.
Elevator Muscle: Frontalis
The frontalis muscles are paired muscles located just below
the subcutaneous tissue and on top of the galea. Each mus­
cle’s origin and insertion are into the skin, and it extends
only to the frontotemporal ridge. Therefore its contraction
results in transverse forehead wrinkles. It is the only eleva­
tor of the eyebrows.
Depressors: Procerus, Corrugators, and
Portions of the Orbicularis Oculi
As opposed to the single brow elevator, three muscles de­
press the brow: the procerus, corrugators, and portions of
the orbicularis oculi muscle. These muscles have a bony
origin and insertion into the skin. They are responsible for
vertical and transverse glabellar creases. Their combined
action lowers and converges the medial aspect of eyebrows.
According to the cadaveric studies performed by Knize,1
the transverse head of the corrugator produces vertical
frown lines and contributes to oblique lines, whereas the
oblique head of the corrugator, depressor supercilii, and
medial head of the orbital portion of the orbicularis oculi
muscle depress the medial eyebrow and contribute to gla­
bellar oblique lines.
Eyebrows and Aging
The eyebrows begin to droop early in life (28 years). With
aging, the medial aspect converges and the tail of the eye­
brow raises (because of overaction of frontalis muscle).
As described by Kaye,2 the eyebrows are a critical part of
facial expression. Therefore correction, in general, should be
done as a unit. In special circumstances, the technique may
be adjusted to improve results—for example, a little extra
lifting in the central part of the flap in a perpetually angry-
looking patient or in the lateral portions of the flap in a pa­
tient that always looks sad.
On the other hand, if too much tension is created in
parts or in the entire flap, inadvertent changes in expres­
sion may occur. For example, excessive brow elevation medi­
ally may result in a sad look, excessive elevation centrally or
totally may create a surprised or startled look, and excessive
elevation laterally could produce an angry look.2

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224
the other forehead scars in bald patients. Another principle
behind this technique is the elastic band principle suggested
by Flowers et al,6 which asserts the farther away the suspen­
sion point, the less effective the lift.
A midforehead lift consists of direct excision of a trans­
verse strip of skin in the forehead. The rationale for this inci­
sion is based on patients who have deep forehead rhytides
that can hide the scar and patients with male pattern bald­
ness, in whom a coronal lift would be troublesome. It is par­
ticularly beneficial in bald patients and should be avoided
in patients with a short forehead, because it advances the
hairline forward.
A coronal incision must be hidden in the hair-bearing
scalp and planned further posterior in balding males. It is
best suited for patients with a short forehead and low hair­
Avoiding Unfavorable Results
and Complications of Browlifts
Summary Box
Unfavorable Results and Complications of
Browlift
•• Scalp numbness
•• Dysesthesia
•• Vertical and transverse glabellar creases
•• Poor eyebrow elevation
•• Scalp necrosis
•• Alopecia
•• Hematoma
•• Front nerve injury
•• Inadequate amelioration of wrinkles
•• Infection
•• Inability to close eye
•• Overelevation of eyebrows
Surgical Technique
Open
An open technique consists of excision of an ellipse of skin
and subcutaneous tissue, varying from partial to complete
excision of the forehead muscles. The type of incision and
size of the resection is planned according to the desired el­
evation and patient characteristics.
For bald patients or those with more than 5 cm between
the brow and hairline,3 the incision is placed the level of
the hairline, which will result in shortening of the forehead.
According to Connell and Marten,4 every 1 mm of eyebrow
elevation produces 1.5 mm of elevation of the hairline
(Fig. 20.1). In patients with a low hairline, a coronal inci­
sion in the hair-bearing scalp is chosen, with the incision
placed perpendicular to the hair follicles to allow the growth
of hair through the scar.5
Once the incision is made, a subperiosteal dissection
will provide the most solid elevation, whereas a subcutane­
ous approach will remove the skin attachments to the mus­
cle, directly addressing the transverse wrinkles (Fig. 20.2).
Several approaches have been described with particular
advantages and disadvantages. These include superciliary,
midforehead, coronal, transblepharoplasty and temporal.
The superciliary approach consists of direct excision im­
mediately above the brow with the intent of hiding the scar
at the superior margin of the brow, avoiding the visibility of
Fig. 20.1 Markings before the hairline incision.
Fig. 20.2 Excess skin after plication. (a) Before plication. (b) After
plication.
a
b

225
Chapter 20 The Forehead Lift: Open and Endoscopic
Endoscopic
With the advent of endoscopy, a minimally invasive ap­
proach to address mild to moderate brow ptosis was devel­
oped (Video 20.1). It is especially suited for patients with
elastic skin who do not require skin excision. This method
is based on ablation of the depressors of the eyebrow, en­
hancing the unopposed effect of the frontalis muscle and
division of the supraorbital periosteum to reposition the
eyebrows freely.17,18
Additional eyelid procedures (e.g., blepharoplasty, eyelid
ptosis) are completed before the endoscopic intervention so
the eyelid surgery is not compromised by edema from pre­
vious interventions.
Three minimal-access incisions are placed at the frontal
prehairline level, one at the midline and the others at the
level of the lateral limbus. Triangular incisions with trans­
verse closure achieve some elevation of the eyebrows and
permit easier entrance of the endoscope. The size and shape
of the triangular excision matches the estimated brow eleva­
tion desired (Fig. 20.4).
Subperiosteal dissection extends to the supraorbital
rims and to the frontotemporal line. Dissection is extended
further to the nasal tip to release the procerus. The perios­
teum is divided at the supraorbital level with a blunt peri­
osteal elevator and a hook knife (carpal tunnel knife). (Fig.
20.5).
Ablation of the corrugators and procerus and more lim­
ited excision of other depressors is achieved with a grasp
forceps. The supratrochlear and supraorbital nerves are
identified and preserved (Fig. 20.6).
After transverse closure of the access ports, temporary
suspension is achieved with cable sutures secured from the
skin incisions to the scalp for 3 to 5 days. This period al­
lows for adhesion of the periosteum and a long-term effect.
The resection of the depressor muscles obviates the need for
other methods of suspension (Fig. 20.7).
line, because elevation of the brow will result in elevation
of the anterior hairline to a higher magnitude (Fig. 20.3).
Temporal browlifting was initially described as an ex­
tensive subcutaneous undermining in the temporal and lat­
eral orbital areas up to the anterior branch of the temporal
artery, at which point the dissection deepened to a subga­
leal plane, with the most common complication being alo­
pecia.7,8 Modifications of this technique included using the
subgaleal plane and extension to the zygomatic arch for an
added midface lift9,10 (see Fig. 20.3).
The goal of a transblepharoplasty incision is to generate
an inconspicuous scar; to elevate the brow by transecting
its attachments to the orbital rim, suspending it superiorly;
and to partially or completely resect the procerus, corruga­
tor, and depressor supercilii muscles through a blepharo­
plasty scar.11–16
Disadvantages
The long coronal incision of an open technique divides
branches of supraorbital nerves, resulting in permanent
scalp numbness and occasional dysesthesia, in addition to
leaving a long incision. Because it elevates the forehead and
sideburns, it is a poor choice in patients with a tall fore­
head, for whom an endoscopic approach will result in more
appealing results.
Another disadvantage is the partial excision of the fron­
talis muscle to ameliorate the transverse wrinkles, because
it is the only elevator of the eyebrows. Because of the poor
visualization, the open technique often results in minimal
division or excision of corrugators and procerus muscles,
which leads to persistence of vertical and transverse gla­
bellar creases. The poor visualization also does not allow a
complete division of the periosteum, which is essential to
elevate the eyebrows.
Scalp necrosis is rare. However, alopecia is fairly com­
mon and of varying severity.
Fig. 20.3 Results of a previous coronal and temporal browlift that caused hairline elevation, scarring, and alopecia with scalp paresthesia.

SECTION IV AESTHETIC SURGERY
226
Fig. 20.4 The typical triangular incisions, used as endoscope
sites and located anterior to the hairline.
Fig. 20.5 (a) Subperiosteal plane entered through the frontalis with a hemostat. (b) Dissection extending to the lateral orbital rims with
a blunt dissector.
a
b
Fig. 20.6 Muscle ablation. (a) An external view of the forceps clamp in place with digital counterpressure. (b) The endoscopic view of the
brow depressor muscles in the glabella and between the supratrochlear and supraorbital nerves. (c) The final result, with muscle excision,
periosteum division, and intact nerves.
a
b
c

227
Chapter 20 The Forehead Lift: Open and Endoscopic
An inability to close the eyes because of excessive eleva­
tion is uncommon. When it happens, it is usually the result of
a concomitant blepharoplasty with skin overresection. To pre­
vent this complication in the open approach, the eyelid surgery
should be performed after the coronal lift. This is not easy be­
cause of swelling of the eyelids. In the endoscopic approach, the
eyelid operation comes first, followed by conservative forehead
elevation. If upper eyelid ptosis is corrected at the same time,
the eyes should be protected by night patching and a daily appli­
cation of a steroid-containing drop solution, because the patient
may temporarily be unable to close the eyes (22%).19
Overelevation of eyebrows is more commonly seen in
the open approach. It has also been seen in the endoscopic
approach when permanent fixation is used (i.e., miniplates,
Endotine, Mitek). Overelevation results in a surprised look.
The surgeon must be precise in the degree of elevation, aim­
ing to obtain open and bright eyes instead.
With experience, we have learned strategies to reduce
or prevent unwanted results. For example, to avoid creat­
ing a sad look, the surgeon should pull less on the central
forehead.2 To obtain a lasting eyebrow elevation, the galea
should be sutured laterally to the deep temporalis fascia.20
If division of the periosteum is vital to elevate the eyebrows,
leaving the periosteum intact will prevent depressions. Be­
cause it travels more superficially, the surgeon can avoid in­
juring the frontalis branch of the facial nerve by staying in
the plane of the deep temporalis fascia. During closure, not
only should the surgeon close the scalp in layers, but pri­
mary approximation of the galea is essential.
Conclusion
The endoscopic approach is superior to the open approach.
It is a physiological method that meets the objectives of
facial rejuvenation of the upper face (Figs. 20.8 and 20.9).
Advantages
We consider this to be a more physiologic operation, a true
balancing operation, which requires knowledge of the lo­
cation and function of the forehead musculature. This ap­
proach provides better visualization of the supraorbital and
supratrochlear nerves with endoscopic magnification and
high definition endoscopes. Scalp numbness is temporary,
with minimal dysesthesia.
Frontal nerve injury is exceedingly rare, with only 2%
demonstrating temporary paralysis.19 Because no skin exci­
sion is made, the vertical height of forehead is not increased.
The technique prevents hyperelevation of the eyebrows,
except in cases when more permanent fixation is used (e.g.,
miniplates, Endotine, or Mitek or even cortical tunnels). De­
pressions do not occur if periosteum is not removed. Be­
cause the skin incisions are limited and performed at the
non–hair-bearing areas, the incidence of alopecia is mini­
mal to none. To date, there are no reports of skin necrosis. It
is a lasting operation, with good results observed for more
than 10 years.19
Complications Common to Both
Approaches
Complications associated with both techniques include he­
matoma; frontal nerve injury, which is usually temporary
and a result of stretching rather than transaction; and in­
adequate amelioration of wrinkles because of incomplete
muscle removal. Scalp necrosis and infections are rare in
both approaches.
Alopecia is more common after the open approach, al­
though it can occur and cause patient concern even with the
vertical incisions of the endoscopic approach.
Fig. 20.7 The transverse closure of the triangular skin incisions with temporary suspension with sutures and staples, resulting in a “func­
tional” suspension.

SECTION IV AESTHETIC SURGERY
228
11. Sokol AB, Sokol TP. Transblepharoplasty brow suspension.
Plast Reconstr Surg 1982;69(6):940–944
12. McCord CD, Doxanas MT. Browplasty and browpexy: an
adjunct to blepharoplasty. Plast Reconstr Surg 1990;86(2):
248–254
13. Leopizzi G. A transpalpebral approach to treatment of
eyebrow ptosis. Aesthetic Plast Surg 1999;23(2):125–130
14. Knize DM. Transpalpebral approach to the corrugator su­
percilii and procerus muscles. Plast Reconstr Surg 1995;
95(1):52–60, discussion 61–62
15. Guyuron B, Michelow BJ, Thomas T. Corrugator supercilii
muscle resection through blepharoplasty incision. Plast
Reconstr Surg 1995;95(4):691–696
16. Paul MD. Subperiosteal transblepharoplasty forehead lift.
Aesthetic Plast Surg 1996;20(2):129–134
17. Vasconez LO, Core GB, Oslin B. Endoscopy in plastic sur­
gery. An overview. Clin Plast Surg 1995;22(4):585–589
18. Ramirez OM. Why I prefer the endoscopic forehead lift.
Plast Reconstr Surg 1997;100(4):1033–1039, discussion
1043–1046
19. De Cordier BC, de la Torre JI, Al-Hakeem MS, et al. Endo­
scopic forehead lift: review of technique, cases, and com­
plications. Plast Reconstr Surg 2002;110(6):1558–1568,
discussion 1569–1570
20. Pitanguy I. Indications for and treatment of frontal and gla­
bellar wrinkles in an analysis of 3,404 consecutive cases of
rhytidectomy. Plast Reconstr Surg 1981;67(2):157–168
References
1. Knize DM. Muscles that act on glabellar skin: a closer
look. Plast Reconstr Surg 2000;105(1):350–361
2. Kaye BL. The forehead lift. In: Goldwyn RM, ed. Long Term
Results in Plastic and Reconstructive Surgery. Boston: Lit­
tle, Brown; 1980:654–662
3. McKinney P, Mossie RD, Zukowski ML. Criteria for the fore­
head lift. Aesthetic Plast Surg 1991;15(2):141–147
4. Connell BF, Marten TJ. The male foreheadplasty. Recogniz­
ing and treating aging in the upper face. Clin Plast Surg
1991;18(4):653–687
5. Camirand A, Doucet J. A comparison between par­
allel hairline incisions and perpendicular incisions
when performing a face lift. Plast Reconstr Surg
1997;99(1):10–15
6. Flowers RS, Caputy GG, Flowers SS. The biomechanics of
brow and frontalis function and its effect on blepharo­
plasty. Clin Plast Surg 1993;20(2):255–268
7. Passat R. La chirurgie esthetique des rides du visage. Pres­
se Med 1919;27:258
8. Gleason MC. Brow lifting through a temporal scalp ap­
proach. Plast Reconstr Surg 1973;52(2):141–144
9. Dingman DC. Lateral temporal transition browlift. Pre­
sented at the Annual Meeting of the American Society for
Aesthetic Plastic Surgery, Los Angeles; April 1983
10. Byrd HS, Andochick SE. The deep temporal lift: a multi­
planar, lateral brow, temporal, and upper face lift. Plast
Reconstr Surg 1996;97(5):928–937
Fig. 20.8 Preoperative appearance (a) and postoperative results (b) of the standard endoscopic technique.
a
b
Fig. 20.9 Preoperative appearance (a) and postoperative results (b) of the standard endoscopic forehead lift.
a
b

229
Chapter 20 The Forehead Lift: Open and Endoscopic
Discussion by Foad Nahai
Until Dr. Vasconez1 introduced the endoscopic ap­
proach for browlifting, the coronal approach was the
standard and for most patients the only option. In my
practice up to that time it was difficult for my patients
to accept the coronal browlift, given the long coronal in­
cision and the possibility of hairline elevation and over­
done, unnatural brow elevation. Although uncommon,
they had seen exaggerated brow elevation in celebrities
and some of their own friends and acquaintances. Fig.
20.3 provides an example of such hairline elevation and
exaggerated overelevation of the eyebrows.
The endoscopic approach reduces the length of the
scars and the risk of hairline elevation. It reduces blood
loss, alopecia, and, in experienced hands, even the oper­
ative time. The magnification afforded by the endoscope
facilitates muscle modification. Results are long-lasting
and comparable to those of the coronal approach.
Chapter 20 summarizes the complications of both
the coronal and endoscopic approach. My experience
parallels that of the chapter authors; I have not seen any
permanent frontal nerve paralysis, and I have seen tem­
porary paresis in only 1% or 2% of cases. Though rare, I
have seen alopecia in the access incisions for the endo­
scopic approach but more commonly at the site of exter­
nal fixation devices such as temporary screws.
This discussion summarizes my approaches and of­
fers some statistics from my own practice. It concludes
with a brief discussion of the most common unfavor­
able results.
Preoperative Considerations
A patient seeking an “eyelid lift” may be advised that
in addition to blepharoplasty, a browlift is also recom­
mended. Most will accept this recommendation, but
many will resist, saying they only want to remove the
excess skin or bags from the eyelid. For some, this is
a financial consideration of the increased cost. Regard­
less, we advise full-facial rejuvenation as the best op­
tion, rather than localized, isolated procedures. How­
ever, we leave the final decision to the patient.
In my practice, an isolated browlift is a rarity. I con­
sider browlift to be just one component of periorbital
rejuvenation encompassing the brow, upper and lower
eyelids, lid–cheek junction, and midface.
I evaluate the morphologic structures and anatomic
features and the other changes resulting from the aging
process. A detailed knowledge of the anatomy is essen­
tial to avoid an unfavorable result or complication.
Evaluation includes assessment of the position of
the brow laterally and medially, the relationship of the
brow to the upper eyelid, and the distance from the up­
per lid sulcus to the hair-bearing brow. Horizontal and
vertical forehead and glabellar rhytids are assessed at
rest and on animation, as are crow’s-feet. The quality,
elasticity, and thickness of the forehead skin are also
evaluated. Lateral orbital bunching or crowding is noted
with the eyebrow at rest and when elevated. Any excess
skin is noted, whether real or apparent.
Open coronal lift was considered the standard pro­
cedure for years; now several options are available, in­
cluding the endoscopic approach and injectables.3–9
I have found the endoscopic approach to be as effective
as the coronal, and in select patients, a combination of
a lateral approach with transpalpebral muscle excision
has also proven satisfactory.
Surgical Techniques
Open Coronal Forehead Lift
The open coronal approach affords excellent exposure
and facilitates release of adhesions, muscle excision,
and brow mobilization. The scalp excision is tailored to
elevate the brow as desired and enhance its shape. The
extensive incision involved brings the risks of sensory
changes, including dysesthesias, numbness, and alope­
cia. Since the introduction of the endoscopic approach
in 1993,1 I have not performed an open coronal brow­
lift. Now almost all of my facial rejuvenation patients
undergo one of the following brow rejuvenation tech­
niques:
•• Full endoscopic (20%)
•• Lateral-temporal (15%)
•• Transpalpebral muscle excision (5%)
•• Combination of lateral-temporal and transpalpebral
muscle excision (60%)
I rarely perform an isolated browlift. In a personal
series of 100 consecutive endoscopic browlifts per­
formed over 14  months, 79 patients underwent up­
per and lower lid blepharoplasty, 2 underwent upper
lid blepharoplasty only, and 19 underwent lower lid
blepharoplasty. Most patients undergoing a lower lid
blepharoplasty also had a transpalpebral midface lift.
No isolated endoscopic browlifts were performed dur­
ing the study.
Endoscopic Forehead Lift
The endoscopic forehead lift has some limitations.
Results vary according to the patient’s anatomic fea­
tures and the aging changes present. Certain anatomic
features make the endoscopic approach challenging.

SECTION IV AESTHETIC SURGERY
230
These patient are best served by one of the alternative
approaches2 (Fig. 20D.1, Table 20D.1).
I believe that a youthful brow is related more to
volume and shape than to height only. Endoscopic pro­
cedures have been modified with this knowledge. Of
course cultural and individual preferences for brow
height must be taken into account as well.
Markings
The major landmarks include the sentinel vein, the
temporal crest, and fixation vectors. If the sentinel vein
is visible with the patient sitting, I mark it, then draw
the likely course of the frontal branch of the facial nerve
1 cm or so above the sentinel. If it is not visible, I ask
the patient to lie flat, which normally makes the vein
visible2 (Fig. 20D.2). These markings are made sym­
metrically on both sides of the head. I prefer the coro­
nal or horizontal incision to a radial incision, because it
allows me to place a minimum of two fixation sutures.
I then ask the patient to frown, which outlines the
origin and insertion of the corrugator muscles. Next, I
mark the glabellar frown line and the midpupillary line;
another mark is placed 2 to 4 cm above the orbital rim
Fig. 20D.1 The best candidates for an endoscopic forehead lift are patients with short, flat foreheads with nonreceding, thick hair­
lines and normal skin, moderate rhytids, and minimal true skin excess laterally and over the nasal radix. Poor candidates have a high
convex forehead, a high, receding hairline with thin hair; thick skin; deep rhytids; and true excess skin on the forehead and brow.
(Reproduced from Nahai F. Endoscopic brow lift: the three-portal approach. In: Nahai F, ed. Art of Aesthetic Surgery Principles and
Technique. 2nd ed. St Louis: Quality Medical Publishing; 2011:751.)
GOOD CANDIDATE
POOR CANDIDATE

231
Chapter 20 The Forehead Lift: Open and Endoscopic
Table 20D.1 Endoscopic forehead
lift: favorable and unfavorable
candidates
Anatomic features
Favorable
Unfavorable
Forehead
Height
Short
High
Convexity
Flat
Convex
Hairline
Height
Short
High
Receding
Nonreceding
Receding
Hair quality
Thick
Thin
Skin
Thickness
Normal
Thick
Rhytids
Superficial
Deep
Fig. 20D.2 Endoscopic surgical marking. After the sentinel vein is marked, the access incision is marked 1 to 2 cm behind the tem­
poral hairline, ensuring the mark is over the temporalis muscle. This facilitates fixation of the temporoparietal fascia down to the
deep temporal fascia. (Reproduced from Nahai F. Endoscopic brow lift: the three-portal approach. In: Nahai F, ed. Art of Aesthetic
Surgery Principles and Technique. 2nd ed. St Louis: Quality Medical Publishing; 2011:755.)
Temporal crest
Sentinel vein
Projected course
of frontal branch
of facial nerve
Temporal crest
Projected course
of frontal branch
of facial nerve
Sentinel vein

SECTION IV AESTHETIC SURGERY
232
Fig. 20D.3 All final markings for an endoscopic browlift. (Reproduced from Endoscopic brow lift: the three-portal approach. In:
Nahai F, ed. Art of Aesthetic Surgery Principles and Technique. 2nd ed. St Louis: Quality Medical Publishing; 2011:763.)
Midline
Temporal
crest
Sentinel
vein
Course of
supraorbital
nerve
Projection line
representing highest
point of brow arch
Temporal
crest
Projection line
representing highest
point of brow arch
Sentinel
vein
Course of
supraorbital
nerve
Midline
in the midpupillary line, indicating a danger zone for
the supraorbital nerve. Finally, the vectors for fixation
are marked2 (Fig. 20D.3).
Operative Technique
The operative sequence is as follows:
1. Hair preparation2 (Fig. 20D.4)
2. Infiltration
3. Right temporal incision and dissection2 (Fig.
20D.5)
4. Left temporal incision and dissection2 (Fig. 20D.6)
5. Central access incision2 (20D.7)
6. Subperiosteal dissection
7. Division of periosteum from one lateral orbital rim
to the other2 (Fig. 20D.8)
8. Muscle modification2 (Fig. 20D.9)
9. Drain placement
10. Closure of central access incision
11. Placement of temporal fixation sutures2 (Fig.
20D.10)
12. Additional fixation, if needed
13. Tying of temporal fixation sutures
14. Temporal scalp excision, if needed
Fig. 20D.4 Hair preparation. (Reproduced from Nahai F. Endo­
scopic brow lift: the three-portal approach. In: Nahai F, ed. Art
of Aesthetic Surgery Principles and Technique. 2nd ed. St Louis:
Quality Medical Publishing; 2011:765.)

233
Chapter 20 The Forehead Lift: Open and Endoscopic
Fig. 20D.5 The incision is made through the scalp down to the deep temporal fascia over the temporalis muscle. (Reproduced
from Nahai F. Endoscopic brow lift: the three-portal approach. In: Nahai F, ed. Art of Aesthetic Surgery Principles and Technique.
2nd ed. St Louis: Quality Medical Publishing; 2011:766.)
Sentinel vein
Temporal crest
Fig. 20D.6 The sentinel veins are easily identified. Divide the septa and adhesions around the vein and extend the dissector into
the upper eyelid, deep to the orbicularis and the retroorbicularis oculi fat (ROOF). (Reproduced from Nahai F. Endoscopic brow
lift: the three-portal approach. In: Nahai F, ed. Art of Aesthetic Surgery Principles and Technique. 2nd ed. St Louis: Quality Medi­
cal Publishing; 2011:768.)
Sentinel vein
(medial zygomatico-
temporal vein)
Division of periorbital adhesions
with endoscopic scissors
Sentinel vein
(all adhesions
have been divided)

SECTION IV AESTHETIC SURGERY
234
Fig. 20D.7 The central access incision is made in the midline,
approximately 1 cm behind the hairline. This radial incision ex­
tends straight through to the periosteum. (Reproduced from
Nahai F. Endoscopic brow lift: the three-portal approach. In:
Nahai F, ed. Art of Aesthetic Surgery Principles and Technique.
2nd ed. St Louis: Quality Medical Publishing; 2011:768.)
Fig. 20D.8 The division of the periosteum from one lateral or­
bital rim to the next. (Reproduced from Nahai F. Endoscopic
brow lift: the three-portal approach. In: Nahai F, ed. Art of Aes­
thetic Surgery Principles and Technique. 2nd ed. St Louis: Qual­
ity Medical Publishing; 2011:770.)
Corrugator
muscle
Supraorbital nerves
Supratrochlear
nerves
Vein
Vein
a
Corrugator
muscle
Supraorbital nerves
Supratrochlear
nerves
Vein
b
Fig. 20D.9 Muscle modification. (a,b) An endoscopic grasper is used to grab a little muscle at a time and tease it upward. (Re­
produced from Nahai F. Endoscopic brow lift: the three-portal approach. In: Nahai F, ed. Art of Aesthetic Surgery Principles and
Technique. 2nd ed. St Louis: Quality Medical Publishing; 2011:771.)

235
Chapter 20 The Forehead Lift: Open and Endoscopic
Fig. 20D.9, cont’d Muscle modification. (c,d) After the muscle modification, the branches of the supratrochlear nerve should lay
bare. (Reproduced from Nahai F. Endoscopic brow lift: the three-portal approach. In: Nahai F, ed. Art of Aesthetic Surgery Principles
and Technique. 2nd ed. St Louis: Quality Medical Publishing; 2011:772.)
Supratrochlear
vein
Supratrochlear
nerves
c
Supratrochlear
nerve
Supraorbital
nerve
Supratrochlear
vein
d
a
b
Fig. 20D.10 The central access incision is closed first. The brow is fixed in
the temporal area with one or two sutures, anchoring the temporoparietal
fascia down to the deep temporal fascia. External screw fixation (a) or an
Endotine device (Microaire Aesthetics) (b) can be used for additional para­
median fixation. (c) A 2-cm incision is made for insertion; then the brow
is pulled close to its desired position and held by the device. (Reproduced
from Nahai F. Endoscopic brow lift: the three-portal approach. In: Nahai
F, ed. Art of Aesthetic Surgery Principles and Technique. 2nd ed. St Louis:
Quality Medical Publishing; 2011:774,775,776.)
c

SECTION IV AESTHETIC SURGERY
236
Fixation Choices
Currently there is no consensus among surgeons re­
garding method of brow fixation. In fact, there is some
debate on whether any fixation is needed. Temporal
fixation is universally applied to every patient in my
practice. Paramedian fixation between the temporal
crest and midline with an upward and medial rota­
tion is selectively applied depending on the patient’s
anatomic structure. I am more likely to use permanent
paramedian fixation in a man with heavy forehead skin
and significant brow ptosis than in woman with mod­
erate or minimal brow ptosis and normal forehead skin
(Box 20D.1).
The general consensus is that to be effective, the fix­
ation should last at least a couple of weeks.
Box 20D.1
Temporary
Emory tapes
Bolster sutures
Fibrin glue
External screws
Permanent
Vertex sutures
Internal screws
Mitek anchors
Cortical tunnels
Endotine device
Endoscopic Brow
Fixation Methods
Fig. 20D.11 This woman in her late 40s had brow ptosis, grade 5 glabellar lines, and full facial aging. She underwent an endoscopic
browlift with no paracentral fixation. Her postoperative results at 18 months include an elevated brow position with significant
improvement in the glabellar lines. (Reproduced from Nahai F. Endoscopic brow lift: the three-portal approach. In: Nahai F, ed. Art
of Aesthetic Surgery Principles and Technique. 2nd ed. St Louis: Quality Medical Publishing; 2011:782.)
Outcomes
The success of this procedure depends on the reposi­
tioning of the hair-bearing brow, improvement of ver­
tical glabellar and horizontal forehead lines, reversal of
brow descent, and conversion of a tired or angry ex­
pression into a rested look2 (Fig. 20D.11).
Lateral-Temporal Browlift
The lateral-temporal approach affords excellent repo­
sitioning and elevation of the lateral brow through a
temporal incision with minimal invasiveness or risk of
sensory changes and can be performed simply, quickly,
and with local anesthesia. This approach is best com­
bined with transpalpebral excision of the corrugator
supercilii and division of the procerus muscles for an
effective browlift. The best candidates are patients with
little or no excess skin at the nasal redux, those requir­
ing little or no medial brow repositioning, and those
who are candidates for upper lid blepharoplasty.
Because I often combine this procedure with a full
facial rejuvenation, I prefer general anesthesia. How­
ever, it can be performed under local anesthesia. I al­
ways infiltrate the surgical field with a combination of
lidocaine and epinephrine. I prefer to do the lateral-tem­
poral browlift first and simulate the new brow position
to confirm the upper eyelid skin excision. Then I proceed
with the upper eyelid component.

237
Chapter 20 The Forehead Lift: Open and Endoscopic
The incision is placed coronally or horizontally or
anywhere in between, depending on the desired final
brow position. It is made and continued through the
temporoparietal fascia onto the deep temporal fascia.
The dissection can continue under endoscopic control,
or I prefer direct vision with the aid of a lighted retrac­
tor or an Aufricht retractor and headlight. The sentinel
vein is preserved. The septa and adhesions are released,
usually with the endoscopic dissector. To ensure com­
plete release of the lateral brow, I skeletonize the sen­
tinel vein. Dissection continues minimally beyond the
orbital rim and then laterally through the temporal crest
and into the subperiosteal space2 (Fig. 20D.12).
The temporal incision must be kept over the tem­
poralis muscle. This eliminates the risk of injury to the
lateral branch of the supraorbital nerve and ensures the
temporoparietal fascia can be anchored down to the
deep temporal fascia. Complete release of the lateral
orbital attachments, adhesions, and septa is essential
for the lateral brow to be successfully elevated.
Dissecting instruments should be kept firmly down
over the deep temporal fascia to prevent frontal branch
injury. Vertical spreading in the vicinity of the sentinel
vein should be avoided to minimize the risk of stretch
injuries to the frontal branch.
I then proceed with upper lid blepharoplasty and
glabellar muscle modification under loupe magnifica­
tion. The upper eyelid skin and muscle is excised and
marked. I prefer to the cutting current of the Colorado
tip needle. I leave the orbital septum intact. Any fat re­
moval is delayed until after the glabellar muscle is ex­
cised. Laterally, the dissection is continued along the
deep surface of the orbicularis. Once the communica­
tion between the eyelid and brow plane of dissection
has been established, I make a number of radial cuts
into the lateral orbicularis, weakening it temporarily to
prevent the downward pull of the orbicularis during the
early postoperative phase to maintain lateral brow posi­
tion. The surgeon must avoid removal of subcutaneous
fat when resecting the glabellar musculature.
Medially, the dissection approaches the supraorbital
rim. The orbicularis fibers running horizontally must be
divided to reach the diagonally running muscle fibers of
the corrugator supercilii muscle. The orbicularis muscle
is divided with the Colorado tip. This brings the corru­
gator muscle and a branch or two of the supratrochlear
nerve into view. I make every attempt to avoid the blood
vessels of these nerves. At completion, there should be
a significant gap in the muscle with preservation of the
supratrochlear and supraorbital branches. Theoretically,
dissection in the upper medial corner of the orbit may
injure the trochlear or superior oblique muscles, but such
injuries are rare and are easily prevented by limiting the
dissection behind the origin of the corrugator muscles.
The next step is brow fixation, in which the brow is ro­
tated upward and medially and the temporoparietal fas­
cia is anchored down to the deep temporal fascia.
Transpalpebral Excision of Corrugator and
Procerus Muscles
In combination with the lateral-temporal browlift, this
is my preferred choice for brow rejuvenation in pa­
tients requiring minimal or no medial brow elevation2
(Figs. 20D.13 and 20D.14). Lateral brow elevation is
performed through the lateral-temporal lift.
Fig. 20D.12 (a) Some of the septa and adhesions, especially beyond the vein, may require division with endoscopic scissors.
(b) Dissection continues minimally beyond the orbital rim and then laterally through the temporal crest and into the subperiosteal
space. (Reproduced from Nahai F. Endoscopic brow lift: the three-portal approach. In: Nahai F, ed. Art of Aesthetic Surgery Principles
and Technique. 2nd ed. St Louis: Quality Medical Publishing; 2011:740.)
Sentinel veins

SECTION IV AESTHETIC SURGERY
238
Fig. 20D.13 Transpalpebral excision. Modification of the glabel­
lar muscles through the upper eyelid results in improvement of
glabellar lines with minimal medial elevation of the brow. (Re­
produced from Nahai F. Endoscopic brow lift: the three-portal
approach. In: Nahai F, ed. Art of Aesthetic Surgery Principles
and Technique. 2nd ed. St Louis: Quality Medical Publishing;
2011:729.)
Fig. 20D.14 This patient with brow asymmetry, glabellar frown lines, and aging of the upper and lower lids underwent upper and
lower lid blepharoplasty with transpalpebral excision of the corrugator and division of procerus muscles. The postoperative and
split-face views at 1 month postoperatively show elimination of glabellar frown lines, improved asymmetry, and appropriate brow
position. (Reproduced from Nahai F. Endoscopic brow lift: the three-portal approach. In: Nahai F, ed. Art of Aesthetic Surgery Prin­
ciples and Technique. 2nd ed. St Louis: Quality Medical Publishing; 2011:729.)
Injection of Toxins
Toxin injections are the most popular method of brow
rejuvenation and are safe and effective for mild to mod­
erate brow elevation. Limitations include the tempo­
rary nature of the correction, the necessity for repeated
injections, and the expense of time.
Injectable toxins with combination transpalpebral
muscle modification or blepharoplasty has greatly re­
duced the number of endoscopic browlifts in my prac­
tice.
Unfavorable Results and
Complications
Infection and bleeding are rare. Alopecia may be seen
along the temporal incision line, but this occurrence
can be minimized by avoiding excessive tension in the
scalp closure and limiting the use of coagulating cur­
rent along the cut edges of the incision. Inadequate
lateral-temporal release may lead to relapse or recur­
rence of brow ptosis.
Alopecia is related to loss of hair roots as a result of
excessive tension with or without injury to hair roots.
It can occur with the coronal or endoscopic approach.
Heat injury to hair roots is reduced by limiting the use of
the Bovie device (Bovie Medical). Tension is somewhat
more difficult to control, especially with the coronal ap­
proach, which relies heavily on scalp excision for the
elevation and brow positioning. Excessive tension must
be avoided, and that is much more easily accomplished
with the endoscopic approach. Temporary paresis of the
frontal branch is reduced by avoiding excessive traction
on the endoscope in the vicinity of the sentinel vein.

239
Chapter 20 The Forehead Lift: Open and Endoscopic
True complications are rare; far more common are
unfavorable aesthetic results, namely undercorrection
or overcorrection of brow position or alteration of brow
shape.
Early in the endoscopic experience excessive eleva­
tion of the brow was a concern, especially the medial
brow, as shown in Fig. 20D.10. This was believed to be
a result of overzealous periosteal release in the glabel­
lar area. The problem was easily resolved by leaving the
periosteum intact in the glabella corresponding with the
medial hair-bearing brow. Although excess elevation was
noted by most surgeons, some abandoned the procedure
because they felt there was insufficient brow elevation,
especially of the lateral tail of the brow. Lack of lateral
brow elevation is likely related to insufficient release of
all the septae and adhesions above and lateral to the orbit.
The endoscopic approach has eliminated the coro­
nal lift from my practice. It had a profound effect on
our approach to browlifting. The emergence, safety,
and efficacy of toxin injections to elevate and shape the
brow had an even more profound effect. It was disrup­
tive, ushering in a nonsurgical option where there was
none. We witnessed a dramatic drop in the number of
surgical browlifts, and the number of injections of toxins
skyrocketed, bringing nonsurgeons and even nonphysi­
cians into the field of brow and facial rejuvenation. In­
jectables remain the most popular of all cosmetic treat­
ment, with toxin injections as the top procedure. Brow
rejuvenation with injectables is far more popular than
surgical intervention.10
Other surgical approaches have also been popular­
ized as alternatives to coronal and endoscopic proce­
dures.11 These include the temporal lift with or without
transpalpebral corrugator excision and direct browlift­
ing. Direct browlifting is very effective in raising and
shaping the brow, and if the incision is well placed it is
rarely noticeable; however, it does not address corruga­
tor or procerus activity. The combination of the tempo­
ral lift and corrugator excision through the upper eyelid
deals with both. This combined approach is my current
preferred approach for most of my patients undergoing
brow rejuvenation where medial brow elevation is not
needed.11 I limit the endoscopic approach for patients in
whom I wish to elevate the medial brow. I also firmly be­
lieve that elevation of the brow is only part of the spec­
trum of brow rejuvenation.
Conclusion
There are many options for brow rejuvenation. Merely
elevating the brow is no longer the end point; it must
be accompanied by maintaining or changing the brow
shape. Reshaping is as important if not even more im­
portant than elevation. Excessive elevation leads to an
unnatural, overdone look.
All the options available will elevate the brow. Re­
shaping requires planning and an understanding of the
muscle balances that result in brow shape. In my prac­
tice toxin injection is the most common procedure for
brow elevation and the most precise for brow shaping.
Surgically, in my practice, the combination of the lateral-
temporal lift and transpalpebral corrugator excision is
the most common procedure.
All described procedures for brow rejuvenation are
safe, effective with minimal scarring. True complica­
tions are rare, and most problems are aesthetic, related
to overcorrection or undercorrection of brow position
and alterations in brow shape.
References
1. Core GB, Vasconez LO, Askren C, et al. Coronal face
lift with endoscopic techniques. Plas Surg Forum
1992;15:227
2. Nahai F. Endoscopic brow lift: the three-portal ap­
proach. In: Nahai F, ed. Art of Aesthetic Surgery Prin­
ciples and Technique. 2nd ed. St. Louis: Quality Medi­
cal Publishing; 2011
3. Behmand RA, Guyuron B. Endoscopic forehead reju­
venation: II. Long-term results. Plast Reconstr Surg
2006;117(4):1137–1143, discussion 1144
4. Byrd HS, Burt JD. Achieving aesthetic balance in
the brow, eyelids, and midface. Plast Reconstr Surg
2002;110(3):926–933, discussion 934–939
5. Carruthers A, Carruthers J. Eyebrow height after bot­
ulinum toxin type A to the glabella. Dermatol Surg
2007;33(1 Spec No.):S26–S31
6. Farkas LG, Kolar JC. Anthropometrics and art in
the aesthetics of women’s faces. Clin Plast Surg
1987;14(4):599–616
7. Knize DM. Reassessment of the coronal incision and
subgaleal dissection for foreheadplasty. Plast Re­
constr Surg 1998;102(2):478–489, discussion 490–
492
8. Knize DM. Transpalpebral approach to the corrugator
supercilii and procerus muscles. Plast Reconstr Surg
1995;95(1):52–60, discussion 61–62
9. Tyers AG. Brow lift via the direct and trans-blepharo­
plasty approaches. Orbit 2006;25(4):261–265
10. Cosmetic Surgery National Data Bank Statistics. Aes­
thet Surg J 2016;36(Suppl 1):1–29
11. Nahai F. Art of Aesthetic Surgery: Principles and
Technique. 2nd ed. St. Louis: CRC Press; 2011

240
CHAPTER
21

Face and Neck Rejuvenation
James M. Stuzin
Surgical rejuvenation of the aging face is one of the most
challenging procedures facing plastic surgeons interested
in cosmetic surgery. The difficulties that the plastic surgeon
encounters include individual variations in facial shape;
variability in the quality of soft tissue; and the morphologic
changes that occur with aging, which are patient specific.
Skeletal support, the age of the patient, skin quality, the
degree of descent of facial fat, the descent of the cervical
platysma, and lipodystrophy of the face and neck all affect
treatment planning and the postoperative result. There is
no simple surgical algorithm in terms of technical approach
that provides for consistency in results.
Expectations are extremely high in most patients seek­
ing a facelift. Although repositioning facial fat and correct­
ing skin laxity will typically improve patient appearance,
surgical rejuvenation of the aging face is not the “fountain
of youth.” Patients will appear younger, but chronologic age
dominates morphologic improvement. In some patients this
leads to frustration, and in others the need for revision and
further surgery to improve undercorrection. An understand­
ing of the aesthetic ideal that is possible for a particular pa­
tient in terms of restoration of facial shape, in my opinion, is
the key to consistency in results. Improving contour, while
minimizing signs of surgical distortion, remains the main el­
ement in avoiding unfavorable results in facial rejuvenation.
Categorizing Unfavorable
Results and Complications in
Face and Neck Rejuvenation
Summary Box
Technical Errors
•• Incision design (pixie ear)
•• Inset of skin flap (hairline distortion)
•• Dissection of skin flap (overly thin or overly thick);
venous congestion
•• Facial nerve injury
Postoperative Care
•• Hematoma
•• Infection
•• Seroma
Unfavorable Results and Complications in Face and Neck Rejuvenation
Aesthetic Errors
•• Issues with skin tension (leading to hypertrophic
scarring and alopecia)
•• Improper vectoring of facial skin (leading to
misdirected, vertically oriented facial rhytides, as well
as a flat contour along the lateral cheek [cross-cheek
depression])
•• Over defatting of the neck
•• Inadequate volume restoration
•• Undercorrection
•• Limited longevity of results
•• Recurrent platysma bands

241
Chapter 21 Face and Neck Rejuvenation
rapid rate than the thicker facial skin. The most common
area to develop recurrent cervical skin laxity is the region
just cephalad to the sternal notch and clavicle. Recurrent
platysma bands also occur despite a properly performed
platysmaplasty.
Undercorrection and recurrent laxity are a source of
frustration for both surgeon and patient, and in some pa­
tients, revision surgery is necessary to correct recurrent
laxity.
Avoiding Unfavorable Results
and Complications in Face and
Neck Rejuvenation
Avoiding Technical Errors
Incision Planning
Perhaps nothing concerns patients more than the quality of
the access incisions used in facelifting. If the incisions are
improperly planned or poorly inset, scars may widen, the
tragus can appear distorted, and the earlobe can be pulled
anteriorly. The unfavorable result of a poorly planned op­
erative access incision is a noticeable scar, which is a telltale
sign that the patient has undergone a surgical procedure.
Surgical revision of poorly planned incisions typically im­
proves the result, but the best chance for a good quality im­
perceptible scar is at the initial procedure.
Preauricular incisions, which are designed anterior to
the tragus, offer the advantage of allowing for more skin
tension without disturbing tragal definition. The aesthetic
difficulty with preauricular incisions is that the color dif­
ferential between the skin of the cheek and the skin of the
ear tends to be more abrupt and therefore more visible in
an anterior location (Fig. 21.1)
Tragal incisions usually provide better camouflage, but
they can produce postoperative distortion of the tragus. To
avoid tragal distortion, the access incision needs to be de­
signed to provide a visible beginning along the cephalad bor­
der of the tragus, extend along the tragal margin, and then
provide for a visual ending of the tragus, preserving the in­
cisura along the caudal aesthetic unit of the cartilage (Video
21.1). Inset of the skin flap with minimal tension along the
aesthetic subunit of the tragus is a key element for consis­
tency in terms of scar perceptibility1,2 (Fig. 21.2)
Avoiding Pixie Ear
A pixie ear deformity occurs when excessive skin tension is
used, and the earlobe is pulled anteriorly. To avoid the pixie
ear deformity, it is often preferable to leave a small amount
of cheek skin, approximately 2 mm, attached to the earlobe
when designing the incision along the base of the earlobe.
This leaves a rim of cheek skin immediately inferior to the
Technical Errors
Technical errors in facelifting are unforgiving. Errors in an
incision design and inset of the skin flap can lead to visible
scarring. Errors in dissection of the skin flap can lead either
to overly thin flaps prone to venous congestion or overly
thick flaps that lead to a diminished utility for facial fat re­
positioning via a superficial muscular aponeurotic system
(SMAS) flap. Inadvertent dissection deep to the superficial
and deep fascia can lead to facial nerve injury. Improper
defatting of the neck and jowls can lead to contour irregu­
larities.
Meticulous postoperative care of the patient is another
factor in avoiding unfavorable results in facelifting. A post­
operative hematoma, if untreated, can lead to scarring and
delayed healing. Untreated infections can lead to skin slough.
Untreated seromas, most commonly noted in the neck, may
result in cervical irregularities. Postoperative complications
commonly lead to further revision surgery and often a dis­
satisfied patient.
Aesthetic Errors
Aesthetic errors in facelifting are perhaps more common
than technical errors. The most common aesthetic error is
the untoward use of skin tension, which can result in hyper­
trophic scarring and alopecia. Improper vectoring of facial
skin can lead to misdirected, vertically oriented facial rhyt­
ides, as well as a flat contour along the lateral cheek, which
aesthetically produces a tight unnatural facial appearance.
Vertical vectoring of facial skin in a patient with lateral cheek
deflation is also associated with the development of the
so-called “lateral sweep,” or more medially what has been
termed a cross-cheek depression, also known as a “joker line.”
Overdefatting of the neck through the untoward use of lipo­
suction can result in a harsh cervical appearance and accen­
tuate underlying cervical irregularities. Inadequate volume
restoration to correct deflation is typically noted in both the
perioral region and central cheeks and requires volumetric
enhancement as part of the original surgical procedure, as
well as maintenance treatment to maintain correction.
Undercorrection and Limited
Longevity of Result
Because of the variations in the quality of soft tissue among
patients, undercorrection in facial rejuvenation is common.
This is especially true in treating elderly patients (older
than 60 years) and patients with inelastic, sun-damaged
skin.1 Simply put, poor-quality soft tissue does not main­
tain the contour correction after intraoperative reposi­
tioning, leading to recurrence of laxity over time. Under­
correction is typically most evident along the jawline and
within the neck. Sun damage is more common in cervical
skin than facial skin, is thinner, and tends to relax at a more

SECTION IV AESTHETIC SURGERY
242
terior to the earlobe, so the earlobe hangs separate and de­
tached from the cheek skin. The earlobe should also be inset
approximately 15 to 20 degrees posterior to the axis of the
pinna, which provides for a more natural appearance and
prevents the pixie ear deformity1,2 (Fig. 21.3).
lobule that can be used for reattachment at the time of clo­
sure, allowing for the creation of a detached earlobe that is
separate from the cheek.
When inserting the earlobe, it is also important to re­
position approximately one centimeter of the skin flap pos­
Fig. 21.1 Preauricular incisions, which are placed within the pre­
auricular sulcus, avoid the tragus and prevent tragal distortion,
and therefore tolerate the use of greater skin tension during
flap inset. The disadvantage of preauricular incisions is that the
color difference between the blush skin of the cheek and the
pale skin of the ear is more noticeable in this anterior location.
Fig. 21.2 (a) Intratragal incisions should be designed to parallel
the descending visual width of the helix and establish a V-like
intratragal notch along the superior aspect of the aesthetic unit
of the tragus. The inferior limb of the intratragal incision should
preserve the incisura along the caudal extent of the tragus, such
that the rectangular shape of the tragus is preserved. A 2- to
3-mm cuff of cheek skin is left intact adjacent to the earlobe to
allow for the creation of a detached lobe after flap inset. (b) The
inset of the skin flap along the tragus needs to be precise, with
little or no tension during flap closure.
a
b
a
b
Fig. 21.3 (a) A pixie ear is a result of poor control of skin tension and is caused by insetting the earlobe along the longitudinal axis of the ear
or anterior to the axis of the pinna. Creation of an earlobe that is directly attached to the cheek skin typically is unaesthetic and a common
stigma associated with a facelift. To avoid the pixie ear deformity, the earlobe should be inset 15 to 20 degrees posterior to the longitudinal
axis of the pinna, and skin tension around the earlobe should be limited so the lobule is not pulled anteriorly. Advancing approximately 1
cm of skin posterior to the lobule allows the creation of a detached earlobe distinct from the cheek, which appears more natural. (b) Well-
designed tragal incisions often provide adequate scar perceptibility, appearing as a color difference between the blush skin of the cheek
and the pale skin of the ear rather than an obvious scar. This patient’s detached earlobe that lies posterior to the longitudinal axis of the
pinna has a natural appearance.

243
Chapter 21 Face and Neck Rejuvenation
line incisions, which are often unpopular in patients who
spend significant time outdoors, is to design the anterior
incision within the temporal hair and avoid vertical vectors
in skin flap redraping. My personal preference is to use ver­
tical vectors for facial fat repositioning via the SMAS rather
than more oblique repositioning of cheek skin, thereby
avoiding temporal sideburn elevation. Judicious use of ten­
sion limits the possibility of alopecia1,3 (Fig. 21.5, Video
21.2)
Avoiding Hairline Distortion
Both the temporal and postauricular hairline can be dis­
torted by facelift procedures. Temporal hairline distortion
and elevation of the sideburns typically result from vertical
skin flap redraping (Fig. 21.4). Surgeons who use a vertical
skin redraping, such as in short-scar facelifting, therefore
typically prefer to use a temporal hairline incision to avoid
elevation of the sideburn. An alternative to temporal hair­
a
b
Fig. 21.4 (a) Vertical skin flap redraping can elevate the temporal hairline and sideburn unless the temporal incision is placed anteriorly
along the temporal hairline. This patient has an unaesthetic elevated sideburn after a short-scar facelift with vertical skin flap redraping.
(b) Another example of temporal hairline distortion and widening of the temporal scar associated with vertical skin flap redraping and the
use of strong skin tension during skin flap inset.
Fig. 21.5 An alternative to vertical skin flap redraping is to vector facial fat vertically using the superficial muscular aponeurotic system
while using a more oblique vector for facial skin, which prevents vertical elevation of the sideburn. (Reproduced from Nahai F, ed. The Art
of Aesthetic Surgery, Principles and Techniques. 2nd ed. New York: Thieme Medical Publishers; 2011.)

SECTION IV AESTHETIC SURGERY
244
robust and thick. Overly wide dissection of the skin flaps,
especially in thin patients, can lead to venous congestion
and should be avoided if possible. If the skin flap appears
to be overly thin with little subcutaneous fat, it is perhaps
best to limit the dissection within the lateral cheek rather
than to risk wide undermining and subsequent skin flap
ischemia.
I find the most helpful method for precisely performing
accurate subcutaneous undermining is the use of transillu­
mination and skin flap dissection performed under direct vi­
sion (Fig. 21.7). When dissecting the skin flap in the subcu­
taneous plane, the terminal fibers of the retaining ligaments
that compartmentalize subcutaneous fat will be encoun­
tered. Typically, the dissection in the preauricular region is
fibrous and vascular dissection is performed within the fi­
brous lateral fat compartment. Approximately 4 cm anterior
to the preauricular incision, the dissection will become less
fibrous, and a thicker skin flap will be more easily dissected
as the surgeon operates within the middle fat compartment.
For subcutaneous undermining, I prefer to dissect thick skin
Postauricular hairline shifts can occur if the incisions
are not properly planned. In general, I prefer to use partial
hairline incisions in the postauricular region to avoid stair-
stepping of the postauricular hairline. After cervical skin flap
redraping, most of the cervical skin excision occurs within
the hairless superior aspects of the incision, whereas the in­
ferior hairline is realigned to avoid stair-stepping. Obviously,
the avoidance of excess of skin tension to produce a fine line
scar is critical so patients can wear their hair up without fear
of a noticeable scar (Fig. 21.6).
Avoiding Technical Errors in Dissection
of the Cheek
Perhaps one of the most difficult technical aspects of per­
forming a facelift is accurate subcutaneous undermining
of the cheek. Because of the variations in terms of facial
subcutaneous fat thickness among patients, in some the
skin flap will be quite thin, whereas in others, it will be
Fig. 21.6 Postauricular incisions are typically planned as partial hairline incisions; the superior limb is designed along the hairline to allow
removal of non–hair-bearing skin and inferiorly extends into the occipital hair. Partial hairline incisions provide for cervical skin removal
while preventing stair-stepping of the postauricular hairline. Control of skin tension is an important aspect of limiting scar perceptibility.
Fig. 21.7 Transillumination is a useful technique that allows for precise
skin flap dissection. To perform transillumination, a light (such as the
contralateral operating room light) is placed on the opposite side of
the patient from the surgeon and is directed through the skin flap to
illuminate the interface between the subcutaneous fat and the super­
ficial muscular aponeurotic system. This allows the surgeon to operate
under direct vision and dissect precise skin flaps.

245
Chapter 21 Face and Neck Rejuvenation
In terms of elevation of the SMAS flap, one useful ele­
ment to provide safety in SMAS dissection is to dissect di­
rectly along the posterior surface of the superficial fascia
and leave the subSMAS fat intact along the underlying deep
facial fascia. Dissecting along the undersurface of the SMAS
and not within the subSMAS fat provides greater soft tissue
protection for the underlying facial nerve branches and de­
creases the risk of motor branch injury.
The most dangerous region for nerve injury during an
extended SMAS dissection is directly inferior and lateral to
the zygomatic eminence when releasing the upper masse­
teric ligaments. Similar to the cutaneous plane, the zygo­
matic branches are in close proximity in this region, and
careful dissection just along the undersurface of the SMAS
is essential in preventing zygomatic nerve injury in this
area. Once the dissection is carried anteriorly into the mo­
bile region of the SMAS, anterior to the retaining ligaments,
the dissection should be terminated, because facial nerve
branches become more superficial in this location. Further
dissection anteriorly within the mobile area of the cheek
increases potential morbidity without recruiting greater
movement of the SMAS and is not necessary to obtain ad­
equate SMAS mobilization5 (Fig. 21.10).
Minimizing Postoperative
Complications
Hematoma
Hematoma is the most common postoperative complication
after a facelift (approximately 70% of all complications).6 The
range of hematoma formation is between 1 and 8% in most
flaps in the middle compartment, dissecting caudally along
the interface between the subcutaneous fat and SMAS to
preserve flap thickness and vascularity. Superiorly, in the
region along the zygomatic arch and malar eminence, where
the SMAS is going to be dissected, I prefer to dissect thin skin
flaps, leaving the subcutaneous fat intact overlying the SMAS
flap. Differential thickness in subcutaneous cheek dissection
helps to preserve vascularity of the skin flap while allowing
the extended SMAS flap to be raised with sufficient thick­
ness to avoid tearing during dissection4 (Fig. 21.8).
Avoiding Facial Nerve Injury
The most important point in avoiding facial nerve injury
in a facelift is to understand the plane of dissection and
recognize the danger zones during specific regions of the
procedure. In general, if the subcutaneous dissection is car­
ried superficial to the SMAS, motor branch injury will be
prevented. Similarly, in dissecting an SMAS flap, dissecting
in the interface between superficial and deep fascia, and
avoiding dissection deep to the deep fascia, will protect the
underlying facial nerve branches.
The most common danger zone in dissecting subcutane­
ous fat of the cheek is in the region directly inferior and lat­
eral to the zygomatic eminence where the upper masseteric
ligaments are encountered. This tends to be a fibrous area of
dissection, and the underlying zygomatic nerve branches are
superficially positioned directly deep to the SMAS in this lo­
cation. When encountering this fibrous region of dissection
inferior to the zygomatic eminence, it is helpful to recognize
that this is a danger zone and dissect this area carefully, en­
suring that the dissection is subcutaneous and not subSMAS
in this specific location (Fig. 21.9; see also Fig. 21.8).
Fig. 21.8 Facial subcutaneous fat is divided into a series of fibrous compartments. The initial subcutaneous dissection begins within the
lateral compartment. Most of the dissection in the cheek is within the middle compartment, which is thicker and easier to dissect (stained
blue). When the fibrous zygomatic ligaments are encountered lateral to the malar eminence (large red arrow), care is required to prevent
dissecting deep to the superficial muscular aponeurotic system, because the zygomatic branches of the facial nerve are superficial in this
location. (Reproduced from Rohrich R, Pessa J. The fat compartments of the face: anatomy and clinical applications. Plast Reconstr Surg
2007;119:2219–2297.)

SECTION IV AESTHETIC SURGERY
246
Fig. 21.9 A cadaver dissection of the facial nerve branches. During subcutaneous dissection, two danger zones, where the facial nerve is
superficially positioned just beneath the superficial muscular aponeurotic system (SMAS), are located along the superior and inferior bor­
der of the masseter associated with the upper and lower masseteric ligaments. Dissection deep to the SMAS in these regions can lead to
injury of either the zygomatic or cervical branches of the facial nerve. (This dissection and image are provided courtesy of Dr. Julia Terzis.)
Fig. 21.10 (a) In an extended superficial muscular aponeurotic system (SMAS) dissection, to liberate the SMAS from the restraints of the
retaining ligaments, the SMAS is dissected from the parotid, the accessory lobe of the parotid, the lateral zygomatic ligaments, and the
upper masseteric ligaments. Dissecting in the interface between the undersurface of the SMAS and the subSMAS fat (leaving the subSMAS
fat down on the parotid capsule and deep fascia) provides safety in terms of prevention of facial nerve injury. (b) This intraoperative photo­
graph shows the upper masseteric ligament (forceps) dissected at the termination of SMAS elevation, because just distal to this ligament
the zygomatic branches course superficially. (Reproduced 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.)
a
b

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Chapter 21 Face and Neck Rejuvenation
If a seroma does develop after drain removal, I see the
patient daily and monitor the seroma with serial aspiration.
In larger seromas (greater than 5 mL), I typically place a se­
roma catheter and leave it in place for 1 to 2 days until the
cervical skin is adherent.
Infection
Infection is rare in facelift patients, and it is most com­
monly secondary to Staphylococcus.6,7 Prophylactic antibi­
otics are helpful in minimizing this problem.
An increasingly common type of Staphylococcus coag­
ulase-negative infection is being noted in facelift patients
around the country.6,7 I believe this largely has to do with
the evolving microbiology and antibiotic resistance of Staph­
ylococcus epidermidis to cephalosporins. Patients who de­
velop coagulase-negative Staphylococcus infections typically
present on day 3 postoperatively with small impetigo-type
milia lesions in regions of venous congestion of the skin flap.
If recognized, these patients should have the milia lesions
evacuated and begin using topical antibiotic ointment. Daily
administration of antibiotics with action against Staphylo­
coccus (such as intravenous vancomycin) is important in
preventing the progression of an S. epidermidis infection to
cellulitis and flap necrosis (Fig. 21.11).
If the condition is recognized early, typically 3 to 5 days
of antibiotic treatment is all that is required. If the infection
is allowed to proceed unabated to progressive cellulitis and
purulence beneath the skin flaps, an invasive infection may
develop and require hospitalization.
The key to avoiding facelift infections is to see the pa­
tient on a regular basis and, if any signs of erythema or in­
fection develop, to proceed aggressively, before skin ery­
thema progresses to cellulitis.
series, and males have a higher incidence of hematoma for­
mation compared with females.6
Although it is impossible to completely eliminate this
postoperative complication, most authors have noted that
the incidence of hematoma formation decreases with blood
pressure maintenance. Many surgeons have noted that de­
creasing systolic blood pressure below 150 mm Hg both in­
traoperatively and postoperatively is important,6 and in my
practice we try to keep the systolic blood pressure below
120 mm Hg in the recovery room. Patients who take an­
tihypertensive medication preoperatively should maintain
their medication regimen both preoperatively and postop­
eratively. Another important factor in limiting hematoma
formation is to be proactive in preventing nausea and vom­
iting. Judicious use of narcotics to prevent nausea is simi­
larly prudent.
Hemostasis
Although it seems obvious, perhaps one of the most impor­
tant factors in avoiding a hematoma is the time spent in­
traoperatively performing hemostasis. I prefer to allow the
epinephrine to wear off before closure and meticulously
perform electrocautery hemostasis of all areas dissected.
Although this is a tedious operative procedure, it typically
pays dividends. In general, a very dry intraoperative field
leads to a very low hematoma rate postoperatively.
Patient Comfort
Patients who are relaxed and comfortable in the postopera­
tive period typically have a more uneventful postoperative
recovery. The use of antianxiety medication is often help­
ful in the early postoperative period, and these are typi­
cally not associated with nausea or vomiting. Most facelift
patients do not have a significant amount of pain, and we
have found that antianxiety medication is often helpful in
providing comfort to the patient without any of the side
effects associated with opiates.
Seroma
Seroma formation is most common in the cervical region,
which typically heals slower than the face. Seroma forma­
tion is not only a nuisance to the patient, because it com­
monly requires serial aspiration, but it often leads to an
untoward result that includes wrinkling and induration of
sun-damaged cervical skin. Patients who develop seromas
of the neck may require later surgical revision.
Drains and tissue adhesives are useful in decreasing se­
roma formation. I favor drains, and I tend to leave drains in
the cervical region in place for longer periods, often for 3 to
5 days. In terms of removing the drains, I am not necessarily
guided by the amount of output, but rather leave the drains
until the cervical skin is totally adherent to the underlying
platysma muscle. I have found that tissue adherence rather
than drain output is the best guide for seroma prevention.
Fig. 21.11 Three days postoperatively, this patient is showing signs
of early onset of Staphylococcus epidermidis cellulitis. This erythema
and the small white impetigo-like lesions of the cheek are apparent
early in this type of infection. Although this infection initially appears
benign, it can progress rapidly if antibiotic therapy specific for an S.
epidermidis infection is not instituted.

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Managing Unfavorable Results
and Complications
Avoiding Unfavorable Aesthetic Effects
of Vertical Skin Redraping
One of the most common stigmas associated with facial
rejuvenation results from vertical skin redraping. In an at­
tempt to tighten the loose face, the surgeon overly tightens
the skin envelope, producing a tight, unnatural appearance
to the facial morphology. As discussed previously, vertical
skin redraping can be associated with distortion of the tem­
poral hairline and, if used, requires a temporal incision to
prevent hairline distortion. The aesthetic consequence of
vertical skin redraping is often an accentuation of flatness
in the contour of the preauricular and lateral cheek, which
is an area that typically deflates with age. Overly shifting
the skin flap vertically, accentuating deflation in an area
that is already deflated, tends to cause the cheek to appear
tight and unnatural (Fig. 21.12).
Another consequence of vertical skin redraping is the
development of misdirected rhytides, lateral sweeps, and
cross-cheek depressions. Lateral sweeps tend to be a conse­
quence of vertical skin flap redraping accentuating an area
of flatness lateral to the zygomatic eminence. In patients
Facial Nerve Injuries
Facial nerve injuries are fortunately quite rare in facelift­
ing.6,8,9 The most commonly injured facial nerve is the
cervical branch, which can be injured either during lateral
SMAS elevation or when dissecting within the superficial
platysma muscle during cervical defatting. A useful method
to differentiate a cervical branch from a marginal branch
injury is to have the patient pucker the lips, because the
orbicularis oris and mentalis muscles remain innervated by
the marginal branch. A unilateral weak full denture smile
in a patient who is able to purse the lips is typical with a
cervical branch injury.
Management of Facial Branch Injuries
Management of a cervical branch injury is straightforward,
and the contralateral depressor anguli oris should be weak­
ened with 2.5 to 5 units of botulinum toxin to provide lip
symmetry while the patient recovers. Recovery typically
occurs in 4 to 6 weeks.
Injury to other nerve branches should be managed with
observation. Most nerve branch injuries heal anywhere be­
tween 2 and 6 months postoperatively. Again, neuromodu­
lators to the contralateral side to provide symmetry with
animation are often useful to aid in postoperative recovery.
Fig. 21.12 One of the consequences of vertical skin redraping is the tendency to accentuate flatness within the lateral cheek, a region that
typically deflates with age. Although vertical skin redraping will often improve laxity along the jawline, the accentuation of flatness in the
lateral cheek associated with a vertical skin vector can impart a tight unnatural appearance to cheek morphology, signifying that the pa­
tient has undergone a surgical procedure.

249
Chapter 21 Face and Neck Rejuvenation
sweeps. Similarly, repositioning of facial fat through SMAS
plication or SMAS dissection within the lateral cheek helps
to improve deflation in this region, which mitigates against
an accentuation of preauricular flatness (Fig. 21.15). Finally,
in patients with a tendency toward submalar deflation, the
use of volume addition injected into the submalar area in
conjunction with lateral vectoring of the skin flaps will mit­
igate against development of cross-cheek depression and
prevent the appearance that the oral commissure has been
pulled laterally into the cheek10 (Fig. 21.16).
with strong malar projection and significant deflation in the
submalar area, vertical skin shift accentuates not only pre­
auricular deflation, but also deflation in the submalar re­
gion, which visually creates the illusion that the corner of
the mouth extends into the cheek, producing the so-called
joker line (Figs. 21.13 and 21.14).
It is possible to avoid the stigma of both lateral sweeps
and cross-cheek depressions if the surgeon recognizes this
tendency preoperatively. Avoidance of vertical redraping
of the skin flap tends to mitigate the occurrence of lateral
Fig. 21.13 Sun-damaged skin with facial wrinkles poorly tolerates
vector errors of skin flap redraping. In this patient the rhytides are
being pulled upward after vertical skin flap redraping.
Fig. 21.15 (a) This 70-year-old patient who underwent a previous facelift is seen with several stigma associated with a surgical appearance,
including misdirected vertically oriented rhytides, a lateral sweep noted in the preauricular region, and a mild cross-cheek depression lateral
to the oral commissure. (b) After superficial muscular aponeurotic system repositioning of facial fat toward the lateral cheek, the lateral de­
flation is corrected and the appearance of the sweep improved. In addition, 3 cc of autologous fat was injected into the submalar region to
correct the cross-cheek depression and serves as a visual barrier to prevent the illusion of the oral commissure being pulled into the cheek.
a
b
Fig. 21.14 Lateral sweeps and cross-cheek depressions are a conse­
quence of vertical skin flap redraping, which accentuates deflation
of the lateral cheek and submalar region, producing unnatural con­
tour and the appearance that the lateral commissure has been pulled
into the cheek. The surgical appearance of flatness accentuated by
vertical skin shift is typically juxtaposed to strong malar projection,
which causes the sweeps and depressions to appear more obvious.

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the mastoid fascia, and the excess postauricular skin excised.
Most patients have minimal morbidity associated with this
small procedure, and typically the efficacy of this simple
revision leads to a satisfied patient with minimal recovery.
I would stress that this limited tightening of cervical skin is
useful as a secondary procedure, especially in a patient who
had a platysmaplasty in the original procedure, but usually
is not particularly effective to restore cervical contour in pri­
mary patients.
Recurrent Platysma Bands
Despite all efforts, the recurrence of platysma banding to
some degree after platysmaplasty is common, and perhaps
develops in 10 to 20 percent of patients. The etiology of re­
current bands is multifactorial, depending on the type of
platysmaplasty performed, the degree of platysma release
performed via transection, the tensile quality of the muscle
being sutured, and the effects of reinnervation and reani­
mation of the anterior platysma over time.
Recurrent banding is difficult to completely address. In
many cases, simply approaching the platysma laterally via a
postauricular incision followed by reelevation of the lateral
platysma from its attachments to the sternocleidomastoid as
a “platysma window” procedure will improve contour along
the anterior neck.
In severe cases, there is no alternative except to approach
the neck anteriorly by reopening the submental incision, fol­
lowed by a through-and-through dissection of the neck. In
performing a secondary platysmaplasty, cervical dissection
is technically difficult, because it requires a reelevation of
a scarred cervical skin flap from the underlying platysma.
Because of the previous cervical lipectomy and generally
thin cervical skin flaps, as well as the need to resuture the
anterior muscle, contour irregularities in the neck after this
procedure are not uncommon. Reoperative platysmaplasty
is often associated with a longer postoperative recovery, in­
cluding induration and tightness in the neck. Lateral plication
alone has much less morbidity but is followed by a higher
degree of undercorrection and recurrent banding.
Performing a platysmaplasty as accurately as possible
during the primary procedure is the best method to avoid
unfavorable results in the neck. If the platysmaplasty is ac­
curately performed, typically postoperative undercorrection
can be managed with lateral platysma plication or a lateral
platysma window. The greater degree of improvement as­
sociated with reapproaching the platysma anteriorly versus
what can be obtained with a lateral plication in the second­
ary procedure needs to be discussed with the patient, be­
cause reoperation anteriorly may be associated with addi­
tional morbidity. Despite all efforts, even with reoperative
platysmaplasty, bands may reoccur.11
A perfect solution for maintenance of cervical contour­
ing is elusive, but typically a combination of a properly per­
formed primary platysmaplasty and, if required, a limited
secondary cervical tightening satisfies most patients.
Undercorrection
Improving Laxity
A “perfect facelift” does not exist. Most surgical procedures
can reverse the biologic changes that occur with aging. Pa­
tients look younger, but not truly young. Not every wrinkle
is effaced; not all facial laxity is corrected. Despite a “per­
fect” correction of shape intraoperatively, the quality of the
patient’s soft tissue often does not cooperate, and intraop­
erative correction is followed by postoperative undercor­
rection.
Poor quality of soft tissue is a consequence of advanced
age. Undercorrection is most commonly noted in the neck,
because inelastic, sun-damaged skin often becomes some­
what loose over time. This is especially noted lower in the
neck in the supraclavicular region, which is the region of
cervical skin furthest from the postauricular incision. The
skin is furthest from the postauricular incision lacks the me­
chanical advantage to maintain the effects of intraoperative
redraping and skin tightening and in some patients loosens
over time.
The treatment of recurrent skin laxity in the neck is usu­
ally simple, and it will typically respond favorably to a small
surgical revision 9 months to 1 year postoperatively. At that
time, the patient is returned to the operating room, and the
previously placed postauricular incision is reincised (Video
21.3). Postauricular skin dissection is performed just ante­
rior to the sternocleidomastoid to release the cervical skin
from the retaining ligaments in the posterior region of the
neck. The lateral border of the platysma may be plicated to
Fig. 21.16 Preoperative recognition of patients with a tendency to­
ward cross-cheek depressions is paramount to prevent their occur­
rence. The patient shown here demonstrates strong malar projec­
tion associated with significant submalar deflation and a tendency
to develop a cross-cheek depression if this area is not augmented
during surgery. The addition of 2 to 4 cc of autologous fat into the
submalar region in conjunction with the facelift will prevent the oc­
currence of a postoperative joker line and allow a better aesthetic
blend between the malar and submalar regions as well as the jowl
and jawline. Limited use of vertical skin redraping is another impor­
tant component in preventing accentuation of submalar deflation
in these patients.

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Chapter 21 Face and Neck Rejuvenation
Volume addition with autologous fat requires mainte­
nance. I prefer not to overcorrect when performing fat in­
jection during the primary procedure, but rather return the
patient to the operating room approximately 3 to 6 months
postoperatively to perform a secondary fat injection. Al­
though undercorrection may masquerade as facial laxity, it
often represents undercorrection of deflation, and second­
ary volume augmentation provides a nonsurgical solution
for restoration of shape in many patients.
Conclusion
Because no facelift is “perfect,” an acceptance of imperfec­
tion by both the surgeon and patient is a component for
successfully approaching surgical rejuvenation of the aging
face. To achieve a favorable result, the pursuit of perfection
is mandatory in terms of aesthetic analysis, precise opera­
tive execution, and postoperative care. Although true per­
fection is not obtainable, a “perfect” intraoperative result
usually leads to a favorable postoperative outcome. The
surgeon must remember that no aesthetic procedure toler­
ates complications as poorly as a facelift, and the avoidance
of both aesthetic and technical errors remains as important
as the pursuit of a perfect result. As in many aesthetic pro­
cedures, secondary revisions to correct “imperfections” is a
component for a successful practice, and in the final analy­
sis, a satisfied patient remains the primary goal for favor­
able results in facial rejuvenation.
Undercorrection of Deflation
Facial deflation is synonymous with facial aging and is
present in virtually all patients seeking facial rejuvenation.
Facial deflation occurs in specific regions of the face with
age and tends to be specific to facial fat compartments over
time.
In most patients, lateral cheek deflation occurs in the
fourth decade of life, whereas superficial and deep malar
deflation is noted during the fifth decade. Perioral deflation
becomes evident in most patients in their 40s and acceler­
ates in older patients.
There are two methods to correct facial deflation. Typi­
cally, lateral cheek deflation is corrected during the surgical
procedure through facial fat repositioning using the SMAS.
Perioral and deep malar deflation requires volumetric aug­
mentation. Most surgeons who incorporate volume addi­
tion into their facelift technique use autologous fat. In a re­
cent survey of American Society for Aesthetic Plastic Surgery
(ASAPS) members, 85% of surgeons in the United States use
volume addition in conjunction with surgical repositioning,
and the most common regions augmented during the face­
lift are the deep malar compartment and the perioral re­
gion. Combining surgical repositioning with autologous fat
transfer allows the surgeon to not only correct deflation, but
improve facial shape, both of which have a positive influence
on postoperative appearance12 (Fig. 21.17).
Fig. 21.17 Autologous fat injection to correct deflation is typically part of any facelift procedure. In this patient volume was added to both
the perioral and deep malar regions, providing for a more complete correction of deflation and a restoration of facial shape.

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8. Stuzin JM. Discussion essays on the microanatomy of the
facial nerve. Plast Reconstr Surg 2010;125(3):890–892
9. Roostaeian J, Rohrich RJ, Stuzin JM. Anatomical consider­
ations to prevent facial nerve injury. Plast Reconstr Surg
2015;135(5):1318–1327
10. Lambros V, Stuzin JM. The cross-cheek depression: surgi­
cal cause and effect in the development of the “joker line”
and its treatment. Plast Reconstr Surg 2008;122(5):1543–
1552
11. Stuzin J. Discussion. Modified deep plane rhytidectomy
with a lateral approach to the neck: an alternative to
submental incision and dissection. Plast Reconstr Surg
2011;127(1):371–373
12. Sinno S, Mehta K, Simmons C, Stuzin JM. Current trends
in facial rejuvenation: an assessment of ASPS members
utilization of fat grafting during facelifting. Plast Reconstr
Surg 2015;136(4, Suppl)141
References
1. Baker TJ, Gordon HL, Stuzin JM. Surgical Rejuvenation of
the Face, 2nd ed. St. Louis: Mosby; 1996
2. Marten TJ. Lamellar high SMAS face and mid-face lift.
In: F. Nahai, ed. The Art of Aesthetic Surgery, Principles
and Techniques. St. Louis: Quality Medical Publishing;
2005:1110–1193
3. Nahai F, ed. The Art of Aesthetic Surgery, Principles and
Techniques, 2nd ed. New York: Thieme Publishing; 2011
4. Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg 2007;119(7):2219–2227, discussion
2228–2231
5. 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(1):290–301
6. Stuzin JM. MOC-PSSM CME article: face lifting. Plast Re­
constr Surg 2008;121(1, Suppl)1–19
7. Dauwe P, Stuzin J, Rohrich J. Infections in facelifting. Plast
Reconstr Surg 2016
Discussion by Timothy J. Marten
The increased number of patients seeking facelifts at a
younger age, coupled with the continued good health
of an older group of patients who have already under­
gone one or more procedures, has resulted in a sig­
nificant increase in requests for secondary and tertiary
procedures.
Although many aspects of planning and performing
secondary surgery are similar to those of the primary
procedure, additional considerations must be taken into
account in the evaluation and treatment of a patient pre­
senting for secondary facelift, because the surgeon must
identify and treat not only new problems that are the
product of age, but those that have resulted from any
prior procedure as well. Often, it is these secondary ir­
regularities that present the biggest challenge to the sur­
geon in terms of creativity, planning, preparation, and
technique. A problem-focused approach emphasizing
the causes and the avoidance of commonly seen second­
ary facelift irregularities is particularly pragmatic and is
worth every surgeon’s consideration, because secondary
irregularities exist as compelling reminders of mistakes
to avoid in the planning and performance of any pri­
mary procedure.
Secondary Facelifts
Patients requesting secondary facelifts present with is­
sues related not only to ongoing aging but problems that
were present but not corrected when they presented
for their primary procedures. This is particularly true
if the primary facelift was limited and consisted of skin
excision and skin tightening only. In such instances, a
tight or pulled appearance will typically be present, but
problems of deep layer origin will still be seen. Regret­
tably, many surgeons have been traditionally taught to
perform a limited “tuck” or “touch-up” in secondary
procedures consisting of additional skin excision and
skin tightening. This does not address the true under­
lying problems, however, and predictably compounds
the secondary irregularities present in many patients.
Using the superficial muscular aponeurotic system
(SMAS) to lift sagging facial tissues and restore facial
contour circumvents the problems associated with skin-
only facelifts that have perplexed plastic surgeons since
that procedure’s inception, because it is a rigid aponeu­
rotic structural layer capable of providing meaningful
and sustained deep-layer support and eliminating skin

253
Chapter 21 Face and Neck Rejuvenation
tension. Although there is no scientific consensus on
how to best use the SMAS, experienced surgeons have
come to acknowledge that some manipulation of the
SMAS and platysma is needed if a natural appearance
and sustained improvement free from secondary irreg­
ularities is to be achieved. Although skin is excised in
SMAS procedures, only redundant tissue is sacrificed,
and closure can be made under normal skin tension.
This “two-layer” strategy has ushered in a new era of
improved outcomes that were previously unobtainable
and form the foundation of the modern facelift proce­
dure (Fig. 21D.1).
Lamellar dissections, in which the skin and SMAS are
dissected as two separate layers, offer the important ad­
vantage that skin and SMAS can be advanced in different
amounts, along separate vectors, and suspended under
differential tension (Fig. 21D.2). This allows each layer
to be addressed individually as indicated and, in turn,
results in a more comprehensive and natural-appearing
improvement. It is a critical concept for avoiding over­
shifting of facial skin, neck-to-face “wrinkle shift,” and
related problems (as discussed in the chapter).
A secondary facelift will generally require a com­
paratively small resection of skin compared with the
primary facelift and requires an increased focus on cor­
recting secondary irregularities, addressing residual
deep layer problems, and restoring lost facial volume—
depending on the skill of the surgeon performing the
primary procedure and the type of technique used. In
many cases the secondary “facelift” is performed largely
to clean up secondary irregularities and correct deep
layer problems not addressed at the primary procedure,
Fig. 21D.1 A traditional skin-only facelift versus a high superficial muscular aponeurotic system (SMAS) facelift. (a) This 57-year-old
patient was seen after a conventional one-layer skin-only facelift was performed by an unknown surgeon. She had residual uncor­
rected tissue ptosis seen as a low lid–cheek junction, a ptotic cheek, poor posture of the mouth, and jowl formation. A preauricu­
lar scar is visible, confirming she has had a previous facelift. (b) Twelve months after a secondary facial rejuvenation that included
a high SMAS facelift, neck lift, and forehead lift. No fat grafting was performed. A youthful facial contour has been restored, and
the patient has a soft, natural, “nonsurgical” appearance with well-concealed scars. (These images are provided courtesy of the
Marten Clinic of Plastic Surgery.)
a
b
Fig. 21D.2 In a lamellar dissection, the skin and superficial
muscular aponeurotic system (SMAS) are dissected as two
separate layers, and the SMAS can be advanced in different
amounts, along separate vectors, and suspended under dif­
ferential tension. This allows each layer to be addressed indi­
vidually as indicated and, in turn, results in a more compre­
hensive and natural-appearing improvement. (This image is
provided courtesy of the Marten Clinic of Plastic Surgery.)

SECTION IV AESTHETIC SURGERY
254
and fat grafting will provide most of the improvement
(see Fig. 21D.4 later in this Discussion and accompany­
ing text).
Facial Atrophy
Traditionally, the aging face has been thought of and
defined in terms of tissue relaxation and surface wrin­
kling, but more recently surgeons have come to appre­
ciate atrophy as integral parts of the aging process and
the hallmark of an aged appearance. A careful examina­
tion of patients presenting for secondary facelift rein­
forces this assertion and reveals that simply smoothing
wrinkles and lifting sagging tissues will fall short of
truly rejuvenating the face in most cases.
Atrophy is usually most profound and most easily ob­
served around the orbits, upper midface, and infraorbital
and perioral areas but can be seen on close inspection in
many patients to be additionally present in the forehead,
brow, temple, cheek, jawline, chin, and neck areas. At­
rophy is not corrected by traditional facelift procedures
and is usually incompletely or poorly corrected by tradi­
tionally used facial implants. These procedures may even
exacerbate the problem and result in an arguably more
unnatural, hard, and objectionable appearance.
Correction of facial atrophy requires the addition of
volume to the face—not a subtraction, lifting, tighten­
ing, or skeletal enhancement—and a rethinking of the
traditionally taught approach to rejuvenation of the face.
Unlike problems corrected by a lift of the face, correction
of atrophy requires the surgeon to use techniques that
fill and sculpt the face, and to think in three, instead of
just two, dimensions (Fig. 21D.3).
Currently, the most effective and natural correction
of facial atrophy is best achieved through fat grafting.
When properly performed, fat grafting produces soft
and natural contours unobtainable by any other means
and offers the opportunity to correct problems tradi­
tional surgery cannot (Fig. 21D.4).
Under-Rejuvenated Neck
It is not enough to limit treatment of the neck to pre­
platysmal lipectomy and postauricular skin excision
in secondary facelift patients. These maneuvers were
typically performed overly aggressively at the primary
procedure and offer little benefit to a patient seeking
secondary surgery. For many patients seeking second­
ary surgery, subplatysmal fat accumulation, subman­
dibular salivary gland “ptosis,” and digastric muscle hy­
pertrophy will instead contribute most significantly to
their neck deformity, and “deep layer” maneuvers are
required if the true anatomic basis of their problems
are to be addressed.
Subplatysmal Fat Excess
Cervical fat is found in three layers in the neck:
1. Subcutaneous
2. Subplatysmal
3. Deep cervicosubmental (interdigastric fat)
Fig. 21D.3 Combined facelift and fat grafting. Correction of facial atrophy requires the addition of volume to the face, not a sub­
traction, lifting, or tightening, and a rethinking of the traditionally taught approach to rejuvenation of the face. (a) This 47-year-old
patient had no prior surgery. (b) The surgical plan for fat grafting showing areas to be treated. (c) Thirteen months postoperatively
after a high superficial muscular aponeurotic system facelift, forehead lift, neck lift, upper blepharoplasty (levator reinsertion),
lower canthoblepharoplasty, upper lip lift, and injection of 38 cc of autologous fat. She has achieved a soft, natural appearance
unobtainable by facelift alone. (These images are provided courtesy of the Marten Clinic of Plastic Surgery.)
a
b
c

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Chapter 21 Face and Neck Rejuvenation
Fig. 21D.4 Combined facelift and fat grafting. Preoperatively (left), this 75-year-old woman had undergone multiple prior face­
lifts and related procedures, including previous laser resurfacing performed by unknown plastic surgeons. She had marked cheek
laxity despite prior surgeries and a fragile, elderly appearance because of uncorrected panfacial atrophy. Another facelift would
predictably produce a gaunt, haggard, or even ill appearance. The postoperative images (right) were taken 19 months after high
superficial muscular aponeurotic system facelift, neck lift, forehead lift, upper and lower eye lifts, canthopexy, and fat transfer to
the temples, cheeks, midface, upper and lower eyelids, lips, nasolabial creases, stomal angles, geniomandibular grooves, chin,
and jaw line. A total of 90 cc of fat was placed simultaneously with the facelift and related procedures. No skin resurfacing, facial
implants, or other ancillary procedures were performed. In these situations fat injections are arguably more important to the over­
all outcome than the facelift itself. Her facial contour has been significantly enhanced, and facial volume has been restored. The
patient has a healthy, fit, feminine, and natural appearance, one that could not be obtained by either procedure performed alone.
(These images are provided courtesy of the Marten Clinic of Plastic Surgery.)

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256
Although the focus has traditionally been on the sub­
cutaneous layer, the secret to obtaining optimal neck
contour is the subplatysmal layer. An adequate layer of
subcutaneous fat is essential to a soft, youthful appear­
ance, and typically patients presenting for secondary
surgery have had their subcutaneous layer overtreated.
Additional liposuction or subcutaneous fat excision by
other means is as such conceptually illogical and com­
pounds existing problems.
A careful evaluation of a secondary facelift patient will
show that any residual neck fullness attributable to resid­
ual fat is present in the subplatysmal layer, and thoughtful
treatment of these patients will require that subplatysmal
fat excision be performed. Subplatysmal fat will be found
as a triangular pad in the submental region with its tip at
the mentum, its base at the hyoid, and each side overly­
ing the anterior belly of the digastric muscle. Subplatys­
mal fat is exposed by elevating the medial edge of each
platysma muscle over the anterior belly of the digastric
muscle when working through a submental incision. Deep
cervical fat (interdigastric fat) should not be removed or an
overly hollow submental appearance will result.
Removing subplatysmal fat but not reducing large
submandibular glands and digastric muscles can result
in a similar objectionable overly hollow central cervi­
cosubmental appearance as removing interdigastric fat,
and aggressive resection of subplatysmal fat to achieve
optimal neck contour will almost always require con­
comitant reduction of submandibular glands and di­
gastric muscles. Neck surgeons must therefore master
treatment of all three problems and use them in con­
junction with each other to obtain optimal results (see
discussion that follows). This is particularly true when
performing secondary surgery, because these problems
typically were not addressed at the primary procedure.
Prominent Submandibular Glands
As experience is gained in evaluating patients for sec­
ondary surgery, the surgeon will increasingly recog­
nize prominent submandibular glands as part of the
secondary neck deformity and the underlying cause
of objectionable residual bulges in the lateral triangle
of the lateral submental region (Fig. 21D.5). In most
instances, a secondary facelift will provide an oppor­
tunity for proper diagnosis and appropriate treatment.
Clinical evaluation of the prominent submandibular
gland has shown it to be large and not ptotic. The sub­
mandibular gland also sits in a confined space and solid
fossa of tissue defined by the digastric muscle, man­
dibular border, and mylohyoid. Attempts to reposition
“ptotic” glands with suspension sutures or by tighten­
ing the platysma is equivalent to trying to put two liters
of water in a one liter bottle and will result in modest
Fig. 21D.5 Prominent submandibular glands are a common part of the secondary neck deformity and the underlying cause of
objectionable residual bulges in the lateral triangle of the lateral submental region. (These images are provided courtesy of the
Marten Clinic of Plastic Surgery. [a,c] Reproduced from Marten TJ. Lamellar high SMAS face and midface lift: a comprehensive
technique for natural-appearing rejuvenation of the face. In: Nahai F. The Art of Aesthetic Surgery: Principles and Techniques. 2nd
ed. St. Louis: Quality Medical Publishing; 2011.)

257
Chapter 21 Face and Neck Rejuvenation
improvement that is short lived only. Subtotal resection
however, by removing only the protruding part of the
gland, results in a significant and sustained improve­
ment in cervical contour (Fig. 21D.6). These observa­
tions underlie the recommendation that resection of the
protruding portion be performed.
Submandibular gland reduction is performed under
direct vision, working through the submental incision
after the subplatysmal space has been opened and the
medial platysma muscle borders mobilized (Fig. 21D.7).
It is usually best performed after subplatysmal fat exci­
sion but before digastric muscle reduction have been
completed, if indicated. The submandibular gland cap­
sule is opened, the gland mobilized inside its capsule,
and the protruding part resected using electrocautery,
taking care to watch for and control any intraglandular
vessels that are encountered. The plane of contouring is
the plane tangent to the ipsilateral digastric muscle and
ipsilateral mandibular border and typically results in the
removal of one third to one fourth of the gland.
Prominent Digastric Muscles
As is the case with the prominent submandibular gland,
as experience is gained in the evaluation of patients
presenting for secondary facelift, large, low-lying, ante­
rior bellies of the digastric muscles will increasingly be
recognized as a common part of the secondary neck de­
formity and the underlying cause of objectionable lin­
ear paramedian fullness in the submental region that
lies medial to the rounder and more laterally situated
submandibular gland fullness (Fig. 21D.8).
Fig. 21D.6 Submandibular gland reduction. Clinical evaluation of the prominent submandibular gland has shown it to be large and
not ptotic, and attempts to reposition “ptotic” glands with suspension sutures or by tightening the platysma will result in modest
improvement that is short lived only. (a) Preoperatively this patient had a prominent submandibular gland. (b) Subtotal resection
of the protruding part of the gland has provided a significant and sustained improvement in cervical contour. (These images are
provided courtesy of the Marten Clinic of Plastic Surgery.)
a
b
Fig. 21D.7 Overview of the technique for reducing a prominent sub­
mandibular gland. A submental incision has been made and the neck
subcutaneously undermined. The right platysma muscle has been el­
evated and is retracted with a double-pronged skin hook and a mal­
leable retractor. The gland will be seen as a distinct bulge just lateral to
the ipsilateral anterior belly of the digastric (the scissors tips are resting
on the digastric). The capsule has been incised and the submandibular
gland isolated using blunt dissection. The gland, once isolated, is gen­
tly pulled inferiorly (forceps). The protruding portion is then excised
incrementally with electrocautery. (The patient’s chin is on the right
and neck is on the left.) (This image is provided courtesy of the Marten
Clinic of Plastic Surgery.)

SECTION IV AESTHETIC SURGERY
258
These bulges often go unnoticed at the primary pro­
cedure because they are either obscured by neck fat and
a lax platysma muscle or are mistakenly viewed as a
“low hyoid” cartilage. In most cases, the secondary face­
lift will provide an opportunity for proper diagnosis and
appropriate treatment (Fig. 21D.9).
Prominent digastric muscles can be treated by su­
perficial subtotal myectomy. Superficial subtotal digas­
tric myectomy is performed under direct vision, working
through the submental incision after the subplatysmal
space has been opened and the medial platysma mus­
cle borders mobilized. It is usually best performed after
subplatysmal fat excision and submandibular gland re­
duction have been performed, if indicated, because it is
easiest to assess the muscles at that time.
Superficial subtotal anterior digastric myectomy is
performed using a tangential strip excision technique in
which the protruding portion of the muscle is grasped
and shaved tangentially in an incremental fashion using
a DeBakey forceps and electrocautery. This maneuver is
repeated until an improved contour is obtained.
Platysmaplasty (suturing the medial borders of the
right and left platysma muscles together in the midline)
and platysmamyotomy (transverse division of the pla­
tysma at the level of the cricoid cartilage) are then per­
formed as indicated after these deep-layer maneuvers
(subplatysmal fat excision, submandibular gland reduc­
tion, and digastric muscle reduction) have been com­
pleted. A 10-Fr round closed-suction Jackson-Pratt drain
is placed in the subplatysmal space when subplatysmal
neck maneuvers are performed.
Tragoplasty
The most commonly observed forms of tragal distortion
seen in patients presenting for secondary facelift are
loss of tragal contour and obliteration of the pretragal
sulcus. These commonly occur concurrently, although
they have somewhat different underlying causes. Loss
of tragal contour is usually the result of improper inci­
sion planning, superior overshifting of cheek skin, and
imprecise trimming of the tragal skin flap. The tragus is
seen to have no distinct beginning or end and no pos­
terior projection. A tell-tale “chopped off” appearance
results (Fig. 21D.10). This is generally correctable if ten­
sion is diverted to the SMAS, skin can be recruited from
Fig. 21D.8 Clinical manifestation of a prominent submandibular gland
(right arrow) and anterior belly of the digastric muscle (left arrow). The
patient has had a prior facelift and neck lift. The anterior belly of the di­
gastric muscle can be seen as objectionable linear paramedian fullness
in the submental region (left arrow). It can be seen medial to the rounder
and more laterally situated submandibular gland fullness (right arrow).
(This image is provided courtesy of the Marten Clinic of Plastic Surgery.)
Fig. 21D.9 Prominent anterior belly of the digastric muscle. This patient
has had a prior facelift and neck lift. The anterior belly of the digastric
muscle can be seen as objectionable linear paramedian fullness in the
submental region that spoils an otherwise good result. Prominent di­
gastric muscles often go unnoticed at the time of the primary procedure
because they are commonly hidden by cervical fat and lax platysma
muscle or mistakenly regarded as a “low hyoid.” (This image provided
courtesy of the Marten Clinic of Plastic Surgery.)

259
Chapter 21 Face and Neck Rejuvenation
secondary advancement of the cheek skin flap, and the
skin flap is subsequently properly trimmed and fit over
the tragal cartilage.
Loss of the pretragal sulcus results from failure to
leave enough skin to fill the pretragal depression when
the tragal flap is trimmed and is almost unavoidable in
any technique in which tension is placed on the cheek
skin flap. The overtrimmed skin flap bridges the pretra­
gal sulcus, which in turn is gradually filled with fibrotic
tissue and scar over time. The tragus appears “bur­
ied” and indistinct from the cheek anterior to it (Fig.
21D.11a).
Correction of the buried tragus deformity requires
recruitment of sufficient skin from the cheek at the sec­
ondary procedure to fill the three-dimensional contours
of the pretragal area. Pretragal subcutaneous scar filling
the pretragal sulcus must also be excised, and the tra­
gal skin flap must be redraped under no tension. Skin
must then be trimmed to a precise fit while the flap is
depressed and held in the pretragal sulcus.
The “retracted tragus” represents an extreme case
of the buried tragus deformity. It, too, is the result of
technical error and has its origin in an overly tight and
excessively trimmed cheek skin flap. The retracted tragus
deformity differs from the buried tragus deformity, how­
ever, in that not only is the pretragal sulcus obliterated by
subcutaneous scar, but the tragal cartilage itself is pulled
anteriorly by the overtrimmed skin flap. This results in
an open auditory canal and a tell-tale and unnatural ap­
pearance (Fig. 21D.11b). Simple recruitment of skin from
the cheek and excision of pretragal subcutaneous scar is
not sufficient to correct the retracted tragus deformity,
however, because the retracted tragal cartilage is usually
stiff, fibrotic, and unable to return to its natural posi­
tion and configuration on its own. Correction usually re­
quires that the cartilage be scored on its anterior surface
and then secured with a few mattress sutures once in
its proper anatomic position (Fig. 21D.12). When these
steps are taken a marked improvement and a much more
natural appearance can be obtained.
Earlobe Reduction
As the face ages, various proportions associated with
youth are disrupted; if not addressed these can result
in a residual marker of aging and a subliminal tip-off
Fig. 21D.10 “Chopped-off” tragus. The tragus appears to have no distinct beginning or
end and no posterior projection. This is usually the result of improper incision planning,
superiorly overshifting the cheek skin, and imprecise trimming of the tragal skin flap. (This
image is provided courtesy of the Marten Clinic of Plastic Surgery.)
a
b
Fig. 21D.11 Buried and retracted tragus. (a) In a buried
tragus irregularity, the tragus appears indistinct from the
cheek anterior to it and the pretragal depression is absent.
This irregularity results from failure to leave enough skin
to and tragal skin flap. (b) The retracted tragus represents
an extreme case of the buried tragus irregularity and is the
result of an overtrimmed cheek skin flap. The retracted
tragus differs from the buried tragus, however, in that
not only is the pretragal sulcus obliterated, but the tragal
cartilage itself is pulled anteriorly. This results in an open
auditory canal and a tell-tale and unnatural appearance.
(These images are provided courtesy of the Marten Clinic
of Plastic Surgery.)

SECTION IV AESTHETIC SURGERY
260
that the patient might not be as young as he or she
otherwise might appear. This is particularly the case
with the large earlobe. Often ignored in primary pro­
cedures, the large earlobe confers the wearer with an
elderly, “grandmotherly” or “grandfatherly” appear­
ance, and the large uncorrected earlobe stands in
stark contrast with the petite ear typically seen on the
young face.
Although many techniques have been devised to re­
duce the earlobe, experience has shown that the sim­
plest and most straightforward way to accomplish it is
a direct incision from the earlobe margin. Essentially
the excess lobule is trimmed off and the wound edges
reapproximated. Performed this way, the surgeon has
precise artistic control over earlobe shape and size, and
the scar can be concealed in an inconspicuous location
on the earlobe margin (Fig. 21D.13). If the earlobe is
pierced, it is often necessary to remove the ear piercing
with a 2.5-mm biopsy punch and repierce the ear in a
new location later once healing is complete.
The Under-Rejuvenated Mouth
Although advanced perioral aging is usually appreci­
ated at the time of primary facelift, more subtle de­
formities often go unnoticed, especially when viewed
against a background of advanced aging elsewhere on
the face. As a result, perioral irregularities often go un­
treated at the primary procedure and usually are more
apparent after rejuvenation of adjacent areas is done.
This can result in a tell-tale “young face, old mouth”
deformity.
Because many patients presenting for secondary
facelift will have an unrejuvenated perioral area, peri­
Fig. 21D.12 Tragoplasty: correction of the retracted tragus. Cheek skin
is undermined and subcutaneous scar in the pretragal sulcus is excised.
The anterior surface of the tragal cartilage is then incised to allow it to
bend posteriorly to its proper anatomic position. The cartilage is secured
in this configuration with a mattress suture of 5–0 PDS (or other suture
of choice). Skin is then recruited by facelift flap advancement and the
tragal flap is carefully trimmed to ensure that adequate skin is preserved
to fill the pretragal sulcus. (This image is provided courtesy of the Mar­
ten Clinic of Plastic Surgery.)
Fig. 21D.13 Earlobe reduction. With age the earlobes increase in size and exist as a residual marker of aging. (a) This patient had a
“grandfatherly” earlobe. (b) After facelift and related procedures that included earlobe reduction. The earlobe is in better propor­
tion with the rest of the ear, and its small size imparts the patient’s face with a lighter, more youthful appearance. (These images
are provided courtesy of the Marten Clinic of Plastic Surgery.)
a
b

261
Chapter 21 Face and Neck Rejuvenation
oral rejuvenation is often an important component of
the planned secondary facelift procedure. This usually
requires some form of skin resurfacing to improve skin
quality and reduce skin wrinkling and fat grafting to
counteract perioral atrophy (Fig. 21D.14). Other treat­
ments such as upper lip lifts (Fig. 21D.15) and corner
lifts of the mouth are also very useful in secondary
­facelift patients.
Case Study: Secondary Facelift
A woman, age 62 years, had undergone a previous
facelift and related procedures. She had ­residual cheek
and jowl laxity; nasolabial creases; and ­deflation of the
­orbits, cheeks, lips, mouth, chin, and ­jawline areas.
The secondary procedures included facelift; neck
lift; forehead lift; trichloroacetic acid peel of the lower
eyelids; and fat grafting to the temples, cheeks, radix,
glabella, upper and lower orbits, nasolabial creases,
lips, mouth, chin, and jawline. No skin resurfacing, fa­
cial implants, or other ancillary procedures were per­
formed. The patient now has an improved facial shape
and soft, natural facial contours. The cheeks and jaw­
line contour have been improved. Hollowness in the
temples, eye area, cheeks, lips, mouth, and chin area
has been ­improved with fat grafting to create a softer,
Fig. 21D.14 The under-rejuvenated perioral area. (a) Preoperatively this patient had a wrinkled, atrophic perioral area that lent an el­
derly, unhealthy, and objectionable appearance to the face. (b) At 2 years and 7 months after high superficial muscular aponeurotic
system facelift that included combined perioral fat injections and perioral dermabrasion. Both atrophy and wrinkling have improved,
and the mouth has a more youthful, vibrant, healthy, and “kissable” appearance. The combined treatment produced a better ap­
pearance than either procedure performed alone. (These images are provided courtesy of the Marten Clinic of Plastic Surgery.)
a
b
Fig. 21D.15 Upper lip lift. (a) Preoperatively this patient had a “long” upper lip (long distance between the base of the nose and
the vermilion–cutaneous junction). The upper lip appeared elderly, and she had poor dental show. (b) After a secondary facelift
that included an upper lip lift, upper and lower lip fat grafting, and perioral laser resurfacing. The distance between the base of
the nose and the vermilion–cutaneous junction has been reduced, the posture of the upper lip has been improved, and better
upper dental show is evident. The mouth has a more youthful, vibrant, healthy, and sensual appearance. The fine scar at the base
of the nose is well concealed and mimics the natural crease in that location. (These images are provided courtesy of the Marten
Clinic of Plastic Surgery.)
a
b

SECTION IV AESTHETIC SURGERY
262
more healthy and attractive appearance. Earlobe reduc­
tion and repair has also been performed and imparts a
lighter, younger, more feminine appearance to the pa­
tient’s face (Fig. 21D.16).
Conclusion
Key concepts in secondary facial rejuvenation include
diverting tension off the skin to the SMAS and platysma
and replenishing lost facial volume with fat injections.
Two-layer SMAS lifts that divert tension off the skin
Fig. 21D.16 Preoperatively (left) this patient had hollow orbits and temples, low cheeks, and a weak jawline despite prior surger­
ies by another surgeon. A low eyebrow, sagging jowl, and neck laxity persisted and she had residual submental fullness because of
untreated deep-layer neck problems, including residual subplatysmal fat and large submandibular glands and digastric muscles.
A large earlobe and earlobe irregularities from the previous procedure were also evident and detracted from the patient’s ap­
pearance. At 12 months after the procedures (right) she looks very natural smiling. She now has a less worn and more attractive
appearance with an improved neck and jawline contour and a soft natural appearance without a tight or pulled look, a result of
the subplatysmal fat excision and submandibular gland and digastric muscle reduction. (These images are provided courtesy of
the Marten Clinic of Plastic Surgery.)
Continued

263
Chapter 21 Face and Neck Rejuvenation
Fig. 21D.16, cont’d Preoperatively (left) this patient had hollow orbits and temples, low cheeks, and a weak jawline despite prior
surgeries by another surgeon. A low eyebrow, sagging jowl, and neck laxity persisted and she had residual submental fullness be­
cause of untreated deep-layer neck problems, including residual subplatysmal fat and large submandibular glands and digastric
muscles. A large earlobe and earlobe irregularities from the previous procedure were also evident and detracted from the patient’s
appearance. At 12 months after the procedures (right) she looks very natural smiling. She now has a less worn and more attrac­
tive appearance with an improved neck and jawline contour and a soft natural appearance without a tight or pulled look, a result
of the subplatysmal fat excision and submandibular gland and digastric muscle reduction. (These images are provided courtesy
of the Marten Clinic of Plastic Surgery.)

SECTION IV AESTHETIC SURGERY
264
The opportunity to perform a facelift is a unique
artistic privilege granted by the patient that carries a
significant responsibility. It deserves nothing less than
the surgeon’s best effort. A few extra hours of time in
the operating room benefits these patients for the rest
of their lives.
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represent a significant step forward in achieving a more
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traced directly to skin tension, and eliminating it mark­
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