Phẫu Thuật Trẻ Hóa Khuôn Mặt (Facial Rejuvenation Surgery)

CHAPTER 3: SMASectomy
46
excised since this has the least durable vascularity
(Fig. 2.3.23).
The assistant now elevates the cheek skin fl ap
with a Deaver retractor to facilitate access to the
SMAS. A rectangular area of SMAS/platysma is
marked for excision. Superiorly this lies along the
upper border of the malar arch and inferiorly
3 cm–4 cm below the mandible. Its direction is
oblique, roughly parallel with the nasolabial fold,
and its width will vary according to the tissue
tension but generally is in the region of 2 cm–
3 cm (Fig. 2.3.24).
The SMAS platysma layer beneath the rectangle
planned for excision is infi ltrated with approxi-
mately 10 mL of 0.5% lignocaine with 1 : 200 000
adrenaline solution. This will facilitate the dissec-
tion (Fig. 2.3.25).
The SMAS platysma layer is incised using a
number10 blade, the superior, inferior and pos-
terior margins of the excision fi rst and, lastly, the
anterior margin. Pressure should be gentle and,
generally, the weight of the knife is suffi cient. It
would be sensible to practise this on a cadaver
dissection initially, but if in any doubt about the
safe dissection plane elevate from posteriorly
before making the anterior incision. The SMAS
platysma excision proceeds from superior to infe-
rior using a number 10 blade (Fig. 2.3.26).
Facial nerve branches may be seen beneath the
sub-SMAS fascia, though this is by no means
always the case. Haemostasis in the sub-SMAS
plane is achieved using bipolar cautery only.
The anterior SMAS incision is then approximated
to the posterior using 4/0 monocryl superior to
Fig. 2.3.23 Excision of marginal skin.
Fig. 2.3.24 SMAS for excision marked.
Fig. 2.3.25 Sub-SMAS infi ltration.
Fig. 2.3.26 SMASectomy excision.

Section 2
47
the mandible and 3/0 monocryl inferior to it. The
direction of closure is such as to increase promi-
nence of the SMAS layer over the malar body
(Fig. 2.3.27).
In most patients this will provide adequate cor-
rection in the neck. However, when platysma
bands are marked it is helpful to divide them from
beneath as described by Owsley. The platysma
bands are marked on the skin pre-operatively. At
the inferior most extent of the SMASectomy a
blunt subplatysmal dissection is carried out using
the Gorney scissors. When the medial aspect of
the platysma band is reached (this can usually be
seen from beneath the platysma, but its site is
confi rmed by the skin marking) the scissors are
turned so that they point toward the skin and the
platysma is cut for 1 cm–2 cm at the site of the
band. Care needs to be taken to avoid injury to
the anterior jugular vein that should be accom-
plished if the dissection is immediately beneath
the platysma. However, vision beneath the pla-
tysma fl ap is usually quite adequate to detect and
deal with any signifi cant bleeding. The SMAS
platysma fl ap is then closed in the manner
described above (Fig. 2.3.28).
At this point any irregularities along the line of
SMASectomy closure are trimmed and any
further direct lipectomy, particularly in the neck
when indicated, is carried out. It may be wise to
tie the superfi cial temporal vessels, both anterior
to the tragus and at the temple to reduce the risk
of late haematoma formation using 3/0 monocryl
(Fig. 2.3.29).
Haemostasis is then checked once more and pulsed
lavage of the dissected area carried out using warm
saline and a bulb syringe (Fig. 2.3.30).
Fig. 2.3.27 Approximation of SMAS/platysma edges.
Fig. 2.3.28 SMASectomy suture line (arrow) closed.
Fig. 2.3.29 Ligation of superfi cial temporal vessels.
Fig. 2.3.30 Pulsed lavage using bulb syringe.

CHAPTER 3: SMASectomy
48
Trimming of the Skin Flaps
The posterior skin fl ap is elevated using an Allis
forcep and a key suture of 3/0 monocryl placed
between the superior aspect of the concha with
the previously marked site on the neck skin. A
mattress suture here assists in eversion of the
skin and facilitates later skin closure (Fig.
2.3.31).
The hair-bearing skin of the dissected neck fl ap
is then elevated and rotated anteriorly and the
excess marked and trimmed using a knife. The
anterior rotation facilitated by the posterior back
cut will reduce the likelihood of a step in the
hairline (Fig. 2.3.32).
Marking of the anterior skin fl ap is facilitated
using a Pitanguy or d’Assumpacao skin fl ap
marker. The sharp jaw of the marker is placed on
the tattooed point at the root of the helix. The
surgeon elevates the corresponding tattoo on the
skin fl ap superiorly and slightly posteriorly. This
elevation should be done by the surgeon so that
he may judge the exact vector and tension that
is most appropriate. The jaws of the marker are
then closed and the point at which the anterior
jaw contacts the skin marked by the assistant
(Fig. 2.3.33).
The distance that the skin has been elevated both
superiorly and posteriorly may then be accurately
measured (it is usually between 1.5 cm–2.5 cm
Fig. 2.3.31 Key suture at mastoid.
Fig. 2.3.32 Anterior rotation (in direction of arrow) of
mastoid skin to avoid a step in the hairline.
Fig. 2.3.33 Marking for anterior key suture using
Pitanguy forcep.

Section 2
49
superiorly and 1 cm–2 cm posteriorly) (Fig.
2.3.34).
An oblique incision may then be made in the skin
fl ap from a point just posterior to the initially
marked point; skin tension may then be checked
once more before the incision is completed.
A single 3/0 monocryl suture can then be placed
from the anterior most extent of the incision on
the skin fl ap to the root of the helix. This should
include helical cartilage to provide a fi rm anchor,
but care must be taken to avoid penetrating the
skin of the ear.
The temporal skin may then be trimmed, but
before doing this it is important to rotate the
temporal skin fl ap inferiorly so as to avoid exces-
sive elevation of the hairline. It is essential that
this is done in such a way that no tension at all
is placed on the hair-bearing skin so that alopecia
is avoided.
Excess skin in the region of the tragus and lobule
may now be marked and trimmed. The tragal
skin fl ap must be designed slightly larger than
the tragus itself to accommodate some post-
operative scar contracture and avoid anterior
traction on the tragus itself. A distinct angle is
made at the junction of tragus and lobule and it
is of vital importance, when trimming the peri-
lobular skin, that no inferior tension is put on the
lobule so that the “pixie ear” deformity is avoided
(Fig. 2.3.35). On the contrary, when the skin
fl ap has been trimmed the lobule should have a
transverse skin crease in it demonstrating that it
has been supported in a superior direction rather
than traction being applied in an inferior direc-
tion. Skin edges should now lie directly apposed
without any supporting sutures. The total amount
of skin excised in the procedure is relatively small
(Fig. 2.3.36).
Fig. 2.3.34 Measurement of skin movement at the
helical root (original tattoo point indicated by arrow).
Fig. 2.3.35 Trimming of anterior skin fl ap.
Fig. 2.3.36 Excised skin – mastoid left, temporal right.

CHAPTER 3: SMASectomy
50
Skin Closure
Two concertina suction drains are used. These
are best brought through the skin in the region
of the mastoid. One extends inferiorly into the
neck and the other anteriorly over the cheek It
is not necessary to secure the drains with sutures
(Fig. 2.3.37).
The neo-tragal skin is defatted subcutaneously so
that it will contour accurately to the tragal carti-
lage (Fig. 2.3.38). Subcutaneous closure is with
5/0 monocryl at the angles of the tragus, the
point at which the lobule and tragus meet, the
inferiormost point of the lobule and posteriorly
over the conchal skin. This last suture should take
a bite of conchal skin, conchal cartilage and the
neck fl ap to reduce the risk of posterior/ inferior
migration of the post-auricular scar.
The hair-bearing skin of the temple is closed with
a continuous, running, absorbable suture such as
Caprosyn or Vicryl Rapide 5/0. The pre-auricular
skin is closed with subcuticular 5/0 prolene that
is tied to itself at the helical root but pierces the
skin below the lobule. A 4/0 prolene subcuticular
suture is tied to this and runs along the conchal
skin to the superior most point of the vertical
scar. A second subcuticular 4/0 prolene suture
extends along the horizontal aspect of the mastoid
scar to within 2 cm of the posterior extent of the
incision where it is tied to itself. Its anterior point
is tied to the vertical suture. This technique facil-
itates easy removal of the stitches – they need to
be cut only at the helical root and the junction
of the vertical and horizontal mastoid scar and
can then be withdrawn from beneath the lobule
(Fig. 2.3.39).
The remaining 2 cm of the posterior incision are
closed using three skin staples that can be easily
removed if it is necessary “milk” any fl uid from
the neck on the fi rst post-operative day.
The three skin staples securing the head drape
may now be removed and the head is turned to
the left so that the right side may be completed.
This operation is identical with the left-hand side
procedure, except that for a right-handed surgeon
it is easiest to begin the pre-auricular dissection
Fig. 2.3.37 Placement of concertina suction drains.
Fig. 2.3.38 Thinning the tragal skin.
Fig. 2.3.39 Final skin closure – E indicates three skin
staples. For suture removal cut at point A and B and
withdraw in the direction of the arrows at point C and D.

Section 2
51
at the tragus and then continue toward the temple
rather than the other way round.
Dressings
Compressive dressings will not prevent haema-
toma, may compromise cutaneous circulation
and are uncomfortable. Therefore if a dressing is
used it should be designed to provide gentle
support only. If submental liposuction has been
carried out then a strip of microfoam cut so that
it can contour easily to the skin is applied to the
region of the neck (Fig. 2.3.40).
Paraffi n gauze backed dressing gauze is applied
over the ears and covered with a little cotton
wool. This is secured using an elastic net, taking
care not to dislodge the drains when it is applied
(Fig. 2.3.41).
Post-operative Care
The patient is transferred to the recovery room
with the head elevated at approximately 30° and
when stable returned to the ward. A semi-sitting
position is retained overnight with the neck
slightly extended. This may be facilitated by
placing two pillows vertically behind the patient’s
back (rather than in their usual horizontal orien-
tation). Blood pressure is carefully monitored
and any signs of hypertension appropriately
treated. Adequate analgesia is given, and anti-
emetic drugs are supplied if necessary.
The dressings are removed on the fi rst post-
operative morning together with the drains. The
hair is washed prior to the patient’s discharge.
All sutures may be removed between the sixth
and eighth post-operative day. General care is
as detailed in Section 2 Chapter 1. A routine
follow-up appointment is made for three months
post-operatively, but it must be made clear to
the patient that they are free to return at any
time they choose if they have any worries or
concerns.
Fig. 2.3.40 Microfoam dressing for neck.
Fig. 2.3.41 Dressings in place.

CHAPTER 3: SMASectomy
52
Clinical pearls
The use of the blunt cannula to inject tumescent
solution allows accurate placement without losing
the plane of infi ltration that can occur with a sharp
spinal needle or cannula.
Submental liposuction performed from two
incisions that criss-cross each other prevents over
resection of fat under the chin in the midline.
All skin fl ap undermining is carried out under
direct vision using scissors to minimize damage to
the subdermal plexus and to preserve a signifi cant
layer of fat on the under surface.
Subcutaneous dissection in the temporal area
must be performed carefully to avoid penetrating
the superfi cial temporal fascia that protects the
frontal branch of the facial nerve
When the SMASectomy is performed it is
important to keep the plane of dissection
superfi cial to the deep facial fascia (parotido-
masseteric fascia). This must be preserved to
provide the static posterior anchor for the
SMASectomy plication sutures.
After SMAS resection, interrupted buried sutures
are used to close the smasectomy obliquely lower
down and with a more vertical vector in its
superior extent. The last suture lifts the malar fat
pad.
Points to note
• Clonidine on induction of anaesthesia to
establish and maintain hypotensive fi eld
• Adequate per operative blood pressure
control – systolic approximately 80 mm
mercury
• Endotracheal tube covered with a sterile
camera drape.
• Tumescent infi ltration containing no
adrenaline.
• Incision designed to avoid disturbance of the
hairline.
• Tattoo key points on the skin to ensure
symmetry.
• Syringe suction to the submental and jowl
region when indicated.
• Accurate elevation of skin fl aps to avoid
irregularities and injury to the skin or great
auricular nerve.
• Secure elevation of the SMAS platysma layer
within the area of SMASectomy.
• Closure of SMASectomy with buried
absorbable sutures.
• Trimming of fat to avoid irregularities prior to
closure.
• Accurate positioning of skin fl aps to avoid
undue tension, disturbance of the hairline or
contour of the lobule and tragus.
• Precise skin closure with sutures that are easy
to remove.
• Careful post-operative observation by
adequately trained staff .
• Blood pressure measurement to prevent
systolic rise over 130 mm mercury
• Detailed provision of information regarding
post-operative care to the patient prior to
discharge.

Pre operative
Post operative
Pre & Post operative
&
Age 69 Lateral SMASectomy facelift, osseous sliding genioplasty

Pre operative
Post operative
Pre & Post operative
&
Age 57 Endobrow, lateral SMASectomy facelift

Pre operative
Post operative
Pre & Post operative
&
Age 59 Endobrow, lateral SMASectomy facelift, osseous sliding genioplasty

Pre operative
Post operative
Pre & Post operative
&
Age 51 Endobrow, lateral SMASectomy facelift, Owsley platysmaplasty, peri-oral structural fat graft

Pre operative
Post operative
Pre & Post operative
&
Age 63 Lower blepharoplasty, lateral canthoplasty, Lateral SMASectomy facelift, Owsley platysmaplasty

CHAPTER 3: SMASectomy
58
ANNOTATED BIBLIOGRAPY
Baker DC. Lateral SMASectomy. Plastic and Reconstructive
Surgery 1997;100:509–513.
Description of the technique of lateral smasectomy
documenting the vector of closure and illustrating
methods of avoiding injury to the facial nerve. In patients
with thin faces the author suggests substituting
SMASectomy with plication to preserve as much facial
volume as possible.
Jones BM. Facelifting: an initial eight year experience.
British Journal of Plastic Surgery
1995;48:203–211.
Retrospective review of initial eight years experience with
description of the auricular anchoring suture for anterior
fl ap fi xation. The use of tattooing the reference point of the
anterior and posterior fl aps to allow symmetry is described
in the methodology.
Jones BM, Grover R. Reducing complications in cervicofacial
rhytidectomy by tumescent infi ltration: a comparative
trial evaluating 678 consecutive face lifts. Plastic and
Reconstructive Surgery 2004;113:398–403.
Detailed description of the use of tumescent infi ltration in
facelifting, comparing the outcome in a large series with and
without tumescence. There was signifi cant reduction in
problems of wound healing as well as hypertrophy and
stretched scars using tumescence. Improvement was seen in
dissection of the skin fl aps particularly in the neck.
Knize DM. Periauricular face lift incisions and the auricular
anchor. Plastic and Reconstructive Surgery
2000;105:2620–2623.
Review of the authors series of 770 facelifts with particular
reference to the aesthetic management of the periauricular
incisions and the resultant wound. The use of the auricular
cartilage to act as an internal splint to prevent pixie ear
deformity and rotation are discussed. Their rationale is
confi rmed from a biomechanical basis by measurements of
the forces that act in the periauricular area.

59
CHAPTER 4
Limited Scar Technique
The limited scar facelift is not a new concept, indeed many recent
descriptions of “new” scar designs bear a remarkable resemblance to
that published by Passot in 1918 (Fig. 2.4.1). The philosophy is to
reduce the extent of the scar in the post-auricular and mastoid region,
restricting it to the temple and pre-auricular/peri-tragal area. The
diffi culty with this approach is to avoid a dog ear at the inferior most
extent of the lobule, i.e., the junction of cheek and neck skin.
Although it is often said that cutaneous or subcutaneous irregularities
will tend to smooth out over time, this has not always been my
experience. As a consequence, short scar techniques should be limited
to those patients who have limited skin excess in the neck and a
reasonable cervico-mental angle.
S E C T I O N 2
Fig. 2.4.1 Illustrations redrawn from Passot’s paper published in 1918.

CHAPTER 4: Limited Scar Technique
60
Short scar approaches have been used with cuta-
neous lifts and in combination with various SMAS
manipulation techniques. The most recent, and
perhaps popular incarnation of a short scar
approach, is the minimal access cranial suspen-
sion (MACS) lift, popularized by Tonnard and
Verpaele. This operation combines a subcutane-
ous dissection of the cheek with a limited dissec-
tion of the neck and suspension of the soft tissues
by two or three purse string sutures (Fig. 2.4.2).
The acronym MACS is catchy but inappropriate
as the incision cannot be considered minimal
access – this usually refers to endoscopic type
approaches leaving much smaller scars, and there
is no true cranial suspension.
Undoubtedly, from a patient’s perspective, if an
equivalent result may be gained with a shorter
scar, the concept is an attractive one. For suitable
individuals (as described above) I prefer to use a
short scar approach with plication or imbrication
of the SMAS/subcutaneous fat layer. This is less
likely to produce subcutaneous irregularities that
may delay the patient’s post-operative recovery
and return to normal activities. I do not believe
that a short scar approach should be used if the
outcome of the operation will be compromised
or if signifi cant cutaneous irregularity will result
in the post-auricular area from “gathering” excess
skin from the neck. This can result in a ruched
appearance for some time post-operatively.
The short scar technique, with no post-auricular
extension, dictates that the vector of lift must be
essentially vertical. As a consequence the tempo-
ral aspect of the scar must be designed in such a
way as to eliminate the risk of elevating the tem-
poral hairline (Fig. 2.4.3).
Pre-operative Preparation
General preparation is much as for other types
of facelift procedures. Markings are made with a
patient in a sitting position outlining any areas for
treatment by liposuction, e.g., the jowl or sub-
mental region or other special features. To aid in
planning the SMAS plication, it is helpful to
mark a point on the skin corresponding with the
Fig. 2.4.2 Diagrammatic representation of the MACS
purse string technique.
Fig. 2.4.3 Short scar confi guration skin markings.

Section 2
61
intersection of a vertical line running inferiorly
from the lateral canthus with a horizontal line
running laterally from the alar base (Fig. 2.4.4).
Hair preparation is simple, needing only to be
tied in a ponytail when of suffi cient length. No
particular parting is necessary.
Surgical Technique
The skin incision is marked initially in the tem-
poral region where it is just within the temporal
hairline following its general contour but in a zig-
zag or w-plasty confi guration (Fig. 2.4.5). At the
helical root it turns inferiorly, following the
natural line of the helix, continuing in a retrotra-
gal position with a distinct angle at the inferior
most point of the tragus anteriorly so that the
tragus itself is well defi ned before continuing
along the line of the lobule and cheek. At the
inferior most extent of the lobule it turns poste-
riorly following the junction of the lobule and
neck skin, but does not extend onto the posterior
aspect of the concha (Fig. 2.4.6).
A point is tattooed at the root of the helix using
a needle and Bonnie’s blue ink to allow precise
measurements of movements during surgery
(Fig. 2.4.7).
The temporal hairline incision is made using a
number 15 blade. The zig-zag pattern is followed
Fig. 2.4.4 The point of cheek suspension marked on skin.
Fig. 2.4.5 Short scar site marked on skin.
Fig. 2.4.6 Posterior extent of scar.
Fig. 2.4.7 Needle point tattoo at helical root.

CHAPTER 4: Limited Scar Technique
62
accurately and it is of vital importance that the
incision is bevelled across the hair follicles, i.e.,
at 90° to them not parallel with them (Figs. 2.4.8
and 2.4.9). This will result in hair growth through
the scar post-operatively so, effectively, making
it invisible. The facial soft tissues may now be
tumesced with 150 mL of tumescent solution
(see Section 2 Chapter 3) introduced with a
blunt cannula and 50 mL syringe through the
temporal incision. If liposuction of the jowl is
planned it is carried out now (see Section 2
Chapter 3).
The remainder of the incision is now completed
using a number 15 blade, taking particular
care to follow the tragus accurately. The surgeon
uses a double-pronged skin hook to elevate
the skin at the posterior margin of the temporal
incision and a number 15 blade to begin the
subcutaneous dissection, following the tragal
cartilage carefully and taking care not to injure it
(Fig. 2.4.10). When the cheek fl ap has been
elevated by a centimetre or so the anterior dis-
section can be completed using a blunt-ended
scissors such as the Tessier design. The technique
is “sharp”, i.e., cutting with the scissors using a
downward motion not blunt burrowing. The
surgeon elevates the skin using a double skin
hook held in his left hand, the little fi nger of
which rests on the surface of the skin so that the
Fig. 2.4.8 Temporal incision. Note the angulation of the
blade across the hair follicles, not parallel with them.
Fig. 2.4.9 The direction of bevel
within the temporal hairline.
Fig. 2.4.10 Skin elevation at tragus.

Section 2
63
thickness of the skin fl ap can be judged (Fig.
2.4.11).
Particular care must be taken in the region of
ligamentous attachments such as the zygomatic
retaining ligament (McGregor’s patch) where the
skin may be tented inward and is at risk of injury
from beneath with the scissors. Again, if the sur-
geon’s left hand is resting on the skin this risk is
minimized. The dissection continues anteriorly
beyond the zygomatic retaining ligament over the
body of the malar bone and the lateral most
aspect of the orbicularis oculae (Fig. 2.4.12).
Inferiorly, the dissection extends towards the
nasolabial furrow and over the margin of the man-
dible into the neck at which point a damp swab is
packed into the anterior aspect of the dissection.
A limited dissection is now performed into the
neck, directly on the platysma, extending later-
ally/posteriorly toward the mastoid and the ster-
nomastoid muscle. This is best done using Gorney
type scissors. The assistant retracts the lobule in
a superior direction using a skin hook while the
surgeon elevates the posterior aspect of the inci-
sion using a double skin hook (Fig. 2.4.13). The
extent of this dissection will vary depending on
the amount of neck skin that it is desired to
elevate. As with other facelift procedures, care
must be taken to remain in a superfi cial plane and
to avoid injury to the great auricular nerve. Hae-
mostasis is now secured in the posterior aspect
of the dissection, following which the pack
beneath the cheek fl ap is removed, the assistant
retracts with a Deaver retractor and haemostasis
is achieved anteriorly.
The SMAS plication is now planned, the vector
of which is essentially vertical. The assistant
retracts the cheek skin with a Deaver retractor
and a line is drawn on the SMAS beginning at the
anterior most point of the dissection beneath the
mark made on the skin pre-operatively, repre-
senting the junction between a vertical line
running inferiorly from the lateral canthus and a
horizontal line running laterally from the alar
base. The line runs laterally to the inferior extent
of the tragus. Two further lines are drawn parallel
with this, the fi rst approximately 1.5 cm inferior
to it and the second approximately 0.5 cm supe-
Fig. 2.4.11 Elevation of the cheek fl ap.
Fig. 2.4.12 Anterior extent of dissection showing lateral
orbicularis.
Fig. 2.4.13 Subcutaneous dissection in the neck.

CHAPTER 4: Limited Scar Technique
64
rior to it (Fig. 2.4.14). The inferior line is
approximated to the superior line using inter-
rupted 3/0 monocryl sutures. It is important that
the needle is passed either from medial to lateral
or lateral to medial, i.e., parallel with the facial
nerve branches in the cheek (Fig. 2.4.15). When
the row of sutures is complete, a further running
4/0 monocryl stitch overlays it to ensure that
there are no subcutaneous irregularities (Fig.
2.4.16). Any unevenness in the SMAS/subcuta-
neous fat layer may be trimmed, and if any lipec-
tomy is planned inferiorly it is done at this point.
Haemostasis is checked and pulsed lavage of the
dissected area carried out using warm saline and
a bulb syringe.
Trimming of the Skin Flaps
An Allis forcep is placed at the superior angle of
the cheek fl ap and appropriate vertical traction
applied. Trimming of the anterior skin fl ap is
facilitated using a Pitanguy or d’Assumpacao skin
marker. The sharp point of the marker is placed
on the tattooed point at the root of the helix and
the jaws closed whilst the surgeon elevates the
cheek fl ap so that he may judge the exact vector
and tension that is most appropriate. The point
at which the anterior jaw contacts the skin is
marked by the assistant (Fig. 2.4.17). The dis-
tance which the skin has been elevated both
superiorly and posteriorly may then be accurately
Fig. 2.4.14 Line of SMAS plication marked. The central
line runs from the pre-operative skin markings to the
inferior margin of the tragus.
Fig. 2.4.15 First layer of plicating sutures. Note the
direction of the needle passage.
Fig. 2.4.16 Second, continuous plication layer
completed.
Fig. 2.4.17 Marking of skin elevation.

Section 2
65
measured (it is usually between 2.5 cm–3.5 cm
superiorly and 0.5 cm–1 cm posteriorly) (Fig.
2.4.18). An oblique incision can then be made in
the skin fl ap from the marked point, laterally. A
single 3/0 monocryl suture is placed from the
anterior extent of the incision in the skin fl ap to
the root of the helix. This should include helical
cartilage so as to provide a fi rm anchor, but care
must be taken to avoid penetrating the skin of
the ear (Fig. 2.4.19).
The excess temporal skin is now trimmed in a
curvilinear manner, paralleling the zig-zag inci-
sion in the hair-bearing temporal skin. It will
facilitate closure if the superior incision line (the
zig-zag) is elevated for a few millimeters, though
the plane of dissection must be deep to the hair
follicles so as not to injure them (Fig. 2.4.20).
Excess skin in the region of the tragus and lobule
may now be marked and trimmed. The tragal
skin fl ap must be designed slightly larger than
the tragus itself to accommodate some post-
operative scar contracture and to avoid anterior
traction on the tragus. A distinct angle is made
at the junction of the tragus and lobule. Excision
of the peri-lobular skin, which will extend poste-
rior to the lobule, is best achieved using scissors
Fig. 2.4.18 Measuring skin elevation.
The arrow indicates the original
tattoo point.
Fig. 2.4.19 Key suture at helical root.
Fig. 2.4.20 Elevation of temporal fl ap deep to hair
follicles.

CHAPTER 4: Limited Scar Technique
66
and must be done in such a way that no tension
is put on the lobule itself to avoid a “pixie ear”
deformity (Fig. 2.4.21).
The skin edges should now lie directly opposed
without any supporting sutures.
Skin Closure
A single concertina suction drain is placed,
brought through the temporal skin above the
incision line. The drain itself must extend to the
inferior most aspect of the cheek dissection (Fig.
2.4.22).
The neo-tragal skin is defatted subcutaneously
so that it will contour accurately to the tragal
cartilage. The subcutaneous closure is with 5/0
monocryl at the angles of the tragus, the point at
which the lobule and the tragus meet and the
inferiormost point of the lobule.
The temporal incision is closed using a running
5/0 prolene suture. The superior (zig-zag) margin
should expand to accommodate the curved infe-
rior margin. It is essential that this closure is
extremely accurate so that the resulting scar,
once hair has grown through it, will be invisible.
The pre-auricular skin is closed with subcuticular
5/0 prolene tied to itself at the helical root but
piercing the skin below the lobule (Fig. 2.4.23).
The needle is re-introduced and the short inci-
sion posterior to the lobule closed with a running
continuation of the prolene suture. It is usually
Fig. 2.4.21 Trimming of peri-aural skin.
Fig. 2.4.22 Insertion of drain.
Fig. 2.4.23 Closure of temporal and pre-auricular skin
incision.

Section 2
67
necessary to gather the post-auricular skin slightly
here and, providing the irregularities produced
are minimal, they should settle during the post-
operative period (Fig. 2.4.24).
The patient’s head is now turned to the left, the
surgeon moves to the right and the assistant to
the left so that the operation may be repeated on
the right-hand side of the face.
Fig. 2.4.24 Post-auricular skin closure.
Clinical pearls
The short scar facelift is not a classical facelift (with
SMASectomy or other SMAS elevation) with a
short scar. It diff ers in that the vector of SMAS lift
is purely vertical and this reduces the likelihood of
a dog ear below the lobule but necessitates the
need for an anterior temporal incision to avoid
elevating the hairline.
The ideal candidate is one in need of mid facial
rejuvenation and has mild to moderate jowls but
with little laxity in the neck, a good cervico-mental
angle and absence of platysma bands.
Poor candidates are those in the older age group
(60 plus) with signifi cant jowling, pronounced
neck laxity, a poor cervicomental angle
and platysma banding. In these patients a
classical retro-auricular extension to the facelift
incision which is well planned and dissection
performed with tumescence will produce a
superior result in terms of rejuvenation and scar
sequelae.
Keeping the temporal hairline incision as discrete
as possible is crucial to a good outcome. Bevelling
the incision perpendicular to rather than parallel
to the hair follicles produces the least visibility and
disturbance of hair growth.
Dressings
Dressings are identical with those used for
SMASectomy (Section 2 Chapter 3).
Post-operative Care
See Section 2 Chapter 1.

CHAPTER 4: Limited Scar Technique
68
Points to note
• Select patient with limited skin excess in the
neck and good cervicomental angle
• Mark areas of jowl liposuction pre-operatively
in the up right position
• Hair is prepared simply by tying back in a
ponytail without the need for parting.
• Clonidine on induction of anaesthesia to
establish and maintain a hypotensive fi eld
• Adequate per operative blood pressure
control – systolic approximately 80 mm
mercury
• Endotracheal tube covered with a sterile
camera drape.
• Incision marked just within the temporal
hairline in zig-zag fashion before following
the retrotragal line.
• Tattoo key point on the skin at root of helix.
• Tumescent infi ltration containing no
Adrenaline.
• Syringe suction to the submental and jowl
region when indicated.
• Accurate elevation of skin fl aps to avoid
irregularities and injury to the skin using
sharp dissection only.
• Closure of SMAS plication with buried
absorbable sutures in a vertical vector.
• Trimming of fat to avoid irregularities prior to
closure.
• Accurate positioning of skin fl aps with skin
resection initially made at the anterior tattoo
point using the Pitanguy or d’Assumpacao
skin marker.
• Closure of the temporal hairline incision with
accurate alignment of the skin edges and
without tension
• Precise skin closure with subcuticular sutures
that are easy to remove.

Pre operative
Post operative
Pre & Post operative
&
Age 41 Limited scar facelift

Pre operative
Post operative
Pre & Post operative
&
Age 46 Transconjunctival lower blepharoplasty, limited scar facelift

Section 2
71
ANNOTATED BIBLIOGRAPHY
Tonnard P, Verpaele A, Monstrey S, et al. Minimal access
cranial suspension lift: a modifi ed S-lift. Plastic and
Reconstructive Surgery 2003;111:1774–1775.
Modifi cation of the S-Lift with short scar and use
of permanent purse string sutures to suspend the facial
soft tissues in a vertical direction with limited skin
undermining in a series of 88 consecutive patients.
In reality the incision used is a short scar rather than
minimal access that would normally be applied to endoscopic
techniques.
Saylan Z. The S-lift: less is more. Aesthetic Surgery Journal
1999;19:406–409.
The original article that was the forerunner of the
MACS-lift and previously described the use of a short
scar, limited undermining and the use of permanent purse
string sutures for facial suspension. This technique was
modifi ed in regard to the temporal hair line incision and
points of suture suspension by Tonnard et al to produce the
MACS-lift itself.
Camirand A, Doucet J, Jocelyne IL. A comparison between
parallel hairline incisions and perpendicular incisions
when performing a face lift. Plastic and Reconstructive
Surgery 1997;99:10–15.
A prospective randomized trial of parallel and perpendicular
incisions made to the direction of hair growth in 30
consecutive facelifts. Each patient had both methods of
incision made on separate sides of their facelift procedure so
they could act as their own control. Statistically signifi cant
improvement in scar quality and hair growth was found
with perpendicular incisions.
Baker DC. Minimal incision rhytidectomy (short scar face lift)
with lateral SMASectomy: evolution and application.
Aesthetic Surgery Journal 2001;21:14–26.
Article describing 749 patients treated with short scar
facelift utilizing SMASectomy as the method of lifting within
the deep plane. The author describes a classifi cation of four
groups to evaluate patients who are best suited to this
procedure for facial rejuvenation.

73
CHAPTER 5
Subperiosteal and Volumetric Procedures
The volumetric facelift is designed to reverse alterations in the dis-
tribution of facial volume that occur with the passage of time. The
general trend is for malar prominence (upper middle third volume)
to decrease whilst jowl prominence (lower third) increases. This has
the effect of changing the outline of the face from a predominantly
heart shape to a squarer contour.
The procedure combines a subperiosteal approach to the central mid
face, to imbricate and move the cheek fat pad in a cephalad direction,
with plication of the SMAS/subcutaneous fat layer of the face, via a
subcutaneous approach, to give the opportunity for fi ne adjustment
of facial contour and, where necessary, to further augment the cheek
profi le.
The subperiosteal approach to the mid face can be used as a stand
alone procedure (subperiosteal mid facelift) to improve facial contour,
usually in relatively younger patients who have minor change in the
lower third of the face. If the operation is to be combined with ancil-
lary procedures such as endobrow, blepharoplasty, etc., then the
order of surgery is as for other facelift techniques.
Endoscopic browlift, when combined with volumetric or subperios-
teal mid face procedures, gives good access to, and visualization of,
the upper part of the subperiosteal dissection.
Pre-operative Preparation
The general preparation is similar to that of other facelift techniques.
When obtaining consent the patient should be warned of a slightly
higher risk of infection because of the intraoral aspect of the opera-
tion and of a 5–8% risk of temporary functional impairment of the
buccal branches of the facial nerve as described by Little, although I
have not found the incidence to be this high.
S E C T I O N 2

CHAPTER 5: Subperiosteal and Volumetric Procedures
74
Skin markings are made pre-operatively with the
patient sitting (Fig. 2.5.1). The jowls and any
submental fullness requiring liposuction are out-
lined together with platysma bands if they are
present and to be dealt with.
It is important to mark on the skin the point at
which the midfacial soft tissues will be suspended.
This point should be low in the mid face so that
after elevation the soft tissues will fold or imbri-
cate to provide good malar prominence, and is
marked at the intersection of a vertical line
running downwards from the lateral canthus and
a horizontal line running laterally from the alar
base (Fig. 2.5.2).
Surgical Technique
General positioning on the operating table is as
for other facelift procedures. The cotton head
drape should be stapled into position bilaterally
at the beginning of the procedure. If no endo-
scopic browlift is being performed the temporal
aspect of the skin incisions should be marked
fi rst. These are similar to those for SMASec-
tomy, within the hairline and with the angle lying
at the intersection of a vertical line running
upwards from the helical root and an oblique line
joining the alar base and lateral canthus. It may
extend slightly more medially than for SMASec-
tomy (Fig. 2.5.3).
Initial infi ltration is with tumescent solution
made up of 500 mL Ringer lactate solution,
25 mL 0.25% marcaine with adrenaline, 25 mL
Fig. 2.5.1 Pre-operative skin markings are made with the
patient sitting upright.
Fig. 2.5.2 Skin marking for point of cheek suspension.
Fig. 2.5.3 Temporal incision site.

Section 2
75
1% lignocaine with adrenaline, 0.5 mL 1 : 1000
adrenaline, 5 mL triamcinolone 40 mg/ml and
1500 U hyaluronidase. Initially 20 mL is infi l-
trated to each temporal region beneath and ante-
rior to the planned incision lines extending to the
temporal crest. The midfacial soft tissues are
infi ltrated with 30 mL on each side. Again, this
is best accomplished with a spinal needle and
20 mL luer lock syringe. The needle is initially
inserted down to bone over the mid maxilla. It
is important that the bevel is against the bone to
try to encourage subperiosteal hydro dissection.
(Fig. 2.5.4). Whilst the infi ltration is proceeding
with the syringe held in the surgeon’s right hand,
he should rest his left thumb on the inferior
orbital margin to encourage the hydro dissection
to proceed inferiorly over the maxilla rather than
superiorly into the orbit; 20 mL is inserted here.
The needle is then moved and inserted once
more down to bone over the malar prominence
and the left thumb moved a little laterally so that
the hydro dissection will continue over the ante-
rior aspect of the malar arch. At least fi ve minutes
should be allowed after infi ltration for the vaso-
constrictor effect of adrenaline to occur.
Making the Incisions
The initial part of the procedure is carried out
with the surgeon standing above the patient’s
head, the assistant on the patient’s left-hand side
and the scrub nurse to the right.
The dissection begins in the temporal region on
the right side. The skin is incised using a number
15 blade and elevated, supporting the fl ap with a
double pronged skin hook superfi cial to the tem-
poroparietal fascia (TPF) (Figs. 2.5.5 and 2.5.6).
If the superfi cial temporal vessels lie beneath the
wound (within the TPF), they are ligated. An
incision is made through the TPF, remaining
Fig. 2.5.4 Subperiosteal infi ltration with needle bevel
against bone.
Fig. 2.5.5 Temporal incision.
Fig. 2.5.6 Extent of subcutaneous dissection – TPF held
in silk stay suture.

CHAPTER 5: Subperiosteal and Volumetric Procedures
76
superfi cial to the temporalis fascia (TF) which is
easily recognized as a tough white shiny fascial
layer (Fig. 2.5.7). A 3/0 silk suture inserted into
the TPF acts as a convenient retractor. The assis-
tant retracts the TPF and skin using the silk stay
suture and a dissection is made between the TPF
and TF using a number 4 periosteal elevator or
one of the Tessier/Obwegeser type; the plane
cleaves easily, little pressure is necessary, but the
elevator should be angled downward so that the
TPF is not penetrated (Fig. 2.5.8). Once the
temporal crest is reached, strong downward pres-
sure is applied toward the bone using a no. 2 ele-
vator and the fascial confl uence at the temporal
crest is penetrated and mobilized (Figs. 2.5.9 and
2.5.10). The dissection is now subperiosteal and
continues inferiorly following the lateral orbital
margin, i.e., zygomatic process of the frontal
bone. This requires fi rm downward pressure on
the elevator to ensure that the plane of dissection
remains subperiosteal. The zygomatico frontal
(ZF) suture can usually be felt and the dissection
should then continue inferiorly along the frontal
process of the zygoma. The frontal branch of the
facial nerve lies within the TPF and therefore, so
long as the entire plane of dissection is deep to
Fig. 2.5.7 TPF retracted revealing underlying TF.
Fig. 2.5.8 Dissection between STF and TF.
Fig. 2.5.9 Extent of dissection to release fascial
confl uence at temporal crest.
Fig. 2.5.10 Releasing fascial confl uence at temporal crest
– position of elevator indicated.

Section 2
77
this and/or subperiosteal, the nerve is safe. Once
the body of the zygoma is reached, the dissection
can be continued anteriorly for a centimetre or so
along the inferior orbital margin and laterally,
ensuring that the plane is subperiosteal, along the
anterior third of the zygomatic arch (Figs. 2.5.11
and 2.5.12). This will be anterior to the course of
the frontal branch as it crosses the zygomatic arch
(Fig. 2.5.13).
A pack is now inserted into the temporal dissec-
tion and the procedure repeated on the left-hand
side. With both temporal dissections complete
and packed, attention is turned to the intraoral
dissection of the mid face.
A right-handed surgeon moves to the patient’s
right side and the scrub nurse repositions herself
above the patient’s head. Exposure is best gained
by the assistant placing a skin hook in the upper
lip frenulum and a Kilner cheek retractor in the
left-hand side of the patient’s mouth. Bilateral
upper buccal sulcus incisions are marked each
approximately 3 cm–4 cm long, leaving a suffi -
cient cuff of mucosa on the gingival aspect to
facilitate easy closure (Fig. 2.5.14). The left inci-
Fig. 2.5.11 Extent of dissection over lateral orbit to
zygoma.
Fig. 2.5.12 Dissection over lateral orbital rim to zygoma
(position of elevator indicated).
Fig. 2.5.13 Position of frontal branch of facial nerve
(arrow).
Fig. 2.5.14 Position of mucosal incision.

CHAPTER 5: Subperiosteal and Volumetric Procedures
78
sion is made fi rst using either a number 15 blade
or Colorado micro needle. The incision is carried
down to the bone of the maxilla (Fig. 2.5.15).
The remainder of the dissection is entirely sub-
periosteal and is accomplished using a Tessier
type elevator. Care must be taken not to damage
the infraorbital nerve. It is usually easy to identify
the nerve as it exits the infraorbital foramen
in the mid pupillary line (Fig. 2.5.16). The sub-
periosteal dissection proceeds medial to the
infraorbital nerve, i.e., along the pyriform margin
and lateral to it as far as the inferior orbital
margin. It may be helpful for the surgeon to place
his left hand on the skin at the infraorbital margin
to guide the dissection (Fig. 2.5.17). The ante-
rior aspect of the malar arch is seen. Mobility of
the mid face will be improved if the anterior
fi bres of the superfi cial origin of the masseter
muscle are detached from the inferior aspect of
the malar arch (Fig. 2.5.18). As the dissection
proceeds superiorly along the frontal process of
the zygoma, it will connect with the inferior
extent of the temporal dissection. The dissection
on the left side is now packed and the procedure
repeated on the right which, in turn, is packed.
Attention is now turned again to the left-hand
side of the face and both the maxillary and tem-
poral packs are removed. To locate the point for
suspension of the mid face on the internal surface,
Fig. 2.5.15 Mucosal incision.
Fig. 2.5.16 Infraorbital nerve exiting foramen.
Fig. 2.5.17 Left hand on skin guiding subperiosteal
dissection to orbit elevator (arrow) held in right hand.
Fig. 2.5.18 Release of masseter origin from anterior
malar arch.

Section 2
79
a Langenbeck retractor opens the dissection plane
and a 23 gauge hypodermic needle is passed
through from the cutaneous surface at the inter-
section of a vertical line running inferiorly from
the lateral canthus and a horizontal line running
laterally from the alar base which had been
marked on the skin pre operatively (Figs. 2.5.19
and 2.5.20).
Two 2/0 PDS sutures are inserted here to suspend
the mid face. It is important that the line of
travel of the needle when inserting the suture
should be from medial to lateral or lateral to
medial (Fig. 2.5.21) and not superior/inferior
which would stand a greater chance of trapping
buccal branches of the facial nerve within the
suture. The bite needs to be reasonably substan-
tial to avoid the suture cutting out. When both
sutures have been inserted, the ends are secured
with an artery forcep and the needles cut off
(Fig. 2.5.22). The procedure is repeated on the
right-hand side.
Each suture in turn can then be passed from the
cheek dissection through to the temporal wound
using either an endoscopic grasper or tendon
Fig. 2.5.19 Transcutaneous needle marking point of
cheek suspension.
Fig. 2.5.20 Transcutaneous needle marking point of
cheek suspension visualised via intraoral incision.
Fig. 2.5.21 Passage of 2/0 PDS sutures in midfacial tissue
note direction of needle travel is from lateral to medial.
Fig. 2.5.22 2/0 PDS sutures inserted, needles removed.

CHAPTER 5: Subperiosteal and Volumetric Procedures
80
passer (Fig. 2.5.23). Since the needles have been
removed there is no chance of them snagging.
Each suture is secured with artery forceps once
more and, before withdrawing the grasper, fol-
lowing passage of the second suture, a mini
suction drain is brought via the temporal incision
(Fig. 2.5.24) into the mouth (Fig. 2.5.25). The
trocar of the drain is then passed through the
temporal skin in a superior direction. The proce-
dure is then repeated on the right-hand side.
At this stage it is wise to apply some traction to
the PDS sutures to ensure that they have a suf-
fi ciently secure grasp of the cheek before closing
the intraoral incisions. It is important that these
are closed before the mid face is suspended, since
otherwise the mucosal edges are distracted
making it diffi cult. The skin hook and cheek
retractor are inserted once more and the cheek
incisions closed with 4/0 vicryl sutures on a round
bodied needle placed in horizontal mattress
fashion (Fig. 2.5.26).
The surgeon now moves to the head once more
and the scrub nurse to the right side for suspen-
sion of the mid face. A spring eye needle is used
for this purpose (Fig. 2.5.27). While the assistant
retracts the temporal incision (using a malleable
retractor to avoid neurapraxia of the frontal
branch of the facial nerve), the needle is attached
Fig. 2.5.23 Passage of sutures from intraoral to temporal
incision (grasper, arrow).
Fig. 2.5.24 Grasping drain (arrow) inserted via the
temporal incision.
Fig. 2.5.25 Pulling the drain through the intraoral
incision.
Fig. 2.5.26 Closure of mucosal incision.

Section 2
81
to each of the suspension sutures in turn and
sutured with a secure bite to the TF (Fig. 2.5.28).
For the fi rst suspension suture on each side, it is
helpful to use a locking slip knot (fi sherman’s
knot) so that its tension can be accurately adjusted
(Fig. 2.5.29). Tension should not be too extreme
but should be suffi cient to produce noticeable
elevation and prominence of the malar area.
Figure 2.5.30 shows the right cheek suspended
before suspension of the left side, and the
increased prominence of the cheek is easily seen.
Once both sides have been suspended symmetry
is checked – most easily accomplished looking
from above the patient’s head, tangentially across
the face (Fig. 2.5.31).
Step 1
Step 2
Step 3
Step 4
Fig. 2.5.27 Spring eye needle with suture attached.
Fig. 2.5.28 Needle with 2/0 PDS passed through TF to
suspend mid face.
Fig. 2.5.29 Diagram of locking slip knot.
Fig. 2.5.30 Right cheek only suspended viewed from
above.
Fig. 2.5.31 Both cheeks suspended.

CHAPTER 5: Subperiosteal and Volumetric Procedures
82
When indicated, submental liposuction is com-
pleted at this stage (Section 2 Chapter 3).
Attention is now turned to the subcutaneous or
‘open’ aspect of the facial dissection. As with
other facial procedures, I prefer, for continuity,
to carry out the left-hand side fi rst and so the
patient’s head is turned to the right. The surgeon
now sits to the patient’s left, the assistant to their
right and the scrub nurse at the head. The cuta-
neous incisions are planned exactly as for a SMA-
Sectomy or limited scar procedure depending on
the patient’s temporal hairline and neck contour
(see Section 2 Chapters 3 and 4) and tumescent
infi ltration is introduced. The making of the inci-
sions and extent of dissection both in the cheek
and neck is identical also. Once the subcutaneous
dissection has been completed and haemostasis
achieved, imbrication of the SMAS/subcutane-
ous fat layer is planned. This is designed to allow
fi ne adjustment, and when necessary, further
augmentation of the malar contour. The assistant
retracts the cheek fl ap using a Deaver retractor
and a guide line is drawn on the SMAS. Its ante-
rior extent is located beneath the cheek suspen-
sion point which was marked on the skin pre
operatively. Laterally it runs to the inferior most
point of the tragus. Two further lines are marked
parallel and approximately 1.5 cm below and
0.5 cm above this line (Fig. 2.5.32). The inferior
and superior lines are approximated using inter-
rupted 3/0 monocryl sutures (Fig. 2.5.33). The
orientation of the needle when passing the suture
should be medial to lateral or lateral to medial
i.e., parallel to the direction of the facial nerve
branches (Fig. 2.5.34). These sutures will provide
a noticeable elevation and folding of the SMAS
layer, further increasing malar prominence. An
Fig. 2.5.32 SMAS imbrication marked.
Fig. 2.5.33 SMAS imbrication – fi rst row interrupted 3/0
monocryl proceeding.
Fig. 2.5.34 SMAS imbrication fi rst suture row interrupted
3/0 monocryl. Note the direction of needle passage.

Section 2
83
overlying continuous suture is then inserted from
medial to lateral of 4/0 monocryl to ensure that
the contour of the SMAS/superfi cial fat layer is
smooth with no irregularities (Fig. 2.5.35).
The platysma may be plicated laterally to the
mastoid fascia when necessary, or when an
Owsley type platysmaplasty is planned it is
carried out at this stage by incising the platysma
at its junction with the sternomastoid fascia and
proceeding as described in Section 2 Chapter 3.
The subcutaneous dissection is thoroughly irri-
gated. Elevation of the skin fl aps, excision of
excess skin and cutaneous closure is exactly as
for SMASectomy or limited scar techniques
appropriate (see Section 2 Chapters 3 and 4).
Dressings
Whether the subperiosteal mid facelift has been
carried out alone, or as part of a volumetric pro-
cedure, it is helpful to apply 2.5 cm micropore
tape to the skin of the cheek in order to reduce
post operative swelling. The drain concertina
bottles are connected (six for volumetric facelift)
and the remainder of the dressing is exactly as
described for SMASectomy.
The dressing is removed on the fi rst post-
operative day, as are the drains. The micropore
tape is left in place for fi ve or six days and is
removed at the time of suture removal. Chlorhex-
idine mouthwash should be used by the patient
four times daily and the mouth rinsed with water
when anything has been eaten or drunk which is
not water. The upper teeth should not be brushed
for the fi rst week unless a water pick type tooth
cleaner is used. The lower teeth may be cleaned
as usual. In view of the transoral aspect of the
surgery, antibiotic prophylaxis should include
adequate
cover
for
anaerobes,
such
as
metronidazole.
Fig. 2.5.35 SMAS imbrication; second row continuous
4/0 monocryl completed.
Clinical pearls
When breaking through the fascial confl uence at
the temporal crest it is important to maintain
downward pressure on the dissector so that
injury to the frontal branch of the facial nerve is
avoided.
Subperiosteal dissection over the zygomatic arch
via the temporal incision is limited to the anterior
third of the arch as the frontal branch of the facial
nerve crosses the middle third where it may be
liable to injury.
Placement of sutures to provide mid face
suspension or SMAS imbrication should be
performed parallel to the direction of the facial
nerve in that area rather than perpendicular to it
so as to reduce the risk of injury by catching it
within the bite of the stitch.
Close intra-oral mucosal incision before
suspending mid face.

CHAPTER 5: Subperiosteal and Volumetric Procedures
84
Points to note
• Clonidine on induction of anaesthesia to
establish and maintain hypotensive fi eld.
• Adequate per operative blood pressure
control – systolic approximately 80 mmHg
mercury.
• Endotracheal tube secured to the teeth and
covered with a sterile camera drape.
• Tumescent infi ltration containing adrenaline
in the temporal regions and mid face to
encourage hydro dissection.
• Initial temporal dissection made between
temporoparietal fascia and temporalis fascia.
• Subperiosteal dissection then performed
beyond the temporal crest to the zygomatico-
frontal suture and inferiorly to the body of the
zygoma.
• Subperiosteal dissection continued along
anterior third of zygomatic arch and for 1 cm
along infraorbital margin.
• Buccal sulcus incision with subperiosteal
dissection over the maxilla avoiding the
infraorbital nerve.
• Join with the temporal dissection by
proceeding cephalad over the zygoma in the
direction of the Z-F suture.
• Mid facial suspension point located with a
transcutaneous needle and suspension
sutures placed before passing them out via
the temporal incision.
• Closure of the buccal incision and fi xation of
suspension sutures to temporal fascia.
• Tumescent infi ltration into face prior to
open part of procedure containing no
adrenaline.
• Incisions and dissection similar to that for
SMASectomy facelift
• SMAS imbrication in vertical direction.
• Platysmal plication to sternomastoid fascia or
Owsley type platysmaplasty in patients with
platysma bands.
• Closure of skin incisions as for SMASectomy
type facelift (Section 2 Chapter 3).
• Application of 2.5 cm micropore tape to
cheek to reduce swelling.

Pre operative
Post operative
Pre & Post operative
&
Age 51 Endobrow, upper and lower lid blepharoplasty, volumetric facelift

Pre operative
Post operative
Pre & Post operative
&
Age 45 Endobrow, lower blepharoplasty, volumetric facelift

Section 2
87
Pre operative
Post operative 3 months
Pre & Post operative
&
Post operative 15 months
Age 50 Endobrow, upper and lower lid blepharoplasty, volumetric facelift

CHAPTER 5: Subperiosteal and Volumetric Procedures
88
Pre operative
Post operative 1 year
Post operative 4 years
Pre & Post operative
&
Age 53 Endobrow, upper and lower lid blepharoplasty, peri-oral structural fat graft, volumetric facelift

Section 2
89
ANNOTATED BIBLIOGRAPHY
Little JW. Volumetric perceptions in midfacial aging
with altered priorities for rejuvenation. Plastic and
Reconstructive Surgery 2000;105:252–266.
Description of the importance of the three-dimensional shape
of the mid face producing an architectural ogee. Features
requiring perio-orbital and perioral rejuvenation are
described as of secondary importance and effacement of the
Nasolabial fold of tertiary importance. Comparison of
outcome with photographs taken in youth are analyzed to
illustrate the importance of this hierarchy.
Little JW. Three-dimensional rejuvenation of the mid face:
volumetric resculpture by malar imbrication. Plastic and
Reconstructive Surgery 2000;105: 267–285.
Review of 172 consecutive patients treated with combined
subperiosteal approach for malar imbrication and
subcutaneous approach for facelifting to provide a three
dimensional approach to mid face rejuvenation. The author
does document that there was an 8% incidence of temporary
upper lip paralysis from facial nerve dysfunction.

91
CHAPTER 1
Endoscopic Browlift
The incorporation of endoscopy into facial aesthetic surgery has, to
a large extent, eliminated the need for a coronal scar and its associ-
ated morbidity in patients requiring rejuvenation of the upper third
of the face. The endoscopic browlift, or endobrow, has two main
objectives: to reduce the visibility of glabellar frown furrows by
weakening the brow depressor musculature, and to elevate the brows
in a supero-lateral direction in order to rejuvenate the appearance of
the upper lateral brow and upper eyelid. It should be considered
whenever there is marked lateral brow ptosis, deep glabellar frown
furrows and in patients requesting rejuvenation of the upper eyelid
since they will, not infrequently, have more signifi cant lateral brow
ptosis than true dermatochalasis of the upper eyelids.
Patients should be assessed sitting or standing with the eyes in direct
forward gaze. The distance from mid-pupil to brow apex can easily
be measured with a calliper (Fig. 3.1.1) and is, on average, approxi-
S E C T I O N 3
Fig. 3.1.1 Pupil to brow measurement using a caliper.

CHAPTER 1: Endoscopic Browlift
92
mately 2.5 cm in an adult female. Average brow
height, i.e., brow apex to frontal hairline is
4.5 cm–6 cm (Fig. 3.1.2). Measurements are a
useful guide in assessment but should not be fol-
lowed slavishly. A relatively heavy lateral brow
with reduced pupil to brow distance is frequently
an attractive feature, particularly in relatively
young individuals. In considering brow surgery it
is important not to skeletonize and so further age
an already hollowed upper orbit.
Brow surgery may be combined with other facial
rejuvenation procedures, particularly facelift
and/or blepharoplasty. If it is considered in com-
bination with upper lid blepharoplasty the brow
surgery should be performed fi rst otherwise there
is a risk of over-resection of the upper lid skin
resulting in post-operative lagophthalmos with
accompanying “dry eye” symptomatology.
Fixation techniques for brow elevation vary from
simple dressings perhaps combined with skin
staples fi xed over outer table cranial screws to
specifi c fi xation devices such as Mitek anchors
and the Endotine. We have found a technique
using PDS sutures to secure the frontal peri-
osteum through drill holes in the outer table of
the skull to be quick, simple, safe, inexpensive
and, very importantly, stable. It has the added bene-
fi t of avoiding the need to remove hardware
post-operatively.
Informed Consent
The patient should be informed of the siting of
the incisions (see below) and warned of specifi c
risks and complications, i.e., infection (0.01%),
haematoma (0.01%), paraesthesia in the distribu-
tion of the supraorbital and supratrochlear nerves
post-operatively and fomication (itching) during
its recovery – this is relatively common though
not universal, alopecia – a minutely small risk so
long as no tension is based on hair-bearing scalp
and the dissection does not continue posterior to
the incision lines, paresis of the frontal branch of
the facial nerve (0.01%), and headache during
the fi rst 8–12 hours post-operatively (30%).
Pre-operative Preparation
Skin markings should be made pre-operatively
with the patient in the sitting or standing posi-
tion. Glabellar furrows are marked with the
patient actively frowning and the planned vector
of elevation of the lateral brow is indicated on
the skin (Fig. 3.1.3).
Fig. 3.1.2 Brow height measurement.
Fig. 3.1.3 Pre-operative skin markings.

Section 3
93
Instrumentation
Endoscopic brow surgery requires some special
instrumentation. The most commonly used endo-
scope is a 30° end viewing arthroscope with an
irrigation/ retraction sleeve (Fig. 3.1.4). A variety
of endoscopic cameras and monitoring equip-
ment are available but in general three chip
devices produce the best colour discrimination in
the viewed image (Fig. 3.1.5).
A series of shaped elevators, scissors, punches
and graspers are necessary to carry out the dis-
section easily and safely. Again, there are a
number of sets commercially available of which
I fi nd the Ramirez elevators the most comfort-
able and convenient. The whole set is unneces-
sary – elevators 2, 4, 6 and 7 will suffi ce for most
purposes, together with a left and right-hand ori-
entated punch and grasper (Fig. 3.1.4).
Surgical Technique
The patient is placed supine on the operating
table with a slight anti-Trendelenberg tilt much
as for facelift (see Section 2 Chapter 1), but with
the whole table positioned rather lower. Three
incisions are planned in the anterior frontal scalp
beginning at the hairline and running in a sagittal
plane posteriorly, each approximately 1 cm–2 cm
long. The fi rst is placed at the midline with each
of two lateral incisions in the marked vector of
brow elevation (Fig. 3.1.6). A temporal incision
is planned on each side measuring approximately
2 cm in length and centred on a line joining the
alar base and lateral canthus as it runs into the
Fig. 3.1.4 Endoscope and irrigation sleeve (central),
periosteal elevators (left), punch and grasper (right).
Fig. 3.1.5 Three chip colour endoscopic camera.
Fig. 3.1.6 Frontal incision sites.

CHAPTER 1: Endoscopic Browlift
94
temporal hair (Fig. 3.1.7). This may be incorpo-
rated into the upper part of a facelift scar when
this procedure is being carried out simultane-
ously. The hair is prepared using gel and tied to
facilitate easy access to the incisions.
The frontal and temporal regions are infi ltrated
with a tumescent solution containing made up of
500 mL Ringer lactate, 25 mL 0.25% marcaine
with adrenaline, 25 mL 1% lignocaine with adren-
aline, 0.5 mL 1 : 1000 adrenaline, 5 mL triamcino-
lone 10 mg/ml, 1500 U hyaluronidase. This is best
accomplished using a 20 ml syringe and 23 gauge
spinal needle. In the frontal region the infi ltration
is subperiosteal and it is important that the bevel
of the needle lies fl ush against the frontal bone;
60 mL of fl uid is infi ltrated and digital pressure is
used to diffuse it (Fig. 3.1.8) and 20 mL is intro-
duced into each temporal region, ideally between
the temporoparietal fascia (TPF) and temporalis
fascia (TF). Fifteen minutes or so should be
allowed between infi ltration of the tumescent
solution and beginning the procedure to allow the
vasoconstrictor effect of adrenaline to function.
The skin of the face is cleaned with colourless
antiseptic solution and a head drape applied. The
drape is best secured with skin staples. The
remainder of the patient is draped as for facelift
surgery using a camera drape to cover the endo-
tracheal tube (see Section 2 Chapter 1).
The surgeon is positioned at the head of the
patient with the assistant to his left and scrub
nurse to his right.
The three frontal incisions are made fi rst using a
number 15 blade carried directly down to the
frontal bone through the periosteum. A subperi-
osteal dissection is then made over the entire
frontal region to approximately 1 cm above the
superior-orbital margin. The number 2 dissector
is used for this, held in the surgeon’s right hand
with his left resting on the frontal region so as to
stabilize the head and give an accurate impression
of the depth of dissection (Fig. 3.1.9). Laterally,
the dissection continues to, but not through,
the fascial confl uence at the temporal crest
Fig. 3.1.7 Temporal incision site.
Fig. 3.1.8 Infi ltration of frontal region.
Fig. 3.1.9 Subperiosteal frontal dissection.

Section 3
95
(Fig. 3.1.10). The head is then turned to the left
and the right temporal incision made. The initial
depth of incision is through the skin only and a
limited dissection is made superfi cial to the TPF
but deep to the hair follicles to identify the TPF
as a distinct layer (Fig. 3.1.11). If the superfi cial
temporal vessels are seen towards the posterior
aspect of the wound they should be ligated. A
double-pronged skin hook is used to elevate the
inferior aspect of the skin incision, the TPF is
incised, identifying the TF as a distinct, white,
shiny layer beneath. A silk stay suture is then
placed in the TPF to act as a retractor (Fig.
3.1.12). The number 4 dissector is used to dissect
between the TF and TPF toward the temporal
crest (Fig. 3.1.13). Very little force or pressure
is necessary, but it is important that the dissector
is inclined towards the TF to be sure to remain
Fig. 3.1.10 Lateral extent of frontal dissection (arrow).
Fig. 3.1.11 Identifi cation of TPF.
Fig. 3.1.12 Silk stay suture in TPF with TF below.
Fig. 3.1.13 Number 4 dissector used to develop plane
between TPF and TF.

CHAPTER 1: Endoscopic Browlift
96
deep to the TPF since the temporal branch of the
facial nerve courses within it (Fig. 3.1.14). The
periosteal confl uence at the temporal crest is
easily felt. At this point the dissector is exchanged
for the number 2 that is used to break through
the periosteal confl uence along the temporal
crest from lateral to medial. This does require
some force and it is important that the elevator
is angled downwards, i.e., toward the bone (Fig.
3.1.15). Sweeping inferiorly, the lateral orbital
margin is dissected subperiosteally to and slightly
beyond the zygomatico-frontal (ZF) suture which
can usually be felt with the elevator. The dissec-
tion should not extend further medial than the
zygomatic process of the frontal bone to be
certain to avoid injuring the supraorbital nerve,
and in particular its deep branch which may be
situated relatively high and laterally (Fig. 3.1.16).
At this point a small swab is inserted into the
temporal wound as a pack, the head turned to
the left and the procedure repeated. It is easiest
for the surgeon to use the elevator in his right
Fig. 3.1.14 Frontal branch of facial nerve within TPF.
Fig. 3.1.15 Breaking through the facial confl uence at the
temporal crest from temporal port.
Fig. 3.1.16 Lateral (deep) branch of right supra-orbital
nerve emerging from foramen superior to orbital margin.
Temporal pocket
dissection
Veins
Temporalis
fascia
Superficial temporal
artery in TPF
Facial nerve