Kỹ Thuật Bậc Thầy Trong Trẻ Hóa Khuôn Mặt

In the 21st century the consumer’s preference has
been for minimally invasive and noninvasive techniques:
fillers, Botox, endoscopy, and limited incision aesthetic
surgery. The rationale for any minimal incision surgery is
evident: less invasiveness, less bleeding, presumably less
pain, faster healing, and less scarring. The primary
advantages of minimal incision rhytidectomy, however,
are that it preserves the posterior hairline and avoids
retroauricular scars, which are particularly important for
a woman with a pulled-up or swept-back hairstyle. It is a
ponytail-friendly facelift.
The primary goal of any surgeon performing
rhytidectomy should be to utilize a technique giving con-
sistently good results with minimal risk, complications,
morbidity, and a speedy postoperative recovery.
My intention is not to discredit these deep dissection
techniques nor to deplete the splendor of creative surgery.
Their contribution is already evident: an increased and
clearer knowledge of facial anatomy, muscle function, and
human expression. I am certain that some aspect of these
techniques will be incorporated by many plastic surgeons.
The questions that remain to be answered are (1)What
are the indications for these newer techniques? (2) How
great are the risks and complications? and most
important, (3) Do the benefits significantly outweigh the
risks to justify using these techniques routinely?
There are several advantages of lateral SMASectomy
in comparison with traditional SMAS elevation. First,
because the procedure does not require traditional SMAS
flap elevation, there is less concern about tearing of the
superficial fascia. Second, the potential for facial nerve
injury is lower because most of the deep dissection is over
the parotid gland. If the SMASectomy is performed
anterior to the parotid, the deep fascia will similarly
provide protection for the facial nerve branches as long as
the resection of the superficial fascia is done precisely and
the deep fascia is not violated. Third, because SMAS flaps
have not been elevated, they tend to hold suture fixation
more strongly, and the potential for postoperative
dehiscence and relapse of contour is decreased.
There are certainly other rhytidectomy techniques
that produce excellent results. Each surgeon must adopt a
technique that serves his or her patients best. Ideally, the
technique should be safe, consistent, easily reproducible,
and applicable to a variety of anatomic problems. The
surgeon also must have the versatility to adapt and
modify his or her technique to the needs and desires of
each patient. At present, the lateral SMASectomy provides
this for most of my patients. In the future, as endoscopy
and fixation techniques advance, I will seek to modify and
further improve my present rhytidectomy operation.
It must be emphasized that I do not perform
SMASectomy in every rhytidectomy. Patients with thin
faces and minimal subcutaneous fat undergo simple
plication or imbrication.
SURGICAL TECHNIQUE
ANESTHESIA
Virtually all my facelifts are performed with the patient
under monitored intravenous propofol sedation. Patients
are given oral clonidine, 0.1 to 0.2 mg, 30 minutes before
surgery to control their blood pressure. The face and neck
are infiltrated with local anesthesia, 0.5% lidocaine with
1:200,000 epinephrine, through use of a 22-gauge spinal
needle. I inject the face before I scrub to provide the
requisite 10 minutes for vasoconstriction.
INCISIONS
When the temporal hairline shift is assessed as minimal,
the preferred incision is well within the temporal hair.
With this incision, it is often necessary to excise a triangle
of skin below the temporal sideburn at the level of the
superior root of the helix.
However, when larger skin shift is anticipated
(frequently the lift is more vertical with minimal incision
rhytidectomy) or the distance between the lateral canthus
and temporal hairline is greater than 5 cm, I prefer an
incision a few millimeters within the temporal hairline
(Figs. 9-1 to 9-3). Although this is a compromise, the
146
Daniel C. Baker
Figure 9-1 Lateral SMASectomy dissection. The temporal hairline
incision allows for a more vertical elevation of the facial flap that is usually
required in a short scar rhytidectomy. Subcutaneous dissection is
performed extending across the zygoma to release the zygomatic
ligaments but stops several centimeters short of the nasolabial fold. The
SMAS resection is performed on a tangent from the lateral malar eminence
to the angle of the mandible in the region along the anterior edge of the
parotid gland. The width depends on the laxity of the tissues and the desired
elevation. Vectors are perpendicular to the nasolabial fold. A platysma flap
is elevated and secured to the mastoid periosteum.

alternative of a receding temporal hairline is never accept-
able to a female patient. When the incisions are executed
properly, these scars heal well and are easy to revise or
camouflage. The only exception might be in a patient with
deeply pigmented skin in whom the scar will contrast and
appear as a white line. The temporal hairline incision
should be made parallel to the hair follicle and no higher
than the frontotemporal hairline.
The temporal hairline incision allows for the more
vertical elevation of the facial flap that is usually required
in a short scar rhytidectomy. Other indications for this
incision are a receding hairline from previous facelifts and
a fine, fragile hairline.
The choice of preauricular incision is up to the
surgeon. When executed properly, all these incisions heal
well and are imperceptible. I usually prefer a curved
incision anterior to the helix and continue inferiorly
anterior to the tragus in a natural skinfold. This preserves
the thin, pale, hairless tragal skin and its demarcation
from the usual coarser, thicker, darker cheek skin with its
lanugo hairs. I perform intratragal incisions in patients in
whom the cheek and tragal skin are similar and the tragal
cartilage is not sharp or prominent. Closure must be
without tension and the flap overlying the tragus defatted
to dermis.
In minimal incision rhytidectomy, efforts are made to
end the incision at the base of the ear lobe. This is usually
possible in young patients, but sometimes a short
retroauricular incision is necessary to correct a dog-ear
after the facial flap rotation.
SKIN FLAP ELEVATION
All skin flap undermining is carried out under direct
vision (with scissors dissection) to minimize trauma to the
subdermal plexus and preserve a significant layer of
subcutaneous fat on the undersurface of the flap (see Fig.
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Lateral SMASectomy Facelift
147
Figure 9-2 The incision and area of dissection in lateral SMASectomy.
The temporal hairline incision is utilized to allow a more vertical elevation of
the facial flap. A curved incision anterior to the helix is utilized, continuing
inferiorly anterior to the tragus in a natural skinfold. Facial subcutaneous
dissection is performed, extending across the zygoma to release the
zygomatic ligaments but stopping short of the nasolabial fold.
Subcutaneous dissection continues over the angle of the mandible and
sternocleidomastoid for 5 to 6 cm into the neck. This exposes the posterior
half of the platysma muscle. If a submental incision has been made, the facial
and lateral neck dissections are connected through and through to the
submental dissection.
Figure 9-3 Outline of the SMAS excision. The SMAS resection is
performed on a tangent from the lateral malar eminence to the angle of the
mandible in the region along the anterior edge of the parotid gland.
Continuous with the lateral SMASectomy is the resection of a strip of
posterior platysma muscle several centimeters long over the tail of the
parotid and anterior border of the sternocleidomastoid.

9-2). I prefer subcutaneous dissection in the temporal
region because the skin seems to redrape better. (I believe
that hair loss results primarily from tension rather than
superficial undermining.) Subcutaneous dissection in the
temporal region must be performed carefully to avoid
penetrating the superficial temporal fascia that protects
the frontal branch of the facial nerve. All dermal attach-
ments between the orbicularis oculi muscle and the skin
are separated up to the lateral canthus.
Dissection extends across the zygoma to release the
zygomatic ligaments but stops several centimeters short of
the nasolabial fold. I have never felt that further
dissection provides significant benefit; on the contrary,
the only result is increased bleeding. In the cheek, dis-
section releases the masseteric-cutaneous ligaments and,
if necessary, the mandibular ligaments.
Subcutaneous dissection continues over the angle of
the mandible and sternocleidomastoid for 5 to 6 cm into
the neck. This exposes the posterior half of the platysma
muscle. If a submental incision has been made, the facial
and lateral neck dissection is connected through and
through to the submental dissection.
DEFATTING THE NECK AND JOWLS
Whenever possible, I prefer closed suction-assisted
lipoplasty in the neck and jowls. I use a 2.4-mm Mercedes
tip cannula, keeping it under constant, steady motion in
the subcutaneous space. I attempt to leave a layer of
subcutaneous fat on the undersurface of the cervical skin.
If I suction the jowls, this is always done conservatively.
I never suction or remove subplatysmal fat because (1)
the facial nerves run just beneath the platysma and (2)
any patient with significant subplatysmal fat probably
has a fat, round face, so removing subplatysmal fat could
create an overoperated look.
I usually perform lipoplasty before elevating the skin
flaps. In doing so, I am careful not to oversuction the
portion of the SMAS-platysma that will be elevated over
the mandible with the lateral SMASectomy.
OPEN SUBMENTAL INCISION WITH MEDIAL
PLATYSMA APPROXIMATION
After many years, I had almost stopped opening the neck,
except in unusual cases, because I found that I could
accomplish excellent results with closed lipoplasty and
strong lateral platysma pull. With short scar rhytidectomy
there is limited access to the platysma and the lateral
vector has changed. Therefore, in patients with active
platysma bands on animation, the medial approximation
provides another vector to enhance the cervicomental
recontouring (Fig. 9-4).
The submental incision is made either in the sub-
mental crease or just anterior to it. The subcutaneous
dissection is performed with the neck hyperextended, and
undermining is usually to the level of the thyroid cartilage
and angle of the mandible. Suction-assisted lipoplasty is
then performed with a large, single-hole cannula under
direct vision. Direct fat excision is carried out if necessary,
but to avoid depressions, subplatysma fat is rarely
removed.
The medial borders of the platysma muscle are
identified and elevated for several centimeters. To break
the continuity of the bands, a wedge of muscle is removed
at the level of the hyoid. The medial borders of the muscle
are then sutured together with interrupted buried
4-0 PDS (Ethicon, Inc., Somerville, NJ).
The submental incision is left open to allow for final
hemostasis and recontouring after communication with the
facial dissection and completion of the lateral SMASectomy.
LATERAL SMASECTOMY INCLUDING PLATYSMA
RESECTION
The outline of SMASectomy is marked on a tangent from
the lateral malar eminence to the angle of the mandible,
148
Daniel C. Baker
Figure 9-4 Medial platysma approximation. Subcutaneous dissection
through a submental incision is performed with the neck hyperextended.
The dissection usually extends to the level of the thyroid cartilage and angle
of the mandible. Suction-assisted lipoplasty is then performed. The medial
borders of the platysma muscle are elevated for several centimeters. To
break the continuity of the bands, a wedge of muscle is removed at the level
of the hyoid. The medial borders of the muscle are then sutured together.

essentially in the region along the anterior edge of the
parotid gland (see Figs. 9-1 and 9-3). In most patients,
this involves a line of resection extending from the lateral
aspect of the malar eminence toward the tail of the
parotid gland. Usually, a 2- to 3-cm segment of superficial
fascia is excised, depending on the degree of SMAS-
platysma laxity.
In SMAS resection, I like to pick up the superficial
fascia in the region of the tail of the parotid, extending the
resection from inferior to superior in a controlled fashion.
When SMAS resection is being performed, it is important
to keep the dissection superficial to the deep fascia and
avoid dissection into the parotid parenchyma. Note that
the size of the parotid gland varies from patient to patient;
consequently, the amount of protection for the underlying
facial nerve branches will also vary. Despite this, as long
as one carries the dissection superficial to the deep facial
fascia, ensuring that only the superficial fascia is resected,
facial nerve injury as well as parotid gland injury will be
prevented. In essence, this is a resection of the superficial
fascia in the same plane of dissection in which one would
normally raise the SMAS flap.
Continuous with the lateral SMASectomy is the
resection of a strip of posterior platysma muscle several
centimeters long over the tail of the parotid and anterior
border of the sternocleidomastoid. The facial nerves are
protected here.
VECTORS
The various vectors accomplish correction of the anterior
neck, the cervicomental angle, the jowls, and the
nasolabial fold. The first key suture grasps the platysma
at the angle of the mandible and advances it in a
posterosuperior direction; it is secured with 2-0 Maxon
(United States Surgical Corp., Norwalk, CT) to the fixed
lateral SMAS overlying the parotid (Figs. 9-3 and 9-4).
This lifts the cervical platysma and cervical skin.
After SMAS resection, interrupted 3-0 PDS buried
sutures are used to close the SMASectomy, fixed lateral
SMAS being evenly sutured to more mobile anterior
superficial fascia (Fig. 9-5). Vectors are perpendicular to
the nasolabial fold. The last suture lifts the malar fat pad,
securing it to the malar fascia. It is important to obtain a
secure fixation to prevent postoperative dehiscence and
relapse of facial contour.
If firm monofilament sutures are used, such as PDS or
Maxon, the sutures should be buried and sharp ends on
the knot trimmed. Final contouring of any SMAS or fat
irregularities along the suture line is completed with
scissors. Fat can also be trimmed at the sternomandibular
trough, final contouring being accomplished with
lipoplasty.
For the neck, a flap of the lateral platysma is
developed in the region inferior to the mandibular border.
After this lateral platysma flap is raised, the platysma is
CHAPTER 9
Lateral SMASectomy Facelift
149
secured to the mastoid periosteum with figure-of-eight 2-
0 Maxon sutures to help define the jawline and improve
contouring in the submandibular region. This is the basic
rhytidectomy operation that I have performed since July
1992.
SKIN CLOSURE, TEMPORAL AND EARLOBE
DOG-EARS
After SMAS and platysma approximation, some tethering
of the skin might appear at the anterior extent of the
subcutaneous dissection because of the pull of the
underlying SMAS. This can also occur in the lower eyelid
with elevation of the malar fat pad. Further subcutaneous
undermining is necessary to free these tethers, allowing
the skin to redrape.
The first key skin suture rotates the facial flap
vertically and posteriorly to lift the midface, jowls, and
submandibular skin. Suture fixation is at the level of the
insertion of the superior helix. I like to use a buried 3-0
PDS through the temporal fascia with a generous bite of
dermis on the skin flap. Closure is under minimal to
moderate tension. Staples are used to close any incisions
in the hair. A wedge is usually removed at the level of the
sideburn to preserve the hairline. If an anterior hairline
incision has been made, I like to close it with buried 5-0
Monocryl sutures (Ethicon, Inc., Somerville, NJ) and 5-0
Figure 9-5 SMAS, platysma, and skin closure in lateral SMASectomy.

Nylon sutures. Extra time and attention must be spent on
this closure to eliminate any dog-ears and obtain the
finest scar. Excess skin is then trimmed from the facial
flap so that there is no tension on the preauricular closure.
Wound edges should be “kissing” without sutures.
In short scar rhytidectomy trimming at the earlobe
must be without tension, and the skin flap is tucked under
the lobe with 4-0 PDS sutures, taking a bite of earlobe
dermis, cheek flap dermis, and conchal perichondrium to
minimize any tension. A small dog-ear might be present
behind the earlobe; this is easily trimmed and tailored
into a short incision in the retroauricular sulcus. A closed
suction drain is usually brought out through a separate
stab in the retroauriculus sulcus. Figures 9-6 and 9-7 are
representative pre- and postoperative photos of patients
who have undergone lateral SMASectomy.
POSTOPERATIVE CARE
For the first 48 hours of the postoperative period, blood
pressure monitoring is continuous to avoid systolic spikes
and potential bleeding. Treatment of rising blood pressure
is essential to minimize hematoma formation.
150
Daniel C. Baker
A
B
C
D
Figure 9-6 Preoperative (A and C) and post-
operative views (B and D) after lateral SMASectomy
and chin implant.

I usually utilize suction drains and a soft head
dressing to cover the flaps and incisions. Although drains
never prevent expanding hematomas, I prefer to remove
serosanguineous fluid in this manner. Sutures are
removed on the 7th and 10th postoperative days.
When large hematomas are recognized early, they are
usually successfully managed at the bedside with
sedation, blood pressure control, and irrigation.
The overall incidence of hematoma for women is
about 1.5%; for men it is 4%.
COMPLICATIONS
Table 9-1
summarizes the complications of this
technique, which are consistent with other standard
CHAPTER 9
Lateral SMASectomy Facelift
151
Figure 9-7 Preoperative (A and C) and post-
operative views (B and D) after lateral SMASectomy.
A
B
C
D

facelift operations. Despite special attention to blood
pressure control in the postoperative period, the
hematoma rate is still 1.5%. The most common problems
are minor revisions of earlobe and temporal hairline scars.
Secondary lifts are occasionally performed, but I require
all patients to allow healing for 1 year before considering
any revisions. My goal is to keep the occurrence of all
revisions to less than 5%. When revisions exceed this
limit, I know I must re-evaluate my technique.
SUGGESTED READING
Baker DC, Aston SJ, Guy CL, Rees TD: The male rhytidectomy.
Plast Reconstr Surg 1977;60:514.
Baker DC, Conley J: Avoiding facial nerve injuries in rhytidectomy.
Anatomical variations and pitfalls. Plast Reconstr Surg
1979;64:781.
Baker DC: Anatomy and injuries of the facial nerve in cervicofacial
rhytidectomy. In Kaye BL, Gradinger GP (eds): Symposium
on Problems and Complications in Aesthetic Plastic Surgery of
the Face. St. Louis: CV Mosby, 1984.
Baker DC, Rees TD: Complications of cosmetic facial surgery. In
Lewis JR (ed): Aesthetic Plastic Surgery. Boston: Little,
Brown, 1989.
Baker DC: Deep dissection rhytidectomy: A plea for caution. Plast
Reconstr Surg 1994;93(7):1498–1499.
Baker DC: Lateral SMASectomy. Plast Reconstr Surg 1997;
100(2):509–513.
Baker DC: Rhytidectomy with lateral SMASectomy. Facial Plast
Surg 2000;16(3):209–213.
Baker DC: Minimal incision rhytidectomy (short scar facelift) with
lateral SMASectomy: Evolution and application. Aesthet Surg
J 2001;21(1):68–79.
Baker DC, Chiu ES: Bedside treatment of early acute rhytidectomy
hematomas. Plast Reconstr Surg 2005;115(7):2119–2222.
Baker DC, Stefani WA, Chiu ES: Reducing the incidence of
hematomas requiring surgical evacuation following male
rhytidectomy: A thirty year review of 985 cases. Plast
Reconstr Surg 2005;116(7):1973–1985.
152
Daniel C. Baker
Table 9-1
Complications Associated with 3,500 Lateral
SMASectomy Facelifts
Complication
Incidence (%)
Hematoma
1.5
Facial nerve weakness
0.1*
Earlobe scar revision
2.0
Skin slough
2.0
Retroauricular and temporal
2.0
scar revisions
Infection
1.0
“Minilift” after 1 year
2.0
*All resolved in 6 months.

HISTORY
The facelift operation has evolved over the past century.
During the early 20th century, aesthetic procedures were
not well accepted socially. The early facelift surgeons
performed skin excisions that did not have long-lasting
results. As the field of aesthetic surgery matured, physicians
and patients demanded more reliable and longer lasting
results. In 1919, Bettman and Bourget simultaneously pre-
sented their experience with subcutaneous rhytidectomy.1,2
Despite limited anatomic understanding, facelift surgeons
were performing extensive skin undermining, which
increased the complication rates and produced minimal
aesthetic improvement.
In 1960, Aufricht was the first to describe plication of
the tissue deep to the superficial fat plane.3 Webster and
other facelift surgeons used similar techniques of suturing
the “deeper layers” to improve their results.4,5 During the
same period Skoog had started performing facelifts
utilizing the skin and platysma as a musculocutaneous
advancement flap.6 In 1976, Mitz and Peyronie advanced
the rhytidectomy procedure into the modern era by
describing the anatomy of the superficial musculoaponeu-
rotic system (SMAS).7 They showed that a deeper fascial
tissue layer exists between the subcutaneous fat and the
parotidomasseteric fascia. Their anatomic studies estab-
lished that the SMAS invests the muscles of facial expres-
sion and is contiguous with the frontalis and platysma
muscles. Following Mitz and Peyronie’s description, the
incorporation of the SMAS layer in cervicofacial rhytidec-
tomy gained popularity.8-14 In the 1980s and 1990s, the
deep plane facelift15-20 and subperiosteal facelift21-30 were
increasingly utilized. However, variations of the SMAS
facelift continued to be the most commonly performed
technique.
Today, most types of SMAS facelifts and subcutaneous
rhytidectomies incorporate extensive skin undermining in
hopes of achieving better results. Advocates of extensive
dissections believe that the release of the osteofascio-
cutaneous ligaments is necessary to obtain better
results.31-37 Facelifting with limited skin undermining
was first advocated by Richard Webster.5,38-41 Webster
published several papers demonstrating that the results of
facelifts with conservative skin undermining and SMAS
plication were no different than more aggressive surgery.
He also demonstrated intraoperatively that this method
not only decreased wound tension in facelifts but also
increased the strength of facial suspension. Webster
believed that the longevity of facelifts would be improved
if a significant portion of the dermal-SMAS attachments
were maintained. McCollough, who further advocated the
approach of maintaining the skin adipose-SMAS attach-
ments, coined the term “suspension rhytidectomy.”42
In 1993, Burgess confirmed some of Webster’s findings in
a cadaveric study comparing different types of SMAS
facelifts. In this study, he demonstrated that wound
tensions significantly increased with more extensive skin
undermining when compared to short skin flaps.43
PERSONAL PHILOSOPHY
Having performed numerous facelift techniques including
the standard (long flap) SMAS, deep plane, and tuck-up
“mini-facelifts,” we have come to the conclusion that a
modified version of the Webster SMAS facelift with
limited skin undermining is a valuable option for many of
our patients. The key components of our “short-flap
SMAS rhytidectomy” include limited skin undermining in
the facial region, SMAS imbrication, platysmaplasty, and
judicious cervical suction-assisted lipectomy. By limiting
the facial skin flap dissection, we maintain the anterior
dermal-SMAS attachments, which allow aggressive
suspension of the face without significant tension on the
skin. The SMAS serves as the carrier of the facelift flap.
Unlike the deep plane facelift, the SMAS is not under-
mined past the parotid gland, thereby limiting the risk for
facial nerve injury and postoperative edema.
The
short-flap
rhytidectomy
provides
some
advantages over other facelift techniques. We have found
a significant reduction in the duration of procedure, rate
of complication, and postoperative recovery time. By
limiting the subcutaneous dissection, the risk of
hematoma formation and facial nerve injury is reduced.
Short skin flaps diminish the chance of flap necrosis in
patients who have compromised vascularity, such as
smokers, diabetics, and elderly patients.44,45 We have also
seen less long-term skin atrophy and telangectasias. The
undissected areas could safely also undergo simultaneous
fat grafting or resurfacing.
Short-Flap SMAS Rhytidectomy
Babak Azizzadeh, MD, FACS • Tessa A. Hadlock, MD • Mack L. Cheney, MD, FACS
153
C H A P T E R T E N

A significant advantage of the short-flap rhytidectomy
is patient satisfaction and aesthetic outcome. Some have
criticized the concept of performing operations that do
not restore the face to its original anatomic and aesthetic
ideals, despite high patient and surgeon satisfaction.46
Our philosophy for elective aesthetic surgery is to obtain
outstanding results, reduce the risk of perioperative
complications, and allow our patients to return to their
normal activity in a reasonable time. Most of our patients
return to their normal routine within 8 to 10 days. In
addition to the shortened recovery period, most patients
are extremely pleased with the long-term surgical out-
come. We have not found any difference between the
longevity of our short-flap rhytidectomy technique versus
more extensive facelift procedures.
SMAS facelifts impact the jowls and lower face but do
not always transmit well to the nasolabial fold. Most
SMAS facelifts, including the short-flap rhytidectomy,
obtain only modest midface enhancement. The short-
flap rhytidectomy, therefore, does not address several
important issues such as the double cheek convexity, infra-
orbital rim hollowness, tear-trough deformity, facial volume
loss, and deep nasolabial folds. Dermal fillers (calcium
hydroxylapatite, hyaluronic acids), subcutaneous volu-
mizers (poly-L-lactic acid), and fat grafting can be used to
address moderate midface ptosis and volume loss.
Submalar implants are utilized for significant volume
deficits in patients who do not desire temporary fillers.47
Endoscopic subperiosteal midface lifts are reserved for
motivated patients with advanced midface ptosis and
prominent nasolabial folds. The reader must, however, be
cautious about the use of endoscopic midface lifts because
of the higher risk for facial nerve injury, steep learning
curve, prolonged postoperative edema, as well as temporary
changes in the patient’s lateral canthal contour. Never-
theless, several authors have had excellent outcome with
minimal complications when utilizing this approach.22-30
The majority of our patients only desire injectables or
fat grafting to address the midface. Webster was one of
the first proponents of utilizing bovine collagen to enhance
the appearance of the nasolabial folds.48 Although injecta-
bles do not provide permanent improvement in the area,
patients are quite pleased with the outcome and are
usually willing to have intermittent in-office procedures. A
new generation of long-lasting fillers and volumizers will
continue to give our patients more options in this arena.
Long-flap facelifts (SMAS or subcutaneous techniques)
incorporate extensive skin undermining in order to release
the fascioosteocutaneous ligaments.31-37 In attempting to
accomplish the ligamentous release, extensive flap elevation
in the subcutaneous plane can destroy the dermal-SMAS
attachments, hence invalidating the SMAS support for the
lift. Anatomic studies by Muzaffar and Mendelson have
also demonstrated that the release of retaining ligaments
in the prezygomatic space through extensive subcutaneous
dissection can potentially cause nerve injury to the motor
branch of the orbicularis oculi.36,37 It is also well known
that the facial nerve has a more superficial course near the
oral commissure and midportion of the zygomatic arch,
placing it at risk during the dissection of long skin flaps.49
The deep plane facelift does not incorporate extensive
skin undermining like the short-flap rhytidectomy. Deep
plane facelifts, however, utilize a sub-SMAS composite
musculocutaneous advancement flap. The results of the
deep plane facelift in the lower face (jowls and neck) are
consistent because the SMAS is utilized as a carrier of the
facelift, just like the short-flap rhytidectomy. Midface
enhancement of the deep plane facelift is more con-
troversial. Owsley and others have shown that in order to
truly obtain nasolabial effacement, the SMAS must be
totally released anteriorly beyond the melolabial fold over
the zygomaticus muscle.50-53 A lengthy anteromedial
dissection is hence necessary and can cause extensive
postoperative edema as well as place the branches of the
facial nerve at significant risk. Furthermore, similar to the
short-flap rhytidectomy, the deep plane facelift does not
truly address the volume deficits associated with the aging
process. In our experience as well as that of others, the
difference in the aesthetic outcome between the deep
plane and SMAS rhytidectomy is not significant except in
older patients with extensive rhytidosis.54-55 The results of
the subperiosteal facelift are better for patients who have
midface ptosis.
In the past decade, patient demands for decreased
downtime has fueled the resurgence of “limited” or “mini-
facelift” surgery. The short-flap rhytidectomy is not a
mini-facelift as it entails a critical amount of cervicofacial
dissection and SMAS imbrication. In our experience,
mini-facelifts are indicated only for a limited number of
patients who have minimal signs of facial aging or those
who require minor facelift revisions.55-58 The post-
operative recovery of mini-facelifts is shorter than most
standard rhytidectomy procedures, but the results are not
as dramatic. Our patient population has a much higher
rate of satisfaction with the short-flap rhytidectomy.
ANATOMY
The salient features of the facial anatomy have been
discussed in detail in other chapters. The most important
aspect of the anatomy relating to our current technique
has been elegantly described by Webster and
McCollough.38-42 They believed that the guiding principle
for safe and long-lasting rhytidectomy is for the skin and
the SMAS to function as a unit; therefore, if you separate
the unit, the SMAS will not truly have any functional
support of the skin. In fact, it is this same principle of
maintaining the skin-SMAS unit that guides the excellent
results achieved by sub-SMAS dissection employed in
deep plane facelifts.15-20 In the short-flap rhytidectomy,
the SMAS is not undermined extensively beyond the
parotid. Subcutaneous, long-flap SMAS and extended
SMAS facelifts widely separate the skin from the SMAS,
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Babak Azizzadeh • Tessa A. Hadlock • Mack L. Cheney

thereby disrupting the skin-SMAS attachments. This
separation does not allow the SMAS to serve as a
foundation for the facelift. If the attachments of the skin
and SMAS are maintained, imbrication of the SMAS will
suspend the entire complex. These attachments are main-
tained only in short-flap rhytidectomy and deep plane
facelifts.
The pathophysiology of midface aging involves both
inferomedial descent as well as well as atrophy of the soft
tissue (Fig. 10-1). The nasolabial fold is an area where
CHAPTER 10
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155
A
B
Figure 10-1 The progression of the aging face. The aging process is
illustrated in this individual in her 20s (A), 40s (B), and 60s (C). The face
continuously and gradually changes, resulting in prominent nasolabial folds,
jowl formation, marionette furrows, neck laxity, volume loss, and rhytids in
the perioral and periorbital region.
C

the cutaneous insertions of the lip elevators fuse onto to
the ligamentous structure formed by the SMAS and
deeper facial fascia. Studies have shown that the
nasolabial fold becomes more prominent as the malar fat
pad and suborbicularis oculi fat (SOOF) begin to
descend.59 Also, a progressive atrophy of the midface
muscles and subcutaneous fat results in cavitary
depressions and midfacial flatness contributing to the
overall aging process.
The safety of the facial nerve is perhaps the most
important aspect of facelift surgery. The facial nerve exits
the stylomastoid foramen and enters the body of the
parotid gland (Fig. 10-2). Within the parotid gland it
bifurcates into an upper and lower division. It further
divides into five main branches, including the temporal
(frontal), zygomatic, buccal, marginal mandibular, and
cervical. Permanent iatrogenic facial paralysis is rare
owing to the extensive arborization of the facial nerve
branches. The frontal branch is a terminal branch with
limited arborization. Injury to the frontal branch has the
highest risk of causing permanent paralysis. The overall
risk of permanent facial nerve paralysis in standard
rhytidectomy is between 0.53% and 2.6%.45,60-61 There
have been very few reports in the literature regarding the
risk for facial nerve injury associated with more invasive
facelifting procedures. The short-flap rhytidectomy
significantly limits the risk for facial nerve injury by
limiting facial subcutaneous and SMAS dissection. This is
the primary reason that the short-flap rhytidectomy is an
extremely safe procedure.
Finally, the skeletal anatomy of the face and neck is
extremely important in obtaining satisfactory results in
cervicofacial rhytidectomy. The key skeletal regions
include the malar-submalar region, dental occlusion, chin
projection, prejowl sulcus, and the position of the hyoid.
Patients with prominent malar prominence and submalar
fullness will obtain better results from short-flap
rhytidectomy. If these areas are extremely underdeveloped
or atrophied, the patient must be consulted for skeletal
and soft tissue volume enhancements. Individuals with
poor chin projection and prominent prejowl sulcus will
also require further evaluation for simultaneous chin
augmentation to enhance the results of the rhytidectomy.
Finally, patients with low and anteriorly positioned hyoid
bone will not obtain satisfactory results in the neck.62
Unlike the other skeletal regions, the hyoid cannot be
manipulated during the rhytidectomy procedure.
PREOPERATIVE ASSESSMENT
The short-flap rhytidectomy is typically indicated for
patients with moderate facial aging as manifested by jowl
formation, neck banding, and early midface aging
changes. Patients are typically between 45 and 65 years
old. A complete history and physical examination are
performed. The most important aspect of the consultation
is to understand the patient’s aesthetic and functional
goals. Mirror and photographic facial analysis are
utilized. Comprehensive facial analysis is prerequisite for
a successful surgical outcome. Please refer to Chapter 1
for an overview of the aging face consultation and facial
analysis.
Following the facial analysis, a treatment plan is
formulated for the patient. The first feature of the
treatment protocol will focus on preventive measures to
slow the aging process. Antiaging regimen, skin care
consultation, sun protection, and tobacco cessation are
discussed with every patient at this time. In the second
phase of the consultation, nonsurgical procedures that
could improve the facial appearance are considered. Skin
resurfacing, soft tissue fillers, and botulinum toxin type A
are discussed at length. The third feature of the con-
sultation focuses on areas of the face that will benefit from
facial plastic surgical intervention. All regions of the face
will be evaluated in order to achieve a balanced and
aesthetically pleasing outcome. Box 10-1 highlights the
surgical and nonsurgical options discussed with every
patient. We invite the patients back for a second con-
sultation to further discuss the risks, alternatives, incisions,
aesthetics, and perioperative course of the short-flap
rhytidectomy and adjunctive procedures. Photographs are
reviewed in detail with patients at that time.
SURGICAL TECHNIQUE
The short-flap rhytidectomy is typically performed at a
certified ambulatory surgical center under general
156
Babak Azizzadeh • Tessa A. Hadlock • Mack L. Cheney
Figure 10-2 The facial nerve. The facial nerve bifurcates in the parotid
into an upper and lower division. It then divides into five main branches:
temporal (frontal), zygomatic, buccal, marginal mandibular, and cervical.
Facial Nerve
Temporal branch
Zygomatic branch
Buccal branch
Marginal branch
Cervical branch

anesthesia. Local anesthesia with sedation may be offered
as an alternative. The patients are encouraged to avoid a
number of medications starting 2 weeks prior to the
surgical date (Box 10-2). All herbal products are
discontinued at the same time. The patients are started on
arnica and Bromolin starting 3 days prior to the surgery.
Although there are very few studies available, we have
found that this regimen helps the patients prepare
psychologically for their surgery as well as reduce the
perioperative bleeding, edema, and ecchymoses.
In the preoperative area, ice packs are applied to the
facial region. The markings for short-flap rhytidectomy,
CHAPTER 10
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157
blepharoplasty, and endoscopic browlift as well as
important landmarks are placed with the patient in
the sitting position. Patients are given a mirror to view the
proposed incisions. We take extreme care to mark the
patient preoperatively, because the facial landmarks are
distorted once the patient is supine and local anesthesia
has been infiltrated.
The patients are placed under general anesthesia or
propofol sedation. A midline endotracheal tube is tied to
the lower teeth with a 2-0 silk suture in patients who are
under general anesthesia. Cefazolin and decadron are
administered. Foley catheter and lower extremity
pulsatile compression stockings are placed in all patients.
Ice gloves are applied to the areas of the face and eyes that
are not in the immediate operative field. Lidocaine 1%
with 1:100,000 epinephrine is infiltrated into all the
pertinent regions prior to the preparation. This will allow
ample time for the vasoconstrictive actions of the
epinephrine. A 3-mL syringe and 27-gauge needle are
used for face and brow infiltration. A 1-mL syringe with
30-gauge needle is utilized for the blepharoplasty
injection. Autoclave tape is applied to the hair 2 to 4 cm
posterior to the hairline (Fig. 10-3). The entire face and
anterior hairline are cleaned with 3% hexachlorophene.
Sterile blue towel is stapled to the autoclave tape and the
endotracheal tube is wrapped in a sterile manner. This is
an effective and rapid method of preparing the patient.
Box 10-3 outlines the specific order of procedures in
patients who are undergoing multiple facial rejuvenation
procedures. Prior to each portion of the procedure, a
second round of local anesthetic using 0.5% lidocaine
with 1:200,000 epinephrine is administered. The facelift
procedure generally begins with suction-assisted lipectomy
of the neck region. A 5-mm incision in the submental
crease is utilized to access the region. If platysmaplasty or
chin implants are to be performed, a 1- to 2-cm incision
is utilized. A 3-mm flat liposuction cannula is used for the
Box 10-1
Comprehensive Evaluation for Facial Rejuvenation
1. Upper third
a. Blepharoplasty
b. Endoscopic browlift
c. Botulinum toxin type A
d. Fillers
2. Middle third
a. Short-flap rhytidectomy
b. Fillers, volumizers, fat grafting
c. Endoscopic midface lift
d. Malar and submalar implant
e. Skin resurfacing
3. Lower third
a. Short-flap rhytidectomy
b. Fillers, volumizers, fat grafting
c. Chin and prejowl augmentation
Box 10-2
Medications Patients Should Avoid before Surgery
A.P. C.
Advil
Alka-Seltzer
Anacin
Anaprox
Arthritis Pain Formula
Ascodeen-30
Ascriptin
Aspirin suppositories (all
brands)
Aspirin
Bayer Aspirin
Buff-a-Comp
Buffadyne
Bufferin
Butalbital
Carna Arthritis Pain
Reliever
Carna-Inlay Tabs
Cheracol Capsules
Congespirin
Cope Coricidin
Coricidin
Darvon Compound
Dristan
Doan’s Pills
Duragesic
Ecotrin
Empirin
Emprazil
Equagesic
Excedrin
Fiorinol
Four-Way Cold Tablets
Indocin
Measurin
Midol
Monacet with Codeine
Motrin
Naprosyn
Norgesic
Nuprin
Os-Cal-Gone
Pamprin
Pamprin (buffered)
Figure 10-3 The preparation. Autoclave tape is applied to the hair 2 to
4 cm posterior to hairline. Sterile towel is then stapled to the autoclave tape,
and the endotracheal tube is wrapped in a sterile manner.

aspiration. The subcutaneous region is cannulized first
without suction, after which suction assistance is used.
Extreme caution is utilized to avoid excessive removal of
fat, which will increase the risk of cobra neck deformity.
The opening of the liposuction cannula should always face
away from the dermis. A fan-shaped region is aspirated
(Fig. 10-4). The body of the mandible is avoided in order
to minimize the risk of marginal mandibular facial nerve
injury.
Using an Aufricht retractor, we commonly identify
the medial borders of the platysma in order to perform the
platysmaplasty (Fig. 10-5). Vertical spreading with the
facelift scissors allows easy identification of the platysma.
Once the medial borders are identified, further sub-
cutaneous dissection is performed laterally in both
directions. A small portion of the platysma muscle’s
medial border is excised. This allows better adhesion after
the two bellies are sewn together and approximated.
Three to six buried interrupted 3-0 Mersilene sutures
(Ethicon, Inc., New Brunswick, NJ) are utilized to plicate
the two muscles. The first suture is placed at the most
anterior portion of the platysma where the two sides are
closest to one another. Instrument ties are utilized to tie
the sutures in this small incision. Three to six sutures are
placed to approximate the muscles. The thyroid cartilage
generally marks the inferior limit. Back cuts in the
platysma are rarely utilized. Platysmal approximation
allows the lateral SMAS/platysma imbrication to lift the
neck as a sling and create a more defined cervicomental
angle. If necessary, chin augmentation is performed at this
point of the operation.
The lateral facelift portion is then initiated. The
facelift starts as a 2- to 3-cm incision in the anterior
temporal hair tuft (Figs. 10-6 and 10-7). The incision
curves back to meet the root of the helix and follows the
preauricular contour down to the tragus. The incision
continues in the retrotragal region and follows the natural
crease of the lobule posteriorly onto the postauricular
conchal bowl. In men, a pretragal incision is utilized to
avoid placing the beard inside the ear. The postauricular
incision is not made directly onto the postauricular crease
but about 3 mm onto the conchal bowl up to the point
where the helix meets the occipital hair tuft. The incision
takes a soft turn back into the occipital hair tuft for about
3 cm. The occipital incision is at a 45-degree angle and
does not follow the hairline because of increased visibility.
The postauricular incision is generally very well
camouflaged because of the high placement and is rarely
a source of concern to our patients. We occasionally
perform a short-scar facelift in selected patients using a
limited postauricular incision.
The flap elevation starts at the temporal hair tuft and
facial region in the subcutaneous plane. A Brown-Adson
forceps and No. 15 blade are utilized to begin the
dissection (Fig. 10-8). Double hooks or three-prong cat-
paws are utilized with Metzenbaum scissors for the
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Babak Azizzadeh • Tessa A. Hadlock • Mack L. Cheney
Figure 10-4 Submental suction-assisted lipectomy. Fan-shaped
aspiration in the submental area is shown in A. The outlined area in B can be
safely aspirated.
A
B
Box 10-3
Sequential Procedure Order
1. Transconjunctival lower blepharoplasty
2. Endoscopic browlift
3. Endoscopic midface lift
4. Upper blepharoplasty
5. Lower pinch blepharoplasty
6. Submental liposuction
7. Platysmaplasty
8. Chin implant
9. Rhytidectomy

majority of the undermining. Retraction by the assistant
is of utmost importance to allow a safe and predictable
depth of dissection. At the level of the tragus, we initially
dissect a thick flap just above the perichondrium for 8 to
10 mm. The facial skin is much thicker than the native
tragal skin; this maneuver in addition to aggressive
thinning of the tailored skin at the end of the procedure
significantly limits postoperative tragal fullness.
The skin elevation is performed for only 4 to 5 cm in
the facial region. This limited skin dissection is the most
important variation of the short-flap rhytidectomy as
compared to other SMAS facelift procedures. Lower facial
dissection at the angle of the mandible is not performed
until posterior (occipital) neck elevation is completed,
thereby decreasing the risk of marginal mandibular
injury. The temporal area also needs to be dissected with
extreme care in the subcutaneous plane as the frontal
branch can have a superficial course over the zygomatic
arch (Fig. 10-9). After the facial dissection is completed,
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159
Figure 10-5 Platysmaplasty. Platysmaplasty allows the lateral
SMAS/platysma imbrication to lift the neck as a sling and create a more
defined cervicomental angle. Three to six buried interrupted 3-0 Mersilene
sutures are utilized to plicate the muscles together. The first suture is placed
at the most anterior portion of the platysma.
Figure 10-6 The incision and area of dissection in short-flap
rhytidectomy. The temporal and occipital incisions are limited. A retro-tragal
route is utilized. The facial region is dissected for 4-5 cm. The neck is widely
dissected to the submental region.
Figure 10-7 Intraoperative markings for incisions: preauricular (A) and
postauricular (B) incision.
A
B

the posterior occipital area is elevated initially with a No.
15 blade (Fig. 10-10). This dissection is more fibrous and
difficult than the anterior dissection. The subcutaneous
plane is more difficult to ascertain. Facelift scissors are
utilized to complete the cervical dissection. We perform an
extensive cervical dissection. The lateral cervical dissection
is united with the central dissection, which was created for
the platysmaplasty and suction-assisted lipectomy. The
inferior limit of the dissection is 4 to 5 cm below the angle
of the mandible and at the level of thyroid notch. The
surgeon must be cognizant of the external jugular as well
as the great auricular nerve, as they can be easily injured.
Complete cervical dissection is necessary in patients with
significant laxity to obtain exceptional aesthetic results.
The lower facial subcutaneous elevation at the level of
the angle of the mandible is performed once the cervical
and superior facial dissections are completed (Fig. 10-
11). Hooks are placed on the facial and cervical regions as
the ear and facial skin are retracted in opposite direction.
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Babak Azizzadeh • Tessa A. Hadlock • Mack L. Cheney
A
C
B
Figure 10-8 Facial subcutaneous dissection. The flap elevation starts at
the temporal hair tuft (A). Brown-Adson forceps and No. 15 blade are
utilized to start the dissection. A double hook is utilized with Metzenbaum
scissors for the majority of the undermining (B and C). The assistant retracts
the facial skin centrally at all times.
Figure 10-9 Danger zone for the frontal branch of the facial nerve.
Typically four rami of the frontal branch of the facial nerve pass over the
zygomatic arch. The most anterior ramus runs about 2 cm posterior to the
anterior zygomatic arch. The branch is almost always anterior to the
superficial temporal vessels.

CHAPTER 10
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161
Figure 10-10 Postauricular skin flap elevation. This posterior dissection is more fibrous and difficult than the anterior dissection. The inferior limit of this
dissection is 4 to 5 cm below the angle of the mandible. An extensive cervical elevation is performed in order to join the submental dissection.
A
B
A
C
B
Figure 10-11 The upper facial dissection and cervical dissection are
joined. Once the cervical and superior facial dissections are completed, the
lower facial subcutaneous elevation at the level of the angle of the mandible
is performed. Hooks are placed on the facial and cervical regions as the ear
and facial skin are retracted in opposite directions. The dissection is usually
carried out for 4 to 5 cm.

This maneuver helps to further protect the marginal
mandibular nerve because the subcutaneous plane is
easily dissected. The anterior limit of this dissection is
4 to 5 cm. Facial liposuction is strictly avoided because of
unpredictable results.
At this time, a segment of SMAS is excised using a
Brown-Adson forceps and facelift scissors (Figs. 10-12
and 10-13). The excision starts 1 to 2 cm anterior to the
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Babak Azizzadeh • Tessa A. Hadlock • Mack L. Cheney
A
B
Figure 10-12 Outline of the SMAS excision. A segment of SMAS (A) is
excised 1 to 2 cm anterior to the preauricular incision at the level of the root
of the helix and extends inferiorly down to the infra-auricular platysma (B).
A
B
Figure 10-13 Intraoperative excision of SMAS. A segment of SMAS is
excised using Brown-Adson forceps and facelift scissors (A and B). The
excision starts 1 to 2 cm anterior to the preauricular incision at the level of
the root of the helix and extends inferiorly down to the infra-auricular
platysma. A segment of SMAS after excision is shown in C.
C

preauricular incision at the level of the root of the helix
and extends inferiorly down to the infraauricular platys-
ma. The anterior segment of the SMAS is then elevated
to the anterior border of the parotid using Metzenbaum
scissors (Fig. 10-14). The SMAS and platysma are
imbricated with buried 3-0 Mersilene sutures, thereby
suspending the anterior facial tissues. Multiple buried
horizontal mattress sutures are placed. The vector of the
SMAS imbrication is in a posterosuperior direction.
Excess skin is then tailored. Our goal is to minimize
tension in the facial region and maximize tension in the
occipital hair tuft. Skin tailoring can be challenging; thus,
we have created a simple method for consistent results.
Several anchor points are created (Fig. 10-15). The skin
between these anchor points can subsequently be easily
trimmed. A Brown-Adson forceps is utilized to place
tension on the skin and calculate the exact distance for
skin excision. The anchor points are all closed in two
layers. The root of the helix serves as the first anchor point
(AP-1). Once this location has been set, excess temporal
hair tuft superior to AP-1 is excised. To avoid a “dog-ear”
deformity, closure is performed toward AP-1. Because our
temporal incision is not extensive, we rarely find any
significant change in hair position.
The second anchor point is at the level of the
antitragus (AP-2). The intervening skin between the first
and second anchor point can now be safely tailored.
Extreme caution is used not to remove too much skin in
this area because excess tension can widen the scar and
pull the tragus anteriorly. The tragus is an extremely
important landmark, and a natural pretragal cleat should
be created in order to reduce the detection of the facelift
incision. Using facelift scissors and curved iris scissors,
the surgeon thins the newly positioned facial skin over the
tragus. A Vicryl suture is then placed in the skin flap to
recreate a natural tragal notch and secure to the
underlying tissue. The suture has to penetrate the dermis
in order to accomplish its goal. This deep suture
additionally prevents the anterior pull of the tragus during
the secondary healing phase.
CHAPTER 10
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163
A
B
C
Figure 10-14 SMAS imbrication. The anterior segment of the SMAS is
elevated up to the anterior border of the parotid gland (A and B). The SMAS
is imbricated with buried 3-0 Mersilene sutures (C). Multiple buried
horizontal mattress sutures are placed. A posterosuperior vector is used for
the SMAS imbrication.

164
Babak Azizzadeh • Tessa A. Hadlock • Mack L. Cheney
AP–1
AP–3
AP–2
AP–4
A
B
C
D
Figure 10-15 Skin tailoring. Several anchor points are utilized for tailoring the skin (A–C). The root of the helix (AP-1) serves as the first anchor point (D).
Once this location has been set, excess temporal hair tuft superior to AP-1 is excised and staples are used for closure. The second anchor point (AP-2) is at
the level of the antitragus (E). The intervening skin between the first and second anchor point is removed (F).
E
F

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165
Figure 10-15 Continued. Using curved iris scissors, the newly positioned facial skin over the tragus is aggressively thinned (G). A Vicryl suture is used to
create a pretragal cleat; it penetrates the dermis of the facial skin and is secured to the pretragal tissue (H). The third anchor point (AP-3) is the apex of the
postauricular incision (I). Excess occipital skin is excised with the help of a hook (J). The occipital hairline is aligned with deep dissolvable sutures. The
intervening tissue between AP-2 and AP-3 is draped over the ear lobule (K). The inferior border of the lobule is then used to make a split into this intervening
skin. The apex of this incision becomes the anchor point of lobule attachment (AP-4). The excess skin between AP-2 and AP-4 is excised. In the postauricular
area, the skin between AP-3 and AP-4 is also trimmed conservatively. The preauricular incision is closed with a 6-0 nylon in a running locking manner (L).
G
H
I
J
K
L

Once the anterior facial skin has been tailored, we
turn our attention to the posterior skin. The third anchor
point (AP-3) is the apex of postauricular incision. After
the anchor point is set, excess occipital skin is excised with
the help of a single hook. The occipital hairline is aligned
with deep dissolvable sutures. Staples are then utilized to
close the hair-bearing occipital hair tuft. The intervening
tissue between AP-2 and AP-3 is draped over the ear
lobule. The inferior border of the lobule is then used to
make a split into this intervening skin. This incision must
be performed in a precise manner, as the apex will become
the anchor point of lobule attachment (AP-4). Pixie ear
deformity is avoided by limiting the tension at this anchor
point. Excess skin between AP-2 and AP-4 is excised. In
the postauricular area, the skin between AP-4 and AP-3
is also trimmed conservatively, completing the skin
tailoring in the cervicofacial region.
The preauricular incision is then closed with running
locking 6-0 nylon or Prolene suture between AP-1 and
AP-4. In the postauricular region, 4-0 fast-absorbing gut
suture is used for closure. Staples are used for the
temporal and occipital hair tufts. Small drains are placed
prior to closure. If the patient is agreeable, Tisseel fibrin
sealant (Baxter, Mississauga, ON Canada) can be used
prior to closure and eliminates the need for drains. The
submental incision is closed with a 6-0 nylon. A pressure
dressing is applied and the patient is extubated and
transferred to the recovery room. Ice gloves are used
throughout the procedure to promote vasoconstriction
and limit perioperative ecchymoses.
POSTOPERATIVE CARE
The patients typically stay in an aftercare facility for 12
to 48 hours where registered nurses attend to their special
needs. Some patients choose to recover at home. We
recommend continuous use of cool compresses in the first
72 hours. Patients are encouraged to have their head
elevated. Antibiotics, analgesics, sleep, and antinausea
medications are prescribed to the patients.
On the first postoperative day, the dressing and drains
are removed. Hydrogen peroxide and antibiotic ointments
are utilized to keep the incisions clean and moist for the
first 5 days. An Ace wrap is then used when the patient is
at home and at night for the first week. Patients are
encouraged to take light showers starting on the second
postoperative day. The preauricular sutures are removed
on the third or fourth postoperative day, and Steri-Strips
(3M, St. Paul, MN) are applied. Staples are removed on
the sixth or seventh postoperative day. The patients are
seen again at the 4-week mark. During this visit, dermal
fillers, volumizers, and botulinum toxin type A are
utilized to address the midface as well as the perioral and
periorbital rhytids (Figs. 10-16 to 10-18).
COMPLICATIONS
Box 10-4 summarizes potential complications associated
with the short-flap rhytidectomy. We have not performed
a prospective randomized study to ascertain the exact
complication rate with the short-flap rhytidectomy.
However, our experience has shown that the short-flap
rhytidectomy lowers the risk for facial hematoma, flap
necrosis, and facial nerve palsy when compared to other
rhytidectomy techniques. The rates of cervical hematoma,
postauricular skin necrosis, alopecia, and numbness is
similar to those for other facelift methods. We have not
noted an increase in the rate of revision surgery with this
technique.
Future Considerations
Patients’ desires for less invasive procedure have become
a common trend during the last decade of aesthetic
plastic surgery. Mini-facelifts, “thread lifts,” and other
limited procedures dominate the television and print
media. The future of facial rejuvenation will likely
converge on combining a variety of surgical and
nonsurgical modalities. Longer lasting fillers, volumizers,
and new noninvasive technology will likely reduce the
number of patients who will opt for surgical intervention.
Time-tested procedures such as facelifts, blepharoplasty,
and browlifts will however continue to be very important
tools for facial rejuvenation. Volume restoration will have
an even a more prominent role in the treatment of the
aging face and eyes.
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Babak Azizzadeh • Tessa A. Hadlock • Mack L. Cheney
Box 10-4
Complications Associated with Short-Flap
Rhytidectomy
1. Cervicofacial hematoma
2. Alopecia
3. Scar
4. Skin slough
5. Infection
6. Numbness
7. Need for revision surgery
8. Facial nerve injury

CHAPTER 10
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167
Figure 10-16 Preoperative (A and C) and early postoperative (B and D) photos of a 37-year-old woman with premature aging who underwent short-
flap SMAS rhytidectomy and upper blepharoplasty.
A
B
C
D

168
Babak Azizzadeh • Tessa A. Hadlock • Mack L. Cheney
Figure 10-17 Preoperative (A, C, and E) and 7-month postoperative (B, D, and F) photos of a 52-year-old woman who underwent short-flap SMAS
rhytidectomy and pinch lower blepharoplasty. The patient also had calcium hydroxylapatite (Radiesse) injections to the nasolabial folds and botulinum toxin
type A (Botox) treatment for her periorbital rhytids in the immediate postoperative period.
A
B
C
D

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169
Figure 10-17 Continued.
E
F
A
B
Figure 10-18 Preoperative (A, C, and E) and 8-month postoperative (B, D, and F) photos of a 67-year-old woman who underwent short-flap SMAS
rhytidectomy, endoscopic browlift, blepharoplasty, and 30% trichloroacetic acid peel. The patient also had calcium hydroxylapatite (Radiesse) injections to
the nasolabial folds and marionette furrows in the immediate postoperative period.

170
Babak Azizzadeh • Tessa A. Hadlock • Mack L. Cheney
C
D
E
F

REFERENCES
1. Bettman A: Plastic and cosmetic surgery of the face. NW Med
1920;19:205.
2. Bourget J: La disparition chiurgicale des rides et plis du
visage. Bull Acad Med (Paris) 1919;82:183.
3. Aufricht G: Surgery for Excessive Skin of the Face.
Transactions of the Second International Congress of Plastic
Surgery. Edinburgh: Livingstone, 1960, p 495.
4. Guerrero-Santos J, Espaillat L, Morales F: Muscular lift in
cervical rhytidoplasty. Plast Reconstr Surg 1974;54:127.
5. Webster RC, Smith RC, Papsidero MJ, et al: Comparison of
SMAS plication with SMAS imbrication in face lifting.
Laryngoscope 1982;92:901.
6. Skoog T: Plastic Surgery: New Methods and Refinements.
Philadelphia: WB Saunders, 1974.
7. Mitz V, Peyronie M: The superficial musculoaponeurotic
system (SMAS) in the parotid and cheek area. Plast Reconstr
Surg 1976;58:80.
8. Owsley JO Jr: SMAS-platysma face lift. Plast Reconstr Surg
1983;71(4):573.
9. Fodor PB: Platysma-SMAS rhytidectomy—A personal
modification. Aesthet Plast Surg 1982;6(3):173.
10. Jost G, Lamouche G: SMAS in rhytidectomy. Aesthet Plast
Surg 1982;6(2):69.
11. Kamer FM, Halsey W: The two-layer rhytidectomy. Arch
Otolaryngol 1981;107(7):450.
12. Adamson JE, Todsu AE: Progress in rhytidectomy by
platysma-SMAS rotation and elevation. Plast Reconstr Surg
1981;68(1):23.
13. Rees TD, Aston SJ: A clinical evaluation of the results of
submusculo-aponeurotic dissection and fixation in face lifts.
Plast Reconstr Surg 1977;60(6):851.
14. Baker DC: Lateral SMASectomy. Plast Reconstr Surg
1997;100(2):509.
15. Hamra ST: The deep plane rhytidectomy. Plast Reconstr Surg
1990;86(1):53-61, discussion 62.
16. Hamra ST: Composite rhytidectomy. Plast Reconstr Surg
1992;90(1):1.
17. Kamer FM: One hundred consecutive deep plane face lifts.
Arch Otolaryngol Head Neck Surg 1996;122:17.
18. Godin MS, Johnson CM: Deep plane/composite rhytidectomy.
Facial Plast Surg 1996;12(3):231.
19. Alsarraf R, Johnson CM: The Aging Face: A Systematic
Approach. Philadelphia: WB Saunders, 2002.
20. Baker SR: Triplane rhytidectomy. Combining the best of all
worlds. Arch Otolaryngol Head Neck Surg 1997;123:1167.
21. Tessier P: Lifting facial sous-perioste. Ann Chir Plast Esthet
1989;34:193.
22. Psillakis JM, Rumley TO, Carmargos A: Subperiosteal
approach as an improved concept for correction of the aging
face. Plast Reconstr Surg 1988;82:383.
23. Ramirez OM: The subperiosteal approach for the correction of
the deep nasolabial fold and the central third of the face. Clin
Plast Surg 1995;22(2):341.
24. Ramirez OM, Maillard GF, Musolas A: The extended
subperiosteal facelift: A definitive soft tissue remodeling for
facial rejuvenation. Plast Reconstr Surg 1991;88:227.
25. Ramirez OM: Endoscopic full facelift. Aesthet Plast Surg
1994;18:363.
26. Ramirez OM: Three-dimensional endoscopic midface
enhancement: A personal quest for the ideal cheek
rejuvenation. Plast Reconstr Surg 2002;109(1):329-40,
discussion 341.
27. Quatela VC, Choe KS: Endobrow-midface lift. Facial Plast
Surg 2004;20(3):199.
28. Williams EF 3rd, Vargas H, Dahiya R, et al: Midfacial
rejuvenation via a minimal-incision brow-lift approach:
critical evaluation of a 5-year experience. Arch Facial Plast
Surg 2003;5(6):470.
29. Quatela VC, Jacono AA: The extended centrolateral
endoscopic midface lift. Facial Plast Surg 2003;19(2):199.
30. Isse NG: Endoscopic facial rejuvenation: endoforehead, the
functional lift. Aesthet Plast Surg 1994;18:21.
31. Furnas DW: The retaining ligaments of the cheek. Plast
Reconstr Surg 1989;83(1):11.
32. Stuzin JM, Baker TJ, Gordon HL: The relationship of the
superficial and deep facial fascias: Relevance to rhytidectomy
and aging. Plast Reconstr Surg 1992;89(3):441.
33. Hoefflin SM: The extended supraplatysmal plane (ESP) face
lift. Plast Reconstr Surg 1998;101(2):494.
34. Mendelson BC: SMAS fixation to the facial skeleton: Rationale
and results. Plast Reconstr Surg 1997;100(7):1834-1842.
35. Ozdemir R, Kilinc H, Unlu RE, et al: Anatohistologic study of
the retaining ligaments of the face and use in face lift:
Retaining ligament correction and SMAS placation. Plast
Reconstr Surg 2002;110(4):1134.
36. Mendelson BC, Muzaffar AR, Adams WP: Surgical anatomy of
the midcheek and malar mounds. Plast Reconstr Surg
2002;110:885.
37. Muzaffar AR, Mendelson BC, Adams WP: Surgical anatomy of
the ligamentous attachments of the lower lid and lateral
canthus. Plast Reconstr Surg 2002;110:873.
38. Webster RC, Davidson TM, White MF, et al: Conservative face
lift surgery. Arch Otolaryngol 1976;102(11):657.
39. Webster RC, Smith RC, Smith KF: Face lift, Part I: Extent of
undermining of skin flaps. Head Neck Surg 1983;5:525.
40. Webster RC: Facelifts: Conservative vs. radical. In Ward P,
Berman W (eds): Plastic and Reconstructive Surgery of the
Head and Neck. St. Louis: CV Mosby, 1984, pp 363-382.
41. Webster RC, Hamdan U, Fuleihan N, et al: The considered
and considerate facelift. Am J Cosmet Surg 1985;2:1.
42. McCollough EG, Perkins SW, Langsdon PR: SASMAS
suspension rhytidectomy. Arch Otolaryngol Head Neck Surg
1989;115:228.
43. Burgess LP, Casler JD, Kryzer TC: Wound tension in
rhytidectomy: Effects of skin flap undermining and superficial
musculoaponeurotic system suspension. Arch Otolaryngol
Head Neck Surg 1993;119(2):173.
44. Rees TD, Liverett DM, Guy Cl: The effect of cigarette smoking
on skin flap survival in the face lift patient. Plast Reconstr
Surg 1984;73:911.
45. Adamson PA, Moran ML: Complications of cervicofacial
rhytidectomy. Facial Plast Surg Clin North Am
1993;1(2):257.
46. Hamra ST: Discussion. Plast Reconstr Surg 1996;98:1144.
47. Binder WJ: Submalar augmentation: A procedure to enhance
rhytidectomy. Ann Plast Surg 1990;24(3):200.
48. Webster RC, Kattner MD, Smith RC: Injectable collagen for
augmentation of facial areas. Arch Otolaryngol
1984;110(10):652.
49. Seckel BR: Facial Danger Zones: Avoiding Nerve Injury in
Facial Plastic Surgery. St. Louis: Quality Medical Publishing,
1994.
50. Owsley JQ, Zweifler M: Midface lift of the malar fat pad:
technical advances. Plast Reconstr Surg 2002;110(2):674.
51. Owsley JQ: Rejuvenation of the midface. Plast Reconstr Surg
2001;108(1):262.
CHAPTER 10
Short-Flap SMAS Rhytidectomy
171

52. Owsley JQ: Face lifting: Problems, solutions, and an outcome
study. Plast Reconstr Surg 2000;105(1):302.
53. Owsley JQ, Fiala TG: Update: Lifting the malar fat pad for
correction of prominent nasolabial folds. Plast Reconstr Surg
1997;100(3):715.
54. Becker FF, Bassichis BA: Deep-plane vs. superficial
musculoaponeurotic system placation face-lift. Arch Facial
Plast Surg 2004;6:8.
55. Ivy EJ, Lorenc ZP, Aston SJ: Is there a difference? A
prospective study comparing lateral and standard SMAS face
lifts with extended SMAS and composite rhytidectomies. Plast
Reconstr Surg 1996;98(7):1135.
56. Anderson JR: The tuck-up operation, a new technique of
secondary rhytidectomy. Arch Otolaryngol 1975;101(12):739.
57. Kamer FM, Parkes ML: Sequential rhytidectomy.
Laryngoscope 1978;88(7 Pt 1):1196.
58. Kamer FM: Sequential rhytidectomy and the two stage
concept. Otolaryngol Clin North Am 1980;13(2):305.
59. Yousif NJ, Gosain A, Matloub HS, et al: The nasolabial fold:
An anatomic and histologic reappraisal. Plast Reconstr Surg
1994;93:60.
60. Rees TD, Aston SJ: Complications of rhytidectomy. Clin Plast
Surg 1978;5:109.
61. Baker DC: Complications of cervicofacial rhytidectomy. Clin
Plast Surg 1983;10(3):543.
62. Dedo DD: “How I do it”—Plastic surgery. Practical
suggestions on facial plastic surgery. A pre-operative
classification of the neck for cervicofacial rhytidectomy.
Laryngoscope 1980;90(11 Pt 1):1894.
172
Babak Azizzadeh • Tessa A. Hadlock • Mack L. Cheney

HISTORY
The tridimensional endoscopic facelift is based upon the
construct of the subperiosteal facelift technique initially
described by Tessier.1
Tessier conceived that this
“orthomorphic” subperiosteal facelift would be an inno-
vative way to provide facial rejuvenation in young and
middle-age patients.2 Subsequently, Psillakis published
his modifications to the subperiosteal approach, demon-
strating that extensive lateral periorbital dissection could
provide improved rejuvenation of the cheek region.3 Soon
after, several authors demonstrated their experience with
the subperiosteal techniques.4,5 The extended subperiosteal
facelift, described in 1991, introduced several innovative
concepts including extensive midface dissection, improved
suspension techniques, and a safer method of access
across the zygomatic arch.6 Further refinements in the
extended subperiosteal technique7-9 ushered in the era of
endoscopy. In the mid-1990s, techniques adapted from
the open subperiosteal rhytidectomy approach proved
that endoscopic methods could be developed to perform
facial rejuvenation.10-12
Over the past decade, the senior author has dedicated
his practice to facial rejuvenation using the tridimensional
endoscopic facelift technique. The knowledge and expe-
rience developed from this approach are presented in this
chapter. The authors hope to provide insight into their
comprehensive approach to endoscopic facial rejuvenation.
PERSONAL PHILOSOPHY
The aging face is characterized by volumetric change
caused by a reduction of the soft tissues and resorption of
bone.13 The volumetric changes affect the central part of
the face earlier than the peripheral areas of the face. The
central portion of the face comprises the mimetic and
sphincteric muscles allowing facial expressions. The
peripheral portion of the face is more static and thus more
resistant to the aging process. Thus, the face can be
broken down into two distinct aesthetic units: the central
oval and the peripheral hemicircle.14 The central oval is
composed of the loose, dynamic structures that fall prey
to the gravitational forces of nature. Combined with loss
of bone volume, it becomes evident that the deflation and
gravitational migration of the soft tissues lead to “earlier
aging” of the central oval of the face.
The authors favor a comprehensive approach for
rejuvenation of both the central oval and peripheral hemi-
circle of the face. Basic tenets to this approach include (1)
a direct approach to the central oval of the face; (2) an
interconnected subperiosteal plane of dissection in the
upper and midface; (3) use of small hidden slit incisions;
(4) absence of visible incisions on the central oval; (5) use
of endoscopic techniques; (6) absence of traction with the
skin or SMAS (superficial musculoaponeurotic system)
from the peripheral hemicircle; (7) ability to modify the
skeletal framework in the same operative plane; and (8)
ability to correct the deficit of soft tissue volume.
Rejuvenation of the central oval of the face can be
accomplished with endoscopic forehead lift,15 endoscopic
midface lift,16 and mentopexy procedures. The endoscopic
forehead lift and midface lift procedures can be used for
all degrees of facial rejuvenation. Mentopexy is performed
in selective cases. Rejuvenation in the peripheral
hemicircle focuses upon the neck and jawline and can be
accomplished through a variety of techniques. Younger
patients with good skin tone and moderate submandibular
fat
accumulation
benefit
from
the
nonexcisional
cervicoplasty.17 The suture suspension method described is
based upon the techniques developed by Giampapa18 and
Guerro-Santos19 in which important modifications have
been made by the senior author. Patients with severe
laxity of the skin are treated with a traditional excisional
cervicoplasty through submental and periauricular
incisions. In select patients, skeletal augmentation of the
jawline is necessary to achieve harmony between the
aesthetic units of the face. The mandibular matrix
system20
has been developed to correct skeletal
deficiencies of the jawline, give more angularity to the
jawline, and to provide support for the soft tissues.
Because of the individual nature of the aging process,
facial rejuvenation can be provided through the use of soft
tissue manipulation, soft tissue augmentation, and allo-
plastic augmentation (Fig. 11-1). The goal of this chapter
is to provide the authors’ approach toward the treatment
of the aging face. The techniques described form the com-
ponents of the tridimensional endoscopic facelift procedure.
Tridimensional Endoscopic Facelift
Oscar M. Ramirez, MD, FACS • Charles R. Volpe, MD
173
C H A P T E R E L E V E N

174
Oscar M. Ramirez • Charles R. Volpe
Bidimensional Lift
Implants
Imbrication
Fat Grafting
Vascularized Fat Mobilization
Figure 11-1 This schematic diagram shows the components available for three-dimensional facial rejuvenation. Bidimensional lifting in vertical and lateral
planes provides the foundation of the endoscopic facelift. Weak skeletal support can be corrected with alloplastic implants, as shown in the upper left corner
of the diagram. Fat grafting, as shown in the upper right corner, is commonly used to enhance areas not corrected by lifting techniques. In addition, fat
grafting is used to treat small areas of depression or creases caused by subdermal damage. Imbrication of soft tissues is amenable in the brow, maxillary
malar area, and mentum, as shown in the lower left corner. The lower right corner of the diagram shows the areas useful for augmentation by adjacent
vascularized fat mobilization, including upper orbital rim augmentation with the upper eyelid fat pads, the infraorbital rim tear-trough area with the lower
eyelid fat pads, and cheek augmentation with Bichat’s fat pad. (From Ramirez OM: Full face rejuvenation in three dimensions: A “face-lifting” for the new
millennium. Aesthet Plast Surg 2001;25:152-164, used with permission from Springer-Verlag, New York.)

ANATOMY OF FACIAL AGING
Successful rejuvenation of the face requires a thorough
understanding of the anatomic changes associated with
aging. Characteristic features in the frontal region include
visible spasm of the corrugator muscles, deep set eyes,
and the appearance of deflated brows with hooding and
upper eyelid skin excess. The temporal region becomes
hollowed. The lower eyelids demonstrate orbital fat
herniation, and in advanced stages, exposure of the lower
orbital rim leads to creation of a “tear-trough” deformity.
The malar area is characterized by loss of thickness and
ptosis of Bichat’s fat pad. Reduction in mandibular volume
through bone resorption results in loss of projection at the
mandibular border and hollowness around the jowls. The
mandibular bone loss is accentuated in edentulous
patients.21 The chin is subjected to loss of tissue bulk and
ptosis leading to the “witch’s chin” deformity, as coined
by Gonzales-Ulloa.22 Facial expression lines become
accentuated owing to collagen damage and loss of elastic
fibers. Significant skin laxity, horizontal neck creases,
accumulation of fat in the submental and submandibular
regions, platysmal banding, and development of an
obtuse cervicomental angle are characteristic.
PREOPERATIVE ASSESSMENT
Patients are all examined in a well-lit room, in a seated
position. An initial assessment is performed, noting medical
history, surgical history, current medications including herbal
supplements, and allergies. Social and family history is
noted. A detailed history of previous cosmetic procedures
is obtained. Patients are then given the opportunity to
express their concerns. We find it extremely helpful to
provide the patient with a handheld mirror during this
part of the examination. Understanding the patient’s
desires allows the proper surgical plan to be developed.
Finally, a directed physical examination is performed
noting the stigmata of the aging process.
Access to photographs of the patient at a younger age
can be quite helpful in the creation of a surgical plan.
Patients are encouraged to provide them when possible.
We keep a book of beautiful faces cut from magazines in
each examination room as an aid to explain aesthetic
principles and features. If alloplastic implantation is
considered, skeletal models and sample implants are avail-
able to assist in the explanation of proposed surgical
procedures. A comprehensive collection of preoperative
and postoperative patient results is available to the
patients for perusal. In our opinion, these visual aids are
essential to attain the desired aesthetic outcome and
patient satisfaction.
PHOTOGRAPHIC DOCUMENTATION
Using a standardized photography studio setup, a series
of photographs are compiled prior to surgery. A full-face
(anteroposterior, AP) frontal view, right and left three-
quarter (oblique) views, right and left lateral views, and a
45-degree down-tilted frontal (AP) view are the minimum
images acquired. Ancillary images are acquired based
upon the developed surgical plan. The images are printed
prior to the operative procedure and are posted in the
operating room for intraoperative reference. Similar post-
operative photographs are acquired at 3, 6, and 12 months,
respectively, and on a yearly basis thereafter. By maintaining
a detailed photographic record of the preoperative and
postoperative results, careful analysis of the three-
dimensional contour changes can be performed.
ADDRESSING THE CENTRAL OVAL OF THE FACE
Heeding the anatomic principles of facial aging, one can
see that a comprehensive approach to facial rejuvenation
is required to maximize the aesthetic results (see Fig.
11-1). The tridimensional facelift technique embraces this
concept. The comprehensive approach developed focuses
on both the central oval and peripheral hemicircle of the
face. The endoscopic forehead lift and endoscopic midface
lift procedures provide the foundation for treating the
central oval of the face, bolstered by the mentopexy
procedure in select patients.
SURGICAL TECHNIQUE
ENDOSCOPIC FOREHEAD LIFT PROCEDURE
The endoscopic forehead lift procedure begins with
careful placement of four incisions in the scalp. The first
two incisions are located approximately 2.0 cm on either
side of the midline, 1.0 to 2.0 cm posterior to the hairline.
For patients with excessively long foreheads (>8 cm) these
paramedian incisions are placed directly at the hairline. It
is important to keep the forehead incisions as anterior as
possible. Otherwise, visualization and dissection in the
glabellar region will be compromised. The next set of
incisions is located in the temple region, bilaterally,
2.0 cm posterior to the hairline. The incisions should be
directed parallel to the hair follicles to prevent un-
necessary alopecia postoperatively. Each incision should
measure 1.5 cm in length (Fig. 11-2).
Prior to surgical dissection, local anesthesia using
50 mL of 0.5% lidocaine with 1:200,000 epinephrine is
diffusely distributed in both the subcutaneous and
subperiosteal planes. Early administration of the anesthetic
will provide maximal hemostasis, which is required during
endoscopic visualization.
CHAPTER 11
Tridimensional Endoscopic Facelift
175

For optimization of the operative procedure, the fore-
head is methodically divided into four zones that cor-
respond with the sequence of facial dissection (Fig. 11-3).
Zone 1 corresponds to the lateral region bounded by the
temporalis musculature and zygomatic arch. The upper
portion of zone 1 (zone 1A) can be safely dissected in a
“blind” fashion. The lower portion of zone 1 (zone 1B)
requires dissection under strict endoscopic guidance.
Important neurovascular structures, including the frontal
branch of the facial nerve, pass through this zone. Zone 2
extends from the hairline to the middle of the forehead.
Zone 3 begins at the hairline and extends posteriorly to
the vertex of the scalp. Zone 4 corresponds to the area
bounded by the superior orbital rims and nasal root
inferiorly and the middle of the forehead superiorly. Vital
structures, such as the supraorbital and supratrochlear
nerves, are located in this zone.
The endoscopic procedure begins with the incision in
the temporal area (the upper portion of zone 1). This
incision is located perpendicular to a tangent drawn from
the nasal ala to the lateral canthal tendon and is 2 cm
inside the temporal scalp (see Fig. 11-2). A 1.5- to 1.8-cm
incision is made through the skin and subcutaneous
tissue, deep through the superficial temporal fascia until
the temporal fascia proper is reached. Dissection is
intiated to clear all the soft tissues from the temporal
fascia proper. Dissection continues inferiorly remaining
above the intermediate temporal fascia. As mentioned
previously, the initial dissection (upper portion of zone 1)
can be performed blindly in a circumferential fashion for
approximately a 2-cm radius. With the tissues elevated, a
Silastic port protector is inserted and the remainder of the
dissection is performed under endoscopic control.
Elevator No. 8 of the Ramirez endoscopic instrument
set (Snowden-Pencer, Inc., Tucker, GA) is used to dissect
to the temporal line of fusion superiorly. The elevator is
then used to score and elevate the periosteum 1 cm medial
to the temporal line of fusion. This is continued superiorly
through the lateral portions of zones 4, 2, and 3,
respectively.
This dissection will aid in the connection of the
temporal and frontal pockets, later in the case. Dissection
continues from the temporal incision in an inferior and
medial direction around the lateral orbital rim. During the
course of this dissection, several temporal veins will come
into view. Temporal vein 1, situated in the region of the
zygomaticofrontal suture, is usually sacrificed. Temporal
vein 2 (also referred to as the “sentinel vein”) is encoun-
176
Oscar M. Ramirez • Charles R. Volpe
2.5 cm
2 cm
3 cm
Figure 11-2 Reference lines and measurements for the placement of
the endoscopic incisions. Note that an imaginary line drawn on a tangent
from the lateral border of the nasal ala through the lateral canthal tendon
determines proper placement of the temporal incision.
Figure 11-3 The zone system has been developed to aid safe
dissection during the endoscopic forehead and midface procedures.
Endoscopic visualization is mandatory when dissecting in zones 1b and 4.
Zone 3
Zone 2
Zone 1a
Zone 1b
Zone 4

tered while dissecting toward the zygomatic arch. Branches
of the zygomaticotemporal nerve may be identified during
this dissection. Temporal vein 3 lies just above the
zygomatic arch at the junction of its middle and posterior
thirds. This is usually not exposed. Temporal vein 2,
temporal vein 3, and the branches of the zygomati-
cotemporal nerve should be preserved when possible.
Preservation of these structures is facilitated with a blunt
rounded tip elevator. As the procedure progresses
inferiorly, the dissection plane moves from temporal fascia
proper to the intermediate temporal fascia. The inter-
mediate temporal fat pad will be visualized through the
thin intermediate temporal fascia. Dissection along the
lateral orbital wall progresses inferiorly to the level of
the lateral canthus. This completes the lateral dissection
of the endoscopic forehead procedure.
The paramedian incisions are then made as
previously described and are carried down through the
periosteum. Dissection in zones 2 and 3 can be performed
with a blind sweeping technique, as long as the dissection
remains in a subperiosteal plane. The endoscope is inserted
during dissection in zone 4. In general, zone 4 begins about
3 cm from the superior orbital rims. Endoscopically
assisted dissection should always be performed in zone 4
(Fig. 11-4). The initial dissection proceeds toward the
lateral aspect of the superior orbital rim. Further
dissection laterally toward the temporal line of fusion will
allow connection of zones 1 and 4. The dissection then
proceeds in a medial direction along the superior orbital
rim. Cautious dissection in this area is mandatory. The
authors have noted variations in the supraorbital nerve
anatomy. Occasionally, an accessory branch of the
supraorbital nerve can be identified as far as 3.0 cm
superior and lateral to the supraorbital nerve proper.
Every effort should be made to preserve any accessory
nerve branch. After identification of the supraorbital nerve,
dissection continues medially, exposing the origins of the
corrugator muscles. The supratrochlear nerve travels in
the substance of the corrugator muscles, so careful
elevation of the corrugators is required. Typically, three
fascicles of the supratrochlear nerve are identified and
preserved. Prior to resection of the corrugator muscle, the
periosteum of the superior orbital rim is released with a
curved elevator. The periosteum should be released from
the zygomaticofrontal suture line laterally, moving
medially toward the glabella. In patients with heavy
tissues, especially males, the periosteum is released by
cutting it with endoscopic scissors. With the periosteum
cut medially, the supratrochlear nerve and corrugator
muscles are clearly delineated.
The corrugator muscle is extensively resected from its
point of origin to just beyond the supraorbital nerve (Fig.
11-5). We prefer to resect approximately 80% of the
corrugator muscle to assure that glabellar frown lines are
eliminated. Once the corrugator has been removed, the
depressor supercilii muscle can occasionally be identified.
CHAPTER 11
Tridimensional Endoscopic Facelift
177
Figure 11-4 Dissection during the endoscopic forehead facelift should
extend down along the supraorbital rims and nasal radix to completely
elevate the periosteum in the inferior border of zone 4.
Corrugator m.
Procerus m.
Figure 11-5 The endoscopic grasper is used to resect the corrugator
and procerus muscles as shown.

Resection of the depressor supercilii muscle is indicated if
medial brow ptosis is present. An endoscopic scissor then
is used to divide the periosteum deep to the procerus
muscle. The procerus muscle is resected after being
thoroughly exposed. Resection of the procerus muscle
should proceed down to the level of the nasoglabellar
angle. Occasionally, bleeding will occur during procerus
resection. Given the superficial location of the dissection,
care must be taken when using cautery in this area.
Overzealous cauterization in this location can lead to
disastrous consequences (burning of the skin). When the
muscle resection is complete, the area is packed with
epinephrine-soaked pledgets. Attention is then directed
back to the temporal region where the endoscopic midface
lift is started at this point. Completion of the endoscopic
forehead lift procedure with elevation and fixation of the
brow typically follows completion of the endoscopic
midface suspension. An example of a pure endoscopic
forehead lift can be seen in Figures 11-6 through 11-8.
ENDOSCOPIC MIDFACE LIFT PROCEDURE
The endoscopic midface lift procedure begins with the
temporal dissection in zone 1, as outlined in the previous
section. The temporal vein 2 (sentinel vein), temporal
vein 3, and the zygomaticotemporal nerves are preserved
178
Oscar M. Ramirez • Charles R. Volpe
Figure 11-6 Anterior views of a patient who underwent a pure endoscopic forehead procedure. The preoperative view is shown to the left. Improved
brow position is shown in the postoperative view on the right.
Figure 11-7 Three-quarter views of the patient shown in Figure 11-6. Note the softening of the glabellar creases and more youthful position of the brows
in the postoperative view (right).

when possible. The dissection continues in an anterior
and inferior direction, remaining above the intermediate
temporal fascia. Dissection along the intermediate
temporal fascia continues down to the level of the
zygomatic arch. The zygomatic arch is entered 2 to 3 mm
above the superior border of the arch. This requires
division of the intermediate temporal fascia, thus exposing
the periosteum of the zygomatic arch. The anterior two
thirds of the zygomatic arch periosteum are typically
elevated. We find that greater lifting and redistribution of
the midface soft tissues occur with this approach. The
periosteum of the entire zygomatic arch is elevated only
when soft tissues lateral to the cheek need to be lifted.
A word of caution is necessary at this point. Comfort
with the endoscopic dissection over the zygomatic arch
from the temporal area is associated with a significant
learning curve. Moving from the plane of intermediate
temporal fascia to zygomatic arch periosteum, although
conceptually simple, can be difficult in practice. Therefore,
we advocate that surgeons pre-elevate the zygomatic arch
or at least elevate to the superior border of the arch from
an intraoral approach during the learning process. Pre-
elevation in this manner will allow safe communication of
both the temporal and lower midface dissection pockets,
later in the case. As skill and comfort with the technique
increase, dissection can be performed as originally
outlined.
The midface dissection at this point continues
through an intraoral (upper buccal sulcus) incision. The
authors’ preferred incision is perpendicular to the alveolar
ridge (vertical) at the level of the first premolar. We find
that the vertically oriented incision preserves the mucosal
integrity at the alveolar ridge, allowing a rapid, watertight
closure that is associated with fewer complications. Under
direct visualization, the initial subperiosteal dissection of
the maxilla and malar area is performed. The endoscope
is used for the upper malar dissection. The use of the
endoscope minimizes trauma to the midface structures
caused by excessive traction. The endoscope is most
useful during periosteal elevation along the lateral half of
the zygoma body, its extension underneath the fascia of
the masseter muscle, and the anterior two thirds of the
zygomatic arch. The fascia covering the upper (medial)
portion of the masseter tendon is also elevated from the
zygoma. A few longitudinal fibers can be included in the
elevated flap as necessary. Endoscopic visualization
assists in the preservation of the zygomaticofacial nerve.
Dissection continues along the inferior and lateral
orbital rim and continues toward the superior border of
the zygomatic arch. Skeletonization of the infraorbital
nerve is not necessary under most circumstances.
With the initial midface dissection now complete, the
endoscope is returned to the temporal area. An assistant
elevates the soft tissue of the midface, thus allowing the
surgeon to safely connect the temporal and midface
dissection pockets under endoscopic control. Gentle
elevation during this step protects the frontal branch of
the facial nerve from injury. With wide communication of
the temporal and midface pockets, the endoscope is
returned through the upper buccal sulcus incision.
The inferior orbital rim is dissected further by
elevating the inferior arcus marginalis. A 4-0 PDS (poly-
dioxanone) suture (Ethicon, Somerville, NJ), introduced
endoscopically, is used to imbricate the medial sub-
orbicularis oculi fat (SOOF) to the lateral aspect of the
inferior arcus marginalis. It is important to check eye
CHAPTER 11
Tridimensional Endoscopic Facelift
179
Figure 11-8 Lateral views of the patient in Figures 11-6 and 11-7. Brow ptosis is evident in the preoperative view (left). The postoperative image (right)
shows an aesthetically pleasing brow position.

globe mobility at this point with a forced duction test
because improper placement of this imbricating suture
can indirectly trap or place traction upon the inferior
rectus muscle.
The lateral aspect of the suborbicularis oculi fat is
then grasped with a 3-0 PDS suture, providing the first of
three suspension sutures (Fig. 11-9). Both ends of this
suture are then passed through the temporal incision,
under endoscopic guidance. We find it helpful to tag the
suture ends of each suspension suture with a labeled
needle driver. This allows the surgeon to keep track of
each suspension suture without confusion. The second
suspension suture is the lower cheek imbrication, or
“modiolus” suture. This suture is placed into the tenuous
periosteal/fascia/fat of the inferior maxillary soft tissue
near the upper buccal sulcus incision. Both ends of this
suture are then directed through the temporal incision
and tagged, as previously described.
Exposure of Bichat’s fat pad follows the placement of
the first two suspension sutures. Bichat’s fat pad is
approached through the superomedial wall of the buccal
space. The periosteum and buccinator muscle are spread
with the use of a blunt dissector. This allows Bichat’s fat
pad to herniate through maintaining an intact capsular
fascia. The fat pad should be carefully dissected free from
the wall of the buccal space. The fat pad should be easily
movable for repositioning as a pedicle flap. A 4-0 PDS
suture is then woven into the fat pad and the suture ends
are delivered to the temporal area, similar to the previous
suspension sutures. The endoscope should be used to
visualize the delivery of the pedicled fat flap over the
zygomatic arch. The endoscope can also assess the
trajectory of the suspensions sutures. It is important to
avoid criss-crossing the suspension sutures as they are
passed temporally.
Each of the suspension sutures is then secured to the
temporal fascia proper, in ordered fashion. The sutures
should be placed in the temporal fascia proper, below the
level of the temporal incision. The first suture, the Bichat’s
pad fat suspension, should be placed most medially. The
inferior malar periosteum/fascia/fat or modiolus suture is
placed next, in a more lateral location of the temporal
fascia proper. The most lateral suture, the suborbicularis
oculi fat suture, is the last to be anchored to the temporal
fascia proper. This completes the suspension of the midface.
Butterfly drains are placed bilaterally through
separate stab incisions in the temporal scalp. Each drain
is carefully directed into the midface and secured to the
temporal scalp with a suture. The superficial temporal
fascia is then anchored to the temporal fascia proper with
two 4-0 PDS sutures, while an assistant provides super-
omedial traction to the advanced scalp. This maneuver
will provide additional support to the suspended soft
tissues. The intraoral incisions are then closed with inter-
rupted 4-0 chromic catgut sutures, to provide a watertight
closure.
Attention, at this point, is directed back to the
forehead region where drain placement, closure of the
paramedian incisions, and brow elevation is performed.
Briefly, two suction drains are placed through
separate stab incisions in the scalp, adjacent to the
paramedian access ports. An endoscopic biter is used to
direct the tips of the drains to the level of the glabella and
the anterior forehead. Each drain is secured with a heavy
drain stitch. The paramedian incisions are closed in two
layers. A blunt traction hook is then used to elevate the
scalp and to position the brow. When proper brow
position is obtained, a small stab incision is made in the
scalp, with a No. 11 scalpel. A 1.1-mm drill bit with a
4-mm stop is inserted through the stab incision and a
unicortical hole in the calvarium is drilled. A 1.5-mm
titanium post (Synthes, Paoli, PA) is then placed in the
drill hole. In most cases, two paramedian posts (one on
each side) are sufficient to maintain the proper brow
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Oscar M. Ramirez • Charles R. Volpe
SOOF
Modiolus
Buccal sulcus
incision
Bichat’s
fat pad
Figure 11-9 Treatment of the midface is performed with key
suspension sutures that provide lifting in a vertical direction. The sutures are
placed from the buccal sulcus incision and directed through the temporal
pocket created endoscopically. The orientation of the anchoring and
fixation of the corresponding sutures into the temporal fascia proper is
indicated. Bichat’s fat pad suture is woven through the fat pad and directed
in a superomedial direction to add lateral bulk to the cheek over the
zygomatic arch. The modiolus suture is directed in a tangential direction to
the nasolabial fold and provides lifting of the lower cheek soft tissues. The
suborbicularis oculi fat (SOOF) suspension suture is directed most laterally
and allows improvement of the tear-trough deformity.

position (Fig. 11-10). Location of the posts will have a
significant impact on brow position. Under most circum-
stances, post placement corresponds to a superomedial
axis from the lateral brow. This will provide maximal
elevation of the lateral brow. More central post placement
is chosen for patients requiring greater elevation of the
central and medial brow. Patient examples of full
endoscopic forehead and midface procedures are shown in
Figures 11-11 through 11-16.
MENTOPEXY
In select cases, addition of the mentopexy procedure is
required to provide aesthetic balance to the rejuvenated
central oval. The aging chin is a complex entity that fre-
quently is not properly addressed during facial rejuvenation
procedures. The “witch’s chin” deformity consists of ptosis
of the premental soft tissues, a prominent submental
crease, and often a loss of bony projection. In an effort to
address the complex pathophysiology of the witch’s chin
deformity, the authors present a multivariate approach
toward correction of the ptotic chin. Soft tissue manip-
ulation and the use of alloplastic implants play a role in
the treatment of the ptotic chin. A subperiosteal dissection
performed through a submental incision is used for each
of the procedures described.
The mentopexy procedure begins with a 3-cm
submental incision, placed one fingerbreadth posterior to
the native submental crease. The skin and subcutaneous
tissue are dissected down to the level of the platysma. A
skin/subcutaneous tissue flap is then generated, 2 cm in
both the anterior and posterior directions. The platysma
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Tridimensional Endoscopic Facelift
181
Figure 11-10 Arrows depict the vectors of pull to the soft tissues at the
completion of the endoscopic forehead/midface procedures. Suture
fixation of the temporal scalp to the temporal fascia proper will maintain the
soft tissue position. Screw fixation of the forehead will maintain the soft
tissue position of the brow in the immediate postoperative period.
Figure 11-11 This 50-year-old patient
had aging changes significant for her
chronologic age. She underwent an
endoscopic midface lift in conjunction with
an
endoscopic
forehead
lift
and
a
mentopexy type I (refer to Figs. 11-19 to
11-21). Note the nasolabial folds and the
jowling present in the preoperative (left)
view. Considerable brow ptosis and lateral
hooding are evident. Postoperatively (right),
the patient demonstrates improved midface
fullness and symmetry associated with a
more youthful appearance. The improved
brow position and absence of lateral
hooding are both evident.

is then incised vertically in the midline up to the level of
the inferior border of the mandible.
The periosteum is divided, in a similar fashion,
allowing the remainder of the procedure to be performed
in a subperiosteal plane. A blunt tip periosteal elevator
is then used to elevate the periosteum of the mandible in
an anterior and lateral direction. Anterior dissection
proceeds to the level of the oral mucosa. Perforation of the
oral mucosa is to be avoided. The periosteal dissection
proceeds laterally to the anterior border of the masseter
tendon. Care must be taken when dissecting around the
mental nerve foramina. We do not skeletonize the mental
nerves in an effort to prevent traction-related neuropraxia.
The type I and type II mentopexy procedures utilize
suspension of the ptotic soft tissue structures. Suspension
is performed with placement of the 3-0 PDS suture at the
182
Oscar M. Ramirez • Charles R. Volpe
Figure 11-12 Preoperative (left) and
postoperative (right) three-quarter views of
the patient shown in Figure 11-11. Improve-
ment in the forehead and midface aesthetic
can be clearly seen from the three-quarter
view. Support of the cheek mass, trans-
position of Bichat’s fat pad, and elevation of
the brow contribute to the more youthful
appearance.
Figure 11-13 Preoperative (left) and
postoperative (right) lateral views of the
patient in Figures 11-11 and 11-12. Elevation
of the lateral brow eliminates the hooding
seen in the preoperative view. Midface
rejuvenation provides significant improve-
ment of the lower eyelid to cheek transition.
In addition, the degree of jowling is reduced
and softening of the nasolabial fold results.

CHAPTER 11
Tridimensional Endoscopic Facelift
183
Figure 11-14 This 46-year-old patient
underwent an endoscopic midface lift pro-
cedure in conjunction with an endoscopic
forehead lift and mentopexy type II (refer to
Figs. 11-22 to 11-24). Preoperative (left) and
postoperative (right) frontal views are
shown, respectively. Note the improved
cheek mass position and softening of the
nasolabial folds.
Figure 11-15 Preoperative (left) and
postoperative (right) three-quarter views of
the patient shown in Figure 11-14. Slight
elevation of the brow and increased fullness
of the lateral cheek mass in the post-
operative view clearly defines a more
youthful appearance.

level of the lowermost aspect of the mentalis muscle/
periosteum. A bicortical drill hole is then created in the
midline of the mandibular symphysis. The drill hole
should be directed in a caudal fashion as shown in Figures
11-17 and 11-18. The suture is then directed through the
bone and tied along the posterior border of the mandible.
Evaluation of the proper chin position is noted prior to
skin closure. Patient examples of the type I and type II
mentopexy is shown in Figures 11-19 through 11-21 and
Figures 11-22 through 11-24, respectively.
The type III mentopexy procedure follows in a similar
fashion. Several caveats should be noted with this
technique. Location of the mental nerves should be noted
prior to chin augmentation. We routinely measure the
184
Oscar M. Ramirez • Charles R. Volpe
Figure 11-16 Preoperative (left) and
postoperative (right) lateral views of the
same patient shown in Figures 11-14 and 11-
15. Note the smooth transition from the
lower eyelid to cheek in the postoperative
(right) view.
A
B
Figure 11-17 The mentopexy type I. A shows the view seen from inferior to superior. The suture is placed in the chin soft tissue at the inferior aspect of
the mentalis muscle. B and C show the effect provided by suture fixation. The chin soft tissue is elevated in a superior and anterior direction. The 3-0 PDS
suture is passed through a midline hole drilled through the inferior border of the mandible and is secured to the posterior aspect of the mandible.
C

distance of each mental nerve from the midline as well as
the inferior border of the mandible with the use of calipers.
These measurements are then transferred to the chin
implant. Any overlap of the implant is removed, leaving a
2- to 3-mm gap around the mental nerve foramina. The
implants are secured to the bone with small titanium
screws placed in a bicortical fashion. The suspension
suture is then driven through the porous polyethylene
implant at the desired level. It is not necessary to place the
suture through the mandible, as described for the type I
and II techniques.
The type IV mentopexy technique, being a redraping
technique, does not require suture fixation, but fixation as
in a type I mentopexy can be used to centralize the chin.
Care must be taken during periosteal scoring to prevent
injury to the underlying mentalis musculature. Scoring
can be performed with a scalpel or electrocautery placed
on a low setting.
Complete mobilization of the periosteum to the level
of the anterior masseter tendon is crucial for the success
of all types of mentopexy. When the proper aesthetic
result is achieved, the dissection pocket is irrigated with
CHAPTER 11
Tridimensional Endoscopic Facelift
185
A
C
B
Figure 11-18 Mentopexy type II. The purse-string 3-0 PDS suture provides elevation and imbrication of the chin soft tissue. Fixation follows as described
in Figure 11-17.
Figure 11-19 Preoperative (left) and postoperative (right) views following a mentopexy type I procedure as seen from the anteroposterior projection.

186
Oscar M. Ramirez • Charles R. Volpe
Figure 11-20 Three-quarter views of the patient in Figure 11-19. Preoperative (left) and postoperative (right) views.
Figure 11-21 Lateral views of the patient in Figures 11-19 and 11-20. Note the chin pad ptosis and poor anterior projection of the chin in the preoperative
view (left). Postoperatively (right), the reference lines demonstrate the improved anterior projection of the chin following the type I mentopexy.
Figure 11-22 Anteroposterior views of a type II mentopexy patient. Preoperative (left) view and postoperative (right) result are shown.

antibiotic solution. The platysma is approximated in the
midline with interrupted sutures. The skin edges are
approximated with 5-0 or 6-0 Prolene sutures. Tape is
then applied to the chin for support. If adjunctive
aesthetic procedures are to be performed in the neck, the
submental incision is covered with a protective bio-
occlusive dressing to prevent desiccation. The incision is
then closed at the completion of the case.
ADJUNCTIVE PROCEDURES IN THE CENTRAL
OVAL OF THE FACE
Skin-Only Blepharoplasty
The endoscopic midface procedure effectively elevates the
cheek soft tissues in a superior direction. The recruitment
of soft tissue toward the lower eyelid can often be
significant. This effect can be exaggerated in patients with
lower eyelid skin excess. In situations in which excessive
lower eyelid skin exists, we perform a skin-only blepharo-
plasty procedure, using a standard subciliary incision.
Plication canthopexy or orbicularis muscle suspension can
be performed through this skin-only exposure. We find
this approach associated with a decreased risk of
ectropion and eyelid malposition.
Bichat’s Fat Pad Excision
A certain subset of patients who present for facial
rejuvenation demonstrate chubby cheeks, significant bulk
and pseudoherniation of Bichat’s fat pad, and good malar
bone support. Augmentation of the cheeks with Bichat’s
fat pad repositioning is relatively contraindicated in this
cohort. These patients benefit from excision of Bichat’s fat
pad rather than suspension. As previously outlined, the
periosteum and buccinator muscle are spread apart in the
superomedial wall of the buccal space. This will provide
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Tridimensional Endoscopic Facelift
187
Figure 11-23 Three-quarter views of the patient in Figure 11-22. Preoperative (left) and postoperative (right) images are shown. The type II mentopexy
was performed to address the mild clefting in the chin soft tissue seen in the preoperative view. The purse-string suture of the type II mentopexy obliterated
the soft tissue cleft and provided improved chin aesthetics.
Figure 11-24 Lateal views of the patient in Figures 11-22 and 11-23. Ptosis of the chin in the preoperative (left) view is corrected with the mentopexy
procedure as shown with the postoperative result (right).

exposure of Bichat’s fat pad. The fat pad will readily
herniate through the opening in the periosteum/
buccinator muscle. With two pairs of blunt forceps, the fat
pad can be gently teased out and resected. However, care
must be taken during delivery and resection of the fat
pad. Undue traction of the fat pad can result in injury to
neurovascular structures or Stensen’s duct. Bichat’s fat
pad resection should be performed in a similar fashion to
orbital fat pad excision during blepharoplasty procedures.
The fat pad is placed on tension during resection and will
retract when divided. Bleeding from the retracted Bichat’s
tissue will be difficult to control safely. Meticulous
hemostasis prior to fat pad excision can be facilitated by
the use of bipolar cautery.
Fat Grafting
Structural fat grafting as described by Coleman23 is used
as an adjunctive component of the tridimensional facelift
in many of our patients. Structural fat grafting provides
an excellent means for treating residual facial asym-
metries or contour irregularities. Deep residual creases,
such as nasolabial and marionette lines, can be improved
with this technique. The fat grafts are typically harvested
toward the end of the rhytidectomy procedure. We prefer
to obtain our fat grafts from the anterior abdomen, through
a small infraumbilical incision. If the abdomen has a
paucity of fat, grafts should be harvested from alternative
locations. Alternative locations for graft harvest include the
hips, medial thighs, and posteromedial knee region.
The donor site is infiltrated with 0.5% lidocaine with
a 1:200,000 epinephrine solution. We prefer to infiltrate
an equivalent amount of anesthetic solution to match the
expected fat graft aspirate. All harvesting and graft
placement is performed with blunt-tipped cannulas
developed specifically for structural fat grafting (Tulip
Medical, San Diego, CA). The use of blunt-tipped cannulas
for the delivery of the graft material cannot be over-
stressed. The authors believe that fat embolization is more
likely with sharp-tipped needle delivery of the graft
material. Inadvertent fat embolization of the middle
cerebral artery24 and right cavernous sinus25 has been
documented following aesthetic fat grafting. The fat
grafts are placed in a subcutaneous plane around the face
and below the lip vermilion and white roll for lip
augmentation. Administered in this fashion, fat grafts can
be safely placed in patients undergoing concomitant
subperiosteal rhytidectomy. We find this approach
advantageous toward the final aesthetic outcome.
ADDRESSING THE PERIPHERAL HEMICIRCLE OF
THE FACE
Whereas the endoscopic forehead and midface procedures
form the foundation of our comprehensive approach to
facial rejuvenation, cervicoplasty techniques form the
keystone of success in the peripheral hemicircle of the
face. In fact, the most dramatic improvements provided
by facial rejuvenation can often be seen in the
cervicofacial region. We offer three techniques to achieve
success when treating the peripheral hemicircle of the
face: the anterior approach cervicoplasty, the excisional
cervicofacial lift, and the mandibular matrix system.
Cervicoplasty versus Cervicofacial Rhytidectomy
The nonexcisional anterior approach cervicoplasty provides
a means of lower face rejuvenation through minimal access
incisions. Considerable aesthetic improvement can be
achieved with the technique. However, not all patients are
appropriate candidates for this approach. Several points
need to be addressed. First, the anterior approach
cervicoplasty should be considered an operation designed
to postpone a traditional cervicofacial lift. Second,
definition around the jawline can be achieved with the
nonexcisional cervicoplasty but it is less than that which
can be achieved with an excisional approach.
Patients desiring a tight, defined jawline should be
offered a traditional cervicofacial procedure. Third, results
with the anterior approach cervicoplasty are typically
better in female patients. Finally, addition of structural
support to the jawline or chin can enhance the final results
of a nonexcisional cervicoplasty.26 The nonexcisional
anterior approach cervicoplasty is effective in those with
young, elastic skin. Patients with poor skin quality or
excessive skin on the neck and jawline should be offered
a traditional excisional cervicofacial rhytidectomy.
Anterior Approach Cervicoplasty
Access is obtained through a submental incision
measuring 2.5 to 3.0 cm. A subcutaneous dissection plane
is developed above the platysma. A uniform 4 mm
thickness of subcutaneous tissue is left on the skin flap.
Wide subcutaneous dissection is performed in an inferior
direction along the midline down to the level of the cricoid
cartilage. Laterally, the subcutaneous dissection tapers
along the sternocleidomastoid muscles in an oblique
direction. We avoid dissection of the upper one third of
the sternocleidomastoid muscle in an effort to prevent
injury to the greater auricular nerve.
The upper limit of dissection is the mandibular border.
The endoscope is used during dissection in the sub-
mandibular triangle to avoid injury to branches of the
marginal mandibular nerve. Excess fat on the surface of
the platysma is removed with scissors or with the aid of a
flat suction device applied only on the platysmal surface.
Excessive defatting of the skin flap should be avoided to
prevent contour irregularities or skeletonized appearance.
The fat pad deep to the platysma is then dissected from
the anterior bellies of the digastric muscles down to the
level of the mylohyoid. The space created from resection
of the subplastymal fat pad is obliterated by plication of
the bellies of the anterior digastric muscles. The muscles
are plicated with inverted 3-0 nylon sutures. If the
188
Oscar M. Ramirez • Charles R. Volpe

digastric muscles are bulky or the hyoid bone is low, we
perform a tangential excision of the superficial fibers of
the digastric bellies.
Dissection under the platysma then proceeds from
medial to lateral. The lateral aspect of the dissection
extends beyond the submandibular salivary glands. It is
important to free the platysma from the capsule of the
submandibular salivary gland.
Failure to do so will result in pseudoherniation of the
submandibular gland when the platysma is advanced
medially. With the subplatysmal plane complete, the medial
borders of the platysma muscles are approximated in the
midline. Redundant muscle is trimmed from the medial
borders, which are plicated with inverted 3-0 nylon sutures.
The next step is to place a 3- to 4-cm backcut in the
platysma muscle below the level of the thyroid cartilage.
The lateral jugular vein should be preserved. If further
definition of the neck is required, a suture suspension with
a double armed 3-0 Gore-Tex (W.L. Gore, Flagstaff, AZ)
suture is performed. The suture suspension starts with the
placement of bilateral 1-cm incisions in the occipital
scalp, approximately 2 cm posterior to the mastoid
process. The incisions are carried down to the level of the
mastoid fascia. The Gore-Tex suture is placed beneath the
medial edge of the platysma muscle at the level of the
hyoid bone. The suture is directed superficially 1.5 cm
from the medial edge and is directed toward the occipital
incision using an endoscopic needle holder. After being
retrieved, the suture is placed through the deep mastoid
fascia-periosteum and delivered back through the
occipital incision. Again, the suture is brought over the
surface of the platysma muscle back toward the midline.
As the midline is approached, the suture is driven through
the platysma 1.5 cm from the midline and is directed to
the medial border of the platysma. The suture is placed in
a parallel fashion approximately 1 cm superior to the first
course of the suture. The same steps are then performed
on the contralateral side. The two free ends of the suture
are then tied together under moderate tension.
Appropriate tension can be gauged by the ability to place
a finger beneath the sutures. Where ptosis of the
submandibular glands exists, we weave the sutures on the
superficial fascia overlying the gland similar to that
described by Feldman.27 If further definition is required,
Z-platysmaplasty or a limited corset platysmaplasty can
be performed.
MANDIBULAR MATRIX SYSTEM
Size and shape of the mandible affects the harmonious
relationship of the skeletal support and the soft tissue
envelope that defines a beautiful face. The mandible is the
framework of the lower face. Deficiencies in mandibular
volume and shape can negatively affect the aesthetics of
the mouth, chin, and neck. The mandibular matrix system
was developed to address the absence of an inadequate
mandibular contour. The mandibular matrix system
allows a method of skeletal support restoration that can
be applied to the entire mandible. The system provides an
excellent construct to redefine the jawline, especially when
combined with standard cervicoplasty procedures.
The system is composed of a series of implants made
from porous polyethylene. The excellent biocompatibility
characteristics make porous polyethylene the authors’
choice for alloplastic augmentation of the mandibular
framework. The implants allow for rapid vascularization
and tissue ingrowth. The rapid integration of the implant
material makes porous polyethylene the ideal alloplast for
a mobile and dynamic structure such as the mandible.
The mandibular matrix system can be fashioned to mimic
the normal contour of the jawline. The multiple com-
ponents of the implant system allow augmentation of
the entire mandible or individual segments that may be
deficient.
The implants have been designed to provide
tridimensional restoration of the mandible. The implants
wrap around the inferior border of the mandible. Owing
to this shape, the implants are self-stabilizing and require
minimal or no screw fixation. This is a significant advan-
tage as compared to two-dimensional onlay implants. In
addition, the component system allows the restoration of
the entire mandibular contour through minimal access
incisions. The system is composed of a two-piece extended
wraparound chin implant and gonial angle implants
specifically designed for the right and left mandibular
angles, respectively. A prejowl implant can be included in
this system when necessary.
THE IMPLANT SYSTEM
Extended Wrap-Around Chin Implant
These implants are available as square or round implants,
as viewed anteriorly. The implants are available in three
sizes: small, medium, and large. These sizes correspond to
3, 5, and 7 mm of anterior projection, respectively. Each
implant is composed of right and left sides that are joined
in the center by an alignment tab. The alignment tab is
designed to allow stabilization of the two halves of the
implant. Use of the alignment tab becomes optional when
proper alignment of the implant along the inferior
mandibular border is jeopardized.
Mandibular Angle Implant
These implants are designed to wrap around the inferior
and posterior borders of the mandibular or gonial angle.
The implants are specifically manufactured in right and
left sides and are available in small, medium, and large
sizes. These sizes correspond to 3, 7, and 11 mm of lateral
projection, respectively. The greatest projection of the
implant is at the level of the new gonial angle.
CHAPTER 11
Tridimensional Endoscopic Facelift
189

Prejowl Implant
The prejowl implant is designed for patients who
demonstrate a significant geniomandibular groove but do
not require chin augmentation. The implant is supplied in
two parts, divided medially. The implant has a 4.0-mm
maximal projection that corresponds with the level of the
prejowl depression.
Button Chin Implant
The button chin implant is a small tridimensional implant
designed for patients who require improved anterior
projection of the chin but do not require lateral augmen-
tation along the mandible. The implant is available in
3.0-mm thickness. The implant is designed to comfort-
ably wrap around the symphysis of the mandible. The
wraparound feature provides stability to the implant,
making rotation or migration of the implant virtually
impossible.
IMPLANT PLACEMENT
The surgical technique employed with the insertion of the
mandibular matrix system has been refined since the early
description in 2000. General anesthesia is recommended
for all cases. When combined with adjunctive aesthetic
procedures, the matrix system should be placed as early
as possible. Access incisions should be closed immediately,
in order to prevent possible contamination. Retromolar
and lower buccal sulcus incisions can be used for the
insertion of the mandibular angle implants and extended
chin implants, respectively. The authors, however, now
place both the mandibular angle and extended chin
implants through a 3-cm submental incision and the
assistance of the 4-mm endoscope, whenever possible.
The mandibular angle implants are secured with a 2-0
PDS suture and the extended chin implants are secured
with small titanium self-drilling or self-taping screws, in
bicortical fashion.
Careful planning is necessary for the placement of the
submental incision. Augmentation of the bony symphysis
will advance the soft tissue envelope. This tends to rotate
the submental incision anteriorly. Therefore, we typically
place the incision 1 cm posterior to the submental crease.
By doing this, the incision remains hidden in the sub-
mental area.
The dissection is carried down through the sub-
cutaneous adipose tissue to the level of the platysma. A
thick subcutaneous dissection is then performed 2 cm
anterior and 2 cm posterior to the incision. The platysma,
mentalis muscle, and periosteum are then divided in the
midline, perpendicular to the direction of the submental
skin incision. A subperiosteal dissection is then performed
in an anterior direction, to the level of the mentolabial
fold. This can be performed under direct visualization,
with the aid of a lighted Aufricht retractor. Care must be
taken to avoid perforation of the oral mucosa.
The dissection continues laterally to expose the entire
anterior and inferior surface of the mandible. This dissection
is facilitated with the use of a No. 4 Ramirez elevator
(Snowden-Pencer, USA). The mental nerves must be iden-
tified and carefully dissected free from the surrounding
structures. Nerve injury can be prevented by early identifi-
cation of the structures and avoidance of excessive retraction.
The lateral dissection proceeds to level of the anterior
border of the masseter muscle. This can be accomplished
with the assistance of the 4-mm endoscope or small fiberoptic
lighted retractor. At this point, dissection is complete for
the insertion of the extended chin implant Silastic sizers.
Insertion of the mandibular angle implants requires
careful dissection of the pterygomasseteric sling. The
4-mm endoscope is inserted and a subperiosteal dissection
continues with an angle periosteal retractor (Snowden-
Pencer, USA). The pterygomaxillary sling is elevated in
continuity (Fig. 11-25). Under direct visualization, the
inferior aspect of the mandibular angle is freed from the
tendinous and periosteal attachments. The posterior
border of the ascending ramus is cleared in a similar
fashion. The bony surface of the mandibular angle is then
exposed sufficiently in anterior, inferior, and posterior
directions to allow the insertion of Silastic mandibular
angle implant sizers.
With the dissection complete, the cavity is irrigated
with antibiotic solution followed by packing with
neurosurgical pledgets soaked in diluted Betadine and
epinephrine solution (1:30,000). The pledgets are left for
several minutes to provide hemostasis and improve
endoscopic visualization during implant placement.
As stated previously, oral incisions can be used for the
placement of the implant system. However, the authors
feel that this approach may increase the incidence of
190
Oscar M. Ramirez • Charles R. Volpe
Figure 11-25 The endoscopic dissection of the pterygomasseteric
sling. Note the pink area highlighted on the mandible. This represents the
area of subperiosteal dissection required for placement of the mandibular
matrix system.

bacterial seeding of the implant and development of early
postoperative infection.
Comfort with the endoscopic approach and access to
the appropriate instrumentation should act as a guide to
the method of implant introduction.
The extended chin and mandibular angle implants
have been developed with corresponding Silastic sizers.
Each sizer has a similar projection, length, and depth at
the groove of the implant. The mandibular implant sizers
are introduced followed by the extended chin implant
sizers. The endoscope is then introduced to assess the fit
of the sizers and the adequacy of the soft tissue dissection.
The external contour of the jawline is then assessed. The
appropriate size implants are chosen based upon fit and
desired aesthetic contour. Calipers are then used to
measure the distance of the mental nerves from the
midline and the lower border of the mandible. These
measurements are recorded and transferred to the chosen
extended chin implant. Grooves in the extended chin
implant can then be carved with the use of a No. 10
scalpel and a cutting board. Adequate space (2–3 mm)
around the mental nerve foramina should be created.
Further carving of the extended chin and mandibular
angle implants can be performed with a scalpel or a high-
speed burr. All carving should be done on a back table
away from the patient. The prepared implants are then
washed of debris and soaked in antibiotic solution.
The sizers are removed and the endoscope is inserted
to assure that hemostasis has been achieved. A smooth
sterile plastic sleeve is then rolled into a conical shape and
inserted into the incision. This sleeve isolates the implant
from the skin surface and creates a smooth, protected
surface for the rough porous polyethylene to slide against.
Without the sleeve, insertion of the implant can be a
humbling experience. The mandibular implants are then
directed to the proper anatomic location under endoscopic
guidance or with a small fiberoptic lighted retractor. The
implants can be manipulated with the assistance of two
periosteal elevators.
The mandibular angle implant is then fixed into
position with either a small titanium screw or 2-0 PDS
(Ethicon, Somerville, NJ) suture passed through a
predrilled bicortical hole through the body of the
mandible. The wraparound design of the mandibular
angle implant prevents rocking of the implant when
properly placed and allows fixation of the implant along
its anterior border. If screw fixation is chosen, trajectory
of the infra-alveolar (mental) nerve must be noted prior
to drilling.
With the angle implants secured, the extended chin
implants are inserted in a similar fashion. Use of the
smooth plastic sleeve during implant insertion cannot be
overstressed. Smooth insertion with minimal retraction
will reduce the incidence of injury to the mental nerves.
The extended chin implant is then positioned along the
inferior border of the mandible. The location of the
mental nerve is checked prior to screw fixation of the
implant. Each side of the chin implant is fixed with a
single small titanium screw in bicortical fashion, after
predrilling. The lateral aspect of the extended chin
implant should overlap the anterior border of the
mandibular angle implant when attempting to achieve a
wide profile. The lateral wings of the extended chin
implant can be trimmed (no overlap with the angle
implant) to maintain a narrow profile (Fig. 11-26).
Should the use of prejowl implants or a button chin
implant be indicated, the implants can be placed through
the same submental exposure. Fixation can be achieved
with small titanium screws in either a unicortical or
bicortical fashion. Aesthetic outcome will dictate the role
these alternative implants play.
Prior to closure, the surgical cavity is irrigated with
antibiotic solution. The platysma is sutured in the midline
with interrupted sutures. If other aesthetic procedures are
to be performed at the level of the neck, the skin incision
is covered with a bio-occlusive dressing. This prevents
tissue desiccation prior to skin closure. Skin closure, when
appropriate, is performed with 5-0 or 6-0 Prolene
CHAPTER 11
Tridimensional Endoscopic Facelift
191
Figure 11-26 Final placement of the entire mandibular matrix system.
The gonial angle implants are positioned along the mandible beneath the
pterygomasseteric sling. Note that the implants are secured with titanium
screws. The authors secure the chin implants with titanium screws as
depicted. The lateral wings of the chin implant should overlap the gonial
angle implants. This maintains a smooth contour to the augmented
mandible. Though screw fixation of the gonial angle implants can be used,
the authors prefer to secure the angle implants with a single 2-0 PDS suture
placed through a drill hole in the inferior portion of the mandible. Significant
support provided by the pterygomasseteric sling makes suture fixation of
the gonial implants possible.

(Ethicon, Somerville, NJ) interrupted sutures. A bio-
occlusive dressing is applied over the incision after
closure. A tight facelift dressing is applied at the end of all
procedures to reduce swelling and dead space fluid accu-
mulation. Patient examples are shown in Figures 11-27
through 11-32.
POSTOPERATIVE CARE
After extensive facial procedures, patients are monitored
for 23 hours and discharged home under the care of a
well-informed relative or practical nurse. The butterfly
drains are attached to vacuum tubes and changed
periodically during the next 48 hours. We find that
192
Oscar M. Ramirez • Charles R. Volpe
Figure 11-27 Anteroposterior pre-
operative (left) and postoperative (right)
views of a 20-year old patient who
underwent placement of the mandibular
matrix system. The patient’s preoperative
concerns centered around the relative
mandibular asymmetry and the narrow,
pointed chin. Improved definition of the
mandibular angles and balanced chin width
are shown in the postoperative view.
Figure 11-28 Three-quarter views of
the patient in Figure 11-27. Preoperative (left)
and postoperative (right) views are shown.
The mandibular matrix system improves the
definition of the entire mandible. Aesthetic
balance of the mandible is achieved
postoperatively with greater definition of the
mandibular angle and chin width.

evacuation of this fluid minimizes the amount of facial
edema postoperatively. Drain output of 10 to 20 mL
should be expected, on average. Drain removal occurs
typically on the second postoperative day. Antibiotics,
started prior to surgery, are continued for 5 days, post-
operatively. Steroids have not provided reduced post-
operative edema in our patients and are not routinely
given. Supportive taping of the forehead and midface
begins at the end of the operative procedure and
continues for approximately 7 to 10 days. A snug-fitting
cervical collar dressing is placed postoperatively for
patients undergoing cervicofacial procedures. This
dressing is kept in place for 24 to 48 hours and then is
changed daily. Loose-fitting dressings and patient
CHAPTER 11
Tridimensional Endoscopic Facelift
193
Figure 11-29 Lateral views of the
patient in Figures 11-27 and 11-28, pre-
operative (left) and postoperative (right).
Note the improvement of chin projection
and shape with the extended wraparound
chin implant of the manibular matrix system.
Figure 11-30 This 42-year-old patient
demonstrates relative asymmetry of the
upper and lower face. Preoperative antero-
posterior view (left) shows a sharp, pointed
chin and poor projection of the mandibular
angles. Postoperative anteroposterior view
(right) after placement of the mandibular
matrix system. Note the improved balance
of the upper and lower face. The wrap-
around chin implant improves lower facial
shape and the increased biangular distance
provided by the gonial angle implants
improves the overall manibular width.

noncompliance can lead to seroma formation in the
cervicofacial region. Fluid collections in this region should
be promptly evacuated to minimize postoperative
scarring. Sutures are removed by day 7, in most cases.
The titanium forehead posts are removed between days
10 and 14.
COMPLICATIONS
Complications related to the endoscopic subperiosteal
facelift procedures include nerve injury, hematoma,
infection, alopecia, and skin flap necrosis. Nerve injury,
perhaps the most devastating complication, is typically
194
Oscar M. Ramirez • Charles R. Volpe
Figure 11-31 Three-quarter views of
the patient in Figure 11-30. The preoperative
view (left) shows the asymmetry of the
broad upper face and narrow lower face.
Postoperatively (right), improved definition
of the mandibular angle and projection of
the chin creates a more balanced aesthetic
result. Harmony between the upper and
lower face has been achieved.
Figure 11-32 Lateral views of the
patient in Figures 11-30 and 11-31, pre-
operative (left) and postoperative (right).
Note the improved projection of the chin
and definition of the mandibular angle.