Video Atlas Phẫu Thuật Tạo Hình Thẩm Mỹ (Aesthetic Plastic Surgery Video Atlas)

Patient Evaluation
87
excellent. In general, patients with aponeurotic ptosis have good-to-
excellent levator function and those with congenital ptosis have poor
levator function. The position of the eyelid crease serves as a guide for
the degree of ptosis and potential for levator dehiscence. A higher than
normal upper eyelid crease (8–10 mm) may be a sign of levator dehis-
cence and aponeurotic ptosis. Common causes of neurogenic ptosis
include myasthenia gravis, Horner’s syndrome and third nerve palsies.
An example of a myogenic-type ptosis is myotonic dystrophy. Pseudo-
ptosis may be caused by aberrant regeneration of the facial nerve with
overactive orbicularis tone or may be present with contralateral lid
retraction.
Excess fullness in the lateral portion of the upper eyelid, particu-
larly in older patients, could denote prolapse of the lacrimal gland or
an extension of the lateral (temporal) eyelid fat pad. Occasionally a
signifi cant degree of fullness is found in the lateral portion of the upper
eyelid as a consequence of a prominent lateral supraorbital rim or
excess retroorbicularis oculi fat (ROOF).16 The lower eyelid usually
touches the lowest portion of the limbus. Generally, any scleral show
is considered undesirable and may serve as a risk factor when removal
of excess skin from the lower eyelids is planned. In this case the
surgeon must either strengthen the lower-lid support mechanism or
be extremely conservative with the skin removal. The fat pads in the
medial, central, and lateral compartments of the lower eyelids are
examined while the patient gazes straight ahead and upward. A depres-
sion above the infraorbital rim (malar groove) or nasojugal area should
be assessed; correction of this condition will enhance the blepharo-
plasty results. Aesthetic surgery patients commonly exhibit hyperpig-
mentation of the lower eyelids and less commonly of the upper
eyelids.
Slow, incomplete blinking may denote a weakness of the orbicu-
laris muscle. Normal spontaneous blinking frequency is 10–15 blinks
every minute, with the lower eyelid movement starting two-tenths of
a second earlier than the upper eyelid.15
A negative Bell’s phenomenon is an indicator of potential for expo-
sure keratitis postoperatively. The patient is asked to close his or her
eyes while the examiner forcefully holds the eyelid open (Fig. 8.3).
Normally, the globe will rotate cephalad. The surgeon has to be con-
servative when planning blepharoplasty if Bell’s phenomenon is poor
or nonexistent.
Several other tests prove signifi cant in evaluating the patient for
periorbital rejuvenation. The snap back and pinch tests are important
in lower eyelid examination. During the snap back test, the examiner
pulls the lid down with his or her index fi nger and allows the lid to
retract. It takes a fraction of a second for a lid with good muscle tone
to resume its previous position. However, on an older patient experi-
encing a loss of muscle tone, return to the normal position may be
slow. In conducting the traction test, like the snap back test, the
examiner pulls the lower lid away from the globe and measures the
distance from the globe to the retracted lid margin. If the examiner is
able to separate the eyelid from the globe in excess of 6 mm, it is
considered abnormal.
The most projected portion of the malar soft tissue on the profi le
view should line up with the most projected point of the eye globe or
project more anterior to it. Defi ciency of the malar soft-tissue promi-
nence (negative vector) creates a negative value and is a signifi cant risk
factor for dry eye syndrome or postoperative lid lag.12
Because of the serious complications and unacceptable outcomes
of a hastily performed blepharoplasty, this operation should be planned
only after a thorough and circumspect patient assessment. Extra
caution should be exercised when planning surgery for patients who
exhibit a tendency toward lower-lid ectropion, eyelid retraction, lag-
ophthalmos, keratitis sicca, recurrent erosion, keloid formation or
Grave’s disease with signifi cant exophthalmos. Most patients have
pre-existing asymmetry which should be noted and brought to the
patients attention.
A gross visual examination with a vision chart may disclose an
abnormality of which even the patient is unaware. This abnormality
could range from minimal to signifi cant visual loss. A visual fi eld
4−5 mm{
Fig. 8.2 The margin refl ex distance (MRD) is measured from the
light refl exion point on the cornea to the upper lid margin at about
4–5 mm.
A
B
Fig. 8.3 Bell’s phenomenon is demonstrated when the patient closes the eyes and the examiner attempts to open them. A, Bell’s
phenomenon is evidenced by rotation of the globe cephalically, protecting the eyes. B, When Bell’s phenomenon is negative, the globe will
not rotate cephalically.

8
PERIORBITAL REJUVENATION
88
examination may indicate a defi cit in the visual fi eld by a true ptosis
of the eyelids or pseudoptosis related to dermatochalasia. The basic
secretion test (basic Schirmer’s test) can be used to measure the
amount of basal tear secretion without the overlying and less predictive
refl ex tearing arc. Topical ophthalmic anesthetic is placed in both eyes.
The fornices are gently swept with a cotton-tip applicator. A 5 ×
35 mm strip of Whatman No. 41 fi lter paper is folded 5 mm and placed
on the lateral third of the lower-lid conjunctiva. While the patient
closes the eyes, the strips of the paper are left in place for 5 minutes.
Generally, wetting of the strips less than 10 mm from the fold is con-
sidered positive for some degree of dryness. This test can be variable
in different patients and in the same individual at different times;
therefore, it cannot always be fully relied upon. A tear break-apart time
is a more reliable test for documentation of the dryness of the eyes.
If there are questions concerning the amount of tear production or
the eye condition, it is always prudent to secure an ophthalmologic
consultation.
Further testing for a patient with eyelid ptosis includes the phen-
ylephrine test. This test is contraindicated with a history of narrow
angle glaucoma, labile hypertension or a shallow anterior chamber on
examination. Phenylephrine may exacerbate increased intraocular
pressure in a susceptible patient. This test is performed for consider-
ation of a Müller muscle – conjunctival resection (Putterman proce-
dure). First, the margin refl ex distance is measured bilaterally. Topical
phenylephrine 2.5% or 10% solution is then placed in the superior
cul-de-sac while the patient is in a reclined position.17 Several minutes
are allowed to pass and the margin refl ex distance is re-measured with
the patient in a sitting position. The eyelid height attained with the
installation of topical phenylephrine can be achieved with an 8 mm
Müller muscle con junctival resection. Levator advancement surgery
can be considered in patients with a negative phenylephrine test and
normal levator function.
It is crucial to discuss the details of potential risks with periorbital
surgery candidates because of the grave nature of some of the rare
complications mentioned earlier, including loss of vision. These
patients should be informed of some fairly common risks and extremely
rare complications that may result from blepharoplasty. The common
complications include slight dryness of the eye, conjunctivitis, chemo-
sis, excessive ecchymosis, or, perhaps more disturbing, conjunctival
ecchymosis, which may take 2–3 weeks to disappear. Somewhat less
likely complications include infection, hematomas, wound dehiscence,
exacerbation of dry eye syndrome, lagophthalmos, hypertrophic scars
and keloids, epiphora, protracted hyperpigmentation of the lower
lid and residual bags, asymmetry, hollow lower eyelids, eyelid retrac-
tion and eyelid ptosis.
Rare complications include ectropion and loss of vision. The
patient should be informed that loss of vision, although one of the
potential risks of this operation, is an exceedingly rare complication.
OPERATIVE APPROACH
Anatomy
Thorough knowledge of the unique structures of the eyelid and their
relation to one another is vital to achieving optimal surgical results.
The eyelid skin is the thinnest integument in the human body, with an
average thickness of 0.5–0.7 mm, the upper eyelid being slightly
thicker than the lower eyelid. The extremely thin nature of the eyelid
skin provides advantages, such as decreased scar visibility and rapid
wound healing, whereas easy wrinkling and faster stretching leading
to premature aging represent the disadvantages.
The supratarsal crease is located 8–10 mm above the upper lid
margin. This crease is formed by adhesion of the orbicularis muscle
and fi brous attachments of the levator aponeurosis to the skin. A
supratarsal fold that is too high or appears to be nonexistent suggests
attenuated, split, or even absent levator attachment to the skin. A male
skin crease is usually 6–8 mm and a female skin crease is 8–10 mm
above the lid margin.18 A vast variation in the amount of skin present
exists between individuals of various races, ages and ethnic descents.
Those from the Far East have an absent supratarsal fold even with
normal levator function. This results from either a lack of aponeurotic
attachments to the skin or attachment at a site much lower than
normal.
The eyelids are covered with fi ne lanugo hairs as well as eyelashes.
There are three to four rows of eyelashes along the upper eyelid
margin and one to two rows along the lower eyelid. The eyelashes are
associated with oil and sweat-producing glands. These sweat glands
may be a potential source of post-surgical cysts.
The lateral junction of the upper and lower lids assumes a more
acute angle than does the medial junction. The lateral canthus is
slightly more mobile than its medial counterpart. A nasojugal or malar
groove may be present; the former appears between the lateral aspect
of the nose and the inferomedial portion of the lower eyelids, and the
latter is located between the upper aspect of the cheek and inferolat-
eral aspect of the lower eyelid. These grooves become more discern-
ible with age, thus their correction becomes an integral component of
successful periorbital rejuvenation.
The orbicularis muscle has two segments concentrically distributed
around the eye, the orbital, and palpebral portions (Fig. 8.4). The
orbital segment of the muscle overlies the orbital rims. This muscle
originates from the superomedial border of the orbital wall and the
maxillary process of the frontal bone. The most cephalic portions of
the fi bers spread upward onto the forehead to interface with the fron-
talis and corrugator supercilii muscles superiorly and continue later-
ally to overlie the anterior surface of the temporalis fascia. There are
additional fi brous attachments to the medial canthal tendon and the
frontal process of the maxilla, as well as the inferior orbital rim. In
the lower lids the orbital portion of the orbicularis facilitates the force-
ful closure of the eyelid during squinting and acts in concert with other
mimetic muscles during animation.
The palpebral portion of the orbicularis oculi muscle is further
divided into preseptal and pretarsal segments. The preseptal segment
extends from the medial canthal tendon to the lateral raphe overlying
the lateral canthal tendon. It has superfi cial origins from the anterior
limb of the medial canthal tendon. The deep heads of the muscle,
originating from the lacrimal fascia overlying the lacrimal sac, con-
tribute to the lacrimal pump mechanism.19
Corrugator superciliaris
muscle
Depressor
superciliaris
muscle
Procerus
muscle
Orbital orbicularis
muscle
Medial canthal
tendon
Preseptal
orbicularis
muscle
Frontalis
muscle
Preseptal
Pretarsal
Palpebral
Pretarsal orbicularis
muscle
Lateral canthal tendon
The orbicularis muscle
Fig. 8.4 The two portions of the orbicularis muscle – orbital and
palpebral. The palpebral segment is divided into preseptal and
pretarsal segments.

Operative Approach
89
The pretarsal segment of the orbicularis oculi muscle arises from
the superfi cial heads at the anterior limb of the medial canthal tendon
and from deep heads originating along the posterior lacrimal crest
and the lacrimal fascia (Horner’s tensor tarsi muscle). The pretarsal
muscle segments from both the upper and lower eyelids fuse laterally,
forming the lateral canthal tendon that inserts onto the periorbital at
Whitnall’s orbital tubercle.
The medial canthal tendon is composed of two heads. The more
prominent superfi cial head attaches to the anterior lacrimal crest,
whereas Horner’s muscle, the smaller, deeper head, attaches to the
posterior lacrimal crest. The canaliculi are positioned just beneath the
superfi cial head of the medial canthal tendon.15 A portion of the orbi-
cularis muscle, known as the muscle of Riolan, which is the smallest
striated muscle in the body, is situated at the lid border. The nerve
supply to the orbicularis is via the seventh cranial nerve. These nerve
fi bers course within the posterior fascia of the muscle and enter
through its deep side.20
The orbital septum is a thin sheet of fi brous tissue that lies deep to
the preseptal portion of the orbicularis muscle. It serves as a protective
barrier and impedes the spread of hemorrhage, infection or infl amma-
tion to the orbit. The orbital septum also restricts protrusion of the
orbital fat. It extends from the arcus marginalis of the orbital rims, a
confl uence of the facial bone periosteum and the periorbita, to the
tarsal borders. In the occidental upper eyelid, the orbital septum fuses
with the levator aponeurosis approximately 2–3 mm above the upper
border of tarsus.15 Once fused, the fi bers pass downward to insert on
the lower anterior surface of the tarsus. In the lower eyelid the orbital
septum attaches directly to the inferior border of the tarsus with the
capsulopalpebral fascia.21
A layer of fat between the orbicularis muscle and periosteum spans
over the lateral half of the orbital rim and sometimes results in protru-
sion, necessitating its removal. This is termed the retro orbicularis
oculi fat pad. There is a similar structure in the lower eyelid termed
the suborbicularis oculi fat pad.22,23 The preaponeurotic orbital fat is
another distinct layer situated between the levator muscle and the
orbital septum of the upper eyelid. Two pockets of fat can be found in
the upper eyelid and three in the lower eyelid.
The levator palpebrae muscle is the principal retractor of the
upper eyelid. It originates from the periorbita overlapping the lesser
wing of the sphenoid bone just above Zinn’s artery and traverses the
orbital roof, extending anteriorly over the superior rectus muscle. The
levator aponeurosis divides into two attachments approximately 10–
12 mm proximal to the tarsal plate.24,25 The anterior aponeurotic fi bers
attach to the orbital septum at a variable distance above the tarsal
border. The posterior fi bers of the levator aponeurosis extend caudally
to insert into the anterior surface of the tarsus 3–4 mm below its
superior border. The levator aponeurosis possesses medial and lateral
extensions designated as the horns. The lateral horn of the levator
aponeurosis courses through the lacrimal gland, dividing it into orbital
and palpebral lobes to attach to the superior edge of the lateral
canthal tendon at the lateral retinaculum. The medial horn, which is
not as thick as the lateral horn, passes over the sheath of the superior
oblique tendon, fusing with the upper border of the posterior limbs of
the medial canthal tendon and fi bers of the orbital septum.
The superior sheath of the levator muscle condenses at the level
of the equator of the globe to form the superior transverse ligament
of Whitnall, a check ligament. It attaches medially to the trochlea of
the superior oblique muscle, extending laterally to insert onto the
capsule of the orbital lobe of the lacrimal gland. Whitnall’s ligament
functions as a pulley to facilitate the change in the direction of the
levator action from horizontal to vertical.26
The overall length of the levator muscle and its aponeurosis is
approximately 55 mm. The muscular portion constitutes about 40 mm
of the total length, and the tendinous portion measures 15 mm.15 The
levator complex derives its innervation from the superior ramus of the
oculomotor nerve (cranial nerve III).
Müller’s muscle is made up of nonstriated muscle fi bers that orig-
inate from the levator muscle and course posterior to the levator
aponeurosis, inserting onto the superior border of the tarsus. It is
approximately 10–12 mm in length and 15 mm wide. Müller’s muscle
receives its innervation from the sympathetic nervous system. The
muscle is fi rmly adherent to the conjunctiva, rending its dissection as
a separate entity quite diffi cult.
The tarsal plates are sheets of fi rm, dense fi brous tissue containing
the meibomian glands. At its widest point the upper tarsus spans
approximately 9–10 mm vertically, whereas the lower tarsus is 4–
5 mm wide. The tarsal plates are 25 mm long and 1 mm thick. The
conjunctiva is a mucous membrane containing numerous mucin-
secreting goblet cells that are fi rmly attached to the posterior surface
of the tarsal plate and loosely adherent to Müller’s muscle. The con-
junctiva also serves to support the accessory lacrimal glands of Krause
and Wolfring.
The principal blood supply to the eyelids is derived from the oph-
thalmic branch of the internal carotid artery and is supplemented by
abundant collateral circulation from the facial branches of the exter-
nal carotid artery. The medial superior palpebral artery joins with a
branch of the angular artery (a branch of the external carotid artery),
extending a few millimeters beyond the anastomosis, and divides into
upper and lower branches (Fig. 8.5). The upper branch courses along
the upper border of the tarsus as the superior palpebral arcade and
superior marginal arcade. The lower branch runs along the anterior
surface of the tarsus at the lid margin. These branches are joined by
branches of both the internal carotid (lacrimal, zygomaticofacial and
infraorbital) and external carotid (superfi cial temporal artery). The
marginal arcades run along the anterior border of tarsus near the lid
margins and the superior peripheral arcade courses along the superior
border of tarsus.
The venous drainage of the eyelids is principally thought the oph-
thalmic, angular and temporal veins. The palpebral conjunctiva drains
into branches of the ophthalmic vein, and the more superfi cial pretar-
sal tissues drain into the superfi cial temporal vein laterally and the
angular vein medially.
The sensory innervation to the upper eyelid is supplied primarily
through the branches of the trigeminal nerve (cranial nerve V). The
ophthalmic branch of the trigeminal nerve divides into the lacrimal,
frontal and nasociliary branches. The lateral palpebral branch of the
lacrimal nerve supplies the sensory innervation to the superior lateral
portion of the upper eyelid (Fig. 8.6).
Frontal branch of
ophthalmic artery
Supraorbital
artery
Ophthalmic artery
Dorsal nasal artery
Superior marginal
arcade artery
Inferior marginal
palpebral arcade
artery
Infraorbital
artery
Angular artery
Lateral nasal
artery
Facial
artery
Frontal branch of
superficial temporal
artery
Lacrimal artery
Superior medial
palpebral artery
Superolateral
palpebral artery
Zygomaticoorbital
artery
Inferolateral
palpebral artery
Transverse facial
artery
The arterial supply of the eyelid
Fig. 8.5 The arterial supply of the eyelid.

8
PERIORBITAL REJUVENATION
90
The frontal nerve passes through the superior orbital fi ssure and
courses cephalad to the levator muscle, where it divides into a larger
supraorbital branch and a smaller supratrochlear branch. The supra-
trochlear nerve provides sensory fi bers to the medial portion of the
upper eyelid. The infratrochlear nerve, a branch of the nasociliary
nerve, also provides sensory fi bers to the medial aspect of the upper
eyelid (Fig. 8.6). This nerve must be blocked completely to ensure a
comfortable resection of the medial fat pads.
Sensory innervation to the lower eyelid is provided primarily
through the infraorbital nerve, which is a branch of the maxillary
division (V2). A small limb of the zygomaticofacial nerve, a branch of
the trigeminal nerve, provides sensory innervation to the lateral aspect
of the lower lid. Patient discomfort during removal of the lateral fat
pads from the lower eyelid can be avoided with adequate blocking of
this nerve. The infratrochlear nerve provides innervation to the medial
aspect of the lower eyelid.
The lacrimal secretory system is composed of basic and refl ex
secretors. The basic secretors include the accessory lacrimal glands
of Krause and Wolfring, the mucin-secreting goblet cells, and the
meibomian glands.24 There are approximately 20 to 40 glands of Krause
located in the upper fornix and six to eight glands situated in the lower
fornix. Far fewer glands of Wolfring exist in comparison, with three
located at the superior tarsal border of the upper eyelid and one at
the inferior tarsal border of the lower lid. The secretions drain directly
onto the conjunctival surface. Approximately 20 to 25 meibomian
glands exist in the upper and lower eyelids, and are positioned verti-
cally within the tarsal plate. Smaller contributions to the lid secretion
are provided by the glands of Zeis (sebaceous) and Moll (apocrine),
which are intimately associated with the cilia of the eyelids.
The tear fi lm has three layers, of which the innermost layer overly-
ing the surface of the cornea is composed of a mucopolysaccharide
substance secreted by the conjunctiva goblet cells.27 This is the thin-
nest layer of the tear fi lm. The intermediate aqueous layer is produced
by secretions from the accessory lacrimal exocrine glands of Krause
and Wolfring. This layer, which is 98% water, represents close to 90%
of the precorneal tear fi lm thickness. The outermost layer of the tear
fi lm is primarily composed of secretions from the lipid producing
meibomian glands. This layer is important in stabilizing the precor-
neal tears and reducing evaporative losses of the underlying layers.
The main lacrimal gland, which comprises the refl ex arm of the
secretory system, is located in the superolateral corner of the anterior
orbit. The lateral horn of the levator aponeurosis transects this gland,
dividing it into a large superiorly positioned orbital lobe and a smaller
caudally positioned palpebral lobe. Refl ex tearing results from stimu-
lation of the branches of the trigeminal nerve. The efferent limb of the
refl ex arc is mediated through parasympathetic fi bers of the greater
superfi cial petrosal nerve, sphenopalatine ganglion and zygomatico-
temporal branch of the maxillary nerve eventually stimulating the
lacrimal gland.
Blinking, mediated by contraction of the orbicularis muscle, results
in vertical distribution of the tear fi lm over the corneal epithelium.
Approximately 12 main excretory ducts drain the orbital and palpe-
bral lobes of the lacrimal gland. The tears formed in the gland drain
into the main ducts on the conjunctival surface, emptying onto the
ocular surface. The lacrimal drainage system begins with the puncti
that are located in the medial portion of each eyelid, adjacent to the
mucocutaneous junction. The canaliculi then drain into the common
canaliculus, the lacrimal sac and into the nasolacrimal duct.
Upper lid blepharoplasty
Upper and/or lower eyelid blepharoplasty can be performed while the
patient is under local anesthesia with intravenous sedation or general
anesthesia. Before the patient is sedated and while he or she is in a
supine position, the upper eyelid incision is designed and the excess
skin is assessed. Error in judgment will be more likely if the amount
of excess skin to be removed is determined while the patient is sitting.
Gravity pulls the forehead skin caudally; therefore, skin appears more
redundant in a sitting position than in the recumbent position. Any
misjudgment will loom even greater if a combined forehead rejuvena-
tion and blepharoplasty is planned. To avoid this, the surgeon elevates
the eyebrows manually to the intended level in order to minimize the
miscalculation. Regardless of the thoroughness of examinations during
previous visits, the patient is examined once more immediately before
surgery.
The caudal or eyelid crease incision on the upper eyelid is marked
fi rst (Fig. 8.7). This incision is made either precisely at the crease on
younger patients or 1 mm caudal to the existing crease on older
patients. This incision line will rise slightly during the wound-healing
phases. It is important to gently stretch the skin while designing the
incision otherwise the incision may ride too high postoperatively. The
excess skin is pinched with a pair of fi ne, smooth forceps, and the
amount of skin to be removed is assessed. The cephalad incision line
is then marked (Fig. 8.8A). These incision lines are checked while the
patient is in a sitting position. While the eyelids are closed, the skin is
pinched gently again, using a pair of smooth forceps, with the patient
in a supine position (Fig. 8.8B). The maximum amount of skin that can
be excised before the eyelid opens up is estimated. The upper lid incision
Supraorbital
nerve
Supratrochlear
nerve
Infratrochlear
nerve
Lacrimal nerve
Zygomaticofacial
nerve
Infraorbital nerve
The nerve supply of the eyelid
Fig. 8.6 The nerve supply of the eyelid.
Fig. 8.7 The caudal portion of the upper eyelid incision is at the
eyelid crease or slightly caudal to it.

Operative Approach
91
marking is then extended laterally and medially with a cephalic curve
at both ends. Next, the fat pads are examined in all of the compart-
ments and marked.
While the patient is in a supine position, the face is prepped and
draped in the usual manner, using saline and povidone-iodine (Beta-
dine) solution. The incision markings are freshened if necessary. The
anesthetist or anesthesiologist will then administer intravenous seda-
tion using a combination of propofol, fentanyl and midazolam.
Usually, patients are instructed to take 10 mg of diazepam (Valium)
the night before surgery and 10 mg the morning of surgery. After
adequate sedation has been achieved, the patient’s eyelids are infi l-
trated using lidocaine hydrochloride containing 1 : 100 000 epineph-
rine and 3 units/mL of hyaluronidase. The upper eyelid surgery is
commenced after adequate time has elapsed to allow the epinephrine
to provide the maximum vasoconstriction (usually 10 minutes). The
assistant retracts the tarsal portion of the eyelid using a folded sponge
while the surgeon pulls the eyelid cephalically with a similar piece of
gauze. The incision closest to the eyelid margin is made and taken
through the skin (Fig. 8.9). If a portion of the orbicularis muscle is
to be removed, which commonly is not the case, it may be included
in the incision; otherwise the orbicularis incision is avoided to mini-
mize the chance of injury to the levator aponeurosis. The assistant
then advances the sponge closer to the cephalic incision as the
surgeon retracts the lid cephalad to the incision (Fig. 8.10). This
retraction and counter traction facilitates precise placement of the
incision and avoids any irregularities. The incision is curved cephalad
at the lateral end to avoid the potential for creation of an epicanthal
fold as a result of scar contracture. The skin is then excised starting
laterally, using a fi ne needle tip cautery, while the assistant is pulling
the skin over the lateral canthal area laterally and extended laterally
(Fig. 8.11). Care is taken to stay in the correct plane between the skin
and orbicularis. A small double skin hook is placed in the cephalic
portion of the incision and another one in the caudal portion, separat-
ing the incisions. Hemostasis is then achieved using a pair of fi ne
forceps and cautery.
After meticulous and complete hemostasis, the orbital septum is
incised superiorly and the preaponeurotic fat is exposed only if its
removal is indicated. The temporal fat pad is seldom removed. Almost
invariably there is an extension of the temporal fat pad laterally,28
A
B
Fig. 8.8 A, The cephalic portion of the upper eyelid incision is marked. B, Pinching the skin and watching the lid ensures that enough skin
is preserved to allow lid closure.
Fig. 8.9 While the assistant pulls the eyelid caudally and the
surgeon pulls it cephalically, the caudal incision is made through the
skin and subcutaneous tissue.
Fig. 8.10 The cephalic incision is made after the surgeon and the
assistants pull the skin taut.

8
PERIORBITAL REJUVENATION
92
although it is not always necessary to expose this fat to remove it.
While exerting gentle traction, the surgeon can readily deliver the fat.
A small vessel that is a branch of the lacrimal artery joining the fat
pads can be observed at this point. This vessel must be cauterized
before transection of the lateral extension of the temporal fat; other-
wise brisk bleeding may occur. The fat is then removed using the fi ne
needle cautery (Fig. 8.12). With blunt dissection using a fi ne hemostat,
the medial fat pad is exposed, pulled anteriorly, and injected with
lidocaine hydrochloride. This not only eliminates potential patient
discomfort, but also minimizes the chance of oculocardiac refl ex,29
which is a common occurrence during this portion of a blepharoplasty.
The medial fat pad is then removed in a similar manner (Fig. 8.13).
Conservatism in removing the fat pads prevails. Overzealous removal
of the temporal fat will result in a signifi cant change in the shape of
the eyelids and an undesirable hollowing of the upper eyelid. This may
create an exaggerated deepening of the supratarsal fold and should
be avoided. The lacrimal gland is explored by applying gentle pressure
on the globe, and if it protrudes beyond the orbital rim, it should be
suspended.30 To do this, the surgeon carefully frees the protruding
portion of the gland and the gland is then anchored to the periorbita,
incorporating the gland capsule using a 6–0 non-absorbable suture.
The suture, after being passed through the gland capsule and the
periorbita, is gently tied while the gland is being reduced in position
by the assistant. A second or third suture is placed if mandated by the
extent of the gland ptosis.
Rarely, some patients exhibit prominence in the lateral portion of
the upper eyelid as a result of excess fat between the orbicularis oculi
muscle or the lateral portion of the supraorbital rim (ROOF). This fat
overlies the periosteum and extends from the middle portion of the
upper eyelid to the area past the level of the lateral canthus. The excess
fat can be removed by retracting the orbicularis oculi muscle anteri-
orly and dissecting between the orbicularis muscle and the fat. The
excess fat overlying the orbital rim is then removed using the coagula-
tion power of the cautery. Electrocoagulation may abate the postop-
erative bleeding and ecchymosis. Should the projection of the lateral
supraorbital rim be excessive, the periosteum is incised parallel to the
rim and elevated using a periosteal elevator. The bone is then removed
gently using an oval burr. The periosteum is repaired to provide a
gliding surface for the orbicularis oculi muscle. To repair the upper
lid skin incision, the surgeon places a simple stitch at the level of the
pupil, using 6–0 plain, fast-absorbable catgut sutures unless the patient
is allergic to catgut (Fig. 8.14). A second stitch is then placed at the
Fig. 8.11 Removal of the skin using needle tip electrocautery is
demonstrated.
Fig. 8.12 Exposure and removal of the preaponeurotic temporal fat
pad using cautery.
Fig. 8.13 Removal of the nasal (medial) fat pad.
Fig. 8.14 Repair of upper eyelid starts with a single 6–0 fast
absorbable catgut suture at the level of the pupil.

Operative Approach
93
level of the lateral canthus. The portion between the medial end of the
incision and the lateral canthus is repaired using 6–0 plain catgut
subcuticular sutures. The remaining portion of the incision lateral to
the canthus is repaired with running locked suture (Fig. 8.15). If a
canthoplasty is part of the surgical plan, the lateral portion of the
incision is closed after completion of lower-lid surgery and canthop-
lasty. The procedure is completed in the same manner for the opposite
upper eyelid.
Skin/muscle lower blepharoplasty
The lower eyelid is retracted, pinched and released once more prior
to surgery so that proper eyelid tone can be assessed. The skin of the
lower eyelid is gently pulled down, and if removal of any excess skin
is planned, the eyelid is observed to determine the amount of caudal
stretch of the eyelid skin that results in retraction of the lid margin
and increase in scleral show. Conservative removal of skin from the
lower eyelids is crucial to reduce the potential problems. The protrud-
ing fat pads are then marked. A lower eyelid skin crease incision is
marked 1–2 mm caudal to the eyelashes above. This mark does not
extend medial to the punctum. Protective eye shields are placed into
position. Local anesthesia and preparation of the surgical fi eld is
performed as described for the upper eyelid. A small incision is made
laterally at the level of the orbital commissure using a #15 blade (Fig.
8.16). This incision is continued through the skin crease closest to the
lid margin (1–2 mm below the eyelashes) using a pair of straight iris
scissors. Next, a small double skin hook or suture is placed on either
side of the incision, retracting it cephalically and caudally. At this
point, the skin incision in the crease closest to the eyelashes is con-
tinued medially, stopping short of the lower punctum (Fig. 8.17). A
retraction suture is placed at the tarsal side of this incision retracted
cephalad to the lid (Fig. 8.18). Using a pair of baby Metzenbaum or
fi ne needle cautery, dissection is continued caudally in a preseptal
plane to the orbital rim (Fig. 8.19). Care is used to leave the pretar-
sal orbicularis intact. At this point, dissection is deepened by incising
the orbital septum to expose the fat in all three compartments. Injec-
tion of a small amount of local anesthetic in the medial fat pad will
curtail patient discomfort as will an injection of local anesthetic in
the lateral compartment. The excess fat is conservatively removed
from these compartments employing careful dissection, retraction,
Fig. 8.15 The rest of the incision is repaired using running locked
sutures temporal to the lateral canthus and subcuticular sutures from
the medial to the lateral canthus using 6–0 fat-absorbable catgut.
Fig. 8.16 A small incision is made laterally for skin muscle lower
blepharoplasty.
Fig. 8.17 A subcilliar incision, stopping short of the punctum, is
made with a pair of sharp iris scissors.
Fig. 8.18 A retraction suture is placed at the tarsal side of the
incision and it is retracted cephalad.

8
PERIORBITAL REJUVENATION
94
and use of fi ne tip cautery for transection of the fat (Fig. 8.20). Care
is taken not to retract the fat too vigorously as this may rupture deep
orbital vessels.
After removal of the initial fat, the globe is gently blotted. The
surgeon will note a bulging if there is residual excess fat. This fat
sometimes does not even retract when the globe is allowed to return
to its normal position, which is a strong indication for removing the
fat. The retraction sutures may distort the surgical judgment if they
are not released. Caudal rotation of the globe, or a downward gaze,
may result in under correction of the protruding fat. Conversely, an
upward gaze or cephalic retraction will result in excess removal of
fat. The amount of residual fat is checked once again. Gentle pressure
of the globe should advance the fat only to the orbital rim level. Care
is used to avoid injury to the inferior oblique muscle when excising
the medial and central orbital fat.
Commonly, a canthopexy is performed in the following manner. If
a skin muscle fl ap is being used, the lower lid retractors are released
close to the lateral canthus (Fig. 8.21). If a skin fl ap blepharoplasty
is being done, a small incision is made in the orbicularis muscle
immediately caudal to the tarsal plate about 5–6 mm in length, almost
3 mm medial and 3 mm lateral to lateral commissure (Fig. 8.22). The
incision is deepened and all of the retractors are released to render
the lateral commissure freely mobile. A 5–0 nylon suture is passed
through the lateral commissure to include the lateral canthus avoid-
ing penetration of the conjunctiva (Fig. 8.23) passed through the
periorbita at the level of the mid pupil, posterior to the lateral orbital
rim and tied incrementally, watching the lateral canthus rise and the
lower lid margin is pulled posteriorly and laterally against the globe
(Fig. 8.24). The lid tightness is tested by retracting it with a pair of
fi ne forceps. One should be able to separate the lid from the globe
only 3–4 mm intraoperatively. It is important to ensure that the lid
margin, thus the eyelashes, would not rotate externally or internally.
There also should be no space between the lid and the globe, and
there should be no lateral redundancy of the tarsal plate causing a
small kink. If this is noted, a small (2–3 mm) wedge excision of the
lower-lid margin, very close to the lateral canthus will correct the
problem (Fig. 8.25). The resultant defect is repaired using 6–0
Monocryl for the tarsal plate and 6–0 fast absorbable catgut for the
skin and orbicularis (Fig. 8.26).
For patients who exhibit signifi cant weakness of the lid support
mechanism as documented by the pinch and traction test, a cantho-
plasty will be performed before the excision of skin and repair of the
lateral portion of the upper eyelid skin, if an upper eyelid blepharo-
Fig. 8.19 Dissection is continued in the submuscular level to the
infraorbital rim.
Fig. 8.20 Removal of the fat from the lower compartments using fi ne
needle cautery.
Fig. 8.21 If a skin muscle fl ap is being used, the retractors are
released close to the lateral canthus.
Fig. 8.22 A small incision is made in the orbicularis muscle
immediately caudal to the tarsal plate about 6 mm in length; almost
3 mm medial and 3 mm lateral to the lateral commissure.

Operative Approach
95
plasty is planned concurrently.32 Prior to making the incision, the
current position of the lateral canthus is marked on the bone using
brilliant green to the periosteum with a 25 gauge needle. The incision
is then deepened to the periosteum. A tattoo mark is transferred to the
bone with a bone pencil. A subperiosteal dissection is conducted
toward the lateral canthus by retracting the soft tissue. The periosteum
is elevated under the lateral canthus and gentle dissection deeper into
the orbit will expose the lateral retinacular ligament. The entire liga-
ment is dissected and detached until adequate mobility of the lateral
canthus is accomplished. Additionally, the lower-lid retractors are
released with a needle cautery. A double armed 5–0 Mersiline suture
is passed through and looped around the ligament. Considering the
previously marked lateral canthus and the degree of cephalic reposi-
tioning and tightening necessary, the surgeon selects the new location
for the attachment of the retinacular ligament. Two burr holes are
made on the lateral orbital wall while the orbital contents are pro-
tected with a malleable retractor. The needles attached to the ligament
are then passed through the holes and tied over the lateral orbital
wall. The degree of the tightness and amount of lid transposition are
judged based on the preoperative and intraoperative fi ndings. The lid
should be tight enough to prevent its separation from the globe beyond
3–4 mm with manual lift, and it should overlap the iris 1–2 mm in a
straight gaze. When a lower blepharoplasty is intended through a
conjunctival incision, it is performed before tightening the retinacular
ligament suture to avoid limitation of the exposure.
At this point, the lower eyelid fl ap is draped back. To estimate the
safe amount of skin to be removed, the surgeon pulls the skin over the
malar area caudally to simulate the gravity effect. The assistant’s
fi nger then replaces the surgeon’s fi nger. While this transaction is
taking place, the surgeon watches to assure that the skin of the malar
area does not move cephalically. While the lid margin remains in a
neutral position with the patient gazing straight ahead, the excess skin
is assessed and excised, including the orbicularis muscle (Fig. 8.27).
If the patient possesses hyperactive orbicularis muscles, an addi-
tional amount of lower-lid muscle is excised from the skin muscle fl ap
cephalically in a beveled fashion. Because a strip of the muscle of
Riolan is always maintained anterior to the lower-lid tarsal plate,
beveling of the lower orbicularis will ensure a smoothly contoured
lower eyelid. After resecting the orbicularis muscle, the surgeon
very gently wipes the remaining portion of the orbicularis with a
Fig. 8.23 A 5–0 nylon suture is passed through the lateral
commissure to include the lateral canthus avoiding penetration of
the conjunctiva.
Fig. 8.24 The suture is then passed through the periorbita at the
level of the center of the globe, posterior to the lateral orbital rim
and tied incrementally, watching the lateral canthus rise and the
lower margin tighten.
Fig. 8.25 If lateral excess is noted, a small (2–3 mm) wedge excision
of the lower lid margin, very close to the lateral canthus, will correct
the problem.
Fig. 8.26 The resultant defect is repaired using 6–0 Monocryl and
6–0 fast absorbable catgut systems.

8
PERIORBITAL REJUVENATION
96
Weck-cel(tm) sponge. This facilitates detection of small vessels that may
bleed postoperatively when the vasoconstrictive effect ceases. Any
bleeding vessel is gently cauterized. The lid is then redraped and lined
up properly. The maneuver that was used to assess the amount of
excess skin removal is repeated, this time with the skin of the lid in
position. Presence of excess skin while the malar skin is being pulled
to mimic the effect of gravity indicates that additional skin should be
excised. The authors have used these techniques in more than 2000
pairs of eyelid surgeries with high degree of success. The orbicularis
muscle is then sutured to the periosteum at the lateral canthus area
using 6–0 Monocryl. Interrupted, fast-absorbable sutures are placed
laterally, and the remaining portion of the lid incision is repaired using
6–0 plain catgut running subcuticular sutures (Fig. 8.28). It is crucial
that deeper bites be taken on the ciliary side compared with the fl ap
side to avoid overlapping of the skin margin. It is necessary not to take
a back bite in order to avoid a purse-string effect. No attempt should
be made to eliminate all of the wrinkles visible when the patient is in
the supine position; otherwise as gravity pulls the lid and malar soft
tissues caudally when the patient assumes a sitting position, lower-lid
retraction will ensue. A Frost suture is used routinely for 24 hours. If
the patient exhibits signifi cant hyperpigmentation, the lower lid can
be treated with one pass of CO2 laser set at 100 mJ (newer lasers),
density of 4, 60 watts. Occlusive dressing like Laser Seal or Flexxon
is applied. After completion of this part of the surgery a temporary
tarsorrhaphy is done using 6–0 plain catgut and a Frost suture is
placed. Steri-Strips (1/4 inch) are applied over the free ends of the
eyelid subcuticular sutures laterally. Throughout the operation, the eye
is irrigated using balanced salt solution if an eye shield is not used.
Ophthalmic ointment is applied routinely. The incisions are then
covered with an ophthalmic Bacitracin ointment, and the patient is
transferred to the recovery room.
Transconjunctival lower blepharoplasty
Should a transconjunctival33–36 approach be selected, a protective eye
shield is inserted. Following injection of lidocaine containing
1 : 100 000 epinephrine and retraction of lid margin with two single
skin hooks, pressure is applied on the eye globe and a bulge in the
lower fornix is noted (Fig. 8.29). An incision is made caudal to the
vascular arcade using the fi ne needle electrocautery, incorporating
the conjunctiva deep in the fornix and Müller muscle. Careful dissec-
tion readily exposes the medial fat pad. To reach the medial and
lateral fat pads, the surgeon must often use two small Crile right angle
retractors or Desmarres retractors (Fig. 8.30). The lateral fat pad is
Fig. 8.27 While the lid margin remains in a neutral position with the
patient gazing straight ahead, the excess skin is estimated and
excised including the orbicularis muscle.
Fig. 8.28 One or two interrupted, fast-absorbable sutures are placed
laterally, and the remaining portion of the lid incision is repaired
using 6–0 plain catgut running subcuticular sutures.
Fig. 8.29 Following injection of lidocaine containing 1 : 100 000
epinephrine and retraction of lid margin with two single skin hooks,
pressure is applied on the eye globe and a bulge in the lower fornix
is noted.
Fig. 8.30 To remove the medial fat pads, the surgeon replaces the
skin hooks with Crile rectangular retractors.

Operative Approach
97
often cephalad and lateral to the central fat pad. Careful dissection
and judicious removal are necessary to achieve an optimal result.
Periodic pressure on the globe may help the surgeon judge the amount
of fat to be removed. The lid is allowed to assume a normal position
and its contour is observed. Minimal depression along the infraorbital
rim is optimal. This depression, however, should disappear as gentle
pressure is applied to the lid. One or two 6–0 plain sutures are used
to repair the incision (Fig. 8.31). This procedure commonly results in
natural-appearing lid rejuvenation (Figs 8.32 & 8.33).
Lower blepharoplasty using
skin-fl ap technique
For the patients who exhibit signifi cant wrinkling of the lower lid with
thin skin, a skin fl ap with canthopexy may provide a better outcome.
The incision is similar to the skin muscle fl ap technique, but the dis-
section will be conducted in the subcutaneous plane using either a pair
of Metzenbaum scissors or a fi ne needle cautery with very low energy
setting to avoid thermal damage (Fig. 8.34). The orbicularis muscle
and the orbital septum are released at the level of orbital rim and
protruding fat will be managed by removal, repositioning, or a com-
bination of both, depending upon the patient’s needs. The orbicularis
muscle is repaired using two 6–0 monocryl inverted sutures. Follow-
ing canthopexy, through a small incision in the orbicularis laterally,
as outlined previously, the skin is re-draped and the excess skin is
excised using the principles discussed for skin muscle fl ap technique.
The skin fl ap is tacked down to the orbicularis muscle in three or four
sites using interrupted sutures of 6–0 fast absorbable catgut, oriented
cephacaudally, to minimize the potential for collection of fl uid under
the skin (Fig. 8.35). This technique provides gratifying results on
patients with signifi cant skin redundancy.
Management of deep nasojugal or
malar grooves
For patients who exhibit deep nasojugal or malar grooves, the fat pads
are dissected, repositioned caudally, and fi xed to the periosteum under
the orbicularis muscle after release of the arcus marginalis.37,38 To
accomplish this goal, the surgeon elevates the orbicularis oculi muscle
and the orbital septum, leaving the periosteum intact. This dissection is
continued medially up to the lateral nasal region. The lower-lid excess
fat is then dissected; the excess portion, beyond what is needed, is
excised, and the remaining fat is partially incised and rolled caudally.
Using 6–0 Vicryl, the surgeon fi xes the adipose fl aps to the periosteum
over the malar region. The fat also can be transected and repositioned
as a graft, or more suitably the malar fat pad can be dissected, repo-
sitioned cephalically, and fi xed to the infraorbital rim position using
two 5–0 vicryl sutures. Both authors prefer the latter technique.
Laser resurfacing of the lower eyelid
In patients who undergo transconjunctival resection of the lower fat
pads, or the patients who are candidates for a skin muscle fl ap, it may
be necessary to resurface the lower lids with laser to improve the lines
and hyperpigmentation.39 The senior author uses the carbon dioxide
laser, set at 100 mJ, density of 5 and 60 watts. Usually, only one pass
is made with minimal or no overlap. A second pass is rarely made
using the same settings, except the density is reduced to 4 with no
overlap on the transconjunctival blepharoplasty, but never on the skin
muscle fl ap technique. The lid is covered with a silicone dressing
(Laser Seal, Innovation Alley, Lyndhurst, Ohio).
Levator aponeurosis
advancement operation
This procedure is technically demanding and requires practice to
produce consistent results.40 The following description is a base to
Fig. 8.31 Conjunctiva is repaired using two 6–0 plain fast-
absorbable catgut sutures.
A
B
Fig. 8.32 Photographs of the patient with excessive upper eyelid skin and fat pads, protruding lower fat pads, and deep tear trough before
(A) and after (B) upper blepharoplasty with removal of skin, orbicularis muscle, and fat from both compartments of upper eyelids;
transconjunctival removal of lower lid fat pads; fat graft to tear troughs; and laser resurfacing, using Coherent laser set at 300 mJ, density of
5, and d60 watts. First pass was made with density of 5, and for second pass, density was reduced to 4.

8
PERIORBITAL REJUVENATION
98
allow the reader to acquire further knowledge and skill. A novice
ptosis surgeon who follows the guidelines in this chapter can achieve
a good result, but an excellent result requires refi nement and frequent
adjustments to one’s technique. To attain proper height and prevent
signifi cant lagophthalmos, this procedure is typically performed under
local anesthesia with minimal sedation to maximize patient coopera-
tion. A standard upper-eyelid blepharoplasty approach is performed
as described previously, if indicated. Otherwise, a shorter incision
confi ned to the upper eyelid crease is suffi cient. The skin is excised, if
planned, and the septum is exposed. Caudal traction is placed on the
inferior border of the incision with a micro two-pronged skin hook.
Once the septum is identifi ed, it is incised superiorly over the preapo-
neurotic fat pad. The fat pad is resected, if indicated, or retracted
superiorly. The levator aponeurosis and muscle belly are identifi ed.
The location of the levator aponeurosis is noted. It is often disinserted
from the anterior surface of the tarsus. The cephalic surface of the
tarsus is then exposed by dissecting the levator aponeurosis off of the
tarsus with a Westcott scissors. The Müller’s muscle is dissected off
the posterior surface of the aponeurosis. Once adequate mobilization
of the levator is achieved, the levator is advanced onto the anterior
surface of the tarsus by suturing the aponeurosis to the anterior tarsus
in a partial thickness, horizontal mattress fashion using a 6–0 nylon
spatula needle. This suture is placed at the medial lid peak. The eyelid
is everted and observed to insure that the suture is partial thickness.
A temporary knot is tied. The patient is asked to open the eyes. The
height and contour of the eyelid is assessed in a reclining position. If
the height and contour are satisfactory, the suture is then permanently
tied. The patient is then seated upright on an adjustable operating
room table and the lid height is assessed as well as the amount of
lagophthalmos. A small amount of lagophthalmos (<2 mm) may be
present due to the effect of the lidocaine on the protractor of the eyelid,
the orbicularis oculi muscle. An additional suture may be placed lat-
erally or medially depending on the amount of ptosis and lid contour.
The wound is closed in a fashion similar to a blepharoplasty proce-
dure. Frequent lubrication of the eye and cold compress are used
postoperatively as lagophthalmos is more prevalent after ptosis
surgery.
Müller muscle–conjunctival resection
The Müller muscle–conjunctival resection procedure was described
by Putterman and Urist in 197529,30 and modifi ed by the senior author
in 1989.31 This procedure may be used in patients with acquired 1–
3 mm ptosis who demonstrate good response with elevation of the
Fig. 8.34 The incision is similar to the skin muscle fl ap technique
but the dissection will be conducted in the subcutaneous plane
using either a pair of Metzenbaum scissors or a fi ne-needle cautery
with very low energy setting to avoid thermal damage.
Fig. 8.35 The skin fl ap is tacked down to the orbicularis muscle in 3
or 4 sites using 3–4 interrupted sutures of 6–0 fast absorbable
catgut, oriented cephacaudally, to minimize the potential for
collection of fl uid under the skin.
A
B
Fig. 8.33 Photographs of the patient before (A) and after (B) lower blepharoplasty and malar lift.

Operative Approach
99
eyelid following instillation of topical 2.5% phenylephrine. If the
response to the installation of neosynephrine is ideal by raising the
lid to normal position 8 mm of Müller’s muscle and conjunctiva is
removed. For a lesser response 9 mm is removed and for an exagger-
ated response 7 mm of this composite tissue is removed. This proce-
dure is performed with the patient under local anesthesia with sedation.
With the patient in the supine and sitting positions, the eyelid is
marked. The lid is then infi ltrated with xylocaine containing 1 : 100 000
epinephrine, avoiding injection in the Müller’s muscle. Next, the eyelid
is everted; 7–9 mm of Müller’s muscle and conjunctiva is measured
(Fig. 8.36). This will be a fold of composite tissue measuring 3.5–
4.5 mm, depending on the response to neosynephrine. Next, a custom-
designed non-crushing clamp (Kupp surgical ptosis clamp – #KS999
GP) is placed across the Müller’s muscle and conjunctiva without
catching any portion of the tarsal plate. A 5–0 plain catgut double-
armed suture is then passed under the clamp in a horizontal running
fashion. The muscle and conjunctiva above the clamp are then excised
using a #10 blade (Fig. 8.37). Hemostasis is secured using a cautery
(Fig. 8.38). The clamp is then removed (Fig. 8.39). The end of the
sutures are then brought through the tarsal plate and tied over it
loosely to avoid kinking of the tarsal plate (Fig. 8.40).
Optimizing outcomes
●
While marking for an upper eyelid blepharoplasty, a pinch test will
help to assure adequate tissue is retained for proper lid function.
●
The procedure has to be individualized based on the patient’s
concerns and physical fi ndings. For excess skin, one uses a
cutaneous or skin muscle fl ap approach and for fat herniation
alone, one has to employ a transconjunctival approach and
remove, reposition, or use a combination of both.
●
Meticulous dissection will help prevent postoperative
ecchymosis, as gentle traction of the orbital fat pads will
prevent tearing or trauma to deep orbital vessels.
●
Conservative removal of lower eyelid skin and fat with careful
dissection around the orbital septum will help to reduce
ectropion and lid retraction.
●
Noting the location of the medial upper lid peak and placing
the cardinal suture just medial to the pupil during a levator
advancement procedure will result in the most natural lid contour.
●
Canthopexy or canthoplasty should be considered on most
patients who undergo lower blepharoplasty.
Fig. 8.36 Next, the eyelid is everted; 7–9 mm of Müller’s muscle and
conjunctiva is measured.
Fig. 8.37 The muscle and conjunctiva above the clamp is then
excised using a #10 blade.
Fig. 8.38 Hemostasis is secured using a cautery.
Fig. 8.39 The clamp is then removed.

8
PERIORBITAL REJUVENATION
100
COMPLICATIONS AND ADVERSE EFFECTS
The blepharoplasty complications can be divided into intraoperative,
short-term postoperative and long-term postoperative risks. Intraop-
erative complications include anesthesia-related complications, the
oculocardiac refl ex, and excessive bleeding. Intraoperative excessive
hemorrhage is commonly related to hypertension, coagulopathy and,
possibly, the surgical technique. Hypertension may be controlled in
the preoperative stages and perioperatively with sedation and hyper-
tensive medications. In the absence of hypertension the excessive
bleeding should be investigated by a coagulation profi le, including a
screening for von Willebrand’s disease. If the bleeding persists, 16–
20 μg of desmopressin (DDAVP) can be infused over a period of 30–45
minutes while the patient’s blood pressure is being monitored for
hypertension. The patient should be observed closely postoperatively
for thrombophlebitis, oliguria, and the very unlikely possibility of
coronary blockage. In patients with known coronary artery disease, use
of desmopressin is not advisable.
Short-term postoperative complications include hematomas, per-
sistent bleeding, marked swelling, ecchymosis, and the gravest of com-
plications, loss of vision. All of these complications are related to one
of three factors. Meticulous homeostasis is one factor. It may not be
possible for the surgeon to observe bleeding during the surgery as a
result of vasoconstriction or hypotension. For this reason, all visible
bleeding vessels should be cauterized thoroughly before the incision is
repaired.
Avoidance of compounds that contain aspirin or other salicylate
derivatives, as well as pharmaceutical products that interfere with
platelet function, is the second factor that can be controlled through
the combined efforts of the surgeon and the patient. Complete control
of this factor, however, is diffi cult, even among the most educated
patients. Patients often forget that they are to refrain from consuming
these products, and even when questioned, they may not recall the
usage.
The most common factor leading to the development of hemato-
mas and excess ecchymosis is hypertension. Patients being treated for
hypertension should take their anti-hypertension medications the
morning of surgery. The patient’s blood pressure should be observed
before, during, and immediately after induction of sedation. Any sys-
tolic blood pressure exceeding 130 mmHg should be treated intra-
operatively. Close postoperative monitoring of the hypertension is
essential. Surgery-related anxiety and undetected hypertension can be
a noxious combination, which if not treated aggressively, may have
catastrophic consequences. Intravenous control of anti-hypertension
with medication, based on the knowledge of the patient’s other medical
problems, is suffi cient for the short-term control of hypertension in
the recovery room and when used in conjunction with clonidine hydro-
chloride (0.1 or 0.2 mg) may suffi ce for a more protracted effect. A
small amount of bloody drainage is only temporary and often ceases
with the application of gentle pressure. Small submuscular hematomas
usually dissolve without a major delay in healing. However, subcutane-
ous hematomas are troublesome and cause induration that may last
for several weeks or months. During this period the patient must be
observed closely, shown a great deal of compassion, and given consid-
erable emotional support. In spite of a cumbersome recovery, generally
the fi nal outcome is not signifi cantly affected by small hematomas.
Larger hematomas, however, must be drained surgically upon
discovery.
Blindness is the most dreaded complication of blepharoplasty and
the incidence in the literature ranges from 1 : 2000 to 1 : 5000 cases.24,41
The loss of vision is thought to be due to a retrobulbar hemorrhage
causing increased intraorbital pressure. This hemorrhage is thought to
cause compression of the ciliary arteries which results in ischemia of
the optic nerve. Another theory is ischemia of the optic nerve due to
constriction of the retrobulbar blood vessels in response to epinephrine
in the local anesthetic. A patient’s complaint of signifi cant pain, pres-
sure, excess swelling or visual disturbances should be investigated
vigorously in order to avoid this complication. Immediate consultation
with an ophthalmologist is crucial if there is any evidence of loss of
vision.
A retrobulbar hematoma may occur as a result of injury to the
deeper orbital blood vessels or from bleeding from the orbicularis
muscle. The patient will exhibit proptosis, pain and mydriasis. The
treatment includes opening the wounds and releasing the hematoma
if possible. Other options include a lateral canthotomy and cantho-
lysis, administration of high-dose intravenous corticosteroids (dexa-
methasone 10 mg) and emergent ophthalmologic consultation.
Surgical exploration and decompression is indicated whenever there is
a loss of vision. Medical management of glaucoma does not play a role
in the treatment of this complication, as increased intraocular pressure
is a refl ection of increased intraorbital pressure.
Diplopia as a result of injury of the extraocular muscles is the next
most severe complication. This will result from transection or surgical
injury to the inferior oblique, inferior rectus or superior oblique
muscles. These muscles may be injured during fat resection and dis-
section of the inferior or superior eyelid respectively.42 Meticulous
surgical technique and observation of tissue planes will help to prevent
this complication.
Unless the surgeon suspects that a suture placed close to the
muscle may have, indeed, caught the muscle, close observation is the
optimal choice, since this muscle dysfunction will, in all likelihood,
be transient.
Eyelid retraction, which may manifest as lagophthalmos, is usually
caused by contraction of the orbital septum. This can be minimized
by avoiding hematomas adjacent to the orbital septum and cauteriza-
tion and manipulation of the septum. Lagophthalmos may also occur
with excess skin excision of the upper eyelid. Ectropion of the lower
eyelid may occur with excess skin resection or excess excision of the
pretarsal orbicularis oculi. Eyelid retraction or ectropion may be exac-
erbated by not addressing lower-lid laxity during a lower blepharo-
plasty. Eyelid massage and frequent topical lubrication may alleviate
mild cases of eyelid retraction during the postoperative period. As
indicated previously, a slight degree of lagophthalmos will improve or
disappear over a period of months or weeks. The moderate-to-severe
lagophthalmos should be corrected surgically by release and excision
of the thickened orbital septum, interposition, if necessary, and lid
support with canthoplasty.
Pre-existing keratoconjunctivitis sicca or dry eye is a relative con-
traindication to eyelid surgery. Any surgery that may cause lagophthal-
mos or exposure keratopathy in a patient with dry eye will result in
Fig. 8.40 The end of the sutures are then brought through the tarsal
plate and tied over it loosely to avoid kinking of the tarsal plate.

References
101
corneal epithelial breakdown and possible corneal ulceration. Ophthal-
mic consultation should be obtained for any patient with a history or
symptoms consistent with keratoconjunctivitis sicca. Patients with
exposure keratopathy may complain of tearing secondary to the tear
refl ex arc that is stimulated by corneal exposure. Frequent lubrication
with ophthalmic ointment or artifi cial tears, or the use of an occlusive
eyelid cover that retains the moisture, may alleviate some of the
symptoms of a patient with exposure keratopathy.
Patients with borderline dryness of the eyes, while they may be
asymptomatic preoperatively, may become symptomatic after blepha-
roplasty. This is commonly short lasting. Chemosis may occur after
any type of eyelid surgery. Swelling of the conjunctiva causes separa-
tion of the lower lid from the sclera and the subsequent exposure of
the conjunctiva. This results in more conjunctival swelling, allowing
the vicious cycle to continue. This may be worsened by an allergic
reaction to topical medication. Impeded lymphatic drainage is probably
the main reason for the development of this condition. In the absence
of corneal/ocular infection, the patient may be started on an ophthal-
mic steroid ointment, such as dexamethosone sodium phosphate oint-
ment, and frequent lubrication. A temporary tarsorrhaphy can be used
in severe cases.
Asymmetry may be noted by a patient postoperatively, this is often
present preoperatively. Careful examination and discussion with a
patient of the asymmetric nature of faces is important preoperatively.
Unilateral eyelid or eyebrow ptosis, proptosis and skin differential is
important to document. Technical error may also lead to asymmetry.
Lid peaking may be noted after ptosis repair. This may resolve over
time if subtle, but if signifi cant may require re-operation to remove
the offending suture causing the lid peak.
Proper preoperative evaluation including assessment for eyelid
ptosis, brow ptosis and asymmetry may prevent these conditions from
becoming apparent postoperatively. Hollowing of the lower eyelid area
can be avoided by performing judicious removal or re-positioning of
lower-eyelid fat. Development of new wrinkles or residual fi ne wrinkles
may be noticeable if eyelid fat is addressed without dealing with the
excess skin of the lower eyelid. Concomitant use of a conjunctival
incision for fat removal and laser resurfacing will reduce this
potential.
POSTOPERATIVE CARE
Patients are observed in the recovery room for a period of 2 hours. The
patient’s blood pressure is monitored continuously. Any hypertension
beyond 130/90 mmHg is treated vigorously using a combination of
short-acting intravenous and long-acting oral anti-hypertensive agents,
such as labetalol and clonidine (0.1 mg), as directed by the patient’s
medical condition. Nausea and vomiting treated aggressively with
intravenous medications such as ondasetron or promethazine.
Cold packs or iced saline dressings are applied continuously during
the fi rst 24–48 hours, being replaced every 30 minutes or so while the
patient is awake. The Steri-Strips are removed in 2–3 days. Periodic
application of ophthalmic bacitracin to the eye and the incisions is
used to keep them supple. The catgut sutures usually dissolve in 3–5
days. The Frost suture is removed in 24 hours. If the remaining sutures
last longer than 5 days, they may be transected at the knot level. Silicone
lower-lid occlusive dressing is removed in 3–5 days if loser resurfacing
is done. The 6–0 fast absorbable tarsorrhaphy sutures usually dissolve
in 5–6 days. The patient is allowed to wash his or her face after 2 or
3 days and can wear contact lenses in 7 days after discontinuing the
ointment. Makeup can be used after all of the stitches dissolve or all
of the scabs are eliminated if laser resurfacing was conducted. Patients
are instructed against strenuous exercises for 2–3 weeks.
Pitfalls
1. Patients who develop lower-lid lines on animation should be fore-
warned that they may not have an optimal outcome.
2. Any type of thyroid dysfunction may prove consequential on
blepharoplasty patients and it should be detected and treated
accordingly.
3. Male patients have a higher propensity for lower-lid edema and
chemosis.
4. Combining a forehead rejuvenation with upper blepharoplasty and
ptosis correction on someone who has dry eyes should be avoided
in most incidences.
5. Patients should be forewarned that their lateral commissures
might appear to be too high during the healing period of several
weeks.
1.
It is important to evaluate for concomitant brow ptosis by
having the patients close their eyes and reevaluate the brow
position, as patients may be recruiting the frontalis muscle to
elevate their eyelids.
2.
It is not as important how symmetrically one removes the
tissues during blepharoplasty as how symmetrically one
retains the tissues.
3.
Addressing lower-lid laxity during a lower-eyelid
blepharoplasty will help to prevent lower-eyelid retraction.
This could be achieved through canthopexy, canthoplasty or
minor wedge excision of the lateral tarsus.
4.
Re-suspension of the orbicularis fl ap, in addition to
canthopexy or canthoplasty augments the lower-lid support
while healing.
5.
Use of temporary tarsorrhaphy may reduce the incidence of
chemosis.
6.
Simulation of gravity effect during the skin or skin muscle
excision minimizes the potential for lower-lid lag.
7.
The occlusive dressings after laser resurfacing should be
extended cephalically, beyond lid margins, to prevent pulling
on the lid and to act like a sling.
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14. Hamra ST. The role of orbital fat preservation in facial aesthetic surgery.
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with lower lid blepharoplasty. In: McCord CD (ed.) Eyelid
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21. Lisman R, Rees T, Baker D et al. Experience with tarsal suspension as a
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22. Matarasso A. The oculocardiac refl ex in blepharoplasty surgery. Plast
Reconstr Surg 1989; 83:243–250.
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resection in aesthetic blepharoplasty: a 6 year study in 63 patients. Plast
Reconstr Surg 1990; 86:682–689.
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and associated eyelid connective tissues. Ophthal Plast Reconstr Surg
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25. Miller CC. Cosmetic surgery. The correction of featural imperfections.
Chicago: Oak Printing Co; 1907.
26. Miller CC. The excision of bag-like folds of skin from the region about
the eyes. Med Brief 1906; 34:648.
27. Naugle TC. Lower blepharoplasty with emphasis on horizontal eyelid
shortening. Facial Plast Surg 1984; 1:299.
28. Nerad JA. The requisites in ophthalmology: oculoplastic surgery.
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93:619–623.
30. Putterman AM, Urist MJ. Surgical anatomy of the orbital septum. Ann
Ophthalmol 1974; 6:290–294.
31. Guyuron B, Davies B. Experience with the modifi ed putterman
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surgery. Plast Reconstr Surg 1981; 68:249–252.
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considerations in transconjunctival blepharoplasty. Plast Reconstr Surg
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42. Zide B, Jelks G. Surgical anatomy of the orbit. New York: Raven Press;
1985.

103
CHAPTER 9
Facelift with SMAS Flaps
Timothy J Marten
that skin and SMAS can be advanced different amounts along
separate vectors and suspended under differential tension.
This allows each layer to be addressed individually as indicated
and results in a more comprehensive and natural appearing
improvement, and less sideburn elevation and displacement.
10. Proper analysis, careful planning and the use of an incision
along the hairline, when indicated, can avert sideburn
elevation and displacement and occipital hairline notching,
without compromising the overall outcome of the procedure.
This is particularly true of patients with marked skin
redundancy and those presenting for secondary procedures.
Summary
1. It is not possible to design a ‘universal’ facelift technique.
Each patient will present with a unique set of problems that
requires precise anatomic diagnosis and an appropriately
planned and individualized surgical repair.
2. Attractive and natural-appearing rejuvenation of the face is
not possible without diverting tension away from the skin to
the superfi cial musculoaponeurotic system (SMAS) and
platysma, and unless other deep layer structures and the aging
midface is addressed.
3. Skin has a covering function rather than a structural or
supporting one. Using skin as the vehicle to support sagging
deep layer tissue corrupts its function and results in abnormal
tension and related secondary problems including poor scars,
tragal retraction, ear lobe mal-position, and a tight and
unnatural appearance.
4. Using the SMAS to lift sagging facial tissues and restore facial
contour circumvents the problems associated with skin-only
facelifts because it is an inelastic structural layer capable of
providing meaningful and sustained support. Although skin
must be excised in SMAS procedures, only redundant tissue is
sacrifi ced and closure can be made under normal skin tension.
5. Most midface lifts are conceptually fl awed in that they
erroneously assume the problem seen in the anterior upper
cheek to be solely one of tissue sagging. Failure to
acknowledge the presence of signifi cant atrophy has led to
general disappointment for both patients and surgeons
following many procedures.
6. Careful evaluation of most patients who need a midface lift
will show that they also need a facelift and it is unusual to
encounter a patient with signifi cant midface aging who does
not also have sagging in the cheek and jowl. Midface lifts as a
result are arguably more logically performed in conjunction
with a formal facelift procedure rather than as isolated, stand-
alone procedures.
7. The conventional low cheek SMAS fl ap elevated below the
zygomatic arch has the drawback that it does not, by design,
have an effect on tissues of the midface, perioral, and
infraorbital regions. Planning a higher fl ap along the superior
border of the zygomatic arch overcomes this problem and
produces an improved result.
8. High SMAS procedures are readily combined with midface fat
injections because midface and infraorbital tissue planes are
not opened or dissected. This averts the need to perform
complex and potentially problematic procedures in which
orbital fat is transposed, the orbital septum ‘reset’ or free
grafts are placed.
9. Lamellar dissections in which the skin and SMAS are
dissected as two separate layers offer the important advantage
INTRODUCTION
The history of surgical modifi cations of the face is perhaps as old as
surgery itself and the historic record is unclear as to when and where
the fi rst ‘facelift’ was performed. By the early 20th century surgeons
had begun performing procedures to rejuvenate the face and techniques
consisting of small excisions of facial skin had begun to evolve. These
initial procedures were limited however, because they were performed
using small discontinuous incisions, and because no skin undermining
was performed.
In 1920 Bettman described the continuous temporal–periauricular
incision plan that became the prototype of that used in contemporary
procedures, setting the stage for more comprehensive and balanced
improvements, and in 1927 Bames recognized that undermining skin
could further enhance outcomes. These developments comprised the
foundation of the classical facelift procedures that were subsequently
performed without major modifi cation over the next four decades.
The modern era of facelift technique began in 1974 when Swedish
surgeon Torg Skoog described dissection beneath the superfi cial fascia
of the face and neck, a tissue layer subsequently described anatomically
by Mitz and Peyronie that ultimately became known as the SMAS
(superfi cial musculoaponeurotic system). Dissecting the SMAS allowed
sagging deeper facial tissues to be repositioned to a more youthful
position by an inelastic fascial layer, and tension to be diverted away
from the skin. This resulted in softer more natural appearances,
improved scars, and a signifi cant improvement in the longevity of the
procedure.
Numerous modifi cations have been made to Skoog’s procedure,
and his idea has spawned alternative ways in which the SMAS is used.
Nonetheless, the concept that the SMAS is the tissue layer most
closely associated with age-associated facial tissue ptosis and the most
logical means by which to correct it forms the foundation of
most modern facelift techniques.
Facelift techniques
Some of the advantages and disadvantages of different facelift tech-
niques are listed in Table 9.1.

9
FACELIFT WITH SMAS FLAPS
104
Table 9.1 Advantages and disadvantages of different types of facelift techniques
Facelift
Advantages
Disadvantages and complications
Skin only
Conceptual and technical simplicity
Secondary facelift deformities caused by skin tension
SMAS plication
No sub-SMAS dissection so technically less
demanding and time consuming than procedures
in which a fl ap is raised
Wide skin fl ap undermining; contour irregularities if sutures
are not placed carefully; potential injury to facial nerve
branches and parotid gland or duct; little if any midface
improvement
SMASectomy
No sub SMAS dissection required; skin and SMAS
can be shifted along different vectors so skin
tension can be set low, and sideburn
displacement and shifting of cervical wrinkles
onto the face can be minimized
Wide skin undermining; facial nerve branches at risk when
SMAS excised and sutured; may be contour irregularities;
minimal improvement in midface
Deep plane
Single-layer dissection so fl ap elevation is easier
and less time consuming than multilayer
dissection and fl ap is thicker with a better blood
supply
Potential excessive sideburn displacement, and shifting of
cervical rhytids to the face; unnatural appearances caused by
extraordinary tension; midface improvement not always as
expected; facial nerve branches and other structures at risk
Composite
Similar to those for a deep plane lift, but also
allows repositioning of orbicularis oculi and
raising of lid–cheek junction
Similar to those of deep plane technique, but also may be
prolonged periorbital edema and denervation of orbicularis
oculi
Lamellar SMAS
dissection and
bidirectional
Skin and SMAS advanced bidirectionally in
different amounts along separate vectors, and
suspended under differential tension so avoiding
skin tension, hairline displacement, and wrinkle
shifts
Technique dependent and time consuming; fl aps more
fragile; facial nerve branches at risk
Extended SMAS
Improved effect in the mid face and infraorbital
region and increased support of the lower eyelid
More technique dependent and time consuming; fl ap is
more fragile; facial nerve branches at risk
High SMAS
Restoration of youthful upper cheek contour;
fi lling of infraorbital region; increased support of
lower eyelid; improved correction of nasolabial
fold; readily combined with midface fat injections
Similar to those techniques using a sub-SMAS dissection
Subperiosteal
Dissection is familiar to most plastic surgeons and
is largely deep to facial nerves; avoids many
problems associated with skin-only procedures;
improvement in infraorbital and upper midface
areas in some cases
Generally longer recovery and often hard to obtain optimal
improvement along jawline; problems of suspension sutures
Endoscopic
Minimal scarring
No means for skin excision; little improvement in lower
cheek and along jawline
Midface
To improve midface area
Steep learning curve and fraught with complications,
especially when performed through a blepharoplasty
incision, including lid retraction, ectropion, canthal
displacement and dry eye; disappointing results
Suture
suspension
Seeming simplicity; easy marketability; can often
be placed quickly under local or light anesthesia
by inexperienced surgeons without surgical
training; small incision; lower risk of hematoma,
fl ap compromise and related complications
Support of the face cannot be predictably obtained;
infection; extrusion; traction dimples; visible bowstringing;
nerve injuries; facial dyskinesias; chronic pain syndromes;
abnormal appearances during animation; a tight or choking
feeling when used in the neck; palpable knots and sutures
beneath the skin and occasional erosion of overlying skin
MACS (minimal
access cranial
suspension)
Seeming simplicity; no formal SMAS dissection;
can be performed under local or light anesthesia;
a shorter scar; shorter operating time.
Technique dependent and contour irregularities can result;
problems associated with the placement of a stiff and rigid
suture in the superfi cial layers of the face; injury to the
parotid gland, parotid duct, facial nerves, and other deep
facial structures
Short scar
Appeal to patients
Limited access to deep layer structures; redundant skin
cannot be shifted along proper vectors; prevent skin from
being properly excised
Mini-lift
Appeal to patients
Minimal improvement

Introduction
105
Skin only
Although the excision of skin formed the foundation of the facelift
procedure for the fi rst 70 years or so after its inception, this has ulti-
mately been shown to be ineffective and conceptually fl awed, and there
are compelling reasons (Box 9.1) not to rely on skin resection only
when surgically rejuvenating the face.
The fundamental fl aw in skin-only facelifts, mini-lifts, and similar
procedures is that skin is meant to serve a covering function and
not a structural or supporting one. Skin tension fl attens contour,
rather than restoring it and because skin stretches as tension is
applied, objectionable temple, sideburn and occipital hairline
displacement is diffi cult to avoid when skin-only facelift techniques
are used.
Despite their inherent drawbacks, well-known weaknesses, and
tendency to produce secondary deformities, however, skin-only face-
lifts remain popular largely because of their conceptual and technical
simplicity.
SMAS
Repositioning ptotic facial tissue using the SMAS is arguably the single
most important advance in facelift technique since the inception of
the procedure and various surgeons have devised different strategies to
use it to improve the outcome of procedures. Each has certain advan-
tages and disadvantages, but all share advantages over traditional
skin-only procedures as follows:
● most changes in the aging face are the result of sagging of tissue
deep to the skin, and not the skin itself – the SMAS is more closely
associated with the tissues that sag as the face ages than skin, and
it is therefore arguably a more logical layer to use to restore them
to a more youthful position;
● the SMAS, unlike skin, is an inelastic layer capable of providing
sustained support and can be used to divert tension away from the
skin, and this will avert most secondary facelift deformities;
● SMAS lifts provide a means by which facelifts can be repeated
without producing excessive skin tightness.
SMAS plication
SMAS plication is perhaps the simplest technique to modify the SMAS.
In these procedures a skin fl ap is raised but an SMAS fl ap is not ele-
vated. Deep facial tissue is then plicated or invaginated with sutures,
rather than lifted, to support the lower cheek, jawline, and lateral
perioral area.
A potential advantage of the SMAS plication technique is that no
sub-SMAS dissection is required and therefore the procedure is viewed
by many as technically less demanding and time consuming than
procedures in which a fl ap is raised.
Disadvantages of the SMAS plication technique are:
● it requires wide skin fl ap undermining because to be effective plica-
tion must be made anterior to the anterior border of the parotid,
and this can be problematic in smokers or others patients with
compromised circulation;
● despite its seeming simplicity the procedure is technique depen-
dent, and if sutures are not placed carefully contour irregularities
can result, facial nerve branches can be damaged, and the parotid
gland or duct can be injured;
● tissue is redistributed into the mid cheek rather than over the upper
malar region as it is in some procedures in which a SMAS fl ap is
raised, and therefore little if any midface improvement can be
obtained.
SMASectomy
SMASectomy is a procedure devised and popularized by Daniel Baker.
Key elements of the procedure are:
● it includes an extended subcutaneous dissection;
● a SMAS fl ap is not elevated.
A strip of SMAS is excised obliquely over the anterior parotid, begin-
ning in the upper lateral neck extending to the ipsilateral lateral malar
region, and the cut edges of the SMAS are reapproximated to support
the jawline and lateral perioral region.
Advantages of SMASectomy technique are:
● no sub SMAS dissection is required
● skin and SMAS can be shifted along different vectors so skin
tension can be set low, and sideburn displacement and shifting of
cervical wrinkles onto the face can be minimized.
Potential disadvantages of SMASectomy are:
● wide skin undermining is required, so the procedure is potentially
more hazardous in smokers and other patients with compromised
skin circulation;
● facial nerve branches are arguably at risk when SMAS is excised
and sutured;
● if cut SMAS edges are not reapproximated carefully contour irregu-
larities can occur;
● tissue is discarded rather than redistributed;
● minimal improvement in the mid-face is obtained
Box 9.1 Reasons why skin-only resection should
not be relied on when surgically rejuvenating
the face
Skin is intended to serve a covering function,
not a structural or supporting one
●
Skin evolved to stretch and move as we express ourselves, and
was not meant to support sagging deep layer tissues.
●
Tightening skin corrupts its natural covering function and
results in unnatural appearances and the older and more
inelastic the skin, the more this is true.
●
Examination of the faces of young persons shows their faces
are not tight
Skin tension fl attens contour rather than
restoring it
●
This is not consistent with the goal of enhancing facial
contour.
Skin is not capable of providing sustained
support of ptotic deep layer tissue
●
Although initial outcomes of skin-only procedures may appear
good, as an elastic layer, skin will rapidly stretch and any
improvement obtained will typically be quickly lost.
Skin tension results in secondary facelift
deformities
●
Almost all secondary facelift deformities such as poor scars,
hairline displacement, tragal distortion, and ear lobe
malposition can ultimately be traced back to skin tension.

9
FACELIFT WITH SMAS FLAPS
106
Deep plane
A deep plane facelift consists of a sub-SMAS dissection fi rst described
by Skoog and later popularized by Lemon and Hamra in which the
cheek skin and SMAS are raised together in one layer as a unifi ed fl ap
(Skoog fl ap). In the deep plane procedure the SMAS was used to
reposition the lower cheek and jowl and the midface was then said to
be elevated by ‘extraordinary tension’ on the preauricular portion
of the fl ap.
Advantages of the deep plane technique include:
● single layer dissection and therefore fl ap elevation is easier and less
time consuming than multilayer dissections in which both a skin
and SMAS fl ap are raised;
● the fl ap is thicker and arguably has a better blood supply then when
a layered dissection is made, and therefore may be safer in smokers
or other patients with compromised circulation.
Potential disadvantages are:
● skin and SMAS must obligatorily be shifted along the same vector
in the same direction and to the same degree, which can result in
excessive sideburn displacement, and shifting of cervical rhytids
from the neck to the face;
● extraordinary tension on the fl ap can result in distortion and
unnatural appearances;
● the midface improvement expected is not always realized;
● facial nerve branches and other structures are also at risk.
Hamra has abandoned the deep plane technique in favor of the com-
posite technique (see below), and the term deep plane has since come
to be used generically by most surgeons for any procedure where there
is some kind of modifi cation of the SMAS is performed.
Composite
A composite facelift consists of a deep plane sub SMAS dissection that
additionally includes the orbicularis oculi muscle in the upper part of
the fl ap (i.e. the fl ap is a composite of skin, SMAS and orbicularis oculi).
Advantages of the composite technique are:
● similar to those for a deep plane lift with the added possible benefi t
that it allows the orbicularis oculi muscle to be repositioned and
the lid–cheek junction to be raised;
● the midface is elevated by a medially vectored fl ap of orbicularis
oculi anchored near the lateral orbit.
Potential disadvantages are:
● similar to those of the deep plane technique – skin and SMAS are
repositioned in a unidirectional fashion, and therefore wrinkle shift
and sideburn displacement may occur, and extraordinary tension
can result in unnatural appearances;
● prolonged periorbital edema;
● potential denervation of orbicularis oculi resulting in atonic lower
lids and eyelid dysfunction.
Because skin and SMAS age at different rates and along somewhat
different vectors, optimal treatment of each layer is generally not
possible when single layer ‘Skoog’ and ‘composite’ dissections are
made.
Lamellar SMAS dissection and
bidirectional facelift
Because skin and SMAS age at different rates and along somewhat
different vectors, optimal treatment of each layer is generally not pos-
sible when Skoog fl aps are used and single-layer composite dissections
are made.
In a lamellar SMAS facelift the skin and SMAS are dissected as
separate and distinct layers and advanced along independent vectors.
The advantage of this technique over a single layer Skoog or compos-
ite fl ap technique is that skin and SMAS can be advanced bidirection-
ally in different amounts along separate vectors, and suspended under
differential tension. Skin tension, hairline displacement, and objec-
tionable wrinkle shifts can therefore be minimized or avoided, and in
turn results in a more natural appearance, a more comprehensive
rejuvenation, and fewer secondary deformities;
Disadvantages of procedures that use lamellar SMAS dissections:
● they are more technique dependent and time consuming;
● the fl aps are more fragile than when a Skoog or composite dissec-
tion is made;
● facial nerve branches are at risk because a sub-SMAS dissection is
performed as part of the technique.
Extended SMAS
The extended SMAS concept was set forth by Stuzin and others, and
is the name adopted by Baker, Gordon, and Stuzin to describe their
personal facelift technique.
In the extended SMAS technique separate skin and SMAS fl ap
dissections are made in a lamellar fashion and, in addition, a sub-
SMAS dissection is performed in the upper cheek and midface to
release retaining ligaments and free up the malar fat pad from the
superior aspect of the lip elevators.
The advantage of the extended SMAS technique is that a more
comprehensive release of SMAS is achieved than in other SMAS dis-
sections, resulting in an improved effect in the midface and infraorbital
region and increased support of the lower eyelid.
Disadvantages of the extended SMAS procedure compared with a
standard dissection include:
● it is more technique dependent and time consuming;
● the fl ap is more fragile;
● the facial nerve branches are at greater risk.
Using the SMAS to lift sagging facial tissues and to restore facial
contour circumvents the problems associated with skin-only lifts
because it is an inelastic structural layer intimately associated with
sagging facial muscles and fat that is capable of providing effective
and sustained support.
High SMAS
The conventional low cheek SMAS fl ap design in which the superior
margin of the fl ap is planned below the zygomatic arch suffers the
fundamental design fl aw that it does not exert an effect on the tissues
of the midface and infraorbital region. Low designs target the lower
cheek and jowl only, and produce little if any improvement in the
upper medial cheek area. Planning the fl ap higher, along the superior
border of the zygomatic arch and making an extended dissection medi-
ally to mobilize midface tissue overcomes this problem and produces
an improved result (Fig. 9.1A–D).
The high SMAS procedure can be performed using a two-layer
lamellar technique with separate skin and SMAS fl aps as advocated by
Connell, or using a one-layer composite fl ap as practiced by Barton.
Advantages of a high SMAS plan include:
● restoration of youthful upper cheek contour;
● fi lling of the infraorbital region;

Introduction
107
● increased support of the lower eyelid;
● improved correction of the nasolabial fold;
● readily combined with midface fat injections because midface and
infra-orbital tissue planes are not opened or dissected, which averts
the need to perform complex and potentially problematic proce-
dures in which orbital fat is transposed, the orbital septum reset
or free grafts are placed.
For many patients, the repositioning of midface tissue obtained with
a high SMAS fl ap will be satisfactory in achieving the desired effect,
and no additional or separate midface lift procedure will be required
(Fig. 9.2A&B).
Disadvantages of the high SMAS technique are similar to other
techniques in which a subSMAS dissection is made although some
surgeons have expressed concern that the frontal branch of the
facial nerve is at risk when high SMAS procedures are performed, they
are chrucally safe and anatomically sound when performed as
described.
For many patients, repositioning midface tissue obtained with a
high SMAS fl ap will be satisfactory in achieving the desired effect,
and no additional or separate midface lift procedure will be required.
Subperiosteal
Despite its seeming unsuitability, the periosteum has been advocated
by Ramirez and others as the layer beneath which facelift dissection
should be performed and the layer by which sagging superfi cial and
deep facial tissues should be elevated.
Potential advantages of a subperiosteal facelift include:
● the dissection is familiar to most plastic surgeons and is made in
large part deep to facial nerves and other deep layer structures;
● when properly performed sagging facial tissues can be repositioned
diverting some tension away from the skin, which averts many of
the problems associated with skin-only procedures;
High and Low SMAS techniques compared
A
D
C
B
No mid-face or
peri-oral improvement
(black oval)
Mid-face and
peri-oral improvement
(black oval)
Low SMAS
High SMAS
Fig. 9.1 High and low SMAS techniques. A,
Plan for low SMAS procedure. The superior
margin of the fl ap lies below the zygomatic
arch. B, Low SMAS fl ap after dissection and
suspension. The area of the fl ap effect
(green circle) is limited to the lower cheek
and jowl and there is no improvement in the
midface or perioral region (black dotted
circle). C, Plan for high SMAS procedure. The
superior margin of the fl ap lies along the
zygomatic arch. D, High SMAS fl ap after
dissection and suspension. The area of the
fl ap effect (green circle) includes not only
both the cheek and jowl, but also the
midface and perioral region (black dotted
circle).

9
FACELIFT WITH SMAS FLAPS
108
● improvement in the infra-orbital and upper midface areas is
obtained in some cases depending on procedure design.
The periosteum is, however, an intuitively and conceptually illogical
choice for overall rejuvenation of the face because it is densely adher-
ent to the facial skeleton and does not signifi cantly descend as part of
the aging process. It is also not closely associated with the intermedi-
ate layers of the face where most of the aging is known to occur.
Potential disadvantages of the subperiosteal technique include the
following:
● the dissection is said to result in prolonged swelling and induration
and generally portends a longer period of recovery for the patient
compared to that in other procedures;
● optimal improvement along the jawline is often hard to obtain;
● because many subperiosteal facelift techniques rely on the con-
comitant use of suspension sutures these procedures can share
related problems.
Endoscopic
Despite the importance of concealing scars in aesthetic surgery, other
surgical specialties were the fi rst to introduce and employ endoscopic
techniques. The introduction and acceptance of the endoscopic fore-
head lift eventually set into motion efforts to design a facelift per-
formed using the same technique. Despite considerable effort, however,
no proven or generally accepted technique for the face has emerged. In
addition, focus has been diverted away from development of an endo-
scopic procedure to some extent by the introduction of techniques
using percutaneously placed barbed threads and suspension sutures.
The major obstacle to the development and wide application of an
endoscopic facelift is that skin redundancy remains a signifi cant com-
ponent of the aging deformity and although some support of deep layer
tissue can be obtained, the endoscopic technique does not provide a
means for this to be excised. Alternatives to excision including laser
resurfacing are inadequate for all but a younger group of patients with
small skin excess, and even these procedures have proven to be skin
smoothing and not skin shrinking technologies.
For the most part the improvements obtained in endoscopic face-
lifts are limited largely to midface elevation, and improvements in
appearance obtained from concomitantly performed forehead and neck
surgery or the result of other ancillary procedures. Less improvement
is obtained in the lower cheek and along the jawline.
Most endoscopic facelifts that have been proposed have been per-
formed in a subperiosteal plane but often also attempt to resuspend
the buccal fat pad, malar fat and the SOOF (sub-orbicularis oculi
fat).
Midface
The midface is generally defi ned as an inverted triangular area situated
over the anterior upper cheek that is bounded by:
● the zygomaticus major muscle laterally;
● the nasolabial fold medially;
● the infraorbital rim superiorly.
In healthy, youthful appearing men and women this area is full and
makes a smooth transition to the adjacent cheek and lower eyelid. As
one ages however, there is generally atrophy of, and loss of volume
from this area, and over time this results in an ill, haggard, and elderly
appearance.
Midface atrophy is considered by some surgeons to be accompanied
by descent of midface tissues, and the aging change occurring in the
upper cheek area is as a result often, perhaps erroneously, referred to
as midface ptosis.
The recognition of midface ptosis as a signifi cant component of
the changes occurring in the aging face, combined with the realization
that the traditional SMAS facelift produced little or no improvement
in the midface region, has led to a variety of procedures designed to
specifi cally target the midface area. Many of these techniques are now
being performed as isolated procedures or in conjunction with lower
eyelid surgery.
Although there is merit in the idea of rejuvenating the midface,
isolated midface lift procedures are still evolving, and have not been
perfected. Most procedures have a steep learning curve and have been
fraught with complications, especially when performed through a
blepharoplasty incision. These complications include lid retraction,
ectropion, canthal displacement and dry eye problems. As a result,
many midface lift techniques have come to incorporate potentially
problematic aggressive adjunctive surgical maneuvers including can-
A
B
Fig. 9.2 Before and after high SMAS facelift,
necklift, hairline lowering, forehead lift,
upper and lower blepharoplasty and partial
facial fat injections. A, Preoperative
photograph of a 49-year-old woman before
surgery. Note the loss of a youthful contour
and midface ptosis. B, Postoperative
photograph 11 months following the surgery.
Ptotic midface tissues have been
repositioned, a youthful jawline contour has
been restored, and redundant skin has been
excised without an unnatural tight or pulled
appearance.

Introduction
109
thotomies, canthoplasties and orbicularis oculi muscle suspensions to
prevent these problems. These maneuvers often result in a changed
look that is disturbing to many patients, however, and carry a high
risk of signifi cant and troublesome complications of their own.
Many other valid arguments can be made against the use of isolated
midface procedures including the fact that attractive rejuvenation of
the face is possible without complete effacement of the nasolabial fold.
Most patients with nasolabial folds had them when they were young
and their presence refl ects the individual’s anatomic make-up, and not
an age related undesirable change. In such cases complete effacement
is neither necessary nor desirable because they are an inherent and
appropriate feature of the patient’s face.
As a practical matter, most of the improvement obtained by midface
lifts consists only of elevation of the lid–cheek junction, and not cor-
rection of the nasolabial fold. Midface lifts also typically produce a
subtle improvement that is diffi cult to document in photographs and
not always noticed or appreciated by the patient. Because of this, it
can be argued that time in the operating room is better spent on lower
risk maneuvers that result in more noticeable improvement of higher
priority to patients.
Careful examination of most patients who need or request a
midface lift will show that they also need a facelift, and it is rare to
encounter a patient with midface aging who does not also have sagging
in the cheek and jowl. Because of this midface lifts are arguably more
logically performed in conjunction with a formal facelift procedure.
When this is done improvement is more balanced and comprehensive,
and a more harmonious and natural appearing result is usually
obtained. Healing is also generally faster and complications are less
likely if midface improvement can be obtained through the facelift
incision, rather than through a blepharoplasty or intraoral approach.
Most midface lifts are also generally conceptually fl awed in that
they mistakenly assume the problem seen in the anterior upper cheek
is solely one of tissue sagging. Failure to acknowledge that signifi cant
atrophy is usually present has led to general disappointment following
many procedures for both patients and surgeons, and has resulted in
the addition of dermis fat grafts, orbital fat transposition and septal
resets to midface lift procedures. It is questionable and remains to be
answered however, whether these procedures can produce a restoration
of lost volume as simply, naturally and effectively as obtained with fat
injections.
Suture suspension
A variety of suture-lift procedures have been devised in which attempts
are made to suspend deep facial tissues with sutures, including those
in which:
● long cable sutures are placed through small temporal incisions;
● barbed sutures and threads are placed percutaneously.
Advantages of suture-lift procedures include:
● seeming simplicity;
● easy marketability;
● can often be placed relatively quickly under local anesthesia or light
anesthesia by inexperienced surgeons and physicians without sur-
gical training;
● small incision;
● less risk of hematoma, fl ap compromise and related complications
because skin is typically not excised or undermined.
Disadvantages of suture-lift procedures include:
● sustained and attractive support of the face cannot be predictably
obtained;
● infection;
● extrusion;
● traction dimples;
● visible bowstringing;
● nerve injuries;
● facial dyskinesias;
● chronic pain syndromes;
● abnormal appearances during animation;
● a tight or choking feeling that is disturbing to patients, and can result
in diffi culties in speaking and swallowing when used in the neck;
● palpable suture knots and sutures themselves beneath the skin if
large, stiff, permanent sutures used;
● occasional erosion of the overlying skin by suture knots, necessitat-
ing their removal.
Research and development continue on suture lift techniques, and it
remains to be seen whether current problems can be solved. The fun-
damental problem in these procedures is that one must rely on a small
rigid thread to support a relatively large area of delicate, inherently
soft, mobile facial tissue. Over a short period of time these sutures
typically cheese-wire through tissues they were intended to support,
and can injure important neuromuscular structures. Suspension
sutures also prevent natural depression and downward movement of
facial tissues, impeding certain expressions and creating unnatural
sensations and appearances.
The second major obstacle to be overcome is that although some
support of deep layer tissue might be obtained, skin redundancy
remains a signifi cant component of the aging deformity for many
patients, and suspension techniques do not provide a means for this
to be excised. Alternatives to excision including laser resurfacing are
inadequate for all but a younger group of patients with small skin
excess, and even these procedures have proven to be skin-smoothing
and not skin-shrinking technologies. As with endoscopic facelifts, a
breakthrough in biomedicine may change this.
MACS lift
The MACS (minimal access cranial suspension) technique was devel-
oped and popularized by Tonnard and Verpaele for patients in the
European market who were thought to be reluctant to undergo longer
and ostensibly more complicated ‘traditional’ facelift procedures that
were being performed in the Americas and elsewhere.
The MACS lift combines features of short-scar procedures with the
concept of suture suspension of deep facial tissue. Tonnard and Ver-
paele assert the procedure shares little with traditional versions of
these procedures, and clinical evidence indicates that when their tech-
nique is used outcomes are improved.
The MACS technique overcomes traditional limitations of suture
suspension procedures in two important ways.
● First, unlike many short-scar procedures in which skin only is
excised, the MACS procedure provides a means of diverting tension
off the skin to deeper tissue layers. This in turn improves the
quality of the scars and the longevity of the procedure.
● Second, Tonnard and Veraele assert that the procedure is not a
suture lift in the traditional sense in that tissue is suspended by
what they regard as a gathering and microplication of the SMAS,
and as such produces a more long lasting improvement with fewer
problems that when looped or barbed sutures are used.
The MACS procedure has evolved and has been refi ned from its
original description in which one or two plication sutures were placed
and non-absorbable permanent monofi lament sutures were used. Mul-
tiple sutures are now generally placed to more specifi cally target the
midface, cheek, jowl and lateral neck, and this is said to distribute
improvement more uniformly over the face and produce a more natural
and long-lived improvement. Softer, absorbable sutures have also been

9
FACELIFT WITH SMAS FLAPS
110
substituted for the stiffer more rigid non-absorbable sutures originally
recommended.
Although the MACS lift is considered by many who perform it to
be a short-scar procedure, the typical incision plan used shortens the
scar in the occipital area, but results in an incision along the more
exposed temporal hairline, which is more diffi cult to conceal. This is
of questionable benefi t to younger patients who are typically thought
to be the best candidates for the procedure.
Potential advantages of the MACS technique include:
● seeming simplicity;
● no formal SMAS dissection is required;
● it can be performed under local anesthesia or light anesthesia;
● a shorter scar;
● shorter operating time.
Potential disadvantages of the MACS technique include:
● the procedure is technique dependent and if sutures are not placed
carefully, contour irregularities can result;
● problems associated with the placement of a stiff and rigid suture
in the superfi cial layers of the face (e.g. palpability, dimpling, facial
creasing, and suture erosion and extrusion) – although these prob-
lems can be avoided to some extent by using an absorbable suture,
it is unclear what effect this has on the longevity of the procedure;
● injury to the parotid gland, parotid duct, facial nerves, and other
deep facial structures during suture placement.
Short-scar
The idea of using small incisions to perform facelift procedures is
appealing to patients and surgeons alike. Indeed, the fi rst procedures
performed a century ago consisted of small excisions of skin near the
ear and along frontal and occipital hairlines. Ironically, and despite the
considerable advances in techniques to rejuvenate the face that have
been made since, as non-plastic surgeons have begun to perform aes-
thetic surgery procedures and market their services, a new emphasis
has been placed on short-scar procedures of questionable value that
are nonetheless alluring in concept to almost any patient.
Although some short-scar techniques such as limited incision
forehead lift have merit and have provided new and better options
to patients, skin redundancy remains a consistent and undeniable
problem for the surgeon seeking to rejuvenate the face and neck, and
shorter incision plans involve signifi cant compromises in the overall
improvement that can be obtained.
The advantage of short-scar procedures rests largely in their appeal
to patients, and their allure and marketability will likely ensure that
they will be with us in some form or another for some time.
Short-scar incision plans suffer the drawbacks that they:
● limit access to deep layer structures;
● prevent redundant skin from being shifted along proper vectors that
produce the most improvement and most natural appearance;
● often require that skin be gathered up when sutured and prevent
skin from being excised in a smooth, well-tailored fashion.
Interestingly, most short-scar procedures have placed their focus on
the postauricular area, and are designed to shorten the postauricular
scar. This scar is situated in a well-concealed area however, and if
tension on the postauricular skin fl ap is avoided an inconspicuous scar
will typically result. This scar is less obvious and less troublesome to
the patient than a shorter, but irregular and puckered scar. Shortening
a scar under these circumstances in a concealed area is of questionable
value to the patient.
Perhaps the most diffi cult aspect of short-scar incision plans to
defend is that to minimize puckering and gathering behind the ear
lobe, the cheek skin fl ap is shifted along an overly superiorly directed
vector, necessitating a scar along the less well concealed sideburn and
temporal hairline areas. Although an incision is sometimes required
in this area in some patients to prevent hairline displacement, shorten-
ing a scar in a concealed area by shifting it to a more visible area is of
dubious value to the patient who might not have required it.
The real issue for all patients is not how long the facelift scar is,
but how well it is concealed. Ultimately, the long versus short scar
debate will come to an end when the wound healing process is deci-
phered and predicted breakthroughs in wound healing research will
provide the means to scarless healing.
Mini-lift
Mini-lift is a loose descriptive term not a scientifi c one, and it is not
a specifi cally defi ned technique. Typically it is used to describe the
simple excision of skin in a younger patient, but is sometimes used to
refer to procedures of limited scope performed on older patients. Mini-
lifts typically use short-scar incision plans and do not include modifi -
cation of the SMAS and platysma.
Unlike skin-only facelifts and mini-lifts in which subsequent
procedures worsen skin tightness and problems associated with it,
high SMAS facelifts, theoretically at least, can be repeated as often as
needed without producing skin tightness and abnormal appearances.
INDICATIONS
Three categories of aging:
●
Aging and breakdown of the skin surface
●
Facial sagging, skin redundancy, and loss of youthful facial
contour
●
Facial wasting, atrophy and age-related lipodystrophy
Recognizing the changes associated with facial aging and appreciating
the underlying anatomic abnormalities is essential to properly advising
patients and to recommending appropriate therapy. Most patient
problems fall into three broad categories:
● aging and breakdown of the skin surface;
● facial sagging, skin redundancy, and loss of youthful facial contour;
and
● facial wasting, atrophy and/or age related lipodystrophy.
Proper treatment depends upon the degree to which each of these
problems is present, the patient’s priorities, and the time, trouble
and expense the patient is willing to endure to obtain the desired
improvement.
Patients primarily concerned with surface aging of their face may
not require surgery and may achieve the type of improvement they
desire through surface treatments of the skin. These include skin
peels, ablative and non-ablative skin resurfacing, chemodenervation
(botulinum toxin type A injections), injection therapy and various
forms of cutaneous laser and other treatments designed to remove or
reduce age spots, spider veins, wrinkles and other age-related skin
surface imperfections.
Patients primarily concerned with facial sagging, skin excess, and
loss of facial contour will typically be disappointed if surface-only treat-
ments are employed. They require formal surgical lifts in which sagging
tissue is repositioned and redundant tissue is excised if these problems
are to be properly corrected and an attractive and natural-appearing
improvement obtained.
Patients with signifi cant facial atrophy and age-related facial
wasting achieve suboptimal improvement from both surface treat-

Preoperative Planning
111
ments of facial skin and surgical lifts. Smoothing skin will not disguise
a drawn, ill, or haggard appearance resulting from the loss of facial
volume, and it is diffi cult to create natural and attractive contours by
lifting and repositioning tissues that have abnormally thinned with
age. These patients may require volume replacement, by autologous
fat grafting or other means, in conjunction with their surgical proce-
dure to achieve a satisfactory result.
Pan-facial rejuvenation
Isolated aging rarely occurs in the lower face and neck, and many if
not most patients requesting facelift surgery need forehead and eyelid
procedures as well. Many are confused, however, by the term ‘facelift’
and take it to imply correction will be made in all areas. These patients
must be counseled carefully because the facelift itself will produce little
if any improvement in upper facial deformities and tends to unmask
and draw attention to them.
It is also not uncommon for patients to request surgery on their
neck only. Although such a plan is acceptable for some men, failure
to concomitantly restore attractive cheek contour and lift sagging jowls
in women generally results in an unnatural and unfeminine appear-
ance. In addition, if an aggressive platysmaplasty is performed as part
of an isolated neck lift, sagging in the cheeks and jowl area can be
accentuated as platysma tightening exerts a downward pull on tissue
in these areas.
PREOPERATIVE PLANNING
Temporal incision
The temporal portion of the facelift incision has traditionally been
placed within the temporal scalp in a well intended, but often coun-
terproductive attempt to hide the resulting scar. When cheek skin
redundancy is small and there is abundant temple and sideburn hair,
such a plan can be used without producing objectionable sideburn
elevation and temporal hairline retrodisplacement.
Patients best suited for this incision plan are usually young and
troubled by mild cheek laxity only. In many other situations however,
larger skin shifts and the presence of sparse temple hair can result in
unnatural and tell-tale displacement of the temporal hairline and
sideburn if such a plan is used (Fig. 9.3A&B).
Proper analysis, careful planning and the use of an incision along
the hairline, when indicated, can avert this problem with out compro-
mising the overall outcome of the procedure (Fig. 9.4A&B).
Important factors in choosing incision placement
Distance between the lateral orbit and anterior aspect of
the temporal hairline
In choosing the location of the temporal portion of the facelift incision
it is important to note the distance between the lateral orbit and the
anterior aspect of the temporal hairline (Fig. 9.5) because this distance
is aesthetically signifi cant and generally increases with age.3 In healthy,
youthful-appearing individuals it usually measures no more than
4–5 cm, but in older patients, or in those who have had a prior facelift,
it will often be seen to be considerably more.
Estimate of the skin redundancy over the upper cheek
Equally important as the distance from the lateral orbit to the tempo-
ral hairline, is the surgeon’s estimate of the skin redundancy over the
upper cheek, and therefore the skin shift that will occur when the
facelift fl ap is repositioned.4 This can be easily assessed by simply
pinching up redundant skin and measuring it. Assessment of skin
redundancy over the cheek, in conjunction with the amount of existing
temporal ‘skin show’, allows rational selection of the best site for
temporal incision placement.
When to place the incision in the traditional location
In patients in whom minimal temporal skin shift will occur and for whom
the temporal hairline will remain within 5 cm of the lateral orbit, the
temporal portion of the facelift incision can be placed in the traditional
location 4–5 cm within the temporal scalp, extending superiorly up
from the superior aspect of the helical facial junction (Fig. 9.6).
When to place the incision along the hairline
When the temporal hairline is predicted to be moved more than 5 cm
away from the lateral orbit, however, or the sideburn hair shifted above
the junction of the ear with the scalp, consideration should be given
A
B
Fig. 9.3 Poor incision plan resulting in
displacement of the sideburn and temple
hair. A&B, The temporal portion of the facelift
incision was made in the traditional location
in the temporal scalp in a well-intended effort
to hide the resulting scar. Because there was
large cheek fl ap redundancy and poor skin
elasticity, advancement of the cheek skin
fl ap resulted in objectionable hairline
displacement. An incision along the hairline
would have prevented this deformity.

9
FACELIFT WITH SMAS FLAPS
112
to placing the incision along the hairline (Fig. 9.7) rather than within
the temporal scalp. This incision will allow large postero superior skin
fl ap shifts while simultaneously providing maximum improvement in
the upper lateral face.5 If it is made with care and closed under no
tension, the resulting scar is usually inconspicuous and far less trou-
blesome for the patient than a displaced hairline (see Fig. 9.3A&B)
Assessment of skin redundancy over the cheek in conjunction with
the amount of existing temporal skin show allows rational selection
of the best site for temporal incision placement.
Patient considerations
Options for the placement of the temporal portion of the facelift inci-
sion should be discussed with any patient in whom signifi cant dis-
placement of the temporal hairline or elevation of the sideburn might
occur. Incision placement is best presented as a choice between
two imperfect alternatives and it is wise that the fi nal decision about
where the incision is located is made by the patient after appropriate
discussion has been made.
The patient should be informed that placing the incision in a tra-
ditional location within the temporal scalp will help conceal the scar,
but often at the expense of a large and objectionable displacement of
the temporal hairline and sideburn, and compromised improvement
over the temporal face. This inevitably results in an old and unnatural
A
B
Fig. 9.4 Healed incisions along the temporal
hairline. When indicated, the use of an
incision along the hairline can prevent
hairline and sideburn displacement without
compromising the end result. A&B, Although
a scar is present along the hairline in each of
these patients, it is not evident upon casual
inspection. Note the preservation of lush
temple hair and a full youthful natural-
appearing sideburn.
Assessment of “temporal skin show”
Fig. 9.5 Assessment of temporal skin show. The distance between
the lateral orbit and the temple hairline and how it changes with
skin fl ap shift must be considered when planning the temporal
portion of the facelift.
Plan for incision in temporal scalp
Fig. 9.6 Plan for incision in the temporal scalp. This plan is used for
patients predicted to have minimal shift of sideburn and temple hair
after elevation of the cheek fl ap. It will not be appropriate for all
patients.

Preoperative Planning
113
appearance and is usually immediately obvious, even upon a casual
glance and at a distance.
An incision along the hairline will prevent hairline displacement,
and although a scar will be present where the incision was made, it is
usually inconspicuous and will not be noticed by others if wound
closure is properly performed.
A suboptimally healed incision along the hairline can be concealed
with makeup or tattooed or revised, but a signifi cantly displaced hair-
line is diffi cult to conceal and a challenge to correct. In my experience
most patients are disturbed by the prospect of temple and sideburn
hair displacement, and recognize this occurrence as a tell-tale sign that
a facelift has been performed. When counseled properly and given
the choice, many readily consent to incision placement along their
hairline.
Preauricular incision
Open to scrutiny, the preauricular region exists as a frequent point of
reference for those seeking to identify a facelift patient.
Traditional incision vs retrotragal incision
Traditionally, incisions in the preauricular region are made well ante-
rior to the anterior border of the helix and continued inferiorly, anterior
to the tragus (Fig. 9.8). This design, however, works well only for the
unusual patient with cheek and tragal skin of similar characteristics
who, in addition, exhibits favorable healing. Unfortunately, most
patients have a marked gradient of color, texture, and surface irregu-
larities over the preauricular area and a tell-tale mismatch will be
evident, even in the presence of an inconspicuous scar.
For these reasons, and in all but the unusual case, the preauricular
portion of the facelift incision should be precisely placed along the
posterior margin of the tragus, rather than in the pretragal sulcus (Fig.
9.9). In this location a mismatch of color, texture, or surface irregu-
larities will not be noticed and the scar, if visible, will appear to be a
tragal highlight6 (Fig. 9.10A&B).
In addition, and despite claims to they contrary, a properly planned
and executed incision along the margin of the tragus will not produce
tragal retraction or other anatomic irregularity (Fig. 9.11A&B).
In the male patient, the tragus can be kept free of beard hair by
intraoperative destruction of beard follicles from the underside of the
tragal fl ap (Fig. 9.12A&B).
The superior portion of the preauricular incision should be planned
as a soft curve in the helicofacial sulcus paralleling the curve of the
anterior border of the helix. This will result in a natural-appearing
Plan for incision along the temporal hairline
Fig. 9.7 Plan for incision along the temporal hairline. An incision
along the temporal hairline should be considered whenever
objectionable displacement of the sideburn and temple hair is
predicted.
Traditional location of the pre-auricular incision
Fig. 9.8 Traditional location of the preauricular incision. This plan
places the preauricular scar in an area open to scrutiny and brands
the patient as having had facelift surgery.
Pre-auricular portion of the face-lift incision
Fig. 9.9 Marginal tragal (retrotragal) plan for the preauricular
portion of the facelift incision. Placing the incision along the natural
anatomic interfaces conceals the scar and disguises differences in
skin color and texture on each side of it.

9
FACELIFT WITH SMAS FLAPS
114
width to the helix and the resultant scar, if visible, will appear to be
a helical highlight.
As the tragus is approached, the mark for incision is carried into
the depression superior to it and then continued along its posterior
margin. In this location the scar, if visible, will appear to be a natural
highlight. It is an error to place this incision in a true ‘retrotragal’
position on the inner surface of the tragus. This usually results in a bulky,
amorphous appearing tragus and obliteration of natural tragal anatomy.
At the inferior portion of the tragus the incision must turn anteri-
orly and then again inferiorly, into the crease between the anterior
lobule and cheek. If a more relaxed plan is made, or if a straight line
incision is used, skin settling and scar contraction will result in crowd-
ing of the incisura, obliteration of the inferior tragal border, and a
tell-tale elongated and ‘chopped off’ tragal appearance (Fig. 9.13).
Perilobular incision
To obtain a natural perilobular appearance, it is essential to preserve
the natural sulcus between the ear lobe and the cheek and to avoid
excision of this aesthetically important anatomic subunit.7 This is
accomplished by marking the incision a 1–2 mm inferior to this junc-
tion. All other factors being equal, a superior result will be obtained
when such a plan is used, in comparison to any plan in which the
incision is placed directly in the sulcus.
A
B
Fig. 9.10 Before and after secondary facelift
to move pretragal incision scar to retrotragal
position. A, Preoperative view. A pretragal
incision has healed satisfactorily but is
visible because of differences in color and
texture on each side of it. B, Postoperative
view. The incision was moved to the
posterior margin of the tragus (retrotragal
position). Color and texture differences and
the scar itself are now concealed along
natural anatomic interfaces.
A
B
Fig. 9.11 Healed retrotragal incisions.
A&B, Postoperative close-up views of patients
who have had a facelift with a preauricular
incision along the margin of the tragus. The
scars are well concealed and there is no
tragal distortion.

Preoperative Planning
115
Postauricular incision
Traditionally, the postauricular portion of the facelift incision has been
made over the posterior surface of the concha. This was done as part
of a well-intended effort to offset inevitable descent of the postauricu-
lar fl ap and inferior migration of the resulting scar that occurred when
skin was tightened in an attempt to improve neck contour. Many
surgeons have since come to realize that such a plan embodies errone-
ous assumptions and can result in undesirable effects including hyper-
trophic scarring, postauricular webbing and obliteration of the
auriculomastoid crease.8
The postauricular portion of the facelift incision should be marked
directly in the existing auriculomastoid groove and the mark turned
posteriorly at the approximate level of the anterior crus of the anti-
helix. Marking must be made with the ear resting near its natural
anatomic position. If the ear is pulled too far forward while marks are
made, mastoid skin will be pulled anteriorly over the posterior surface
of the concha and the incision will end up posterior to its intended
location. Incorrect marking in this manner is the most common cause
of a poorly situated postauricular scar.
Occipital incision
Planning the location for the occipital portion of the facelift incision
is conceptually similar to that of the temple region and the incision
plan must address similar concerns of hairline displacement and scar
A
B
Fig. 9.12 Healed retrotragal incisions. A&B,
In these male patients the incision has been
made along the posterior margin of the
tragus and the tragus has been kept free of
beard hair by intraoperative destruction of
beard follicles from the underside of the
tragal fl ap.
Fig. 9.13 ‘Chopped-off tragus’. The unnatural and objectionable-
appearing elongated tragus with an indistinct inferior border that
results from poor incision planning and improper excision of the skin
at the time of incision closure.
Traditional plan for the occipital portion of the face-lift incision
Fig. 9.14 Traditional plan for the occipital portion of the facelift
incision. The incision is placed transversely high on the occipital
scalp in a well-intended but usually counterproductive attempt to
hide the resultant scar.

9
FACELIFT WITH SMAS FLAPS
116
visibility. Traditionally this incision is arbitrarily placed transversely,
high on the occipital scalp, in a well-intended but usually counter-
productive attempt to hide the resultant scar (Fig. 9.14).
Important factors in determining
incision placement
For patients with a small amount of neck skin redundancy is small
and for whom excision of postauricular skin is unnecessary, such a
plan is appropriate and will result in a well-concealed scar. Patients in
this category are usually young and troubled by mild neck deformity
only. In these situations the incision is used for access to the lateral
neck only, and not as a means to remove postauricular skin. Skin
excision using this incision plan will result in the advancement of neck
skin into the occipital scalp and ‘notching’ of the occipital hairline
(Fig. 9.15A&B).
Although not all patients will recognize this deformity for what it
is, most are nonetheless self conscious of it, especially those who wear
their hair up or back or who lead active lives where wind, water and
outdoor activities may displace camoufl aging wisps of remaining hair.
Proper analysis, careful planning and the use of an incision along the
hairline when indicated, can avert this problem with out compromis-
ing the end result (Fig. 9.16A&B).
In choosing the location of the occipital portion of the facelift
incision an estimate must be made of the skin redundancy along
the predicted posterior-superior direction of fl ap shift. This can be
accomplished by pinching up tissue over the upper lateral neck and
measuring it:
● if 2 cm or less of excess neck skin is present, a traditional incision
over the mastoid extending posteriorly into the scalp at the level
of the mid ear (see Fig. 9.14) may be used and will not result
A
B
Fig. 9.15 Notching of the occipital hairline.
A&B, Examples of notching of the occipital
hairline in two patients whose surgeons used
traditional occipital incision plans.
A
B
Fig. 9.16 Healed incisions along the occipital
hairline. A&B, Postoperative close-up views
of scars along the occipital hairline. Note that
an inconspicuous scar will result if this
incision is planned carefully and properly
closed.

Preoperative Planning
117
in objectionable disruption of the occipital hairline if the postau-
ricular skin fl ap is not advanced and is returned to its original
position;
● if more than 2 cm of neck skin redundancy is present, however,
the incision should be placed along the occipital hairline, but
designed in such a manner that a tell-tale scar will not be visible
in front of the fi ne hair on the nape of the neck – this can be
accomplished by turning the inferior portion of the incision
back into the scalp at the junction of thick and thin hair.
(Fig. 9.17).
From a practical standpoint the traditional incision on the occipital
scalp should be used for access to the neck only and closed without
shift or advancement. Any patient with signifi cant neck skin redun-
dancy will require an incision along the occipital hairline if hairline
displacement is to be avoided.
From a practical standpoint the traditional incision on the occipital
scalp should be used for access to the neck only and closed
without shift or advancement. Any patient who has signifi cant
neck skin redundancy will require an incision along the occipital
hairline if hairline displacement is to be avoided.
Patient considerations
As with temporal incision placement, options for the placement of
the occipital portion of the facelift incision should be discussed
with the patient and presented as a choice between two imperfect
alternatives:
● a scar ‘hidden’ in the scalp and hairline displacement; or
● a scar along the hairline with hairline preservation.
It is wise that the fi nal decision about where the incision is located is
made by the patient after the advantages and disadvantages of each
Inferior position of the incision into the scalp
Fig. 9.17 Plan for incision along the occipital hairline. The incision is
planned so that its inferior portion turns posteriorly into the occipital
scalp at the junction of thick and thin hair. This plan prevents
hairline displacement and results in a well-concealed scar.
Traditional, but incorrect placement of the submental incision
Fig. 9.18 Traditional but incorrect placement of the submental
incision. The submental incision should not be placed directly along
the submental crease because this will accentuate it and reinforce a
double-chin appearance. Note that the typical plan of skin
undermining also promotes a double chin because the crease is not
undermined and the retaining ligaments are not released.
Correct placement of the submental incision
Fig. 9.19 Correct placement of the submental incision. Placing the
submental incision posterior to the submental crease prevents
accentuation of the double chin and witch’s chin deformities and
provides for easier dissection and suturing in the anterior neck.
Note that this incision plan allows the submental crease to be
undermined (shaded area) and released, and the fat of the chin pad
and neck to be blended.
option have been discussed. It has been my experience that most
patients are concerned by the prospect of occipital hairline displace-
ment and recognize it as an objectionable sign that a facelift has been
performed. When properly advised and given a choice, most consent
to a hairline incision.

9
FACELIFT WITH SMAS FLAPS
118
Submental incision
Most facelift patients require modifi cation and repair of the neck and
submental regions that can only be performed through a submental
incision, and optimal improvement in the neck can generally not be
obtained unless a submental access incision is made.9–11 Traditionally
this incision is placed directly in and along the submental crease in a
well intended, but counter-productive attempt to conceal the resulting
scar (Fig. 9.18). This incision plan should be avoided, however,
because:
● it will surgically reinforce the crease and accentuate a double chin
or witch’s chin deformity;12
● exposure of the submental region will be compromised, and there
will be diffi culty suturing or dissecting beneath the skin in the
lower neck.
A more posterior placement of this incision will eliminate these
problems, but still result in an inconspicuous and well-concealed scar
(Fig. 9.19 and Fig. 9.20A–D).
The submental incision should be placed well posterior but paral-
lel to the submental crease at a point lying roughly one half of the
distance between the mentum and the hyoid (Fig. 9.21). This usually
corresponds to a site situated approximately 1 cm posterior to the
crease.
The incision should be approximately 3.5–4.5 cm in length, but
may be made longer provided neither end will be advanced up upon a
visible portion of the face when skin fl aps are shifted. Healing will be
best and the scar best concealed if it is made as a straight rather than
a curved line (Fig. 9.22).
A
B
C
D
Fig. 9.20 Correction of the double chin
deformity. A–D, Pre and postoperative views.
The submental incision was made posterior
to the submental crease to allow undermining
and release of the submental-retaining
ligaments and blending of chin and neck fat.
OPERATIVE APPROACH
Planning modifi cation of the SMAS
All patients undergoing a facelift will benefi t from some modifi cation
of the SMAS and a high posterosuperior advancement of the cheek
SMAS serves as the fundamental step in rejuvenation of the face and
avoidance of secondary deformities (Fig. 9.23A&B).
SMAS advancement provides a natural appearing and long-lasting
correction in the cheek and jowl and will consolidate the lower face.
When a high-SMAS plan is used improvement can be obtained in the
midface and infraorbital area without the need for a separate midface
lift procedure.13
Operative technique
Skin fl ap elevation
● After incisions are made skin fl aps are elevated according to the
preoperative plan over the cheek and neck. Skin fl aps should be
elevated sharply under direct vision. This is especially important
in the preauricular region and over the cheek where a deep or
careless dissection can injure the underlying SMAS and render it
useless as a fl ap.
● Subcutaneous undermining should not arbitrarily include the entire
face. If SMAS dissection is planned, preservation of the anterior
platysma–cutaneous ligaments will allow attractive and youthful
appearing elevation of perioral tissue that cannot be obtained with
a skin-only technique or when wide skin undermining is performed

Operative Approach
119
(Fig. 9.24). These ligaments anchor the dermis of the perioral
cheek to the SMAS and upper platysma and provide a means of
lifting and supporting the lateral perioral area without overtight-
ening the skin of the upper-lateral face.
If subcutaneous dissection is extended too far anteriorly and the
platysma–cutaneous ligaments are divided, the SMAS effect on the
superfi cial tissues of perioral cheek and jowl will be negated and a
signifi cant portion of the benefi t of SMAS elevation and
advancement will be lost.
Temple incision and fl ap dissection
● The temple incision is made according to the preoperative plan
based on the redundancy present over the upper cheek and the
predicted degree of displacement of the sideburn and temporal
hairline.
Fig. 9.21 Plan for the submental incision. The submental portion of
the facelift incision (solid line) should be placed posterior to the
submental crease (dotted line), approximately one half of the
distance between the mentum and hyoid (arrows).
Fig. 9.22 Healed submental incision. Placement of the submental
incision posterior to the submental crease will result in an
inconspicuous well-healed scar.
“High” SMAS flap
Fig. 9.23 High SMAS fl ap. A, Plan for basic
high SMAS fl ap. Note that the superior
margin of the fl ap is planned at the level of
the zygomatic arch (i.e. not inferior to it).
B, High SMAS fl ap after advancement and
suturing.

9
FACELIFT WITH SMAS FLAPS
120
Extent of subcutaneous undermining
Fig. 9.24 Extent of subcutaneous undermining. The shaded area
shows the area of subcutaneous undermining. Note that the
platysma–cutaneous ligaments (black dots) are not undermined and
are preserved. Preservation of platysma–cutaneous ligaments and
proper elevation and fi xation of the SMAS will provide support for the
lateral periorbital tissues and prevent the lateral sweep deformity.
Fig. 9.25 Dividing the mesotemporalis. The bridge of tissue situated
between the subfascial (subgaleal) dissection in the temple and
subcutaneous dissection in the cheek can be safely divided posterior
to the course of the frontal branch of the facial nerve (dotted line).
This bridge of tissue usually contains the anterior branch of the
superfi cial temporal artery, which must be divided and cauterized or
ligated.
Dividing the mesotemporalis
● The dissection is then deepened and carried down through the
galea (superfi cial temporal fascia) to the fascia of the temporalis
muscle and the temporal hair bearing fasciocutaneous fl ap ante-
rior to the incision undermined.
● The bridge of fascia lying inferiorly between the deep dissection
in the temple and the subcutaneous dissection in the cheek can be
safely and conveniently partially divided posterior to the temporal
hairline (Fig. 9.25). Usually this bridge of tissue contains the
anterior branch of the superfi cial temporal artery and it must be
divided and ligated when encountered, or thoroughly cauterized.
This is of no clinical consequence, and is a routine part of the
dissection of this area. The frontal branch of the facial nerve lies
well anterior and inferior to this chosen point of transition between
planes, and this dissection, when executed as described, is clini-
cally safe.
● Partially dividing the bridge of tissue between the deep plane of
the temple and the subcutaneous plane of the cheek allows the two
planes of dissection to be joined laterally, and this in turn facili-
tates exposure in the upper cheek and lateral orbit, dissection of
the SMAS, and re-draping of the temporal portion of the facelift
fl ap.14,15 This method of dissection also protects hair follicles on
the undermined temporal scalp by moving the plane of dissection
deep to them.
Flap dissection with incision along the temple hairline
● When an incision along the temporal portion of the anterior hair-
line is indicated, it is made a few millimeters within it with a slight
bevel, or parallel to the hair follicles.
● The temporal skin fl ap is then carefully undermined subcutane-
ously and joined with the subcutaneous dissection in the cheek. No
transition between planes is necessary under these circumstances,
no hair-bearing fl aps are raised, and the superfi cial temporal
vessels and frontal branch of the facial nerve are left undisturbed,
beneath the superfi cial temporal fascia (Fig. 9.26).
Flap dissection with traditional incision on the temporal
scalp
● When a traditional incision on the temporal scalp is indicated, it
is made precisely parallel to hair follicles. This generally requires
that the incision is beveled to varying degrees and in different
directions along its length.

Operative Approach
121
Fig. 9.26 Flap dissection with a temporal hairline incision. When an
incision is made along the temporal hairline all dissection will be in
a subcutaneous plane and no transition between planes will be
necessary, no hair-bearing fl aps are raised and the superfi cial
temporal vessels are left undisturbed beneath the superfi cial
temporal fascia.
Flap dissection with hairline incision
Plan for high SMAS fl ap
● Once the skin fl aps have been elevated they are retracted and the
zygomatic arch is palpated.
● A line is then traced “high” over the mid portion of the zygomatic
arch in water-soluble surgical ink (methylene blue) beginning over
the outer malar region at the level of the infraorbital rim and
extending laterally to a point approximately 1 cm anterior to the
superior portion of the tragus. This line lies higher that the dissec-
tion made in most other techniques, and well above the malar
origin of the zygomaticus major muscle.
● The mark is then turned inferiorly and carried over the preauricu-
lar portion of the parotid 1–1.5 cm anterior to the ear.
● Inferior to the lobule the line is carried inferiorly and posteriorly
in a soft curve to the anterior border of the sternocleidomastoid
muscle (Fig. 9.27).
Advantages of the high fl ap
A basic high fl ap of this type is used for most patients and there are
several important aspects of its design worth considering.
● Planning the superior margin of the fl ap over and along the zygo-
matic arch, rather than inferior to it, expands the effect of the fl ap
to include the upper midface and allows a better vector to be
applied to it.
● Carrying the incision posteriorly and inferiorly over the tail of the
parotid to the anterior border of the sternocleidomastoid muscle
in the upper lateral neck maintains a safety zone between the inci-
sion and the mandibular margin and moves the dissection away
from the marginal mandibular nerve (Fig. 9.28).
Incising the SMAS and fl ap elevation
● Flap elevation is begun by incising the SMAS over the zygomatic
arch. This is accomplished by grasping the preauricular tissue
overlying the lateral arch with an Allys clamp on each side of the
marked line and using them to provide tension to the SMAS layer
tissue plane.
● An incision is then made with Metzenbaum scissors and continued
medially 2–3 cm along the marked line in the tensed plane.
● The Allys clamps are then released and reapplied incrementally as
the dissection proceeds further medially along the marked line in
the tensed plane in 2–3 cm increments in a similar fashion.
A considerable amount of tissue lies over the arch and the frontal
branch will be safely concealed beneath several millimeters of
fi brous fat if the dissection is performed as described. The margin
for error may be reduced in the thin, aged patient with advanced
facial atrophy and less soft tissue cover over the arch or in a
secondary procedure. Extra caution must be taken under these
circumstances.
● The preauricular limb of the SMAS incision is then made using a
similar technique over the posterior parotid along the marked line
in the preauricular region. It is continued inferiorly and posteri-
orly to the anterior border of the sternocleidomastoid muscle.
These two incisions defi ne the high SMAS fl ap to be elevated.
● After initial SMAS incisions have been completed preauricular
tissue comprising the posterosuperior corner of the SMAS fl ap is
grasped with Allys clamps. Flap elevation is then begun using
careful scissors technique. Undermining should be limited in the
pre-parotid cheek and more extensive over the zygoma and upper
midface (Fig. 9.29). SMAS fl ap elevation entails dissection in the
plane of the facial nerve in close proximity to important motor
branches. Although fl ap elevation over the parotid is safe, great

9
FACELIFT WITH SMAS FLAPS
122
Plan for “High SMAS” flap
Fig. 9.27 Plan for high SMAS fl ap and the frontal branch of the facial
nerve. The superior margin of the fl ap is planned over the zygomatic
arch and not below it. The frontal branch of the facial nerve (dotted
line) lies safely posterior and deep to most of the dissection.
Plan for “High SMAS” flap
Marginal mandibular branch
of facial nerve
Fig. 9.28 Plan for high SMAS fl ap and the marginal mandibular
branch of the facial nerve. The marginal mandibular branch of the
facial nerve (yellow line) emerges from the anterior border of the
parotid gland well anterior to the SMAS incision in the preauricular
region. Note that the posterior incision curves posteriorly to the
anterior border of sternocleidomastoid.
care must be taken when dissecting more medially, and over the
zygomatic arch.
● A separate and distinct plane exists medial to the parotid between
the SMAS–platysma and the parotidomasseteric fascia. This plane
is most easily identifi ed and established in the lower cheek where
it can usually be entered by gentle blunt dissection. The paroti-
domasseteric fascia will be seen as a thin, shiny transparent layer
covering the masseter muscle, parotid duct, buccal fat and the
branches of the facial nerve. Blunt dissection on top of this layer
is safe and will not result in nerve injury, but great caution must
be exercised when dissecting sharply, or when clamping or coag-
ulating in this area. Frequently motor nerve branches accompany
perforating vessels and each bleeding point must be carefully iden-
tifi ed when hemostasis is being performed. Blind clamping should
not be performed and low coagulation current should always be
used. The patient’s face should also be carefully watched whenever
cauterization is performed and the current discontinued immedi-
ately if facial movement is noted.
● Sub-SMAS dissection must generally be carried over the anterior
border of the parotid in the lower cheek to ensure that the paroti-
domasseteric ligaments tethering the SMAS are released. These
are most easily identifi ed by fi ngertip palpation along the front of
dissection. If these restraining attachments are not released an
optimal SMAS effect will not be realized and minimal overall
benefi t will be obtained.
● As SMAS fl ap dissection is made anteriorly, and medially in the upper
cheek over the superior portion of the parotid and its accessory
lobe, the SMAS will thin and invest the lip elevators. At this point
the dissection must be taken superfi cial to the superior portion of
the zygomaticus major muscle and its origin carefully exposed.
● Just at the malar origin of the zygomaticus major muscle the zygo-
matic ligaments will be encountered. These fi brous connections
between the periosteum and skin must be divided and when com-
pletely released a signifi cant liberation of the fl ap will be obtained.
The lateralmost ligaments are typically more substantial and gen-
erally require sharp dissection and formal transection. The liga-
ments lying more medially are generally softer and can often be
disrupted bluntly with open scissors tips.
● Directly inferomedial to the origin of the zygomaticus major
muscle and superomedial to the accessory lobe of the parotid and
the parotid duct is the zone of transition between the zygomatic
and masseteric–cutaneous ligaments and the most potentially
dan gerous part of the SMAS dissection. Proper liberation and
release of the SMAS fl ap usually requires at least partial division
of restraining attachments in this area, but moves the dissection
into very close proximity to the zygomatic branch of the facial nerve
(Fig. 9.30).

Operative Approach
123
● Dissection of the SMAS fl ap and release of restraining ligaments
is continued until gentle traction on the fl ap produces motion at
the nasal ala, philtrum and stomal angle, and elevation and com-
pression of infraorbital and lower eyelid tissue. This ‘traction test’
clinically confi rms adequate fl ap release and is a more important
indicator of a complete dissection than any arbitrary anatomical
endpoint.
● If fl ap release is incomplete, residual tethering fi bers are identifi ed
and carefully divided and the traction test repeated.
● When dissection is complete, the malar pad and attached skin
should move freely as part of the high SMAS fl ap superiorly and
laterally as needed, and no separate malar pad suturing, midface
anchoring, or subperiosteal dissection is required.
Directly inferomedial to the origin of the zygomaticus major muscle
and superomedial to the accessory lobe of the parotid and the
parotid duct is the zone of transition between the zygomatic and
masseteric–cutaneous ligaments and the most potentially
dangerous part of the SMAS dissection.
SMAS suspension
Securing the superior margin
● Once the SMAS fl ap has been elevated and adequately released,
the superior edge of the fl ap is grasped and it is shifted variously
to determine which direction produces the best effect on the upper
midface, cheek and jowl. In all but the unusual case this is along
a posterosuperior vector parallel to the long axis of the zygomati-
cus major muscle. If an overly ‘vertical’ or posterior vector is used,
the function of the zygomaticus major muscle may be corrupted
and this may result in abnormal appearances during animation
(Fig. 9.31).
Variation in the management of the superior margin of the
SMAS fl ap Management of the superior margin of the SMAS fl ap and
the technique of fl ap suspension will vary depending on the problems
present and other considerations particular to the patient including
sex, racial features and overall facial morphology.
● In most cases the superior margin of the fl ap is not trimmed
because the overlapping tissue segments of SMAS add volume to
the upper lateral cheek and restore lost projection over the zygo-
matic arch. In these situations the superior edge of the fl ap is
anchored with multiple interrupted sutures of 3-0 braided polyes-
ter (Mersilene) well over the zygomatic arch directly to the deep
temporal fascia, superior to the mesotemporalis. Suspension in this
manner is greatly facilitated if the mesotemporalis is gently pushed
inferiorly as the sutures are placed. This allows the midface, upper
cheek and jowl to be securely suspended with little if any risk of
injury to the frontal branch of the facial nerve.
● No suturing is needed or should be performed over the zygoma or
along the infraorbital rim. These parts of the face are mobile and
need to move during animation and to impart natural expression.
Directly suspending the midface along the zygoma or infraorbital
rim, especially rigidly, can result in tissue tethering and dimpling
sometimes referred to as ‘smile block’.
● If direct anchoring of the fl ap to the temporal muscle fascia is not
possible, even when the mesotemporalis is pushed inferiorly, sus-
pension can still be made in this manner if sutures are allowed to
bridge the intervening gap.
● In patients with wide faces and a small mandible, in many men,
and in many patients of Asian or Slavic ancestry, enhancement of
the upper cheek and arch obtained by overlapping the SMAS may
not be artistically appropriate, necessary, or desired. In such cases
the redundant tissue along the superior fl ap margin can be excised
and discarded, and the superior fl ap margin sutured edge to edge
to the superior margin of the initial incision made in the SMAS
over the zygomatic arch.
● When an incision along the temporal hairline is used and temporal
dissection is made in a subcutaneous plane, temporal muscle fascia
will not be exposed and a mesotemporalis will not be present. In
these cases the superfi cial temporal fascia can be incised along the
edge of the sideburn, posterior and superior to the frontal branch
of the facial nerve. The sideburn can then be refl ected superiorly
Approximate extent of SMAS undermining
Zygomatic
ligaments
Parotido-
masseteric
ligaments
Fig. 9.29 Approximate extent of SMAS undermining.
Complete release of the SMAS fl ap will require that both the
parotidomasseteric ligaments (squares) and the zygomatic ligaments
(circles) are released.
zygomatic
ligaments
zone of transition
masseteric-cutaneous
ligaments
1
2
3
Fig. 9.30 Completed SMAS fl ap dissection. Inferior to the origin
of the zygomaticus muscle and superomedial to the accessory
lobe of the parotid lies the transition between the zygomatic and
masseteric–cutaneous ligaments (dots) and the most potentially
dangerous part of the SMAS dissection. Proper liberation and
release of the SMAS fl ap usually requires at least partial division of
restraining attachments in this area, but moves the dissection into
very close proximity to the zygomatic branch of the facial nerve.

9
FACELIFT WITH SMAS FLAPS
124
in a subgaleal plane, the newly created mesotemporalis pushed
inferiorly, and the SMAS fl ap suspended to the deep temporal
fascia (see Fig. 9.32). Alternatively, the redundant tissue along the
superior fl ap margin can be excised and discarded, and the supe-
rior fl ap margin sutured edge to edge to the superior margin of the
initial incision made in the SMAS over the zygomatic arch.
Securing the posterior margin of the SMAS fl ap
Regardless of how the superior margin of the fl ap is secured, some
trimming of the posterior margin of the cheek SMAS fl ap is invariably
required thereafter to allow an edge-to-edge approximation of the
SMAS fl ap to the SMAS remnant in the preauricular region. Overlap-
ping of the SMAS in the preauricular area is functionally unproductive
and artistically inappropriate because such an arrangement lends no
additional support to the anterior face and obliterates natural preau-
ricular contours and the pretragal hollow.
● Trimming of the posterior margin of the cheek SMAS fl ap should
be performed after the superior margin has been suspended over
the zygomatic arch.
● Excision is accomplished by placing gentle traction upon it and
tracing a line in marking ink over the cut edge lying beneath it.
● The amount of tissue excised will vary depending upon the size of
a given face, the degree of release of the fl ap, and the chosen vector
of advancement.
● It is unproductive and an error to place excessive traction on the
SMAS in the preauricular region and the posterior margin of the
fl ap should be trimmed carefully to avoid overexcision and a tight
closure. Excessive posterior traction on the SMAS will result in
perioral distortion, a ‘pulled appearance’ and other abnormal
appearances.
● After trimming of the posterior margin of the SMAS fl ap, the cut
edge is approximated to the preauricular remnant with multiple
interrupted sutures of 3-0 braided polyester (or other suture of
choice). These sutures consolidate the cheek and help support the
superior suture line.
● Upon completion of suturing of the cheek SMAS improved facial
contour should be seen and a faint smile on the ipsilateral face
should be evident. Usually elevation of the lid–cheek junction and
compression of the ipsilateral lower eyelid will also be noted.
Use of excess tissue as a postauricular transposition fl ap
● To provide additional support in the anterior neck and along the
submental region, the excess tissue along the posterior margin of
the cheek SMAS fl ap can be left attached to the cervical–submen-
tal platysma and used as a postauricular transposition fl ap.
● This fl ap improves neck contour by correcting horizontal platysma
redundancy and increasing submental support. Frequently this
cannot be accomplished by lateral platysmapexy alone due to
mobility of the tissues in the upper lateral neck. Suturing the trans-
posed segment of cheek SMAS to the mastoid fascia, while leaving
it attached to the cervical platysma, circumvents this problem and
produces an improved result. In addition, a dynamic sling is
created that tightens the submental region when the patient looks
down. This tightening is obtained because the mastoid moves supe-
riorly during neck fl exion and away from the anterior neck, pulling
the transposed fl ap, and attached tissue, with it.
● When a postauricular transposition fl ap is used it must be carefully
designed and its effect thoroughly tested intraoperatively.
● The SMAS must be incised in such a fashion that the transposition
fl ap exerts its effect on the cervical platysma below the mandibular
border, and not more superiorly on the SMAS in the cheek.
● Flap suspension is best delayed until after anterior platysmaplasty
is completed.
● A postauricular transposition fl ap when used in conjunction with
anterior platysmaplasty, results in a mastoid to mastoid sling of
Proper and improper vector of SMAS shift
A
B
C
Fig. 9.31 Proper and improper vector of
SMAS shift. A, Correct shift of the SMAS fl ap
is along the long axis of the zygomaticus
major muscle. This allows for the natural
muscle function. B, If the SMAS is shifted
along a posteriorly directed vector and not
along the axis of the zygomaticus muscle,
the muscle will be pulled off its axis and its
function will be compromised. This can result
in deepening of the nasolabial fold and
abnormal appearances during animation.
C, An analogous problem is encountered
when a vertical vector is used in a vertical
facelift.
Fig. 9.32 High SMAS fl ap suspension. The SMAS fl ap has been
advanced superiorly, the mesotemporalis pushed inferiorly, and the
fl ap secured to the temporalis muscle fascia.

Operative Approach
125
autologous tissue. This is a more natural and superior maneuver
that any attempt to accentuate neck contour by the placement of
suspension sutures.
Drain placement
Drains are used routinely and experience has shown that they reduce
postoperative ecchymosis and seromas, and allow patients to return to
their work and social lives sooner. Drains will not, however, substitute
for poor hemostasis and will not prevent hematoma formation.
● A 10 F round soft Silastic Jackson-Pratt-style closed-circuit suction
drain is used. It is placed through a small stab incision on the
occipital scalp 1–2 cm superior to the apex of the occipitomastoid
incision and is anchored at its exit site with a 4-0 nylon or similar
suture. The drain tip is then passed beneath the cervical skin across
the anterior neck to the opposite side of the face.
● No drains are needed or placed in the cheeks. Blood or fl uid
originating from these areas will move under the infl uence of
gravity to the neck area.
Skin fl ap repositioning and suspension
suture placement
The goal of skin excision should be to remove redundancy, and not to
tighten the skin fl ap. In addition, to avoid unnatural appearances, skin
fl aps must be shifted in a slightly more posterior, less superior direc-
tion than that of the SMAS. Shifting skin along an overly superior or
posterior vector or suspending skin fl aps under tension will result in
hairline displacement, unnatural appearances, poor scars, and other
objectionable problems.
Cheek skin
Cheek skin fl aps should be shifted along a vector approximately per-
pendicular to the nasolabial fold. This will minimize sideburn eleva-
tion and displacement, and skin will lie more naturally over the tragus
once healing is complete. Maximum improvement will also be obtained
in the nasolabial area when this vector is used.
Postauricular area skin
In the postauricular area skin should be shifted along a vector roughly
parallel to the mandibular border. This provides optimal improvement
in the anterior neck and allows maximum excision of skin fl ap redun-
dancy without compromising the fl ap’s covering function. If the post-
auricular skin fl ap is shifted along a more superiorly directed vector,
improvement in the anterior neck will be compromised, skin will be
mistaken excised over the apex of the occipitomastoid incision, and a
wide scar will result once healing is complete.
Points of skin fl ap suspension
There are two points of skin fl ap suspension that should be set fi rst
before the remainder of the closure is performed.
● The fi rst point is located in the supra-auricular area where the
anterosuperior most part of the ear joins the scalp. To set this point
the cheek skin fl ap should be shifted along a vector roughly per-
pendicular to the nasolabial fold and skin redundancy gauged with
a facelift marker or similar implement (Fig. 9.33). The skin fl ap
should be held under normal skin tension when the mark is made
and an incision made into the fl ap up to the marked point. The fl ap
should then be anchored at this point with a half buried vertical
mattress suture of 4-0 nylon with the knot tied on the scalp side.
No deep sutures are necessary or used.
● The second point of suspension is located in the postauricular
crease at the anterosuperior aspect of the occipitomastoid incision.
The postauricular fl ap should be shifted posteriorly and superiorly
roughly parallel to transverse neck creases and the mandibular
border in such a manner that skin is suspended under minimal or
no tension and that little or no skin is trimmed from the anterior
(postauricular) fl ap border. The fl ap is then secured at this point
with a simple interrupted suture of 4-0 nylon. No incision into the
fl ap is necessary and no deep suture is used.
Incision to exteriorize the lobule
● Once the initial two suspension sutures have been placed, the stage
is set for the remainder of the closure and the fl ap overlying the
inferior portion of the ear can be carefully divided and the lobule
exteriorized.
● Incision of the fl ap and exteriorization of the lobule is a key step
in the procedure that must be performed incrementally and with
great care if a visible scar, lobular malposition and other objec-
tionable secondary deformities are to be avoided.
● If the incision to exteriorize the lobule is made correctly, the apex
of the incision should rest snugly against the inferiormost portion
of the conchal cartilage beneath the lobule. If the incision into the
cheek fl ap is made too far anteriorly or inferiorly, however, artisti-
cally appropriate resetting of the lobule will be impossible, and the
outcome of the overall procedure will be signifi cantly compromised.
Skin fl ap trimming and closure
Skin fl ap trimming and incision closure is conveniently begun in the
postauricular area along the auriculomastoid sulcus, and should be
completed before trimming and closure of the occipital portion of the
incision and resetting of the lobule.
Trimming and closure of the postauricular skin fl ap This stage
is begun by conservatively trimming the anterior border of the post-
auricular skin fl ap into a soft curve to match the curve of the incision
made behind the ear in the auriculomastoid sulcus. Typically, no more
than a few millimeters of tissue are removed. The incision is then closed
with several interrupted sutures of 4-0 nylon. No deep suture is used.
It is an error to excise any skin over (superior to) the apex of the
occipitomastoid incision and to shorten the postauricular fl ap along
the long axis of the sternocleidomastoid muscle as is commonly prac-
The facelift marker
Fig. 9.33 Facelift marker. A, Close-up view of the tip design.
B, Diagram showing the instrument in use. Use of a fl ap marker
provides a reliable means for making appropriate excisions of skin.
The pin on the lower jaw of the marker is designed to be placed
near the edge of the incision. The skin fl ap is then pulled over the
lower jaw of the instrument and when proper tension is set the
instrument is closed. On closing, the upper jaw of the instrument
marks the precise position of the edge of the scalp fl ap beneath it.
This serves as a valuable guide to the degree of redundancy present
and is particularly useful in gauging the depth of pilot incisions
initially made into the fl ap at points of initial fl ap suspension.

9
FACELIFT WITH SMAS FLAPS
126
ticed. Despite an apparent redundancy in this area when the patient
is supine on the operating table, there is never a true skin excess at
this location. This deceptive pseudoexcess of skin is present only
because of the patient’s high shoulder position in the supine position,
and will vanish when the patient sits up and the shoulders drop to a
normal location. Skin along the long axis of the sternocleidomastoid
muscle in the postauricular region is also needed for side-to-side head
tilt. Inappropriate excision of skin over the apex of the occipitomastoid
defect is the underlying cause of hypertrophic healing in the postau-
ricular region and a wide postauricular scar (Fig. 9.34).
Trimming and closure of the occipital incision
● Trimming and closure of the occipital portion of the facelift inci-
sion should be performed after closure of the postauricular area.
● If the occipital incision was made into the occipital scalp (see Fig.
9.14), it should be closed without shifting or excision of skin or
scalp in one layer with multiple simple interrupted sutures of 4-0
nylon (or other suture of choice). This incision plan is used to
provide access to the lateral neck only and cannot, by design,
accommodate skin excision in this area without producing dis-
placement and notching of the occipital hairline or shifting of the
postauricular skin fl ap along an inappropriate vector. Because this
incision is typically beveled when properly made, staples will not
provide precise wound edge approximation. Sutures are usually
required if wound malalignment and step-offs are to be avoided.
● If the occipital incision has been made along the occipital hairline
as is most often the case (see Fig. 9.17), skin will be excised from
the posterior border of the postauricular skin fl ap. A facelift marker
should be used to gauge skin fl ap redundancy, and it must be
remembered that the goal of skin excision is to remove redundancy
and not to tighten the cervical skin fl ap. If trimming is performed
correctly wound edges should abut one another before sutures are
placed. The incision is then closed in one layer with multiple half
buried vertical mattress sutures of 4-0 nylon with the knots tied on
the scalp side and a simple running suture of 6-0 polypropylene
(Prolene) (Fig. 9.35). No deep sutures are required and staples
should not be used. This scheme will provide precise wound edge
alignment and prevent cross-hatched scars (suture marks).
Incorrect trimming of postauricular skin flap
Fig. 9.34 Incorrect trimming of the postauricular skin fl ap. It
is an error to excise any skin over (superior to) the apex of the
occipitomastoid incision and shorten the postauricular fl ap along the
long axis of the sternocleidomastoid muscle. There is no true excess
of skin along this vector nor any aesthetic benefi t from shifting the
skin in this direction. Excision of the skin in this fashion is the
underlying cause of hypertrophic healing in the postauricular area
and a postauricular scar.
Suturing scheme for incisions along hairlines
A
B
Fig. 9.35 Suturing scheme for incision along
hairlines. A, Wound edges are approximated
with interrupted half-buried vertical mattress
sutures of 4-0 nylon with the knots tied on
the scalp side. B, Final approximation is
made with simple interrupted sutures of 6-0
nylon.
If there is a dog-ear
● If the postauricular skin fl ap has been shifted along a proper
vector, and tissue distributed appropriately under no tension over
the occipital area, a near precise fi t should be obtained. If there is
a large amount of neck skin redundancy or if the postauricular fl ap

Operative Approach
127
has been suspended under tension, a dog-ear will often be present
at the inferiormost portion of the occipital incision.
● A dog-ear, if present should not be chased down the occipital
hairline because an obvious scar will result in the fi ne hair on the
nape of the neck. A better result is obtained under these circum-
stances if the dog-ear is inset posteriorly into the occipital scalp,
above the junction of thick and fi ne hair, and secured with simple
interrupted sutures of 4-0 nylon. This requires excision of a small
ellipse of scalp from the scalp side of the incision, but moves the
end of the incision into dense hair where it is well concealed.
Trimming and closure in the preauricular area
● Once the postauricular and occipital areas have been closed atten-
tion should be turned to the preauricular area.
● Skin fl ap redundancy should be carefully gauged using a facelift
marker while the pretragal portion of the skin fl ap is held down
into the pretragal hollow with an instrument by the assistant. This
ensures that enough skin will be present to fi ll the pretragal sulcus
and to provide natural and attractive preauricular contours once
healing is complete. This is also a key step in avoiding a ‘retracted
tragus’ deformity.
● Using marks made by the facelift marker as points of reference,
the prehelical portion of the fl ap is trimmed to form a soft curve
that matches the prehelical incision. If trimming is performed cor-
rectly wound edges will abut one another before sutures are placed.
The incision is then closed in one layer with a simple running
suture of 6-0 polypropylene. No deep sutures are necessary.
● The prelobular (subtragal) portion of the cheek skin fl ap is trimmed
next, guided by marks made with the facelift marker. If trimming
is performed correctly, wound edges will abut one another before
sutures are placed. The incision is then closed in one layer with
several simple interrupted sutures of 6-0 nylon or polypropylene.
No deep sutures are necessary.
● Only after the prehelical and prelobular areas have been closed
should the tragal fl ap be trimmed. This trimming must be per-
formed with great care and while the assistant holds the pretragal
portion of the skin fl ap into the pretragal hollow. As elsewhere in
the periauricular closure, the tragal fl ap should be trimmed with
2–3 mm of redundancy. Closure is then made with a simple running
suture of 6-0 polypropylene. No deep sutures are necessary.
Overexcision of skin from the tragal skin fl ap is a serious technical
error that will result in tragal retraction and an unnatural chopped
off tragal appearance.
Insetting the lobule
● The lobule should be inset into the cheek fl ap as the last step in the
closure of the peri-auricular area because little is as tell-tale
and aesthetically objectionable as abnormal position of the ear
lobe.
● Trimming the cheek fl ap in the lobular area must always be per-
formed incrementally with great care to prevent over-excision. In
addition, the cheek fl ap should be trimmed and the ear lobe inset
in such a manner that the lobule ends up situated in a posterior
and somewhat superior position, even it if was in a more anterior
or inferior position before surgery. This is because the long axis
of the ear lobe of an artistically ideal nonsurgical-appearing ear
sits approximately 15º posterior to the long axis of the ear itself in
the lateral view (Fig. 9.36A). If this angle is reduced or shifted
anteriorly or the lobule is mistakenly placed too far inferiorly, an
unnatural and facelift look is produced (Fig. 9.36B).
Abnormal position of the ear lobe results in an aesthetically
objectionable, unnatural, facelift look. Because of this the lobule
should be inset into the cheek fl ap as the last step in the closure of
the periauricular area.
● Insetting the lobule into the cheek so that its long axis sits posterior
to the long axis of the rest of the ear often requires release of the
lobule from tethering tissue.
● The lobule is then secured in two layers. The fi rst layer consists of
several deep dermal sutures of 4-0 chromic gut (or other absorb-
able suture). These sutures provide initial alignment, and protect
the incision from disruption in the fi rst few weeks after surgery
when patients pull clothing, jewelry and other items off over their
heads. Final approximation is then made with a simple running
suture of 6-0 polypropylene. A running polypropylene suture is
much easier to remove at this location than a running or inter-
rupted suture of 6-0 nylon.
● If the lobule has been inset correctly, there is often some skin
redundancy on the posterior surface of the ear at the lobular–
conchal junction. This is easily and conveniently managed by
excising a triangle of skin corresponding to the tissue redundancy
in this area. Closure is made in one layer with several simple
interrupted sutures of 4-0 nylon or other suture of choice.
Closure of the temporal incision
● If foreheadplasty is to be performed as part of the procedure,16–19
closure of the temporal portion of the facelift incision is delayed
until after it is complete. This preserves access to the upper lateral
face and affords precise realignment of tissue in this area.
● If the temporal portion of the facelift incision has been made on
temporal scalp (see Fig. 9.6) the incision is closed in one layer
without excision of any hair-bearing temporal tissue with multiple
simple interrupted sutures of 4-0 nylon. A small amount of cheek
skin and scalp only will be excised immediately above the ear at
the completion of the closure. Because the incision on the temporal
Proper insetting of the ear lobe
A
B
Fig. 9.36 Proper insetting of the ear lobe. A, In the artistically ideal
nonsurgical-appearing ear the long axis of the ear lobe (dotted line)
is approximately 15° posterior to the long axis of the ear itself (solid
line) in the lateral ear. B, As this angle is reduced or the axis of the
lobule is shifted anterior to the long axis of the ear, an old,
unnatural and facelift look is produced.

9
FACELIFT WITH SMAS FLAPS
128
scalp is usually beveled when properly made, sutures, and not
staples, are generally required, if malalignment and step-offs are
to be avoided. It is clinically unproductive, a conceptual error, and
a serious technical mistake to excise scalp over the temple region
in attempt to tighten the forehead or upper lateral face.
● If the temporal portion of the facelift incision has been made along
the temporal hairline (see Fig. 9.7), skin only will be trimmed when
it is closed. A facelift marker should be used to gauge temporal
skin excess and the fl ap intentionally trimmed with 2–3 mm of
redundancy. If trimming is performed correctly the wound edges
should abut one another and no gaps should be before the sutures
are placed. The incision is then closed in one layer with a combi-
nation of half-buried vertical mattress sutures of 4-0 nylon with
the knots on the scalp side and a simple running suture of 6-0
polypropylene (see Fig. 9.35). Staples should not be used. This
scheme will provide precise wound edge alignment and will prevent
cross-hatched scars (suture marks).
Submental incision closure
● Once all other incisions have been sutured, and all concomitantly
performed procedures have been completed, the submental inci-
sion is closed. The closure is usually delayed in this manner so that
a fi nal check for hemostasis in the neck can be made.
● The incision is closed in one layer using a running intradermal
suture of 4-0 polypropylene.
Optimizing outcomes
●
Carrying the SMAS incision posteriorly and inferiorly over the
tail of the parotid to the anterior border of the sternocleidomastoid
muscle in the upper-lateral neck, maintains a safety zone
between the incision and the mandibular margin and moves
the dissection away from the marginal mandibular nerve
●
Partially dividing the bridge of tissue between the deep plane
of the temple and the subcutaneous plane of the cheek allows
the two planes of dissection to be joined laterally, and this
facilitates exposure in the upper cheek and lateral orbit,
dissection of the SMAS, and re-raping of the temporal portion
of the facelift fl ap.
●
Inappropriate excision of skin over the apex of the occipitomastoid
defect is the underlying cause of hypertrophic healing in the
postauricular region and, ultimately, of a wide postauricular
scar. Although an apparent excess of skin will be present in
this area when the patient is supine on the operating table,
this skin is necessary once the patient’s shoulders drop in the
upright position, and for side-to-side head tilt.
●
SMAS fl aps should be advanced along a posterosuperior vector
parallel to the long axis of the zygomaticus major muscle.
If a posterior or vertical vector is used, the function of the
zygomaticus major muscle will be corrupted and may result in
abnormal appearances during animation.
●
Incision of the facelift skin fl ap and exteriorization of the lobule is
a key step in the procedure that must be performed incrementally
and with great care if a visible scar, lobular malposition and
other objectionable secondary deformities are to be avoided.
COMPLICATIONS
Complications depend on the facelift technique used (see Table 9.1)
and include:
● secondary facelift deformities such as objectionable temple, side-
burn and occipital hairline displacement and scarring related to
inappropriate skin tension, poor planning of incisions or perfor-
mance of the surgery itself;
● alopecia and/or skin fl ap necrosis due to imprecise fl ap dissection,
rough fl ap handling, wound closure under tension, or tying sutures
too tightly;
● general surgical complications such as hematoma, infection and
nerve damage.
POSTOPERATIVE CARE
After all planned procedures have been completed and all incisions have
been closed, the patient’s hair is shampooed, rinsed and conditioned.
Failure to do this can result in matting and tangling that can be prob-
lematic in the postoperative period. No dressing is required or applied.
Patients are asked to rest quietly and apply iced compresses to their
eyes for 15–20 minutes of every hour they are awake for the fi rst 3
days after surgery. For most patients, edema peaks at about this time.
It is not necessary or productive to apply ice compresses continually
throughout the day or at night. Applying iced compresses to the cheeks,
neck, or forehead has not proven necessary unless fat injections have
been performed, and is generally not well tolerated by the patient.
Medication
All patients are provided with oral analgesics, sleeping pills, antiemetic
suppositories, bland ophthalmic ointment and artifi cial tears solution.
They are required to use ophthalmic ointment each night for the fi rst
3 weeks after surgery or until all signs of eye irritation have abated.
Artifi cial tears are used throughout the day as needed.
Other measures
All patients are instructed to sleep fl at on their backs without a pillow
for 2 weeks. A small cylindrical neck roll is permitted if the patient
requests it. This ensures an open cervicomental angle and averts neck
fl exion and dangerous folding of the neck skin fl ap, which inevitably
occurs if the patient is allowed to elevate their head on pillows, as is
commonly recommended.
Patients are asked to avoid salty, sour, and diffi cult to chew foods,
and to abstain from alcohol for 2 weeks after surgery.
Patients begin a daily routine of showering and shampooing no
later than 3 days after their procedures. This helps remove crusting
about the suture lines, keeps incisions clean and bacteria counts down,
and usually improves the patient’s general overall wellbeing. It also
facilitates suture removal. Patients must usually be reassured that
shower water, shampoo and conditioners are not harmful and will not
cause infection. Showering and shampooing are permitted and encour-
aged, even when drains are still in place.
Removal of drains and sutures
The neck drain is typically left in place for 4–5 days until the fi rst
suture removal visit. This reduces the likelihood that small collections
will form and will speed the overall resolution of edema and ecchymo-
sis in the neck area.
Sutures are removed in two visits over a period of 7 days. Fine
sutures are removed on the fi rst visit 4–5 days after surgery. Half-
buried vertical mattress sutures and scalp sutures are removed on the
second visit 7 days after surgery.
Return to normal activities
When patients return to work and their social lives depends upon their
tolerance for surgery, their capacity for healing, the type of work they
do, the activities they enjoy and how they feel overall about their
appearance.
Patients are asked to set aside 2–3 weeks to recover from surgery.
Patients who are doing well and not experiencing problems are allowed
to return to light offi ce work and casual social activity 9–10 days after

Further Reading
129
surgery. If a patient’s job entails more strenuous activity or physical
labor, a longer period of convalescence may be required.
Patients are advised not to drive for the fi rst 10 days after surgery
and until they are feeling well, their vision is clear, and they are off
pain medications.
Patients are advised to avoid all strenuous and aerobic activity
during the fi rst few weeks after surgery, including heavy lifting, stoop-
ing, straining and bending forward. They are allowed to begin light
exercise 2 weeks after surgery and gradually work up to their presurgi-
cal level of activity. 4–6 weeks after surgery they are allowed to engage
in more vigorous activities, including most sports, as tolerated.
CONCLUSION
Rejuvenation of the face is a considerable undertaking and its diffi culty
should not be underestimated. The procedure must be carefully
planned, meticulously carried out, and the patient’s safety and wellbe-
ing unfailingly ensured.
The opportunity to perform a facelift is a unique artistic privilege
granted to us by our patients that carries a signifi cant responsi-
bility. It deserves nothing less that our best effort and a few extra
hours of our time in the operating room benefi ts our patients for
the rest of their lives. The facelift procedure fulfi lls only part of our
obligation to the patient and the care patients receive perioperatively
is arguably as important as the surgery itself. Diligent perioperative
care will ensure the best result and reduce the likelihood of problems
and complications.
FURTHER READING
1. Marten TJ. Lamellar high SMAS face and midface lift. In: Foad N, ed.
The art of aesthetic surgery. St Louis: QMP; 2005:1110–1193.
2. Connell BF, Marten TJ. Mastery of plastic and reconstructive surgery.
Boston: Little Brown; 1994:1873–1902.
3. Marten TJ. Facelift. Planning and technique. Clin Plast Surg 1997
24(2):269–308.
4. Connell BF, Marten TJ. Deep layer techniques in cervico-facial
rejuvenation. Deep facelifting. Thieme Medical; 1994; 104(5):1521–
1523.
5. Marten TJ. Customized incisions in facial rejuvenation. Aesthetic Surg J
1999; 105(7):2620.
6. Connell BF; Marten TJ. Facelift for the active man. Instructional
courses in plastic surgery. St Louis: CV. Mosby; 1991:11–26.
7. Marten TJ. Secondary rejuvenation of the face. In: Mathes S, ed. Plastic
surgery. Philadelphia: Saunders-Elsevier; 2006:715–764.
8. Marten TJ. Periauricular face lift incisions and the auricular anchor.
Plast Reconstr Surg 1999:105(7).
9. Marten TJ. Cervical contouring in facelift. Aesthetic Surgery Journal
2003.
10. Marten TJ. Management of the full, obtuse neck. Aesthetic Surgery
Journal 2005; 25(4):105–111.
11. Marten TJ, ed. Facelift – state of the art. Seminars in Plastic Surgery
2002:(16)303–304.
12. Connell BF; Marten TJ. The submental crease and elimination of the
double chin Deformity at rhytidectomy. Aesthetic Surgery 1990:(10)10–
11.
13. Marten TJ. Maintenance facelift: early facelift for younger patients. In:
Marten TJ, ed. Facelift: state of the art. Seminars in Plastic Surgery 2002;
16(4):375–390.
14. Connell BF; Marten TJ. Surgical correction of the crow’s feet deformity.
Clin Plast Surg 1993; 20(2):295–302.
15. Connell BF, Marten TJ. Orbicularis oculi myoplasty: surgical treatment
of the crow’s feet deformity. Operative Techniques In: Plastic surgery.
Philadelphia: WB Saunders; 1995.
16. Marten TJ. Open foreheadplasty. In: Knize D, ed. The forehead and
temporal fossa: anatomy and technique. Philadelphia: Lippincott
Williams and Wilkins; 2001.
17. Marten TJ. Forehead aesthetics and pre-operative assessment of the
foreheadplasty patient. In: Knize D, ed. The forehead and temporal
fossa: anatomy and technique. Philadelphia: Lippincott Williams and
Wilkins; 2001.
18. Connell BF; Marten TJ. The male foreheadplasty – recognizing and
treating aging in the upper face. Clin Plast Surg 1991;18(4):653–687.
19. Marten TJ. Hairline lowering during foreheadplasty. Plast Reconstr Surg
1999;103(1):224–236.

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131
CHAPTER 10
Neck Rejuvenation
Patrick K Sullivan and Erik A Hoy
and skin. In the neck the SMAS blends with the platysma fascia to
form a continuous sheet.3 Here, signs of cervicofacial aging are initially
manifest as faint vertical platysmal bands overlying the thyroid carti-
lage and hyoid. These then progress to longer, more pronounced bands
as more support is lost from the retaining ligaments and the platysma
descends further.4 The laxity of the platysma causes a cervical obliq-
uity, which is compounded by supra- and subplatysmal fat deposits.
Subplatysmal fat can exacerbate the development of cervicomental
angle obliquity. Submandibular gland ptosis may contribute to cervical
fullness as well, supplying bulk laterally, below the angle of the man-
dible. The end result of these processes is a neck with a prematurely
aged appearance.
INDICATIONS
●
Young patient with an obtuse cervicomental angle
●
Neck as a prominent aspect of facial aging
●
Patients undergoing other aesthetic facial surgical procedures
that accentuate the neck laxity
Submandibular gland suspension
●
Glandular ptosis
Submandibular gland resection
●
Glandular hyperplasia5
Indications include young patients with a prematurely aged neck, or
patients with the neck as a prominent aspect of facial aging. Other
indications include those patients undergoing other aesthetic facial
surgical procedures which otherwise accentuate the neck laxity.
Submandibular fullness results from increased glandular ptosis
as muscular and fascial support of the gland weakens or glandular
hypertrophy. SMAS plication in rhytidectomy or platysmal suspension
may indirectly address this fullness because these techniques re-
establish fascial support, but they have not proven helpful long term.
However, residual submandibular gland ptosis often persists after
platysmal, cervical fat, and skin laxity surgical objectives have been
met, and tightening of the overlying tissues may accentuate the
deformity.
Patients with lesser degrees of submandibular gland fullness may
benefi t from suspension, whereas those with very signifi cant subman-
dibular gland ptosis or hypertrophy may be candidates for partial
resection.6 The idea of aesthetics as an indication for submandibular
gland resection, which is a technically challenging operation, is con-
troversial.2,7 The primary criticism for resecting the gland is the risk
of nerve injury. Prior to their widespread acceptance, SMAS-rhytidec-
tomy techniques were similarly criticized for their risk to the facial
nerve. Through multiple studies documenting the anatomy of the
Summary
1. Moderate to severe laxity of soft tissues in the submental
region may diminish with submental lipectomy, but most
likely will not be eliminated.
2. Redraping of these tissues can dramatically rejuvenate the
neck.
3. Key features of the aged neck include platysmal banding, pre
and subplatysmal fat deposits, skin laxity, protruding anterior
belly of the digastric muscle and submandibular gland ptosis.
4. Treatment of the platysmal banding may bring about a more
youthful cervicomental angle.
5. In selected patients, conservative contouring of subplatysmal
fat corrects submental fullness.
6. Submandibular gland resection or suspension is a technique to
address fullness below the mandible, which is the result of the
ptotic gland.
7. The submandibular glands can be approached safely, if the
surgeon is mindful of the detailed anatomy and vascular
supply in this region.
8. Not all these features are found in all patients requesting neck
rejuvenation, but one or more of the techniques are often
applicable.
9. A protruding anterior belly of the digastric muscles may have
to be resected in some patients.
10. As with most aesthetic procedures, patient selection is a key
aspect.
INTRODUCTION
Loss of neck contour, especially at the cervicomental and cervicoman-
dibular angles, is a common sign of aging. Procedures to rejuvenate
the face and neck are among the most commonly performed cosmetic
surgical procedures in the United States. The delineation of the cervi-
comandibular angle is an important factor in facial harmony and
an overall youthful appearance.1,2 Rejuvenation of the aging neck gives
a more pleasing appearance to the soft tissues in that area, and can
cause the face to appear more youthful as well. The goal is to provide
an even, smooth platysmal layer that closely invests the thyroid car-
tilage, hyoid, and fl oor of the mouth. Procedures to lift and redefi ne
the jaw line and submental region are often used as adjuncts to
rhytidectomy.
Anatomy and effects of aging
Traditionally, facial rejuvenation techniques have involved reposition-
ing of portions of the superfi cial musculoaponeurotic system (SMAS)

10
NECK REJUVENATION
132
facial nerve and refi ning the surgical approach to it, SMAS procedures
were accepted. Similar studies of the submandibular gland have been
undertaken, but controversies remain.4 All of the nerves in the area of
the gland, with the exception of the autonomic plexus, are found
exterior to its capsule.
Contraindications
Contraindications are similar to those for other elective aesthetic
procedures such as advanced cardiopulmonary dysfunction, bleeding
disorders, connective tissue diseases and wound healing problems.
PREOPERATIVE HISTORY AND
CONSIDERATIONS
After understanding the patient’s goals and expectations, the patient’s
face is assessed from the front and profi le views with the chin and face
held in repose and tilting down (reading position, as coined by Connell).
The skin, underlying layers of fat, and the submandibular glands are
palpated. The patient is asked to tighten the platysma by trying to
depress the corners of the mouth and the platysmal bands are observed.
If the neck bands become tighter by this type of animation, they are
dynamic bands and would respond favorably to surgery or injection of
botulinum toxin. If the bands do not become tighter, the skin folds
would require skin tightening. The anterior belly of the digastric
muscles are palpated to detect hypertrophy.
OPERATIVE APPROACH
Intravenous sedation and injection of lidocaine with 1 : 200 000 epi-
nephrine is suffi cient for most patients, even those who undergo partial
or complete removal of the submaxillary glands. The standard proto-
col includes a thorough betadine prep of the neck and oral cavity
followed by intraoral administration of local anesthesia to block the
area.
Neck exposure is gained through an inconspicuous 3.5 cm sub-
mental incision in the shadow posterior to the submental skin crease.
This allows access to the platysmal plane. Laterally the neck is
Fig. 10.1 Platysmal imbrication and redraping of the soft tissues of the neck. This technique tightens the platysma, and resuspends the soft
tissues of the submandibular and submental regions. The end result is a more acute cervicomental angle, giving a more youthful appearance
to the neck.
Platysmal imbrication and redraping of the soft tissues of the neck
Platysma sutured
edge to edge
in midline, 2 layers:
Platysmal release
improves neck contour
1st layer (deep)
Simple interrupted sutures
2nd layer (superficial)
Continuous running suture
Midline approached to neck contouring

Operative Approach
133
approached through a conventional pre- and posterior auricular rhyt-
idectomy incision, if rhytidectomy is part of the goal. This gives good
visualization along the inferior border of the mandible, and provides
an avenue for directly visualized suction lipectomy of the lateral neck.
SMAS suspension and platysmal plication
Rhytidectomy in conjunction with a neck lift can provide further sus-
pension of the soft tissues of the lateral neck. This is accomplished
by the changed vector that results from the transposition of a ver-
tical strip of preauricular SMAS to an anchor point in the retro-
auricular area. The lift is thereby changed from a vertical one to a
more attractive line along the angle of the mandible, with a hammock
effect.
● The anterior platysma is best approached by a transverse submen-
tal incision.
● The skin is then undermined caudal to the level of the cricoid or
beyond.
● To correct the effects of platysmal banding, the muscle is separated
in the midline and freed from the underlying subplatysmal fat and
anterior muscle bellies of the digastrics.
● The edges of the cut platysma are grasped and brought together
in the midline.
● The excess tissue is then resected and the edges reapproximated
with an interrupted or running suture (Fig. 10.1). Alternatively, the
platysmal borders are overlapped in vest-over-the-pants fashion.
Non-absorbable suture is used for the muscle repair.
● Platysmal muscle is released as low in the neck as possible using
cautery, if indicated. The muscle can then be allowed to redrape,
which provides for a deeper, more attractive cervicomental angle.
A release that is too caudal can result in window shading of the
platysma over the submandibular glands, or in denervation and
lower lip dysfunction.
Subplatysmal fat resection
● Subplatysmal fat can add considerable convexity to the cervico-
mental angle. The degree of subplatysmal fat is typically an inher-
ited feature, but may be a refl ection of total body fat.
● A subset of patients in whom the midline subplatysmal fat is the
only feature of aging in the cervicofacial area can benefi t from a
subplatysmal fat resection and platysmaplasty alone, requiring
Subplatysmal fat contouring
Platysma
Subplatysmal fat
Trachea
Strap muscles
Fig. 10.2 Subplatysmal fat contouring. The platysma is divided, providing access to deeper fat deposits in the submental region. These may
be resected via a midline incision, and along with plication of the platysma, can help restore a more youthful cervicomental contour.

10
NECK REJUVENATION
134
Submandibular gland procedures
Submandibular gland
capsule suture-suspended
to mandibular periosteum
Platysma
Facial artery and vein
Marginal mandibular nerve
Fig. 10.3 Submandibular gland procedures. In patients with submandibular glands apparent as lateral ovoid masses present in the neck,
glandular suspension or resection may be indicated. Here the approach to the gland and the suspension suture are presented.
only a submental incision.8 This has proved particularly benefi cial
in some young patients. The submental incision gives good expo-
sure medially, but most patients have additional aspects of the
aging neck that also require lateral approaches. Although some
patients benefi t from suction lipectomy alone,9 most benefi t from
platysmal procedures or subplatysmal fat resection.
● Cervicosubmental lipectomy is usually performed after SMAS lift,
when it is carried out concomitant with rhytidectomy and SMAS
suspension. The fat over the mandibular angle is contoured only
after the fi nal muscle position is set to prevent removal of fat from
an unintended portion of the jaw line. If this occurs, contour defor-
mities may be apparent on the face.
● Vertical separation of the platysmal decussation in the midline
allows visualization of the subplatysmal fat deposit (Fig. 10.2). The
fat interposed between the platysma and the anterior bellies of the
digastric muscles is conservatively resected with cautery. Open or
closed liposuction techniques may be useful adjuncts to neck con-
touring provided they are used selectively.10 Most cervical adipose
tissue is contoured using long facelift scissors.
● Some authors recommend resection of the anterior digastric muscle
bellies if there is residual fullness11,12 – the muscle is isolated and
gently detached from the caudal border of the mandible using
electrocautery. There is a well-defi ned plane between the anterior
belly of the digastric muscle and the mylohoid muscle leaving some
muscle fi bers on the bone. The anterior belly of the digastric
muscle is pulled caudally and the muscle is partially or completely
removed. Meticulous hemostasis is essential.
Submandibular gland suspension
and resection
● The neck is approached via a submental incision and dissection is
carried out beneath the platysma to the area where the subman-
dibular gland has been marked out preoperatively. This allows
direct visualization of the submandibular capsule.
● A vertical 1.5 cm capsular incision along the anterior-inferior
surface is made parallel to the body of the mandible.
● Careful dissection around the gland frees any inferior or lateral
capsular adhesions and allows intracapsular gland mobilization.
● A blunt clamp is inserted until the inferior border of the mandible
is encountered, and then is advanced subperiosteally along the
lingual aspect of the mandibular body. This is continued until the
oral mucosa tents over the instrument tip and a 2–3 mm incision
is carefully made with a number 15 scalpel.
● The tip is then delivered into the oral cavity and a 2-0 suture end
is brought back out through the neck.
● A second pass is then performed, also from within the glandular
capsule, but lateral to the gland. The periosteal tunnel created for
this suture is parallel to, but 3 cm anterior to the initial pass. The
opposite end of the free suture is grasped and pulled down into the
neck.
● After both ends of the suture have been pulled caudally, mild trac-
tion on the suture ensures adequate purchase of a sling of perios-

Operative Approach
135
teum to provide support for the gland. This is the zone of periosteal
adhesion.
● The gland is elevated to the level of the posterior belly of the
digastric muscle and the inferior border of the mandible with
gentle digital pressure (Fig. 10.3).
● The knot is cinched, tied, and the gland’s elevated position secured.
● After a durable suspension is obtained, the incised glandular
capsule is imbricated with permanent suture to bolster the suspen-
sion sling inferiorly.
● Hemostasis is verifi ed and the intraoral incision closed with a
chromic suture.
The medial to lateral approach to the gland is recommended because
it maximally avoids the marginal mandibular nerve, and allows a
caudal approach to the gland within the capsule.13 Trying to approach
the gland via the submental approach is technically diffi cult due to
limited access and the presence of variant blood supply.
A medial to lateral approach to the submandibular gland
maximally avoids the marginal mandibular nerve, and allows a
caudal approach to the gland within the capsule
Submandibular resection may be a diffi cult procedure, but can
produce dramatic results in selected patients. Codner and Nahai found
that submandibular resection was carried out more often in patients
undergoing secondary rather than primary rhytidectomies.11 The
resection can be done after careful isolation of the gland, ligation of
the facial branches entering the gland and Stenon’s duct. Partial
removal can be accomplished with electrocautery.
Submaxillary glands should not be removed from patients who
have xerostomia or who wear dentures.
Suction drains using TLS vacuum system may minimize the collec-
tion of blood or seromas in the neck.
Optimizing outcomes
●
Understand the patient’s objectives.
●
Obtain an accurate history and physical examination,
including preoperative photos on front and profi le views.
●
Pair the correct procedure to the fl aw to be addressed.
●
Clearly understand the anatomy, including neurovascular
structures to avoid, and techniques to reposition and redrape
the tissues of the neck.
●
Practice good surgical and anesthetic techniques, including
meticulous hemostasis and avoidance of hypertension
postoperatively.
●
Ensure postoperative follow-up and evaluate one’s results
critically and honestly (Fig. 10.4).
A
B
C
D
E
F
Fig. 10.4 59-year-old man with a
ptotic submandibular gland
before and after submandibular
suspension and neck
rejuvenation. A,C&E,
Preoperative views. B,D&F,
Postoperative views.
(Reproduced from Sullivan PK,
Freeman MB, Schmidt S.
Contouring the aging neck with
submandibular gland suspension.
Aesthetic Surgery Journal 2006;
26(4):465, with permission from
Elsevier)