Dissecting the Facelift

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Dissecting the

Facelift BB Publications


Dissecting the

Facelift First published in 2016 by BB Publications

Imprint: Beyond Black Physical products Š B.B. Publications 2016 All rights reserved. No part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of both the copyright owner and the publisher of this book. http://www.beyondblack.org ISBN 9781905904365 Designed by www.squareandcircus.co.uk

contents Preface 4 GLOSSARY 6 8

Introduction: Commonly asked Questions and Answers Timothy Marten, M.d. Dino Elyassnia, M.d.


The “Couture” Facelift: Custom Designed, Concealed Incision, High SMAS Facelift with Simultaneous Fat Grafting Timothy Marten, M.d


Rejuvenating the Face and Neck: A Natural Result Ramsey Alsarraf, Md, Mph


The contemporary facelift: Combining the strength of deep plane facelift with the softness of autologous fat grafting Dr. Jamil Asaria


The Evolution of Facelift Daniel C Baker, Md The Stem Cell- Enriched Face Lift Dr. Renato Calabria


Cutting edge face lift including eyelids, concentric malar lift, long lasting neck lift and lip lift Dr Claude Le Louarn


The Necklift 176 Alan Matarasso Md, Facs Sammy Sinno Md The Limited Dissection Composite Facelift: A Journey Inside The Operating Theatre Dr Bryan C MendelsON


A Measured Approach to Facelifting Henry A. Mentz, Md, Facs


The Biplanar Facelifting Procedure Dr Vladimir Mitz

200 204


Total Face Rejuvenation. My Face Lift Methodology: The Result Of 20 Years of Development Dr Frank Muggenthaler The Round-Block SMAS Facelift Dr Tomaz Nassif



The Anterior SMAS Approach for Facelifting and Midface Contouring Malcolm D. Paul, M.d., Facs


Face Lift: My Personal Technique Dr. Michel E. Pfulg


Endoscopic Assisted Biplanar and Triplanar Facial Rejuvenation Oscar Ramirez Md


The Natural Lift And Fill Face Lift: The Blending Of Science And Art In Facial Rejuvenation Rod J. Rohrich, M.d Smita R. Ramanadham, M.d


Mag-5: Upper And 106 Mid-Face Rejuvenation Dr Adil Ceydeli Dr Robert Flowers Dissecting The Face Lift: The Suture Suspension Scarless Face Lift Dr Des Fernandes


The Eye Lid Cheek Junction: Correction of a key point in Aging Sebastien Garson, Md



Aesthetic Surgery Is The Only Pschychological Surgery Dr Claude Le Louarn

Minimal Access Vertical Vector Extended Deep Plane Face Lifting: The M.a.d.e. Face Lift Creates More Natural, Rejuvenating And Long Lasting Results Andrew A. Jacono, M .D., Facs


Dissecting the Facelift

Preface U

nlike most forewords and prefaces that go largely unnoticed and seldom read, this one is very important for a number of reasons. To begin with, the reader must understand that the book is unique of its kind in that it offers prospective plastic surgery clients, for the first time ever, the scientific rather than the PR/marketing rationale for choosing a surgeon and/or a procedure, bridging the consumer and academic sides in the process. Secondly, the reader has to be aware of the concept and structure of the book – it is styled as individual essays by 20 participating surgeons who make a case for a specific technique they have developed and/or perfected/modified and published papers on. Surgeons are featured in alphabetical order. The book is conceived with the consumer in mind and at the same time, as a comparative point of reference for other plastic surgeons – highlighting the difference of approach outside of the medical symposia circuit. Indeed, there are today a number of different approaches to facelifting, some being variations (or a combination) of previously established surgical techniques, but virtually all offering the prospective patient a natural and lasting result. Plication, SMASectomy, High SMAS, thread lifts, suspension lifts, MACS lifts, lipolifting, etc. all challenge even the bestinformed consumer when it comes to making what is a hugely important decision. Thus, we frequently see individuals in the public eye, who have both the means and the access to information needed to choose well, sporting a post-operative look that amounts to a drastic transformation of their facial features or an operated appearance. The publisher’s role here is not to endorse this surgeon or that, but to equip the reader with the information needed to cut through the sales jargon and understand how different surgeons approach the facelift procedure; what their technique


consists of; what their philosophy is and how their sense of aesthetics influences the final result. The book features some of the best surgeons in the world today, if not necessarily the best known to the average consumer, even though the internet and the proliferation of special subject forums have gone a long way to providing information. Sadly, information is often misused and manipulated and so we see average and occasionally incompetent practitioners’ results on top of search engines, on TV and on youtube, hosting celebrity programs or being drafted in as pundits simply because they have invested in clever marketing and PR. The rationale for publishing this book is simple: having worked on a number of plastic surgery projects, we have realised that: • The overwhelming majority of patients have no idea what the selected procedure consists of. They go to a plastic surgeon to correct a real or perceived defect or to counter the effects of aging. Quite how the surgeon would arrive at the result is mostly shrouded in mystery (often, this is the surgeon’s intention, but mostly it is the patient’s lack of interest or understanding of the surgical procedures). • Prospective patients/clients look online when they research surgeons or rely on recommendations that may be flawed for a number of reasons, not least because no two patients are the same. • This brings us to the marketing ploys used by a vast multitude of plastic surgeons to capitalise on booming market demand. Offering ever more creative acronyms, labels and descriptions of their approach; vaguely or openly suggesting they have operated on well-known personalities; using highly paid PR firms to promote them on social media, TV, forums and across glossy magazine; publishing cleverly manipulated before and after pictures and citing paid-for awards given by unscrupulous publications, are just some of the baits utilized to reel in the uninformed consumer. • Lastly and quite crucially, although plastic

surgery techniques, at their most basic, do not differ vastly from one good/qualified surgeon to the next, there are a number of very important differences between these techniques and consequently, between down time, results and their longevity.

The concept for this book has evolved over time and in the process of meeting and having conversations with different surgeons, all of whom are at the top of their game and continuously perfecting their techniques or coming up with new procedures. Facelift procedures have changed considerably since the introduction of the subfacial dissection by Tord Skoog (Mitz and Peyronie described the anatomical SMAS in 1974). Additionally, our collective sense of aesthetics has evolved and continues to do so, with patients preferring a more natural and timeless beauty v. over-enhanced features. Harmonious, measured and subtle rejuvenation is the norm today. Plastic surgery can of course enhance one’s beauty or make someone more classically beautiful, changing them from a fairly ordinary face in the crowd to someone outstandingly attractive. Patients/clients who are interested in perfecting their appearance should take special care to consider if the surgeon’s aesthetic judgement fits their expectations. Plastic surgery evolves incrementally, with the occasional paradigm shift transforming a given procedure/set of procedures or making it obsolete (for example, the discovery and wide use of Botox has led to the quasi-obsolescence of the endoscopic brow lift). In the end, the skill of your surgeon and his familiarity with a particular procedure – rather than the prowess of his PR team – are the most important factors in predetermining the outcome. It follows without saying that a surgeon who has changed, developed, perfected/adapted or even created an innovative approach, is the best placed to carry out the procedure requiring that particular approach.

As with previous publications on elective surgery, we have sought to invite some if not every single one of the best plastic surgeons in the world. As a matter of fact, if all were to participate, the book would be too long and at times repetitive. Our selection has not been arbitrary or commercially motivated as is so often the case with countless books and periodicals on the market. The surgeons we have invited to participate are recognised for their outstanding achievements, lecture/teach on the global academic circuit, and are household names (in some cases iconic names) in the field of plastic surgery. Their websites – if they have any – might not come on top of Google searches and their success is not measured in number of TV appearances. These are ‘surgeons’ surgeons’.


• An informed would-be patient/client can tailor their budget and expectations accordingly. As with everything in life, we get what we pay for and “kiss-me-quick”, conveyor belt procedures that cost relatively little have results to match. One caveat here: some of these procedures are actually disastrous if performed by unqualified/little qualified or unscrupulous practitioners and hard to correct to boot.

About the participating surgeons

The order of chapters in the book has no particular significance – each text has been positioned in geographical order starting with the USA simply because it has a higher number of prominent surgeons than a single European country (there is no implication here that US surgeons are necessarily better than their European counterparts, for example). We have started with Dr Timothy Marten’s text because it addresses the core questions patients may have in Q&A style and explains at length some of the more complex terminology. Consequently, his text is longer than other surgeons’. The length of the texts is not significant – some surgeons, who have published extensively on their approach and procedure (and indeed, coined a term), have limited themselves to an overview. Others have gone into great anatomical detail and we have added a customized drawing on every page to help the non-medically trained leader to follow the text. We have also added a glossary which will serve a similar purpose. This book does not constitute endorsement of this technique or that or of a particular surgeon over another. The prospective patient/client should use the information therein to make the best-informed decision about a surgery that will have a very considerable and lasting impact on their personal and professional life, as well as on their perception of self.


Dissecting the Facelift


Auricular – related to ear or hearing Canthopexy - A surgical procedure designed to tighten the lower eyelid by shortening supporting structures at the lateral canthus (lateral canthal tendon or lateral retinaculum) Corrugator - The corrugator supercilii is a small, narrow, pyramidal muscle close to the eye. It is located at the medial end of the eyebrow Deep cervical fascia - The deep cervical fascia (or fascia colli in older texts) lies under cover of the Platysma, and invests the neck; Dermis - the vascular, thick layer of the skin lying below the epidermis and above the superficial fascia Dissecting plane – the anatomical location of the dissection Flap – a layer of tissue Hemostasis - the stopping of a flow of blood


Melo-labial/naso-labial - The folds from the side of your nose to the side of the mouth downward towards the sides of the chin Orbicularis oculi muscle - The orbicularis oculi is a muscle in the face that closes the eyelids. Orbicularis oris muscle - a complex of muscles in the lips that encircles the mouth Orbiculo-Zygomaticus- levator labiiplastysma pexy (see figure) Platysma – a broad thin layer of muscle that is situated on each side of the neck immediately under the superficial fascia Platysmaplasty - A platysmaplasty is an operation of the muscle of the neck called the platysma. Typically a platysmaplasty is used to treat a sagging neck.The operation removes the excess platysma and tightens the muscle much like a corset in order to improve the angle from the chin to the neck.

Mandibular – pertaining to the chin (mandible = chin)

Tragus - ear

Melo-labial/naso-labial - The folds from the side of your nose to the side of the mouth

Tragal – pertaining to the ear/ Post or pretragal – behind or in front of the ear

Mastoid bone - the temporal bone behind the ear at the base of the skull Masseter – the muscle of mastication (chewing)

SMAS - Superficial muscular aponeurotic system (SMAS) is an area of musculature of the face. This muscular system is manipulated during facial cosmetic surgery

Masseteric-cutaneous ligament – supporting ligament in the area of the masseter

SMAS plication – the technique of folding the tissues

Masseteric fascia - The masseteric fascia (parotideomasseteric fascia) is a strong layer of fascia derived from the deep cervical fascia on the human head and neck. It covers the masseter, and is firmly connected to it. Above, this fascia is attached to the lower border of the zygomatic arch

Smasectomy - removal of a strip of SMAS tissue Subcutaneous – fatty area just under the skin Subdermal – under the skin Submental – under the chin


Supra-mimetic – muscles that control facial expression Ptosis – sagging Undermining - Undermining is a term that describes the act of using scissors or another instrument to go through layers of tissue, underneath the skin, in order to gain access so they can be manipulated. It’s a standard part of any variation of a face lift Zygomatic arch - The zygomatic arch or cheek bone is formed by the zygomatic process of temporal bone (a bone extending forward from the side of the skull, over the opening of the ear) and the temporal process of the zygomatic bone (the side of the cheekbone)


AESTHETIC SURGERY is the only psychological surgery

Dr Claude Le Louarn

Dr Claude Le Louarn Plastic surgeon President 2010 Société Française Chirurgie Plastique Reconstrutrice 59 rue Spontini Paris + 33 1 45532717 www.lelouarn.net



n today’s world we see thousands more face and body images in one day than we did in a lifetime 50 years ago. Our life span has increased too and with it has the demand for aesthetic improvements and rejuvenation. In the past an individual was defined by their pedigree first. Today appearance is more important and has becomes an essential “business card” of sorts. It is the reason why having one’s own appearance surgically enhanced may well be the most advanced expression of one’s personality. To complicate matters, we want to conceal the evidence of any surgical intervention, yet we want the results to be admired. Consequently, surgical techniques need to keep ahead of the curve of general awareness – just like juiced up athletes need to stay ahead of anti-doping control. For surgeons, being able to define beauty and understanding the beauty criteria in timeless terms is mandatory before even considering performing any aesthetic procedure. This is because beauty is both relative and subjective. In the 50’s, the ideal of beauty was defined by the art nouveau style of the likes of Christian Dior and Yves Saint Laurent; the 2016 definition is informed by contemporary giants of the fashion industry such as John Galliano and his peers. The canons of beauty may have been defined as far back as antiquity, but they are constantly modified and updated with time. Thus, we went from the boisterous blonde of the 19 century - symbol of sufficient nourishment to the worked-out body of the 21 century - a symbol of healthy nourishment combined with fitness training. We surgeons have a moral obligation to mitigate the risk of creating a class of ultra-wealthy patients who turn into aesthetic mutants, simply because they are in a position to fund multiple interventions. The aesthetic mutant, that is to say an individual whose appearance is vastly different from that of the rest, is not a new phenomenon. It could be argued that the French aristocrats of 1789 contributed to the disgruntlement of the disenfranchised revolutionaries by branding themselves as a class apart with their white powdered faces and giant wigs.

Claude Le Louarn 9

The only aim of aesthetic surgery is happiness, well being. Like the only aim of philosophy is not science but happiness.

As surgeons we have an obligation to guide our patients towards a harmonious and natural appearance. Beauty is not a fashion parade - we must avoid creating identikit individuals with Brazilian buttocks, almond shaped “Asian” eyes, African mouths, American boobs, French legs, Swedish fitness bodies, etc. This multi-ethnic beauty is unattainable but for the 1%. What is more, those within the 1% subscribing to the beauty ideal of the day would be forever “dated” by their decision. Today, a short upturned nose and big siliconeenhanced lips betray a surgical choice made some 10 to 20 years ago. An easy way to conceal mid-face aging is to augment it with a filler or fat injections, but this would result in puffiness later on. The only way to address mid-face aging without this side effect further down the line is to perform a mid-face lift. We must always advise our patients that long term beauty is a better option than up-to-date beauty. If everyone agrees that beauty is subjective, how do we then explain that people from different ages, sex, social standing and nationality all agree that Marilyn Monroe, Brigitte Bardot or Audrey Hepburn were unanimously considered as beautiful? In 1979 Symons published a theory that beauty was the mean of all the faces or bodies seen in a lifetime. Fortunately, if mean faces are interesting, very interesting faces are not mean. Another theory proposed by Magro develops the argument that the universal interest in a specific type of beauty is due to exaggerated anatomical characteristics that we see for instance in the Barbie doll – far removed from the ape appearance, so as to maintain the species barrier.


I would argue that the aim of aesthetic surgery is not simply the pursuit of aesthetic beauty but rather, the pursuit of happiness and wellbeing – just as the aim of philosophy is not the advancement of science but achieving a state of serenity/wellbeing. A surgeon’s job is to find a compromise between what a patient expects/what would make them happy on one hand and what the surgeons can technically perform – as well as what is aesthetically acceptable both in the short and long term. It follows then that aesthetic surgery is not simply consumer-driven, but is the surgical expression of treating a problem that has everything to do with self-image. One of the main goals of aesthetic surgery is to achieve a result that looks natural.This should make surgery unnoticeable, meaning that it should be impossible for the public to differentiate between an operated individual and a “natural” one – something that’s not stillalwaysthe case at present. The aim of aesthetic surgery – an aim that is still a work in progress – is to become so unnoticeable, in fact, that it frees the patient from having to make the choice between having it done or not. In some parts of the world obvious signs of aesthetic surgery are a validation of the patient’s wealth – is this going to become a trend or will discreet refinement remain the norm?

Dr Claude Le Louarn

Aesthetic surgery is unique. AND Here is why: DISSECTING THE FACELIFT

1) Of all surgical procedures, Aesthetic Surgery is technologically the most simple. All other surgical interventions require 3D localization, microscope, laser, automatic suture system, and some form of cutting edge technology. Aesthetic surgery needs a needle and a thread, that’s all. To the proponents of this notion, I would like to say: yes, that, plus the surgeon’s intelligence and skill. For every few seconds, your surgeon has to make a choice about the dissection plane, the vector of traction, the type of thread… In aesthetic surgery, intelligence and adaptability make all the difference. The most sophisticated of today’s aesthetic surgery procedures could have been performed eight centuries ago, had humanity been familiar with hygiene and a bit of anesthesia, requiring just needle, thread and a competent surgeon.

Claude Le Louarn

2) Aesthetic surgery is the most creative surgery Creativity in other types of surgery is mainly linked to new material, technology, or a new application of the existing technology In Aesthetic surgery, creativity is only linked to the intelligence of your surgeon. Creativity is essential for two reasons: - to adapt the technique to the patient’s specific case Example: adapting the technique to the specific patient’s case means considering the tissues’ strength, elasticity, disposition, resistance, vascularization…. A facelift that’s very tense can be efficient on your marionette fold, but very thin skin would show the lines of tension: less tension, with a direct action on the marionette fold (no need to tense the skin), and a thin superficial layer of fat reinjection would be more appropriate in this case. - to advance, that is to say to find new solutions to old limitations; to achieve more natural results of longer duration and to decrease complications and reasons to re-operate. Example: Mid face is never improved even with the most efficient, sophisticated facelift. Consequently, two options are proposed:



Aesthetic Surgery is the most challenging surgery for a surgeon. All other surgical procedures are difficult, refined, demanding, but the only key point is functionality. For instance, when a gastrectomy, breast tumor removal, or a hip prosthesis are performed, the outcome is good if: the tumor has been completely removed; the angle of flexion of the hip is in the good range;

Claude Le Louarn

3) Excellence and refinement are the aims of aesthetic surgery

the gastrectomy is functionally satisfactory. All these procedures restore function. When we perform a facelift surgery, on the other hand, not only do we need to remove a quantity of skin, but we also we need to achieve a harmonious result. A good result is simply not sufficient: an excellent result is expected by the patient from the plastic surgeon. If we remove the hump off a nose, not only does the nose have to be straighter, but it has to fit within the face as a whole, creating a new harmony with it. Of course perfection cannot be a proposed result, but excellence must always be our aim. A patient is perfectly able to see the difference between an average result of an aesthetic surgery procedure and an excellent/refined one. A patient cannot see any difference between an average, functionally correct result and an excellent result of a hip prosthesis, gastric tumorectomy or frontal glioma excision. The main reason being: this type of surgical procedure is not visible. That said, most surgeons are excellent and even if an excellent surgeon achieves in one day one average and one good result, the difference between the two would not be visible.


a. fat grafting to fill the depressions of the midface. However, the volume of fat could be insufficient or excessive, in addition to which, there may be no volume loss in the area and thus, no real reason to add any; b. the midface lift, which will relocate each malpositioned volume to its youthful and original position (nasolabial volume, malar mound, palbebral/eye socket bags). This technique was, however, a source of too many complications and nearly abandoned until the arrival of the last version, or the concentric malar lift with barbed sutures. All this has a very interesting consequence: creativity is subjective in aesthetic surgery because it is based on the surgeon’s personal aesthetic judgement.


introduction Commonly asked Questions and Answers by Timothy Marten, M.D. Dino Elyassnia, M.D.

Excerpted from A Patient’s Guide to Facelift Surgery and used with permission

Timothy Marten, MD, FACS 450 Sutter St, Suite 2222 San Francisco (415) 677-9937 www.martenclinic.com



his chapter has been put together to answer commonly asked questions regarding facelift surgery and related procedures and to provide you with the information you need to make informed choices regarding surgery to rejuvenate the face. The decision to undergo plastic surgery is an important one and plastic surgery of the face warrants specialized care performed by a specially trained and experienced surgeon. The information contained herein are views as expressed by Timothy Marten, MD and Dino Elyassnia, MD and are not intended to constitute definitive or complete descriptions of the procedures they perform, nor specific medical advice. Information applicable to specific individuals can only be provided after consultation and appropriate examination. Individual outcomes of procedures vary and photographic examples of surgical results are presented for the purposes of illustration and education only and do not represent a warranty of any kind.

Marten & Elyassnia

What is a facelift and how is a facelift performed? In simplest terms, a contemporary facelift is an operation that repositions the skin, muscle, and fat in the cheek and jawline area that has sagged as a result of time and gravity, and removes the excess skin that has accumulated as a result of aging, facial movement, and skin stretching. Is a facelift performed the same way for every patient? It is not possible to design a “universal” facelift technique. Each patient will present with a unique set of problems that require precise diagnosis and an appropriately planned and individualized surgical repair. Plastic surgeons who treat all patients the same and use a “cookie cutter” approach fail to recognize this fact and are destined to produce inferior outcomes. Committed study, careful planning, and a custom designed, detailed and meticulously performed “couture” procedure that address the anatomic basis of each patient’s problems will maximize improvement, produce the best and most natural outcomes, and limit potential problems and complications.


How has the way facelifts are performed changed? Traditional facelift techniques have relied upon the tightening of aging skin to elevate and support sagging deeper facial tissue. Although initial results from these procedures sometimes appear good, early recurrence of facial sagging is common and poor scars, earlobe mal-position, and healing problems are frequently seen. These “one layer” “skin only” procedures also typically produce an easily recognized tight or “face lifted” appearance that is usually made worse when subsequent procedures were performed. As plastic surgeons have pursued improved outcomes our understanding of the aging process has grown and facelift techniques have evolved. Experience has since shown that an attractive and natural appearing facelift result is not possible without diverting tension away from the skin to deeper tissue layers of the face. For most patients an improved result is also obtained if scars are placed inconspicuously along natural anatomic interfaces, the facelift is designed to include correction of the aging mid-face (upper cheek and under-eye area), and age related loss of facial fat is concomitantly corrected with fat grafting (“fat injections”), or by other means. These three milestones – performing the facelift in two layers instead of one to divert tension away from the skin to deeper layers of the face and to avoid a tight or “pulled” appearance, placing the incisions in a concealed location so they cannot be


easily seen, and adding fat grafting to offset age related loss of facial fat and soften the face – form the foundation of the modern “facelift” procedures now performed by surgeons with a special interest in rejuvenating the aging face. Why do so many facelifts look tight and unnatural or like nothing was done? The fundamental flaw with traditional “skin only” “one layer” facelifts, “mini-lifts” and other procedures typically performed by many surgeons is the fact that skin was meant to serve a covering function and not a structural or supporting one. Skin is inherently elastic and was intended to stretch and move as we express ourselves. It was not intended to support sagging muscle, fat and other structures lying underneath it. Attempts to use skin to support sagging deep layer tissue corrupts its covering function and results in abnormal skin tension and related problems including poor scar formation, distortion of ear anatomy, earlobe malposition, and a tight and unnatural appearance. In addition, because skin is inherently elastic and not capable of providing a sustained support of deep facial tissues the results of most “skin only” “onelayer” facelifts and “mini-lifts” are usually short lived (Fig 1 A). It is important to remember that while we all notice poorly performed facelifts that look tight and unnatural, the well performed ones leave no telltale signs that surgery has been performed and look non-surgical and natural.




Marten & Elyassnia

Fig 1 AB. Skin only vs SMAS Facelift. A) Patient after skin only facelift performed by an unknown surgeon (note visible scar in front of the ear). Despite having a previous facelift her cheek is sagging, a heavy jowl is present, a heavy nasolabial fold (line from corner of nose to corner of mouth) is visible, the corners of the mouth are sagging, and neck laxity can be seen. The skin only facelift has failed her and she still has an elderly appearance. B) Same patient after SMAS facelift, forehead lift, and neck lift. The patient’s facial contour has been markedly improved, her cheek contour is improved, the posture of her mouth has improved, a clean jawline is present, and her neckline is improved. She has a soft natural appearance without a tight or pulled appearance. All surgical procedures seen in Fig 1 B performed by Timothy Marten, MD, FACS. Courtesy of the Marten Clinic of Plastic Surgery


How can a tight and unnatural look be avoided? Directly below the skin and facial fat layer (“subcutaneous fat”) lies a firm, inelastic, fibrous layer known as the superficial muscluoaponeurotic system. This layer is usually referred to by the acronym “SMAS” and it is most conveniently thought of as a thin, flat, firm, inelastic structural layer that lies on top of, and is attached to, the muscles and fat of the face. The name is not as important as understanding that this layer can be used to lift sagging facial muscles and fat back up where they once were in their natural arrangement without pulling on the skin. Using the SMAS to lift sagging facial tissues and to restore facial contour avoids the problems


associated with procedures in which skin is tightened. This is because the SMAS is a firm, inelastic structural layer capable of providing meaningful and sustained support. Although skin must be removed in SMAS procedures, only skin that is truly redundant is sacrificed, and closure of incisions can be made under normal skin tension. Facial skin so treated will distribute itself naturally over newly created contours and is capable of selfrepair and contraction. This “two layer” approach averts a tight or “lifted” appearance and is felt by many plastic surgeons to comprise the most important advance in facelift surgery since its inception (Fig 2 B and Fig 1B ).

After Fig 2 AB. SMAS Facelift. Using the SMAS layer to lift sagging facial tissues avoids the problems associated with procedures in which skin is tightened as the SMAS is a firm, inelastic structural layer capable of providing meaningful and sustained support. Although skin must be removed in SMAS procedures, only skin that is truly redundant is sacrificed, and closure of incisions can be made under normal skin tension. This “two layer” approach averts a tight or “lifted” appearance and is felt by many plastic surgeons to comprise the most important advance in facelift surgery since its inception. All surgical procedures performed by Timothy Marten, MD, FACS Courtesy of the Marten Clinic of Plastic Surgery


Why do so many facelifts seem to produce only temporary improvement? The majority of facelifts performed today are performed as “one layer” procedures in which a misguided attempt is made to lift sagging facial fat and muscles by tightening the skin or by placing suspension sutures only. When this is done the patient will initially appear improved, but because skin relaxes and suspension sutures eventually cut or tear through tissue, initial improvement seen is quickly lost.

Is there a permanent benefit from a SMAS facelift? Yes, but facelift surgery only turns back the clock and does not stop it. That said, if a person has an identical twin and she or he had a facelift and their twin did not, they would both continue to age but the twin having the surgery would look better than the twin who did not for the rest of their lives, even if no additional surgery was ever performed.

Marten & Elyassnia

How long will a SMAS facelift last? It is not possible to provide a precise answer to this question as everyone has their own genetically determined rate at which they age, and this will be affected by dietary and lifestyle factors. In general, fair skinned, blue-eyed northern Europeans do not age as well dark-eyed individuals of Mediterranean ancestry, and people of Asian and African ancestry tend to age better than dark skinned Caucasians. The rate at which one ages will also vary depending on whether one smokes or not, how much alcohol one drinks, and how much sun one is exposed to. It

How long a facelift lasts is also very much dependent on how it is done. If the procedure consists only of a “one layer” tightening of the skin or suspension suture placement patients often find they need the procedure repeated as soon as a few years thereafter. If the facelift is performed in two layers and elevation of sagging facial fat and muscles is achieved by lifting the deeper SMAS layer and not the skin, the lifespan of the facelift is often tripled or quadrupled, and for many patients is extended to the 10 to 15 yr range. Not all surgeons choose to use the SMAS layer in the same ways however, and some methods are more effective than others.


Is there a way of performing a facelift so that it lasts longer? Using the SMAS, the firm, fibrous, inelastic layer lying under the skin, to elevate sagging facial tissues and to create contour in the face and neck areas provides a scheme in which sustained support can be obtained from non-elastic, strong, structural tissue, and one in which tension can be transferred away from the skin. Diverting tension away from the skin and to the SMAS results in a soft, natural facial appearance, high quality scars, and markedly improves the lifespan of improvement obtained. Diverting tension to the SMAS and away from the skin also prevents ear and ear lobe distortion, and minimizes displacement of temple and sideburn hairlines. In addition, unlike “skin only” facelifts and “mini-lifts” in which subsequent procedures worsen skin tightness and problems associated with it, SMAS facelifts can theoretically be repeated as often as needed without producing skin tightness and abnormal appearances. This removes the “two facelift limit” set by many surgeons performing skin only procedures, and allows patients to undergo procedures at an earlier age and more frequently, if desired.

is also true that everyone has their own definition of when their procedure needs to be repeated, and a model or actor will typically return sooner that the average person undergoing the procedure.

What is a “mid-face” lift? The mid-face is a medical term for an inverted triangular area situated in the upper cheek and under eye area that encloses a specialized collection of fat referred to as the “malar fat pad”. In healthy, youthful appearing individuals this area is full and makes a smooth transition into the lower eyelid. As one ages however, and as men and women enter their early mid-life and beyond, there is generally a deflation and loss of volume from this area. Over time this results in a loss of the smooth transition for lower eyelid to cheek and, eventually, in an ill, haggard, and aged appearance. Mid-face deflation is felt by some surgeons to also be accompanied by drooping of mid-face tissues (medically known as “mid-face ptosis”), and this largely erroneous assumption has led to procedures in which an attempt is made to lift the mid-face area and the malar fat pad, rather than fill it which is usually the more appropriate treatment.


The recognition of mid-face deflation as a significant 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 mid-face region, has led to a variety of procedures designed to specifically target the mid-face area. Some of these techniques are still being performed in conjunction with facelift or lower eyelid surgeries. Why are fewer mid-face lifts being performed? Although there is merit in the idea of rejuvenating the mid-face, isolated mid-face lift procedures have failed to produce the improvement hoped for and have largely been abandoned. Most procedures have a steep learning curve and have been fraught with complications including eyelid retraction (pulling down of the eyelid), eyelid eversion (turning out of the eyelid), canthal displacement (change in shape of the eye), and dry eye problems. As a result, many mid-face lift techniques have come to incorporate potentially problematic aggressive adjunctive surgical maneuvers (“canthotomy”, “canthoplasty”, and orbicularis oculi muscle suspensions) to prevent these problems from occurring. These maneuvers often result in a “changed look” that is disturbing to many patients however, and carry a high risk of significant and troublesome complications of their own. In the end analysis most mid-face lifts are conceptually flawed in that they erroneously assume the problem seen in the aging upper cheek and under-eye area to be solely one of sagging of the malar (upper cheek) fat pad. Failure to acknowledge the fact that malar fat atrophy (deflation) is present to a significant degree in most cases 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 appears questionable however, that these procedures can produce a restoration of lost volume as simply, naturally, and effectively as can be obtained with fat injections (see discussion that follows).


Does lifting the SMAS lift the mid-face? The conventional cheek SMAS flap and SMAS plication (suture tightening) procedures suffer the drawback that they cannot, by design, have an impact on tissues of the mid-face and under eye areas. Typical “low” SMAS flap designs target the lower cheek and jowl only and produce little if any improvement in the upper cheek area. Planning the flap "higher" in the cheek overcomes this problem, and produces a more balanced and comprehensive imporvment (Fig 3 ABCD - illustration). Benefits of a high SMAS plan include restoration of youthful upper cheek contour, an aesthetically significant fill of the under eye area, increased support of the lower eyelid and improved correction of the “nasolabial” (cheek) fold, and these benefits can be obtained without the need to perform a separate mid-face lift procedure. High SMAS procedures are also readily combined with mid-face fat grafting (“fat injections”) since surgical dissection is not made in the mid-face and under eye area when a “high SMAS” operation is performed. This averts the need to perform complex and potentially problematic procedures in which eyelid fat is transposed, or “reset”. Only a “high SMAS” strategy incorporates all these advantages. What is the best way to use the SMAS? A number of specific strategies have been devised for utilization of the SMAS. These include “composite” procedures in which the SMAS and skin are elevated as a single, one layer unit and advanced in the same direction and two layered “lamellar” procedures in which skin and SMAS are elevated as separate layers and advanced “bi-directionally” in different directions. Composite type dissections have the purported advantage that they are quicker to perform. These procedures have the distinct disadvantage however, that skin and SMAS layers must be advanced the same amount, in the same direction, and suspended under more or less the same amount of tension. Because skin and SMAS age at different rates and in different directions however, optimal treatment of each layer is generally not possible when one layer composite techniques are used, and skin over-shifting, skin over-tightening, hairline





mid-face and corner of mouth improvement

upper border of SMAS flap “high”




no mid-face or corner of mouth improvement

upper border of SMAS flap “low”


displacement, ”wrinkle shift” from the neck to the cheek, and other objectionable occurrences and unnatural appearances can result. Two layer “lamellar” procedures offer the distinct advantage that skin and SMAS can be advanced different amounts, in different directions, and suspended under differential tension as circumstances indicate. This allows each layer to be addressed individually as needed and appropriate, while skin tension, hairline displacement, and objectionable “wrinkle shifts” can be avoided. This in turn results in a more natural appearance, and

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Fig 3 ABCD “High” and “Low” SMAS Techniques Compared. A) Plan Low“High” SMAS Note that upper border of the flap lies below the Fig for 3 ABCD andprocedure. “Low” SMAS Techniques Compared . A) Plan for Low SMAS procedure. Note that upper border of the flap lies below the cheek bone arch cheek bone arch B) Low SMAS flap after dissection and suspension. Area of flap effect (green solid circle) is limited to the lower cheek and jowl and no improvement is obtained in the Patient’s Guide to Facelift Surgery Timothy Marten, MD, FACS © mid-face, under-eye, or corner of the mouth regions (black dashed circle). 450 Sutter St Suite 2222 San Francisco (415) 677-9937 C) Plan for High SMAS procedure. Note that upper border of the flap lies over the cheek bone arch. D) High SMAS flap after dissection and suspension. Area of flap effect (green solid circle) includes not only the cheek and jowl, but the mid-face, under-eye, and corner of the mouth regions (black dashed circle) as well.

avoids telltale irregularities seen when composite techniques are used. “Lamellar” techniques suffer the drawback that the procedure is technically more demanding and time consuming to perform. Why don’t all plastic surgeons perform a SMAS facelift? Although SMAS procedures have revolutionized how facelifts are performed and allow plastic surgeons to produce natural appearing, long-lasting outcomes unobtainable by other means, they are time consuming, require special training, and a


detailed knowledge of the anatomy of the face. As such many surgeons don’t know how to perform these procedures, don’t perform them often enough to become proficient in the technique, or don’t want to take the extra time required to perform them properly. Are SMAS procedures more dangerous than simpler facelift procedures? Some surgeons have made this claim but they are typically non-plastic surgeons who are not trained in how to perform the procedure, and there is no evidence to support these claims. In fact, the available evidence suggests that complications are actually fewer when SMAS procedures are performed, and this is thought to be due to the fact that SMAS procedures are generally performed by more experienced surgeons. I know some people who say they had a SMAS lift, but it didn’t last very long and I don’t think they look very natural. Why is this? Many surgeons know that patients are looking for surgeons who use this technique and some stretch the truth about actually performing it. Others will dissect the SMAS layer timidly and inadequately to properly release it and obtain the desired benefit, but feel they are warranted in referring to the surgery as a SMAS procedure. In these and similar situations, tension is not transferred off the skin to the SMAS layer and the procedures amount to little more that an old fashion one layer “skin lift. What is a SMAS “plication” or “imbrication” facelift? SMAS “plication” and “imbrication” are procedures in which the SMAS layer is not dissected as a separate flap and is simply folded or bunched up upon itself with sutures. Advantages of plication and imbrication are that they are quick to perform and can be performed more easily by surgeons who have not been formally trained in facelift surgery. These procedures also conserve volume in the face and as such are better for patients with thin faces who might be made worse with a procedure in which tissue is removed. Disadvantages are that plication and imbrication procedures can make fuller faces rounder and tissue is gathered in the


lower face rather than redistributed the upper cheek as it is with SMAS flap procedures. These procedures also create a suture line in an exposed part of the cheek where any irregularity can show through the skin. When does someone need a facelift, or some other procedures to rejuvenate the face? Recognizing the changes that occur with age and appreciating the underlying anatomical abnormalities is essential to choosing appropriate treatment. Careful analysis will reveal that most changes will fall into three broad categories: 1) aging and breakdown of the skin surface, 2) facial sagging, skin redundancy, and loss of youthful facial contour, and 3) facial atrophy (deflation and wasting) and age related loss of facial fat. Proper treatment will depend upon the types of problems present, the patient’s priorities, and the time, trouble and expense the patient is willing to go to obtain the desired improvement. Patients primarily concerned with surface aging of their face may not require formal open surgery and may achieve the type of improvement they desire through salon care and dermatologic surface treatments of the skin. These treatments include skin peels, skin resurfacing, Botox injections, “fillers” (Restylane, Juviderm, etc), and various forms of 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 achieve unsatisfactory improvement however, if surface treatments only are employed. They will require formal surgical lifts in which sagging tissue is repositioned and redundant tissue is removed if these problems are to be properly corrected and attractive and natural appearing improvement is to be obtained. The misapplication of surface treatments of the skin to the sagging face with excess tissue will produce little more than a smooth saggy face with no improvement in contour. This “smooth-saggy look”, typically seen in the older patient who has undergone laser resurfacing, is inconsistent with a natural appearance as patients with loss of facial contour generally also have concomitant skin surface aging. It is arguably more attractive and natural appearing to have a

well-contoured (lifted) face with a few wrinkles and surface imperfections, than an artificially smooth but saggy one.

Does a facelift help the forehead, eyes, and neck? The term “facelift” is misleading in the sense that most people think of their face as including the forehead, eyes, and neck. The facelift operation technically is a lift of the cheek, corner of the mouth and the jawline areas only however, and separate procedures are needed to address aging in the forehead, eyes, and neck, if problems are present in these areas. Many patients who undergo facelift surgery also have surgery on their forehead, eyes, and neck, and as a matter of convenience use the term “facelift” to refer to this group of procedures.


Many, if not most, of the changes associated with loss of facial contour represent primarily “deep layer” problems that will be inadequately corrected with traditional one layer “skin only” or “low SMAS” techniques however. Regrettably, surgeons unfamiliar with deep layer techniques often employ “skin only” facelifts or “mini-lifts”, and resort to misguided and misapplied ancillary procedures to overcome the shortcomings of these methods. These procedures include facial liposuction, “buccal” (deep cheek) fat extraction, cheek implant placement, “pre-jowl” implant placement, “Gortex” strip implantation, and various types of suspension suture (“barbed suture”) insertion.

Although some of these procedures are at times indicated, they will be unnecessary in the majority of cases if a high SMAS facelift and deep layer rejuvenation is performed. (Fig 4 AB).

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Fig 4 AB. High SMAS Facelift. A) 47 year old woman before surgery. Note loss of youthful contour. B) Same patient following high SMAS facelift, neck lift, forehead lift, upper and lower eye lifts, fat grafting and chin implant. Sagging tissues have been repositioned, youthful jaw line contour restored, and redundant skin excised without a tight or pulled appearance. All surgical procedures performed by Timothy Marten, MD, FACS Courtesy of the Marten Clinic of Plastic Surgery


Undergoing multiple procedures at the same time has other advantages as well. When multiple procedures are performed at the same time there is typically a substantial savings on the additional surgeries and the overall cost is significantly lower than if done separately. Even more important for many patients is that only once does time need to be taken off from their personal and professional lives to recover than if the procedures were performed in separate stages. Is it better to do everything all at once, or to do it a little at a time? This will depend on the philosophy of the treating plastic surgeon and the patient’s own notion of what is best. Dermatologists and other non-plastic surgeons often claim that an ongoing sequence of small procedures in conjunction with surface treatments of the skin and the regular injection of fillers is best. Too often this approach requires a considerable commitment of the patients time however, and results in an on-going financial commitment and modest improvements that are short lived. It can in some cases also result in a telltale unnatural appearance, chronic reactions to filler materials, and skin and deep tissue damage making future surgical procedures more difficult. Most plastic surgeons feel that surgery is ultimately superior to non-surgical treatments, but some feel that not everything need be done at the same time. For some patients such an approach is possible, but in many cases it can result in a situation analogous to only painting one wall in a room and leaving the other three unpainted – the treated areas draw attention to those that were not, resulting in a disharmonious and unnatural “surgical”, “done”, or “work in progress” appearance. Most plastic surgeons specializing in rejuvenation of the face recognize that the whole face ages, not just parts of it, and they rightly feel that in most cases comprehensive improvement is superior and more natural appearing than trying to spot rejuvenate only part of it. They also feel that it is part of their job to explain and communicate this to patients seeking their advice. It is a bit of a paradox, but doing more surgery can actually look like less due to the fact that a more balanced, harmonious and natural appearance is obtained.


What is the best age to have a facelift? Is it better to do a facelift at the first signs of aging or to wait until one is older and the problem is more advanced? How one ages will vary, and it is also true that each patient has their own definition as to when their time has come. A model, actor, performer, or public figure whose face is their professional instrument or identity will typically seek surgery to rejuvenate their face before the average person typically would. Traditionally patients were led to believe that it was best to “hold off ” as long as possible, often until they were in their sixties or seventies and an aged appearance was well established, and then to undergo a major “reconstructive” procedure after which it was obvious to everyone that something had been done. Many patients now wish to avoid waiting until an advanced problem is present however, and undergo surgery at an earlier age. The goal of these patients is to preserve a youthful appearance, rather than lose it and then regain it again, and to undergo a “maintenance” procedure at an earlier age and at a time in their life when the result of the surgery is most personally and professional beneficial, and when the change associated with it will be more subtle and less likely to be noticed by others. For these patients it often makes sense to undergo surgery in their forties or fifties (Fig 5 AB see also case example 3)). That said, the best answer as to what age is best is when the patient knows in their heart their time has come and that they are ready. Patients should not undergo surgery at the insistence of, or to please another person. Patients should also not be seduced by advertisements, discounts, or special offers - or succumb to sales pressure exerted by a member of a doctor’s office staff.




Fig 5 ABCD Traditional and “Early Maintenance� facelift AB) A 65 year old woman seen before and after a facelift and related procedures. The patient has had previous upper and lower eyelifts performed by an unknown surgeon. Before surgery (Fig 5 A) it can be seen that she has a well established aging changes and an a distinct elderly appearance. After surgery (Fig 5 B) she has a soft, natural appearance but states that the change was pronounced enough that her friends noticed she had something done. CD) A 42 year old woman seen before and after a facelift and similar related procedures as the patient in Fig 5 AB. It can be seen in Fig 5 C that the young patient has a microform of the same problem the older patient has. In the after photo (Fig 5 D) it can be noted that the change after surgery is less drastic than in the older patient seen in 5 AB and her friends only thought she had lost weight or changed her make-up. All surgical procedures performed by Timothy Marten, MD, FACS Courtesy of the Marten Clinic of Plastic Surgery


Does a facelift accelerate the aging process? Although it does not stop the aging process, a properly performed SMAS facelift will slow it down and provide a lifelong benefit to the patient. Properly and skillfully performed procedures do not accelerate the aging process. Unfortunately most “week-end”, “short scar”, “skin-only” and “mini” lifts don’t utilize the SMAS or address underlying anatomical problems and as a result tend to create tell-tale secondary deformities that can make patients look unnatural, and operated on as they get older. In this sense these “quick fix” procedures, especially when not performed carefully, can make patients look older than they should or would later in life. Once someone has a facelift do they have to keep having them? No, having a well-performed facelift does not obligate one to continue having them. In a high SMAS facelift sagging facial muscles and fat are elevated in their natural relationships as a unit by raising the strong SMAS layer to which they are attached to and enveloped by. This results in a balanced outcome that is more long lasting and ages naturally over time. How many facelifts can a person have? SMAS procedures directly address the anatomic layers at which aging is occurring and produce a more sustained and long lasting improvement. Because of this SMAS procedures don’t need to be performed near as often. Also, because SMAS procedures divert tension away from skin to deeper structural layers, the skin tightness and related abnormalities typically seen with older style lifts are avoided. Theoretically at least, a patient having a skillfully performed SMAS facelift could have it repeated as many times as needed or desired without it resulting in skin tightness, as the repeat lifts would be made by lifting the SMAS layer, and the skin would then be trimmed to fit under natural skin tension.


Is it always necessary perform “the works”, or can some patients have only part of the job? Only surgery that is needed, wanted, and approved by the patient should be performed. It is a fact however, that the whole face ages, not just part of it, and that spot rejuvenation of just part of it is not always appropriate and can result in abnormal and unnatural appearances. It is also a fact, although a bit of a paradox, that doing more surgery can actually look like less if skillfully carried out in that a harmony and balance is maintained, and the face is holistically rejuvenated, and not treated in piecemeal fashion. This is not always the case when only part of the job is done (Fig 6). It is understandably the hope of many patients, of course, that undergoing just one procedure can somehow naturally rejuvenate their face and transform their appearance, even though this is rarely the case. It is also true however, that most patients come to understand that additional procedures are needed if a natural and balanced appearance is to be obtained when it is clearly explained to them. It is, in fact, a “secret weapon” of most experienced plastic surgeons that they see the need to treat the face in its entirety, perform multiple procedures as indicated, and that they can communicate the need to do so to their patients. The typical patient presenting for rejuvenation of her aging face is usually best served when procedures are performed in a way that a balanced and natural appearance is obtained. Some areas will require more aggressive treatment than others, and sometimes procedures need not be performed on all parts of the face. Some patients will additionally require treatment of the mouth area, and many will need fat grafting to replace fat lost with age. Performing more procedures or performing these procedures together does not necessarily mean that the patient will take a longer time to recover, however.


Fig 6. Forehead lift as an important part of rejuvenation of the face. Often patients present concerned about their neck or jawline but it is a fact that the whole face ages, not just part of it, and that spot rejuvenation of just part of it is not always appropriate and can result in abnormal and unnatural appearances.

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A) Patient seen after a facelift, neck lift, and chin implant placement performed by an unknown surgeon. Her forehead appears older than the rest of her face and she has a “young face – old forehead deformity”. She has an unnatural and incongruent appearance. B) Same patient after hairline lowering forehead lift. No other procedures have been performed. Eyebrow position and configuration have been improved, the forehead is smoother, and the patient’s high hairline has been lowered. Her forehead and face now appear to be the same age and she has a more balanced, harmonious and natural appearance. All surgical procedures in the after photo B performed by Timothy Marten, MD, FACS. Photos courtesy of the Marten Clinic of Plastic Surgery

When is fat grafting (“fat transfer”, “fat injections”, “lipofilling”) needed? Patients with significant age related loss of facial fat, an occurrence medically known as facial atrophy, will generally achieve suboptimal improvement from both surface treatments of facial skin (laser resurfacing, etc) and surgical lifts. Smoothing skin will not hide a drawn appearance due to loss of facial volume, and it is difficult to create natural and attractive contours by lifting and repositioning tissues that have abnormally thinned with age. Restoring lost facial volume using fat injections is a powerful technique that has gained wide acceptance by plastic surgeons and other physicians engaged in

treating the aging face, and many now consider fat transfer to be the most important advance in facial rejuvenation since the introduction of the SMAS facelift technique. Properly performed, replenishing fat in areas of the face that have thinned with age can produce a soft, healthy, natural, and sensual appearance unobtainable by other means. (Figs 7 and cases examples 1-5). Won’t fat injections make a person’s face look fat? No, the purpose of fat transfer is to replace fat that was present in youth but lost with age, not to make the face bigger, and fat is only injected where it is


Fig 7 Combined facelift and fat grafting A) Before surgery view of a woman, age 75 who has had multiple prior facelifts and related procedures performed by unknown plastic surgeons. Note in addition to residual facial sagging the patient has marked deflation of the cheeks, lips, mouth, and under eye area. B) Same patient, 1 year 4 months after “redo” facelift, neck lift, forehead lift, upper and lower eyelifts, “corner lift” of the eyes, and fat grafting to her temples, cheeks, upper and lower eyelids, lips, mouth, temples and jaw line. No skin resurfacing, facial implants or other ancillary procedures were performed. Note patient now has soft, natural facial contours that would be unobtainable with facelift alone. The patient has softer, more healthy, youthful, vibrant, and feminine appearance. All surgical procedures in the after photo B performed by Timothy Marten, MD, FACS. Photos courtesy of the Marten Clinic of Plastic Surgery

How are fat injections performed? Fat transfer is performed by removing fat from diet and exercise resistant areas of the patient’s own body with a small, specially designed, hollow, blunt, toothpick sized needle attached to a small syringe, and then re-injecting it into areas of the face where it is needed. The idea is to harvest intact, living fat cells from areas of the body where the fat is biologically programmed to always be present, and to move it to areas of the face where fat is biologically programmed to thin with age. Fat must be harvested, processed, and injected in a special way using specially designed instruments if fat cells are to be expected to live, and the desired effect is to be obtained. Harvested fat is then processed in a special centrifuge machine to separate the intact, living fat cells from fat cells damaged during the harvesting process. If a sharp


needle is used, if fat is harvested carelessly under high vacuum, or if the fat is not processed in a way to separate damaged cells from healthy ones, a temporary effect only will be obtained. Properly harvested and processed fat must also be injected in a special way for fat cells to survive and persist. If fat is injected like fillers or like a “flu” shot the fat cells will be bunched together and most won’t be able to get needed oxygen and nutrients from adjacent tissue. For fat cells to survive they must be scattered as individual, small, pin head sized pieces of tissue so that each piece sits in its own tiny compartment. Where is the fat taken from? Fat is typically harvested from the hip, outer thigh and abdominal areas, and even though small amounts are usually needed, fat is removed from

areas that will improve the patient’s silhouette to a varying extent (depending on how much fat is harvested) in and out of clothing. What is the difference between “fat transfer”, “fat grafting”, “autologous fat grafting”, “fat transplantation”, “fat injections”, “lipo-filling”, and “lipostructure”? These are all terms coined to describe transferring living fat from one part of a person’s body to another, and for the most part mean more or less the same thing.

How long do fat injections last? Doesn’t the fat go away? Fat injections, when properly performed, are intended to be a transfer of living fat cells from one area of the body to another. Like hair transplants, in which hair follicles are transplanted from an area of the scalp where they are abundant to an area where the are absent, transferred fat is intended to take hold at the site it is transferred to and persist as living tissue. It is not intended to be a temporary treatment. Like hair transplants, the fat transfer procedure does not stop the aging process however, and as

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Can some of my fat be frozen and used later? No. Although some physicians do this, it is not considered optimal surgical technique or an ideal medical practice although tissue banks may come into existence to allow this to be done at some future date. Currently, most plastic surgeons feel that freezing fat damages the majority of the fat cells harvested and significantly compromises the ultimate outcome of the fat injection procedure. When fat is frozen and stored there is also the risk that it is mislabeled, contaminated, or not stored at the proper temperature. If a patient elects to have additional fat transfer procedures, it is easiest and best to have “fresh”, living fat harvested from their body each time.


Can fat be donated by someone else? No, fat cannot be donated by someone else or taken from another person (except an identical twin), and this is why many plastic surgeons avoid using the term “fat transplantation”.

a person ages they will continue to lose facial fat in certain areas. In such situations additional procedures may be desired. This is not a failure of the fat grafting treatment, it is merely a change resulting from ongoing aging. The fat injection procedure also results in swelling that can produce a temporary smooth, full, and very youthful facial appearance. Patients often mistake the subsequent resolution of swelling as fat absorption and loss, and as failure of the treatment. In most cases, however, a careful examination of the patient’s before and after photographs will show that they has benefited from the procedure, and that they had forgotten how hollow their face had become in certain areas before the procedure. Adding volume to the face by transferring fat to it also produces a subtle change involving the play of light and shadow on it that is not as immediately obvious as lifting the neck or jawline, and thus not as easily recognized or appreciated by some patients. It is often the case that a surgeon not experienced in the fat injection procedure will perform it too timidly and not inject enough fat. In such a case the procedure results in temporary swelling that can produce a temporary smooth and youthful appearance, but as the swelling subsides it becomes evident that inadequate fat had been injected and no improvement was obtained. Can the fat move or fall overtime? No, fat is living, particulate, cellular, tissue, not a liquid or oil, and as such it cannot move or fall over time. For fat cells to survive they must stick to adjacent tissues and small blood vessels must grow into them in a very short time to obtain oxygen and nutrients. Fat cells that move or are somehow displaced will die and be absorbed by the body over time. Is the fat lumpy? No, transferred fat is typically very soft and natural appearing, and the fat transfer technique is quite forgiving and usually produces a soft, natural, uniform result when correctly performed using proper equipment. Lumps and irregularities can occur, but these are very rare when the fat grafting procedure is performed by an experienced surgeon. In fact, fat grafting produces a youthful and healthy appearing facial smoothness


unobtainable by a facelift alone (see Fig 4 and 7 and case examples 1-5). Why not have cheek implants instead of fat injections? Cheek implants are specially shaped plastic wafers placed on top of the cheekbones that are used to enhance and fill the cheek area. For many years implants were the only way to add volume to the face, and they are still useful today to enhance the cheeks in patients born with markedly flat cheekbones. For many patients however, facial flatness and shrinkage with age is the result of loss of facial fat, and it makes better sense to replace what has been lost with what was once there. Fat injections also typically produce a softer, more natural, youthful and feminine appearance than cheek implants do, especially in women and patients with thin faces. Fat injections offer the additional advantage that they can be used to simultaneously treat other areas of the face, and not just the cheeks, and this markedly improves the overall improvement possible. Can fat injections be done instead of a facelift? Age-related loss of facial fat rarely exists as an isolated event in a healthy person and thus most patients troubled by it are not logically or appropriately treated by fat injections alone. Fat injections alone are also arguably of questionable benefit to the patient troubled by significant facial sagging and skin redundancy. Although aggressive filling of the sagging face with fat can produce improved contour and smoother appearing skin, it generally results in an unusually large, overfilled face that appears both unnatural and unfeminine. Such an overfilled face can be hard to correct at a later date, and it is both more logical and practical to perform fat grafting in conjunction with a facelift if needed, and after sagging facial tissues have been repositioned and redundant tissue has been removed. When a high SMAS technique is used in conjunction with fat injections both loss of contour and age related facial shrinkage can be corrected and optimal improvement can be obtained.


Are fat Injections always needed when a facelift is performed? No, but they can enhance the result in the majority of cases. The need for fat injections is determined by the degree of age related thinning and shrinkage of the face. Fat injections can also be performed after a facelift at a later date if needed. What areas of the face is fat typically transferred to? Fat injections are targeted at each patient’s own individual problems and thus the treatments vary from patient to patient. Areas frequently treated are the under eye area, “mid-face”, cheeks, “nasolabial creases” (lines running from nose to corner of mouth), lips, lip lines, and “drool lines” (lines running down from corners of mouth). Other areas often of benefit to patients include the temples, frown lines, upper eyelids, chin, and jaw line (Fig 8 ABC). Do fat injections have any benefits other than filling deflated areas of the face? It appears that this may indeed be the case and mounting scientific evidence now strongly suggests that fat injections may have a rejuvenating and antiaging effect. For many years surgeons performing fat transfer have noticed that patients seem to have an unexplained improvement in the quality and texture of their skin (and sometimes even scarred areas) above and beyond what would be expected by the addition of volume alone to the face. This beneficial effect of fat injections is now believed to be mediated through a “stem cell” effect, and due to an increase in the adult stem cell population in the treated areas. Stem cells are specialized cells that can transform themselves into other tissues and are an area of intense research interest. It seems that the stem cell effect obtained by the transfer of fat cells has a rejuvenating effect on tissues the fat is injected next to. This effect is now thought by many to impact all layers of the face, including bone, muscle, facial fat, and skin., and thus by injecting fat as part of the facelift procedure we can not only turn the hands of the clock back, we may be slowing them down.


Fig 8 ABC Patient Before and After Simultaneous Facelift and Fat Injections A) A 47 year old patient before procedure. She has had no prior surgery. B) Shaded areas (yellow) showing were fat was placed. 3 cc was placed in each temple, 1 cc was placed in each upper orbit (“eyelid”), 1 cc was placed in each “tear trough”, 3 cc was placed in each infra-orbital (under eye) area, 3 cc was placed in each cheek, 2 cc was placed in each mid-face, 1 cc was placed in each nasolabial crease (lines from nose to corner of mouth), 1 cc was placed in each stomal angle (corners of mouth), 1 cc was placed in each geniomandibular groove (depression on each side of the chin), 3 cc placed along each jawline, and 1 cc was placed in the upper and lower lip. C) Same patient 1 year and 1 month after high SMAS facelift, neck lift, conservative upper and lower blepharoplasties (“eye-lifts”), upper lip lift, and 38 cc of fat injections.

Why do some surgeons not perform fat injections as part of their facelift procedures? Although fat grafting has revolutionized how facelifts are performed and allows plastic surgeons to produce soft, natural appearing, results that were previously unobtainable, performing them requires special training, special instruments, and is a time consuming process when meticulously and comprehensively performed. As such many surgeons don’t know how to perform these procedures, don’t perform them often enough to become proficient in the technique, or don’t want to take the extra time required to perform them properly. Where are facelift incisions made and why are these necessary? There are four general parts to the facelift incision – a temporal part (part above the ear), a part in

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All surgical procedures performed by Timothy J Marten, MD, FACS. Photos courtesy of the Marten Clinic of Plastic Surgery

front of the ear, a part behind the ear, and if a neck lift is being performed, a part under the chin. The temporal part, and the part of the incision in front of the ear, provide surgical access to the SMAS layer in the cheek, and are the sites at which excess skin on the cheek and jowl areas are removed. The incision behind the ear provides surgical access to the sides of the neck and is where excess skin on the neck is removed. The incision under the chin provides access to the neck muscles, deep layer neck fat, and other neck structures that typically require modification. Skin is not removed at this location. Do the scars show? Traditionally facelift incisions were made in visible areas and patients were expected to do their best to conceal the resulting scars with make-up, hair, and bulky jewelry. Because traditional facelift techniques were also only performed in one layer and relied on obligatory skin tightening to lift


sagging facial tissues, incisions typically healed as thick scars that stretched and widened over time. Scars were thus often visible to others on casual inspection and from a distance, and patients often felt “marked” or “branded” as having had plastic surgery. Unfortunately, the majority of surgeons still perform facelifts in a similar way and scar visibility remains a persistent problem for many patients having the procedure. Experienced surgeons concerned with these problems have since developed techniques to conceal facelift scars by placing then in inconspicuous locations, diverting tension away from the skin to the deeper SMAS tissue layers, and beveling incisions at skin-scalp interfaces (“tricophytic” incision) to allow hair to grow back through scars to hide them. When these measures are taken the scars heal as fine lines that are typically not detectable in social situations, and make-up, contrived hairstyles, and bulky earrings and jewelry, are not needed to camouflage them (see Figs 9, 16 and case examples 1-5). Are staples used? Staples are not used on any surgery to rejuvenate the face when an experienced surgeon seeking the best possible result performs the procedures. Although staples allow incisions to be closed quickly,

they were designed for use by general surgeons and intended to make crude closure of incisions on the body. They were not intended to be used in more delicate plastic surgery procedures in which incisions are frequently made on hair bearing scalp to hide the resulting scars. The problem with using staples is that incisions on the scalp or at skin scalp interfaces must be beveled (cut at an angle) if they are to be made parallel to hair follicles to prevent injury to them. When stapled, the edges of beveled incisions tend to override each other, and proper alignment cannot be maintained. Staples are also often uncomfortable for the patient after surgery and removal can sometimes be painful. Although it takes a bit longer, it is best if incisions are carefully aligned with sutures. I have seen patients who have no sideburn hair after a facelift. Can this be avoided? The temporal portion of the facelift incision has traditionally been planned and performed in a causal fashion that all too frequently resulted in temporal hairline elevation and displacement or even the complete absence of hair in the temporal area. Proper analysis, careful planning and the use of an incision tucked up against the hairline, when necessary, can prevent this problem. (Fig 9 AB ).

Fig 9 A B. Healed Incisions Along the Temporal Hairline. The use of an incision along the hairline, when indicated, can prevent hairline and sideburn displacement without compromising the end result. Although a fine scar is present along the hairline in each of these patients, it is not evident upon casual inspection. Note the preservation of lush temple hair and a full, youthful, natural appearing sideburn. Surgical procedures performed by Timothy Marten, MD, FACS Courtesy of the Marten Clinic of Plastic Surgery


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Fig 10 Traditional “Pre-tragal” Location of the Facelift Incision. This places the scar in an area open to inspection by others and “brands” the patients as having had facelift surgery. This incision plan is not used by Dr Marten and Elyassnia.

evident, even in the presence of an inconspicuous scar. These mismatches cannot always be hidden with make-up as the scar will be smooth and the adjacent skin porous in texture. For these reasons, and in all but the unusual case, this portion of the facelift incision should be precisely placed along the natural contours of the ear, rather than in front of it (Fig 11). In this location a mismatch of color, texture, or surface irregularities will not be noticed and the scar, if visible, will appear to be a reflected highlight or part of the ear (Fig 12 AB, 13 AB).


Where is the incision in front of the ear made? Is a scar in front of the ear necessary? Open to scrutiny, the portion of the facelift incision made in front of the ear exists as a frequent point of reference for those seeking to identify a facelift patient. Traditionally, incisions here are made well in front of the ear in a visible “pre-tragal” location. (Fig 10). This plan, however, works well only for the unusual patient with cheek and ear skin of similar characteristics who, in addition, exhibits favorable healing. Unfortunately, most patients have a marked gradient of color, texture, and surface irregularities over these areas and a tell-tale mismatch will be

Fig 11. “Concealed Incision” Plan for Hiding the Part of the Face-lift Incision in front of the Ear. Placing the incision along natural ear crevices and contours in a “retro-tragal” location conceals the scar and disguises differences in color and skin texture on each side of it.


Fig 12. “Pre-tragal” (left) and “Retro-tragal” (right) Incisions Compared. A) Pre-tragal incision in front of the ear has is visible due to it exposed location and differences in color and texture of the skin on each side of it. It is easy to tell the patient has had a facelift (note: this procedure was not performed by Dr Marten or Elyassnia and was performed by an unknown surgeon) B) Same patient after “redo” facelift in which the incision was moved to a concealed location inside the ear (“retro-tragal” position) (see Fig 9). Color and texture differences, and the scar itself, are now hidden along natural anatomic interfaces and the patient appears to have not had facelift surgery. “Redo” surgery performed by Timothy Marten, MD, FACS Courtesy of the Marten Clinic of Plastic Surgery

Fig 13. Healed “Retrotragal” Facelift Incisions. Close-up views of facelift patients after surgery with incisions along natural ear contours. Scars are well concealed and difficult to detect (see Fig 9 for diagram of scar locations). Surgical procedures performed by Timothy Marten, MD, FACS Courtesy of the Marten Clinic of Plastic Surgery


little extra time and trouble spent in the operating room concealing the scar in a retro-tragal location (Fig 9 and 12 B, 13, 14) is worth the extra effort and something that will be of benefit to the patient the rest of their life. Many surgeons in fact, regard the scar in front of the ear (and the inability to detect it) as their “signature” (or lack of one). Where is the facelift incision in front of the ear made in men? Because men typically wear their hair short and don’t wear make-up it is very important that a pretragal incision in front of the ear is not made and that a more concealed “retro-tragal” incision plan is used (Fig 14).


Why don’t all surgeons use a “concealed incision” technique and hide the scar in a “retro-tragal” location? Different surgeons have conflicting philosophies and view this issue differently. Many feel a scar in front of the ear is not a problem and should not concern the patient. Pre-tragal incisions (Fig 8 and 12 A) are also quick to make, quick to sew back together, and easier for the less experienced surgeon to perform and this may be the real reason they are frequently still used. Other surgeons (and most patients) view a scar in front of the ear as a “brand” and a tell-tale sign that a facelift has been performed - and as something that should be avoided. They feel that a

Fig 14. Healed “concealed” Facelift Incisions in Male Patients. The incision has been made along ear contours in a retro-tragal location, rather than in front of the ear (see Fig 9 for diagram of location of scar). This results in well-concealed scars even in men with short hair.

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Surgical procedures performed by Timothy Marten, MD, FACS Courtesy of the Marten Clinic of Plastic Surgery

Are the ears removed and reattached when a facelift is performed? No, the ears are left attached to the head in their original positions. Only the skin around the ears is lifted and removed. Where is the incision around the earlobe made? To obtain a natural appearance about the earlobe, it is essential to preserve the natural grove between the ear lobe and the cheek, and to avoid to damage to this and aesthetically important anatomic sub-unit. This is accomplished by making the incision just below this junction. 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 grove between the earlobe and cheek and an attempt is subsequently made to directly join thin, soft earlobe with coarse, thicker cheek. Why are earlobes sometimes in unnatural positions after facelift? There is perhaps nothing as tell-tale and aesthetically objectionable as abnormal position of the earlobe after facelift surgery, and these types of deformities must be assiduously avoided. In the artistically ideal, “non-surgical” appearing ear, the earlobe sits naturally with its attachment to the cheek tucked up in a concealed location. If the earlobe is mistakenly placed too far forward and/or too low in the cheek, an unnatural and "facelift look" is produced (Fig 15 AB).


Fig 15 A B. Proper and Improper Positioning of the Ear Lobe. A) In the artistically ideal “non-surgical” appearing ear the long axis of the earlobe (dotted line) sits approximately 15 degrees behind the long axis of the ear itself (solid line) in the side view and the scar around the earlobe is tucked up in a concealed location. B) As the axis of the earlobe is shifted in front to the long axis of the ear, or if the earlobe is placed too low into the cheek, an old, unnatural and “facelift look” is produced and the scar around the earlobe becomes obvious. Note that in A the scar around the earlobe will be tucked up in a concealed area but in B will be exposed and visible to others.

Why do some people who have had facelifts have strange looking “pixy” earlobes? “Pixy” ear is a term sometimes used to describe the unnatural impish appearance of the ear that occurs when the earlobe is improperly placed in a pulled down position. It is one of the most objectionable and obvious signs that an amateurish facelift has been performed. Typically, the problem is the result of a lack of artistic sensitivity and/or a technical mistake, and it is a common reason why patients are often wearing oversized earrings or have their hair placed over their ear in many “after” surgical photos. If a patient has large earlobes can they be made smaller? How is this done? As many people age their earlobes enlarge and add to an overall aged and elderly appearance. Reducing them restores a more feminine, balanced, and youthful appearance. Earlobe reduction is easy to do, can be done at the time of a facelift procedure, and can add to the overall improvement obtained with the surgery. It can also be done as a separate procedure at a later date if desired (see case example 5).


Why do some patients have wide scars and step-offs in the hairline behind their ears. Can the surgery be done so a scar won’t show in this area? Skin removal using traditional facelift incision plans with the incision “hidden” in the scalp will predictably result in the advancement of neck skin into the scalp behind the ear and "notching" of the hairline in most cases. This hair has not fallen out, it has been displaced and discarded as a result of a poor incision plan. 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 outdoors where wind, water and outdoor activities may displace camouflaging wisps of remaining hair. Can hairline displacement and notching behind the ear be avoided? Yes, proper analysis, careful incision placement in a concealed location along the hairline, and meticulous suturing of the surgical incision can avert this problem (Fig 16).

Fig 16. Healed “concealed” Incisions Along the Hairline Behind of the Ear. Both patients are seen after surgery using an incision along the hairline. Note that if this incision is planned carefully and properly closed an inconspicuous scar will result.

most improvement and most natural appearance. In addition, shorter incisions require that skin be gathered up when sutured and prevent it from being removed in a smooth, well–tailored fashion. This can result in objectionable puckering and gathering. A “longer” scar, conversely, allows skin to be shifted in a geometrically correct fashion and for it to be removed without these problems (see Fig 16). It is not really how long the scar is, it is whether it is well concealed or not, and whether it can be seen by others. Ironically, most short scar procedures have placed their focus on the area behind the ear and seek to shorten the incision in that area. This incision is situated in a well-concealed area and if tension is diverted to deep layer tissue and skin removal is carefully planned and the wound meticulously sutured, an inconspicuous scar will almost always result. This scar is arguably less obvious and less disturbing to the patient than is 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 difficult to understand aspect of “short scar” incision plans is that to minimize puckering and gathering behind the earlobe the cheek skin flap is shifted in an overly upward direction necessitating a longer and more obvious scar along the less well concealed sideburn and temporal hairline. Although an incision is sometimes required in this area in some patients to prevent hairline displacement, shortening a scar in

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What about “short scar” facelifts? The idea of shortening the incisions used to perform procedures to rejuvenate the face is conceptually appealing to patients and surgeons alike. Indeed, the first facelift procedures performed over a century ago consisted of the removal of small sections of skin in front of the ear along the forehead hairline, and along hairlines behind the ear. Ironically, and despite the many amazing advances in techniques to rejuvenate the face that have been made over the past century, as non-plastic surgeons have begun to perform aesthetic surgery procedures and market their services, a new emphasis has been placed on ill-conceived “short scar” procedures of questionable value that nonetheless seem appealing to most any patient who they are recommended to. Although some short scar techniques such as limited incision temple and forehead lifts have merit and have provided new and better options to many patients, skin redundancy remains a consistent and undeniable problem for the surgeon seeking to rejuvenate the cheeks, jawline, and neck, and shorter incision plans involve significant compromises in the overall improvement that can thus be obtained. Short scars incision plans suffer the drawback that they limit access to the SMAS and other deep layer structures that need to be lifted or modified if tension is to be diverted away from the skin and a natural appearance is to be obtained. Short scar procedures also prevent redundant skin from being shifted in proper directions that produce the


Surgical procedures performed by Timothy Marten, MD, FACS Courtesy of the Marten Clinic of Plastic Surgery


a concealed area by shifting it to a more visible area is also arguably of dubious value to the patient who might not have required it. Finally, and ironically, short scar procedures are often recommended to younger patients who are arguably most burdened by a scar along the temporal hairline. If we see a scar in this area on a 65 year old woman we smile and say “maybe she had a facelift”. If we see that same scar on a 45 year old woman she is judged more harshly and the scar carries more of a social stigma.

When is an incision under the chin needed? Many facelift patients will need work on their neck that requires fat removal from deep layers of the neck and tightening of the muscles in the neck region that can only be performed through an incision under the chin, and optimal improvement in neck contour can generally not be obtained unless such an incision is made (Fig 17ABCD).

Fig 17. Correction of the “Double Chin” Appearance. AC) Patients with “double chin” seen pre-operatively (before surgery) BD) Same patients seen after face and neck lift. The incision under the chin was made behind the chin crease to allow the crease retaining ligaments to be released, deep layer fat of the neck to be removed, the neck muscles to be tightened (“platysmaplasty”), and the fat of the chin and neck to be blended to create fit athletic neck line. Surgical procedure performed by Timothy Marten, MD, FACS Courtesy of the Marten Clinic of Plastic Surgery


Fig 18. Healed Incision Under the Chin. Placement of the incision behind the chin crease will typically result in an inconspicuous, well-concealed scar (arrow). Note how the scar appears to be a natural skin crease. Surgical procedure performed by Timothy Marten, MD, FACS Courtesy of the Marten Clinic of Plastic Surgery

most women typically results in an unbalanced, unnatural and unfeminine appearance, and a square, “bottom heavy” facial appearance – and is ultimately an artistic and aesthetic failure. In addition, if an aggressive isolated neck lift is performed, sagging in the cheeks and jowl area can actually be accentuated, as neck tightening under the chin exerts a downward pull on tissue in these areas. Can patients just have liposuction on their neck instead of a neck lift? Liposuction is a technique in which fat is vacuumed out of the body using special hollow metal tubes attached a suction source. It can sometimes produce good results in the neck in well-selected younger patients with good skin, tight neck muscles, and accumulations of “baby fat” situated under the skin and not deep in the neck. Although these patients are uncommon and the exception, their before and after photographs are typically the ones shown in magazines, plastic surgery promotional materials, and on plastic surgery websites - and patients who are not good candidates for the procedure are left with the erroneous impression that this is the type of improvement they will obtain if they undergo the procedure. Liposuction is an inherently limited technique in that it can only remove fat from under the skin and it cannot remove it from the intermediate or

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Can patients just have a neck lift if they are only concerned about their neck? It is not uncommon for patients to request that surgery be performed upon their neck only. Although such a plan is acceptable for some young men and women, failure to concomitantly restore attractive cheek contour and lift sagging jowls in


When is a neck lift needed? Why perform a neck lift? Why not just lift the cheeks and jawline or perform other procedures that rejuvenate the eyes or upper face? The simple answer to that question is that a well-contoured neck is an artistic imperative to an attractive and appealing appearance. A good neckline conveys a sense of youth, health, fitness and vitality, and lends the face an appearance of decisiveness, sensuality and beauty (Fig 17, 20, 21 and case examples 1-5). Neck improvement is of high priority to almost every patient seeking facial rejuvenation, and the results of “facelift” procedures are largely judged by the outcome achieved in the neck. If the neck is not sufficiently improved patients will feel their surgeon has failed them. Regrettably many surgeons ignore the neck when performing facelifts, or fail to provide optimal improvement. After a well performed neck lift the neck should look good in the profile (side view) and from the side when the neck is flexed.


Fig 20. The importance of neck lift in rejuvenating the face. A) Before surgery profile view of a woman, age 47. Note poor neckline. B) Same patient, 1 year and 7 months after facelift, neck lift, forehead lift, upper and lower eyelifts, and fat injections to the cheeks, mouth, lips, jawline, and under eye areas. Note well-defined and attractive jaw line, and markedly improved neckline. C) Before surgery view of woman, age 47 looking down. This is how she would be seen looking at a menu in a restaurant, a program at the theater or work on her desk. Note poor neckline. D) Same patient, 1 year and 7 months after facelift, neck lift, forehead lift, upper and lower eyelifts, and fat injections to the cheeks, mouth, lips, jawline, and under eye areas. Note improved jawline, and attractive neckline. All surgical procedures performed by Timothy Marten, MD, FACS. Photos: Marten Clinic of Plastic Surgery

deep layers. For most facelift patients fat in the layer under the skin has actually thinned with age and little if any should be removed. If liposuction is performed in a misguided attempt to improve neck contour under these circumstances, or if too much fat is removed by other means, the patient’s neck will appear gaunt, unnatural, and old. Most patients in their thirties and beyond, and patients who have a lifelong history of poor neck contour and a full neck, have fat accumulation deep in the sub-platysmal neck layer that cannot be removed by the liposuction technique, in addition to laxity of the platysma muscles that support the neck. In these situations liposuction typically does little more than strip out the superficial fat lying


under the skin that makes the neck appear soft and youthful, and exposes neck muscle laxity (see Fig 21 below). If liposuction is performed too aggressively the neck can appear unnatural or even deformed. This situation is difficult for the patient to conceal and is a challenge for a plastic surgeon to correct. Unlike liposuction, a neck lift allows fat from the deeper layers of the neck to be removed (where it most often accumulates in facelift aged patients) and lax platysma neck muscles to be tightened. Skin can also be removed. This allows actual underlying problems to be addressed, and preserves precious fat lying immediately under the skin that gives the neck a soft, healthy, and youthful appearance.


Fig 21. ABCD Liposuction of the Neck and Neck Lift Compared. “Before” photographs on the left show patient age 39 after liposuction of her neck has been performed by an unknown surgeon. Fat that made the neck appear soft and feminine had been inappropriately removed and the patient was displeased that lax muscles were exposed and that redundant skin was still present. The “after” photographs on the right show the patient age 41 after a neck lift was performed. Lax muscles under the skin have been tightened and excess skin removed. Note that the patient has a more fit, athletic, and appealing appearance, and that problems not addressed by liposuction have been corrected. Neck lift surgery (“after” photographs) performed by Timothy Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.

Is all fat from the neck removed, or just some of it? Removing fat from the neck is a technically demanding maneuver that requires patience, perseverance and artistic sensitivity, and a properly performed neck lift can sometimes encompass several hours of operating room time. The technique by which fat is removed is not as important as the contours created and it must always be the aim of the surgeon to produce an attractive neck, and not simply one devoid of fat. In most patients the majority of fat in the neck is present in the intermediate sub-platysmal layer. Fat in this layer cannot be removed by liposuction and thus is not removed in “mini-lifts”, “short scar” lifts, “week-end” lifts, “fast lifts”, “feather lifts”,

“MACS “ lifts, “suture” lifts, and similar and related procedures in which liposuction is performed. Fat removal from this layer requires a formal neck lift procedure be performed through an incision made under the chin in which the superficial layer of neck muscles are lifted and the fat under them removed. Removal of fat from the intermediate subplatysmal layer is artistically powerful in that it is fat in this layer that is predominantly responsible for a “full neck” and loss of attractive neck contour in most patients. Sub-platysmal fat accumulations are universally present in patients with firm necks with obtuse contour and who have been troubled by lifelong neck fullness. Removing fat from this layer allows the surgeon to uncover the patient’s true neck contour, and obtain the best neckline possible.


How should the neck lifted? Despite the fact that it is a common practice by many surgeons, it is not enough to perform chin and neck liposuction and tighten the skin in most patients as such an approach ignores a number of anatomical problems almost universally present in many patients seeking neck improvement, including laxity of the platysma muscles (thin muscles forming the hammock that supports the neck), platysma bands (cords that form in the neck when the platysma muscle becomes lax), excess subplatysmal fat (fat underneath the platysma muscles that can’t be removed by liposuction), large submandibular salivary glands, digastric muscle hypertrophy (age associated enlargement of muscles under the chin that degrades neck contour), and developmental factors such as the size and shape of the jawbone and chin. Removing subcutaneous fat (fat immediately under the skin) and tightening skin over these problems does not address or correct them, and the presence or absence of each must be looked for in order to create and apply an appropriate and effective surgical plan. How should the neck be tightened? It is a common misconception that tightening the skin of the neck will produce a sustained improvement in neck contour and this is in fact the way most plastic surgeons attempt to rejuvenate the neck. Unfortunately, such an approach ignores the

fact that most neck contour problems have their origin in platysma neck muscle laxity and loss of the platysma muscle “hammock” that supports the neck. Trying to lift the neck by tightening the skin results in a short term improvement at best and the resulting tension on the skin results in a variety of other problems including wide and/or thick scars, distortion of ear anatomy, earlobe malposition (“pixie ears”), and a tight and unnatural appearance. If neck support is poor or optimal improvement in the neck is desired, platysmaplasty (suturing the inner edges of the platysma muscles back together) is performed (Fig 22). Platysmaplasty, when properly performed in conjunction with needed deep layer neck treatments (such as removal of excess subplatysmal fat and reduction of enlarged submandibular salivary glands (see Fig 25 and 26), restores the natural muscle hammock that supports the neck and produces optimal improvement in neck contour. When optimal improvement in neck contour is desired, a post-auricular transposition flap of cheek SMAS is used in conjunction with a platysmaplasty to support the outer (“lateral”) platysma muscle borders. A post-auricular transposition flap is created by splitting off redundant tissue from the margin of the cheek SMAS flap (Fig 23) but leaving it attached to the platysma muscle border on each side. These flaps allow the outer border of

Fig 22 AB. Platysmaplasty. Suturing the separated inner borders of the platysma muscle together improves neck support and when properly performed in conjunction with needed deep layer neck treatments (such as removal of excess subplatysmal fat and reduction of enlarged submandibular salivary glands), restores the natural muscle hammock that supports the neck and produces optimal improvement in neck contour



Figure 23 Plan for Post-auricular Transposition Flap. The Post-auricular Transposition Flap is used to accentuate the jawline and tighten the neck. A) Plan for Post-auricular Transposition Flap B) Elevation and transposition of flap to area behind the ear C) After SMAS elevation and suturing. Note improvement in jaw and neckline.

What is a chin implant and can’t a chin implant be used to improve the neck? Chin implants are solid medical grade pieces of plastic placed on the chin bone to enhance chin projection and contour. Chin implants are intended for the treatment of a small chin and not a means to improve neck contour, although this fact is commonly misunderstood by patients and surgeons alike. The need for a chin implant is determined by assessing the relationship of the chin to the rest of the face and is independent of the condition of the neck. Making the chin bigger when it is normal in an effort to make the neck appear better is conceptually and artistically flawed endeavor destined to create unnatural appearances.

When a small chin is present a chin implant is a simple and straightforward way to improve a patient’s appearance and to create a more balanced and photogenic profile and jawline (Fig 24). What can be done about large glands in the neck? Neck salivary glands (“submandibular glands”) must be assessed before surgery as they often contribute to the appearance of a full neck and are frequently evident as lumps under the jaw line. Large salivary glands are most easily seen in the patient who has had prior facelift that included aggressive liposuction of the neck. In these patients the large glands have been uncovered and made more obvious by fat removal. Large glands are frequently hidden by fat under the neck skin or lax neck muscles in the patient with a full neck presenting for a first time procedure however, and an surgical plan that does not recognize this problem will lead to disappointing and unexpected bulges in under chin area after surgery (Fig 25). Submandibular glands can usually be felt as firm, smooth, discrete, mobile protrusions in the upper neck area, just under the jawline, on each side. Submandibular glands that do not protrude and disrupt neck contour will usually not require treatment.

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the platysma muscles to be suspended up behind the ears and insures the muscles are draped smoothly and snugly over the neck and providing for optimal support. If properly constructed and secured, these flaps will provide dynamic reinforcement and tightening of the upper neck areas when the patient looks down. When used in conjunction with platysmaplasty (see above), post-auricular transposition flaps result in a continuous ear-to-ear “hammock” of muscle support across the chin-neck (“cervico-mental”) angle that cannot be obtained if only lateral muscle border suspension techniques are used.


Fig 24. Microgenia, chin implants, and neck lift. The need for a chin implant is determined by assessing the relationship of the chin to the rest of the face and is independent of the condition of the neck. Making the chin bigger when it is normal in an effort to make the neck appear better is conceptually and artistically flawed endeavor destine to create unnatural appearances. When a small chin is present a chin implant is a simple and straightforward way to improve a patient’s appearance and to create a more balanced and photogenic profile and jawline. AC) Patient with weak chin seen pre-operatively BD) Same patient, 1 year 6 months after facelift, neck lift, limited incision forehead lift, upper and lower eyelifts, chin augmentation, and fat grafting to the cheeks and lips. Note welldefined jaw line and attractive neckline. Note also that her chin appears stronger and in better balance with the rest of her face. All surgical procedures performed by Timothy Marten, MD, FACS. Photos courtesy of the Marten Clinic of Plastic Surgery


Fig 25 Protruding “Submandibular” Salivary Glands. Submandibular glands are usually evident as protrusions in each side of the upper neck area just under the jawline.


A) Patient with protruding submandibular gland after facelift and liposuction of the neck (note: surgical procedure was not performed by Dr Marten and was performed by another surgeon). B) Patient with protruding submandibular gland after a “week-end neck lift” (note: surgical procedure was not performed by Dr Marten or Elyassnia and was performed by another surgeon).

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Fig 26. Submandibular salivary gland reduction. Experience has shown that protruding submandibular salivary glands have enlarged with age, and are not drooping. Attempts at tightening neck platysma muscles to lift a protruding gland usually results in modest improvement that is short lived. The most effective treatment of enlarged submandibular glands is to remove the protruding portion AC) Patients seen preoperatively with large submandibular salivary glands. A large lump is can be seem in the neck area (arrow) BD) Same patients after facelift, neck lift and related procedures that included submandibular gland reduction. The protruding part of the gland has been removed and optimal neck contour has been created. All surgical procedures performed by Timothy J Marten, MD, FACS. Photo: Marten Clinic of Plastic Surgery


How are protruding glands in the neck treated? Experience has shown that protruding submandibular salivary glands have enlarged with age, and are not drooping. Neck muscles contribute little to their support and attempts at tightening neck platysma muscles to lift a protruding gland usually results in modest improvement that is short lived. Attempts to suspend protruding glands directly with sutures has also proven to be ineffective. The most effective treatment of enlarged submandibular glands is to remove the protruding portion, much in the way that a bump is removed from the bridge of an oversized nose, and for experienced neck surgeons gland reduction is a standard part of neck lift procedures (Fig 26). Only a small portion of the gland itself is typically removed but patients should know that the procedure carries a small risk of causing bleeding, fluid collection, and dry mouth symptoms. Should patients lose weight before surgery if they need to? What happens if a patient gains or loses weight after surgery? When traditional one layer, “skin-only” facelifts are performed there is a balance between how tight the skin is and the amount of fat in the face, and for patients undergoing these procedures weight loss after the procedure can cause the face to droop and have other negative effects on the outcome. When a two-layer SMAS technique is used however, facial fat is elevated along with the SMAS and the overall outcome becomes, for the most part, independent of skin tension and weight loss. Patient undergoing High SMAS facelifts need not be at their ideal weight when it is performed, need not lose weight before having it, and need not be concerned about spoiling the result if they lose weight afterwards. Is a dressing needed after surgery? After all planned procedures have been completed the patient’s hair is washed with shampoo and rinsed. Conditioner is then applied and the hair carefully detangled with a wide toothed comb. No dressing is needed or applied. Patients are typically discharged with a hat, scarf and sunglasses. If dermabrasion (sanding of skin wrinkles around the mouth) or lip augmentation has been performed a rigid disposable surgical “allergy” mask that rests off of the treated area is also provided.



Is facelift surgery painful? Most prospective patients are surprised to learn that facelift and related surgeries (forehead lift, eye lifts, neck lifts and fat injections) are not painful, and that generally only mild pain pills are needed for a few days. After the procedure is complete, but before the patient wakes up, the face is injected with a long acting local anesthetic (“numbing medicine�). When this is done the patient typically wakes up in the recovery room with little or any pain.

Marten & Elyassnia

When can patients return to work after a facelift? When patients return to work and their social lives will depend 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 to 3 weeks, to recover from surgery and additional time off is recommended before an important business presentation, family gathering, vacation, or like event. If the patient is doing well and not experiencing problems, they are allowed to return to light office work and casual social activity 9 to 10 days after surgery. It is recommended that they begin with a limited workday at first and to adjust their schedules thereafter. If a patient’s job entails more strenuous activity or physical labor, a longer period of convalescence may be required. When are patients completely healed? Patients are usually pleased with their appearance, look good in a photograph, and can be seen at an important event 2 months after surgery. They are advised to expect some numbness and firmness in the face and neck areas for 6 to 9 months after surgery however.


The “Couture” Facelift: Custom Designed, Concealed Incision, High SMAS Facelift with Simultaneous Fat Grafting Excerpted from A Patient’s Guide to Facelift Surgery and used with permission

Timothy Marten, M.D.

CASE STUDIES All surgical procedures performed by Timothy Marten, MD, FACS. Photos courtesy of the Marten Clinic of Plastic Surgery


Patient Example 1 (Front View) A) Before surgery view of a woman, age 42. Note suboptimal eyebrow position and configuration, cheek and jawline laxity, and hollowness in the cheeks and under eye area. She has had no prior plastic surgery. B) Same patient, 13 months after facelift, neck lift, limited incision forehead lift, conservative upper and lower eyelifts, fat transfer, and upper lip lift. No skin resurfacing, facial implants or other ancillary procedures were performed. Note soft, natural facial contours and the absence of a tight, pulled, or “face lifted� appearance. Note also improved eyebrow position provides a more feminine and alert appearance. The cheeks and jaw line have been lifted and redundant skin removed. Hollowness in the upper cheek and under eye area has been filled by lifting sagging cheek tissue to a youthful position and by fat transfer.


Patient Example 1 (Front Smiling View) A) Before surgery view of a woman, age 42. Note that she has a somewhat sad and melancholic appearance even when she is smiling. Also note suboptimal eyebrow position and configuration, cheek and jaw line laxity, and hollowness in the cheek and under eye area. She has had no prior plastic surgery. B) Same patient, 13 months after facelift, neck lift, limited incision forehead lift, conservative upper and lower eyelifts, fat grafting, and upper lip lift. Note soft, natural facial contours and the absence of a tight, pulled, or “face lifted� appearance. Improved eyebrow position provides a more feminine and alert appearance. The cheeks and jaw line have been lifted and redundant skin removed. Hollowness in the upper cheek and under eye area has been filled by lifting sagging cheek tissue to a youthful position and by fat grafting. (note: the patient has had her teeth whitened and straightened after the surgery was performed)

Patient Example 1 (Oblique View) A) Before surgery view of a woman, age 42. Note low eyebrows, sagging cheeks, sagging jowl, neck laxity, flat cheeks, and hollow under eye areas. She has had no prior plastic surgery. B) Same patient, 13 months after facelift, neck lift, limited incision forehead lift, conservative upper and lower eyelifts, fat grafting, and upper lip lift. A mole on the neck was also removed. Note improved position of eyebrow, restoration of cheek fullness, improved transition from lower lid to cheek, elevation of corners of mouth, smooth jaw line, and improved neck. The lip lift has shortened the distance from the bottom of the nose to the upper lip border and improved the appearance of her mouth. The patient’s face has a lighter, fresher, more alluring appearance.



Patient Example 1 (Side View) A) Before surgery view of a woman, age 42. Note low eyebrow, large lower eye bag, “tear trough”, sagging cheek, sagging jowl, “drool line”, and neck laxity. She appears tired and unfit even though she is trim and in excellent overall health. She has had no prior plastic surgery. B) Same patient, 13 months after facelift, neck lift, limited incision forehead lift, conservative upper and lower eyelifts, fat grafting, and upper lip lift. A mole on the neck was also removed. Note improved position of eyebrow, restoration of cheek fullness, improved transition from lower lid to cheek, elevation of corners of mouth, smooth jaw line and improved neck. The lip lift has shortened the distance from the bottom of the nose to the upper lip border and improved the appearance of her mouth. Note also that the no scars are visible, no distortion of the ear is present, and the earlobe is in normal position. She appears fit, youthful and more attractive.

Timothy Marten

Patient Example 1 (Side View - Looking Down) A) Before surgery view of a woman, age 42 looking down. This is how she would be seen looking at a menu in a restaurant, a program at the ballet, work on her desk, or while texting on her phone. Note neck laxity and poor neckline suggest an worn and unfit appearance. She has had no prior plastic surgery. B) Same patient, 13 months after facelift, neck lift, limited incision forehead lift, conservative upper and lower eyelifts, fat grafting, and upper lip lift. A mole on the neck was also removed. Note improved position of eyebrow, restoration of cheek fullness, improved transition from lower lid to cheek, improved posture of the mouth, smooth jaw line, and improved neck. The lip lift has shortened the distance from the bottom of the nose to the upper lip border and improved the appearance of her mouth. She now appears young, fit and alluring.


Patient Example 2 (Front View) A) Before surgery view of a woman, age 44. Note heavy upper eyelids, facial laxity, and deflation in the cheek, mouth, lips, and under eye areas. The patient has had no previous plastic surgery. B) Same patient, 2 years and 7 months after facelift, neck lift, limited incision forehead lift, upper and lower eyelifts, dermabrasion of lip lines, and fat grafting to the cheeks, mouth, lips, and under eye areas. No skin resurfacing, facial implants or other ancillary procedures were performed. Note soft, natural facial contours and the absence of a tight, pulled, or “face lifted� appearance. Hollowness in the upper cheek and under eye area has been filled by lifting sagging cheek tissue to a youthful position and by replacing fat lost with age by fat grafting. Fat grafting has also been performed in the lips and mouth area. Unwanted moles have been removed from the neck, chin, and upper lip.



Patient Example 2 (Front Smiling View) A) Before surgery view of a woman, age 44. Note that she has a somewhat sad appearance even when she is smiling. Also note cheek and jaw line laxity, and hollowness in the under eye area. The patient has had no previous plastic surgery. B) Same patient, 2 years and 7 months after facelift, neck lift, limited incision forehead lift, upper and lower eyelifts, dermabrasion of lip lines, and fat grafting to the cheeks, mouth, lips, and under eye areas. Note soft, natural facial contours and the absence of a tight, pulled, or “face lifted� appearance. The cheeks and jaw line have been lifted and redundant skin removed. Hollowness in the upper cheek and under eye area has been filled by lifting sagging cheek tissue to a youthful position and by replacing fat lost with age by fat grafting. Fat grafting has also been performed in the lips and mouth area. Unwanted moles have been removed from the neck, chin, and upper lip.

Timothy Marten

Patient Example 2 (Oblique View). A) Before surgery view of a woman, age 44. Note low, flat, eyebrow, sagging cheeks, sagging jaw line, neck laxity, hollow under eye area, and age related deflation of the mouth and lip areas. The patient has had no previous plastic surgery. B) Same patient, 2 years and 7 months after facelift, neck lift, limited incision forehead lift, upper and lower eyelifts, dermabrasion of lip lines, and fat grafting to the cheeks, mouth, lips, and under eye areas. Note improved eyebrow position, soft facial contours, smooth jaw line, natural appearing full lips, decreased lip lines, improved neck, and overall vibrant appearance. Unwanted moles have been removed from the neck, chin, and temple areas.


Patient Example 2 (Side View). A) Before surgery profile view of a woman, age 44. Note low eyebrow position, excess skin on the upper eyelid, lower eye bag, sagging cheek, sagging jowl, deflation in the lips and mouth, and poor neckline. The patient has had no previous plastic surgery. B) Same patient, 2 years and 7 months after facelift, neck lift, limited incision forehead lift, upper and lower eyelifts, dermabrasion of lip lines, and fat grafting to the cheeks, mouth, lips, and under eye areas. Note improved eyebrow position, improved transition from lower eyelid to cheek, reduction in lip lines, welldefined and attractive jaw line, and youthful appearing neckline. Note also that lips are fuller but natural appearing, no scars are visible, no distortion of the ear is present, and the earlobe is in normal position. Unwanted moles have been removed from the neck, chin, and temple areas.

Patient Example 2 (Side View - Looking Down ). A) Before surgery view of woman, age 44 looking down. This is how she would be seen looking at a menu in a restaurant, a program at the ballet, work on her desk, or while texting on her phone. Note neck laxity and poor neckline.


B) Same patient, 2 years and 7 months after facelift, neck lift, limited incision forehead lift, upper and lower eyelifts, dermabrasion of lip lines, and fat grafting to the cheeks, mouth, lips, and under eye areas. Note fuller lips, improved transition from lower eyelid to cheek, elevation of corners of mouth, well-defined jaw line, and attractive neckline.


Patient Example 3 (Front View) A) Before surgery view of a woman, age 37. She has had prior upper blepharorplasty, rhinoplasty, chin implant, and neck liposuction preformed by an unknown surgeon. Note cheek sagging and jawline laxity. Note also upper eyelid hollowness resulting from her previous eye lift (“blepharoplasty”) procedure. B) Same patient 1 year and 3 months after early maintenance facelift, neck lift, temple lift, lower eyelift and fat injections. She has also had cosmetic eyebrow, eye line, and lip tattooing*. No skin resurfacing, facial implants or other ancillary procedures were performed. The patient has soft, natural facial contours and the absence of a tight, pulled, or “face lifted” appearance. Note improved eyebrow position and configuration, improved cheek fullness, improved jawline, and overall more alert, fresher, more feminine appearance. Note also that the cheeks and jaw line have been lifted and redundant skin removed. Fat injections have been used to reduce hollowing in the upper and lower eyelid areas, fill “tear troughs”, blend chin and jawline, and subtly augment lips. * Cosmetic tattooing performed by Athena Karsant, RN.


Patient Example 3 (Front Smiling View) A) Before surgery view of a woman, age 37. She has had prior upper eye lift (“blepharorplasty”), rhinoplasty, chin implant, and neck liposuction preformed by an unknown surgeon. Note somewhat sad appearance, even though she is smiling. B) Same patient 1 year and 3 months after early maintenance facelift, neck lift, temple lift, lower eyelift and fat injections. She has also had cosmetic eyebrow, eye line, and lip tattooing*. No skin resurfacing, facial implants or other ancillary procedures were performed. Note improved facial shape, soft, natural facial contours, and the absence of distortion or a change in appearance of her smile. The patient appears more rested and engaged.

Patient Example 3 (Oblique View) A) Before surgery view of a woman, age 37. She has had prior upper eye lift (“blepharoplasty”), rhinoplasty, chin implant, and neck liposuction preformed by other surgeons. Note cheek sagging and jawline laxity. Note also upper eyelid hollowness resulting from her previous eye lift procedure done by an unknown surgeon. B) Same patient 1 year and 3 months after early maintenance facelift, neck lift, temple lift, lower eye lift and fat grafting. She has also had cosmetic eyebrow, eye line, and lip tattooing*. No skin resurfacing, facial implants or other ancillary procedures were performed. Note improved facial shape, restoration of cheek fullness, improved transition from lower eye lid to cheek, and smooth jaw line. Note also subtle filling of lips achieved with fat injections. The patient’s face has a fresher, fit, athletic, and more feminine appearance.



Patient Example 3 (Side View). A) Before surgery view of a woman, age 37. She has had prior upper eye lift (“blepharoplasty”), rhinoplasty, chin implant, and neck liposuction preformed by an unknown surgeon. Note hollow upper eyelid, “tear trough”, sagging cheek, “drool line”, and poor jawline. Note also neck fullness, despite prior neck liposuction performed by another surgeon. B) Same patient 1 year and 3 months after early maintenance facelift, neck lift, temple lift, lower eye lift and fat grafting. She has also had cosmetic eyebrow, eye line, and lip tattooing*. No skin resurfacing, facial implants or other ancillary procedures were performed. Note restoration of cheek fullness, improved transition from lower eyelid to cheek, elevation of corners of mouth, smooth jaw line, and improved neck. Note also that the no scars are visible, no distortion of the ear is present, and the earlobe is in normal position.

Timothy Marten

Patient Example 3 (Side View - Looking Down). A) Before surgery view of a woman, age 37 looking down. This is how she would be seen looking at a menu in a restaurant, a program at the ballet, work on her desk, or while texting on her phone. She has had prior upper eye lift (“blepharoplasty”), rhinoplasty, chin implant, and neck liposuction preformed by an unknown surgeon. Note sagging cheek, “drool line”, and poor jawline. Note also neck fullness, despite prior neck liposuction performed by another surgeon. B) Same patient 1 year and 3 months after early maintenance facelift, neck lift, temple lift, lower eye lift and fat grafting. She has also had cosmetic eyebrow, eye line, and lip tattooing*. No skin resurfacing, facial implants or other ancillary procedures were performed. Note elevation of corners of mouth, improved jaw line, and fit appearing, attractive neck line. Note also that the no scars are visible, no distortion of the ear is present, and the earlobe is in normal position.


Patient Example 4 (Front View) A) Before surgery view of a woman, age 62 who has undergone a previous facelift and related procedures performed by an unknown surgeon. Note residual cheek and jowl laxity, deep “nasolabial lines” (creases from nose to corners of mouth), and deflation of the cheeks, lips, mouth, chin, and under eye areas. B) Same patient, 12 months after “redo” facelift, neck lift, forehead lift, TCA peel of lower eyelids, fat grafting to the temples, cheeks, upper and lower eyelids, nasolabial folds, lips, mouth, chin, and jaw line. No skin resurfacing, facial implants or other ancillary procedures were performed. Note patient now has improved facial shape and soft, natural facial contours. The cheeks and jaw line have been lifted and redundant skin removed. Hollowness in the temples, eye, cheeks, lips, mouth, chin areas has been improved with fat grafting to create a softer, more healthy and attractive appearance.



Patient Example 4 (Front Smiling View) A) Before surgery view of a woman, age 62 who has undergone a previous facelift and related procedures performed by an unknown surgeon. Note hollow eyes and temples, low cheeks, and weak jawline despite prior surgeries. B) Same patient, 12 months after “redo” facelift, neck lift, forehead lift, TCA peel of lower eyelids, fat grafting to the temples, cheeks, upper and lower eyelids, nasolabial folds, lips, mouth, chin, and jaw line. No skin resurfacing, facial implants or other ancillary procedures were performed. Note fuller temples, eyes, and cheeks and improved jawline. The patient now has a fresher more joyful appearance. The cheeks and jaw line have been lifted and redundant skin removed. Hollowness in the cheeks, lips, mouth, and under eye area has been corrected with fat injections to create a softer, more healthy appearance.

Timothy Marten

Patient Example 4 (Oblique View) A) Before surgery view of a woman, age 62 who has undergone a previous facelift and related procedures performed by an unknown surgeon. Note hollow temples and upper and lower eye areas, poor cheek and chin contour, thin lips, heavy jowl, poor jawline, and poor chin and neck contour. B) Same patient, 12 months after “redo” facelift, neck lift, forehead lift, TCA peel of lower eyelids, fat grafting to the temples, cheeks, upper and lower eyelids, nasolabial folds, lips, mouth, chin, and jaw line. No skin resurfacing, facial implants or other ancillary procedures were performed. Note the patient now has a less worn and more attractive appearance. Redundant skin has been removed and hollowness in the cheeks, lips, mouth, and under eye area has been corrected with fat injections to create a softer, more youthful appearance.


Patient Example 4 (Side View) A) Before surgery view of a woman, age 62 who has undergone a previous facelift and related procedures performed by an unknown surgeon. Note low eyebrow, sagging jowl and poor jaw line, and neck laxity despite prior surgeries. Note also earlobe from previous procedure. B) Same patient, 12 months after “redo” facelift, neck lift, forehead lift, TCA peel of lower eyelids, fat grafting to the temples, cheeks, upper and lower eyelids, nasolabial folds, lips, mouth, chin, and jaw line. No skin resurfacing, facial implants or other ancillary procedures were performed. Note improved neck contour and natural appearing fullness in the cheeks, lips, and mouth. Note also well concealed scar and that irregularities around the ear have been corrected.

Patient Example 4 (Side View - Looking Down) A) Before surgery view of a woman, age 62 who has undergone a previous facelift and related procedures performed by an unknown surgeon. This is how she would be seen looking at a menu in a restaurant, a program at the ballet, work on her desk, or while texting on her phone. Note poor neck and jaw line. B) Same patient, 12 months after “redo” facelift, neck lift, forehead lift, and fat transfer to the cheeks, upper and lower eyelids, lips, mouth, temples and jaw line. Note improved neck and jawline contour and soft natural appearance without a tight or pulled appearance. Note also that irregularities around the ear have been corrected.



Patient Example 5 (Front View) A) Before surgery view of patient, age 68. Hollowness can be seen in the under eye and upper cheek area. Loss of youthful facial contour can be seen in the cheek and jowl areas. A) Same patient, 1 year 9 months after facelift, neck lift, closed forehead lift, upper and lower eye lifts, earlobe reduction, and partial facial fat grafting. Fat grafting has provided filling of the under eye and cheek areas. Note restoration of youthful facial shape without a tight or pulled appearance. The patient has a natural, healthy, masculine appearance.


Patient Example 5 (Front Smiling View) A) Before surgery view of patient, age 68. B) Same patient, 1 year 9 months after facelift, neck lift, closed forehead lift, upper and lower eye lifts, and partial facial fat transfer. Note natural contours are present, even when smiling.

Patient Example 5 (Oblique View) A) Before surgery view of patient age 68. Note sagging cheek and loss of youthful jawline contour. Poor definition between the face and the neck can be seen. B) Same patient, 1 year 9 months after facelift, neck lift, closed forehead lift, upper and lower eyelifts and partial facial fat grafting. Note smoother forehead, restoration of cheek fullness, improved transition from lower lid to cheek, smooth jawline and improved neck contour.



Patient Example 5 (Side View) A) Before surgery view of patient age 68. Note cheek flatness, sagging jawline and neck laxity. A protruding salivary gland can also be seen in the neck area. B) Same patient, 1 year 9 months after facelift, neck lift, forehead lift, upper and lower eye lift and partial facial fat grafting. The protruding portion of the salivary gland has also been removed. Note the restoration of cheek fullness, a smooth well-defined jawline, and improved neck contour. The face has a natural appearance and all scars are well concealed. Note that the patient’s oversized earlobe has been reduced and this has resulted in a lighter, younger, and more proportionate appearance.

Timothy Marten

Patient Example 5 (Side View - Looking Down) A) Before surgery view of patient age 68. This is how he would be seen looking at a menu in a restaurant, a program at the ballet, work on his desk, or while texting on his phone. Note poor neck and jaw line that results in a elderly appearance. B) Same patient, 1 year 9 months after facelift, neck lift, closed forehead lift, upper and lower eye lifts and partial facial fat transfer. Note improved neck contour in the flexed position. The face has a natural appearance and all scars are well concealed. The earlobe reduction adds to the overall more youthful appearance.


Rejuvenating the Face and Neck: a Natural Result

Ramsey Alsarraf, MD, MPH

Ramsey Alsarraf MD, MPH Clinical Instructor, Harvard Medical School Director, The Newbury Center Cosmetic Facial Plastic Surgery 69 Newbury Street, Suite 3 Boston, MA 02116 (617) 375-0500 www.thenewburycenter.com mail@thenewburycenter.com



he goal of any face lift procedure should be a rested, refreshed, and natural appearing result that makes the patient look ten years younger without causing them to look operated-upon or ‘done.’

Ramsey Alsarraf

Most patients are not trying to look like they are nineteen again, nor do they want to advertise the fact that they have had surgery. Any well done facial plastic surgery procedure must strive to leave no surgical evidence and, at the same time, must also achieve the kind of rejuvenation that’s only attainable through surgical intervention. This is the fine line upon which the skilled facial plastic surgeon must balance. If the result is under-done, then the patient has gone through an expensive procedure for little or no benefit; if the result is over-done, the patient will be unable to hide the evidence. Too many procedures fall on either one side or the other of this line. I see many patients who have had so-called “weekend” or “mini” procedures, having spent thousands of dollars, and yet have very little improvement to show for it. Similarly, I also see many patients who have been pulled too tight, or in the wrong direction, or have simply been subjected to too much surgery by another surgeon. The term “face lift” can mean many different things, depending on the context, surgeon, or stigma associated with it. Unfortunately, the stereotypical image of a face lift patient is one who is overdone, wind-blown, or clearly post-surgical. Obviously this is not any surgeon’s goal. To me, the term ‘face lift’ is in some ways a misnomer. Most patients who present to my office at The Newbury Center in Boston are not seeking a tighter or more lifted face but, rather, trying to eradicate a droopy or saggy neck, heavy aging jowls, or improve their jawline and chin. Often, the patient does not, under any circumstances, say they want a face lift-- they just want to lift up the sagging that makes their neck look heavy and less attractive. In this scenario, the patient requires more of a ‘neck-lift,’ or ‘jawlinelift,’ or ‘jowl-tightening.’ The procedure, therefore, must focus on these problem areas, and result in a dramatic and significant change without visible signs of surgery. My face lift technique is focused not only on tightening the loose or wrinkled skin, but re-suspending the deeper soft tissues and muscles, to provide a result that is dramatically younger, and long


lasting as well. The cheeks and mid-face are lifted without the mouth being pulled or stretched in a way that shows signs of surgery. The jowls are eradicated, the neck tightened, and the jawline defined. The key to achieving consistency is a reliance on the normal deep tissue anatomy of the face and neck. Patients present with variable amount of skin damage, related to sun, cigarettes, or other environmental exposures. Similarly, patients have their own unique bone structure and present at various stages of aging. At the same time, the nature of soft tissue descent and these tissues’ anatomical location remain the same in all patients – in other words, in some respect, we are all unique but we are also all the same. Although some suggest that volume loss is the most important aspect of facial aging, in reality the overwhelming cause of the aging face is the effect of gravity on the skin and soft tissues. By reversing the effects of this gravity, the patient will obtain a dramatic improvement and avoid the need for ongoing non-invasive treatments such as filler injectables. In addition, I favor neither the minimal procedures (the so-called ‘weekend’ or ‘mini’ lifts), nor the more invasive ones, such as the ‘composite’ or ‘subperiosteal’ lifts, because I feel that the technique I have developed delivers consistently excellent, natural, and long-lasting results.

My Face lift Technique I have described this technique in a textbook I co-authored fifteen years ago (The Aging Face: A Systematic Approach). I have made several modifications to this approach over the years, and refer to it as a ‘modified deep plane technique.’ My face lift (or rather, neck-lift/ jawline-lift) always addresses the deeper tissues of the face. It relies upon many of the original aspects of the deep plane approach to which I have added some personal nuances that, in my opinion, create an improved result. While all reputable face lift surgeons incorporate a number of similar technical details in their procedures, the end result comes down to individual aesthetic sense, personal skill, and a gentle, meticulous hand. The incisions that I use for my face lift approach are always hidden in the region of the ear, curving naturally from under the sideburn tuft, but never creating an incision line in front of the ear, in the traditional ‘face lift’ location. By using an incision inside of the ear (post-tragal), one can avoid a scar that, even when well-healed, may appear noticeable when up-close and personal. The incision curves gently behind the ear and ends well up in the hairline, hidden by the



Figure 1. Once the skin has been elevated a short distance, the SMAS is incised from the angle of the mandible to the notch where the zygomatic arch joins the zygomatic body in order to enter the deep plane (X). Elevation is continued anteriorly under the jowls and melo-labial folds.

Ramsey Alsarraf

patient’s ear and hair. Thus, I also avoid placing any incision on the skin of the patient’s neck, in order to avoid a scar that might appear noticeable when their hair is pulled back. These so-called ‘pony-tail friendly’ incisions heal incredibly well, leaving only the finest of lines in the natural skin creases by the patient’s ear. In addition, I always make one small submental (under the chin) incision in a natural skin crease both to provide access for liposuction and to allow the tightening of the platysma muscles of the neck that is so important for a substantial rejuvenation. The first step is to perform liposuction under the chin, in addition to sculpting the fat along the jawline and across the expanse of the neck. Liposuction must be aggressive enough to remove all of the excess weight under the skin, yet delicate enough not to create any unnatural contour changes or textural problems. Once complete, the neck should be thin and all that should remain is the loose skin with a fine layer of subdermal tissue, and the deeper muscle that is addressed subsequently. My lateral dissection creates only a short skin flap both in front of and behind the ear and elevation in the neck is carried forward into the submental region in the pre-platysmal plane, overlying the muscle of the neck. This plane protects the important deeper neurovascular structures of the neck, such as the marginal mandibular branch of the facial nerve. The skin of the neck is thus freed up from ear to ear, allowing a tightening that is both smooth and dramatic. Before returning to the submental incision, the key aspect of this technique is performed, and the superficial musculo-aponeurotic system (or SMAS) is incised from the angle of the mandible to the zygomatic arch (Figure 1). This enables the surgeon to enter the deeper plane of the face, as described in the original deep plane face lift approach, and outlined previously in my own text. Elevation of the sub-SMAS fat is crucial to achieving a good result and great care must be taken to protect the underlying neurovascular structures of the face, particularly the facial nerve branches. By maintaining a smooth plane of dissection on top of the masseteric fascia inferiorly and on top of the zygomatic major muscle superiorly, one is able to elevate the entire cheek complex anteriorly to the level of the melolabial fold and deep to the jowl. This flap is then resuspended in a primarily superior and partially posterior vector, and secured with deep permanent sutures (Figure 2). The exact same procedure is performed on both sides of the face, and then the submental incision is revisited and the platysmal edges plicated in the mid-line with several buried permanent sutures. If any banding is seen with this plication, the muscle is relaxed with bilateral back-cuts that allow it to lie flat in its appropriate anatomic location. In most patients, further direct lipo-sculpture is performed to remove any excessive

Figure 2. The deep plane flap is then elevated and secured with multiple deep, buried permanent sutures in a primarily superior and partially posterior vector. The majority of the lift occurs at the inferior aspect of this flap along the jawline; as the flap is sutured further superiorly in the cheek, less resuspension is needed.



Figure 3A. Preoperative frontal view, patient with thin neck.

Figure 3B. Postoperative frontal view, patient with thin neck. Note the subtle upward lift to the lower and mid-face.

Figure 3C. Preoperative lateral view, patient with thin neck.

Figure 3D. Postoperative lateral view, patient with thin neck. The jawline is now sharply defined, and the loose sagging skin is gone.

Not every patient who presents for facial rejuvenation looks like they necessarily need a

Ramsey Alsarraf

The Thin Face and Neck

significant change. A younger patient in their forties or early fifties may have minimal signs of aging, but enough that bothers them to visit a facial plastic surgeon. Many of these patients do not have much excess fat under their chins but simply some loose or sagging skin. Often, gravity is just beginning to have an effect on these patients, with a small amount of jowling or deepening of the melo-labial folds. If the patient has good bone structure and minimal sun damage on their skin, addressing the thin neck should result in a dramatically rejuvenated appearance that looks incredibly natural. Two patients are presented here in order to demonstrate this result. I have intentionally chosen average looking patients, neither of whom have undergone any other ancillary procedures (such as rejuvenating their eyes) so as to emphasize the result that can be achieved with the face lift alone. There are two points that I feel compelled to mention here. First, we all treat VIP patients and it is easy to impress with a surgical result on someone who looks like an actress or a supermodel. The true test of a surgical result should be viewed on an average person because, in reality, most patients that will present to the cosmetic surgeon have similar aging concerns, and the improvement can be observed without distraction. Secondly, although the overwhelming majority of my patients do undergo further surgery during their face lift procedure, particularly to address the aging in the upper face, forehead and eyes, once again I feel it is unfair to evaluate the face lift procedure unless it is considered as a stand-alone intervention, without additional improvements to distract the observer. Figure 3 shows a relatively young, forty-eight year old patient, who presented with the desire to rejuvenate her neck and jawline. She had not undergone any other facial cosmetic surgery procedures and was not interested in rejuvenating her eyes or upper face-- she simply wanted to get her chin back and had a thin neck with primarily loose skin. Despite the fact that she had significant sun damage to her skin, an asymmetric ptotic


fat that might be present in this area and assure a nice tight result. Once the incision under the chin is closed, attention is returned to the incisions by the ears. The skin is separated slightly from the secured deeper flap and then resuspended as well with, in general, a good inch to two inches of skin removed about the ear. The skin edges are tailored to fit around the ear and the traguses recreated with several fast absorbing stitches inside the ear. Care is taken to create a natural appearing tragus, with a single deep pre-tragal suture that recreates the pre-tragal skin crease and prevents webbing or an unnatural look post-operatively. In addition, the earlobe is carefully re-sutured to prevent excessive tension or a pixie ear deformity. All suturing relies on skin edge eversion with the use of vertical mattress sutures and the avoidance of any tension whatsoever, in order to assure adequate healing and prevent scarring post-operatively. I prefer the use of a light cotton pressure dressing and two small suction drains for only one night after the procedure. I perform my surgery at one of the Harvard hospitals in Boston (Massachusetts Eye & Ear Infirmary), use a light general anaesthesia given by one of our Harvard board-certified anaesthesiologists, and send the patient home the following day with a light face wrap and cotton bandage. My patients do not require any ice, ointments, or other treatments in the post-operative period. The dressing is taken off the following day, and within three days most of the sutures are removed, with skin glue and tape used to protect the incisions while they are healing. After a week, all of the stitches are out and at two weeks patients are free of any tape or glue, with only minimal residual swelling. Most patients by this time are out and about, or back to work, and looking fabulous.



Figure 4A. Preoperative frontal view, patient with thin neck.

Figure 4B. Postoperative frontal view, patient with thin neck. Once again, the improvement to the jowls and face is subtle and natural.

Figure 4C. Preoperative lateral view, patient with thin neck.

Figure 4D. Postoperative lateral view, patient with thin neck. Despite excessive loose skin, the neck is now tight and the jawline defined.

be a less than perfect bone structure because of the sagging soft tissues has become a very attractive and aesthetically pleasing jawline.

The Heavy Face and Neck Achieving a natural, consistent, and long lasting result for patients with a much heavier neck is simply a matter of degree of how much to remove and re-suspend. Most patients fall, in fact, somewhere in between these two broad categories and are neither excessively thin nor tremendously heavy. The average patient is just that, average: a fifty or fifty-five year old woman who has some loose skin and sagging, with just enough fat under her chin to warrant a visit to the plastic surgeon. The main difference between a heavy and a thin neck is the amount of fat found in the submental region and, thus, the amount of liposuction that must be performed there to achieve a significant improvement. There may also be differences in skin thickness that contribute to a heavier pre-operative appearance, or an abundance of sagging or flaccid muscle underneath the skin, but in general, this is a matter of excess fat and the need to remove it. Figure 5 shows a somewhat older, seventy-two year old patient, who presented with a much heavier face and neck. Her concern, similar to the two patients already discussed, was simply her heavy neck and jowling and she also did not desire upper face or eye rejuvenation, although she did have signs of aging in those other areas. Figures 5A and 5C show her preoperative appearance. Although, in contrast to the thinner, younger patients already shown this would appear to be more of a challenge, applying the same face lift technique will result in a similar improvement. Figure 5B shows the one year


(sagging) brow, and substantial lower lid dark circles, she was not interested in having these other issues addressed. Her preoperative photographs (frontal and lateral) are shown in Figure 3A and Figure 3C. The patient underwent a face lift procedure and her one year post-operative photographs are shown in Figures 3B and 3D. As can be seen, from the front, in a patient with only early sagging of the face and neck, the result is relatively subtle. Although the cheek pads are elevated back onto the cheekbones and the jowls are resuspended, reducing the downward pull on the patient’s mouth, the mouth itself is not stretched or pulled in any way. The lateral views (Figures 3C and 3D) illustrate the real improvement she obtained from this procedure. The jawline is now defined, the jowling is gone, and the neck is returned to its dramatically tighter, more youthful appearance. In a patient who is relatively thin with minimal aging in this area, such a result is straightforward to achieve. The goal here is to reveal and emphasize the patient’s own given bone structure and eradicate the signs of aging in the neck, while maintaining a natural result. The second patient that illustrates the improvements which can be achieved on the relatively thin neck is shown in Figure 4. This patient, a fifty-six year old woman with more significant skin and muscle laxity in the neck, was also interested in having just her neck and jawline lifted. She had not undergone any other facial surgery, nor did she want any, although she would have benefited from rejuvenating her upper and lower eyelids as well. Figures 4A and 4B show her frontal before and after photographs one year post-op and, once again, the result is relatively subtle, as it should be from this view. From the side, in Figures 4C and 4D, the dramatic improvement is more evident. What appeared to



Figure 5A. Preoperative frontal view, patient with heavy neck.

Figure 5B. Postoperative frontal view, patient with heavy neck. The heavy jowls are now gone and the face looks, in general, thinner.

Figure 5C. Preoperative lateral view, patient with heavy neck.

Figure 5D. Postoperative lateral view, patient with heavy neck. The double chin and so-called ‘turkey waddle’ are gone, and the jawline sharply defined.

the face lift should strike the perfect balance

Ramsey Alsarraf

between looking noticeably improved, younger, and rejuvenated, while not crossing that fine line that shouts plastic surgery.�



We all want to look our best at any age and

post-operative frontal view and in this case the changes are more noticeable. The heavy jowls are gone and the jawline has regained its definition. The peri-oral wrinkling is softened, as are the melo-labial folds. The cheek pads are re-suspended and the heavy, sagging neck is gone. From the side, in Figure 5D, the bulk of the improvement is also observed, revealing the patient’s underlying bone structure. Although some of the peri-oral lines remain, the overall effect is that of a woman at least ten years younger. Rejuvenating the upper face and eyes, had the patient desired it, would have made this effect even more dramatic. A final patient is shown in Figure 6, with another very heavy and sagging neck. This patient was only 56 years old, but presented with significant aging related primarily to the heaviness of her face and neck. As seen in Figures 6A and 6C, her preoperative appearance reveals very heavy ptotic cheeks, jowls, and submental soft tissues. This patient also presented with a ptotic brow and heavy upper and lower lid dermatochalasis, however, unlike the previous patients, because she did agree to have a more comprehensive facial rejuvenation, her case is included to show how the face lift procedure can be combined with other procedures to provide a complete facial rejuvenation. Thus, she underwent the face lift with a browlift and upper and lower lid blepharoplasty procedure. In her one year postoperative photographs, the changes are truly dramatic. In Figure 6B, aside from the obvious feminization and softening of her upper face and eyes, in the lower face and neck most signs of gravity are gone. Her cheek tissues are re-suspended, and the jowls are now lifted up instead of squaring off her jawline. The sagging in her neck is gone, replaced by smooth, tight skin. From the side, in Figure 6D, all of the heavy skin, muscle, and fat of the neck has been eradicated and her bone structure is now visible.


Figure 6A. Preoperative frontal view, patient with heavy neck.

Figure 6C. Preoperative lateral view, patient with heavy neck.


Figure 6B. Postoperative frontal view, patient with heavy neck. In addition to the face lift procedure, this patient underwent a browlift and blepharoplasty as well. Note how the angry, masculine look to the eyes is now gone.

Figure 6D. Postoperative lateral view, patient with heavy neck. Despite a substantially heavy neck, the jawline is now sharply defined and the double chin eradicated.



When applied with technical precision and skill, the face lift is a procedure that can take 10 to 15 years off a patient’s appearance. The results should be natural enough even for closest friends to think that the patient has simply lost weight or changed their hairstyle. The ultimate goal is to look fabulous for one’s age, no matter what that age may actually be. However, there are two warnings that I feel are important to make. First, patients must be cautious of procedures that simply sound too good to be true. I am referring to ‘weekend’ or ‘mini’ procedures that are, more often than not, seen in advertisements, heard on the radio, or even watched on television. They usually have a catchy name, offer unrealistic improvements, and are performed in the back room of a doctor’s office or spa. Their promoters claim to minimize the risks by avoiding essential components of safety such as accredited hospital operating room suites and board certified anaesthesiologists. Surgery of any kind should not be unduly risky or invasive, however, it must be taken seriously and treated with the respect it deserves. My caution is to beware of any procedure that offers to cut corners or costs because, in the end, it is often the patient who pays the price. Many of the revision surgeries that I perform are on patients who have fallen prey to these temptations and it is far easier to achieve an excellent result the first time around, rather than having to correct someone else’s mistakes. Secondly, patients must exercise caution when it comes to non-invasive treatments to rejuvenate the face and neck. These treatments consist of the use of the myriad of filler substances that are currently flooding the market, fat injections, as well as those next generation machines designed

to ‘tighten the face’ without the need for surgical intervention. The judicious use of fillers CAN offer the perfect icing on the cake for postsurgery patients, particularly to correct any fine lines or wrinkles that may remain even after the most thorough rejuvenation. However, these treatments cannot be a substitute for the results that will be obtained with a surgical procedure. Of course, there will always be examples to find of surgery gone awry, and the media often shows images of overdone or obviously done celebrities, but the answer is not to avoid surgery. Rather, it is a question of having the RIGHT surgical procedure. The overuse of fillers, fat injections, and other non-invasive treatments may create a temporary rejuvenation based on increased volume, however, patients should be aware of unwanted results such as the overfilled look which is neither natural or attractive. Additionally, these procedures cannot address the neck, or the deeper sagging soft tissues of the face. Obviously, the portrait can only be as good as the canvas on which it is based, and those patients with good bone structure, fine skin with minimal sun damage, and minimal soft tissue sagging will attain the best or most attractive results. However, even the patient with poor bones, significant skin wrinkling, and a very heavy neck can still achieve a result that is rejuvenated and rested with this technique. Because my approach addresses the deeper tissue in a consistent and definitive manner, it is applicable to all patient types and, thus, all faces. We all want to look our best at any age and the face lift should strike the perfect balance between looking noticeably improved, younger, and rejuvenated, while not crossing that fine line that shouts plastic surgery. Simply put, the procedure is only a success if the result is naturally fabulous.


The contemporary facelift: Combining the strength of deep plane facelift with the softness of autologous fat grafting

Dr. Jamil Asaria

Jamil Asaria MD BSc FRCSC FACE Cosmetic Surgery 255 Davenport Road Toronto, Ontario M5R 1J9 tel: 416-479-4244 tel: 888-675-4244 fax: 416-920-4244 www.facetoronto.com



ith a practice located in the heart of the world’s most diverse city, Dr. Asaria has earned a reputation for being a leader in aesthetic facial surgery. His clinic, simply known as FACE, caters to an international list of patients seeking cutting-edge techniques in face lift procedures. His approach is defined by an artisitic vision coupled with an uncompromising attention to detail. Dr Asaria is a strong believer in sharing knowledge to enhance results and he serves as Co-director of one of only two accredited fellowships in Facial Plastic and Reconstructive Surgery in Canada.


Jamil Asaria

When seeing me for a face lift consultation, almost universally, my patients share the same fears and apprehensions. Certainly, they want to see significant improvements in their neck and jawline, to reduce hollowness and loss of volume of their cheek region, to soften deep folds around the eye and mouth—all in order to present a more youthful and healthy appearance. But what they dread is the risk of looking overly pulled and stretched. Everyone has an image of a poorly done face lift producing distortion of the mouth, a windswept appearance to the cheeks, and an unnatural transition and balance of the lower face. Combine that with broad and visible scars, facial nerve disruptions, pulled earlobes, and hairline irregularities--improperly performed face lift surgery can cause serious deformity. While these are the common factors that come to mind when thinking of poorly performed face lift surgery, I see another series of disappointments when patients come to see me for revision face lift surgery. Often times, a previous inadequate surgery has produced substandard correction and minimal improvement. Furthermore, these patients often describe a very short-lived result, returning to their baseline in a few short years. It is with the goals of producing the most effective and natural appearing result while avoiding any distortion, that I am a strong believer in deep-plane


No other procedure can “set back the clock” like face lift surgery. When we allow an individual’s inner vibrancy and youthfulness to be reflected in their face, it provides incomparable rewards for both the patient and the surgeon.” face lift surgery. The procedure should be envisioned as a repositioning and volumizing procedure rather than a pulling or stretching. Sometimes our patients may envision the term “deep-plane” as being a more invasive procedure, however, this is certainly not true. Rather, in experienced hands, elevating the delicate facial tissues in a slightly deeper layer allows us to produce a more effective, long-lasting result without any difference in downtime or recovery.

The Aging Process Recently, we have developed a much more sophisticated understanding of the facial aging process. Over time, three primary elements undergo significant change: the quality of the skin envelope, the composition of subcutaneous fat and muscle, and the support of the facial bones. We can all appreciate that over time and with exposure to our environment, facial skin loses elasticity and develops both coarse and fine wrinkles. Deep to the surface, the facial fat compartments not only descend in position, but they undergo atrophy and loss of volume. These positional and volumetric changes result in the transition from elevated and defined upper cheeks to a more aged, heavy redistribution of softtissue along the jowls and upper neck. Furthermore, the facial skeleton itself undergoes significant involution over the years. The bony support of the eyes, cheeks, and jaw actually starts to recede. This loss of framework compounds the hollowing and lack of projection seen in the older face. In our approach to patients undergoing face lift surgery, we must also expand our focus beyond simply the jowls and submental regions. The interplay between the lower face the lower eyelids, temples, and forehead should be assessed carefully. While additional procedures such as eyelid surgery and forehead lifting may contribute significantly to a comprehensive result, an effectively performed face lift should have the power to enhance the midfacial and lower orbital regions by itself.

Procedural Details In my practice, face lift surgery is an out-patient, day-surgery procedure. I generally favour deep intravenous sedation for anesthesia as it reduces the post-operative recovery period after surgery.



The incision is precisely marked out prior to surgery so that it may hide in the most favourable locations, thereby minimizing visibility. Placed within the first few rows of hairs along the temporal tuft, it is almost completely camouflaged in this region. As it courses along the junction of the ear and cheek, it is concealed within the natural crease. A millimeter cuff is left along the ear lobe to avoid distortion in this region, and then the incision is brought into the post-auricular sulcus and along the margin of the posterior hairline. I prefer this placement as opposed to extension into the posterior hair as it avoids any step-deformity in the hairline. Once healed, the incision is almost invisible when it is closed without any tensiom. I tell my patients that they will not have to hide their incision lines at all, and they will be able to wear their hair back or in a ponytail without hesitation. Producing a perfectly natural hairline, with near-invisible scars should be an achievable goal for all our patients undergoing face lifts. The skin is elevated in a subcutaneous plane, just above the SMAS and platysmal layer of the face. This layer is a fine, but sturdy layer upon which all the lifting is performed. Elevation and mobility of the SMAS is where all of the power of face lift surgery lies. The SMAS is incised along a line that extends from the angle of mandible to the malar eminence (or lateral-most projection of the cheek). The platsyma is then freed along its posterior border, inferiorly for five to six centimeters. The SMAS and platysma are elevated anteriorly in the deep-plane over the zygomaticus and masseter muscles as a continuous layer. Importantly, the zygomatic and masseteric-cutaneous ligaments are deliberately divided which allows for maximally mobility of the overlying soft-tissues. Following this maneuver, the SMAS and platysma are repositioned posteriorly and superiorly to allow for an incredible tightening of not only the neck and jowls, but also the malar cheek mound of the midface. This method is what produces a superior lift, but also an incredibly natural facial contour which is free from the appearance of any stretching or tension. When there is significant laxity of the platysma or fat deposition in the central neck, platysmaplasty (central tightening) and liposuction will be used in conjunction with the face lift.

Jamil Asaria 79


Figure 1: Blue line corresponds to the face lift incision line. Blue shaded area shows region of sub-SMAS elevation. Blue dots indicate location of zygomatic and massetericcutaneous ligaments.

Perhaps the greatest advance in my ability to produce exceptional results for my patients with face lift surgery is the addition of fat grafting during the procedure. While my technique for deep-plane face lift certainly elevates the fat pads of the cheeks to a higher position, the addition of volume along the hollows under the eyes, nasolabial folds and marionette lines, lips, and chin creates a much more youthful and natural appearance. When combined with the extremely powerful elevation of deepplane face lift, fat grafting gives me the ability to replenish volume and enhance my patients’ results to the next level. I consider fat transplantation to be the one of the most delicate components of the surgery and thus

I do it first. Fat is harvested extremely gently with a very fine cannula and under gentle pressure. It is hand-centrifuged to purify the fat while minimizing trauma to the cells and then meticulously injected micro-droplet by micro-droplet. With experience I have learned that the time and patience this requires is worth every ounce of effort.

Jamil Asaria

Complementary Fat Grafting


With this face lift technique, all of the tension is placed on the deeper layers and there is no pulling on the skin itself. After the repositioning, the skin is simply redraped, excess skin is tailored and then closed meticulously. No staples are used. Rather the incisions are closed with a combination of extremely fine 5-0 and 6-0 sutures which are removed on postoperative days 5 and 8 (Figure 1).

Summary In the end, no other procedure can “set back the clock” like face lift surgery. When we allow an individual’s inner vibrancy and youthfulness to be reflected in their face, it provides incomparable rewards for both the patient and the surgeon. As face lift surgeons we must remind ourselves that producing the most natural and long-lasting results are the paramount goals that our patients deserve. Every bit of effort must be spent to ensure that any visible signs of surgery are minimized. Gentle tissue handling during surgery and careful follow-up afterwards will reduce their downtime. The modern face lift must incorporate a marriage of art and science, and combination of the most advanced innovations with time-tested, proven techniques.



Daniel C Baker, MD

Daniel C. Baker, M.D. Professor of Surgery Institute of Reconstructive Plastic Surgery New York University www.danielbakermd.com



ost face lift techniques are a variation on a theme to tighten the deeper structures of the face and restore the facial foundation, and remove excess skin: Deep plane, high SMAS flaps, SMASectomy, and SMAS plication are the most common approaches. When I lecture, I do not say my technique is the best – I present it as a method that has worked well for me by giving consistently good, long lasting, natural results(10-15 years), with minimal complications and short recovery. I disagree that there is one best technique – rather, each surgeon employs what he has the most experience doing, to give his patients consistently good results. The technique is important but the surgeon’s surgical and aesthetic judgement is more important. As with most things, there are a number of ways you can arrive at the same conclusion.

Daniel Baker

APPROACHES TO Face lift There are several basic approaches to face lift surgery: the SMAS plication, the (high) SMAS flap, the lateral SMASectomy and the deep plane face lift. The latter has fallen out of favor with most plastic surgeons, but there is a group of surgeons who still utilize the technique or a type of variation.

THE 1970s: EVOLUTION OF THE SMAS TECHNIQUE In the Mid 1970’s an anatomical description of the SMAS (superficial musculoaponeurotic system) in the face was described. Plastic surgeons began elevating this layer of tissue as a flap beneath the skin in order to re-contour the face and elevate sagging tissues. Tightening this layer either by elevation and reposition, or by plication (sewing layers together) are still the most popular face lift techniques today. There are many variations and names given these techniques.


THE 1980s: DEEP PLANE TECHNIQUES In the late 1980’s several plastic surgeons described and advocated dissecting a deeper layer in the face which exposed the facial nerves. These techniques were named “Deep Plane”, “Composite”, and “Subperiosteal”. Although the surgeons stated these techniques gave better “more natural”, “longer lasting” results, I was never convinced to use them because the risk of facial nerve injury and weakness was greater. Also, I never thought the results they showed were superior to those obtained by simpler, less invasive SMAS techniques and plication. Today only a few surgeons employ these techniques.

THE 1990s: SMASECTOMY In 1992, I discovered an alternative to formally elevating the superficial fascia (SMAS)flap was to perform a “lateral SMASectomy,” by removing a portion of the SMAS in the region of its fixed and mobile junction. Excision and suturing of the superficial fascia in this region allows the surgeon to accomplish similar results to a formal SMAS flap, but the technique is simpler and less invasive. I continue to utilize this technique in many of my face lift patients. The width of SMAS resection depends upon the fullness of the patients face and if de-bulking is advantageous. HOWEVER, IN THIN PATIENTS SMASECTOMY IS NOT PERFORMED IN ORDER TO PRESERVE FACIAL FAT. Instead SMAS PLICATION is performed in these patients to augment and sculpt the face.

LIPOSUCTION In the 1980s liposuction was described and I continue to utilize open or closed liposuction in many of my face lifts when necessary. It has proved to be an invaluable technique for sculpting the jawline and neck and is an adjunct to my surgery. I have not yet found any reason to abandon liposuction as it was originally described finding no advantage or value with the newer laser assisted methods.

1995 IDENTICAL TWIN FACE LIFTS WITH DIFFERING TECHNIQUES: A 10-YEAR FOLLOW-UP Daniel C. Baker, M.D., Sam T. Hamra, M.D., John Q. Owlsey, M.D., Oscar Ramirez, M.D.



My comments: All twins appear considerably better than preoperatively. All results are holding up. My main thought: “finally deep plane and subperiosteal techniques have been demystified.” All those surgeons utilizing other techniques can feel relieved and confident with their personal choice. No doubt differences of opinion as to which variable is most important will occur. One point of agreement accepted by all of the involved surgeons, “find a technique which is consistent, predictable, reliable, and reproducible, with low morbidity and minimal risks and complications.”


Daniel Baker


At 10 years postoperatively Dr. Rod Rohrich commented that “what was the most impressive in the 10-year follow-up was everybody had a really good result, and what was most amazing was they looked more alike than different;“ there were more similarities than differences.” So what is it – the operator, the operation, or the patient – that is the variable most critical to determining the outcome in face lift surgery? Experts vary in their perspectives. Dr. James Stuzin said, “It is interesting to see the similarities in results with a variety of techniques. It makes you think it is not necessarily the technique but the surgeon that is able to get these good results.”


SUMMARY: This study was done to evaluate the efficacies of four different surgical techniques in facial rejuvenation. Two sets of identical twins were operated on by four different surgeons using four different techniques. The technical approaches to face lift included lateral SMASectomy with skin undermining (Baker), composite rhytidectomy (Hamra), SMAS-platysma flap with bidirectional lift (Owsley), and endoscopic midface lift with an open anterior platysmaplasty (Ramirez). All patients were photographed by an independent surgeon at 1, 6, and 10 years postoperatively. At the same time interval, the cases were presented and discussed in a panel format at the annual meeting of the American Society for Aesthetic Plastic Surgery. Each operating surgeon was allowed to critique the results and discuss how his methods had changed over the intervening 10-year interval. Postoperative photographs at 1, 6, and 10 years after surgery were published to allow the reader to examine long-term results utilizing various face lift techniques by four different surgeons in identical twins. (Plast. Reconstr. Surg. 123:1025, 2009.)

“Minilifts” have been around for almost a century; The first description of such a procedure was in 1919. These operations were usually small skin excisions with minimal undermining, resulting in minimal, short-lived improvement. But in the 21st century the concept of shorter incisions, combined with SMAS plication or SMAS flaps has gained popularity and produces longer lasting and better results. I developed my shorts scar face lift out of a demand from younger female patients (aged mostly in their 40s to early 50s) who sought facial rejuvenation but were adamantly opposed to any scarring behind the ears. They objected to the posterior hairline distortion, wide scars, and hypopigmentation that they often observed in their friends or mothers who had undergone face lifts. The primary advantage of the short scar face lift is for the young active female who often wears her hair pulled up or in a ponytail. It avoids scarring behind the ear with disruption of the posterior


The fillers and laser and “non-invasive” techniques are good adjuncts to our surgery and are certainly beneficial prolonging our results and postponing surgery but are NOT A SUBSTITUTE FOR WELL PERFORMED SURGERY.

hairline which makes such a patient unhappy.Since 1992 I have performed over 3,000 short scar face lifts with excellent long lasting results in properly selected patients. But this is not a technique to be used in patients with significant neck laxity and excess skin. To obtain the best result in older patients with excess neck skin classical face lift incisions must be used.

CORRECTING THE DIFFICULT NECK STILL THE BIGGEST CHALLENGE “YOU ARE ONLY AS YOUNG AS YOUR NECK.” The goal of neck contouring surgery should be a graceful looking neck, attractive by virtue of its simplicity rather than by its complexity. Why many surgeons prefer not to open the neck is obvious: less dissection, less bleeding, less complications such as hematomas. But in my hands trying to correct platysma bands and thick necks by only suturing the platysma laterally usually results in suboptimal neck contouring, recurrent platysma cords, and early recurrence of neck deformities. Under-corrected necks are the most common complaint from patients who consult with me after having surgery from another Plastic Surgeon. They usually say “My doctor did not correct my neck.” For 35 years this has been the most common mistake requiring a major revision after 1-1 ½ years. I have not yet found an effective long lasting technique to correct neck deformities without a submental incision and direct platysmaplasty with neck sculpting. Today I continue to open the neck on all patients with active platysma cords which contribute to the neck deformity.


Face lift LONGEVITY Patients often ask “Doctor, how long will my face and neck lift last?” When I see patients with good skin elasticity, I usually tell them the face lift I perform will last 10-15 years. Over that period of time they will get a certain amount of relaxation, but having done this for more than 35 years (over 8000 face lifts), I have a good idea of the longevity a particular patient will get. Many patients have returned to me for a second face lift, and some for a third face lift. Patients usually come back because they have some skin relaxation but when I compare their appearance 10-15 years after the original face lift surgery, they still show improvements in the facial, jowl and neck areas compared to their pre-operative photos. They want to maintain how they looked the previous 10-15 years, so they often have a second face lift and get another 10-15 years looking their best. I have a group of patients who have had 3 face lifts and are well into their 80s. They don’t look perpetually 40-50 but they look younger than their age, and natural. We all live much longer today and this group of patients remains active well into late 80s. Today we restore the facial foundation with SMAS flaps and plication. We sculpt the neck with platysma muscle flaps and defatting. We restore facial volume with autologous fat grafting and fillers. All this is accomplished before redraping and removing excess skin. Simultaneously we can do full face resurfacing with peels and lasers, and utilize Botox for wrinkles previously resistant to treatment. I usually combine all these procedures



Today most of the patients I see who look unnatural are not the result of bad plastic surgery. These patients present with over filled, overbotoxed, over lasered distorted faces that the lay population mistakes for bad plastic surgery. They have lips like guppies and faces shaped like Avatar. Their faces are so overfilled their smile is restricted. This is not the result of surgery! Many patients have had these non-invasive treatments spending years and great amounts of money for disappointing, poor unnatural results. Their cost and recovery downtime is often significantly greater than having a surgical face and necklift which gives superior, longer lasting results.

Although the debate continues about which rhytidectomy technique yields the best results, there is no single technique that is “best.” Most techniques are variations on a basic theme. What has clearly evolved in the 21st century is the trend to less invasive procedures with low morbidity, short recovery, and minimal scars. Most patients are happy with these new simpler techniques. I believe that deeply invasive, more radical techniques do not give better or longer lasting results. Results and longevity are more surgeon dependent than technique dependent.

THE GOLD STANDARD FOR FACIAL REJUVENATION I tell my patients that a well performed face and necklift combined with fat grafting or fillers, and skin resurfacing will last between 10-15 years, giving them a more natural look and be far less expensive than paying for fillers, botox, and laser over the same period. We as plastic surgeons have the ability to accomplish a superior natural facial rejuvenation in a more economical way than our non-surgical colleagues. The fillers and laser and “non-

Daniel Baker

invasive” techniques are good adjuncts to our surgery and are certainly beneficial prolonging our results and postponing surgery but ARE NOT A SUBSTITUTE FOR WELL PERFORMED SURGERY.


with the face lift surgery to obtain the maximum facial improvement with a natural appearance. One of the most common compliments my patients’ hear from their friends is “You lost weight, you look great.”

REFERENCE: Alpert, B.S., Baker, D.C., Hamra, S.T., Owsley, J.Q., Ramirez, O., - Identical Twin Face Lifts with Differing Techniques: A 10-Year Follow-Up. Plast. Reconstr. Surg. Vol. 123, No.3, March 2009.


Daniel C Baker, MD

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The Stem CellEnriched Face Lift

Dr. Renato Calabria

Dr Renato Calabria 436 N. Bedford Drive, Suite 200 Beverly Hills, CA 90210 Tel: (310) 777-0069 Fax: (310) 858-3150 71-511 Highway 111, Suite E Rancho Mirage, CA 92270 Tel: (760) 836-0077 Fax: (760) 836-0067 http://www.drcalabria.com/




ost of the current face lift techniques are based on some sort of variation of the traditional SMAS face lift with really minimal differences among the various types. The SMAS technique is based on a vector of pull which is, by definition, a horizontal or, at best, oblique. The final result is a flattening of the face creating a so called “wind-swept” look. Recently, fat grafting has been added to the face lift procedure in the effort to compensate for the flattening effect of pulling the skin tight in the wrong direction. The fat grafting has not improved the result of the SMAS face lift for the simple reason that it is placed in areas which have not been previously undermined by the face lift dissection (for blood supply reasons) thus not only limiting the effect of the volume enhancing effort, but also failing to deliver a natural result due to the location(fat is mostly grafted medially, in the naso-labial fold or the deep fat compartment). Additionally, fat grafting has an unpredictable resorbtion rate which affects the outcome negatively. The stem cell-enriched face lift is one of the most technologically advanced facial rejuvenation procedure available and combines a true vertical vector face lift with a volume enhancing procedure, using stem cell-enriched fat grafting. It differs completely from the SMAS facelift both in the vector of pull and in the location of the enriched fat grafting placement. Furthermore the stem cellenriched fat grafting appears to affect the longevity of the graft survival and it delivers a longer lasting result. Other important improvements like the facial hydro-filling, the tension-free closure, etc. make the stem cellenriched face lift a procedure that stands out as one of “the best and most innovative llternatives” among the current and most popular facial rejuvenation techniques.

Renato Calabria

Philosophy behind the procedure For a face lift to be successful, the ideal procedure should deliver a natural result, have a short down time, minimalcomplications, acceptable longevity, be easy to replicate, be applicable to most patients of different age groups, race, and type of skin and body habit.


Facelift techniques that don’t meet these standards may be trendy for a short while but eventually are self-obliterating. Most of all, it is important to educate the patient that there is no one technique that should be used for everyone. Each facial rejuvenation should be tailored to each patient’s needs.The art of face-lifting is choosing what is right for each patient. Having said that, there is definitely a shift in the conceptual understanding of what a face lift should achieve. From the skin tighten only procedure of the past, facelift has evolved to a more comprehensive approach where the tissue re-positioning has taken a secondary role, and the volume enhancing and skin rejuvenating features take a predominant importance. Of course, the magic is to find a perfect formula where all factors come together to create natural beauty.

Anatomy of the stem cell enriched face lift In order to understand why the stem cell-enriched face lift is different, a few anatomical concepts need to be clarified. It is also important to have a simple understanding of the aging process of the face. During this process, the gravitational force causes a vertical descend of the malar fat pad and mimetic facial muscles. In order to restore a more youthful anatomy and framework, the tissues should be re-position in the opposite direction of gravity, which means upward and vertically. Most face lift techniques may claim to have a vertical vector but, in fact, this is not so. In order to move tissues in a true vertical vector, a wide skin undermining is essential. SMAS face lift can’t afford to have a wide undermining of the skin because, anatomically the SMAS layer blends in with the skin in the medial aspect of the face and a wide dissection of the skin would end up disconnecting the SMAS from the medial insertion. Thus, without a wide undermining, the vertical pull is impossible to obtain.



This is the reason why most face lift have a horizontal pull of both the skin and the SMAS, perpetrating over and over the same mistake and creating the ‘Wind -Swept” look over and over again.

The “cellular” theory

Renato Calabria

One of the main limitations of the traditional facelift, in addition to the horizontal pull is that no matter what vector of pull the surgeon uses, the pulled skin looks always “Old”. This means that you can have a dress made and tailored to perfection but if you use an old, worn-out fabric, the dress is never going to look good. In the stemcell-enriched face lift, the attention is shifted to the texture and turgor of the skin. From previous fat grafting experience, it has been noted that the skin appears rejuvenated after fat grafting. With the discovery of stem and regenerative cells in the adipose tissue, it has been postulated that it is their action that enhances the skin texture and improves its quality. Further work has made adipose derived stem cells available in higher concentration trough an enzymatic process which breaks down the fat into to the Stromal-Vascular Fraction. Concentrated regenerative cells can be used in conjunction with fatin the same way fat alone is used. A longer survival rate and improved result of skin rejuvenation has been noted with the use of the “turbo-charged” fat. The Stem cell-enriched face lift uses this type of regenerative cells for volume enhancement and tissue rejuvenation.

Unique features of the Stem cellenriched face lift. The unique aspects of the Stem Cell-enriched face lift are: 1) Facial Hydro-filling and wide supra-mimetic muscle undermining of the skin flap. 2) Vertical Orbiculo-Zygomatic-levator labii-platysma pexy. 3) Sub-SMAS, Sub muscular and sub periosteal placement of Stem Cell-enriched graft. 4) Tension-free skin closure with triangular tragal and post-auricular flaps closure. All these features are different to most of the other facelifting techniques.


Technique details Facial hydro-filling and wide supramimetic muscle undermining of skin flap with electro-cautery.

Facial hydro-filling consists of filling the superficial dissection plane under the skin with a solution similar to the one used for liposuction. The injection is done with a blunt micro-cannula to avoid excessive bruising and bleeding. Approximately 120 cc of fluid is used. This maneuver creates a virtual plane of dissection and makes the dissection itself easier to perform. An electro-cautery with a Colorado needle tip is then used instead of a knife or scissors. This sharply minimizes post-operative bruising, bleeding and hematomas. The plane of dissection is deeper than in traditional facelift and it is right off the SMAS and facial muscles. This allows todevelop a thicker skin and subcutaneous flap and the more elegant dissection creates a more uniform plane and less risk of creating an irregular contour. Furthermore, by leaving all the subcutaneous tissue on the skin flap and not over the musclesas it is most commonly done, there are less chances to cause any vascular compromise post-operatively. The extent of the dissection is fundamental to the success of the face lift because only through a wider dissection is it possible to re-position the mimetic muscles and fat pad vertically. Pre-auricular, it is to the naso-labial fold and over the entire cheek area. Postauricular, it is carried over the mastoid area down to the neck almost for the entire length of it and to the medial edge of the platysma. The vertical orbicularis oculi- zygomaticuslevator labii-platysma pexy

A true vertical plication of the facial mimetic muscles and fat can be accomplished only by elevating a much wider skin flap,. Most of the SMAS techniques and their variations limit the undermining of the skin for anatomical reasons. A wider dissection in the cheek would interfere with the medial attachment of the SMAS layer itself and is therefore not possible. After the elevation of the SMAS, the SMAS itself can only be re-positioned with a horizontal or, at best oblique vector, thereby creatingan unnatural look. In the stem cell-enriched facelift, the orbicularis oculi , zygomaticus muscles along with the elevators and the cheek fat pad are plicated with a true vertical vector. There is no lateral pull at all. Only the lateral edge of the platysma is re-positioned with a


Levator*labii*superioris Orbicularis*oculi

Zygoma6cus* minor*and major** Platysma

! Anatomy



Area undermined



Renato Calabria

Orbicularis!approached!through subciliary!incision


Ver$cal(vector of(li.


cell-enriched fat grafting

lateral vector but because the original framework of the face is re-created trough the vertical pull, the lateral plication is almost obsolete until the neck area is reached. With the vertical plication a dramatic improvement in the downshift of the corner of the mouth is obtained along with the re-positioning of the entire cheek area. This is very noticeable by comparing it with the opposite cheek. Because the vector of pull is diametrical opposed to the gravitational aging force, a much more natural result is obtained. Sub SMAS- Sub muscular and subperiosteal placement of Stem cell-enriched fat graft

The aging facial process consists not only of the gravitational descent of existing muscles, fat and skin but also atrophy of the existing tissues and thus loss of volume of the face. Even though the vertical re-positioning of the muscles delivers a much more natural result than the traditional horizontal pull, it is still not perfect. By definition when you approximate two points, no matter which vector is used, a flattening of the surface between the two points occurs. So two phenomena occur: one, the natural loss of volume due to aging and two, the iatrogenic (surgeon-induced) flattening due to the re-positioning of the existing tissues. This is one of the reasons why a filler such as fat is useful to mechanically counter the above mentioned effects.. The second and more important reason for using fat or, even better, the stem cell enriched-fat is the potential rejuvenating action of the adult adipose derived stem and regenerative cell. The fat is harvested with syringe-liposuction. In the stem cell-enriched face lift, the stem and regenerative cells (the so called stromal-vascular fraction) are isolated trough an enzymatic process and then the fat is enriched with the SVF cells. Latest literature evidence seems to support the fact that stem cell-enriched fat has a longer survival rate then fat grafting alone. The unique feature of the Stem cell-enriched face lift is the placement of the turbo charged fat. This is done through blunt micro canula underneath the SMAS layer, the mimetic muscles and the platysma and also subperiosteally in the cheek area, the angle of the mandible (transbuccal) and in the orbicularis orii area. The placement of the stem cell-enriched fat in this fashion ensures survivability because of the highly vascularized patterns of these areas. The stem cell-enriched graft has two main effects: the first is purely mechanical, to fill the empty space created by deflation and atrophy of the aging face; the second is regenerative, to improve the turgor and texture of the skin itself.



Zygoma'cus+minor++ Zygoma'cus+major++





Levator+labii+superioris Orbicularis+oculi




Renato Calabria



The stem cell enriched face lift interprets a totally different conceptual philosophy of the ultimate facial rejuvenation.�



The tension-free face lift closure














The tension-free face lift closure

Renato Calabria

There is no question that tension applied to the closure lines is the major cause of hypertrophic scars in face lift. Without tension though, the results are not long lasting. In the effort to minimize hypertrophic scarring yet maintaini an adequate pull on the skin flaps, a new technique is used. At the time of closure, when the skin flaps are re-draped over the face, instead of excising excess skin once anchoring sutures are placed, the excess skin in the temporal and post-auricular areas is partially de-epithelialized for the entire length. Two small separate incisions are made in the temporal and mastoid areas and tunnels are created at the subcutaneous level on the opposite side of the traditional anchor points. The tunnels are big enough to accommodate the de-epithelialized portion of the flaps. The flaps are then pulled through, tension is adjusted appropriately and the flaps are anchored in place (dermis to fascia) with absorbable sutures. Excess skin is then removed from the rest of the flaps and the rest of the incisions are approximated in the standard fashion. In this fashion two suspender flaps are created to sustain most of the tension which shifts from the entire length of the incisions to the de-epithelialized portion, allowing a tension-free closure in the remaining incisions. In conclusion, the stem cell-enriched face lift interprets a totally different conceptual philosophy of the ultimate facial rejuvenation: it consists of a tri-dimensional face lift with a new vertical vector re-positioning of the existing tissues, combined with a volumeenhancing augmentation using stem cell-enriched fat graftis at a deeper planeultimately delivering skin rejuvenation due to the effect of the regenerative capacity of adipose derived stem cells.


MAG-5: Upper and Mid-Face Rejuvenation

Dr Adil Ceydeli Dr Robert Flowers

Adil Ceydeli, M.D., M.S. Double-Board Certified Plastic Surgeon Plastic Surgery Institute & Spa, Panama City, Florida ceydeli@ceydeli.com www.ceydeli.com



Ceydeli & Flowers

n order to achieve the most natural results through a facial rejuvenation procedure, we, plastic surgeons, must know how to analyze the face, and deliver a personalized surgical plan for every individual patient. There is no cookie-cutter/one fits all face lift technique. Generally speaking, most of our patients come asking for a more refreshed, younger look. Most of the time they don’t come asking for an improvement on their jowling or midcheek alone, rather they want an overall improvement. Frequently, when older patients come for a consultation, they mostly write “face lift” on the medical chart by way of past surgical history. Only upon further questioning would they admit to having had a brow lift and eyelid surgery, taking this to mean a “full face lift”. It is not that patients are trying to conceal their past history – it’s just that they really do think these are part and parcel of a past face lift. Is there a patient who is properly educated by their surgeon and able to afford an aesthetic procedure that would ask for a jawline and neck improved, but wouldn’t care about their droopy eyebrows and baggy eyelids that give them an older, tired look? They all want to look more refreshed, natural, and a younger version of themselves. Nobody wants the tight, windswept look, and nobody wants to change their facial characteristics and look like someone else ( if a patient requires something different, I personally choose not to operate). Certainly, we all have a choice: they, to select another surgeon and I, not to operate on every patient. A patient and their surgeon need to be in agreement and in agreement on most aspects of the procedure. Coming back to the analysis of the face as a whole, this is divided in five different sub-units: upper face, mid face, lower face, peri-oral region and skin. The upper face consists of eyebrows and forehead, the mid face includes the cheek tissue as well as the upper and lower eyelids, the lower face of the jowls and neck, the peri-oral region of the lips, downturned mouth corners and chin, and lastly, the skin itself is treated as a separate unit on the face. There is not a single procedure or operation on the face that can rejuvenate all the sub-units at the same time. Most patients are

Fig: The aging face


not aware of this, but they ought to be prior to signing up for any kind of facial procedure. It’s our job to analyze their face, show them all the imperfections that we feel comfortable improving, and then tell them what facial procedure will improve which area or areas of the face. All patients should be aware that “face lift” is a catch-all word for a total facial rejuvenation, and all surgeons should remember that a face lift is not a cookie-cutter procedure that will benefit all patients.

So what facial procedure is needed to correct which area or areas of the face? The upper face requires a browlift procedure. A face lift will improve part of the mid face (excluding the eyelids) and the lower face/ neck. The peri-oral rejuvenation consists of lifting the downturned corners of the mouth/lips, lip shortening in selective cases, dermal fillers to define lip borders (never fat, never silicone, never lip implants, the reasons for which are outlined further down) and chin augmentation, again in selective cases. Finally fractional CO2 laser is the gold standard to improve the skin texture and quality. Even the best face lift will not lift the brows, get rid of the eyelid bags or correct the droopy corners of the mouth, anymore than a beautifully done brow lift would address the aging neck. And even if a surgeon performs all of the procedures, but fails to treat the skin, the patient would end up with a rejuvenated, younger looking face, covered with older skin. So we have to decide what to address first. Of course what the patient wants is important, but only when she or he is well informed. If the patient comes asking for a face lift, but in actuality wants an overall improvement of the face, and just happens to refer to the facial rejuvenation as a “face lift”, then face lift may not be the most appropriate course of action. On the other hand if a patient states that she or he hates their “turkey neck”, but is at the same time well aware of the deep forehead wrinkles caused by droopy eyebrows (typically covered by a fringe), that patient is a good candidate for a face lift procedure.



In my opinion, upper and midface, particularly the eye region, along with the mouth area, are the most important parts of the face that need to be addressed first, even though most of my patients come to my office asking initially for a face lift consultation. We all communicate by looking into each others’ eyes or moving lips. How many people do you see looking at your neck during conversation? Almost none. Why are there so many women obsessed with their necks? Because they have looked at a picture of themselves, especially if the camera has caught them in profile, and noticed the sagging. They start paying more and more attention to the neck, completely ignoring other tell tale signs. I see so many patients with significant brow asymmetry, one eyebrow being lower than the other, but not really significantly enough to notice from a distance. Most patients are not aware of significant asymmetry in their mid face until I point it out during the examination - because they’re so preoccupied with their neck. There is a very similar analogy for women asking for breast implants. Female patients come for a consultation because they want to recapture the fullness of their breasts during pregnancy, believing implants to be the fix and overlooking a very important detail: the loose, saggy skin is due to deflated breasts. For whatever reason, it is very difficult for women (especially younger ones, age 30 or less) to admit that they need a breast lift. They think putting those silicone implants will be the perfect procedure with minimal scarring. Nobody wants a scar on their breasts, even though I exclusively perform short scar lifts. Not only is it wrong to put huge implants to fill the loose skin envelope, but in my opinion, it is blatant malpractice. Yet there are plastic surgeons out there who still place lage implants in droopy breasts, just because that is what the patient has requested. And so it is with the face. Should we perform the same procedure on every face, even though it is not the right one? My position is: better lose a few patients but get great results by choosing the right procedure.

...even if a surgeon performs all of the procedures, but fails to treat the skin, the patient would end up with a rejuvenated, younger looking face, covered with older skin.”

The MAG-5 procedure The MAG-5 procedure along with the Valentine mouth rejuvenation, described below, can address almost all of the sub-units of the face apart from the neck. The MAG-5 procedure was initially developed by my mentor Dr. Flowers, and we subsequently published the technique in the “Clinics in Plastic Surgery” journal (1) as well as presented it at numerous conferences. MAG-5 consists of a coronal brow lift, forehead rejuvenation, removal of the corrugator (frown) muscles, upper and lower


Droopy eyebrows causing forehead wrinkles, and interfering with vision due to lateral hooding of the eyelids


blepharoplasty along with lower eyelid tightening (canthopexy) and subperiosteal mid cheek lift. All the components of this technique are intertwined and performed together in a single setting. Brow lift, forehead rejuvenation, and upper blepharoplasty can be done as a stand-alone procedure, however if the lower eyelid needs to be addressed, this should be done with the rest of the MAG-5 to achieve the best results. I personally do not perform isolated lower eyelid procedures anymore. One sees many botched eyelid surgeries from insufficiently trained surgeons who seem to believe that eyelid surgery consists of simply cutting the excess skin, removing the fat pads under the lid, and suture the skin, all of which is the absolute worst a surgeon can do to a patient’s face. Botched eyelid surgery is impossible to hide and fixing it is even more complicated than doing it right in the first place. Botched eyelid surgery results in either ectropion (a condition in which the lower eyelid turns outwards), with too much sclera (the white of the eye) showing laterally and with round looking eyelids, and/or a hollow look with an exacerbation of the tear trough deformity. Ectropion is due to too much skin removal, lack of canthopexy sutures and lack of midcheek support. Hollow eyes are the result of too much fat removal, absence of canthopexy and midcheek support to cover the tear trough. The Mag-5 procedure will prevent these problems from occurring while giving patients the most natural and rejuvenated eyelids and face. As we age, the eyebrows lose their secure attachments to the bone, and start sagging. Sometimes this sagging is so severe that, it interferes with the vision, and the person constantly raises the eyebrows in order to see, which creates deep forehead wrinkles. The frown muscles between the eyebrows further exacerbate the problem (2, 3). The coronal brow lift component of the Mag-5 will lift the eyebrows to their natural position, giving them a youthful and sexy arch (3). The removal of the frown muscles during the brow lift improves the deep frown wrinkles in between the brows. This eliminates the need for botox in the glabella lines, because there is no muscle to inject any longer. Lifting the brows minimizes the need to raise them constantly (we raise our brows to compensate for

Change in eyelid shape and tone due to loosening of its attachments to the bone


Aging lower eyelid

A botched lower eyelid surgery was performed by another surgeon without canthopexy, which is a vital component of any lower blepharoplasty.

The tear trough deformity under the eyelid was corrected by MAG-5 procedure

Ceydeli & Flowers

loss of vision when they are too low) which in turn improves or even altogether eliminates transverse forehead lines/wrinkles. The eyelids are securely attached to the bone with tendons and ligaments. With aging, these secure attachments get loose, and the lower eyelids start to sag. The beautiful and youthful almond shape eyes then become round and tired looking, with excess skin and fat bags. The lower blepharoplasty component of the Mag-5 procedure eliminates skin excess conservatively and helps improve under eye bags by either repositioning the fat or removing it partially. A canthopexy is a vital component of the Mag-5, restoring the youthful almond shape of the eyes. Doing anything to the lower eyelid skin without recreating its tone will make matters worse, and will cause the “round eye” deformity, as shown below. This lady underwent a traditional lower eyelid surgery, which did not address the lower eyelid tone. She lost her excess fats, however ended up with round, hollow, and more saggy eyelids. Tear trough deformities are present in half the people asking for blepharoplasty. This can only be corrected by filling in the anatomical defect by properly done mid-cheek lift, which is another vital component of MAG-5. Mag-5 ‘s midcheek lift differs from the traditional facelift. Instead of pulling the face eastward and westward, Mag5’s subperiosteal midcheek lift raises the face northward, repositioning the tissues rather than pulling them sideways. All these components are performed as a single surgery, giving the entire face a rejuvenated, natural and refreshed look. The results are also far longer lasting than with traditional facelifts because we don’t rely on the skin for support - rather, the tissues are suspended to the cheek bone for more secure and longer lasting fixation results. The incisions are essentially invisible, because the eyelid incision is placed right under the lash line, while the forehead incision is within the hairline. The only drawback of Mag-5 procedure is the longer recovery period – 2-3 weeks - due to the extent of surgery in the area of the eyes. The flipside of this is that the results are not only longer lasting but also get better with time.

Another botched eyelid surgery performed by another surgeon, which caused significant ectropion. This severe complication was corrected by canthopexy and subperiosteal midcheek lift components of MAG-5 procedure.


Several before and after results of MAG-5 procedure:




Several before and after results of MAG-5 procedure:




If the Mag-5 procedure is performed competently, it is complication-free and can also address complications that might have arisen from previous procedures. Mag-5 is an outpatient procedure which takes about 4 hours, with the patients being able to go home after surgery. A pressure bandage is applied over their eyes and forehead for the first night and the dressing is removed on post-op day 1. Eyelids sutures and scalp staples are removed after one week.

Valentine mouth rejuvenation The mouth is one of the most important aesthetic units of the face. Along with the eyes, it is one of the primary foci of human communication. It has the power to override eye messages, and owns the dominant role in broadcasting the disposition. Due to abundance of fillers on the market, as well as doctors lacking the aesthetic touch, one sees a multitude of what is commonly referred to as “duck lips�. The sad thing is, many patients seem to think their lips look good and even sadder, their surgeons do too. Problems cannot be fixed if neither patient nor surgeon is able to see them as such. The basic mistake many surgeons make is to focus excessively on lip volume, hoping that in making the lips bigger, they would fix all the age-related issues in the mouth area. Injecting fillers in a lip, particularly the aging lip (30 years or older), is like inserting an implant in a saggy breast. The lip may be bigger but not prettier. What happens when the lip ages along with rest of the face? It doesn’t just get smaller, it also loses its natural curves and shape. With age the corners of the mouth start turning downward, resulting in a sad, grumpy look. The upper lip also elongates with age and the distance between the base of the nose to the lip border increases. Because of this, the lip literally disappears inside the mouth as does the vermilion border. Skin quality around the mouth also changes with age, and vertical lip lines start showing even in people who are not smokers. The end result is elongated, thin lips with no definition, downturned mouth corners and multiple vertical smoke lines on the upper lips. Valentine mouth rejuvenation is an easy, office based procedure, performed under local anaesthesia only, and it addresses every single component of the aging mouth. Valentine mouth rejuvenation consists of lip lift (corner of the mouth lift, upper lip shortening or both), injection of soft tissue filler (to the lip lines and vermilion border only), and peri-oral CO2 laser resurfacing of the skin of the mouth.


Due to abundance of fillers on the market, as well as doctors lacking the aesthetic touch, one sees a multitude of what is commonly referred to as ‘duck lips’.” DISSECTING THE FACELIFT

Unnatural duck lips created by a surgeon who is not well trained in mouth region.

Ceydeli & Flowers

Upper lip shortening performed in selected cases to restore the natural volume of the upper lips.

Injection of the soft tissue filler to the lip lines (vermilion border, cupid’s bow, and philtral columns)


Several before and after results of ‘Valentine mouth rejuvenation’


Above: CO2 laser resurfacing of the skin around the mouth

Ceydeli & Flowers

Valentine procedure. A lop sided heart shape skin is removed from the corner of the mouth, and when the defect is closed, the downturned corners are corrected, and the sad/ negative line is converted to a happy/positive one.


A small lop-sided heart shape skin is removed from the corner of the lip and when the skin is sutured, the negative line becomes a positive one. If the upper lip is thin due to elongation, an upper lip shortening is performed, and the natural volume of the lip is restored by shortening the distance between the base of the nose and the lip line. Soft tissue fillers are only used to redefine the vermilion borders, the cupid’s bow, and the philtral columns (the vertical groove in the middle area of the upper lip). Essentially no filler is injected into the lip itself, thus avoiding unnatural results. The end result is naturally full, well defined, sexy lips. See several before and after results of Valentine Mouth Rejuvenation procedure. The vertical smoke lines are addresses by CO2 laser resurfacing, not by pumping up the lips with fillers. The Valentine Procedure is not advised for surgeons who lack extensive experience/background in aesthetic surgery. After all, I, as a plastic surgeon, would not make a good brain surgeon for the same reasons. The ready availability of a syringe of a soft tissue filler to general medicine doctors, dentists, or dermatologists, does not mean that they should be offering lip rejuvenation, if the goal is to create youthful, attractive, and most importantly, natural lips.

References: 1. Flowers RS, Ceydeli A. Mag-5: A magnificent approach to upper and mid-facial “magic”. Clinics in Plastic Surgery 2008; 35(4):489-515 2. Ceydeli A, Duong TC, Flowers RS. Upper blepharoplasty. In Farhadieh RD, Bulstrode N, Cugno S (editors): Plastic and Reconstructive Surgery. Oxford, UK, Wiley, 2015. 3. Flowers RS, Ceydeli A. The open coronal approach to forehead rejuvenation. Clinics in Plastic Surgery 2008; 35(3):331-51.


Dissecting the Face Lift The suture suspension scarless Face lift

Dr Des Fernandes

Dr Des Fernandes 3F Renaissance Body Institute Bree Street, Cape Town 8001 South Africa Tel: 021 424 4868 Email: info@drdes.co.za http://www.drdes.co.za/




he classical facelift, especially when combined with fat grafting, can give quite amazing rejuvenation but there are many people who are not excited by the idea of a long operation and a potentially protracted recovery period. There are others who start becoming concerned about their face as facial aging commences and when they go to the plastic surgeon they are told that they are still too young and should come back in 10 years time. I thought about this for a long time and eventually realised that we had to look at facial rejuvenation in a totally different way.

Facial aging and the rationale for the scarless Face lift.

Des Fernandes

I believe that if we look carefully at early aging then what we should recognise is that photoageing of the skin means that the skin envelope looses its elasticity and tightness and cannot hold the deeper tissues in their correct place and so the skin can sag. That is why every facial rejuvenation has to be accompanied by a scientific skin care regime based on vitamin A combined with antioxidants and selected peptides. Vitamin A is the only known molecule that actually rejuvenates skin from the basic cellular mechanisms. Certain peptides help to build greater density of structural fibres of the skin. Jenny Munro and I wrote called “YOUR SKIN FACTORY” where we liken the production of healthy beautiful skin to a factory to help people understand that they have all the “machinery” to make good skin and just need the right raw ingredients. This book is essential reading for people who want to do their best to rejuvenate skin. I advise people against all laser-skin tightening procedures but I recommend skin needling to give the most natural rejuvenation of the facial skin. You can also learn more about skin needling in “WHY YOU NEED SKIN NEEDLING” - a book written by Matthias Aust, Jennie Munro, and I . I started skin needling research in 1996 and I believe it is the most effective, safest skin treatment that is the only one that actually regenerates normal healthy skin.



Figure 1 shows a young face with the fat of the cheeks in their normal high position to produce a padded cheekbone and covering the lower edge of the bones surrounding the eye. Figure 2 demonstrates the descent of the cheek fat that creates the groove below the eye and flattens the cheekbone, causes the groove at the sides of the nose downwards and turns the corner of the mouth downwards. Red lines show the position of the non-absorbable polypropylene loops used to pull up the cheek fat. Blue lines show the secondary tightening with polypropylene “square sutures to lift temple and tighten the lateral cheek.


As we get older we gradually lose bone as well as the fatty tissues and so our face sags and becomes deflated. Our mid-face start sagging towards the lips as shown in the diagram. I believe that this happens more in people who sleep on their side as compared to people who sleep virtually the whole night on their back. I believe that when we sleep on our sides, our pillow pushes the skin towards the nose and because we spend a long time stressing and stretching our deep facial tissues we eventually rupture the fine fibres that hold our deep facial fat in position. Ideally we need to restore the function of those fibres and hold the fat in its original position. That is the origin of the suture suspension loops which aim to reconstruct these supportive fibres. The concept of reconstructing the fine retaining fibres is what lead to the idea of the “scarless” face lift in1994. I soon realised we need a specially shaped pillow to avoid the deforming effects of the standard pillow. Therefore I designed a pillow that applies pressure only on the temple and below the jaw line and the facial tissues are not distorted at all when one sleeps on one’s side. This pillow also allows my patients to sleep on their sides after their operation without spoiling my reconstruction. Of course that is somewhat simplistic because at the same time we are resorbing deep bone, and also losing fat which deflates the face and can only be masked by well judged fat grafting or fillers. I believe that fat grafting should be done either in conjunction with the scarless suture suspension face-lift or at another time to get the ideal rejuvenation of the face.

The consultation The most important thing I want to know from my patient is what troubles them when they look in the mirror. That then becomes important in devising a strategy to make them feel happier. Not everyone wants all the signs of facial ageing to be erased or improved. Many people come in and have some facial ageing but their main focus is only the crow’s feet. Others come in and they only want their neck improved. I have to find out what I need to do to satisfy my patient’s needs. Once I know what the main concern is then I proceed to analysing the face.

Facial structural analysis

Des Fernandes

With this analysis of the face I can discover what is the most effective way of achieving the patients wishes and then we discuss the surgery that I would advise. It is always important to remember that one cannot always achieve the perfect result especially if the patient has not been entirely open about the degree of change they really want. Some people come in wanting the smallest operative procedure yet expecting the greatest degree of change. By collaborating well with the surgeon, I believe the patient stands a greater chance of getting what they want. I tell my patients that we are now embarking on an adventure together which is why I like my patients and I to be on first name terms. I give the patient information about the operation and explain that they will be swollen for a period of time. I also explain that in the beginning one may notice some indents and bulges that will either melt away as the swelling disappears. In some


1. I like to start at the top and I check the quality of the hair and hairline, the width of the forehead and the presence of horizontal lines. 2. That helps me to understand the natural position of the brows which then help me to understand the upper eyelid. 3. By analysis I can deduce how much excess skin and hooding etc really exists on the upper eyelid. I must also check for any fat bulging on the upper eyelid, especially on the medial side. 4. I also have to see how laxity of the temple area affects the lateral eyebrow and the presence of the crow’s feet. 5. I check if there is any sign of a “water-bag� which is located below the side of eye on the bone of the cheek. Some people inherit this and it makes them look tired. The importance of noting this is that after an operation they may become more swollen for a protracted time. They need special attention. 6. Of course I must also see how much fat seems to be bulging on the lower eyelid and then I assess the depth of the so-called tear trough leading from the middle corner of the eye onto the cheek (the naso-jugal groove). This often splits the cheek into two bulges and makes the face look particularly tired. 7. The lower eyelid is affected enormously by the descent of the normal fat accumulations on the cheek and cheek-bone. I believe these areas are distorted towards the nose by the way that we sleep on our sides on an ordinary pillow. Take a mirror and look at your face when you lie on the side and you will see how you are aging. Notice how the vertical lines of the upper lip are accentuated. I believe your pillow causes those lines, not gravity. As the fat descends the nasolabial gooves and skin folds get more prominent.

Many people develop this when they are young adults. 8. I also check the jowls and see how much of their prominence is the result of lax skin in front of the ears. 9. At the same time I look for the slightly curved vertical creases in front of the ear. These are classical signs of loss of elastin and collagen in photoageing. 10. The neck is often improved when one corrects early stages of facial aging. However, I need to understand the degree of laxity of the skin under the chin, the prominence of the vertical platysma folds that demarcate the medial edge of the important platysma muscle of the neck. 11. One also needs to check the skin in the lower neck that generally is un-responsive to the classical face lift.


Figure 3 and 4 Figures 3 and 4 demonstrate the scarless Brow-lift before operation and 12 months after the operation and the effects of vitamin A based cosmetics for 14 months

cases we have to do minor degrees of traction and for that we might have to use a local anaesthetic injection. There is always the possibility of getting an infection but this is extremely unlikely. One thing I like to stress is that we work to make the best result possible but we are dependant on their skin holding on to the traction that we place on the tissues. Not all tissues are equally strong and in some, the threads “cut” through the tissues and one loses some of the tension. I explain that if that should happen then we wait a period of say 3 to 6 months and then retighten the threads with a relatively small operation on the temples. Finally I explain that this type of surgery is totally different from the classical full face lift in that it can be serviced and maintained in optimal state by tightening the tension when it is necessary. That is a major advantage over the standard Face Lift. However, what I have found is that this operation is also useful for people who have had a facelift and want the effects to be restored. The major advantage of the scarless face-lift is that it can be done a in a “modular” manner and so I will describe an illustrate each of these modules

The scarless Forehead lift By using a series of nylon threads in a loop, or as a square shaped sutures one can lift and shape the eyebrow. This I done through small (2-3 mm) incisions at the hairline or in the hairline. Targeted sutures can be used to shape the eyebrow. (see illustration) Tunnelisation under the skin helps the skin to tighten up even though the distance between the


hairline and the eyebrow has been shortened. Similar suture can be used to tighten the skin of the forehead if necessary. Unfortunately tunnelsation particularly can cause bruising post-operatively. However, the bruising passes within a few days but the results last for very many years. I know that this procedure can be extremely painful in the first 24 hours and that is why I specially anaesthetise the forehead nerves for the first day. After that the pain is tolerable and disappears within a week to 10 days. This operation lifts and shapes the brows and often removes all the excess skin that seems to be on the upper eyelid. If there is more excess skin then I advise patients to wait about six months for the brows to settle before we can accurately remove the skin from the upper eyelid. Many patients ask me to do the two operations at the same time and in these cases I have to guess the real amount of excess skin that is present. However, I use the tarsal plication technique for the upper eyelid and so exact precision is not as critical if I err in taking slightly too little skin from the upper eyelid. The tarsal plication technique is also a procedure of restoring the natural anatomy and is not a “skin tightening” procedure.

The scarless temple lift (I call this the “Horibe” suture after two Brazilian plastic surgeons who instigated the idea). I use a series of about four tiny incision in the hairline to place square suture loops to lift and tighten the temple and lift the lateral eyebrow and reduce the appearance of the crow’s feet. I think this is one of the most useful procedures in cosmetic surgery

Figure 5 and 6 This shows the tightening achieved of the lateral eyebrow and the crow’s feet one year after scarless temple tightening. The results are amplified by the consistent use of vitamin A based cosmetics . (*Environ Skin Care)


of the face and I do it in virtually everyone I operate on. Unfortunately too few surgeons around the world understand the value of this technique. Patients can usually have this operation and no-one else knows even the same evening. It is sore in many people and some say it feels like a vice is gripping their head. The pain disappears within a week but some people are aware of the sutures when they cough or sneeze for several months after the operation. In some people the operation can last for many years and the longest I have observed is about 10 to 12 years. However, it is a relatively simple procedure that is easily done in the office at minimal expense if necessary.

The extended sideburn and temple tightening

Des Fernandes

I use this procedure for people who want minimal surgery and maximal refreshing without much downtime. This is a very useful procedure if people want to freshen up for an important date and don’t have too much free time. After tightening the temple I add a few extra tiny incisions amongst the hairs of the sides of the head and insert some extra suture loops that extend to the area behind the cheek bone and I lift and tighten the cheek as well as the skin in front of the ear. I like using this technique for people who have had a facelift and want a smaller touch up with minimal down time. It can be a useful procedure to reduce the appearance of the water-bag because it tightens the skin lateral to the water bag and smoothens it out. Fortunately this is generally not much more uncomfortable than the temple tightening. I occasionally see a little bulge just behind the cheekbone in the initial period, which is from the swelling of the tissues that have been tightened. This usually settles after a few weeks. The downtime is only 3-4 days and the discomfort rapidly disappears. It is done best about a month before an important date to be sure a flawless appearance. The extended sideburn tightening gives much more global tightening of the face and for many people it is an affordable and effective rejuvenation, especially for people who don’t want too much change or have minimal signs of aging in the mid-face.


The Scarless Mid-face-lift This is one of my most frequently requested operations. Younger patients in their thirties and early forties are presenting to the plastic surgeon because they want to reduce the early tear-trough shadows that run obliquely across their cheeks, and eradicate naso-labial grooves that make them looked tired and jaded. This droop of the mid-face results from the medioinferior descent of malar fat and Sub-Orbicularis Oculi Fat. There is a loss of the “ogee” curve of the face and in order to restore a youthful appearance to the face the surgeon has to reposition these two essential “padding” structures. However, this is not achieved even with the standard full face-lift, which tends to address the lower face and hardly deals with the mid-face. Improvement of the sagging mid-face can only be achieved by re-positioning of the malar and SOOF pads. We cannot directly approach this area without causing noticeable scars and because we are aesthetic surgeons we have to try and do this with virtually no scars. I believe the solution is to anchor the tissues of the cheek with loops of non-absorbable sutures, to the temporal fascia on the side of the head and avoid making visible scars. I call this “Suture Suspension Loops” which I started doing in 1994. Alternatively, or in combination, one can use specially designed anchoring threads to lift the midface tissues. I have tried various types of these threads but I prefer Silhouette threads sometimes alone but usually in combination with suture suspension loops. I believe that this is the real base of all face-lifts but sadly is not appreciated by many surgeons who do the standard face lift that is not effective in lifting the tissues of the midface and lightening the folds running from the nose lateral to the mouth down to the jowls. I often see people who have a somewhat strange appearance because their face seems tight but the corner’s of the mouth droop and the nasolabial folds are too prominent. That is because the fat of the mid-face has not been restored to its youthful position. I started using suspension suture loops in about 1994 to bring the cheek fat back into position and restore the natural “ogee” curve of the face as seen in the ¾ view.


Figure 7 Dissatisfied patient 2 years after standard facelift and before starting vitamin A based skin care* . (*Environ Skin Care) Figure 8 1 year after a Scarless midface and temporal lift plus skin care to produce more convincing rejuvenation.

Des Fernandes

I use 4-6 stab-incisions in a special pattern behind the temporal and side-burn hairline to position a number of 4/0 non-absorbable suspensory sutureloops, with a special technique using only a needle. That allows me to easily lift the malar and suborbicularis oculi fat to create a youthful lower eyelid and ogee curve to the face. Traction on these tissues will eliminate the jowls and improve the corner of the mouth. This creates the classical “ogee” cheek contour. The principle is surprisingly simple but does cause swelling of the facial tissues. One of the major advantages of this procedure is that the anchoring area can be marked with silicon or even metallic rings and then at a later date, when the tissues start to sag again, they can be tightened up with a small operation in the temporal area without any signs of surgical intervention in the face. This is a unique feature of the technique and stands out as an important difference from virtually all other facelift operations. I like to use the suture suspension loop to lift heavier tissues of the cheek, but in other cases with very little malar fat, I prefer to use “Silhouette” threads with absorbable cones to lift the cheek. These threads are also anchored onto the same anchoring system as the suture loops. I usually use both sutures and threads. One of the great

advantages of the mid-face-lift is that the corner of the mouth is lifted and the jowl is softened. Silhouette Lift threads are made of a nonabsorbable nylon type of thread which has a number of absorbable “funnels” that are stabilised by fine knots on the non-absorbable thread. These funnels act as traction points and allow us to tighten the skin. The threads are relatively close to the skin but cannot be felt. By using deeper suspension suture loops and a combination of Silhouette threads, I believe we can achieve a long-lasting tightening of the facial skin. As I pointed out, the greatest advantage is that at any time afterwards the skin can be re-tightened. I believe the mid-face-lift is actually also the correction of the lower eyelid even when there seems to be excess skin. By lifting up the cheek fat the fat bags of the lower eyelids are generally covered and no further surgery is necessary. At times it may be necessary to use a filler of fat or hyaluronic acid for a deep groove under the middle side of the eye. If there is a loss of elasticity of the eyelid skin this can be improved by doing skin needling of that area. This does cause quite noticeable bruising but this fades quickly. In many cases after a scarless mid-face-lift we also see a tightening of the area under the chin. However if this is not enough then we need to address the neck properly.


Suture suspension Loops


Figure 9 shows the typical loss of shape seen as one gets older. Figure 10 shows the result 10 months after a “scarless” modified Trampoline Neck lift with special sutures to define the neck angle

The neck Many patients come in complaining only of their neck and want a simple operation to treat a “turkey” gobbler, or prominent platysma bands. I believe that my modification of the trampoline neck lift gives us an excellent results with minimal down-time even in people with relatively large floppy necks. It is possible to do liposuction of the neck at the same time. The “trampoline lift” supports the area under the chin with a meshwork of the same nylon-type of fibres as used in suture suspension loops and has the advantage of lifting the lower neck skin and defining the neck crease. I use a modification without any incisions on the jawline and five tiny incisions in the area under the skin and one small incision on each side near t I do a special he angle of the jaw. I generally add a suture to define the neck angle and sometimes it is necessary to add specially oriented suspension loops to lift the lower neck skin. When these are used, people can complain of some pain, but generally there is downtime of only 2-3 days.

The possible problems seen after suture suspension, Silhouette lifting of the face and Trampoline correction of the neck 1. Bumps early from swelling on the hairline or sometimes on the cheek behind the cheek bone.


These irregularities usually fade away within a week but sometimes can take over a month. This is from the collection of fluid following the needle trauma and minor bleeding. 2. Localised depressions from traction of Silhouette threads that need correction by tugging on the skin to free it. Sometimes these can be due to pre-existing scars. A small local anaesthetic may be necessary. 3. Because I have to guess at the traction necessary, sometime I can pull too tight on one side compared to the other side. Usually this settles after several weeks 4. Necessity for additional sutures especially the neck. If we are aiming as perfect a result as possible then it may be necessary to add some sutures within the early post-operative period up to six months. 5. If the patient is overweight and the skin is too heavy, then the durability of the operation may be compromised.

Notes I give to my patient: PRE-OPERATIVE CARE – 1. I always recommend a skin care with vitamin A and C and antioxidants for as long as possible before the operation and then continue postoperatively indefinitely to keep your skin as healthy and young-looking as possible. I personally designed and formulated the Environ Skin Care Range specifically for my patients and so naturally I recommend Environ. I prefer not to operate on patients who will not use a good skin care.


Figure 11 and 12 shows the photo damage and the result after using recommended topical Vitamin A

2. I have designed a special pillow (The Better Pillow™) to remove the distorting pressure on your face that is partially responsible for the aged appearance and the development of the naso-labial grooves and upper lip lines. This pillow will also be essential to help you sleep comfortably after the operation.

Des Fernandes

POST-OPERATIVELY 3. You will be given a special mask that I have designed to use post-operatively to prevent distortion of your facial tissues no matter what pillow you choose to use. This also allows you to sleep on your side immediately after the operation. You must use the “Fulacare” cheek and chin support mask to protect the repair as much as possible and definitely while sleeping for the first two weeks. 4. Generally you may use topical vitamin A and C products again within a day or two of the operation or as soon as you would like to use them. 5. You have had a major operation so please remember to be gentle with yourself. Many people laugh in the initial phases after the operation and are euphoric but then become depressed as they realize the gravity of the operation. The local anaesthetic may also make you feel depressed. You should not be surprised to feel a little depressed about a week after the operation. Slowly, as the swelling in your eyes disappears, you will regain your confidence, and feel much happier. The suture suspension “scarless” facelift is a combination of all the modules that I have described

above and it gives beautifully natural results that can be maintained and serviced as never before. How long does a face lift last is a common question and the usual answer for the standard face lift is about 6 to 10 years. What is meant is that by 6 to 10 years the “decay” of the facelift will make people want to do the operation again. It didn’t actually last 6 to 10 years. The advantage of the scarless modular face lift is that we can re-tighten when necessary and restore the initial result with minimal surgery. Rejuvenation of the face is commonly asked for yet, sadly, often not delivered. A Face-lift is not automatically facial rejuvenation. Surgeons who concentrate on surgery only fail to recognize that the very best surgery done without any attention to the skin will deliver only a semblance of rejuvenation and very often a disharmony between structure and surface appearance. For real rejuvenation, one needs to pay attention to the skin in particular and restore naturally young, and not just smoother skin. An important point to remember is that all face lifts will last longer if one uses a scientific skincare and does skin needling that promotes the restoration of normal youthful collagen and elastin matrix under the skin to keep it tight. Figure 1 shows the degree of photo-damage often seen in “sun-worshipping” people who may come to you for surgery and Figure 2 shows the changes that can be expected from using topical vitamin A as retinyl palmitate in doses that I recommend. The skin is clearly healthier and will respond well to a face lifting procedure.


The Eye Lid Cheek Junction: Correction of a key point in Aging

Sebastien Garson, MD

Sebastien Garson, MD 7 impasse de la Passerelle 60300 Senlis France e: webinfo@drgarson.fr



he aging of the face is a very complex process, the understanding of which has greatly improved during the last decade. One of the major challenges of rejuvenating surgical procedures is reversing the signs of aging in the lower eyelid in a way that achieves a long lasting and stable result.



Sebastien Garson

The author has studied and summarized the different existing techniques and adapted them to create his own The different studies teach us how the aging process of the entire face impacts on the eyelid cheek junction, with the anatomy changing from the bone up to the skin. • The bone is subject to change with age. The skull increases in width with time. The orbital ring also increases in high and width. The orbital rim is also subject to regression. • The fat moves into a different compartment from the bone up to the skin. Both deep and superficial fats change with age. We note a deflation of all of these compartments adding to the regression and deflation of the medial face. • The ligament network in the peri-orbital region is important and complex. Understanding it highlights its role in the visibility of the eyelid cheek junction. • The orbicularis muscle doesn’t change with time but its long-term activity contributes to pushing down the fat of the deeper compartment. • The skin is closely attached to the muscle. As the latter doesn’t change, nor is the skin itself prone to drooping. Rather, the skin is subjected to matching the overall relief modifications occurring with time. In any event, everyone has their own genetic make-up that pre-determines skin changes and aging, leading to a change in their general aspect. With time or due to a genetic pre-disposition, the orbital rim will get a posterior regression or negative vector (resulting in bags under the eyes). This movement is transmitted to the muscle and the skin by the ligaments,especially the orbital retaining ligament(ORL).The volume deflation also contributes to accentuating the descent of this boundary.


The Goal The medical or surgical intervention’s goal is to correct one or more of the aging factors in order to restore a youthful aspect of the eyelid cheek junction by changing the negative into a positive vector in a stable and long-lasting manner. The author’s approach is to correct the volume with fat grafting, especially for the internal part because the loss of volume is the main cause of visibility of the tear trough and we can’t pull up this region as much as we want. For the medial and external parts of the eyelid cheek junction we need to restore both the volume and the position of the deep and superficial fat. Moreover, the ORL transmits the strength backward from the bone regression and needs to be released from all the inferior orbital rim up to the lateral canthus (the outer corner of the eye). To restore the position of the fat pad and stabilize it, a first limited sub-periostal dissection is performed. A distal periostal incision is done in order to visualize the deeper fat compartment and allow a good efficiency of traction. As we need to stabilize it, the suspension is maintained by two drilled holes in the orbital rim at 7 and almost 8’o clock. The result with the healing process gives us the creation of a new ORL which stabilizes the new eyelid cheek junction in long term. The muscle as mentioned before is not properly involved in the aging process and does not need aggressive resection, a light canthoplasty is enough to tight the eyelid. The skin excision is performed mostly in the external part which avoids any risk of round eye or ectropion.

The approach of the eyelid cheek junction In the last decade, the use CT scans ad 3D analysis have enabled us deepen our understanding of the anatomy of the aging face and improve the techniques for reversing the signs of the aging process. The eye region is an important key point in face aging. The lower eyelid bulging has been treated mostly by resection for decades but the resulting squeletization and unnatural look are common in the long term. Patients’s requests are invariably the same: “Could you remove the fold and shorten my lower eyelid?” If we compare the profile views of a young and an older patient, the difference is obvious: the latter shows a longer lower eyelid with a more pronounced fold of the eyelid cheek junction. Clearly, we need to correct the eyelid cheek junction. There is some controversy and difference of opinion between surgeons on this subject.


Fig 1: Profile Matching

Fig 2: Youthful Eyelids

Val Lambros1 maintains that the Eye Lid Cheek Junction does not change with age and is not subject to drop. The analysis of 2D pictures shows a good stability of the skin tag with age. Other authors2, 3 show a dramatic change of the eye lid cheek junction resulting in a more aged look.

What is the author’s position on this?

Fig 4: Medial drop of the face

All of the anthropomometric works5, 6, 7, 8, 9 since the last century have found a global widening and lengthening of the skull with age, as well as an increase in the height and width of the orbital rim. In a profile view, they also found a posterior regression of the radix, the maxillary and the infra-orbital rim10, 11, 12, 13, 14. All of these findings have been confirmed by a tri-dimensional computer tomographic study showing the appearance of the negative vector of the infra-orbital rim with age 15.

Sebastien Garson

The bone


Fig 3: Reference Points

In 2001, the first face aging study in 3D (3D mD® system) was performed by the author4 on 73 females candidates divided into 3 groups from 20 to 60 years of age. We analyzed the difference in position of twenty references points of the face (Fig 3). The distances have been calculated in absolute length from the same control point (0,0,0) and relative compared to the inter pupillary distance. Only the significant results have been kept. We have found a significant modification of the eyelid cheek junction with a 3.1mm drop of the fold. Otherwise the aging process had resulted in a global ptosis of the entire midface. (Fig 4) Five years later we used the 3D Digitizer (Inspeck®) on twelve candidates aged from 45 to 55 (median age of 50).Once again, even though the group was smaller, we found a 5mm drop in the eyelid cheek junction fold. The peri-orbital region is a rich junction between the skin and the bone made of fat, ligament, septa and muscles. Studies give us an accurate view of the aging modification of this section.

Fat The fat concept has changed dramatically the last fifteen years.Early on, the aging aspect of the lower eyelid was only focused on the retro septal fat pad16.(Fig 7) We now know that In most cases, the « hernia » concept is not the major component of the aging modification. The infra orbital region has a superficial layer, a malar fat pad, and a deeper layer behind the orbicularis oculi muscle, the Suborbicularis Occuli Fat pad ( SOOF). The SOOF itself has two Fig 6: Regression Points


Fig 7: Intra orbital fat hernia

compartments, medial and external (Fig 8). The deep medial cheek fat pad (DMCF) gives the support to medial part of the eyelid. The volume deflation of the fat compartments gives a pseudo ptosis (a false impression of drooping) of the face with a drop of the cheek on the nasolabial fold.17, 18, 19, 20

Fig 8: Rohrich. RJ. The anatomy of suborbicularis fat

Muscle The orbicularis occuli muscle is not subject to change with age. It doesn’t change either its length, strength or position. 21 In the ‘Face Recurve® concept’, 22 the iterative movement of the orbicularis occuli muscle pushes down the SOOF and the Deep Medial Cheek Fat pad of the SOOF moves down with the levator alaeque nasi contraction contributing to the mid face deflation. (Fig 9)

Ligaments The orbicularis retaining ligament (ORL) attaches the orbicularis occuli muscle to the orbital rim23, 24, 25. It’s quite a stable peri-orbital support, even if some authors26 found it could be subject to laxity. The skin reflexion of the ORL is the eye lid cheek junction. This is one of the key points in treating the eye lid cheek junction.

Results: The combination of this anatomic data gives us an accurate understanding of the aging process in this region. We can distinguish two categories of tissues: The first ones are stable in time: the ligaments, the septa, the oculars occuli muscle and the skin which is very closely attached to the muscle. The second ones change with time: the bone and the fat. The bone gives a negative vector with the expansion and the posterior regression of the infra orbital rim. The fat itself will drop and deflate, increasing along the same negative vector.


Fig 9: Le Louarn. C. Soof / muscle interaction

Fig 10: Ghavami. A. The orbicularis retaining ligament of the medial orbit interaction

Fig 12: Volume Correction HA only

Fig 11: Negative Vector by Sam Hamra

Discussion: Considering all of these anatomical facts, the pre-operative analysis is fundamental for the evaluation of the different anatomic compartments of this area of the face. First of all, we are able to establish if the negative vector is severe or moderate. The aging process may not be the only reason for a negative vector – family traits could contribute, resulting in a tired and older appearance much earlier in a patient’s life. The medical or surgical treatment has to correct one or more of the aging factors if we want to restore a youthful aspect of the eyelid cheek junction.

Sebastien Garson

The key point of the eyelid cheek junction is now clear. As the fold is caused by the attachment of the ORL, this stable ligament is pulling backward and downward due to the modification on the inferior orbital rim. Also as the SOOF and the malar fat pad deflate, the ORL loses its internal support increasing the descent of the fold. (Fig 11) This data has been verified by cadaver dissection. It doesn’t mean that the eyelid skin descends because of its support, the orbicularis occuli muscle remaining stable with age. This is one of the answers of the controversy; « Does the Eyelid cheek junction drop or not? » If the analysis is done is a 2D picture, as we look for dots modifications, we won’t find any. If, however, you look at the surface modification in 3D, you will see the descent of the eyelid cheek junction.


Fig 13: Orbicularis Occuli Muscle hypertrophy correction by Botulinum Toxin and HA

Medical Approach: A non-surgical treatment could be sufficient for patients with a good skin tone and a moderate lack of volume. Volume is added with hyaluronic acid (HA).(Fig 12) A visible eyelid cheek junction due to an orbicularis hypertrophy and a light lack of volume can be corrected, combining HA and botulinum toxin.


Fig 14: Lipostructure ® at 1 year post op

Surgical Approach: The goal here is to change the negative vector into a positive one and make it stable with time. In some rare cases, this can be achieved with just volume augmentation and a good tightening of the skin. A fat transfer as a lipostructure® can be done into the SOOF in the two compartments. (Fig 17) This technique allows a stable correction but also a stable weight. In the event of an important weight gain, the treated area can inflate and result in a puffy face. When the negative vector is considerable and combined with a lack of volume, it’s necessary to correct the position of the tissue, the volume and the ORL. The volume correction is focused on the internal part of the SOOF. The DMCF graft will give support to the internal part of the lower eyelid. It’s important to correct the loss of volume which causes the tear trough to be visible and also because this area can’t be pulled up as much as we want. Lipostructure is performed following the Coleman’s principles. The harvesting is done from the internal part of the knees with a 10cc syringe, with a 3 mm canula. Centrifugation is performed for 1 minute. The graft is done with a 1cc syringe and a 1.2 mm canula in the SOOF from two entries points, malar and naso labial. (Fig 15) Studies show a drop effect of the region, combined with a lack of volume, and a ORL which pulls the eyelid-cheek junction backward. We need to release all the inferior orbital rim up to the lateral canthus. The incision is sub-ciliary, combining a skin flap and a muscle flap as a blow out fracture. The arcus marginalis is released form the orbital rim with a subperiostal dissection. If this is performed correctly, the ORL doesn’t pull the eyelid cheek junction back any more. (Fig 16) To restore the position of the fat pad and stabilize it, we don’t perform a wide subperiostal dissection to lift up the medial face as used in other techniques.28 This is so that we can limit the post operative swelling and oedema. Additionally, the layer involved in


Fig 15: First step; Fat graft on the right side

Fig 16: Arcus Marginalis release

Fig 17: Two fixation holes

Fig 20: Lateral Skin resection

Sebastien Garson

Fig 19: Retroseptal Fat Flap transposition


Fig 18: SOOF traction

the sagging is not the periostium but the SOOF and the malar fat pad only. A limited sub periostal dissection is performeddownward and stop when the SOOF mobilizationis visible and get up whenwe push up the cheek’s skin. A distal periostal incision is done in order to visualize the deeper fat compartment and allow a good lifting effect. This gives a good efficiency of traction on the fat pad. As we need to stabilize it,the suspension is maintained by two drilled holes in the orbital rim at 7 and 9 o’clock. A limited sub periostal dissection is performed downward and stopped when the SOOF mobilization is visible at which point we push up the cheek skin. A distal periostal incision is done in order to visualize the deeper fat compartment. This enables a good efficiency of traction of the fat pad. As we need to stabilize it, the suspension is maintained by two drilled holes in the orbital rim at 7 and 9’o clock. The suspension uses permanent stitches Prolene® 3/0 from the holes and the SOO which rise up to the infra orbital rim.(Fig18). The periostium incision will match the infraorbital rim and with the healing process, it will create of a new ORL which stabilizes the new eyelid cheek junction in the long term. In order to enhance the volume, we can use the retro-septal fat pad through small septa incisions and stitches on the SOOF in front of the inferior orbital rim. (Fig 19) The orbicularis occuli muscle, as mentioned before, is not properly involved in the aging process and does not need an aggressive resection. A light canthoplasty is performed to tighten the eyelid without distortion. This key point is important to respect to avoid any transformation of the looks. The skin excision is performed mostly in the external part to avoid any risk of a round eye or ectropion. (Fig 20) The post operative care is really important to manage easely. A Micropor®tapping is done for one month every night to avoid the swelling of the morning and protect the tightening of the skin. Sun block screen is common use for three months.


Surgical Cases

CASE 1: Result at one year



CASE 2: Result at 2 years

CASE 3: Result at 3 years


Fig 21: Enlightenment of the face with an Eyelid cheek junction surgery

Conclusion The eyelid cheek junction is an important key point in the treatment of the aging process of the face. Surgical intervention is increasingly conservative to allow for a better post-operative healing process and achieve a greater natural result. The goal is not to change the look of our patient but to rejuvenate it in an attractive way. Even if performed on its own, this surgical procedure would greatly improve the overall perception of facial attractiveness.


REFERENCES 1 Val Lambros, Observation on Periorbital and Midface Aging, Plast. Reconstr. Surg. 120; 5,2007 2 Sam T Hamra, Arcus Marginalis Release and Orbital Fat Preservation, Plast. Reconstr. Surg. 96; 2, 1995 3 Richard J Warren, Face Lift, Plast. Reconstr. Surg. 128: 747e, 2011

5 Goldstein. MS. Changes in dimensions and form of the face and head with age. Am J Phys Anthropol. 1936. 6 Susanne. C. Individual age changes of the morphological characteristics. Journal of human evolution. 1977.

8 Levine. RA. Adult facial growth: applications to aesthetic surgery. Aesthetic Plast Surg. 2003 Jul- Aug;27(4):265-8. 9 Sforza. C. Age- and sex-related changes in the soft tissues of the orbital region. Forensic Sci Int. 2009 Mar 10;185(1-3):115.e1-8. 10 Pessa. J. Relative maxillary retrusion as natural consequence of aging : Combining skeletal and soft-tissue changes into an integrated model of midfacial aging. Plast. Reconstr. Surg. Jul 1998 11 Pessa. JE. Changes in ocular globe-to-orbital rim position with age : Implications for aesthetic blepharoplasty of the lower eyelids. Aesthetic plast surg. Sept-Oct 1999

14 Richard. MJ. Analysis of the anatomic changes of the aging facial skeleton using computerassisted tomography. Ophthal Plast Reconstr Surg. 2009 Sep-Oct;25(5):382-6. 15 Shawn. B. Aging on the midface bony elements: a tridimensionnal compute tomographic study. Plast. Reconstr. Surg. 2007 Feb, 119: 675, 16 Gola. R. Paupière sénile. Rev Stomatol Chir Maxillofac. 1991, 92 : 4 ; 247-258 17 Mendelson. BC. Age-related changes of the orbit and midcheek and the implications for facial rejuvenation. Aesthetic Plast Surg. 2007 SepOct;31(5):419-23. 18 Rohrich. RJ. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg. 2008 Jun;121(6):2107-12 19 Rohrich. RJ. The anatomy of suborbicularis fat: implications for periorbital rejuvenation. Plast Reconstr Surg. 2009 Sep;124(3):946-51.

23 Muzzafar. AR. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002 Sep 1;110(3):873-84; discussion 897-911. 24 Beden. U. Lateral canthal dynamics, correlation with periorbital anthropometric measurements, and effect of age and sleep preference side on eyelid metrics and lateral canthal tendon. Eur J Ophthalmol. 2007 Mar-Apr;17(2):143-50 25 Mendelson. BC. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002 Sep 1;110(3):885-96; discussion 897-911 26 Ghavami. A. The orbicularis retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg. 2008 Mar;121(3):994-1001 27 Chao. Yang. Tear Trough and Palpebromalar groove in young versus elderly adults: A sectional anatomy study. Plast Reconstr Surg. 132: 796, 2013. 28 Le Louarn. C. Midface region: functional anatomy, ageing process, indications and concentric malar lift, Ann Chir Plast Esthet. 2009 Oct;54(5):41120

Sebastien Garson

7 Ferrario. VF. Morphometry of the orbital region: a soft-tissue study from adolescence to midadulthood. Plast Reconstr Surg. 2001 Aug;108(2):285-92; discussion 293

13 Mendelson. BC. Age-related changes of the orbit and midcheek and the implications for facial rejuvenation. Aesthetic Plast Surg. 2007 SepOct;31(5):419-23.

22 Le Louarn. C. Muscular aging and its involvement in facial aging: the Face Recurve® concept Ann Dermatol Venereol. 2009 May;136 Suppl 4:S67-72.


4 Sebastien Garson, The Faces of the face aging: A 3D Analysis on 73 cases, Thesis, Jules Vernes University Amiens France.

12 Levine. RA. Adult facial growth: applications to aesthetic surgery. Aesthetic Plast Surg. 2003 Jul- Aug;27(4):265-8.

20 Le Louarn. C. Midface region: functional anatomy, ageing process, indications and concentric malar lift. Ann Chir Plast Esthet. 2009 Oct;54(5):41120. 21 Pottier. F. Aging of orbicularis oculi: anatomophysiologic consideration in upper blepharoplasty. Arch Facial Plast Surg. 2008 Sep-Oct;10(5):346-9


Minimal Access Vertical Vector Extended Deep Plane Face lifting: The M.A.D.E. Face lift Creates More Natural, Rejuvenating and Long Lasting Results Andrew A. Jacono, M .D., FACS

Andrew Jacono, M.D., FACS 630 Park Avenue New York, NY 10065 001 212 570 2500 www.newyorkfacialplasticsurgery.com


t some point in their life every woman, and also every man, will tug on the slack skin under their neck and wish it were gone.


The most common age for considering surgery is the late 40s all the way through to the 70s. The main factors that compel patients to visit a surgeon’s office are premature aging or a lower tolerance threshold for aging. This tolerance differs and a woman/ man who has had a heavy neck since the age of 60 may wait until she/he is 78 for their first face lift. Although there is no prescribed age when the face needs to be supported by a lifting procedure, the most common age for women is 54 or on average three years post-menopause. After three years without estrogen stimulation, the quality of the skin changes significantly and the facial muscles loosen more in those three years than in the prior 50. In older faces it is not enough to simply fill the face (for example with temporary fillers or fat transfers) because the facial tissues cannot support the additional volume as they have become too loose. The goal of facelift surgery is to re-establish the heart shaped face of youth. As we age, jowls form on either side of the chin, making this horizontal length of the lower face wider, and “marionette lines” or grooves between the corner of the mouth and chin develop (Figure 1). This is accompanied by a “double chin” or “turkey gobbler” with vertical folds or bands developing in the neck. The cheeks deflate and the horizontal distance between them becomes shorter. These drooped cheeks create folding between the nose and mouth called nasolabial folds. In order to restore the natural beauty of youth, a combination of lifting the jowls to reduce the width of the face along the jawline, and repositioning the cheek higher to add height and width to the cheek bones is necessary.

Figure 1 Heart shaped face


Prospective patients are offered a smorgasbord of options, such as mini lifts, s-lifts, MACS lifts, SMAS lifts and deep plane lifts. This is all very confusing and most people do not understand the inherent differences of these techniques. How do you decide what procedure gives the best results, with minimal scarring and downtime, and the longest lasting results? This is the most commonly asked question by my patients. My primary approach is a technique that I developed and called the M.A.D.E. Vertical Vector Facelift (an anacronym for Minimal Access Deep Plane Extended), published in the Aesthetic Surgery Journal of the American Society of Aesthetic Plastic Surgery. I feel it is important for patients to understand the differences between my approach and the more traditional approaches, which is why I will summarize them all below.

Short Scar, S-Lift, and Mini Face Lifts Figure 2 Short scar facelift or an S-Lift


A mini-facelift is a popular method to rejuvenate the lower third of the face. It is also referred to as a short scar facelift or an S-Lift because the shape of the smaller incision used is that of an S. It starts hidden in the sideburn hair, runs just inside the ear canal, and ends just behind the earlobe without running into the scalp skin behind the ear. This is different from a traditional face lift scar that is usually twice as long, runs up higher into the scalp above the ear, and runs onto the scalp skin behind the ear (Figure 2). The S-lift incision is relatively well hidden; it is often called a “pony tail lift� because you can put your hair up in a pony tail without having visible scars behind the ears like in a traditional face lift. In a mini-lift the skin is then elevated like in a traditional facelift. The muscle layer underneath the skin in the face and neck are the SMAS and the platysma, respectively. These supportive muscles are not elevated off the face, but are simply tightened with stitches. These are plication or imbrication sutures. The jowls are corrected, but improvement in the neck is usually not complete. This greater

Figure 3


improvement in the face compared to the neck looks like the wrong lid on a jar. Because the muscles, which are the foundation of the face, are not lifted and re-supported but simply stitched, the majority of the tightening is on the skin surface that was elevated. This can leave patients with a windswept, stretched or pulled appearance. This is why patients who have had a facelift bear the tell tale signs of it, one of which is a pulling of the corners of the mouth. There is a lack of strength in the repair of a mini-lift as it relies mostly on the relatively thin skin and results last only three to five years. The facial muscles are the structure of the face, the beams that hold up the face lift if you will, and if only lifted by placing some stitches on their surface, the face will descend again within a relatively short space of time. What compounds this problem is that most facelifts of all types usually tighten the face along the jawline in a mostly horizontal direction. This is unnatural because the face falls vertically with gravity. Pulling horizontally across the face will flatten the cheeks, worsening the deflated effect on an older face. Although it can improve the jowls, the nasolabial folds remain unchanged (Figure 3). When the excess skin is removed from the horizontal dimension, the sideburns are often cut away which is a tell-tale sign of a facelift. This becomes difficult to hide and requires creative camouflaging.

SMAS Face Lifts The difference between the “mini-facelifts� and SMAS face lifts is the incision and amount of work done to the underlying muscle of the face. SMAS lifts usually have a longer incision that continues onto the scalp skin behind the ear in order to perform more work on the neck. After the skin is lifted, the SMAS muscles in the lower face along the jowl region and the platysma muscle in the neck are not simply stitched but are lifted giving the face more support. SMAS techniques do not release the drooping cheeks because the latter are held into place by ligaments that extend from the cheek bones, through the cheek fat pads, to the skin. This cheek structure is


Figure 4

different from the SMAS muscle and not part of the SMAS operation. The neck results are better and the lifts have been shown to last around 10 to 12 years. SMAS lifts still suffer from lack of improvement in the cheeks because they are a horizontally oriented tightening procedure and the cheek muscles are not released. Because the skin is separated from the muscle, i.e. the skin is delaminated from the face, it still has a tendency to appear more tight on the surface or “plastic.”

Deep Plane Face Lifts A deep plane face-lift is similar to the SMAS face lift with respect to the incision and the more horizontally directed tightening, but it differs in that the skin is never separated from the underlying muscle layer; the skin and muscle are lifted as one unit. Because the skin is never separated in a deep plane lift these patients get less bruising. The SMAS and ‘mini-lifts” described above separate the skin more superficially and the bleeding and bruising are more visible as you recover. Another difference is that the cheek ligaments and fat pads are released as part of the deep plane technique so they too can be lifted. Because the surgery places the tightening on the deeper muscle layer that is not separated from the skin, the face appears more natural and unstretched. Like a SMAS lift, these lifts usually last 10 to 12 years. Even though the cheeks are released, this is still a more horizontal based lift and there are some mild but not dramatic


changes in the cheek. Interestingly, deep plane lifts are the only type that can be performed safely on smokers. Because of the nicotine in cigarettes the blood vessels in the skin are narrowed. If the skin is separated as described in SMAS and mini-lifts, the skin can necrose or die off which results in weeks of healing and bad scars. It is difficult for patients to stop smoking because nicotine patches are as bad for the surgery as actively smoking. I have performed studies showing that deep plane lifts can be performed safely in smokers; this is because the skin and muscle are not separated so the blood supply to the lifted tissues is better.

THE MADE LIFT – Minimal Acess Deep Plane Extended Vertical Vector Volumizing Face Lift The MADE Lift is a state-of-the-art hybrid technique. It is a vertically oriented lift that works against the normal gravitational changes of aging. Additionally, it fuses the optimal features of oldergeneration, short-incision “mini” face lifts with the benefits of the muscle support of deep plane face lifts. Because it releases the ligaments of the cheek that limit motion of the cheek fat pads, the vertically oriented tightening supports the drooping cheeks, restoring volume to the cheekbones and smoothing nasolabial folds (Figure 4). In fact, we have published a study in the Asethetic Surgery


Figure 5

in consultation who want to revise a prior facelift performed elsewhere because the neck still hangs after surgery, This is also why I developed the MADE facelift. The MADE lift differs from more traditional deep plane facelift and all other techniques because it is “Extended” creating more youthful necklines that last longer. A traditional deep plane facelift as well as SMAS and MACS lift approaches do not lift the drooping neck muscle called the platysma below the jawline; they just simply use tightening sutures on the surface of the muscle that have a limited longevity and effect. In the MADE lift I extend the deep plane facelift down into the neck, releasing the platysmal muscle (which creates vertical banding in the neck) off the cervical retaining ligaments that limit redraping and tightening of the loose neck muscles. This creates a more supported necklift resultling in crisp jawlines and necks. When patients have more severe neck drooping, often called a “turkey gobbler”, then an additional procedure called a plastysmaplasty is combined with the MADE lift to ensure the best necklift result. Many times surgeons perform this with an incision under the chin that is 4 cm which can be unsightly. I utilize an incision of only 1 cm and work with fiberoptic instrumentation so that I can limit scarring. Through this incision we remove some of the redundant platysma muscle and suture the bands together to remove the central neck vertical banding. When combing this and the muscle tightening described above during the MADE lift I

Andrew Jacono

Journal of the American Society of Aesthetic Plastic Surgeons recently that demonstrated that the cheeks increase their volume by 3 cc or the equivalent of three vials of injectable hyaluronic acid per cheek. This results in a youthful, beautiful, heart- shaped face. Vertical vector lifting was first described in a “mini” face lift called the MACS Lift that only tightened the muscles with stitches by Belgian plastic surgeons Patrick Tonnard and Alex Verpaele. The MADE facelift differs in that it does not tighten the muscles superficially but lifts the sagging muscles off of the deep structures of the face and repositions them back to their position in youth. I prefer this method of replenishing lost volume in the face over fat grafting or transfers that inject fat into the face. Fat transfers are removed from the belly or thighs and injected into cheeks and other parts of the face. In my experience, fat transfers reabsorb and go away 33% of the time or leave irregularities or can inconsistently take on two different sides of a face creating facial asymmetry. Fat grafts can grow when borrowed from the abdomen, thighs or love handles if one gains weight, creating an unnatural appearance. Additionally, when one does not lift the cheeks which are heavy and drooping around the mouth region and simply stacks fat on top of them, the face appears overfilled and somewhat “simian” (monkey-like) appearance (Figure 5) One of the more common problems with facelifting surgery is that the procedure does not adequately tighten the neck. I see many patients


Facelift patients Before and After


The standard lifetime of a facelift that simply tightens the surface of the SMAS muscle and platysma is between three to five years, but the MADE lift relies on the support of a deep plane face lift, results last 10 to 12 years.”

Andrew Jacono

Adjunctive Procedures, Eyelid Lifts, and Endoscopic Temporal Lifts


can achieve neck tightening that will last even in severely aged necks. The MADE Lift uses a short incision S-type incision as described above, while lifting the facial tissue and muscles as one unit – so patients get the superior results of a deep plane face lift, combined with the minimal scarring of a “mini lift”. It is not only an option that delivers best-in-class results, but a procedure that offers longerlasting results as well. In my experience, the standard lifetime of a facelift that simply tightens the surface of the SMAS muscle and platysma is between three to five years, but the MADE lift relies on the support of a deep plane face lift, results last 10 to 12 years. For years, my patients have had to choose between better results or less scarring. With this hybrid facelift, they get the best of both worlds. In patients with advanced aging and more excessive neck skin necks, a hybrid lift can still be performed but the incision length behind the ear may need to be increased. Given the level of difficulty in performing this procedure, a more detailed understanding of the anatomy is required. I encourage any patient considering this procedure to seek a surgeon who specializes in facial plastic surgery and possesses the level of expertise required to perform it.

In order to create a more complete facial rejuvenation it is common to combine the MADE Lift with lower eyelid surgery and lifting of the lateral brow area that droops with age and creates upper eyelid hooding. There are two ways to perform a lower eyelid lift: one that requires an external incision in the skin and the other an incision inside the eye. The choice of approach depends upon whether excess skin needs to be removed or just the fat bags under the eyes need to be treated. The external incision technique is used when extra skin needs to be removed. The incision is placed just underneath (2 millimeters below) the lower eyelash line. This gives access to the lower eyelid excessive muscle and fat, and also allows for the skin to be trimmed and


Facelift Combination procedure Before and After

tightened. Extremely fine sutures are then used to meticulously close the incisions, thus minimizing the visibility of any scar. The “scar-less� technique called a transconjunctival blepharoplasty places an incision inside the eyelid, through the lining of the eye (the conjunctiva) to access the redundant muscle and fat. This technique is used on younger patients who have not yet developed excess skin. In the vast majority of lower eyelid surgery cases it is important not to remove the fat bags under


the eyes, but rather transpose or move the fat into the deep grooving and hollows that appear as dark circles. When fat bags are removed from the lower eyelids, this creates a hollowed out effect – another telltale sign of surgery. As part of the natural aging process the area underneath the lower eyelids bags sinks in and the cheeks droop making the lower eyelid appear to lengthen. Removing fat gives the perception of a further elongated lower eyelid resulting in an older look but just in a different way.


Facelift Combination procedure Before and After

including the skin and muscle is lifted off the bone. The layer that attaches the overlying tissues to the bone is the periosteum. This burlap like layer is the one that weakens as you get older and allows the tissues to drop; it is one of the supporting cables that weakens. In this surgery we never lift the center of the brows much if at all, because this is what creates the surprised or startled appearance of older browlifts. The outer edge of the eyebrow, also called the tail of the brow, is elevated which creates a natural and feminine appearance. By balancing the upper third, middle third and lower third of the face, more complete facial rejuvenation is possible. When utilizing volume restoring techniques repositioning facial and eyelid fat planes, as well as the deep facial and forehead muscularture the face looks smooth and natural. The MADE facelift combined with these procedures makes this possible, and avoids the tightened and overfilled appearance I see created by many other contemporary techniques.

Andrew Jacono

Because part of getting older is losing the natural volume of the face, refilling the deflated eyelid and cheek junction defines a more youthful appearance. Since the fat is left attached to the blood supply around the eye these fat pads which are stitched into position and cannot move will last a lifetime. This is different from transfers of fat that is removed from the belly or thighs and injected into these hollow compartments. As previously mentioned, this fat risks reabsorbing 33% of the time. To open the upper eyelids, I most commonly use an endoscopic lateral temporal lift. The procedure is accomplished through a few incisions in the hairline, just large enough to pass the endoscope (which is the width of a drinking straw). It is the same concept as telescopic gallbladder excisions: years ago when doctors removed your gallbladder they made an incision that was a foot long under the rib cage. Now, with a few small incisions and a telescope the same surgery is performed with a quicker recovery and less scarring. With the keyhole technique, the outer aspect of the eyebrow


Cutting edge face lift including EYELIDS, concentric malar lift, long lasting neck lift and lip lift Dr Claude Le Louarn

Upper eyelid surgery. the simplest rejuvenation


Today three additional options are available:

1) Avoiding Upper Eyelid “ A” Deformity Removing the upper eyelid skin excess results in the skin redraping along the underlying bone shape. As this shape presents a depression, the supraorbital notch (the bony elongated path located above the eye socket and under the forehead) becomes visible. This depression isn’t visible in youth because the skin is thicker and tighter, with more subcutaneous fat. To recreate this fat interposition, fat grafting is possible but a certain degree of resorption is common (resorption, i.e. the fat being re-absorbed by the body, is a source of skin irregularity). An easier and more reliable way to recreate this volume is the transfer of upper eyelid fat bags in this depression, mainly a prominent nasal fat pad. The fat volume is elongated toward the supra orbital notch (eyebrow bone) and sutured in this new position. The original vascularization is maintained and the correction is stable. This technique was first published by Dr Le Louarn in 1996.

Claude Le Louarn

pper eyelid surgery is the simplest and most efficient rejuvenation procedure that can also turn into the most sophisticated surgery. Skin excess in this procedure needs to be removed starting from the inner part to the lateral part of the eye area. Medially, the scar has to be a little higher than the precise location of the skin excess medially, so as to avoid an inflammatory reaction if the scar location is too low. Laterally, patients have to accept that the procedure involves a temporarily visible lateral scar necessary in order to completely remove the skin excess in the area of the temples. Occasionally, some of the lateral skin excess has to be left alone so as to avoid a scar in the visible area. From personal experience, patients prefer to camouflage a thin scar with make up for a month in order to get rid of the descending lateral skin excess and prevent the shortening of the eye shape.


Dr Claude Le Louarn Plastic surgeon President 2010 Société Française Chirurgie Plastique Reconstrutrice 59 rue Spontini Paris + 33 1 45532717 www.lelouarn.net


Before: This patient required face rejuvenation and manifested upper eyelid skin excess. The supraorbital notch depression is visible on the left side of the patient. The two vertical glabella lines are pronounced.

Post-face rejuvenation and upper eyelid surgery. The upper eyelid skin removal has refreshed her eyelids and the fat transfer has minimized the supra eyelid depression: the supra orbital curve is natural. The two vertical glabella lines are faded thanks to the corrugator muscle weakening performed through the upper eyelid incision.

2) Decreasing Glabella Lines (Lines Between Eyebrows, Just Above The Nose) The repeated contraction of the corrugator muscle (facial muscle of eyebrows) is the cause of appearance of glabella lines and partially of the eyebrow position. The most common way to weaken this muscle is to descend through the frontal area (endoscopic or bicoronal incision). It is easier and faster to dissect this muscle through an upper eyelid incision and then to weaken it with a vertical staged incisions. A moderate contraction necessary for natural facial expression can be maintained but the excess of contraction is eliminated. At the same time, a light elevation of the medium part of the eyebrow is performed. following technical points are respected:

3) Direct Supra Brow Skin Excision The usual way to elevate a too low located eyebrow is to perform a frontal lift, either direct or endoscopic. But frontal skin laxity, which is the source of the eyebrow descent, can recreate a secondary partial descent. The solution to this is the direct suprabrow skin excision (removing skin just above the eyebrows) in order to achieve the eyebrow lift. This is very effective in this specific area and injecting the tissues with Botox to prevent from mobilising in the post-operative period result in a better healing process, with the suprabrow scar barely visible. This simple procedure (the direct eyebrow lift) can give satisfactory results only if the


-Skin excision is performed just above the eyebrow -Pre operative markings have to be traced with precision. -The inferior incision line is made so as to avoid damage to the hair follicles. --The superior incision line can be located high enough to achieve a good eyebrow elevation. -Cautery (cauterizing the tissues via burning) should be used as little as possible to preserve the hair follicles. -The inferior flap is undermined, thus increasing the possibility of lifting of the brow.

Dr Claude Le Louarn

LOWER eyelid surgery standard procedure



he standard procedure includes lower eyelid subciliary (1 mm below the eyelashes) incision , subcutaneous or/and submuscular dissection, fat bags and skin removal. Concerning skin removal, the main questions for the surgeon are: - how much skin do I remove ? (Because the more we remove, the more tensed the lower eyelid skin and the happier the patient) - where, at the length of the lower eyelid, do I remove the skin excess ? - at the medium part of the scar where the lower eyelid skin excess is at its maximal or - at the lateral part, near the temporal area, where it seems the easiest to remove at the skin redraping stage upward and laterally. The answer is difficult because the problem is the lack of stability of the lower eyelid/ eyelashes margin: if only a small downward tension is applied on that margin, descent (drooping) appears and the patient will complain about a change of eye expression, i.e. a round eye effect.

Claude Le Louarn

Fig. 1 a,b, Before. Patient asking for removal of his fat bags of the lower eyelid. The vertical bulging (convexity) between the eyelashes and the cheek is visible on both views. After removal of the fat bags, the skin between the eyelashes and the cheek is concave. This increases the shadow and the effect of depression of the tear through. This is not a rejuvenated aspect but an operated look.

Fig. 2 a,b, After standard lower eyelid surgery. The lower eyelid has been descended, which is acceptable in this case with small height of the eye opening. But could be difficult in case of normal height of eye opening.


Consequently, to minimize this risk, the orbicularis oculi muscle, which is subcutaneous in the lower eyelid, is attached laterally to the bone of the lateral orbit contour (lateral orbital rim) to stabilize the lateral part of the lid. Skin removal is thus laterally possible with more safety. Nevertheless, lower eyelid improvement is real but limited and in some cases risky. Another technical point can be made: We learn that the aging of the lower eyelid has equally to do with the tear trough depression than with the volume of the palpebral bags (bags under the eyes). The consequence of the palpebral bag removal is the posterior transfer of the lower eyelid skin. Let’s explain this disagreement and propose a solution. Profile view:

Fig. 1 Before

Figure 1 shows the palpebral bag volume and the underlying depression. Figure 2 shows the posterior transfer of the lower eyelid skin after fat bags removal. This transfer of the lower eyelid skin deepens the orbital contour, creating a hollowness that is NOT associated with the fullness of youth: the lower eyelid shadow, visible below the fat bags before the surgery, has been changed for a shadow now visible along the full lower eyelid height. The ideal solution is a partial decrease in volume of the palpebral bags and a partial filling of the depression to achieve a more rectilinear direction rather than a concave shape (Figure 3). This technique of fat transfer from the fat bags to the tear trough was created a long time ago by a Brazilian plastic surgeon, Dr Loeb and updated in 2004 by an American plastic surgeon, Dr Hamra. This technique is a part of the concentric malar lift.


Fig. 2 Standard lower eyelid surgery

Fig. 3 The aim

Dr Claude Le Louarn

Concentric malar lift



Claude Le Louarn

he aim of this technique (published in 2004 Le Louarn Claude, Aesthetic Surgery Journal) is to propose an en bloc (muscle, fat, skin) repositioning in the exact opposite direction of the natural aging process. Nearly all published techniques propose an action reversing the direction of the aging process! The questions are: what is the direction of the aging process? How does it works and why? The answer could seem obvious, but in fact is a source of continual debate and not so simple to address. The photographic work (2007) of Val Lambros, American plastic surgeon, is essential to observing how the aging process develops. The second question is: why does this happen the way it does? Dr Lambros studied images of the evolution of the mid face in 130 patients, between the ages of 10 and 89, who had not had any surgery. He wrote the following conclusion: “There seems to be very little ptosis of the lid-cheek junction. These findings suggest that vertical descent of skin, and by association, subcutaneous tissue, is not necessarily a major component of aging in those areas.� Vertical descent is gravity and this means that gravity alone cannot explain mid face aging. While everyone agrees that gravity makes aging tissues droop vertically, a procedure addressing gravity alone is not an anti-aging procedure. The answer to the second question, why does aging happen is this: the real causes of facial aging are repeated muscle contractions, which induce fat migration and skin excess. More specifically, the aging of the superior mid face is due to the repeated contraction of the orbicularis oculi muscle (the muscle that closes the eyelids), which presses on the orbital rim to elevate the lower lid. This pressure on the bony rim expels the underlying fat (between muscle and bone), which goes upward and downward. The so created trough shows/emphasises the palpebral bags and the malar mound (cheekbone). The aging process shows equally in the tear troughs, the bags, the depressions and the volumes, all of which are specific to aging.


The orbicularis oculi contraction, in it’s medium part, is so strong that it ‘s named age marker fascicule.

Under the muscle, the deep fat is expelled because of this orbicularis oculi contraction.

For the inferior mid face, the mid cheek furrow, it is the sliding junction between the contraction of the orbicularis oculi muscle and that of the zygomaticus muscles (used for smiling), going in two almost opposite directions. With time, this junction does of course increases and deepens as does the nasolabial fold. The only way to relocate the naso-labial volume in the above mid cheek furrow, the malar mound in the above palpebro malar groove and the palbebral bags in the underlying tear trough is the concentric malar lift. > In blue, the two deep concentric threads to concentrically elevate the malar area (green arrows) on the opposite way of the aging process (excentric). In red the usual lower eyelid skin opening. The small green arrow near the nose figures the descent of the palpebral bags in the tear through. Aging, due to repeated contractions of the orbicularis oculi, expels palpebral bags upward. Rejuvenation surgery has to make the opposite.

In so far as the skin excess is concerned, this can be removed, for the first time, from the area of the mid-pupil without tightening downward the lower eyelid vertically (something that results in a round eye effect). As the elevated soft tissues of the cheekbone area are permanently fixed to the orbital rim, if we get, for instance, 2 cm of skin excess at the lower eyelid incision line, 17 mm are removed and 3 mm are lowered to the eyelid incision level. Instead, in a standard lower blepharoplasty, of being suspended to the overlying eyelid level. > In this case, 3 cm of tensed (with the forceps) skin could be removed but it was decided to remove 26 mm, leaving a 4 mm safety of skin excess. Then, there will be no traction on the lower eyelid margin and no eyelid change in position.


How is this procedure performed?

The malar mound has faded and mid face looks natural thanks to the concentric malar lift. Jawline and neck are refreshed without excess of skin tension.

Claude Le Louarn

After: The corrugator muscle weakening has faded the glabellar lines, the upper eyelid skin excess has disappeared with fat transposition to avoid the supraorbital notch visibility.


Before: Patient with skin excess in upper eyelid with supraorbital depression, in midface with a malar mound and on jawline and neck.

After the lower eyelid sub ciliary incision, a subcutaneous dissection, the height of skin we consider removing, is performed. Then a lateral muscle incision, through the subcutaneous incision, allows the possibility to detach the soft tissues from the bone. Six very small holes are drilled through the lateral and inferior orbital rim to stabilize the desired elevation “en bloc� of the soft tissues with threads. Two non resorbable barbed threads determine and fix the concentric elevation level. The healing of the dissection plane between soft tissues / bone will definitely fix the level because it is the only plane of dissection at which elevation will never slip with time. If the dissection plane through soft tissues is more superficial, it risks slipping and becoming destabilized with time. The two threads will not be palpable because located deeply on the bone. The skin excess, nearly always more than 1cm high, is removed within 2 or 3 mm of safety to be ensure prevention of any secondary eyelid descent. The main height is at the mid-pupil level (rather than laterally at the canthus/eye corner level), where skin excess in the lower eyelid and mid face is more important. Nearly half the height of the lower eyelid skin is removed safely with this technique. An important technical point is the verticality of this skin excess brought to light by the concentric malar lift. Because in the other type of mid face lift, the temporo malar lift, with the axe of traction being more oblique, skin excess is more lateral, toward the temporal area. This has two consequences: 1. the lower eyelid scar needs to be elongated toward the temporal area and an associated temporal lift minimizes this lateral skin excess. 2. only some mm of skin (from 2 to 4 most of the case) are removed on the mid pupil line, that is to say with less efficacy. Efficiency at the lower eyelid level is not comparable between the two techniques.

Post-operative period This is the one negative, but logical point: as surgery is more extensive (4 cm height for the malar area) than for a standard lower eyelid surgery ( 6mm height from incision to fat bags), post-operative period is 2, even 3 times longer, taking 2-3 weeks as opposed to 7 days. Using make-up and sun glasses after a week mitigate this to some extent, but more time is required for full confidence to return. The longer recovery period is offset by much longer-lasting results and enhanced appearance with natural aspect. Effect on skin excess in the mid-face area is real with repositioning of the mid-face volumes as previously explained. In more than 90% of cases, there is no need for fat grafting because it is not necessary


thanks to fat repositioning. A good test to check if fat reinjection is necessary is to lie down in supine position and use a mirror to see if your mid-face volumes are sufficient or not: lying down creates a fat repositioning very near the one achieved with the concentric malar lift. If you see an harmonious area, you are a candidate for the CML (Concentric Malar Lift) only. If not, complementary fat grafting at the time of the CML surgery is necessary.

Discussion In the international plastic surgery community, the polemic concerning midface rejuvenation is between these two propositions, in fact: to fill with fat or to lift. Mid-face filling is a good technique of rejuvenation, but only partially. Why? Because the filling procedure is simple: fat harvesting and reinjection after preparation (centrifugation, cleaning..),carried out in an operating room. First of all, numerous MRI studies, X rays volumetric analysis and computed tomographies conclude that there occurs a natural increase of volume in the mid-face area with time. This clearly means volume addition is not the solution for rejuvenation. Secondly, volume addition in the mid-face, as we all know, can change the appearance and even gives a puffy look. Thirdly, limited volume grafting cannot get rid of a real skin excess. And finally an unknown degree of fat resorption exists, source of skin irregularity: if, for instance, 2 cc of fat are injected to fill a tear through, 6 months later 1,6 or 1,3 cc could definitively stay. A second session of injection would be necessary to refill the trough. On the opposite, a 50 year old patient performing a midface filling at a body weight of 58 kg can have 10 years later a body weight of 68 kg with a bulging of the injected area. The fat, harvested on the abdomen, thigh….follows exactly the evolution of volume of it’s original location. Treatment is surgical removal of the fat excess. Limited volume addition in the mid face is an interesting compromise only if there is nearly no skin excess, to fill the furrows of the tear trough and of the mid cheek. But why is it so popular among surgeons while mid face lift is so rare? Patrick Tonnard and Alexis Verpaele, two very good surgeons, wrote: “Microfat grafting appears to be a valuable and safe alternative to complicated, difficult, and potentially dangerous eyelid and mid-face rejuvenation techniques” They are right: the standard lower eyelid and mid face lifts are potentially dangerous techniques. However, for the reasons already outlined, i.e. limited lateral muscle opening, subperiosteal dissection, periorbital trans-osseous fixation for two concentric elevations with


non-resorbable barbed sutures, vertical skin excess, 2 mm safety in skin excess removal, this technique is unique and safe. Only the concentric malar lift is able to relocate at their young positions descended midface volumes and to get rid of the midface skin excess.

Claude Le Louarn

After A concentric malar lift only was able to achieve a natural and stable result


Before Patient, 50-years old, who had a standard lower eyelid blepharoplasty, complicated with an ectropion. He had many surgeries to try to cure un successfully his ectropion: temporo-malar lift, canthopexy.

Indications Indications include lower eyelid skin excess, malar mound, to important nasolabial fold, which means centrofacial aging. The patient has to notice that lower eyelid aging is normally associated to centrofacial aging. Of course a lower eyelid surgery can be performed alone, with no consequence on centrofacial aging and with a more limited rejuvenation of the lower eyelid itself: much less skin is removed. Indication include also the lower eyelid descent, congenital or du to a previous surgery. The concentric malar lift realizes an en bloc elevation of the midface which induces elevation of the lower eyelid and cure the natural congenital descent or the ectropion.


In one session of 5 hours, this patient of 28 year old had asked for creation of a new face harmony to minimize the frontal and mid face descent for creation of a new face harmony: • a secondary rhinoplasty • upper and lower lip VY flaps to advance mucosae, increasing lip envelop, to make natural lip augmentation with fat injection, but keeping a central opening for more refined look • DAO weakening to lightly elevate the corner of the mouth and slow down the bitterness fold arrival • Concentric malar lift to elevate the lower lid and the mid cheek area • Lateral canthopexy to achieve an almond shape eye with supero lateral bone removal of the orbit enlarge laterally the orbit •

Temporo frontal subperiosteal lift with precapillar temporal incision and intracapillar frontal incision to smooth the frontal area and elevate the eyebrow with a natural shape

The general anesthesia was associated with a 8 hours local anesthesia to drastically minimize product of general anesthesia. Recovery was fast after this surgery with one night in hospital. I recently performed a more extensive face harmonization, with the addition of a neck lift, liplift, upper eyelid remodeling, frontal bone remodeling with a good recovery and a surprising result.




Dr Claude Le Louarn

Fronto temporal lift E

levating the eyebrows and fading the inter-brow and frontal lines are achieved with the fronto-temporal lift. This surgery was commonly performed before the arrival of the Botulinum toxin injections (1992). Since the use of Botulinum toxin (Botox) became commonly used, the frontal area is much less subject with surgical procedures. In any one year, in my office, around 500 injections in the frontal area are performed for every 10 fronto-temporal lifts. This procedure is for both young or older patients wishing to change their sad appearance and for mature patients needing to rejuvenate the upper third of their face, reshaping their eyebrows and forehead. Surgical techniques are of four main types: 1) Endoscopic brow lift, with limited intra-capillar incisions and a deep subperiosteal dissection, to perform a fronto-temporal lift 2) Fronto temporal, intra-capillar with coronal incision and subperiosteal dissection to perform a fronto-temporal lift 3) Fronto-temporal precapillar incision and sub cutaneous dissection to perform a fronto-temporal lift 4) Temporal lift, either subcutaneous or subperiosteal 1) Endoscopic brow lift:

It is an interesting technique, because it leaves the shortest scars: one 2 cm length incision in the mid hairline and one temporal incision of 4 cm on each side of the mid hairline. Through theses incisions, a subperiosteal dissection with specific instruments and an endoscope is performed to arrive at the brow level, where the corrugator muscle is weakened. Then through the 3 incisions, a traction/pull action is achieved with threads attached to drill holes or screws, passing through the superficial scull. The hairline


This procedure is for both young or older patients wishing to change their sad appearance and for mature patients needing to rejuvenate the upper third of their face.”

2) Fronto temporal, intra-capillar

If a patient has already too high a frontal area with a receding hair line, it is impossible to perform an intra-capillar incision. Because the incision is anterior, at the hairline level, and not more posterior in the hair area, the incision cannot reach the subperiosteal plan of dissection without cutting sensitivity nerves branches, something that would compromise sensitivity from the hairline area all the way to the upper part of the vertex. Consequently, dissection has to stay subcutaneous. This subcutaneous dissection is very efficient in cases of severe wrinkling and skin excess in the frontal area. A lot of skin can be removed and the hairline can be lowered through the pre-hairline incision. The frontal height is reduced which is an advantage in cases where the forehead is too high. The key point is to achieve a nice pre-capillar scar. The healing process has to be checked on other scars and the patient needs to stop smoking at least 20 days before surgery. The hair must be directed in part anteriorly to hide the scar. 4) temporal lift, sub-cutaneous dissection

This is an intra capillary incision to tract on skin or on galea (an aponeurosis below the hair bearing area) in order to improve skin tension . As skin tension relapses in most cases some weeks or months later, subcutaneous temporal lift isn’t a reliable technique

Claude Le Louarn

This is the classical technique, with dissection being performed under direct vision. Paul Tessier is the creator of the subperiosteal technique which he named the masklift, i.e. designed to improve the area of the mask (frontal, temporal and partially malar area). This technique can rejuvenate the upper face but also, if required, change the eye shape, the eyebrow shape and the malar position. A strip of skin and hairs of 1,5 cm is removed in the frontal area, with no skin removal in the temporal area. The consequence is the retrusion of the frontal anterior hairline by 1 cm. If a patient has an already high frontal hair line, this subperiosteal dissection, being performed only through intra-capillar incision, is not indicated. As with any very efficient techniques, this one depends on the patient’s requirements and the surgeon’s skill. Some patients had, when this technique was first in use, too many modifications and surgeons decided to limit the indications. In fact, the magnitude of the effect can be perfectly determined beforehand, subject to discussing it with the patient – starting from a moderate rejuvenation of the upper third of the face to malar elevation, almond shape eyes and lateral eyebrow elevation. The result is really stable with time.

3) Fronto-temporal pre-capillar incision with subcutaneous dissection


retrusion (receding) is of around 1 cm. There is some disagreement over the lack of stability of the technique with time, which explain why the technique was frequently performed until about 10 years ago but seldom today. Another easier option is to make the same intracapillar incisions plus an upper eyelid incision. The corrugator muscle weakening is easily performed because, as explained in the upper eyelid part, incision and corrugator are very close. Dissection is done toward the frontal and temporal area without a specific instrument.

5) temporal lift, sub-periosteal dissection

temporal lift, sub-periosteal dissection pre capillary (preserving hair line) or intra capillary ( with hair line retrusion), is reliable and stable with time. Technically, the subperiosteal dissection is more demanding and the post-operative period is much longer. This surgery is the temporal part of the mask lift, or of the fronto-temporo malar lift.


Dr Claude Le Louarn

the NECK lift


he aim of necklift is to recreate an acute cervicomandibular angle (the angle formed by the chin and the neck which stands at 90 degrees in a young person) and a well defined jaw line. Surgical neck rejuvenation is typically associated with posterosuperior traction on the skin (pulling the skin back and upwards, see graphic) and on the plastysma “PLA� (subcutaneous neck muscle). For more efficacy and more stability with time, this can be associated with an anterior vertical PLA corset (a supporting corset-like structure in front of the neck) or a digastric corset, in the submental area. This action makes an anterior traction. However, even this sophisticated technique could produce medium-term instability at the cervicomandibular angle. Until now, the anatomical analysis position has been as follows: When contracting, the platysma (subcutaneous neck muscle) pulls the jaw line. The PLA muscle is a downward tractor. This continued and repeated contraction causes the neck and jawline skin to sag. Rejuvenating this area requires an intervention that would elevate neck and jaw to the side/behind the ear and upwards. I have published an anatomical study proving that, in fact, the platysma is a neck elevator and that it is the muscles below the lower lip that act as depressors, i.e. pulling the structure downwards. This study offers, for the very first time, a simple explanation of the jaw line aging, caused by the antagonistic forces of neck elevation below the jaw line and jaw descent above the jaw line. Additionally, the study allows us to develop a new concept technique of neck rejuvenation: the hyo neck lift. The hyoid bone is the most posterior part of the cervico mandibular angle (the horseshoe shape


bone at the base of the chin) and the only bone of the area. When we are younger, a ligament (the hyo platysmal ligament) connects this bone to the platysma and the skin. The cervico-mandibular angle is an acute one. With time, this ligament elongates and the cervico-mandibular angle becomes rounder – i.e. we lose definition between chin and neck and the area between the two starts bulging. The aim of this technique is to fix again the platysma and the skin at the most posterior place of the cervicomandibular angle: the hyoid bone. In other words, harness neck muscle and skin covering it to this bone, re-defining and rejuvenating the chin/neck angle. This specific neck lift technique is simple, because like the standard facelift technique, only a subcutaneous dissection (cutting below the skin) is needed. A specific dissection, such as performing a digastrics (twin pouch) corset, is not needed. In the platysma corset or in the digastric corset, the anterior advancement of the muscle realizes also an anterior skin advancement. As the skin has to be transfered posteriorly to rejuvenate the face, a complete separation of the skin from the underlying muscle is necessary. This means that the vector of muscle traction (anterior) is the opposite of the posterior vector of rejuvenation. The posterior vector of traction on the muscle of the hyo neck lift is the only one vector in the submental area to go in the good direction. Technically, the natural projection of the hyoid bone on the muscle is defined and marked and sutures are placed through the muscle on the bone to ensure a good fixation of the muscle to the bone. Further, the subcutaneous skin is redraped along

The usual platysmaplasty procedure to rejuvenate the neck is the platysma corset, which creates a midline tension. The muscle is transferred from the lateral neck to the submental area, that is to say from posteriorly to anteriorly.

With time, platysma bands tend to appear 2 cm in front of the hyoid bone. During the subcutaneous neck dissection, these platysma bands are sutured to the only bone of the area, the hyoid bone, defining the most posterior part of the cervico mandibular angle. The platysma muscle is transferred from anteriorly to posteriorly, in the correct direction for neck rejuvenation. This bone attachment gives a more stable result.

Claude Le Louarn

Another, more logical way, for neck rejuvenation is proposed:


However, neck rejuvenation has to be done from anterior to posterior - in the opposite direction. The consequence is that the skin, which must go posteriorly for rejuvenation has to be completely disconnected from the muscle, which goes anteriorly in an illogical way.




the same line to the muscle. This procedure allows for a strong physiological neck rejuvenation that counters the aging process. In order to achieve a jaw line improvement in this new concept, the rejuvenation surgical intervention has to be performed upward and posteriorly (upwards and towards the back of the ears), which is the standard in fact. I was very interested in the sub-smas dissection, as a means to achieving a more stable tension on skin and muscle, however experience and studies have demonstrated that the sub smas dissection was not more efficient or more stable than the smas placation. The submandibular gland is descending with time and can create a bulging below the mandibular line, visible after a necklift. The submandibular skin is tensed with the face lift and the gland volume is perfectly visible like a jowl descent. This submandibular gland ptosis is palpated before the surgery and the patient has 3 choices: - either nothing specific is performed: if the gland ptosis is moderate, the hyo neck lift with the platysma tension will minimize the gland visibility - either gland ptosis is more important and a surgical partial excision is decided, with a rare risk of paralysis of a the mandibular branch of the facial nerve: smiling can be changed on one side for some months. If a safer and simplier alternative is preferred, botox injection in the bulging part of the gland melt it. Injection has to be repeated every 6 months for 2 years to maintain the effect. What is the fastest and more efficient way to improve the marionette or bitterness fold (the lines that run from the corners of the lips downward towards the sides of the chin)? A technical point has to be added to stabilize this bitterness fold area (drooping corners of the mouth).The descent of the corner of the mouth is due to the increase in resting tone of the Depressor anguli oris muscle (the facial muscle running between chin and and the corner of the mouth, and associated with frowning). Skin at the preauricular level (in the area of the ear) can be tensed very high, but this would not give a long term improvement to the marionette fold (no longer than 3 months). If a more long lasting effect is desired, a direct action, the DAO, on the cause of the descent is necessary.


Dr Claude Le Louarn


(depressor anguli oris-dao release procedure) or corner lip lift


hrough a 1 cm incision in the mucosae of the corner of the mouth (non visible), this muscle is weakened. As this muscle acts only in one direction, i.e. to pull down the corner of the mouth when smiling, disabling it means that the corner of the mouth will henceforth remain horizontal or lightly, no matter what the facial expression. Consequently, a huge pre auricular or retro auricular tension (pulling the skin in front or behind the ear) is no longer necessary because the actions on the medial zone (marionette fold and platysmal bands) are more efficiently performed by specific localized actions through the DAO and hyo neck lift. Pre auricular and retro auricular actions are, in fact, only useful for lateral skin excess and only partially efficient on paramedial aging marks. The direction of redraping of the smas and of the skin is determined by the effect desired on the smas and on the skin. On the skin, a vertical redraping shortens the retroauricular scar (the scar behind the ear) but elongates the preauricular and temporal ones (the scars in front of the ear and at the hair line temples) in a visible area. The efficacy of the vertical redraping of excess skin of the jowl is good but is very limited on the excess of skin of the neck. This type of redraping is a philosophy promoted worldwide by 2 very good plastic surgeons Tonnard and Verpaele. I prefer a redraping that achieves the best compromise between neck and jowl efficiency - which is more logical and functional than with this vertical jaw lift because the temporal scar is shorter and because this includes dao section and hyo neck lift. Scars are closed with resorbable threads and draining is frequently not necessary.

Lay summary To tighten the neck and jawline, Dr Le Louarn uses a moderate incision and introduces a barbed suture to attach lose muscle and skin to the horse-shoe like bone in the jaw area. Weakening the muscle that runs between chin and corners of the mouth, he inhibits the drooping of the mouth corners. This allows for a better redraping of the skin and minimal scarring, as well as a long-lasting result.









(B, D, F) Six months postoperatively, flattening and elongation of the submental area are visible and stable.

Claude Le Louarn

Figure 1. (A, C, E) This 61-year-old woman presented with ptosis of the neck and jugal region. The quantity and moreover the quality of her skin made this surgical rejuvenation difficult to be stable with time. She underwent hyo necklift with DAO section, and upper eyelid blepharoplasty.


Dr Claude Le Louarn

Lip Lift and VY flaps

Graphic illustrating the lip lift


he lips are as important in rejuvenating/beautifying the lower face as is the nose in the mid-face and both need to be properly analyzed in order to achieve natural facial harmony. Whenever lips are mentioned, this evokes the deformations caused by silicone injections (now disallowed) that gave patients such a distorted look in the past. Today, the emphasis is on a natural but enhanced effect. I recall a patient of mine who had a full facelift, including chin, nose and perioral (around the mouth) area surgery. She told me 6 months later that the most spectacular and surprising rejuvenating effect was achieved by this perioral rejuvenation. To achieve a natural facial harmony, the lower third has to be studied in synchronicity with the upper and middle third, and we need to know the effect of the lip lift and VY flaps on the whole. The perioral area is one of the most expressive parts of the face because we use it to smile and speak, which is why rejuvenating it is so important.

When a patient performs a liplift with her fingers, she sees a lip volume increase. It is mandatory to explain that liplift will never create any added lip volume.


Drawing on the skin of the lip lift (excision of the blue surface below the nose and closure upward) and projection on the skin of the mucosal VY flaps.

They will be advanced (green arrows for lower lip) to add mucosal tissue to the lip advancement of the VY flap

This is the ultimate sophistication adding to an even more natural and sexy look. Normally, the increased lip volume is homogenously bigger from one corner to the other, and mainly in the middle.

In fact, keeping a small depression in the middle of the lip makes it nicer and even more natural.

Claude Le Louarn

a natural mouth with an attractive midline opening

after: post- lip lift and VY flaps: natural appearance and natural wrinkles on the augmented lips


before: elongation of the white lip with time

As the increase of mucosal envelop is created by a flap advancement from the teeth to the lip opening, no flap has to be performed on the midline. The consequence is that the midline remains thin.


Look at these before and after pictures. Before, the upper lip was convex in the middle.

Post-operatively, the middle opening results in this mouth looking outstanding.

The lip lift associated with the VY flaps rejuvenated this patient and at the same time harmonizing her perioral area as she wanted it. A limited chin advancement was added to complete the effect.



How does the perioral area age? - Through elongation of the white lip, that is to say the distance between the nasal sill and the vermillion border (upper border of the red upper lip). When the mouth is open, the upper teeth become invisible with age, due to the elongation of this white lip (skin) . - Through the shortening of the height of the red lip, which is covered with mucosae ( with age the red mucosal lip becomes thinner). Consequently, the rejuvenation procedure needs to shorten the white lip and at the same time augment the red lip. The technique of shortening the white lip is a lip lift including a curved incision at the nasal sill. The final scar is barely visible. An important point to understand is this: when a patient mimics the lip lift with their fingers, the lip volume appears to increase but in fact, this is not at all the case in reality. We can now look at the technique aimed at increasing lip volume. This is seldom achieved by lipofilling as the latter can only make a difference if the lip was already full in the patient’s youth. If that were not the case, injecting a thin lip would never add volume. The mucosal envelop of the lip can not extend with the lipofilling and the consequence of the filling is always a lip that stays thin, with descent and advancement mimicking the appearance of a duck, hence “duck-lips”. Nor does a filling create a real elevation. The only option, therefore, is to transfer an envelop excess, that is to say a mucosal excess, which is then filled itself to achieve the desired volume. There won’t be an appearance of mucosal tension because sufficient mucosal envelop is transferred giving the lip augmentation a totally natural aspect. This technique is referred to as the VY flap: a V is designed on the mucosae of the lip, on the dental side. The central part of the V is advanced, inducing a mucosal excess between the extremities of the two branches. This mucosal excess can be filled with fat to achieve a permanent augmentation. Scars are not visible because they stay on the inside (the teeth side) and the healing is exceptionally good. Angelina Jolie has fabulous lips. Nobody can say it is not natural because there is no mucosal tension or smoothing (as in the filler-induced augmentation). Her lip volume is enveloped with mucosae presenting wrinkles. This is the key element to replicate - if we want the result to look natural.


THE necklift

Alan Matarasso MD, FACS and Sammy Sinno MD

Alan Matarasso MD, FACS Department of Plastic Surgery, Manhattan, Eye, Ear and Throat Hospital www.alanmatarassomd.com Sammy Sinno MD Department of Plastic Surgery, New York University Medical Center




he appearance of neck aging can occur as early as the late 30’s and progress thereafter, becoming more apparent with time. In some respects due to the differences in the character of skin below the jawline, aging of the neck can be independent from facial aging and more pronounced in appearance. Morever, it is often one of the first areas that people are troubled by. Recent advances in technology and surgery now allow plastic surgeons to treat the neck alone without necessarily having a face lift or, as has traditionally been done, in conjunction with a face lift. Consequently, if the neck is all that is troublesome it can be treated alone.

Figure 1a: Front view of the neck muscles and the submandibular gland. The skin covers this layer. All of these structures are important in surgical necklifting.

Matarasso & Sinno

When the neck ages, the platysma muscle in the neck, which is a thin sheet-like muscle extending from the clavicle to the lower face, shortens and causes banding, or what some people describe as cords below the chin to the collar bones. Also there can be an increase in fat below the skin in front of or behind the platysma muscle, along with enlargement and change in position of the digastric muscles and submandibular salivary glands. When neck aging occurs ahead of facial aging, these changes require dedicated treatment of the neck. Treatment options vary based on individualized patient assessment of key anatomic landmarks and patient goals [Figures 1, 2].

Figure 1b: Lateral view.


Figure 2: Typical pre- and post-operative views of an isolated necklift patient (illustration). Note the blending of the chin and neck and cleanly defined cervicomental angle.


Figures 3a and 3b: Lateral view of patient who underwent a submentalplasty procedure which involves liposuction and platysma muscle tightening. No skin was removed.

Treatment Considerations

Technique for Necklift

Ideal candidates for an isolated neck procedure are those who want to address neck rejuvenation without the need to concomitantly address the midface with a face lift. It is important to discuss relevant related procedures that may play a role in enhancing the result of neck surgery, such as chin augmentation, buccal or cheek fat pad removal (which makes the face appear more chiseled and angular), salivary gland (these can appear as small balls below the jawline) treatment, skin quality enhancement such as chemical peels to improve the quality of skin discoloration or lasers to reduce lines such as the vertical lipstick bleed lines, or midface treatments. Surgical procedures for the neck include liposuction for circumstances of fatty necks, or a submentalplasty procedure that involves liposuction and tightening the loose midline platysma muscles if there are muscle cords (Figure 3a, b). More advanced cases of the aging neck are treated with a necklift which encompasses liposuction as indicated and submentalplasty along with wide skin flap undermining, elevation, and skin excision and tightening. Less severe cases of neck aging can be treated nonsurgically with various modalities. UltherapyTM (Ultherapy, Mesa, Arizona) uses ultrasound technology to tighten the skin in the neck. KybellaTM (Allergan, Weston, Florida) is a medication that when injected properly can melt away fat underneath the chin. Typically several treatments spaced weeks apart are needed. BotoxTM (Allergan, Weston, Florida) prevents the platysma from causing bands or cords and can be injected every few months as the effect wears off. None of these non-surgical treatments replace the effects of surgical treatment. Non-surgical treatments that improve the quality of the skin can also be used in conjunction with surgery.

The targeted area of improvement in a necklift includes the area from the jawline down to the clavicle to the collar bone. If a patient desires improvement in the jowls, an “extended necklift� incision is used which extends slightly toward the tragus and will improve the jowl as well as the neck. The necklift is performed under systemic anesthesia administered by an anesthesiologist in an accredited surgical facility. The anesthesiologist’s role is to monitor safety of the patient and ensure comfort. Local anesthesia is also used. Surgery begins with by liposuctioning subcutaneous fat as indicated. We then make a submental incision just in front of or behind the submental chin crease based on individual patient anatomy. The neck skin is then widely undermined in the subcutaneous plane and elevated. The platysma muscle just below it is identified for treatment as indicated. If the platysma muscles are hypertrophic or redundant or cords can be visible, a strip of midline muscle can be removed. If necessary, small amounts of fat underneath the platysma muscle can be excised or electrocoagulated for contouring. In order to discourage recurrent platysma bands, a wedge of muscle is removed at the level of the hyoid bone and diastasis in the muscles repaired with a 3-0 mersilene suture. Next we turn our attention to the postauricular and mastoid incision. The skin is undermined with face lift scissors under direct vision. The neck is completely undermined from side to side connecting the dissection with the prior submental plane. We then tighten a lax or redundant platysma laterally by undermining the muscle and then suturing it to the fascia of the sternocleidomastoid muscle. If jowl improvement is needed, we include the lower superficial muscular aponeurotic system (SMAS) to improve contour in this area.

Figures 4a and 4b: Lateral pre- and post-operative views of a patient who underwent an isolated necklift procedure. Note the excellent blending of the chin and neck and cleanly defined cervicomental angle.


Figures 5a and 5b: Lateral pre- and post-operative views of a patient who underwent an isolated necklift procedure. Note the excellent blending of the chin and neck and cleanly defined cervicomental angle.

Postoperative Care We prefer patients to remain in a semi-sniffing position with the chin elevated as much as possible for the first few postoperative days to avoid skin ischemia. Minimal discomfort can occur for about 1-2 days after surgery and is well-controlled as necessary with pain medication. Dressings and drains are removed the morning after surgery. Cold compresses are used thereafter. Staples and sutures are removed within the first ten days. Patients are encouraged to return to normal activity progressively from 2 to 6 weeks.

We recommend all patients avoid excess sun exposure or non-surgical facial treatments for the first 3-6 months. The incisions typically fade over a period of many months.

Discussion With the proliferation of surgical and of non-surgical modalities, patients have many options for face and neck rejuvenation. Theoretically some degree of neck rejuvenation can be obtained using recently FDA approved KybellaTM for submental fat, BotoxTM for platysmal bands, and UltheraTM for skin contraction. These alternatives while useful in appropriate circumstances will not replace surgical neck rejuvenation, but rather add to the surgeon’s armamentarium for treating various aspects of neck aging. Isolated surgical treatment for the aging neck is a great option for a subset of patients that either do not require or may not wish to have a concurrent treatment of the midface. Optimal aesthetic results can be achieved by tailoring the procedure to the underlying anatomy and expectations of the patient. In the properly selected patient, a necklift offers a very high degree of patient satisfaction (Figures 4, 5).

Matarasso & Sinno

Final hemostasis is achieved by electrocautery. Excess skin is elevated, advanced, redraped and excised so as to optimize the result and preserve the integrity of the hairline. The wounds are closed over Jackson Pratt drains (Cardinal Health, Dublin, Ohio) soaked in betadine are placed and brought out through the wound and sutured in place; these are generally removed the next day. After closure antibiotic ointment is placed on the incisions. A 3-layer face lift dressing, with gauze, and Surginet (Won Industry, Gyeonggi-do, Korea) are used.



Dr Bryan C Mendelson

Dr Bryan C Mendelson 109 Mathoura Road, Toorak VIC 3142, Australia info@bmendelson.com.au https://bmendelson.com.au


The start of an operation is a quiet, purpose-filled time when all members of our small team are busy preparing for their role in the operating theatre. We usually have Beethoven piano music playing for comfort so the patient’s arrival is tranquil and welcoming. At key parts of the operation I’ll have the volume reduced or the music switched off altogether. As a Composite Facelift takes five hours or more, with key segments of intense concentration, having an environment for calm focused attention is important. At the beginning, the anaesthetist has centre stage and while they are the focus I concentrate on the final planning for the surgery, mentally rehearsing the sequence and important individual variations in what I’m about to do.

Bryan Mendelson



esthetic facial surgery is completely different to any other form of surgery – for the patient and the surgeon. For surgeons it is intensely personal surgery. We know that the emotional happiness of our patient lies in our ability to provide a beautifully natural looking result that will sustain them through the future. As surgery is rarely measured by psychological responses, this gives us a special responsibility. Using the recent understanding of facial anatomy, we can provide the sort of facelifts we could only dream about in past decades. The limited dissection composite facelift is the name of the technique I perform because it incorporates the recent understanding of this anatomy which is significant. Every year I am invited to centres around the world to perform live demonstration surgery of this technique for other plastic surgeons who want to learn the technique. In this article I’ll take you inside that operating theatre with me, to explain what I do. As we proceed to the surgery, there are a couple of things to look out for; the importance of excellent anaesthesia to minimise bleeding and post-operative bruising, and the critical importance of a detailed understanding of facial anatomy – especially of the facial spaces that allow the surgeon to access the deeper layers of the face. This inherently provides an individualised, natural result in the central part of the face (where most aging occurs) and with safety. Let’s go.


But I keep an eye on the anaesthetic monitor to watch the patient’s blood pressure. Maintaining a low and steady blood pressure from the very start is important for facial surgery, because it enables the surgery to proceed with minimum bleeding. Even a tiny bit of oozing blood limits visibility in critical areas. In addition, bleeding causes bruising in the tissues that will slow post-operative recovery. Reducing the recovery time is a key part of advanced facial surgery. I now place the consultation notes containing the surgical plan and the series of enlarged photos of the patient’s face taken from several angles, on a long docket rail on the wall (just like a chef uses to hang up the orders in a restaurant kitchen). I’ll study them many times in the next few hours, as the photos reveal subtle detail of patients variations as well as minor differences between the two sides. I would not be able to operate without them. Then I re-read through the patient’s original request form. Because these notes are written in the patient’s own words, they remind me of the person and the reason they visited me. I double-check that what I’m planning to do is what they really wanted, and that the degree of change I’m aiming for is what they were hoping for. Now the operating room door is closed. Any extraneous chatter about what we did on the weekend ceases. We’re like actors before a performance, locked away in our sealed world Once the anaesthetist moves away from the patient’s head to sit by the anaesthetic machine, the time has come for the surgical team to move in. There’s a healthy build up of tension as we quickly move into our routine. Now with access to the patient’s face I make surgical markings with a fine surgical marking pen. They’re not usually needed so much for the operation as to focus my mind, attuning it to the


individual aspects of the procedure - and the individual nuances of the patient’s face. In some places the markings are critical, such as when planning for the removal of eyelid skin, which is measured to a fraction of a millimetre. Precision here is so important that the eyelid markings are done with the patient still awake, opening and closing their eyes, for placement in the dynamic lid crease and then double checked. The next step is to inject local anaesthetic solution into the part of the face I will be operating on first. Again, this is done with the precision of surgical thought, as the fluid facilitates the surgery. It is injected at the correct depth for the specific layers of the facial tissues where the dissection will be performed. Part of its role is to expand the tissues, which make the dissection easier, hence the term ‘hydro-dissection’. Even though the patient is asleep, local anaesthetic is used as it reduces the body’s response to the surgery by sparing the brain the sensation of pain which causes the patient’s blood pressure to go up. Another component of the injection fluid is adrenalin. Adrenalin causes the blood vessels to constrict, which reduces the blood supply into the area I’ll be operating on. You can see the skin blanching as the adrenalin starts to take effect. During the ten minute response time required by the adrenalin, the surgical team gets ready. I position the patient’s head in the ideal way for operating and the scrub nurse applies antiseptic to the face and to the abdomen as a facelift usually includes some injection of fat into the face, which we harvest from the abdomen or hips. The fat is removed using a special cannula with many small holes in it so that fine particles of fat are collected. An exciting recent advance is a cleansing and filtering chamber in which the fat is processed, so that only tiny particles of pure fat containing

Steps in the Limited Dissection Composite Facelift Step 1. The incision is placed in the groove in front of the ear. Step 2. The dissection is limited, initially in the white area under the skin then when the spaces are reached, inside them only to their forward extent; not into the front of the face.

the ear. Usually it’s possible to end the incision in the groove behind the ear, which is called the ‘short scar’ technique, but if the patient has considerable neck laxity, the incision will have to be extended further, from the top of the ear at the back, and across the hairline. This extended incision needs to be done with absolute care, so it is undetectable if/ when the patient wears her hair up. After the incision is made, I will be able to see into the interior of the face. From here-on in, I’m working three dimensionally inside the patient’s face. Imagine the patient lying there, with their face turned to the side away from you, the incision open down the front of their ear. Entering into that incision, I’ll be moving under their skin, opening up various layers in the deeper anatomy of their face and travelling towards the centre of their face, which is where the correction will be. It’s important to appreciate where aging occurs. We age primarily in the ‘communication zone’ at the front of the face, in the area between the eyes and the mouth. This is a long distance from the incision at the ear. While it’s a long and careful journey through the interior of the face, it is quite familiar to an experienced surgeon. As I dissect through, I will see the layers there, especially the spaces I’m looking for and the nerves I expect to see. I know the face intimately and each landmark is both a comforting sight and also a reminder that I’ve entered deeply personal territory, the face of the patient, so it’s psychological and emotional

Bryan Mendelson

stem cells are used. This results in less bruising and swelling and a faster recovery. The first step in the procedure is usually to inject the lips with fat, to improve their shape and volume to match the fresher appearance of the patient’s face. The lips need specific attention, as a facelift itself doesn’t improve them. Using tiny needle prick entry points at each corner of the mouth, a fine cannula is used to thread in minute droplets of the purified fat, gradually building up the volume. The amount of fat placed is monitored to ensure complete symmetry and control, so that the volume is not excessive. Even a small excess at the beginning here could ruin the natural look of the whole procedure. Now, at last, the real operating. The next few hours will be a blend of routine operating interspersed with higher tension, critical moments, which occur when dissecting or placing sutures (stitches) near nerve branches. These are actually my favourite moments. Face lift surgery consists of three main stages. The first and most demanding of these is the dissection, or carefully cutting a path through the interior of the face to get to the area that needs to be corrected. It starts with an incision on the skin just above the ear that moves down past the front of the ear, under the earlobe and finishes up in the groove behind the ear. Precision is critical so that when it is healed the scar is imperceptible, being concealed in the subtle grooves immediately in the front of


Step 3. The few key support stitches at the back and top of the cheek securely tighten the SMAS support layer.


territory as well. What I’m about to do, as I move forward, millimetre by millimetre, completing each step precisely, will affect their entire future life. To start the journey from the incision I separate the skin, through the next layer, the soft yellow subcutaneous fat, lifting it off the next deeper layer (the third layer), called the SMAS. This is the fibrous support layer and has some white texture on its surface. Doing this separating involves surprisingly little bleeding, as the adrenaline injection and careful blood pressure control do their work. For many surgeons, this is as deep as they’ll go. Using this layer only, they will simply correct the outer cheeks (where some, but not the most important, aging occurs) and attempt to tighten the skin of the inner cheek and around the mouth. Unfortunately, tightening by pulling the skin directly is inimical to a natural and a lasting result. But for the surgeon who is unsure of the anatomy of the deeper layers, it is safer for them to stay at this level. So why is it important to go further and access these deeper layers? Because, in this facelift, the aim is to re-position the support layer of the face, This is the third layer, known as the SMAS. In youth, the SMAS is close to the facial bones and thus faithfully reveals our facial shape, which is set by the bones. But as we age and the soft tissues stretch, this close relationship with the underlying bone is lost. And so our face appears to sag and age. By restoring tone to the support layer we’ll restore the naturally attractive contour of a more youthful face. But we’ll do this by working beneath the SMAS itself, leaving intact its normal relationship to the overlying layers. This allows the benefit achieved to be transferred to the layers above, without bruising or distortion (which means faster recovery) and without the need to stretch the upper layers to achieve the result. As we’ve seen, most surgeons are not comfortable working that deeply inside the facial layers, and so they choose not to. However, having researched facial anatomy my entire life I recognise the importance of the facial spaces which I have defined. How can a space be important? By providing a ‘safe space’ in which to operate at this level, without the danger of damaging a facial nerve.


Spaces are almost like rooms in your house. We don’t even think about it, but rooms allow you to move through the interior of a house in safety. We are actually surrounded by potentially dangerous electrical wires, but they are enclosed in the wall cavity – keeping you and them safe. In the same way, facial nerves are enclosed behind the walls around the facial spaces, allowing safe passage through those spaces (the rooms) without disturbing the nerves. This means a skilled surgeon with good anatomical understanding can move deeper into the face to provide contour tightening in the deeper anatomy while avoiding direct pull on the skin layer. As I travel the world lecturing and demonstrating to other surgeons, it is these spaces that are the focus of their interest, as using their ‘safe passage’ allows us to obtain the most natural facelift result for our patients, in a more natural way because the anatomy being used is already there. Once I’ve separated the skin for about 30mm forward of the incision, I then move one level deeper into the face, by passing through the underlying SMAS and into the fourth layer. We change at this point – and not earlier – as the SMAS does not lift readily until this far forward because it is strongly adherent up to where it overlies the fourth layer spaces under the SMAS. The spaces are part of a gliding plane system that is unique to the face. It allows the soft tissues, skin and outer part of the facial soft tissues around the eyes or around the mouth to move when muscles contract. Once I’m underneath the SMAS in the space, the dissection progresses more easily. The roof of the space above forms what is known as a Composite Flap. Essentially this is the natural fusion of the outer 3 layers of soft tissue; the skin (with its underlying padding) and the subcutaneous layer, fused with the 3rd layer SMAS, which is the fibrous muscular and supporting layer. Given the multiple components in its structure, the Composite Flap is complex and strong but , significantly, it has a rich blood supply that is kept intact. Now that I’m below the SMAS, in the ‘space’, I also change the way I dissect, giving up sharp cutting instruments and switch to using blunt dissection. This means gently spreading blunt scissors in the glide-plane as it helps me to define the ‘spaces’ and then enlarge

Bryan Mendelson

is to hold the SMAS in position, but as I want to reposition the SMAS, first I have to release these ligaments and then replace them with sutures of my own, to hold the SMAS in the new and correct position. This is why it is so important for the surgeon to have a detailed understanding of the facial anatomy. The second stage of the facelift involves placing those sutures into the underside of the SMAS to reposition it close to the bone as it was in youth (before the ligaments weakened). Surgically, this is the payoff ! Once the first suture is placed into the flap, I test the effect by drawing it tight. Immediately the result is seen as a tremendous take-up of laxity on the side of the mouth, along with contouring over the cheek - across a much larger area of the face than you would expect from just a single suture. It shows the instant effect of these sutures taking up laxity of the Composite flap. Every time I see this response it fills me with confidence and I often wish the patient could see it too! The dramatic and instantaneous removal of laxity, coming from deep within the face without any stretching on the overlying skin, is sensational. Now I place additional sutures at the key support areas of the face, to ensure uniform correction. These sutures must endure so the patient can open her mouth, chew, bite and sleep on her face, so I use a strong permanent thread. Even now, before the skin has been replaced into position, the benefit of the facelift in the central (key aging) region of the face is obvious. I’m now ready for the third stage in the facelift, which is to


them to their boundaries. For the largest space, the lower premasseter space just above the jowl, I use the tip of my index finger as it has great sensitivity. These spaces are a wonder for the surgeon as there is absolutely no bleeding and minimal risk of injuring important structures when operating in them properly. Operating in them reminds me of the board game we played as children, Snakes and Ladders. Once the dissection lands in a space, it is like landing on a ladder as the reward allows you to move straight ahead to the front of the space, like getting to the top of the ladder. The only risk of being under the SMAS is the presence of facial nerve branches. However, the nerves have a predictable journey. They are not in the spaces, but in the intervening tissue between the spaces. Also, the nerves travel under the protection of the ligaments (behind the outer walls of the spaces). So I identify the ligaments first, then note the presence of nerves and keep away from them. To an inexperienced surgeon, the nerves and ligaments look similar but experience makes it easy to differentiate one from the other. Knowing where the nerves are in relation to the ligaments is tremendously empowering for the surgeon, just as familiarity with a track through the forest means a rally car driver can safely negotiate it, and at high speed. The ligaments look like short white fibrous cords. These tiny white cords are my interest as they are really the reason I’m here. In a young patient the ligaments are firm, but in an older patient they have already weakened. The role of the ligaments


gently re-drape the skin over the outer cheeks and trim any excess with precision, using very sharp scissors. I am constantly surprised by just how much excess skin there is to be removed. Closure is simple with a forty year old because they still have good elasticity of their skin but with an older patient who has lost elasticity of the skin it takes some skill and patience to gather the loose skin without little pleats being left. Finally, I close the incision in front of the ear and reset the earlobe into the correct position. It is critical that there not be even the slightest pull on the earlobe. Now I can hand over to my assistant to complete the suturing of the incision. This allows me time for a break. There’s no risk in that: a good assistant knows how to do this more straightforward part as there is no decision making and you cannot detect any difference from his suturing to mine. Having a break during a long operation is critical to the maintenance of concentration. Just before handing over, however, I gently turn the patient’s head back to a central position in preparation for the injection of the local anaesthetic solution to the second side, so that it has plenty of time to work while the closure of the first side is being performed. This is the time I really see the improvement of the side I’ve just operated on, by comparing it to the second side yet to be lifted. When I place my hand on the cheek and move it forwards to mimic the effect of gravity, the un-operated side has extraordinary movement, which always surprises me - while the corrected side scarcely moves. This demonstrates an immediate ‘before’ and ‘after’ effect. Finally, when the second side of the face is finished and surgery is complete, I review how the patient now looks compared to the photographs on the wall. This is the moment I wish patients could see themselves. While I usually leave the theatre tired, I also feel uplifted. All the years of effort to develop the understanding, skills and experience to perform this quality facelift is justified when the patient looks this good. I can’t wait for the days to pass so they can see their new appearance. It won’t be long. At every step, the surgery has been carefully performed to minimise bruising and swelling. This patient will enjoy the benefits of this operation all her life.




nor lax and yet the previous sagging is no longer evident. This paradox is the result of the tightening being performed on the inner support layer. These benefits come only with the highest quality surgery. To maximize the benefits of internal correction surgery, it should ideally be undertaken at a younger age as the rate of future aging is slowed.


Bryan Mendelson



Fig 1. The only way you can tell this 47 year old woman has had the benefit of a facelift is by reference to her photograph 18 months previously. This surprises many people who think ‘you can always tell if someone has had a facelift’. While this is true for the average facelift, a quality facelift is quite different as it’s completely undetectable. She now appears as a fresher version of herself with youthfully plump tissues that are neither tight

Fig 2. A 54 year old woman one year after her facelift. Note the improvement in the lower face and ‘jowl’ area. Neither injectable fillers nor standard facelifts are effective in this part of the face. The only way to achieve this natural and undetectable result is to have proper reshaping of the support layer, performed internally in the deeper anatomy near the corner of the mouth.



Knowing where the nerves are in relation to the ligaments is tremendously empowering for the surgeon, just as familiarity with a track through the forest means a rally car driver can safely negotiate it, and at high speed�



Fig 3. 54 year old woman seen 4 years after a proper internal tightening facelift of the type discussed here; that is operating deeper in the face through the natural sub SMAS spaces to take up laxity of the composite flap to provide shape and to tone the skin while avoiding tension.







Bryan Mendelson

Fig 4. A timely quality facelift provides a long term solution to the inevitable changes of facial aging. This is shown in this 50 year old woman, seen before correction and then, 1 year after a proper facelift (B). To provide youthful neck contour required in addition a reduction of the excessive prominence of her glands on each side. This surgery dramatically slowed the rate of her subsequent aging,

so that after 10 years later,( 4C) wanting to remain young for her age she had a secondary, proper internal support facelift. (D) This result builds on the benefit of the original surgery. It would not be possible to obtain a result as impressive as this, but yet not be detectable, had she waited until now for her first surgery.


A measured approach to facelifiting

Henry A. Mentz, MD, FACS

Henry A. Mentz, MD, FACS Triple Board Certified Plastic Surgeon The Aesthetic Center for Plastic Surgery Houston, Texas www.drmentz.com



Henry Mentz

As Abraham Maslow’s phrase from The Psychology of Science goes, “If all you have is a hammer, everything looks like a nail.” My philosophy in facial aesthetic surgery has been to evaluate patients with precision and genuine interest, establish and clarify their unique goals,and provide the best individualized treatment available to achieve a natural, refreshed, and rested appearance. Therefore, if one were to ask if I had a singular strategy, it would be that my signature face lift technique is to fit the patient to the technique rather than the technique to the patient. In establishing the appropriate plan for a patient, all options must be reviewed. The offerings in facial rejuvenation have substantially evolved in my 25 years of private practice. When I first began practicing, the only available options were the face-lift, brow lift, neck lift, and skin resurfacing.Many new techniques have developed since with each having its advantages and disadvantages. Selecting the best technique for each patient is the keyto aesthetic rejuvenation. Timing is also an important part of the surgeon’s craft. Establishing a lifetime improvement strategy requires proper planning and foresight as well as a comprehensive approach. The goal is to enrich and maintain youthfulness utilizing the besttechniques and technology delivered in a timely manner.


atients generally seek the best plastic surgeon in their community to be their face lift surgeon. The fundamental problem is that most plastic surgeons will perform the surgery that they are most comfortable with and adapt that procedure to fit every patient’s needs.

OUR APPROACH We begin by evaluating our patient’s thoughts, goals, and limitations because they all have lifestyle, scheduling requirements, recovery, and expectations that are unique to them. Most patients wish to improve their appearance and most express a preference for minimal change, yet without any residual wrinkles or laxity. The goal is generally to achieve the appearance that closely approximates their best photo of adult life. Others may have more modest goals and prefer to accept


incremental changes. Visible signs of surgery are often the most feared complication, especially the“face lifted” or over tightened look (almost everyone has seen a terrible result either personally or in some Hollywood magazine). Artificial-looking results are typically because of over-tightening, overfilling, or simple disharmony with one area rejuvenated while another is not. Face lift scars are an additional concern. While any surgery leaves a scar, it is possible to make virtually undetectable to most observers. Abright, rested, youthful appearance and restored freshness is my goal for every patient. During the evaluation, there are four key aspects of facial aging, which include:

Most patients wish to improve their appearance and most express a preference for minimal change, yet without any residual wrinkles or laxity. The goal is generally to achieve the appearance that closely approximates their best photo of adult life.


• • • •

Skin quality Skin laxity Soft tissue descent Volume deficiency

Each key factor contributes tothe outcome and allows rejuvenation with little or no “tell- tale” sign. The quality of the skin may reveal fine lines, porosity, hyperpigmentation (age spots), and excessive texturing. Skin laxity is noted typically in the upper and lower lids, around the mouth, and in the neck. Skin almost always loosens because of muscular actions such as smiling or squinting of the eyes. This can be measured by the millimeter and recorded for surgery. The laxity of the skin may define whether skin incisions should be made within the hair or at the hairline. Greater laxity requires more skin removal and more upward movement of the skin and this determines exactly where to make the temporal and neck incisions. Choosing the least conspicuous incision for each patient’s hairstyle and lifestyle is paramount. Skin laxity is a result of lifetime sun exposure, genetics, and inadequate skin maintenance. Soft tissue descent or sagging appears at the brow, mid-face, jowl, and neck. It is also apparent in the upper and lower lids leading patients to complain of puffiness and a tired look. Soft tissue always

My signature face lift technique is to fit the patient to the technique rather than the technique to the patient.”


gives way to gravity causing the brows, jowl and neck to descend vertically. Laxity may be measured and recorded in these key areas. Soft tissue descent is related to genetics. Finally, the fourth aging feature is volume atrophy or shrinkage. Northern Europeans are an example and tend to lean out as they age, becoming more hollow or skeletal. As patients lose their baby fat, they go from round and full to athletic and chiseled, then finally appear more hollow, aged, and skeletal. Volume atrophy is often seen in the temporal area, the upper lids, the tear trough area below the lower lids, around the cheeks, and around the mouth and lips. Computer imaging is a helpful tool in this process for both the surgeon and the patient, allowing for detailed facial analysis and visual demonstration of the improvements that can be achieved through various surgical and non-surgical options. Imaging oftenhelps patients and their families or friends understand how one technique may provide improvement while another may fall short. After careful assessment of these factors, options can be determined and reviewed for each area of concern.Examination and evaluation of the four keys to aging are paramount andare the foundation in establishing facial harmony witha natural result.


Henry Mentz

Formulating a singular strategy for the aging face is difficult and Dr. Mentz’s philosophy has evolved over more than thirty years of aesthetic training and practice. Dr. Mentz’s philosophy is based on four principles.The first principle calls for a multi-tiered approach, the second for blending or combining treatments, the third for completeness and the last for maintenance. The first, a ratcheted, or multi-tiered approachis basically fitting the solution to the problem. That is, minimal surgery for more restrained improvements and goals, more assertive surgery for larger problems and loftier goals. The second is blending treatments to reduce the detectability. For example, in some cases when only laser is used to tighten facial skin, the skin may become whiter, shinier and take on a waxier texture. If face lift surgery is the only procedure conducted, then the skin may appear tight,but the skin quality may appear blotchy and aged. Blending the two with a softer laser and gentle lift may allow pinker and more youthful skin and less apparent stretch from over utilizing tension as a single strategy. Blending techniques effectively improves the quality and authenticity of the result. Third, a naturally rested, more youthful result is achieved with completeness in addressing and improving each of the four components of aging: skin quality, skin laxity, soft tissue descent, and volume deficiency. In re-establishing harmony and balance to the face, the surgeon must re-balance aging structures. If the goal is to look thirty eight


Each option has its advantages and disadvantages and may only benefit a particular patient. The assembly of a surgical plan must interlock and come together to create the finest possible result. A textbook or template can never replace experience and inspiration.

at fifty, all four keys must be addressed. The skin quality should be smooth, even in color, minimally textured and have some translucence and glow. The skin must be soft yet unwrinkled. The cheek fullness must be nicely shelved back onto the cheekbone and the jawline clean with no jowling. Areas that may have hollowing, such as the temples, under the eyes, and around the mouth should be restored to their original softness. This comprehensive, methodical, and systematic method allows for a rejuvenated appearance that is natural and holistic. Lastly, restoring youthfulness is the first step whilemaintaining beauty is the second. The last twenty years have been beneficial in this regard. The addition of Botox, fillers, fat grafts, stem cell grafts, pin treatments, creams, ointments and new energy treatments like smarter lasers, ultrasound and radiofrequencyhave vastly improved the ability to sustain and improve the surgical results of the face lift.



I have found advantages to numerous face lift techniques for specific aging issues and each patient deserves the advantages of each. If a surgeon is tied to a singular or “signature” face lift, the results for some patients would be incomplete or less satisfying. Expertise and skill are crucial. Because face lifts typically account for only a small fraction of a plastic surgeon’s practice, seeking afocused expert who can draw from and assimilate multiple strategies may provide the best results. Here are some advantages and disadvantages of the most popular techniques. To simplify, there are two major formats in technique for face lifting. The lift may be performed in one or two layers. Secondly, the deeper layer, called the SMAS (SubmuscularAponeurotic System), may be tightened or lifted and repositioned. Each of these four options has

advantages and disadvantages and there can be many other additional adjustments possible. A single layer lift of the skin provides excellent skin tightening and wider dissection will allow for more skin wrinkle elimination. This is the oldest format for face lifting and while great for eliminating wrinkles, it does not address the sagging of the deep soft tissues. The deeper structures of the SMAS may be tightened by plicating or placing pleating sutures into the sagging cheek fat and muscle. The pleats may be placed in several directions in order to tighten and lift certain areas. These lifts have many labels but generally are SMASplicationlifts andMACS (Minimal Access Cranial Suspension, Short S-scar lift, Minilift) face lifts. These offer a nice reduction of facial skin laxity and a limited improvement in the SMAS elevation and mid-face sagging and jowling. Generally they fall short in neck improvement. My experience is that when utilizing sutures to tighten or suspend the cheek, over time the sutures give way and relax which limits the longevity of the improvement. The recovery is faster since there is a single layer of dissection. This is best for patients seeking a five to seven year result witha quicker recovery. The SMAS may be included in a thicker single layer lift called a composite lift or deep layer lift, which lifts the skin and deep soft tissue together. Deep plane and composite face lifts have value since the cheek skin flap is thicker and has better vasculature and stronger healing. The disadvantage is that the skin and SMAS are united and so the two are elevated together in the same direction. This lifts the hairline substantially since there is no separation between skin and SMAS layer and may leave behind some skin laxity. Sometimes laser can improve the leftover skin looseness around the mouth. In these cases, I have found skin laxity is often undertreated and the temporal hairline is lifted unnecessarily high. However, this procedure

Henry Mentz

in published papers for the various lifts and this provides the basis for measuring and quantifying skin with soft tissue laxity in the examination. Any of these face lift techniques may be combined with micro liposuction for reduction of fullness or with fat grafting for additional fullness or volume in selected areas depending on facial contours. The recovery is lengthier because the surgery is more extensivebut this style of lifting provides more control and completeness in lifting and repositioning. This is best for patients seeking ten to fifteen year resultsand who are not concerned with the longer recovery. To make things more complicated there are just as many surgical options for rejuvenation of the brow, upper and lower eyelids, and the neck. Each option has its advantages and disadvantages and may only benefit a particular patient. The assembly of a surgical plan must interlock and come together to create the finest possible result. A textbook or template can never replace experience and inspiration. The selection of face lift surgery must be firmly grounded in aesthetics and based on individual examination, measurement, and goals. Analysis is the foundation of good surgery. The skill and judgment of the surgeon, his aesthetic sensibilities, and his artistic approach all provide advantages in achieving the most satisfying results. Every face lift strategy may have a “best fit� and it is up to the surgeon to guide his patient through the consultation, to seek the very best operation to achieve a youthful, natural, and refreshed appearance.


is especially useful in select patients who have thin skin and minimal skin laxity, or smokers and less healthy patients who need more healing power. Actual SMAS lifts are utilized with a two-layer dissection, one for lifting the skin and the second layer for the SMAS lifting. This approach allows for a separation of the two layers and a more elegant tailoring to lift the skin and SMAS independently. Secondly, the SMAS is released from its retaining ligaments and will move/lift more freely. Since the layers are separated, the correction of skin laxity and SMAS lifting is calibrated, set, and corrected. For these reasons,actually lifting and releasing the SMAS offers greater versatility, movement,overlapping and positioning control. SMAS lifting may be performed in one of four ways: high SMAS, low SMAS, SMASectomy (forward), or extended SMAS. There are advantages and disadvantages to each of these. High SMAS allows for overlap and enhancement of the high cheekbone. Low SMAS allows for overlap in the mid-cheek to correct flattened or drawn mid-face features. SMASectomy provides little change in the cheekbone or lower cheek area with removal of the excess centrally. An extended SMAS lift is a high SMAS with greater release of the attachments below. This extended SMAS lift is best for patients with more substantial jowling and soft tissue descent (cheek sag). This SMAS release is extended by releasing attachments high in the cheek and low in the neck, transecting/releasing the neck SMAS or platysma. The extended SMAS elevates the SMAS most effectively. These differences have been measured and quantified



Patient 1. This 44 year old patient did not like the fullness in her cheeks and softened neck line. She received composite SMAS face lifting with microliposuction of the lower face and neck suspension sutures to enhance her neck and jawline. Since the surgery was abbreviated, the recovery was brief.

Patient 2. This 55 year old patient has downslanting brows with some upper and lower lid skin laxity, flattening in the lid-cheek and midcheek areas with modest skin laxity, with minimal jowling and neck aging. She received an endoscopic browlift, conservative upper and lower lid blepharoplasty, a composite SMAS lift to lift cheek and jowl without necessitating cheek skin lifting.



Patient 3. This 50 year old patient had flattening of the mid cheek and lower lid cheek junction with early jowling. She received a dual layerhigh SMAS with mid cheek overlap to lift the jowl and add volume to the midface. Note the gentle lift of the corner of the mouth and softness in the cheek. A necklift was also performed.

Henry Mentz

Patient 4. This 52 year old patient showed signs of heavy features and flatness in the lower face and neck and some skin laxity in the eyes. She was treated with neck and jowl liposuction, dual layer high SMAS to lift jowls and add volume to the cheekbones with SMAS overlap high in the cheek, and pinch blepharoplasty for eyelid skin excess. She improved the strength in her cheek bones and jawline while lifting her SMAS and skin.



Patient 5. This 57 year old patient has high rounded brows, upper lid heaviness, flattened lower lid cheek area, with heaviness in the jowl and neck. She received a temporal brow lift to enhance the brow shape, with upper and lower lid blepharoplasty and canthopexy, dual layer high SMAS with microliposuction in the jowl and neck to lift the cheek and corner of the mouth and add volume over the cheekbone, necklift with platysmaplasty and suspension sutures to accentuate the neck jaw line.

Patient 6. This 68 year oldhad aging in the eyes with heavy soft tissue excess, puffy orbital fat or bags and eyelid skin laxity. In her neck and cheeks she had soft tissue descent with low positioned cheek fat and jowls (SMAS). Her neck has skin laxity and two strong platysmal bands that bowstring and animate when she talks. She received upper and lower lid blepharoplasty, dual layer extended SMAS lift and partial platysma transection with jowl liposuction to lift the SMAS substantially and lighten up the lower facial fullness, and a necklift with platysma muscle plication. Her face lift received the award for “Best Facial Rejuvenation in 2013�. (AMEC : Anti-Aging Medicine European Congress).



Patient 7. This 73 year old patient had extensive aging in all key areas. She required left upper eyelid ptosis repair, canthopexy, upper and lower blepharoplasty, dual layer extended SMAS lift and full neck platysma transection, fat grafting to the temporal area, cheek and tear trough, nasolabial and marionette creases and chin, neck lift with platysmaplasty and suspension sutures to accentuate the neck jaw line, and dual mode Fraxel laser to improve skin quality.

Henry Mentz

Patient 8. This 58 year old male patient showed signs of heavy and lengthened features in the lower face and neck and some skin laxity in the eyes. He was treated with neck and jowl microliposuction, dual layer high SMAS to lift jowls and add volume to the cheekbones with overlap, and conservative pinch upper and lower blepharoplasty for eyelid skin excess. Men require special adjustment of the bearded skin in front of the ear to remove the hair follicles. Their eyes require more subtle surgery so as not to feminize the eyelids. An example of how soft tissue laxity is measured in areas of the midface for evaluation and consignment to a specific SMAS/face lift style.



Dr Vladimir Mitz

Dr Vladimir Mitz MITZ 176, Boulevard Saint-Germain 75006 PARIS http://vladimir-mitz.com

In 1973-74 I was dissecting the Fibrous Squeleton of the Face(FSF), at the anatomical laboratory of rue des Saint Pères in Paris, where I also worked on the vascular anatomy of the face. Being a resident doctor with Paul Tessier, I was keen to respond to his directive of making an « anatomical return to the sources », a theme he adopted for his year of presidency at the French society of plastic and reconstructive surgery. We set up a team of young colleagues, each of them dedicated to a different facial area. I kept the general lead and worked with M.Peyronie in the jugofacial area;F.Firmin and J.Lepesteur focused on the nose, A.Thion on the neck,H.Quilichini on the orbital area, while C.Raybaud,radiologist made the scans on the different head sections. We also did a study of vascular lead -injected samples. Together with Tessier, we choose the acronym SMAS for describing this particular surgical structure that I

Vladimir Mitz




ace lift is a surgical procedure aimed at rejuvenating the face giving it a natural and fresh appearance. The bi-planar face lift technique that I have been using (and described as far back as 1976) involved dissecting the skin and then releasing the SMAS separately, thus allowing for better differentiation of the skin and SMAS tension vectors (the lifting and pulling/repositioning of the skin and soft tissues). My technique has not changed much since, because it’s been proven to be efficient, useful and reliable. Volumetric enhancement was something I adopted in the early nineties. More specifically, I made a presentation on adding SMAS strips to the lips in Rio de Janeiro in 1999, then from 2001 onwards, I have been using fat grafts, as originally advocated by Dr YG Illouz. J.Owsley and B.Connell were the American surgeons who promoted and popularised this technique (fat grafting) internationally, showing beautiful and long lasting results, with many refinements.


was able to dissect from the temporal to the platysmal muscles as a continuous layer involving fibrous and muscular structures bound together under the knife. Our team presented the results in the October 1974 meeting of our society. T.Skoog from Sweeden was sitting in the room – he had already been dissecting the platysma muscles with view to tightening the neck. In 1976 I decided to publish a paper on my work on the midface and jowl SMAS because this presented new surgical possibilities. My publication was not well accepted in France. To begin with, G.Jost dismissed my ideas, only to accept them through the work of Y.Levet, his pupil, eventually describing another type of SMAS anatomy . It is thanks to Owsley whom I met in San Francisco’s RK DAVIES hospital (where I was studying microsurgery with H.Buncke in 1975), that my publication gained wide recognition.

THE BIPLANAR FACE LIFTING PROCEDURE There are many types of surgical face lifting techniques and several segmental variations (if needed). The usual technique involves two separate plans of dissection -skin and SMAS - and different vectors for tightening these. The final result should be natural and without any distortion, taking into account the down rotation of the submalar (below the cheek bone) fat pad, which sits above the nasolabial fold. Thus the work on the SMAS consists of rotation and elevation : the SMAS is elevated through a long infrazygomatic horizontal incision and rotated along a vertical vector. The excess is removed and the remaining strong SMAS is sutured toward the Zygomatic SMAS structure, meaning we have to dissect it until we can see the zygomatic major muscle. The platysma is transected very low(6 or7cm below in important drooping cases),then anchored to the sternocleidomastoid aponeurosis; in more light cases, the platysma back borders are simply tightened to the


sternocleidomastoid aponevrosis, much alike we repair the abdominal muscular wall by a midline suture, except in the neck, we make only a very strong lateral pull. The skin is gently redraped with a vertical vector in the facial area, and a 45°lateral pull in the neck area. The basis of the skin incisions come from R.Millard’s technique (Millard was my mentor for skin elevation, almost always using a temporal incision added to the regular face lift incision, in order to achieve some lateral brow lift). The details are as follows : 1. Local potentially reinforced anesthesia trough IV sedation 2. Extensive Lipolifting(liposuccion) of fatty areas in the neck and jowls - if excess fat is present 3. Skin incisions without cutting off any hairs and endotragal 4. Skin elevation ,extended as required by each different case, using long and powerfull scissors which I designed. I start with the Mastoid area, the Intermediate (around the ear), then the Temporal, and finishing in the Zygomatic area (referred to as the MITZ sequence) 5. Hemostasis (the stopping of flow of blood) 6. SMAS testing to check if there is a vertical mobilisation more than a few millimeters ; if not (young patients), a mere thightening by non absorbable sutures is performed ; 7. SMAS incisions : horizontal below the zygoma 6 to 9 cm, then vertical in front of the ear, in cases where there are marked jowls. This represents a second deeper face lifting, taking care not to injure the facial nerve and preserving the parotid fascial layer,whenever possible; but in some case the SMAS is so thin that a simple Smassectomy is performed ; 8. Hemostasis 9. SMAS suturing along the described vectors, with non-absorbable sutures 10. Hemostasis control 11. Mastoid area drains for24 hours ; 12. Skin suturing in 3 resorbable layers

13. Then volumetric enhancement by lipofilling is performed ; 14. Eyelids are eventually corrected last ; sometimes a lip-chin dermabrasion and lip augmentation are added through microlipofilling ; 15. Overnight light compressive dressing on the face is applied;


In my 40 years of practice, I have had to deal with all of the below :

I have not changed my operating technique in any major way during all these years, notwithstanding the numerous publications on touted improvements in the field of plastic surgery, presented yearly at meetings and congresses . Since 1995 I have used the endoscopic subperiostal approach for the forehead, then switched to frontal and glabellar muscles release without endoscopy, by means of ruginating and the transection of muscles with modified instruments to be palpated through the skin. Today, however, these techniques are used only occasionally or hardly ever even, because of the triumph and simplicity of Botox. I am satisfied that many experienced surgeons in the world perform a variation of the biplanar face lift in standart cases of facial rejuvenation, rather than the composite or subperiostal face lift. Only the future will show the merit of new concepts that are more useful and longer lasting than what we currently have.

1. Facial palsy: just a few number of transient numbness of the inferior branch, and zygomatic branch ; 2. Hématomas – giant - to reoperate urgently or minor, treated conservatively 3. Infection, usually localized and treated easily ; 4. Skin necrosis, mostly partial temporal, or islands preauricular,treated by secondary monitored healing ; 5. Great auricular nerve numbnessor injury, repaired by microsurgical secondary suturing ; 6. Insatisfaction or unexpected early relapse to be reoperated after one year of evolution; the redo rate for skin relapse is approximately 5% in my personal experience ; mean duration of lifting effect and skin secondary redundancy is between 8 to15 years, depending on the skin inner elastic tissue; 7. Fascial Fasciitis, kind of Dupuytren disease of the face, which I studied and published

Vladimir Mitz



Light cases are treated on an ambulatory basis ; more complex cases stay one night after surgery. Many variations do exist ; especially redo technique, or segmental face liftings when appropriate.

in french journal of plastic and esthetic surgery : to be treated conservatively ; 8. Parotid localized Sialoreha , or lymphatic swelling, treated by injection of corticosteroids ; 9. Asymetry : I take great care in preop pictures to discuss this problem with the patient, prior to surgery 10. Bad scarring, cheloid or scar widening, to be adressed specifically ; 11. Hair loss, mostly in the temporal area, where hair grafts,flaps,or simple resection are helpful, depending on the case.


Total face rejuvenation My face lift methodology: The result of 20 years of development

Dr Frank Muggenthaler

Klinik MUGGENTHALER ÄSTHETIK für Plastische Chirurgie und Ästhetische Medizin Landstraße 3 D – 79261 Gutach, Germany www.muggenthaler.com Facial Plastic Surgery Dr. Muggenthaler Blumenrain 12 CH – 4051 Basel, Switzerland www.muggenthaler.ch

Introduction: my foundations DISSECTING THE FACELIFT


Frank Muggenthaler

urgeons choose the field of aesthetic surgery (and facial plastic surgery in particular) for different reasons. Each surgeon who has made the choice to dedicate himself/herself to this speciality has acquired, in the course of their journey to perfecting their skill, the experience and explored the various techniques that shape their own unique approach, allowing them to offer their patients the best possible results. My own personal journey that led to face lift surgery began in my childhood. My father, Dr. Hermann Muggenthaler, had already been practicing as a plastic surgeon in the mid-50s, successfully carrying out all the procedures that were possible, at that time, in this specialist field. He opened one of the first private clinics for aesthetic plastic surgery and was co-founder of the German Society of Aesthetic Plastic Surgery. Always on the lookout for ways in which he could improve the results, he was constantly exchanging ideas with colleagues at home and overseas. I recall vividly the excitement with which my father would talk about his work, having performed a face lift, and even back then I could sense how fascinating it must be to altera person’s face so asto improve their appearance. His enthusiasm for his profession and the importance he attached to his image as a doctor influenced me greatly, while his comprehensive treatment records helped me to master the fundamental groundwork. Aside from my father, who remains my most important and influential role model to this day, I was impressed by the life and work of Dr. Ivo Pitanguy from an early age. With his dedication to sharing new findings, this outstanding plastic surgeon has filled me with enthusiasm for aesthetic plastic surgery, as he has so many other surgeons. I was fortunate enough to be able to follow in my father’s footsteps, having discovered my special interest for facial surgery early on. I studied dentistry alongside medicine and completed my residency in maxillo-facial and aesthetic plastic surgery. Important focus points of my early work included tumour surgery of the face and neck, as well as orthodontic and craniofacial surgeryto correct skeletal misalignment.


My subsequent successes in face lift surgery would not have been possible without these experiences. Tumour surgery requires comprehensive knowledge of the deep anatomical structures of the face and neck, whilecraniofacial surgery allows for a precise analysis of facial proportions. My training in oral and maxillofacial surgery has provided without a doubt the foundation for my face lifting procedures. In addition, many years of experience and having performed more than 2.000 face lifts, have allowed me to refine and optimize my techniques in a number of ways. Today, my face lift methodology is characterised by five factors in particular: extensive analysis, the use of an advanced SMAS technique, the optimisation of brow lifting, the optimisation of anaesthesia as well as the application of Obagi’s sophisticated skincare concept.

The starting point of my work: analysis of the face and neck Following my training in cranio-maxillo-facial surgery in Germany I was able to gain much insight into the finer points of face lift surgery in the course of a fellowship with Dr. Bruce Connell in Santa Ana, California. This period significantly influenced my professional career and it fills me with pride to be one of Connell’s students and to be able to play my part in passing on his extensive knowledge of face lift surgery to younger colleagues. While Pitanguy is indisputably the biggest promoter of aesthetic plastic surgery in the 20th century overall, Bruce Connell is regarded by many experienced plastic surgeons as the master of face lift surgery– and rightly so, in my opinion. A notable strength of Connell’s process is his particularly detailed


method of analysing faces, as well as describing the impression certain anatomical variants convey to the beholder. He also takes the aging of the face into close consideration. He places great emphasis on the optimisation of the smallest details of his facial surgery procedures. Lastly, the neck area is also given particular attention by Connell. These three distinctive features – the detailed analysis, the fastidious and systematic procedures and the consideration of the neck area – have had a lasting influence on my methodology. For me, the starting point of a successful procedure is always a thorough analysis of my patient’s face. This originated during my fellowship with Bruce Connell. At the time he gave me the task of developing a mechanism to describe the aesthetic appearance of the neck scientifically. The product of my in-depth analysis of this exciting topic is the Neck Check. It is often said that the perception of beauty is relative, however many arguments clearly support the idea that beauty is connected to certain prerequisites that are generally applicable. It is particularly important for doctors who practice aesthetic surgery to be aware of these prerequisites and to be able to apply these standards when changing their patient’s appearance. The Neck Check offers a great opportunity to peruse objective reference points of the neck and to help the surgeon identify the best method in order to obtain the desired treatment outcome. The actual “window” that connects our soul to the surrounding world is the face, especially the part framed by the eyebrows, cheekbones and chin. This area is also described as the “magic triangle” of the face. The eyes and mouth are most important in that they enable us to express ourselves and obtain information. This is why faces with larger magic triangles appear more expressive than faces with

Further development of the SMAS technique with deep fixation sutures

Frank Muggenthaler

When I perform a face lift, what is of the utmost importance to me is torestore all of the patient’s facial areas to their youthful location andappearancein an even and harmonious manner:the forehead, the eyebrows, the cheeks and last but not least the neck, which is unfortunately often neglected by surgeons during a face lift. The SMAS face lift has become the standard in face lift procedures over the past years. At this point it is not necessary to outline the fundamental procedures of the SMAS technique, however I would like to touch upon its limitations as well as describe the advances/modifications I have developed that present a number of advantages. With the classic relocation and suture of the Superficial Musculo Aponeurotic System (SMAS), fixation sutures are merely applied to the flap edgesin the cheek area and below the ear. This can cause the following problems: the expansion of

the SMAS/platysma and the tent-shaped tension above the sternocleidomastoid muscle (the muscle on the side of the neck, ED. Drawing) lead to tissue augmentation in those areas and a discreet widening of the neck which can be aesthetically displeasing. This is also why the distinct depression at the front side of this muscle is overlaid by the flaps,which has a negative effect on the clear definition of the jaw angle. Post-operative haemorrhages can also cause problems as they can accumulate to a significant size beneath the mobilised SMAS/platysma flaps, which may require surgical revision. For many years I have been placing four to five additional 4/0 fixation sutures during my face lifts (non-absorbable, braided polyester thread) which run ventrally from the front edge of the sternocleidomastoid muscle to the underside of the platysma. The advantages: the front edge of the sternocleidomastoid muscle as well as the platysma and subcutaneous fatty tissue attached to it are ventrally relocated, which results in an aesthetically advantageous narrowing of the neck contour. Additionally, the dead space below the platysma and the SMAS is significantly reduced. This also reduces the risk of a post-operative haemorrhage necessitating a revision. The additional fixation sutures allow for an even better tightening of the platysma and for an optimal contouring of the neck profile than with the usual SMAS technique. My method also facilitates a comparatively easy method of lifting sunken and enlarged submandibular glands (the glands below the chin, ED Drawing). On one hand this procedure enables me to achieve an optimal shaping of the face, especially the contour of the cheeks and neck. On the other hand the risk of complications which occur more frequently with other face lift methods is reduced to an absolute minimum. Thanks to this method I can substantially spare my patients from these


smaller features. In this context the neck contributes a great deal to the overall aesthetic appearance of the face. The neck should be as inconspicuous as possible in order to draw the observer’s attention to the magic triangle. The Neck Check I developed takes twenty two criteria into consideration, which describe various proportions of, and anatomical findings in the neck region and converts these into figures. The results of this check form an objective measurement for the aesthetic appearance of the neck. This test is very helpful to me personally and to other surgeons who specialise in face and neck lifting as it enables a precise diagnosis. The necessary treatment steps can therefore be identified with near mathematical precision.


Image 1: Depiction of the expansion of the skin dissection (dark dotted line), the expansion of the SMAS/platysma preparation (yellow dotted line), thestress vectors following thedeep suspension sutures (red arrows) and the relocation of the SMAS to the cranial and posterior (blue arrows).

Images 2 and 3: Sequence of fixation sutures: the first suture elevates the SMAS to the approximate level of the zygoma (cheekbone). The following sutures put the platysma under tension and reduce the dead space under SMAS and platysma successively.

complications, which specifically include postoperative haemorrhaging, nerve damage or pain. Following this procedure, my patients experience significantly fewer issues with swelling and discolouration than patients who were operated on using other face lift methods. Finally, this protective procedure also means that I can carry out every face lift using twilight anaesthesia (see below).

Optimisation of brow lifting through modified subcutaneous brow lifting Wide, large, bright eyes are a central aim for all surgical procedures intended to give the face a younger, more harmonious appearance. Lid correction is a correspondingly important factor in aesthetic facial surgery. The impression of a tired appearance is caused not least by the agerelated sinking of the eyebrows. The sinking of the forehead and a low brow position can lead to an apparent excess of skin on the upper eyelids, a so-called pseudoblepharochalasis. If this is ignored during the planning of the treatment, the improvement of the appearance is incomplete or can even lead to a reduction of the periorbital area. My solution for good results in the brow region is


Image 4: The overlap of the SMAS/ platysma flap is then turned under the ear and similarly fixed.

a limited subcutaneous brow lifting which can be adapted to individual needs, is relatively easy to carry out, and very effective. In medical literature, endoscopic techniques of the sub-periosteal brow lifting are seen as the “gold standard� for the lifting of the eyebrows, pretending that visible scars may be avoided by this approach. However, the subperiosteal procedure is anything but sparing and can lead to significant and long lasting oedema and paraesthesia. In my opinion, one crucial disadvantage of endoscopic brow lifting is its insufficient effectiveness, as it merely leads to a slight lift of the brows and does not offer sufficient long-term effects. Good longlasting results are only achieved by a few very experienced doctors, while the indication for this technique appears to be limited to younger patients with no significant excess skin in the brow area. In these cases in particular a simple botulinum toxin treatment of the lateral orbicularis oculi muscle can achieve a similar or even more satisfying lift of the brows. The subcutaneous brow lift with the incision at the hairline receives little attention in literature, despite being the oldest procedure with verifiably impressive and long-lasting brow lifting results. Reservations towards this technique are


Images of patient 1 before the operation: 60 year old patient with elastosis and rhytidosis of the cheeks and neck.

Frank Muggenthaler

Images of patient 1 after the face lift: The same patient after a face and neck lift with the implementation of deep suspension sutures and submandibular liposuction.


Images of patient 2 before the operation: 44 year old patient with significant cervico-facial elastosis as well as low positioning of the enlarged submandibular glands.

Images of patient 2 after the face lift: The same patient after face and necklift with the application of subplatysmal fixation sutures.


Anaesthesia is an important component of my face lift method. Unlike the majority of my colleagues I carry out almost all of my face lifts using so-

Frank Muggenthaler

Optimisation of the anaesthetic procedure

called twilight anaesthesia. Over the years I have refined this technique. The most important aims of applying twilight anaesthesia are controlling the patient´s circulation and blood pressure, avoiding pain and improving the overall wellbeing of my patients. Last but not least, this technique also enables better surgical results. In order to keep my patient’s circulation stable on the day of the face lift and post-op, I apply a well-balanced premedication. I use a highly effective and safe combination of sedatives, long lasting pain killers and medication to reduce swelling. If required, liquids and medication can be admitted via infusion during the procedure . The patient’s circulation and cardiac function are continuously monitored, while local anaesthesia ensures complete absence of pain. My knowledge of the facial anatomy and facial nerves allows me to administer the anaesthetic exactly and effectively. In my clinic we make sure that our patients feel comfortable and safe during the surgery as well, which is supported by the gentle twilight anaesthesia. Additionally we provide a calm and relaxing environment: warm blankets, a comfortable operating table cover and relaxing music to create a pleasant atmosphere. The success of an operation does not depend on the surgical procedure alone, however. The immediate recovery period is also very important for a successful outcome. The twilight method enables our patients to experience a much faster recovery period and a far more pleasant surgical procedure, including the hours following the procedure. Avoiding general anesthesia is better for the circulatory system, which in turn benefits the healing and recovery process. Twilight anaesthesia patients are able to socialise


presumably based on two fundamental factors: firstly with the dissection of the forehead skin over a large area, circulatory disorders can occur more easily at the edges of the skin flaps, in particular in the upper temporal region, than with other well-known techniques. Secondly, unsightly and obvious scarring can occur when the incision is consequently carried out along the entire hairline, as the hair shafts generally run at a sharp dorsal angle in the upper temporal area and therefore do not obscure the scars. In order to minimise the risks mentioned I apply the subcutaneous brow lift in a modified form, using two separate horizontal incisions, lateral to the midline with a length of 4 to 5 cm each. With a careful and protective method of incision and dissection the advantages of the technique are obvious:it is an easy and timesaving procedure which allows a very effective repositioning of the brows, while the individual extent of the brow lift can easily be adapted. Furthermore this procedure does not cause any permanent loss of skin sensitivity and leads to very good long lasting results. I either carry out the subcutaneous brow lift in combination with a total face lift or as an isolated procedure in order to correct pseudoblepharochalasis. In many cases this eliminates the need to carry out blepharoplasty of the upper eyelids.


Image of modified and limited brow lift technique: horizontal incision at hairline, area of subcutaneous skin dissection, skin elevation with buried absorbable fixation sutures.

again at a significantly quicker pace than following a face lift under general anesthesia. A face lift with twilight anaesthesia is not just a safer and more pleasant method for the patient, it also facilitates a better monitoring of results. This technique allows me to discern and reproduce the patient’s facial expression very well during surgery, unlike with general anaesthesia . Nerve damage is also more easily avoided than with the conventional method.

Integration of Obagi’s skincare concept For me the integration of a highly efficient skin care is a crucial requirement for the success of aesthetic surgical procedures. The recognition that a complete rejuvenation of the face is only possible with due consideration to the skin quality has had a significant influence upon my face lift method. It is one thing to restore younger, more harmonious facial proportions with a face lift, but for a face to truly look younger, fresher and healthier the skin’s signs of aging need to be corrected and neutralised as well. In accordance with this knowledge I have been regularly exchanging ideas with dermatologists for many years and have as a result integrated many valuable ideas from there into my work as a surgeon. The desire to have beautiful skin is probably


one of the most important attributes of human culture. All known aids, remedies, balms and techniques have been in existence for a very long time and the choice of products on the cosmetic market is predictably vast. Unfortunately, the majority of well-known cosmetic products only achieve very limited results. If, however, one is aware of the exact mechanisms of skin aging and of the substances that have an effective correcting effect on the skin, one can achieve astonishing corrections to the aging skin and an overall improvement in skin quality. In this respect we owe much to the Californian dermatologist Dr. Zein Obagi, who developed systematic treatment methods for the skin as early as the 1980s. It is based upon a five step programme, through which practically any type of skin can regain its healthy, beautiful qualities. The steps recommended by Obagi include cleansing, activation, stimulation, calming and care, as well as protection. With a systematic skin treatment concept such as Obagi’s the problems of aging skin can be solved where they originate, thanks to a targeted and attuned use of effective cleansing, antioxidants, bleaching agents, vitamin A or retinoids. I recommend this treatment to all of my patients. Adopting a good skin regimen is critical in order to improve the appearance and quality of the skin and to achieve complete rejuvenation, especially before and after a face lift procedure.


References: Baker C. Daniel: Face Lift With Submandibular Gland and Digastric Muscle Resection: Radical Neck Rhytidecomy, Aesth Surgery J. 26:85, 2006 Bernard R W, Greenwald, J A, Beran, S J, Morello D C: Enhancing Upper Lid Aesthetics with the Lateral Subcutaneous Brow Lift. Aesthetic Surgery Journal, 2006, Volume 26, Seiten 19 - 23

Connell BF: Facial rejuvination. In Brent B (ed): The Artistry of Reconstructive Surgery. St Louis, CV Mosby, 1987 Connell BF: Neck contour deformities: Ther art, engineering, anatomic diagnosis, architectural planning and aesthetics of surgical correction. Clin Plast Surg 14:4, 1987 Connell B F, Lambros Val S: The Forehead Lift: techniques to avoid complications and produce optimal results. Aesthetic Plast Surg; 1989, Volume 13, Seiten 217 – 237 Connell BF, Marten TJ: Deep layer techniques in cervicofacial rejuvination. In Psillakis J (ed): Deep Face lifting Techniques. New York, Thieme Medical Publishers, 1994 Connell BF, Marten TJ: Face lift. In Cohen M (ed): Mastery of Plastic and Reconstructive Surgery. Boston, Little Brown, 1994, pp 1873-1902 Ellenbogen R, Karlin JV: Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg66:826, 1980 Giampapa Vincent: Long-Term Results of Suture Suspension Platysmaplasty for Neck Rejuvenation: A 13-Year Follow-up Evaluation. Aesthetic Plastic Surgery (Springer), 29:332, 2005 Guyuron B, Davies B: Subcutaneous anterior hairline forehead rhyitdectomy. Aesthetic Plast Surg, 1988; Volume 12, Seiten 77 – 83

Marten J. Timothy: Face lift: Planning and Technique, Clin Plast Surg, April 1997 Marten J. Timothy: Maintenance Face lift: Early Face lift for the younger Patient, Course #802, The Aesthetic Meeting, New Orleans, 2005 Mitz V, Peyronie M: The superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 58:80, 1976 Miller T A: Lateral Subcutaneous Browlift. Aesthetic Surgery Journal, 2003, Volume 23, Seiten 205 – 210 Muggenthaler F: der Neck Check – ein neues Analyseverfahren zur Bestimmung der Halsästhetik. FACE – international magazine of orofacial esthetics, 4/2007, 26 – 33 Muggenthaler F: Das umfassende Gesichtslifting. Der MKG – Chirurg. Issue 3, November 2008, 176 – 180 Randall P, Skiles MS; The “SMAS sling”; An additional fixation in face lift surgery. Ann Plast Surg 12:1, 1984 Singer P. David, Sullivan K. Patrick: Submandibular Gland I: An Anatomic Evaluation and Surgical Approach to Submandibular Gland Resection for Facial Rejuvination. Plast Reconstr Surg 112:1150, 2003

Frank Muggenthaler

Bruce V, Young A (1998)In the eye of the beholder, the science of face perception. Oxford university press, p 139


In the past, face lifts were primarily requested and offered as individual procedures. Today, aesthetic facial surgeons should place emphasis on the complete and harmonic rejuvenation of the face. On my journey to develop my own face lift methodology I have taken much inspiration from many excellent teachers. I have practised and optimised the essential key techniques for successful face lift surgery. The classic SMAS lifting is the solid basic approach, similar to the frame of a car, on which my procedure relies. Thorough analysis is the starting point that makes the aim of my work discernible and makes its results measurable.

My adaptation of the SMAS method, using deep fixation sutures, and the modified subcutaneous brow lift have allowed me to achieve optimal contouring – not least of those facial areas that significantly contribute to a youthful appearance and radiance. The consistent application of twilight anaesthesia helps me monitor the results and makes the procedure as pleasant and safe as possible for the patient. The integration of a carefully balanced skincare concept rounds off the results of my work perfectly. Using a combination of various complementary procedures, surgical modifications and supporting measures I can promise my patients exactly what they want in good faith: total facial rejuvenation.

Skoog T: Useful Techniques in Face Lifting. Presented at the Annual Meeting of the American Association of Plastic and Reconstructive Surgeons, San Francisco, 1969 Stuzin JM, Baker TJ, Gordon HL: The relationship of the superficial and deep facial fascias: Relevance to rhytidectomy and aging. Plast Reconstr Surg 89:3 Sullivan K. Patrick: Contouring the Aging Neck With Submandibular Gland Suspension. Aesthetic Surgery J. 26:465, 2006 Troilius C A: A Comparison between subgaleal and subperiostal brow lifts. Plast Reconstr Surg, 1999, Volume 104, Seiten1079 – 1090

Knize D M: Limited Incision Forehead Lift for Eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg 2000, Volume 105, Seiten 1120 - 1127


The Round-Block SMAS Facelift

Dr Tomaz Nassif

Tomaz Nassif Plastic Surgery Rua General Garzon 22, suites 303/304 22470-010 Jardim Botânico/Lagoa Rio de Janeiro - RJ - BR 55-21-2512 7497 tomaznassif@uol.com.br



Tomaz Nassif

any people conflate plastic surgery with a number of general cosmetic procedures, such as laser therapy, Botox applications or even fillings. Prospective patients often come to our offices, identify a problem area, pull the skin up and sideways and ask that we perform that exact lift as if it is something simple and easy to accomplish. A face lift is, of course, as real and complex a surgery as any other one, with potential risks, trauma and a certain incertitude regarding the final results. In common with all participating surgeons in this book, I was trained in both reconstructive and aesthetic plastic surgery. Both utilise the same principles and address the same tissues and anatomy. They have the same healing processes in common and share many other important aspects and techniques. I have been Chief of Department of Reconstructive Plastic Surgery and Microsurgery in Rio de Janeiro, Brazil for the last 30 years. During the years I have also worked in a private clinic, performing primarily aesthetic surgery. Face lift has been my specialty and one to which I dedicate all my efforts in order to achieve lasting results with naturalness and effectiveness without risks. Skin undermining and excess trimming was in the origin of the face lift procedure. This simple technique was used for a long time, without touching or treating the deep structures and tissues of the face. As a result of this superficial lifting of the skin, the scars became more visible after a while because the skin always tries to return to its previous position, thus enlarging and distorting the scar lines. More recently, but not much, in the middle of the seventies, two French surgeons, Mitz andPeyronie, described the SMAS (an anacronym for “superficial musculoaponeurotic system�) and the SMASplatysma (there is an intrinsic continuity between these two important structures).


Picture 1: this picture shows the directions of the deep tractions exerted on the platysma muscle (in red) and by the roundblock SMAS suture (showed in yellow).

Someone asking for a face lift means that she or he wants to look better, to have a beautiful, youthful and equilibrated face... First of all, the plastic surgeon must examine a potential client and understand her or his requirements.”


As is the case with many a paradigm shift in medicine, the popularization and application of the techniques using these “newly” revealed structures took some time. Approximately 10 years later other authors began to present their experience with lifting the SMAS, in combination with some personalized applications of the technique. A new era for the facial lifting had begun! Ligamentous skin attachments, different approaches to the SMAS-platysma and other deep plane techniques were being published in scientific journals. Since the beginning of the eighties I’ve been doing the extended dissection of the SMAS-platysma that I developed during my stay in France in 1980-1981. Working with Daniel Marchac and being a friend of Wladimir Mitz and other important surgeons in France at that time, I was able to develop considerable experience with the then “revolutionary”, now commonly used SMAS-platysma deep face lifting. Indeed, with the suspension of the deep structures of the face, providing elevation of the musculature and its deep soft tissues, the redundant skin could simply be trimmed out, without using traction and without exacerbating the scar lines’ visibility. The main question facing newly qualified plastic surgeons is, which is the better approach to face lifting: using extended dissection or just folding (plication) the excess structures without dissecting them? In my view there are no hard and fast rules for or a definitive answer to that because there isn’t just one way to work with and treat the tissues in all their particularities. Just as there are differences in patients’ skin quality, age, fat, muscles and personal desires, there is no surgical prescription that fits all. Someone asking for a face lift means that she or he wants to look better, to have a beautiful, youthful and equilibrated face, with less skin laxity, no eyelids sagging, just the right amount of fat in this area or that, and so on. First of all, the plastic surgeon must examine a potential client and understand her or his requirements. The parameters that will guide a surgeon to choose the correct technical procedure include the anatomical and personal characteristics of the individual patient, as well as their general state of health.


Picture 2: the same patient showing the natural aspect that results from the technique. The scars in front of the years are very recent, only three months after the surgery, but nevertheless inconspicuous.

Tomaz Nassif

Picture 3: close-up showing that the well positioned and tensionless scars all around the ears are barely apparent. An important result of this technique is that the sideburns are maintained at their original places, as well as the hairline in the posterior aspect at the back of the ears.



Picture 4: schematic drawing showing the location of the incisions and the skin area to be undermined. These are exactly the same incisions used in the patient appearing in the pictures 2 and 3.

Picture 5: in this picture, the platysma muscle is being freed to allow its repositioning towards the back of the ear, redressing the tissues of the neck to its original position.

Picture 6: the platysma muscle is then fixed in the retro auricular position and the SMAS is showed being pursed with a strong non resolvable stitch in a round-block maneuver to tension the muscular fascia of the face.

Picture 7: the skin is then pulled up and forth without particular tension to estimate the excess to be trimmed out. Doing so, the sutures of the skin are completely tension free, avoiding stretched and hypertrophic scars around the ears, as can be seen in the picture 3.

Tomaz Nassif

I always treat the SMAS-platysma in all cases, using plication or resection, depending on the volume and weight of a particular face. The extent of the scars will vary depending on the extent of skin laxity. If needed, the use of lipofilling (permanent) or synthetic absorbable filling substances at the same time would complement the face lift. If the neck shows strong platysma bands, they should be resected or folded in the midline to smoothly redress the skin over this muscle in that area. That will certainly contribute to a beautiful, sustainable and fair result, with adequate volume to the various compartments of the face. Many surgeons favour the deep subperiosteal or submuscular planes of dissection. These are more invasive operations that are said to offer greater longevity and better overall results. The 1995 twin study that used two couples of identical twins operated on by four different plastic surgeons using different techniques shows postoperative results at 10 years that unquestionably favour, in my opinion, the SMAS-platysma dissection, demystifying the subperiosteal and deep plane of dissection. Either way, I feel very strongly that the skilled surgeon will always make more of a difference in obtaining a good result than the technique itself. I would go as far as saying that the best surgeon is the one who can obtain a good, effective, natural and lasting result using a more conservative and safe technique. Looking back on my career as a surgeon, I feel it was important for me to have experienced almost all of the described techniques: from the deep plane, to the subperiosteal and SMAS-platysma, over the last 30 years. I have come to the conclusion that the most important thing for a patient is to have a quick recovery time with less trauma and no complications at all. The result may be less than all it could be, but to me, the boundary to respect above all is the principle of “first do no harm”.


Today, face lifts are combined with a number of surgical and non-invasive procedures. Volume, for example, is important and can be reduced or augmented. Liposuction is an important and safe procedure for the submental and neck areas. On the other hand, autologous fat or synthetic fillings can be used to restore volume if necessary. When necessary, the repositioning of the forehead andperiorbital tissues and/or elevating the eyebrows can be done at the same time using the video endoscopic technique. The video surgery differs from the previous “all around the top of the scalp” incision in that it allows the surgeon to perform the procedure through just four or five small and inconspicuous scalp incisions. This technique also prevents the widening of the forehead, which was a real problem in the old, but still commonly used by some surgeons technique. Many articles have been written to determine the distribution of the elastic and collagenous fibers of the skin and the SMAS, as well as its re-positioning. There is an important relationship between these structures and both must be treated simultaneously in order to obtain a good and lasting result. In the majority of my cases, approximately 70%, I use the “round-block” SMAS technique of plication. This procedure, first described by the Brazilian plastic surgeon Stocchero, used with my modest personal modification, folds the SMAS in a strong suture around the ears (see the figure), while at the same time the platysma is pulled towards the back of the ear. Nevertheless, I am a strong proponent of the SMAS-platysma whenever we want to elevate and reposition the tissues of the face. Short scars or traditional “long” incisions around the ears are to be considered on a case by case basis - which depends on the amount of skin to be removed and the skin’s elasticity. Well positioned scars in the face should not unduly worry the patient because, if there is no excessive tension, the scars will be almost always invisible.


The Anterior SMAS Approach for Facelifting and Midface Contouring

Malcolm D. Paul, M.D., FACS

Malcolm D. Paul MD, FACS Clinical Professorof Surgery Departmentof Plastic Surgery University of California, Irvine www.surgery.org/drmpaul



Malcolm D Paul

y search for a safe, predictable, and broadly applicable technique for face and neck lifting has evolved from the following observations. Simply lifting the ski and repositioning it only applies to secondary cases that require a modest correction to maintain a previously achieved result. Performing a skin lift only face lift provides a mini improvement for a mini period of time. Most patients present to my office with concerns about the appearance of their neck. Therefore, a treatment plan that does not adequately correct the aging neck will result in dissatisfied patients. My only regret in terms of improving the appearance of the neck has occurred when I have decided not to open the neck and directly treat all of the underlying elements that contribute to the undesirable appearance of the neck. We have learned to understand how the face and neck age. What was previously thought to be purely changes related to the gravitational descent of soft tissues has changed. We have come to understand that the aging changes in the face and neck are the result of the loss of structural support at the bony level as well as the soft tissue level principally due to the loss of facial fat with aging. These findings combine with the effect of gravitational changes to produce the signs of aging of the face and of the neck. Because we now know what causes aging of the face and of the neck, we have developed treatment plans that involve not only repositioning of drooping soft tissues, but replacement as well with the use of facial implants and soft tissue fillers including the use of one’s own fat as a graft material. More invasive face lift techniques require a thorough understanding of the underlying facial anatomy to avoid complications which can occur in more aggressive dissections. My technique for face lifting involves deep facial dissection and soft tissue repositioning utilizing a different approach than that of most face lift surgeons. My component separation technique for rejuvenating the neck has achieved results that I could not obtain with methods that I have previously used for many years.


I begin my physical examination by evaluating the quality and texture of the skin because addressing the aging of the skin and correcting it with lasers, peels, cosmeceuticals, etc. is a frequent component to the overall plan for facial rejuvenation.”


DESCRIPTION OF THE METHOD Every patient that I see requires a thorough physical examination which takes place after I have had an opportunity to listen to the patient’s main concerns with regard to facial aging. Typically, patients will begin by pointing out their unhappiness with the appearance of their neck. They object to loose, drooping soft tissue, the extreme of which is the “turkey gobbler neck”. They also will state that they look “old and tired” and often will point to the areas around their eyes and mouth which appear quite different than when they were younger. Frequently, they will state that they appeared aged almost “overnight”. Many times, they mention that their friends say that they “look tired”. It is valuable to have patients bring photos of themselves that were taken when they were much younger, perhaps when they graduated from college or their wedding photos. Front and side views are important because they allow me to see the shape of their face and neck in youth. There will be varying degrees of loss of volume and of support as the patient ages. Aging faces are “bottom heavy”. Youthful faces are heart shaped with a greater horizontal dimension in the upper face compared with the lower face. I begin my physical examination by evaluating the quality and texture of the skin because addressing the aging of the skin and correcting it with lasers, peels, cosmeceuticals, etc. is a frequent component to the overall plan for facial rejuvenation. I then begin examining the patient from the forehead to the lower neck. I will not include techniques for forehead or eyelid rejuvenation in this presentation. I spend considerable time examining the lower eyelid junction with the cheek. Facial aging includes a lengthening of the lid/cheek junction and the technique that I have developed over the past several years has, as one of its objectives, to raise the cheek and shorten the lid/cheek junction while avoiding more than the simple removal of a pinch of redundant skin from the lower eyelids. Occasionally, protruding lower lid fat requires trimming and/or repositioning. I carefully look at the contour of the jawline because the appearance of prominent jowls creates an irregular contour to the jawline and should be corrected as part of the overall plan. The hair pattern mainly in the temple and behind the ear must be viewed as an aid to planning the incisions. Also, the presence of a deep crease in front of the ear provides an option for incision placement that, in some patients, may be a better option than placing an incision along the edge of the tragus. I look at the contour of the neck and visualize

the structures beneath the skin that are causing the deformity of the neck. The geometry of the neck is a cylinder, but the components are varied in terms of volume and descent. The components include: skin, multiple fat compartments, muscles, and salivary glands. Typically, more than one component must be addressed to provide a comprehensive rejuvenation of the neck.

Malcolm D Paul

Obtaining a thorough medical history is important in all patients who plan to undergo elective surgery, but even more so in facial cosmetic surgery patients who are frequently older and may have pre-existing medical issues such as hypertension, coronary artery disease, diabetes, etc., that need to be addressed before an elective surgical procedure is performed. It is desirable to have patients cease smoking at least 3 weeks before undergoing a facial cosmetic surgery procedure to minimize the risk of wound healing problems related to smokingwhich impairs the circulation to the skin.Obtaining preoperative medical clearance is frequently required in patients with medical conditions that may impact the anesthesia, surgery, and/or recovery. All patients are advised to cease taking aspirin-containing medications and anti-inflammatory medications for 10 days before surgery. If a patient is taking anti-coagulant medications or is a diabetic on insulin, their medical management must be coordinated with their Internist. Choice of anesthesia: Patients are given several options with regard to anesthesia. • Local anesthesia with oral sedation and analgesia. • Intravenous sedation combined with local anesthesia • General anesthesia


Preparing the patient for surgery

I have found that many patients prefer local anesthesia with oral sedation or intravenous sedation combined with local anesthesia. However, there are many patients who are quite anxious and feel that they would be more comfortable if they were placed under full General Anesthesia. The technique of administering the oral sedation and injecting the local anesthetic agent without the use of intravenous medication has been refined and improved so that patients are completely comfortable, do not feel nor remember the injections, and recover quickly because they are not recovering from the effects of intravenous sedation or general anesthesia.










Markings for the procedure(s)

I begin with an incision below the chin to allow access for liposuction of the neck. This is followed with opening the incision and dissecting as low as is necessary dictated by the length of the muscle bands which can descend for a short distance or all the way to the clavicles (collar bone). With good exposure, I can address the fat compartments of the neck individually. Frequently, fat has to be removed above, between, and behind the platysma muscles. Next, I undermine the muscles to free them from the underlying deep muscles which will help in the contouring of the neck. The platysma muscles are

Malcolm D Paul

Surgical Technique:


For many years, I have told my patients that if they have to change their hairstyle to cover the incisions, the planning of the incisions was not done artistically. The incisions should follow the hairline above and behind the ear as well as the natural contour of the ear both in front and behind. The planned rotation and advancement of the cheek and neck skin has to be pre-determined as that will dictate the placement of the incisions principally slightly above the hairline in the sideburn and behind the ear in the adjacent hair bearing scalp. The incision in a woman will be placed higher, inside the occipital (behind the ear) hair, and will be placed lower, just inside the hairline, in men to avoid distortion of the hairline after the skin is advanced. Injecting local anesthesia: This has to be performed slowly to minimize discomfort in the patient who elects to have the procedure performed only with oral sedation, analgesia, and local anesthesia. This process including the time for oral medications to take effect may take up to 1 hour. Patients appreciate the time that they are given for medications to work which insures their comfort.

sutured together as a seam from under the chin to a predetermined level. Frequently, the lower edge of each muscle is divided to allow a backward and upward rotation of the platysma muscles which will define the contour of the neck. At this time, I use a series of dilators on both sides to lift the skinfrom the underlying muscles which will re-drape the skin and allow rotation and advancement of the neck skin. If a chin implant is to be inserted to correct an under-projecting chin, this can be inserted through the same incision that was used to access the neck re-contouring procedure(s). The dissection is performed from the incision beneath the chin in the direction of the mandibular border elevating the soft tissues on both sides of the midline of the chin. Placement of a chin implant will improve the projection of the chin while simultaneously improving (deepening) the angle between the chin and the neck. I then begin to elevate the skin on one side of the face. The undermining of the skin continues to the nasolabial fold as dictated by the patient’s anatomy. Dilators facilitate the elevation of the cheek flap, minimizing any bleeding. The neck skin is undermined for a short distance and dilators are used again to release and re-drape the skin of the neck. The jowl area is completely released and any residual fat can be safely suctioned for improved contour. At this point, my procedure begins to differ from the most commonly performed face lift procedures. Many surgeons will either simply plicate (suture) the layer beneath the cheek fat named the SMAS (superficial musculo-aponeurotic system), resect the lateral part of the SMAS and suture the mobile SMAS to the non-mobile SMAS, or dissect the SMAS from in front of the ear for a variable distance onto the cheek and then rotate and fix the SMAS to elevate the cheek and the jawline. Several years ago, I began the incision in the SMAS layer further forward than what was published by other surgeons. This maneuver requires



The SMAS maneuver requires a thorough understanding of the underlying anatomy to avoid injury to deeper structures.�

a thorough understanding of the underlying anatomy to avoid injury to deeper structures. The procedure allows access to the front of the cheek and the jowl area and includes elevating the corners of the mouth which frequently droop due to gravity and loss of underlying fatty soft-tissue support. Many patients present with a fullness in the jowl area that represents enlargement and/or herniation of the buccal fat pad (ED. Drawing of herniated bucal fat pad) . Failure to remove this structure prevents us from obtaining a straight jawline that has no more bulging fat pads. Fortunately, my technique allows for the safe removal of the buccal fat pad through the incision in the SMAS because my dissection is far forward, allowing easy visualization and fat pad removal. The elevated SMAS flap is fixed to nonmobile structures which insures a longer lasting result. Essentially, the lower edge of the SMAS is attached to Lore’s fascia, a fixed deep structure which will not move forward resulting in loss of correction and the upper edge of the SMAS is fixed to non-mobile SMAS in the temporal area. After securing hemostasis, a drain is inserted and is left in place for 48 hours. This removes any fluid that will accumulate beneath the flap and allow the skin to attach itself to the underlying soft tissues. Bruising and swelling are minimized with the placement of a drain on each side. Redundant skin in the temporal area, in front of, and behind the ear is carefully trimmed after key sutures are placed in the temporal area and behind the ear. There should be absolutely no tension on the skin. Tension on the skin can produce wide scars, hair loss, downward pull of the earlobes, forward rotation of the tragus (front of the ear), and traction lines that are nearly impossible to correct secondarily. Skin closure is performed with skin clips (only in the hair bearing scalp), as well


as absorbable and non-absorbable sutures. Skin clips and non-absorbable sutures are removed at one week. A similar procedure is performed on the opposite side of the face. If procedures are required on the eyelids and/or the forehead, they are performed after the face lift is completed. When fat grafting is required to restore lost facial volume, fat is harvested from the abdomen, hips, thighs, and/or knees and is carefully injected with small diameter cannulas in the deep compartments of the cheek, the temporal area, just below the eyebrow, deep in the lower eyelid, the jawline, and around the mouth. I believe that harvested fat should be injected soon after it is aspirated to improve the survival of the fat cells. Because my technique repositions the cheek, shortening the lid/cheek junction, fat grafting is frequently unnecessary to obtain a harmonius rejuvenation of the central component or the middle one-third of the aging face. Fractionated CO2 laser resurfacing can be safely performed at the conclusion of the procedure in areas where the skin has not been elevated such as the forehead, upper lids, lower lids, nasal skin, and perioral areas. Dressings are applied and are changed at 24 and at 48 hours followed by the use of a Velcro support garment for 5-7 days. The garment provides moderate, even pressure, which helps to smooth any swollen areas and support the neck while it is healing, ensuring the maintainance of a new contour.

Post operative care Ice compresses and the use of Arnica Montana (which helps resolve bruising and swelling), often oral or injectable steroids for a few days, antibiotics, sedatives, and mild analgesic medications are routine. Most patients are able to resume their


work and social schedules in 7-10 days, but some take longer depending upon the procedures that were performed and whether they tend to bruise easily. Patients are cautioned to avoid strenuous activity for 3 weeks.

RESULTS In a series of more than 200 consecutive face lifts using this technique, complications and sequelae have been extremely rare and patients have been able to maintain a youthful contour of their face, jawline, and neck. I find it useful to compare the photos of youth with pre and post-op photos to see how close we came to re-establishing the contours of youth. As mentioned, a thorough understanding of the underlying facial anatomy is required before safely performing deeper dissections in the face and neck. I feel that the results justify the effort.

Malcolm D Paul

REFERENCES: 1. Lambros, V.S. Observations on periorbital aging. Plast. Reconstr. Surg 2007; 120(5) 2. Mendelson BC, Muzaffar AR, Adams, WP jr. Surgical anatomy of the midcheek and malar mounds. Plast. Reconstr. Surg. 2002; 110(3): 885-96 3. Hamra, ST Composite Rhytidectomy. Plast. Reconstr. Surg. 1992;90(1):1-13 4. Feldman, JJ Corset Platysmaplasty. Plast. Reconstr. Surg. 1990;85(3):333-43 5. Marten, TJ Facelift. Planning and Technique. Clin. Plast. Surg.1997;24(2)269-308 6. Baker, DC Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy: Operating Strategies. Aesthetic Surg. J 2001;21(1):68-80 7. Connell, BF, Marten, TJ. Deep layer technique in cervico-facial rejuvenation. In Psillakis J, editor. Deep face-lifting techniques. New York: Thieme Medical Publishers; 1994. Pg. 161-90 8. Cardoso de Castro, C. The value of the anatomical study of the platysma muscle in cervical lifting. Aesthetic Plast. Surg. 1984;8:7-11 9. Tonnard P, Verpaele A, Monstrey S, et. al. Minimal access cranial suspension lift: a modified S-lift. Plast. Reconstr. Surg. 2002;109:2074-86 10. Ramirez, OM Advanced considerations determining procedure selection in cervicoplasty; Part One. Anatomy and Aesthetics. ClinPlastSurg 2008;35:679-90 11. Paul, M.D. Clinics in Plastic Surgery / August, 2008 / Facelifts Part 1 / Editor / W.B. Saunders, Philadelphia, PA 12. Paul, M.D. Clinics in Plastic Surgery / October, 2008 / Facelifts Part II / Editor / W.B. Saunders, 13. Philadelphia, PA 14. Paul, M.D. Clinics in Plastic Surgery / January, 2014 / Necklift / Editor / Elsevier, Philadelphia, PA


face lift: my personal technique

Dr. Michel E. Pfulg

Dr. Michel Pfulg, MD, FMH, CEO, CMO Laclinic-Montreux Avenue de Collonge 43 CH-1820 Montreux SWITZERLAND +41 21 9667000 www.laclinic.ch



ace lift is a cosmetic procedure that reverses aging and rejuvenates the operated person. This should be carried out in a harmonious manner to include both the face and the neck. In my experience of 30 years, having performed more than 1300 surgeries, using both the traditional and short scar method (Soft-lifting), I find that the conventional face lift approach suits many of my patients, because of its predictable outcome and lasting results. In this article I share my data, techniques, and also my modifications to make the scar least visible to the eye. I also discuss the indications,explaining why I prefer sometimes to use the short scar method and why I have gradually moved away from the short scar technique to go back to the more conventional approach.


Michel E. Pfulg

The anti-aging treatment is, by definition, a treatment designed to reverse the clock. This reverse shift must be accomplished in such a way that when the clock re-starts ticking thereafter, it has to be consistent with the entire face. A differential ageing pattern in the different components of the face (1) defeats the purpose of anti-ageing procedures and results in an unhappy patient. Patients prefer a cosmetic improvement of their face with a rapid recovery time, low risk of complications and no giveaway signs of surgery. As all patients age differently, so do the surgical scars. Having operated on more than 300 patients using my original technique first described in 1994 “The Soft-Lifting� (2) , I was able to follow my patients through the years and see how important the vectors of traction are, and how this affects the ageing process. I was able to modify some aspects of the traditional Bruce Connell technique to make the procedure less invasive, make the scar less visible, and also apply the concept of treating the face as a whole. With more than thirty years of practice in plastic surgery, I have performed almost equal numbers of Softliftings and traditional face lifts from 1992 till 2002. The clinical assessment of the results and patient feedback have changed my understanding and approach, and now I perform the majority of face lifts using the traditional method with a few modifications, reserving the Softlifting technique for selected patients (3).


OPERATIVE TECHNIQUE Design of the incisions The incision begins superiorly within the scalp in the temporal area or pre-capillary in this region to avoid an undesirable backward shifting of the hairline. In women, the incision is placed behind the tragus, but in men the incision is pre-tragal (in front of ear), to prevent backwards shifting of the sideburns. At the lower level of the incisura intertragica the incision makes a right angle before curving around the earlobe,following the postauricular fold to the level of the tragus, and angles posteroinferiorly with an S shape going into the occipital hair {hair at the back of the head} (Fig 1). Skin laxity, position of the hairline in the temporal, retroauricular and occipital regions and the vectors of pull resulting in shifting of the hairlines are evaluated to plan the incision in each individual patient. Attention is given to preserve the curvature of the lobule of the ear and a lobuloplasty might be needed to make lobes rounded in some patients. In the occipital region, the S shape of the incision allows to preserve the alignment and to avoid a step in the hairline (female patients want to be able to pull their hair high up without any scar showing). The hair is never shaved.

Anaesthesia Local infiltration of Lidocaine with adrenaline is performed under heavy sedation with propofol. It causes a significant reduction in bleeding and the surgery is quicker. Two litres per minute Oxygen is given through a nasal catheter and monitored closely by the anaesthesiologist. The risks associated with intubation are avoided and the recovery period is shorter. I use 20cc. of 0.5% Lidocaine with 1:200’000 adrenaline along the incision and 30 cc. of 0.25% Lidocaine with 1:200’000 adrenaline for the area to be undermined. Infiltration is important to facilitate hydro-dissection, especially in the retroauricular (behind the auricle of the ear) area and along the sternocleidomastoid muscle (neck muscle). Analgesia lasts for three hours. I do not perform any nerve block anaesthesia. Local infiltration in those concentrations does not normally impair motor nerve function and it remains possible to detect any nerve irritation during the operation. On the contrary,


Fig 1: Design of the incision (Above: short scar and intratemporal; Below: classical approach and pre-capillary)

Fig 2: Pfulg’s original “Wrenching technique”


in men, I often operate under general anaesthesia as they tend to be more anxious, use more local anaesthetics and the duration of surgery is longer.

Surgical procedure

Michel E. Pfulg

* injection of a small amount of fluid subcutaneously for dissection and maneuverability

The incisions are made with a scalpel. In the hairline, the oblique incision preserves the hair shafts and allows some hair to re-grow through the scar. The dissection is started with a liposculpture of the neck through a 3 mm submental incision (4,5) and a blunt cannula. Even if there is a minimal quantity of fat to be removed, it facilitates the “en bloc” lifting of the neck. The dissection next starts in the postauricular area facilitated by the hydrodissection*. Because of the dense tissues over the mastoid region dissection is sharp, slow and under direct vision taking care to preserve the great auricular nerve. As the dissection descends to the neck, care must be taken not to injure the sensory nerves and external jugular vein that course immediately beneath the fascia. When the platysma muscle is visible the dissection is blunt, by cautiously spreading the scissors(outer surface approach), facilitated by the already performed liposculpture. The mandibular branch of the facial nerves is protected by staying 1cm below the level of the mandible. The skin in the preauricular (before the ear lobe) region is elevated next, starting with the skin over the tragus, with care taken not to injure the cartilage of the tragus. The dissection is between the thin fascia that covers the subcutaneous tissue layer and the deep fascia of the face, facilitated by the previous infiltration. When the dissection is 2 cm in front of the ear, I dissect in the temporal area using my own “wrenching technique” (Fig 2). Using the No.15 blade, the skin is incised parallel to the hair shafts, a double hook is put in place and the flap is torn off by blunt finger dissection. The flap elevates very easily without any risk of damaging the vessels or the nerves. It is an easy and blunt dissection in the loose areolar plane, superficial to the temporalis fascia and the temporal vessels (see drawings below). The dissection can be done high enough, to slightly raise the eyebrows and to correct the lateral canthal region. The dissection of the lateral cheek area and over the zygoma is then performed. Minor connecting vessels encountered are cauterised by a bipolar diathermy. The anterior dissection proceeds


Fig 3: Horizontal and vertical lines mark the areas of undermining for classical and short scar face lift (Soft-lifting) respectively.

up to the lateral border of the orbicularis oculi muscle. In rare cases, the orbicularis muscle is so strong that we split it laterally and separate the cut ends, flattening out the muscle with the scissors. This type of adjustment of the muscle is very rare now that we are able to use Botox. The dissection over the cheek bone is carried out until the zygomatic ligament of Furnas is passed, up to the level of the insertion of the zygomatic minor muscle. The dissection concludes at this point. No further undermining is necessary to allow a good redraping of the hemiface and to improve the midline contour of the neck (Fig 3). At the end of the dissection, the shape of the skin flap represents about one third of the hemiface, but will become much smaller - about one fifth - at the end of the rhytidectomy.

Smas Plication and / or Smasectomy The two layer SMAS type face lift is commonly used because of its aesthetic versatility. The level of SMAS resection is precisely marked with Bonnie’s blue ink. It is horizontal over the zygoma, oblique over the parotid gland and vertical along the anterior border of the platysma muscle (Fig 4). The amount of tissue resected depends on the facial architecture of the patient, the shape of the skeleton and the proportions to be achieved. The artistic sense of the surgeon plays an important role on deciding how much to resect, to lift or to plicate. Most commonly 1 to 2 cm of SMAS resection is performed. In thin faces I perform only a plication without resection. The great advantage of the smasectomy (surgically removing layers of tissues) compared with the SMAS mobilisation (repositioning of the tissues) technique is the rapid nature of the technique, great safety and good results. The vector of elevation of the SMAS is purely vertical (6). Two key sutures performed with 4/0 PDS are very important at this stage. The first stitch is to fix the fascia at the point of the maximal vertical elevation of the SMAS over the zygoma, approximately 4 cm in front of the ear. The second suture grasping the platysma muscle about 2 cm lower than the tip


Fig 4: Smas Excision


of the earlobe and attaching it very strongly to the LorĂŠ fascia (7) at the level of the incisura intertragica as described by LabbĂŠ (8). This dramatically improves the midline contour of the neck and the oval of the face. A running suture of vicryl 3/0 is used to close the fascia. The first knot over the zygoma at the level of the zygomatic minor muscle grasps the fat more medially in the direction of the nasolabial fold and helps to correct it by elevating the fat laterally in a superooblique manner. As the resection of the SMAS occurs just anterior to the retaining ligaments, at the junction between the fixed and mobile units of the superficial fascia, it allows the mobile anterior facial soft tissues to be repositioned in a secure fashion to the upper lateral midface.

Excision of redundant skin and closure

Michel E. Pfulg

Fig 5: Pre- (left) and post- (right) operative pictures of a middle age lady who had a Soft-Lifting a year before. It demonstrates a slight insufficiency of the result in the neck, but an overallgood and natural result.

The vectors of redraping the superficial fascia and skin gives the ultimate result for a face lift. A tube suction drain is always kept in the cheek extending to the neck before skin closure. Two key sutures are placed: the first and most important stitch is placed above the ear, at the anterior crus of the helix. The second is at the peak of the postauricular incision. Between the sutures the excess skin is excised in a line parallel with the adjacent skin edges. I prefer to use staplers in the scalp as they leave excellent scars avoiding damage to hair follicles. The skin flap in the groove in front of the tragus is defatted to leave a natural depression at this level. In front of the tragus, the skin flap is fixed to the pretragal groove with 5/0 vicryl, grasping the dermis and attaching it to the fascia. This is to avoid oedema in that area, which often results in incomplete resorption and a contour deformity, a sure sign that face lift has been performed. The skin in the retroauricular region and preauricular region is closed with 4/0 prolene in a running intradermal fashion. Attention must be paid to the axis of the ear lobe, which must be 12 degrees with respect to that of the ear. The axis of the ear is at 20 degrees with relation to the vertical plane of the face and from behind the ear pavilion is at 30 degrees from the vertical.

Dressings The suture lines are covered with a moisture permeable spray dressing (marketed as Opsite) and twogauzes cut in the middle to allow the ear to show are applied over the ear on either side and fixed with tape. Cold packs are applied over the neck and preauricular areas


in the first 24 hours, changed every two hours. The drains are removed on the first postoperative day and the patient is discharged. No bandage is left in place when the patient leaves the clinic. The stitches are removed on day 6 and 12. After the removal of sutures and confirmation of satisfactory healing and appearance, the follow up is scheduled at 3, 6 and 12 months and yearly thereafter.

The sex distribution of patients Women 95% Men 5% The Age distribution of patients

Complications The complications encountered were minor in most of the patients. The complication rates are similar to techniques reported by many surgeons (9,10,11). •

Haematoma: 1.4%, treated conservatively in most patients Seroma: 3%, treated by aspiration Alopecia in temporal region: 1.4% Neuropraxia: 1,2%, recovered completely within a month Hypertrophic scar: 3%, managed by triamcinolone injection and/or scar revision Minor skin necrosis: 1%, managed conservatively. Retouch surgery within a year: 2% (scar correction, ear lobule)

• • • • • •

DATA AND OUR EXPERIENCE The data collection period is from 1992 to 2014. The patients were followed for 1 to 8 years. The mean follow up period was 3 years. A total of 1292 face lifts has been performed in this period.


Procedures Combined with Face Lift Aesthetic procedures are sometimes combined with a face lift either due to the clinical condition or at the patient’s request. Blepharoplasty is the commonest procedure combined with face lift in 45% of our surgeries, to treat the upper eyelid skin laxity. • • • • • • • • •

Blepharoplasty: 45% Lipofilling of malar area and/or tear trough deformity: 15% Dermabrasion of upper lip: 5% Mid-face lift: 0,8% (Fig.10) Chemical Phenol peel for chin: 2% (Fig.9) Breast Lift / Change of Implant: 5% Partial rhinoplasty: 6% Chin Implant: 3% Minor liposuction of abdomen and/or hips: 3%

Brief round-up of techniques Lower facial descent and jowl formation is a common complaint among patients seeking facial rejuvenation through rhytidectomy. The goal of a rhytidectomy should be the restoration of the curvilinear profile of the face. Mitz and Peyronie procedures involving manipulation of the superficial musculoaponeurotic

Fig 6: Pre- (left) and post- (right) operative pictures of a middle age lady who had a classical face lift a year before. It demonstrates the good and natural result.


system(SMAS) has been the workhorse for surgical rejuvenation. In 1997, Baker showed an evolution towards minimal incision techniques and from a lateral pull to a more vertical directed suspension of soft tissues (12). He developed a lateral strip SMASectomy parallel to the nasolabial fold and sutured be reapproximation without skin tension. Saylan described the S -lift technique where skin pre-excision, extended dissections and suspension of sagging facial features by a strong permanent purse string suture with maximal correction are combined with short scars and decreased signs of manipulation (13). Minimal access cranial suspension lift described by Tonnard and derived from the S-lift (MACS lift) is a pure anti-gravitational lifting procedure that will suspend the sagging soft tissues of the face and neck, together with the adhering skin in a vertical direction (14). The retaining ligaments of the face have been described, and these ligaments are to be divided to resect more skin. Preservation of these fibrous bands between the skin and the SMAS/Platysma with limited skin undermining and lifting the SMAS/Platysma unit results in early recurrence. Marchac noted that a good result can be obtained with an alternative longer but hidden scar that is minimally invasive and almost invisible if meticulously made (15). He also found that the vertical retroauricular incision enables the surgeon to eliminate cervical skin excess. Consequently there is less skin excess at the temporal level and the temporal scar can be hidden in the hair. The author’s experience of the last two decades (the short scar approach) was more commonly used in the nineties, based on patients’ requests, irrespective of magnitude of clinical laxity. A review of my first 32 short scar face lifts, described as the “The Soft Lifting” was first published in a Swiss Medical Journal in 1994, having been refused for publication by the American Annals of Plastic Surgery in 1993 (2). In 1997 Daniel Baker published his review of his own short scar face lifts (12). The majority of patients seeking face lift fall in the 50-60 age group, where there is significant laxity of skin in the lower face and


Fig 7: Early recurrence of laxity in neck following a short scar face lift (Soft-lifting).

neck. It was noted to have a high degree of recurrence in the neck and therefore the need to have an early secondary face lift (16). This resulted in a rethinking of my strategy in the last ten years, performing more traditional face lift incisions, with some modifications for most of the patients, and reserving short scar techniques for selective indications (Fig 5 and 7). My technique of hydrodissection and liposculpture for the neck reduces the trauma of extensive dissection. The defatting and dermal suturing of the tragal area produces fewer deformities in that region. Careful planning of the retroauricular skin incision with an S shape extension and avoiding haematomas helps to achieve a fine, almost invisible scar. There is a demand from patients for less aggressive procedures and faster recoveries, but the main objective of course is the final aesthetic result. Performing a short scar technique approach when the removal of excess neck skin is mandatory can create a slightly insufficient result (Fig. 5). Doing a conventional skin undermining with an “en bloc� vertical elevation of the smas, combined with a smasectomy, gives longer lasting results in such cases. Therefore I prefer to use today my Soft-lifting technique for young patients (Fig. 5 and 8) with less laxity of skin in the neck and/or for patients planned for secondary face lifts with no neck laxity.


Fig 8: Pre- (left) and post- (right) operative pictures of a younger lady 12 months after her Softlifting.


Fig 9: Pre- (left) and post- (right) operative pictures of a middle age lady who had a classical Face lift combined with a light phenol peel of the face a year before. It demonstrates the improvement of the skin texture together with a good and natural result.

Fig 10: Pre- (upper) and post- (lower) operative pictures of a lady who had a classical Face lift combined with a Mid-face lift a year before. It demonstrates that sometimes a more aggressive surgery is needed to achieve the desired aesthetic result.


CONCLUSION The Soft-lifting technique will provide good results in a younger patient, but the ageing process will accelerate in the neck rather than in the middle third of the face, and therefore a secondary lifting might be necessary. The surgeon must adapt his technique to the person, in full awareness of its limitations. When significant fat layer, skin excess and laxity are present, the classical face lift approach with adequate skin undermining gives, in my hands, the best results. NB. : The author would like to express his gratitude to his fellow Dr. Sathish Manivel, M.D., for going through his data and helping him to finalize this publication.



Michel E Pfulg: Le Soft-Lifting: Premier Bilan. Revue Medicale de la Suisse Romandie.114,465-470,1994

Jacono AA, Rousso JJ: The modern minimally invasive face lift: has it replaced the traditional access approach? Facial Plast Surg Clin North Am. 2013 May;21(2):171-89.

Fedok FG, Sedgh J: Managing the neck in the era of the short scar face-lift. Facial Plast Surg2012 Feb;28(1):60-75.

Sclafani AP, Kwak E: Alternative management of the aging jawline and neck. Facial Plast Surg. 2005 Feb;21(1):47-54.

Somoano B, Chan J, Morganroth G: Vertical vector face lift. Dermatol Ther. 2011 JanFeb;24(1):108-20

O’Brien JX, Rozen WM, Whitaker IS, Ashton MW: Lore’s fascia and the platysma-auricular ligament are distinct structures. J Plas Reconstr aesthetic Surg 2012 Sep;65(9):e241-5.

Labbé D, Franco RG, Nicolas J: Platysma suspension and platysmaplasty during neck lift: anatomical study and analysis of 30 cases. Plast Reconstr Surg. 2006 May;117(6):2001-7.

Griffin JE, Jo C: Complications after superficial plane cervicofacial rhytidectomy: a retrospective analysis of 178 consecutive face lifts and review of the literature. J Oral Maxillofac Surg 2007 Nov;65(11):2227-34.

Chang S, Pusic A, Rohrich RJ: A systematic review of comparison of efficacy and complication rates among face-lift techniques. Plast Reconstr Surg. 2011 Jan;127(1):423-33.

Tanna N, Lindsey WH: Review of 1,000 consecutive short-scar rhytidectomies. Dermatol Surg. 2008 Feb;34(2):196-202

Baker DC: Lateral SMASectomy, plication and short scar face lifts: indications and techniques. Clin Plast Surg. 2008 Oct;35(4):533-50

Fulton JE, Saylan Z, Helton P, Rahimi AD, Golshani M: The S-lift face lift featuring the U-suture and O-suture combined with skin resurfacing.Dermatol Surg. 2001 Jan;27(1):18-22.

Tonnard P, Verpaele A:The MACS-lift short scar rhytidectomy.Aesthetic Plast Surg. 2005 JulAug;29(4):213-20.

Daniel Marchac, MD: Against the “Visible” Short Scar Face Lift. Aesthetic Surg J 2008;28:200– 208

Beale EW, Rasko Y, Rohrich RJ: A 20-year experience with secondary rhytidectomy: a review of technique, longevity, and outcomes. Plast Reconstr Surg. 2013 Mar;131(3):625-34

Brackup AB: Advances and controversies in face lift surgery. Curr Opin Ophthalmol. 2003 Oct;14(5):253-9

Carniol PJ, Ganc DT: Is there an ideal face lift procedure? Curr Opin Otolaryngol Head Neck Surg. 2007 Aug;15(4):244-52

Rousso DE, Brys AK: Minimal incision face-lifting. Facial Plast Surg 2012 Feb;28(1):76-88.

Coleman JR Jr: Short incision, short flap face-lift surgery versus deep plane face-lift surgery. Facial Plast Surg. 2007 Feb;23(1):45-8

Michel E. Pfulg

Jones BM, Lo SJ: How long does a face lift last? Objective and subjective measurements over a 5-year period. Plast Reconstr Surg. 2012 Dec;130(6):1317-27



Endoscopic Assisted Biplanar and Triplanar Facial Rejuvenation

Oscar Ramirez MD

Former Clinical Assistant Professor The Johns Hopkins University School of Medicine Travelling Professor for the International Society of Plastic Surgeons (ISAPS) Adjunct Clinical Faculty Cleveland Clinic, Florida Elite Aesthetic & Surgical Center 2665 Executive Park Drive, No. 1 Weston, Florida 33331 Phone: 954-446-6464 Email: RamirezMDPS@gmail.com www.ramirezmd.com




raditional techniques to rejuvenate the face have been called facelift because they relied on pulling and lifting the skin under tension, typically in a horizontal or slightly oblique direction. These types of strategies have three effects: 1. the facial soft tissues tend to get flat under stress of tension 2. they give the typical “wind swept” appearance 3. they produce facial bands

Oscar Ramirez

Some of these features may not be readily seen in still photographs but they become apparent on facial animation. Because of the tension applied to the tissues, the resultant scars may stretch or become thick. Patients may also lose hair in the sideburns or temple regions if the incision is extended into the scalp. Over a period of time (usually about 1 year) the facial tissues are subjected to a phenomenon called “stretch relaxation”, during which the central oval of the face becomes loose and the skin near the ear becomes tight and shiny. This is more noticeable after a second or third facelift. Another common problem seen in patients who undergo a partial facelift is that one area of the face is “lifted” while other areas are left untreated. A typical case is the lifting of the lower face and neck, but leaving the areas around the eyes and forehead untouched. This disrupts completely the harmony of the face. Even though a completely nonoperated face looks its age, there is at least some harmony in it. There is nothing more obviously operated on than a partially lifted face. Another issue I have encountered over the years is the poor understanding of the facial and neck aging process, which leads to improper surgical planning and treatment. Likewise, a thorough understanding of the facial aesthetics is essential for a proper surgical outcome, particularly nowadays that we live in a multicultural world with patients being able to travel long distances and seek surgical treatments outside of their ethnic and cultural background.


Fig. 1: A beautiful face has geometric polygonal facets. These give highlights and shadows that give angularity to the face. Those faces take better photographs and look better in different lighting conditions. Drawing is after Durer’s concept.

FACIAL BEAUTY AND YOUTH Beauty, particularly facial beauty has an important place in modern society. Although philosophers and mathematicians have struggled to define beauty since times immemorial, we need but our intuition to recognize it when we see it. In our daily exchanges we instantly judge people as being attractive or not and increased beauty confers remarkable advantages socially, reproductively, and professionally1. Human beauty crosses ethnical boundaries and has a huge cultural and economic impact. Both the movie industry and literature portrait the villains as being ugly and the ugly as being evil. The hero who saves the day is usually a beautiful one. Furthermore beauty and youth are intimately related. Beauty is youth and youth is beauty. This perception has important evolutionary roots. In primeval times to procreate man will seek a beautiful and young female. He was attracted not only to their curvaceous bodies but also to their plump face and glowing skin because there were equated with health and only a healthy woman could assure the perpetuation of the human species. Although in modern societies the importance of youth and beauty may not have the same anthropological significance, our brains are wired to accept and be more socially inclined towards beautiful and younger people. There are many researchers and writers that have dealt with these issues.2,3 There is also a general perception that when we age our faces changes for the worse. We become less physically attractive and our faces show the expression of tiredness and depression. Younger individuals usually have a rested and happy face. So there is a conscious and subconscious desire to look younger and more beautiful. This can be achieved through make up, nice clothing, skin care and more recently with Botox, fillers and surgical procedures. It explains the explosive growth of the cosmetic and plastic surgery industries. This desire to look younger and more beautiful is more prevalent in females than in males. This is because the so-called“neoteny� has followed a different trend in men and women.4 The interest for cosmetic surgery in men is more in accordance with their evolutionary trends. Their aim is to look physically stronger, more athletic and younger to be competitive in


Fig. 2: The face in a ¾ view shows the double ogee outline: the S shape of beauty and youth.


FACIAL AGING As I said beauty is bone deep. Aging is also bone deep. For centuries beauty professionals and patients or clients have focused on the superficial envelope of the face: the skin. Plastic surgeons too have paid attention only to this superficial layer of the face. Only in the last 2 decades have we realized that the fatty layer of the face shrinks with aging therefore surgical techniques have been devised to replenish the loss of volume.7,8 Loss of fat is an important component of aging but it is not all. Many surgeons have embraced the idea of correcting the aging face with fat injections either predominantly or exclusively. I will warn against that. Cherubic faces will develop when patients gain weight and the injected fat becomes enlarged. On the other hand absorbable fillers are temporary solutions only. Likewise surgical procedures and neuromodulators (Botox and others) to rejuvenate

Oscar Ramirez

A smooth and glowing skin is paramount to a beautiful face. However beauty is more than “skin deep”. I say that is “bone deep”, passing through adequate distribution of facial fat.5 These components give to a beautiful and young face volume, angularity and curves. The latter mean that younger faces have plumper brows, full eyelids and big eyes. The cheek has a particular fullness with nice blending between it and the lower eyelids. The lips are fuller with a proportionate golden ratio between the upper and lower lips. The jaw line is well-defined with a distinct separation from the neck outline. The face also has angles and geometric polygonal facets with highlights and shadows that make them look better in different lighting conditions and also look better in photographs. (Fig.1) Within this geometric frame there are several curves in the shape of a soft letter S that are together referred to as the “ogee lines”. The most important of these ogee lines is the one that is seen in a ¾ view and outlines the “double ogee line” of the upper and midface.6 (Fig. 2) This is the view in which ancient painters and sculptors have portrayed their models. More recently, since the invention of photography and turn of the 20th century publications of glamour magazines as well as the trend for personal portraits, female models and photographers have preferred the ¾ view images to better appreciate the female facial beauty. Males have not escaped this trend. Only very recently have plastic surgeons

come to recognize these aesthetic features. In terms of angles and facial highlights the most beautiful faces have a curve forehead with adequate prominence of the brows to provide a frame for the eyes, a well-defined cheekbone that is a bit different in males and females. Males are bonier on their cheeks than the females. Both have a well-defined chin bone, mandibular line and mandibular angles with the tendency of modern females to have these features more accentuated than a century ago. In that context there is a tendency for a female face to look more masculine and for the male face to look more feminine. This is perhaps a manifestation of the blending of evolutionary roles that both male and females are playing in modern society.


the modern world for “hunting power, social status, money and women”.


the facial expression have been introduced only recently. Despite scientific evidence that the facial skeleton also shrinks with age only a handful of plastic surgeons in the world address the facial skeleton at the time of facial rejuvenation. Facial implants for enhancement in younger patients are more common, on the other hand. A comprehensive approach to facial rejuvenation should include all the components of the aging face: skin, fat component, muscle layer and the skeletal foundation.(Fig. 3)

MY PERSONAL QUEST TO THE IDEAL FACIAL REJUVENATION: In the mid-eighties as a recently graduated young plastic surgeon I recognized that the standard techniques of face lifting did not provide a true facial rejuvenation. Patients looked pulled and lifted but not younger. The investigations, clinical experience and national and international presentations on my initial approach concluded with three publications between 1990-1992. My landmark publication was called “The Extended Subperiosteal Face-Lift: A Definitive Soft Tissue Remodeling for Facial Rejuvenation”.9 As you see I did call it “facial rejuvenation” because patients indeed looked truly rejuvenated. Most importantly

they did not have the stigmata of the operated look. (Fig.4). However this operation required a long scalp incision on the top of the head and the swelling was long lasting. Subsequent changes I introduced to my facial rejuvenation in the early 90’s made the surgery less onerous. The most important of these changes was the introduction of endoscopic techniques. These techniques use tiny (about ½ inch) hidden incisions that are not visible even to the most astute observer. (Fig 5) For this reason the procedure has been called “Scarless” and I used the term “Rejuvenation” because the procedure maintained the positive features of my original open techniques. Again patients looked significantly younger without the telltale signs of having gone through a surgical procedure.10 The pure endoscopic operation without skin removal is suitable for patients with signs of early aging, typically aged from early 40s up to age fifty.(Fig. 6-7) In these cases the technique of “Endoscopic-Scarless” facial rejuvenation is applied with great results without any scars offsetting the dramatic improvement. The same endoscopic techniques can also be applied to much younger patients from age 18 to the late 30’ who wish to improve congenitally unfavorable facial contours. I call this procedure “Facial Beautification”.(Fig 8-10)

Fig. 3: A comprehensive facial rejuvenation includes endoscopic treatment of the central oval of the face and superficial skin lift of the lower face and neck. The vascularized fat mobilization and the imbrication techniques are part of the endoscopic methods. The fat grafting and implants are included on a case-to-case basis.


Fig. 5: The endoscopic rejuvenation is done with very small incisions located inside the scalp and inside the mouth. These are the best access for the central oval of the face.

Fig. 4: The initial open subperiosteal facelift for me was a breakthrough in the understanding and execution of the modern facial rejuvenation. This is a before and 2 years after of that technique.


Fig 6-7.- This is a patient in the mid forties with signs of early aging. The procedure was endoscopic midface rejuvenation, lower eyelid skin-only blepharoplasty and 80 cc of fat to the entire face was injected. No forehead lift or chin implant were performed. Observe the beautiful ogee of the midface. She is at 12 months post op.

Fig. 8-10: This patient is in the late thirties. She underwent endoforehead, endomidface, upper blepharoplasty with eyelid ptosis repair, skinonly lower blepharoplasty and grafting of 70 cc of fat to the entire face. The posterior oblique view shows the ogee line from a different angle. Her post-ops are at 18 months after.


Older patients or those with significant laxity of the lower face and neck can still benefit from the endoscopic approach for the forehead and the mid face. The part of the face that includes the forehead, eyes, cheeks, mouth and the front of the chin is what I refer to as the “Central Oval”, usually elevated in the vertical anti gravitational direction.11 The lower part of the face (lower lateral cheeks, jowls, jawline, submental area and the neck) are the “peripheral hemi circle”. This large area is treated with a personal modification of the standard “cervicofacial” lift (cervico means neck, facial means face). The skin and the fat underneath it are peeled off and re-draped in a more horizontal direction. Because of the deep layer repositioning of the central oval in the vertical direction, pressure is taken away from the lower face, which is then lifted with minimal tension. This combination minimizes the length and visibility of the scars. Most importantly it gives the most natural result: young without signs of surgery.

THE SUBPERIOSTEAL ENDOSCOPIC AND MULTIDIMENSIONAL FACIAL REJUVENATION: To obtain the best result the aging face needs to be treated in all dimensions and in all layers of the face. A superficial and/or intermediate layer surgery may not correct all the problems. As mentioned the central oval of the face is lifted and remodeled at the deep subperiosteal (on top of the bone) plane. This lift is done in a vertical direction and using endoscopic techniques with minimal incisions (this is similar to the laparoscopic surgery used to remove the gallbladder for example). This rejuvenates the forehead (endoforehead) via 2 to 4 tiny incisions placed inside the scalp. In difference to the re-injectable Botox, the endo-forehead removes the unwanted frown muscles (surgical Botox), lifts the sagging brows and smooths out the forehead lines permanently. The mid face or cheeks (endomidface) are lifted borrowing the temple mini-incisions used for the forehead and another small incision made inside the mouth close to the gums. (ED drawing_ One of the most important aspects of this surgery is that recreates the beautiful ogee of the mid face by a process called imbrication of the SOOF (sub-orbicularis oculi fat), an anatomical structure described by Adrian Aiache and myself.12 The Buccal fat pad (the fat that gives the chubby-cheek look to children) is an important structure that usually droops with aging in the direction of the jowls. When this occurs, the cheek becomes flat and loses the beautiful architecture of the ogee line with the fullness sagging lower. The youthful triangular shape changes to an old looking round or square face. My approach allows me to lift this Buccal fat pad from its lower location near the jowls to an upper location in the center of the cheek. This augments the convexity and emphasizes the concavity of the ogee of the mid face.13 The added benefit of this procedure is that most patients will not need cheek implants or the use of exaggerated amounts of fat grafting to volumize the flat cheek. The most important benefit, as


To obtain the best result the aging face needs to be treated in all dimensions and in all layers of the face. A superficial and/or intermediate layer surgery may not correct all the problems.

What is the role of Fat Grafting in Facial Rejuvenation?

Oscar Ramirez

Although the vertical endoscopic facial rejuvenation provides volume to key areas of the face, many patients require more volume. This is because loss of fat is a natural part of the aging process. This lost volume can be replaced with the technique of micro fat grafting. This fat is obtained usually from the patient’s abdomen and injected with small syringes and minicannulas in almost the same way as are temporary fillers. Many patients and surgeons believe that the fat grafting technique is not durable and that fat gets reabsorbed with time. My experience is the opposite. I have been doing fat grafting to the face and other areas of the body for more than 25 years.16 The results are durable and this is the best way to enhance the volume of the face. The advantage of fat grafting over temporary fillers is that in the long run it is more economical and offers many biological advantages over the fillers. It usually improves the quality of the skin and gives a more natural fullness to the face. Moreover it is abundant in supply.


my recent studies have shown, is that the Buccal fat pad has huge amounts of stem cells and its more superficial repositioning in the cheek may account for the improvement of the texture of the skin in those areas. The endoscopic mid face lift in a vertical direction also facilitates the lower eyelid rejuvenation making it a “skin only” surgery, and the transition between eyelid and cheek smoother and more beautiful. Some patients may still require facial implants or some bone contour surgery to mitigate loss of the facial contour due to aging or to beautify the face/ give it a more sophisticated look.14 Dissection in the subperiosteal plane gives me a unique opportunity to do this without having to open another plane that would be required if a more superficial plane of face lift is performed. The lower face and neck (the peripheral hemicircle) is done with variable length incisions in front and back of the ear. It never goes above the sideburns. The lower neck is usually treated in one plane (a more superficial one). In the majority of cases this is a skin re-draping procedure after the fat underneath the chin has been aspirated. Although many surgeons believe that the neck can be rejuvenated exclusively by pulling the skin and the thin platysma muscle coming from the periphery, I contend that about 30% of patients if not more require an incision underneath the chin on the submental crease to do what I call a “deep subplatysma cervicoplasty”. This procedure addresses the deep neck fullness that can be caused by different structures: excess deep fat, bulging digastric muscle and enlarged submandibular salivary gland.15 Those cannot be corrected with a pull from the distance and the skin-platysma are not strong enough to support and hide these structures.

What about Stem cells and Growth Factors? Growth factors are obtained from your own blood and referred to as PRP or Platelet Rich Plasma. It is rich in several kinds of growth factors and works better if it is mixed with fat. The PRP is promoted as a sole way to improve the collagen of the skin (“The Vampire Face Lift”). The problem with this technique is that after injection the PRP recirculates quickly into the blood stream and does not stay in the area where it has been injected.


However the injected fat will trap the PRP and will stay in the areas where you want it to work. An advanced technology is the use of Stem Cells to enhance the injected fat. After the fat has been harvested, half will be processed for Stem cell and half will be used for reinjection. Both are mixed prior to injection providing an abundant amount of stem cells in the fat grafting. This technique is called “Stem Cell Enriched Fat Grafting”. The stem cell has the ability to enhance the quality of the skin increasing the collagen content, elasticity, color and vigour giving an improved rejuvenating effect.

MY CURRENT APPROACH TO FACIAL REJUVENATION: Back in March 2005 four surgeons were elected to perform four differing face lifts on two set of twins. I was one of the surgeons. After 10 years of follow up the general consensus was that all four patients looked younger than before their surgeries and comparing each set of twins they had similar results17. At the time I used the subperiosteal endoscopic technique that was still “in its infancy” as doctor Bernard Alpert pointed out. The techniques I use now have been refined and improved significantly. They are safer and provide both short and long term improvemens. Below is a summary of my current approach. My cardinal principle is to treat patients individually - it is a “tailor cut”, not a “cookie cut” approach. My preference is for treating all the areas affected by the aging process - I rarely agree to performing a partial rejuvenation unless the patient requires it. The least I would do is advise to the patient on my philosophy. That way the consultation becomes a teaching process for the patient, therefore a better informed decision can be made. If any shortcomings or an unbalanced appearance occur after the surgery, the patient would have been made aware of the reasons. The aging process should be corrected by functional and anatomical units. From my point of view the forehead and upper eyelid constitute one unit. The lower eyelid and midface are another. The lower face and neck, another. Correcting one unit usually facilitates and enhances the correction of


the adjacent one. For patients up to the physiological age of 50 I do a pure endoscopic facial rejuvenation with small incisions for access: endoforehead, endomidface and endo-cervicoplasty. The midface is key in this rejuvenation. I will use the buccal fat to recreate the ogee line of the midface. Additional volume in the brows, lips and jaw angles is achieved with microfat injections usually obtained from the abdomen. Lower eyelid tuck becomes a skin only surgery because of the support to the lower orbital area given by the midface lift. This surgery can be performed under “twilight” anesthesia and typically patients can return to work in two weeks. For patients over the age of 50 or those with laxity of the neck I do the same operation for the forehead, lower eyelids and midface. However the jawline and neck are approached with a short incision in front of the ear and a high incision in the back of the ear. This is done to make the scars the least visible and takes care of the jowls, dimples around the chin and laxity of the jawline and neck. Patients with heavy necks require special attention. A good preoperative diagnosis is crucial to ascertain the abundance of fat deep to the platysma, prominent muscles and enlarged salivary glands so that this can be removed totally or partially. Otherwise patients will be left with contour irregularities, excessive fullness and a poorly defined neck angle. As previously mentioned, the facial skeleton is not exempt from the ravages of the aging process. Bone shrinks with age. If the skeletal support is not strong enough or not well defined, no facelift technique would give an optimal result. Therefore I use liberally alloplastic facial implants, hydroxyapatite cement or bone advancements (rarely). I have designed several implants to enhance the orbits, cheeks, chin and mandibular angles. Because most of my work is deep in the subperiosteal plane, it is safe to inject fat in the intermediate layers of the face, and the skin can be treated simultaneously with laser resurfacing if needed. All of these can provide a comprehensive rejuvenation(see Fig.3). Obviously treating the most severe cases in one setting can take many hours. In those cases we can split the surgery in two stages with a short interval between them. This approach does not affect the final outcome. Patients look truly rejuvenated without telltale signs of the standard facelift. (Fig. 11-22)

Fig. 11-13: Patient age 55. She underwent Endoscopic forehead rejuvenation of the forehead and midface, upper and lower eyelid skin-only blepharoplasty, her lower face and neck was treated with a skin-only lift and the Ramirez’s woven-suture suspension. She also had 25 cc of fat injected to facial creases and to obtain symmetry. Her picture is 12 months postoperatively.


Fig. 14-16: Patient age 58. Her post op is shown at 2 years. She underwent endoscopic forehead and midface rejuvenation, lower face-skin only lift, lower eyelid blepharoplasty and 40 cc of fat grafting to temples, lips, marionette lines, jawline and mandibular angles.

Fig. 20-22: This is a 63-year-old patient. She is edentulous and wears a full upper and lower dentures. She previously had 3 standard face-lifts that lead to loss of sideburn and temple hair. Her surgeries involved biplanar endoscopic assisted forehead rejuvenation, endo-midface, scalp flap transposition to recreate her sideburn, lower face lift and deep cervicoplasty with salivary gland partial resection, deep fat resection and digastric muscle shaving. Additionally she underwent a Mandibular Matrix Implant system to support and augment the entire mandible.

Oscar Ramirez

Fig. 17-19: Patient age 60. Her post op is at 2 years. She underwent endoscopic forehead and midface rejuvenation, lower eyelid skin-only blepharoplasty, lower face-lift with deep subplatysma cervicoplasty. This deep neck surgery removed the excess fat deep to the platysma, and I did partial salivary gland excision. The improvement of her chin is due to a procedure I developed called “Subperiosteal Mentopexy” (Total chin-lift). 30 cc of fat was injected into the glabella, brows, and lips.


Fig23-25: This is the first case in the world of a full endoscopic facial rejuvenation: endoforehead, endo-midface and endo-cervicoplasty without skin excision (scarless facial rejuvenation). Preop op in 1993 (left), two years postop (center), ten years post-op (right)


The recovery time varies subject to the extent of the surgical procedure. For the pure endoscopic procedure of the central oval, I can take between 3-4 weeks, although patients can return to work in 10-15 days. The combined procedure,(endoscopic rejuvenation of the central oval and lower face/neck lift) requires about 4-6 weeks. The addition of facial implants or large amounts of fat grafting will add 2-3 weeks to down time. In general, regardless of the face lift technique (superficial, intermediate layer, or deep) it will take up to one year for a complete recovery. Patients will have low degree oedema, numbness, tightness that gradually efface in that period of time. Most are noticeable to the patient only and do not interfere with her working or social activities. The endoscopic rejuvenation of the central oval is very durable (Fig 23-25). Secondary endo-forehead or endo-midface surgery is almost unheard of in my practice (less that 1%) however patients return, typically after 8-10 years for a secondary lower face/neck lift. This is the area that relapses more often and sooner. At this time we also notice that the face has deflated somewhat, therefore the typical secondary procedure is lower face/neck lift and fat grafting. Secondary facial rejuvenation in patients not previously operated by me usually poses a different challenge. Most standard SMAS (Superficial Musculo-Aponeurotic System) type of face lift presents the stretch relaxation phenomenon described above. Those patients require a similar approach to my primary rejuvenation: endoscopic rejuvenation of the central oval with volumetric augmentation of the brows, cheeks etc. and secondary lifting of the lower face and neck18. Some will also require deep cervicoplasty to correct the droopiness and/or enlargement of the deep structures of the neck. Many patients at that stage have also lost facial bone support. Because of their age I take a more conservative approach with implants and I prefer to camouflage those deficits with fat injection deep adjacent to the bone surface.


References 1. Nancy L. Etcoff. Survival of the Prettiest: the science of beauty. 1999. Doubleday. New York 2. David Van Praag Marks. Human beauty: An Economic Analysis. Ph.D Thesis. Harvard University. Cambridge, MA. 1989 3. K.K. Dion, E. Berscheid and E. Walster: What is beautiful is good. Journal of Personality and Social Psychology. 24: 285-290, 1972

5. Oscar M Ramirez. Facial Beauty “Bone Deep”. Body Language. Plastic and Cosmetic Surgery. Issue # 19 6. Ramirez OM, Volpe CR. Double Ogee Facial Rejuvenation. In Aesthetic Surgery of the Facial Mosaic. Panfilov DE. Springer-Verlag Berlin Heidelberg 2007: ch 43. 296-307 7. Ramirez OM. Fourth-generation Subperiosteal Approach to the Midface: The Tridimensional Functional Cheek Lift. Aesth Surg Jour, Vol 18, No.2:133-135, 1998 8. Ramirez, O.M.: Three Dimensional Endoscopic Midface Enhancement: A Personal Quest for the Ideal Cheek Rejuvenation. Plast Reconstr Surg Vol. 109, No. 1:329-340, 2002 9. Ramirez, O.M., Maillard, G.F., Musolas, A: The Extended Subperiosteal Face-Lift: A Definitive Soft Tissue Remodeling for Facial Rejuvenation. Plast Reconstr Surg, 88:227, 1991

12. Aiache, A.E., Ramirez, O.M.: The Suborbicularis Oculi Fat Pad: An Anatomical & Clinical Study. Plast Reconstr Surg. Vol 95 (1):37-42, 1995 13. Ramirez, OM.: Buccal Fat Pad Pedicle Flap for Midface Augmentation. Ann of Plast Surg 43:109-118, 1999 14. Ramirez, O.M.: Mandibular Matrix Implant System: A Method to Restore Skeletal Support to the Lower Face. Plast Reconstr Surg, Vol 106, No. 1: 176-189, 2000 15. Ramirez OM.: Multidimensional Evaluation and Surgical Approaches to Neck Rejuvenation. Clinic Plastic Surgery 41: 97-105, 2014

Oscar Ramirez

4. Desmond Morris. The Naked Woman. A Study of a Female Body. Thomas Dunne Books, St. Martin’s Press. New York. 2004

11. Ramirez, O.M.: The Central Oval of the Face: Tridimensional Endoscopic Rejuvenation, Facial Plast Surg, Vol. 16 No. 3:283-298, 2001

16. Ramirez, O.M.: Full Face Rejuvenation in Three Dimensions: A “Face-Lifting” for the New Millennium. Aesth Plast Surg Jour, Vol. 25, No. 3: 152-164, 2001 17. Alpert B, Baker DC, Hamra ST, Owsley JQ, Ramirez OM: Identical Twin Face Lifts with Differing Techniques: A 10-Year Follow-Up. Plast Reconstr Surg 123(3): 1025-1033, 2009 18. Ramirez OM, Pozner JN. Continuing Medical Education- Facial Rejuvenation Subperiosteal Endoscopic Techniques in Secondary Rhytidectomy. AesthSurg Jour 17(1):22-6. December 1966

10. Ramirez, O.M.: Endoscopic Assisted Full FaceLift. Aest Plast Surg. 18:363-371, 1994


The Natural Lift and Fill Face lift: The Blending of Science and Art in Facial Rejuvenation

Rod J. Rohrich, M.D Smita R. Ramanadham, M.D

Dr Rod Rohrich 9101 N. Central Expressway Suite 600 Dallas, TX 75231 e: rohrichrod@gmail.com www.drrohrich.com




he current state of the art, lift-and-fill face lift, provides natural, youthful, and longstanding results. This technique has evolved from the deep understanding of the anatomy and the knowledge base of the science of aging in the face. It has been established that fat atrophy occurs first and skin sagging secondarily. The natural sequence to correct this is to fill the deficient fat compartments using the knowledge of the unique fat compartments we described and the science of how we age, and lift the outer cheek areas using the powerful SMAS layer to further reshape and refine the face.

Science of Aging1

Rohrich & Ramanadham

Facial aging involves a combination of loss of volume and descent of tissues, in addition, to the changes in the underlying skeletal scaffold. While lifting of the sagging subcutaneous tissues of the face is well established in face lift surgeries, the knowledge that the fat is divided into specific compartments and deflates differentially has revolutionized our approach to facial rejuvenation and has allowed for targeted volume restoration in these areas. Additionally, attenuation of the various retaining or anchoring ligaments (zygomatic-cutaneous, orbitomalar and mandibular retaining ligaments) of the face further gives the appearance of facial descent and leads to aging deformities seen around the eyes, cheeks, mouth, and jawline. Underlying skeletal changes including posterior shift of the maxilla, orbital bone changes creating a larger orbital aperture and shrinking of the mandible, leads to a multifaceted etiology of facial aging, which must be recognized during preoperative patient analysis1. Aging, additionally, directly affects the skin itself. The skin, acting as an envelope, not only reveals in the underlying changes that occur in the bone and soft tissue but also undergoes changes directly including wrinkles from habitual movements of the underlying muscles and damage from smoking and sun exposure. With this deep understanding of the science of aging, my Lift and Fill face lift technique is centered on two key concepts: restoration of central facial volume and lifting of the skin and supporting structures (superficial musculoaponeurotic system, SMAS) laterally with release of the anchoring ligaments. Based on preoperative evaluation, the specific compartments that preferentially deflate are filled directly by fat and/or


Fig. 1: An artist’s rendition of the subcutaneous compartments (Rohrich RJ, Pessa JE. The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery. Plast Reconstr Surg. 2007; 119: 2219-2227)

filler material, which allows for precise and dramatic restoration of volume. The skin and SMAS are manipulated and lifted to reshape and create an overall balanced and natural restoration of a youthful appearance. Finally, the damaged skin itself is treated to improve texture and wrinkles.

How Fat Compartments changed how we look at facial aging2 Historically, the face was believed to be one uniform mass of fat. Studies have now shown, however, that the subcutaneous fat of the face is partitioned into multiple, independent compartments. Each region of the face (cheek, forehead, orbital, etc) is comprised of discrete compartments creating a map or “GPS system� with distinct borders that limit shearing forces on the face and act as a retaining system (Figure 1).2,3 These deflate independently and lie above and below the muscles that allow for facial expression. The concept of separate compartments of fat suggests that the face does not age as a whole. Facial aging is in part characterized by how these individual compartments change with age in relation to one another. Knowledge of this anatomy has led to a better understanding and greater precision in the preoperative analysis and surgical treatment of the aging face allowing for targeted volume restoration into specific compartments with increased control and reliability. The most important and relevant fat compartments include the deep cheek (malar), the deep nasolabial fat, the superficial, and lateral cheek (malar) compartments.4, 5 Filling of the deep cheek compartment provides improved lower lid support to blend the lid and cheek and adds projection to a deflated cheek.6 Once these compartments are filled, the sagging skin and soft tissue can be lifted laterally in a more natural manner.


The understanding of the fat compartments of the face has improved our ability to more precisely restore facial volume while rejuvenating it through lifting. The lift-and-fill face lift has evolved to merge two key concepts in facial rejuvenation: tissue manipulation by means of lifting and tightening and selective fat compartment filling to control facial volume precisely. This allows for improved control in contouring while addressing loss of volume, one of the key problems identified in facial aging. Fat restoration of the deflated compartments is a necessary complement to surgical lift techniques and addresses the central aspects of the face in which the deflation is most pronounced. With targeted deposition of fat into these four specific fat compartments mentioned above, less volume can be used to achieve the desired effect and avoid an overdone and unnatural appearance. As with most cosmetic procedures, keen visual inspection of facial shape before, during, and following surgery is essential for a successful outcome. The

Fig. 3. SMASectomy: Indicated when excess volume would inappropriately widen the face. Fat grafting is deep to SMAS manipulation. (Rohrich RJ, Ghavami A, Constantine FC, Unger J, Mojallal A. Lift-and-Fill Face Lift: Integrating the Fat Compartments. Plast Reconstr Surg. 2014; 133: 756e-767e)

soft tissue is lifted laterally to address sagging. The type of SMAS treatment is based on the overall fullness, width and length of each side of the face.5 SMAS-stacking allows for selective enhancement exactly where the SMAS is manipulated. When the stacked region is located directly over a grafted fat compartment, the enhancement effects are most powerful. SMAS-stacking and SMASectomy both influence the facial rejuvenation process differently. SMAS-stacking is indicated when more fullness is required in the malar or mid-cheek area (Figure 2), whereas SMASectomy is utilized when the facial volume is excessive in the mid-cheek area preoperatively (Figure 3). With the skin re-draped properly following volume restoration and SMAS lifting, the result is restoration of a youthful and balanced facial appearance.

Rohrich & Ramanadham

Why the Lift-and-Fill Face Lift5,7


Fig. 2: SMAS stacking: Allows for enhanced augmentation in the precise location that is indicated. It bridges the contouring effect between the deep medial and lateral (high) superficial malar compartments. DM, deep malar fat; DN-L, deep nasolabial fold. (Rohrich RJ, Ghavami A, Constantine FC, Unger J, Mojallal A. Lift-and-Fill Face Lift: Integrating the Fat Compartments. Plast Reconstr Surg. 2014; 133: 756e-767e)

Syncing neck rejuvenation with face lift 8, 9, 10 The cornerstone of the face lift is a neck contour that is balanced, natural appearing and youthful.


Figure 4. Key fat compartments for augmentation. ( Rohrich RJ, Ghavami A, Constantine FC, et. Al. Lift and fill face lift: integrating the fat compartments. Plast Reconstr Surg. 2014; 133: 756e-767e.)

An untreated neck is a sure giveaway of aging with the anterior neck most often being the first region to capture the eye of an observer. Furthermore, failure to treat this region oftentimes results in Facial and neck skin undermining the appearance of a more pronounced deformity Submental access and detracts from an otherwise good facial result. Fat excess? Direct excision of fat Without sound principles, the neck can appear Bands present? Midline platysmal plication Lateral platysma window too thin and hollowed. The pursuit of reliable Assess contour +/- release of mandibular septum and reproducible results has led plastic surgeons SMAS and Skin redraping: SMASectomy or SMAS stacking to investigate a multitude of different approaches that address the layers and components of the neck (skin, platysma, fat, digastric muscles and submandibular glands) in varying degrees. Most agree, however, that manipulation of the most superficial layers (skin, fat and platysma muscle) is key in restoring a youthful neck. A five-step neck lift technique was initiated that creates an algorithmic approach to each patient and minimized the increased risks associated with more aggressive techniques including damage to nerves and poor contour (Table 1). This includes wide medial and lateral undermining of the skin, platysmal release medially and laterally, platysmal window suspension, release of the mandibular septum and ligament if necessary and redraping of the SMAS by plication or SMASectomy. This approach ensures correction

Table 1: Five-step neck-lifting sequence to optimize results


Figure 5: The perioral zone is demarcated by the nasolabial folds. The central facial zone is demarcated by the perioral and pink shaded areas. Full facial resurfacing encompasses the green shaded area in addition to all other shades areas. (Scheuer JF, Costa CR, Dauwe PB, Ramanadham SR, Rohrich RJ. Laser Resurfacing at the Time of Rhytidectomy. Plast. Reconstr. Surg. 136: 27, 2015)


Role of skin care and lasers As stated above, the skin itself undergoes changes during aging and sustains damage from sun or smoke exposure. In order to obtain youthful and rejuvenated results, the skin must be treated appropriately via skin care and/or laser resurfacing. While multiple topical skin treatments exist on the market to improve wrinkles, there is substantial evidence for the use of tretinoin and retinols for the treatment of damaged skin. These products work by increasing skin cell turnover, making way for healthy underlying skin and strengthen collagen leading to a thickening of the deeper skin layers, and improved skin texture and color. It is optimal to begin these products several months before their surgery to improve the strength of the skin and combat photoaging.1 The addition of various resurfacing procedures, specifically, lasers have proven to be impressively beneficial in improving facial wrinkles. When performed at the time of face lift, we have found a substantial improvement in dyschromias, texture abnormalities, and central face wrinkles. These are preferentially used in problem areas such as the perioral and periorbial areas.11 (Figure 5)

Rohrich & Ramanadham

of jowling, a smooth jawline, and a well-shaped neck and was introduced as a technique to address the aging neck in an efficient, safe, and reproducible manner. The end result is a neck that is in sync with the rejuvenated face. The platysma window technique is used to tighten the muscle laterally and minimize complications such as nerve injury. It is created by using a reference point anterior to the lobule of the ear located one fingerbreadth inferior to the angle of the jaw and one fingerbreadth anterior to the anterior border of the sternocleidomastoid muscle. A 2 cm vertical incision is then made in the anterior muscle to create a small ‘window.’ Two figure-ofeight sutures using 4-0 Mersilene are placed from the window to the mastoid fascia posterior to the ear spanning and avoiding the great auricular nerve. Placing the window inferior and anterior to these structures ensures a safe area for executing platysma tightening. This maneuver can augment the Lift and Fill face lift technique and provides a balance between developing neck contour and limiting contour deformities or nerve injuries. (Figure 4)


Clinical Cases: Case 1: 64- year- old patient presented with moderate facial asymmetry. Her right side is long and narrow relative to the left side, which required differential treatment of the right and left SMAS. She underwent a horizontal SMAS-ectomy on the left side to reduce midface fullness with vertical SMAS reposition. On the right, a minimal SMAS excision was used to balance the facial fullness oriented in an oblique direction. Fat augmentation of the nasolabial and deep malar fat compartments were performed, in addition to, open necklift, quad-blepharoplasty, and full-face laser skin resurfacing. (Figure 6)

Figure 6: Case 1. The patient is shown preoperatively (left); after primary rhytidectomy (second from left); 9 years later, before secondary rhytidectomy (second from right); and after secondary rhytidectomy (right). (Above) Frontal, (center) lateral, and (below) oblique views of each point in time. (Reprinted from Rohrich RJ, Ghavami A, Lemmon J, Brown S. Plast Reconstr Surg. 2009;123:1050–1063.)


Case 2: 44-year-old woman presented with minimal asymmetry. Her right side was short and wide relative to her left side, which was slightly greater in midface height and narrower. She had severe malar descent bilaterally and jowling. She demonstrated an overall square facial shape. She underwent a individualized component face lift with open neck lift. SMAS-stacking was performed bilaterally to balance the lower third of the face. Horizontally oriented SMASstacking was used to allow a vertical lift on the right, and oblique stacking was used on the left. Other procedures included a quad-blepharoplasty, laser resurfacing of the central face, fat augmentation to the malar and nasolabial fat compartment, and hyaluronic acid augmentation of the upper and lower vermilion. (Figure 7)


Figure 7: Case 2: (above, left) preoperative clinical analysis of facial asymmetry. (above, center) preoperative frontal view of a 44-year-old patient with minimal asymmetry. (above, right) postoperative view after SMAS-stacking facelift, four-lid blepharoplasty, malar and nasolabial fat compartment augmentation, and central facial erbium laser resurfacing and hyaluronic acid lip augmentation. (below, left) preoperative oblique view. (below, right) one year postoperive oblique view.


Case 3: 48-year-old woman with severe facial asymmetry. Her right side was long and narrow relative to the left facial side, which was short and wide. She had less midface fullness on the right relative to the left side. Overall, she demonstrated a square facial contour with moderate overall facial fullness. She underwent an individualized component face lift with open necklift, and fat augmentation to the medial nasolabial fat compartments and marionette/commissure regions. For the face lift, extended undermining was done on her right side compared to left. SMAS-stacking was performed on the right side with repositioning in an oblique direction. SMAS-stacking was also performed on the left side but was oriented horizontally for a vertical lift. Other procedures included a quadblepharoplasty, endo-brow lift, and a 35% trichloroacetic acid full-face chemical peel. (Figure 8)

Figure 8: Case 3: (above, left) facial analysis of a 48 year old patient with significant facial asymmetry. (above, center) preoperative frontal view. (above, right) one year postoperative view after a SMAS-stacking facelift, four-lid blepharoplasty, endo-brow lift, and full face trichloroacetic acid peel. (center, left) preoperative lateral view. (center, right) one-year postoperative lateral view. (below, left) preoperative oblique view. (below, right) one year postoperative oblique view, highlighting malar fullness.


Case 4: A 60-year-old woman underwent a lift-and-fill face lift with individualized component technique for correction of facial asymmetry. The right side was shorter and wider compared to the left side. Fat transfer volumes were as follows: 3 cc in the right deep malar fat compartment and 2 cc in the left, and 2 cc in the right superficial lateral malar compartment and 1 cc in the left side. In addition, the prejowl area received 2 cc bilaterally. SMAS-stacking bilaterally was performed in an oblique vector on the right and a horizontal vector on the left. (Figure 9)


Figure 9: Case 4: Preoperative and postoperative views of a 60-year-old patient who underwent a lift-and-fill face lift with individualized component technique, open necklift and fat grafting to the deep malar, superficial lateral malar compartments and prejowl areas.


Longevity- what really matters12 A major goal of facial rejuvenation is to achieve long-lasting results. A review of our reliable techniques and our experience point to factors that we have identified that increase longevity of facial rejuvenation. Our experience spans 25 years and 1,089 facial surgery patients. Key points include selecting the right patients, patients with better long term results included younger, more attractive patients with fuller faces. Age is a crucial factor. Face lift patients in their forties maintain better results because of the improved properties of the skin and soft tissue. Patients with fuller necks had a higher relapse rate. Opening and treating midline platysmal Table 2: banks in the neck decreased recurrence of neck The earlier the facelift is performed in the well-selected deformities. Skin resurfacing with laser and/or peels patient, the longer the results and the use of topical retinoids have also improved Patients with better facial proportions, will have better long-term results long term results. (Table 2) Skin resurfacing with laser or peel during the operation, including skin care with retinoids Fuller necks will have earlier and higher relapse rates Fuller faces and less deflation have more longevity as natural volume is preserved Opening the neck has lasting effects. Suturing platysmal bands leads to less recurrence Males and females have similar results


Facial rejuvenation remains a complex procedure and can be achieved with varying techniques. The key to success is to minimize complications and adverse events while optimizing outcomes and restoring a youthful facial harmony. Aging occurs via a combination of descent of facial tissues and loss of volume. The knowledge of facial fat compartments and varying levels of deflation within these individual components has enabled us to target a key component of aging, which remains to be loss of volume. This can be replaced and augmented with fat or fillers. It is important to remember that volume augmentation acts as a complement to traditional face lift techniques of skin and SMAS lifting and manipulation. The Lift-and -Fill technique specifically addresses these two components of aging in a reproducible and safe manner in order to achieve a balanced and natural youthful appearance.


References: 1. Farkas JP, Pessa JE, Hubbard B, Rohrich RJ. The Science and Theory behind Facial Aging. PRS GO 2013; 1:e8. 2. Rohrich RJ, Pessa JE. The fat compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery. Plast. Reconstr. Surg. 119: 2219, 2007.


3. Rohrich RJ, Pessa JE. The Retaining System of the Face: Histologic Evaluation of the Septal Boundaries of the Subcutaneous Fat Compartments. Plast Reconstr Surg. 121: 1804-1809, 2008 4. Rohrich RJ, Pessa JE, Ristow B. The Youthful Cheek and the Deep Medial Fat Compartment. Plast Reconstr Surg. 121: 2107-2112, 2008. 5. Rohrich RJ, Ghavami A, Lemmon JA, Brown SA. The individualized Component Face Lift: Developing a systematic approach to facial rejuvenation. Plast. Reconstr. Surg 123: 1050, 2009 6. Rohrich RJ, Mahedia M, Shah N. The demise of the isolated lower blepharoplasty-How the deep cheek fat compartments changed eyelid surgery.


Narasimhan K, Stuzin JM, Rohrich RJ. Five-step neck lift: Integrating Anatomy with Clinical Practice to Optimize Results. Plast. Reconstr. Surg. 132: 339, 2013.

9. Cruz RS, O’Reilly EB, Rohrich RJ. The Platysma Window: An Anatomically Safe, Efficient, and Easily Reproducible Approach to Neck Contour in the Face Lift. Plast Reconstr. Surg. 129: 1169, 2012. 10. Rohrich RJ, Rios JL, Smith PD, Gutowski KA. Neck rejuvation revisited. Plast. Reconstr. Surg. 118: 1251, 2006.

Rohrich & Ramanadham

7. Rohrich RJ, Ghavami A, Constantine FC, Unger J, Mojallal A. Lift-andFill Face Lift: Integrating the fat compartments. Plast. Reconstr. Surg. 133: 756e, 2014.

11. Scheuer JF, Costa C, Dauwe P, Ramanadham S, Rohrich RJ. Laser Resurfacing at the time of Rhytidectomy. Plast. Reconstr. Surg. 136: 27, 2015 12. Rohrich RJ, Narasimhan K. Long term results in faceliftingobservational results and evolution of technique. In review for publication in Plast. Reconst. Surg.


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