Plastic Surgery -

Published on February 2017 | Categories: Documents | Downloads: 107 | Comments: 0 | Views: 2022

of 136

Content

Aging of the face is a multifactorial process that can be explained
on an anatomical basis.
The face is constructed of ﬁve basic layers that are bound together
by a system of facial retaining ligaments.
To facilitate the mobility needed for facial expression independent
of the basic functions of the face, particularly of mastication, a
series of soft tissue spaces are incorporated into the architecture
of the face.
This arrangement, most clearly seen in the scalp, also exists in
the rest of the face, although with signiﬁcant compaction and
modiﬁcations.
This chapter will describe, in detail, the ﬁve-layered construct of
the face, including the spaces and retaining ligaments, and will
highlight the relevance of these structures in the aging face.
In addition, the profound impact of aging of the facial skeleton
should be appreciated.
Understanding these principles will help not only in understanding
the aging process but also in designing procedures that are logical
and effective in reversing the stigmata of the aging face.

2013, Elsevier Inc. All rights reserved.

©

Facial aging is a complex process that is the cumulative effect
of simultaneous changes of the many components of the face
as well as the interaction of these components with each other.
An understanding of the anatomical changes associated with
aging is required in order to design effective procedures to
rejuvenate various aspects of the aging face. Fundamental to
understanding these changes is a ﬁrm grounding in the principles on which the facial soft tissue layers are constructed.1
This is important because the pathogenesis of facial aging is
explained on an anatomical basis, particularly the variations
in the onset and outcome of aging seen in different individuals. Understanding the principles on which the facial soft
tissues are constructed is the basis for an accurate and reliable

Introduction

䊏

䊏

䊏

䊏

䊏

䊏

䊏

SYNOPSIS

Bryan Mendelson and Chin-Ho Wong

The traditional approach to assessing the face is to consider
the face in thirds (upper, middle, and lower thirds).2 While
useful, this approach limits conceptualization, as it is not
based on the function of the face. From a functional perspective, the face has an anterior aspect and a lateral aspect. The
anterior face is highly evolved beyond the basic survival
needs, speciﬁcally, for communication and facial expression.
In contrast, the lateral face predominantly covers the structures of mastication.3 A vertical line descending from the
lateral orbital rim is the approximate division between the
anterior and lateral zones of the face. Internally, a series of
facial retaining ligaments are strategically located along this
line to demarcate the anterior from the lateral face (Fig. 6.1).
The mimetic muscles of the face are located in the superﬁcial
fascia of the anterior face, mostly around the eyes and the
mouth. This highly mobile area of the face is designed to
allow ﬁne movement and is prone to develop laxity with
aging. In contrast, the lateral face is relatively immobile as it
overlies the structures to do with mastication, the temporalis,
masseter, the parotid gland and its duct, all located deep to
the deep fascia. The only superﬁcial muscle in the lateral face
is the platysma in the lower third, which extends to the level
of the oral commissure.
Importantly, the soft tissues of the anterior face are subdivided into two parts; that which overlies the skeleton and the
larger part that comprises the highly specialized sphincters
overlying the bony cavities.4 Where the soft tissues overlie the
orbital and oral cavities they are modiﬁed, as there is no deep

Regions of the face

intraoperative map for the surgeons to safely navigate to the
area of interest to correct aging changes. This is most important in addressing the overriding concern, being the course of
the facial nerve branches. An anatomical approach to surgical
rejuvenation of the face provides the way to obtaining a
“natural” result that is lasting and with minimal morbidity.

Aesthetic Surgery of the Face

Anatomy of the aging face

6

SECTION I

The soft tissue of the face is arranged concentrically into the
ﬁve basic layers5,6: (1) skin; (2) subcutaneous; (3) musculoaponeurotic layer; (4) areola tissue; and (5) deep fascia. This
ﬁve-layered arrangement is most clearly seen in the scalp and
forehead as a result of evolutionary expansion of the underlying cranial vault necessary to accommodate the highly developed frontal lobe in humans. Accordingly, the scalp is an
excellent place to study the principles of the layered anatomy
(Fig. 6.2). Layer 4 (the loose areolar tissue) is the layer that
allows the superﬁcial fascia (deﬁned as the composite ﬂap of
layers 1 through 3) to glide over the deep fascia (layer 5). The
simpliﬁed anatomy over the scalp gives the basic prototype
of layer 4. There are not any structures crossing this plane,
which is essentially an avascular potential space. At the
boundaries of the scalp along the superior temporal line and

Surgical anatomy of the face, SMAS,
facial spaces and retaining ligaments

fascial layer for support. Accordingly, support does not come
from within the cavity beneath, but from the rim of the cavities. The transitions between these areas, while not seen in
youth, become increasingly evident with aging.

Fig. 6.1 Regions of the face. The mobile anterior face is functionally adapted for
facial expressions and is separated from the relatively ﬁxed lateral face (shaded),
which overlies masticatory structures. A vertical line of retaining ligaments (red)
separates the anterior and lateral face. These ligaments are, from above: temporal,
lateral orbital, zygomatic, masseteric, and mandibular ligaments. In the anterior
face, the mid-cheek is split obliquely into two separate functional parts by the
mid-cheek groove (dotted line) related to two cavities: the periorbital part above
(blue) and the perioral part below (yellow). (© Dr Levent Efe, CMI.)

79

The epidermis is a cell-rich layer composed mainly of differentiating keratinocytes and a smaller number of pigment producing melanocytes and antigen-presenting Langerhans cells.
The dermis is the outer layer of the structural superﬁcial fascia
and comprises predominantly the extracellular matrix secreted

Layer 1: skin

across the supraorbital rim, the scalp and the forehead are
ﬁrmly anchored by ligamentous attachments. Vital structures,
the nerves and vessels are always located in close proximity
to the retaining ligaments. In the face proper, while the principles of construction remain the same, there is considerably
greater complexity. This is due to the compaction resulting
from the absence of forward projection of the midface, as
occurs in other species, and the predominance of the orbital
and oral cavities that limit the availability of a bony platform
for attachment of ligaments and muscles. To secure the superﬁcial fascia to the facial skeleton, a system of retaining ligaments bind the dermis to the skeleton, and the components
of this system pass through all layers (Figs 6.3, 6.4).7,8
The structure and composition of each of the 5 layers will
now be described in turn.

Fig. 6.2 The face is constructed of ﬁve basic layers. This ﬁve-layered construct
is most evident in the scalp but exists in the rest of the face, with signiﬁcant
modiﬁcation and compaction for functional adaptation. Layer 4 is the most
signiﬁcantly modiﬁed layer, with alternating facial soft tissue spaces and retaining
ligaments. Facial nerve branches also transition from deep to superﬁcial in
association with the retaining ligaments through layer 4. (© Dr Levent Efe, CMI.)

Surgical anatomy of the face, SMAS, facial spaces and retaining ligaments

SECTION I •

6

• Anatomy of the aging face

B

by ﬁbroblasts. Type I collagen is the most abundant protein.
Other collagen types (III, V, VII), elastin, proteoglycans and
ﬁbronectins are present in smaller quantities. A rich vascular
plexus is an important component of the dermis. The thickness of the dermis relates to its function and tends to be
inversely proportionate to its mobility. The dermis is thinnest
in the eyelids and thickest over the forehead and the nasal tip.

Fig. 6.4 Three morphological forms of retaining ligaments of the face. (© Dr Levent
Efe, CMI.)

A

80

The subcutaneous layer has two components: the subcutaneous fat, which provides volume, and the ﬁbrous retinacular
cutis that binds the dermis to the underlying SMAS.9 Of note,
the retinacular cutis is the name given to that portion of
the retaining ligament that passes through the subcutaneous
tissues. The amount, proportion and arrangement of each
component vary in different regions of the face. In the scalp,
the subcutaneous layer has uniform thickness and consistency
of ﬁxation to the overlying dermis. In contrast, in the face
proper, the subcutaneous layer has signiﬁcant variation in
thickness and attachments. In specialized areas such as the
eyelids and lips, this layer is signiﬁcantly compacted such that
fat may appear non-existent. In other areas, such as the nasolabial segment, it is very thick.4 In areas with thick subcutaneous tissue, the retinacular cutis lengthens signiﬁcantly,
predisposing its ﬁbers to weakening and distension with
aging. Within the subcutaneous tissue, the overall attachment
to the overlying dermis is stronger and denser than the attachment to the underlying SMAS.9 This is a result of the tree-like
arrangement of the retinacular cutis ﬁbers (Fig. 6.3), with
fewer but thicker ﬁbers deep as its rises through the SMAS
that progressively divide into multiple ﬁne microligaments as
they reach the dermis. This explains why it is easier to perform
subcutaneous dissection in the deeper subcutaneous level
(just on the surface of the underlying SMAS) than more superﬁcially nearer the dermis, as there are fewer retinacular cutis
ﬁbers and the subcutaneous fat here does not attach directly
to the outer surface of the underlying SMAS.
Furthermore, the retinacular cutis ﬁbers are not uniform
across the face, but vary in orientation and density according
to the anatomy of the underlying deeper structures. As will
be apparent when the anatomy of the underlying Layer 4 is
described, at the location of the retaining ligaments, the vertically orientated retinacular cutis ﬁbers are the most dense
and are the most effective in supporting for the overlying
soft tissues and in so doing, forms boundaries that

Layer 2: subcutaneous tissue

The thinner the dermis, the more susceptible it is to qualitative deterioration aging changes.

Fig. 6.3 The retaining ligaments of the face can
be likened to a tree. The ligaments attach the soft
tissues to the facial skeleton or deep muscle fascia,
passing through all ﬁve layers of the soft tissues. It
fans out in a series of branches and inserts into the
dermis. At different levels of dissection, it is given
different names, such as the retinacular cutis in the
subcutaneous layer and ligaments in the subSMAS
level. (© Dr Levent Efe, CMI.)

The muscles of facial expression are unique and fundamentally different from skeletal muscles beneath the deep fascia
because they are situated within the superﬁcial fascia and
they move the soft tissues of which they are a part. All muscles
of facial expression have either all or the majority of their
course within layer 3 and they are predominantly located over
and around the orbital and oral cavities. In the prototype
scalp, the occipital-frontalis moves the overlying soft tissue of
the forehead, while its undersurface glides over the subaponeurotic space (layer 4). Layer 3 is continuous over the entire
face, although for descriptive purposes, different names are
given to certain parts according to the superﬁcial muscle
within. It is called the galea over the scalp, the temporoparietal (superﬁcial temporal) fascia over the temple, the
orbicularis fascia in the periorbital region, the superﬁcial musculoaponeurotic system (SMAS) over the mid- and lower face
and platysma in the neck.5,12
Within layer 3, the facial muscles themselves have a layered
conﬁguration, with the broad, ﬂat muscles forming the superﬁcial layer that covers the anterior aspect of the face. The
frontalis covers the upper, orbicularis oculi, the middle and
the platysma, and lower thirds, respectively. The muscles of
this layer have minimal direct attachment to the bone, stabilized to the skeleton at their periphery indirectly by the vertically orientated retaining ligaments as noted earlier. The
frontalis is ﬁxed along the superior temporal line by the superior temporal septum, the orbicularis oculi laterally by the

Layer 3: musculo-aponeurotic layer

compartmentalize the subcutaneous fat. These areas, such as
the so-called McGregor’s patch over the body of the zygoma,
often require sharp release to mobilize. In between these
retaining ligaments in layer 4 are located the soft tissue spaces
of the face, that facilitate the mobility of the superﬁcial fascia
over the deep fascia. Where the subcutaneous fat overlies
a space, the retinacular ﬁbers are less dense and orientated
more horizontally, as a result of which, the tissues tend to
separate with relative ease, often with just simple blunt ﬁnger
dissection (Fig. 6.5). This variation in the density and orientation of the retinacular cutis ﬁbers in the subcutaneous fat is
the anatomical basis for the compartmentalization of the subcutaneous fat into discrete compartments, described in detail
in Chapter 11.1.10,11

Fig. 6.5 The density and strength of the retinacular cutis ﬁbers in the subcutaneous
layer varies in different areas of the face. Where it overlies the retaining ligaments,
the ﬁbers are denser and oriented more vertically. In these areas, sharp release is
usually necessary to raise a subcutaneous ﬂap. In contrast, in areas overlying a
space, the ﬁbers are less dense and oriented more horizontally. Here, it is relatively
easy to elevate a subcutaneous facelift ﬂap. (© Dr Levent Efe, CMI.)

81

Layer 4 is the plane in which dissection is performed in
subSMAS facelifts. It is an area of signiﬁcant complexity and
contains the following structures: (1) soft tissue spaces;
(2) retaining ligaments; (3) deep layers of the intrinsic muscles
passing from their bone attachment to their more superﬁcial
soft tissue origin; and (4) facial nerve branches, passing from
deep to superﬁcial. Functionally, a series of soft tissue spaces
exist in layer 4 to allow independent movement of the periorbital and perioral muscle of facial expressions over the deep
fascia responsible for mastication directly beneath the muscles
of facial expression.13 The retaining ligaments of the face are
strategically placed within the boundaries between the soft
tissue spaces and functions to reinforce the boundaries (Fig.
6.6). In the lateral face, immediately in front of the ear, extending 25–30 mm forward of the ear cartilage to the posterior
border of the platysma, is a diffuse area of ligamentous attachment, described by Furnas as the platysma auricular fascia
(PAF).7 As no facial expression occurs here, the dermis, subcutaneous tissue, SMAS and the underlying parotid capsule
(layers 1–5) are bound together as an area of retaining ligament. Layer 4 is reduced to a layer of fusion here, without a
soft tissue space. The ligamentous character of this immobile

Layer 4

lateral orbital thickening and the main zygomatic ligament at
its inferolateral border and the platysma at its upper border
by the lower masseteric ligament. The deeper muscles in layer
3 provide greater functional control of the sphincters over the
bony cavities. For the upper third, these are the corrugators
and procerus, and around the oral cavity, the elevators (zygomaticus major and minor, levator labii superioris, levator
anguli oris), and the depressors (depressor anguli oris, depressor
labii inferioris) around the oral sphincter and the mentalis.

Fig. 6.6 Topographical anatomy of layer 4 over the lateral face. Spaces (blue),
ligaments (red) and the areas of important anatomy (stippled). The largest area
of ligamentous attachment, the platysma-auricular fascia (PAF), dominates the
posterior part of level 4 at the least mobile part of the face. The lateral face
transitions into the anterior face at the vertical line of retaining ligaments.
Immediately above and below the arch of the zygoma are the triangular-shaped
areas that contain the important anatomy proceeding from the lateral into the
anterior face. (© Dr Levent Efe, CMI.)

Surgical anatomy of the face, SMAS, facial spaces and retaining ligaments

SECTION I •

6

• Anatomy of the aging face

The general pattern of the ﬁve-layered anatomy is modiﬁed
where the soft tissues overlie the orbital, oral and nasal cavities over the anterior face (Fig. 6.7). Only the outer three layers
of the composite continue from the periphery as the soft tissue
over the cavities. The SMAS layer within this composite
includes the sphincteric orbicularis muscles that extend right
to the free edge of the soft tissue aperture of the eyelids and
lips. The retaining ligaments, which are such a key feature of
the ﬁve-layered anatomy, are not present over the cavities.
There are thus anatomical variations associate with thee functional transitions from the relative stability of the “ﬁxed”
areas to the high mobility of the soft tissue shutters over the
cavities. At the transition, to support the shutters, the retaining ligaments are condensed along the bony orbital rim (Fig.
6.8). This is the anatomical basis for the periorbital ligament
around the orbit, of which the lower lid part is the orbicularis

Anatomy over the cavities
in the skeleton

The deep fascia, the deepest soft tissue layer of the face, is
formed by the periosteum where it overlies bone. Over the
lateral face, where the muscle of mastication (temporalis and
masseter) overlie the bone, the deep fascia is instead the fascial
covering of the muscles, the deep temporal fascia above the
zygomatic arch, and masseteric fascia below the arch. The
parotid fascia is also part of the deep fascia. The investing
deep cervical fascia is the corresponding layer in the neck
where it covers the supraomohyoid muscles and splits to form
the submandibular space that contains the submandibular
gland. The deep fascia, although thin, is tough and unyielding
and gives attachment to the retaining ligaments of the face. In
the mobile shutters over the bony cavities, the deep fascia is
absent, being replaced by a mobile lining derived from the
cavities, that of the conjunctiva or oral mucosa.

Layer 5

area makes it surgically useful for suture ﬁxation. Furnas had
originally described the lower part of the PAF, the platysma
auricular ligament,7 also named by Stuzin and colleagues, the
parotid cutaneous ligament5 and this ligament was subsequently named the tympanoparotid fascia.14 The part of the
PAF immediately in front of the lower tragus has been labeled,
Lore’s fascia.14
In contrast, in the anterior face where there is considerable
movement over and around the bony cavities, the ligaments
are signiﬁcantly compacted and arranged around the edges
of the bony cavities. These boundaries provide the last position where there is underlying deep fascia for the mobile
shutters of the lids and lips to be supported. Importantly for
the surgeon, the retaining ligaments also act as transition
points for the facial nerve branches to pass from deep to
superﬁcial, on their way to innervate their target muscles.
Soft tissue spaces of the face are in two forms: (1) those
overlying bony cavities, such as the preseptal space of the
eyelid over the orbit and the vestibule of the oral cavity, under
the lips and the lower nasolabial segment of the cheek and
(2) those overlying the bone, where soft tissue spaces allow
the overlying superﬁcial fascia to glide freely over the bone.

82

Fig. 6.8 The system of retaining ligaments situated around the bony cavities
stabilizes the soft tissue over the cavities. (© Dr Levent Efe, CMI.)

Fig. 6.7 The anatomy over the skeleton and over bony cavities (1–5), showing
the relationship of the soft tissue spaces to bony cavity spaces. (© Dr Levent Efe,
CMI.)

The upper temporal space separates the temporoparietal
fascia (superﬁcial temporal fascia) from the (deep) temporal
fascia and is separated from the forehead by the superior temporal septum (STS) along the superior temporal line (Fig. 6.9).
Anteroinferiorly, the upper temporal space is separated from

Upper temporal space

A large part of the subSMAS layer 4 consists of soft tissue
“spaces.” These spaces have deﬁned boundaries that are strategically reinforced by retaining ligaments.18 Signiﬁcantly,
these areas are by deﬁnition anatomically “safe spaces” to
dissect, as no structures crosses within and all branches of the
facial nerve are outside these spaces. As the roof of each space
is the least supported part, it is more prone to developing
laxity with aging, compared with the ligament-reinforced
boundaries. This differential laxity accounts for much of the
characteristic changes that occur with aging of the face. Once
a space has been surgically deﬁned to its boundaries, the
retaining ligaments in the boundary can then be precisely
released under direct vision to achieve the desired mobilization, while preserving the vital structures closely associated
with the ligaments. A brief description of surgically signiﬁcant facial soft tissue spaces is given below.

Facial spaces

retaining ligament, which stabilizes the orbicularis oculi to the
orbital rim periosteum. Around the oral cavity where the
boundary is less distinct, the ligaments arise mainly from the
platform of the body of the zygoma, and from the deep fascia
over the masseter.15–17
The deeper component of the eyelid and lips are derived
from the origin of the cavity and are not an extension of
the facial soft tissues. In the eyelid, the deeper lid muscles
with their related aponeurosis (levator and capsulopalpebral
fasciae) and fat are retained by the fascial system of the septum
orbitale. The free edges of the upper and lower eyelids obtain
their ligamentous support from the tarsal plates, with their
canthal tendon attachments to the medial and lateral orbital
rims. In the pretarsal area, the superﬁcial and deep lid structures, the anterior and posterior lamellae, merge. But between
the pretarsal area of the lid and the orbital rim the lamellae
remain quite separate, i.e., the preseptal orbicularis does not
have an attachment to the septum orbitale. This is the anatomical basis for the, surgically signiﬁcant, preseptal space of
the lower lid. In the upper lid, there is not an equivalent space
as the submuscular fat pad over the superior orbital rim continues on the outer surface of the septum orbitale where it
is adherent to the overlying fascia on the underside of the
orbicularis almost down to where the levator crosses into
the orbicularis.
The extent of the vestibule of the oral cavity covering the
maxilla and the mandible has a major impact on the susceptibility to aging of the overlying soft tissue. The skeleton
underlying the space is not available to provide ligamentous
attachment for support of the soft tissues that cover this large
area. The extreme mobility of the lip and adjacent part of the
cheek renders it susceptible to aging changes and the indication for a lower facelift is largely to correct aging changes in
this unsupported tissue.

83

the lower triangular shaped temporal area that contains
important anatomy, by the inferior temporal septum (ITS).
These septi merge at the triangular-shaped zone of adhesion
called the temporal (orbital) ligament.15 The upper temporal
space provides safe surgical access to the lateral brow and
upper mid-cheek. The space can be readily opened by blunt
dissection to its boundaries. Once identiﬁed, the boundaries
are then released by precise sharp dissection. The superior
temporal septum can be released sharply, taking care only to
preserve the lateral (deep) branch of the supraorbital nerve,
which runs parallel to the septum about 0.5 cm medial to it.19
The inferior temporal septum provides a marker to the important anatomy here as the temporal branches of the facial nerve
are located parallel to and immediately inferior to this septum.
To release the inferior temporal septum, the roof of the space
is gently lifted off the deep temporal fascia ﬂoor, which threedimensionalizes the septum in preparation for its gentle
release at the level of the ﬂoor, bearing in mind the frontal
branches are located under the roof of the lower temporal area
where they travel in the ceiling within the layer of fat suspended on the underside of the temporoparietal fascia. Once
released, the sentinel vein comes into view. The sentinel vein
is not a good landmark for locating the temporal branches as
they course cephalad to the vein, that is, inferior to the inferior
temporal septum. This anatomy is also reviewed in Chapter 7.

Fig. 6.9 The upper temporal space and the retaining ligaments of the temple. The
boundaries of the space are the superior temporal septum (STS) and the inferior
temporal septum (ITS), which are extensions of the temporal ligament adhesion
(TLA). No structures cross the temporal space. The TLA continues medially as the
supraorbital ligamentous adhesion (SLA). Inferior to the temporal space is the
triangular-shaped area of important anatomy (stippled). Crossing level 4 in this
area are the medial and lateral branches of the zygomatic temporal nerve (ZTN) and
the sentinel vein. The temporal branches of the facial nerve (TFN) course on the
underside of the temporal-parietal fascia over the area immediately inferior to the
inferior temporal septum. The periorbital septum (PS, green) is on the orbital rim at
the boundary of the orbital cavity. The lateral orbital thickening (LOT) and the lateral
row thickening (LBT) are parts of the periorbital septum. SON, supraorbital nerve;
ZFN, zygomaticofacial nerve. (© Dr Levent Efe, CMI.)

Facial spaces

SECTION I •

6

• Anatomy of the aging face

This space overlies the lower half of the masseter and is analogous to the temporal space, in that it overlies the deep fascia
of a muscle of mastication (Fig. 6.11).18 This gliding soft tissue

Premasseter space

This triangular-shaped space overlies the body of the zygoma,
its ﬂoor covering the origins of the zygomatic muscles. The
space allows the independent displacement of the orbicularis
oculi (pars orbitale) in the roof from the zygomatic muscles
under the ﬂoor. Contraction of the overlying orbicularis
elevates the prezygomatic soft tissues, which results in
zygomatic smile lines (below the crow’s feet) (Fig. 6.10). With
the laxity of aging the roof of the space rests at a lower level
than in youth. As a result, there is a now a greater amplitude
of movement on orbicularis contraction that has the effect of
exaggerating the zygomatic lines with aging.13,16 This aging
of the prezygomatic space, with bulging over its roof accentuated by its well-supported boundaries, is the anatomical
basis for the clinical entity variously described as malar
mounds, bags or malar crescent. These deformities indicate
the presence of signiﬁcant laxity and the treatment is directed
to tightening the laxity of the roof and upper ligamentous
boundary.

Prezygomatic space

Fig. 6.10 The prezygomatic space overlies the body of the zygoma. The origin
of the zygomatic muscles extends under the ﬂoor. The roof is formed by the
orbicularis oculi line by the suborbicularis oculi fat (SOOF). The upper ligamentous
border formed by the orbicularis retaining ligament is not as strong as the
zygomatic ligament reinforced lower border. (© Dr Levent Efe, CMI.)

84

This is one of the deep facial spaces, being, like the submandibular space (which contains the submandibular gland),
deep to the deep fascia (layer 5). The buccal space is located
in the anterior face, medial to the anterior border of the masseter above the level of the oral commissure in youth.20,21 The
space and its contents, the buccal fat, facilitates movement of
the overlying nasolabial segment of the mid-cheek as well as
buffering this area from excessive motion from jaw movement. Aging and attrition of the boundaries, particularly of
the masseteric ligaments inferiorly result in the platysma

Buccal space

plane allows opening of the jaw without restriction and avoids
excessive distortion of the overlying soft tissues. The roof of
this space is formed by the platysma. The lower premasseter
space has profound clinical signiﬁcance, as it is the anatomical
basis for the development of jowls with aging. Laxity in the
roof of the space, particularly where it has a weakened attachment to the anterior masseter by the masseteric ligaments and
its inferior boundary where there is no ligament, manifests as
the labiomandibular fold and jowl, respectively. The relatively
stable ﬁxation at the anteroinferior corner of the premasseter
space provided by the mandibular ligament accounts for the
dimple that is commonly seen separating the labiomandibular
fold above and the jowl below.

Fig. 6.11 The rhomboidal-shaped premasseter space overlies the lower half of the
masseter. The roof of the space is formed by the platysma. The posterior border is
deﬁned by the anterior edge of the strong PAF and the anterior border is reinforced
by the masseteric ligaments near the anterior edge of the masseter. The inferior
boundary is mesenteric-like and does not contain any ligament. Weakness of
attachment of the platysma roof at the inferior boundary leads to the formation
of the jowl directly behind the strong mandibular ligament. The buccal space
containing the buccal fat is anterior to the upper masseteric ligaments. All facial
nerve branches course around and outside the space. The surgically important
mandibular branch, after leaving the ﬁxed PAF, courses under the inferior boundary
of the space, then rises onto the highly mobile outer surface of the mesenteric
inferior border before reaching the mandibular ligament. (© Dr Levent Efe, CMI.)

Fig. 6.12 The relationship between facial nerve branches, spaces and retaining
ligaments. The nerves stay deep to and outside of the spaces at all times in the
lateral face. In the boundary between the lateral and anterior face, the facial nerve
branches transition from under layer 5 to enter layer 3, always in close association
with the retaining ligaments of the face. (© Dr Levent Efe, CMI.)

The danger zone for facial nerve injury has been well described
in the literature, but is of limited value to the surgeon due to
the two-dimensional perspective that gives the expected
course of the nerve relative to surface landmarks.22–24
Conﬁdence when approaching the nerve surgically comes
from an understanding the three-dimensional course of the
nerve relative to the layered anatomy as described above and
visually identifying the nerves in relation to deﬁned landmarks (Fig. 6.12). The facial nerve branches exit the parotid
gland and remain deep to layer 5 in the lateral face. As they
approach the anterior face, the branches traverse layer 4 to
reach the underside of mimetic muscles of the face. It is at
these transition points across layer 4 that the nerves are at
greatest risk of injury.1,25 The transitions occur at predictable
locations, in close association with retaining ligaments that
provide stability and protection for the nerves. The surgical
release of these ligaments to gain the needed mobility should
be performed with extreme care on account of the proximity
of the nerves.
The surface marking of the temporal branch of the facial
nerve is along the Pitanguy line, from a point 0.5 cm below
the tragus to a point 1.5 cm lateral to the supraorbital rim.26,27
It is traditional teaching that once the temporal branch exits
the parotid, it immediately runs superﬁcially from the deep
fascia and comes to lie just deep to the SMAS as it crosses the
arch of the zygoma.5,28,29 Because of its superﬁcial location,

Facial nerve branches

being less ﬁrmly bound to the masseter. This allows the space
to enlarge and also allows the buccal fat to prolapse inferiorly,
below the level of the commissure into the lower face. As the
buccal fat comes to overlie the anterior border of the lower
masseter it results in increased prominence of the labiomandibular fold and jowl.

85

surgical transection of the SMAS here, so-called high SMAS
transection (i.e., at or above the arch) has been generally discouraged. It is now apparent that the nerve is deeper than was
previously thought as it crosses the zygomatic arch.30 A histological study conﬁrmed that the frontal branches are in transition from where they exit the parotid below the zygomatic
arch, to where they enter the underside of the temporoparietal
fascia some 2 cm above the arch. They course in a tissue layer
(layer 4), just deep to the temporoparietal fascia (layer 3) and
immediately superﬁcial to the periosteum and above that, the
temporalis fascia (layer 5), all along protected by a fascial,
fatty layer, which is an upward prolongation of the parotidmasseteric fascia and named the parotid-temporal fascia.27
Another study noted the temporal branch to transition to
under the temporoparietal fascia (layer 3) at a distance of
1.5–3 cm above the zygomatic arch.31 The temporal branch
completes the transition to the underside of the temporoparietal fascia well before the nerve crosses cephalad to the sentinel vein.15 Accordingly, once the sentinel vein is visualized
from the temporal aspect, the temporal branches would
already be located in the roof of the lower temporal area.
The zygomatic branch exits the parotid gland deep to the
deep fascia just below the zygoma and cephalad to the parotid
duct. It travels horizontally on the masseter with the transverse facial artery.32,33 At the lateral border of the origin of
zygomaticus major muscle is the substantive zygomatic
retaining ligament (that attaches to the body of the zygoma).
At the lateral border of zygomaticus major, after a branch
is given off to supply the orbicularis oculi, entering the
muscle at its inferolateral corner, the zygomatic nerve continues medially and then transitions to the underside of the
muscles it innervates zygomaticus major and minor, and
supplies them from the deep aspect in close association
with the zygomatic ligaments. Careful dissection by vertical
spreading of the scissors is crucial to avoid damaging this
branch here.16,24,34
The upper buccal trunk exits the parotid, about in line with,
but superﬁcial to, the parotid duct and continues deep to the
investing masseter fascia. Approaching the anterior edge of
the masseter, this branch leaves the ﬂoor under the masseter
fascia in close association with the upper key masseteric ligament.5,35 The lower buccal trunk leaves the parotid lower
down, at about the level of the earlobe and remains under the
masseter fascia as it crosses under the ﬂoor of the premasseter
space . Similarly, upon approaching the anterior edge of the
masseter, in the upper membranous boundary of the premasseter space, the lower buccal trunk transitions from deep to
gain the underside of the SMAS in close association with the
upper surface of the lower key masseteric ligament.18 After
the nerves reach level 3, the zygomatic, upper and lower
buccal trunks, and mandibular branch connect with each
other before continuing their course to innervate the mimetic
muscles. This accounts for the overlap in muscles innervated
by these nerves.
The temporal and mandibular branches are the most signiﬁcant in terms of surgical risks because of the lack of cross
innervation of their target muscle. The marginal mandibular
nerve is at risk where it is ﬁxed by its close association with
the retaining ligaments. Early in its course, around the angle
of the mandible, this is within the PAF, and then well anteriorly by the mandibular ligament. Over most of its course, the
mandibular branch is mobile, being in relation to the inferior

Facial nerve branches

SECTION I •

6

• Anatomy of the aging face

Skin aging is inﬂuenced by genetics, environmental exposure,
hormonal changes and metabolic processes.39–41 With aging,
the supple skin of youth becomes thinned and ﬂattened, with
loss of elasticity and architectural regularity. Atrophy of the
extracellular matrix is reﬂected by the decreased number of

Skin

The youthful face has the general appearance of high rounded
fullness, while the aging process is characterized by a look of
depletion and sagging, suggestive of tiredness. Changes with
aging occur at every level of the facial anatomy, starting with
the facial skeleton. A key unresolved question is how much
of the change at each level is intrinsic aging and how much is
secondary to the changes from adjacent layers. This is not easy
to quantitate due to the difﬁculties of measurement of a single
layer in the context of the complicated and interrelated layered
structure.
Current understanding of the aging process remains
largely empirical, given that it is based on the effectiveness
of treatments designed to satisfy the requirements of patients
for a younger appearance. Historically, stretching of loose
facial skin (traditional facelift), removal of apparent tissue
excess (traditional blepharoplasty), tightening the dermis and
evening the complexion (early phenol peels and CO2 laser
resurfacing) and, in recent years, soft tissue volume augmentation (lipoﬁlling and soft tissue ﬁllers) have all had a positive
impact on rejuvenating appearance. The success of each is
attributed to having reversed a cause of facial aging. Yet,
when each of these modalities is continued as the sole treatment, to further reverse the aging appearance, the results tend
to be bizarre, leading to the conclusion that multimodal
therapy is required to further reverse, what must be, multiple
components of the aging process.
An understanding of the changes that occur in the layered
anatomy forms the basis for logical treatment. Changes of the
skin are readily observable and changes in the skeleton effecting layer 5 can also be observed radiologically. Because the
changes within the superﬁcial fascia (layers 2 and 3) are not
directly measurable, empiricism has remained prevalent. A
correlation of the surface anatomy changes of aging with the
anatomy of layers 2, 3, and 4 indicates that bulging occurs
over the roof of soft tissue spaces, which stand out in contrast
to the absence of bulging of the adjacent cutaneous grooves.
The grooves reﬂect the restriction imposed by the dermal
insertions of the retaining ligaments at the boundaries of the
spaces. The degree to which the bulging reﬂects true elongation from primary tissue degeneration and laxity and how
much it is ‘apparent’ laxity secondary to loss of volume (skeletal and soft tissue) remains unanswered.

Aging changes of the face

boundary of the premasseter space. It is not necessary to
dissect in the vicinity of the nerve because of the inherent
mobility of the platysma where it overlies the jaw and submandibular area. The mobility of the nerve as it travels within
the inferior membranous boundary of the lower premasseter
space accounts for the reported variability of the location of
this part of its course (occasionally below the mandible).36–38

86

Skeletal muscles, in general, have been noted to atrophy up
to 50% with age.48 This may be applicable to the muscle of
mastication such as the temporalis and masseter (compounded
by the decreased demand and deterioration of the dentition
with aging) although no speciﬁc study on the effect of aging
on these muscles has been done to date. The mimetic muscle
of the face, in contrast to skeletal muscles, may not undergo
the same degree of degeneration with aging because of their
constant use with facial expression. The orbicularis oculi has
been noted to remain histologically unchanged with no loss
of muscle ﬁbers aging.49 The upper lip elevators, zygomaticus
major and levator labii superioris were also noted to remained
unchanged with aging, based on magnetic resonance imaging
(MRI) of their length, thickness and volume.45 In contrast, the
upper lip orbicularis atrophies with aging, with decreased
muscle thickness, smaller muscle fascicles and increase in
surrounding epimysium.50

Muscle aging

The ﬁbrous and fat components in the subcutaneous tissue
are not a uniform but arranged in discrete compartments.10
Over speciﬁc sites, due to the prominence of the subcutaneous
fat it has been given speciﬁc names such as the malar fat pad
and nasolabial fat. The boundary of these subcutaneous compartments corresponds to the location of the retaining ligaments, which pass superﬁcially to insert into the dermis. In
youth, transition between compartments is smooth and nondiscernible. With aging, a series of concavities and convexities
develop which separates these compartments. These changes
have been attributed to a number of causes including fat
descent, selective atrophy and hypertrophy and attenuation
of the retaining ligaments that causes fat compartments malpositioning.9,10,45,46 It is now apparent that fat descends minimally with aging.47 As noted the subcutaneous fat is not a
conﬂuent layer that can descend with aging. Distinct compartmentalization by the retaining ligaments holds the fat in its
relative positions.

Subcutaneous tissue

ﬁbroblasts and decreased levels of collagen (especially types
I and III) and elastin in the dermis. While chronological
skin aging and photo-aging can be readily distinguished
and considered separate entities, both share important
molecular features, that of altered signal transduction that
promote matrix-metalloproteinase (MMP) expression, decreased pro-collagen synthesis and connective tissue damage.
Oxidative stress is considered of primary importance in
driving the aging process, resulting in increased hydrogen
peroxide and other reactive oxygen species (ROS) and
decreased anti-oxidant enzymes.42,43 These changes result in
gene and protein structure alterations. Other environmental
factors notably smoking accelerates skin aging, by between 10
and 20 years.44 Increased collagenase and decreased skin circulation has been suggested as possible mechanisms. The
muscles of facial expression ﬂex the skin in a speciﬁc pattern.
As the underlying collagen weakens and the skin thins,
the dermis loses its capacity to resist the constant force of
the muscles and these lines become etched in the skin and
ultimately even at rest.

The facial skeleton changes dramatically with aging (Fig. 6.14)
and this has a profound impact on the appearance of the face
with aging (Fig. 6.15). At birth, the facial skeleton is underdeveloped and rudimentary. This explains why infants and
toddlers often transiently have distinct mid-cheek segments
(despite excellent tissue quality), which disappear as they
grow older with the expansion of the mid-cheek skeleton.51
Peak skeletal projection is probably attained in early adulthood. Thereafter, while certain areas continue to expand,4,52–55
selective areas of the facial skeleton undergoes signiﬁcant
resorption. Areas with strong predisposition to resorption
include the superomedial and inferolateral aspects of the
orbital rim, the midface skeleton, particularly that part contributed by the maxilla including the pyriform area of the nose
and also the prejowl area of the mandible.56–64 The resultant
deﬁciencies in the skeletal foundation have a signiﬁcant effect
on the overlying soft tissues. In the mid-cheek in particular,
retrusion of the maxilla causes increased prominence of the
tear-trough and the nasolabial folds.59 The retrusion of the
facial skeleton causes the origin of the multi-linked ﬁbrous
retaining ligaments to be displaced posteriorly. This pulls the
skin inwards, exaggerating the concavity between the areas
of relative convexity that develop with aging. Retrusion of the
mid-cheek with loss of projection gives the visual impression

Bone changes

The multi-linked ﬁbrous system attenuates with aging, with
decreasing strength of the ligaments and increasing laxity. The
spaces expand with aging as well, to a greater extent than the
laxity that develop in the ligaments within their boundaries,
resulting in bulges between areas of relative ﬁxations.18
Accordingly, the spaces dissect easily in older patients, and
the boundaries widen as the ligaments weaken.13 In young
people, the spaces are more potential that real and do not
open quite so easily with blunt dissection (Fig. 6.13).

Facial spaces and retaining ligaments

87

of tissue descent with aging. Some patients have a congenitally weak or inadequate skeletal structure. In such cases, the
skeleton may be the primary cause of the manifestations of
premature aging. Accordingly, patients who suffer premature
facial aging, a weakness of the relevant part of the underlying
skeleton is immediately suspect and should be addressed in
order to obtain better aesthetic results.

Fig. 6.14 Arrows indicate the areas of the craniofacial skeleton that are susceptible
to resorption with aging. (© Dr Levent Efe, CMI.)

Fig. 6.13 In youth, the spaces are tight. The
retaining ligaments are stout and the transition
between spaces is not discernible. With aging,
spaces expand to a greater extent than the laxity
that develops in ligaments within their boundaries,
resulting in bulges between areas of relative
ﬁxations. These spaces open with relative ease with
blunt dissection. (© Dr Levent Efe, CMI.)

Facial spaces and retaining ligaments

SECTION I •

6

• Anatomy of the aging face

The skin of the temple differs from that of the forehead, being
thinner and less ﬁrmly supported to the underlying layers.
The loose attachment reﬂects the underlying temporal space,
which is extensive, and the nature of the surrounding temporal ligaments that are septal like and do not continue through
the thin, loose subcutaneous layer over the temple to ﬁx to the
dermis as do facial ligaments elsewhere. This explains why
deep layer procedures in the temple are not as effective in
toning the overlying skin as they are, for example, in the
cheek.
Corrugator muscle contraction is associated with the
emotional states of grief and sadness.65 The transverse head
of corrugator supercilii moves the eyebrow medially and
produce vertical glabella lines. The oblique head of the corrugator, the depressor supercilii and the medial ﬁbers of the

Temple and forehead

Regional changes observed with
the aging face

Fig. 6.15 The darker areas denote areas of greatest bone loss. Note how the
stigmata of aging as manifested by the facial soft tissues correspond to the areas
of weakened skeletal support due to bone loss. (© Dr Levent Efe, CMI.)

88

The mid-cheek is the anterior part of the midface.4 It is triangular in shape and bounded superiorly by the pretarsal part
of the lower eyelid, medially by the side of the nose and
the nasolabial groove below, and laterally around the lateral
cheek where the arch of the zygoma meets the body. A smooth
rounded mid-cheek is a powerful image of youth and gives a
certain freshness to the face. With aging, the three mid-cheek
segments become clearly discernible, as they become separated by the three cutaneous grooves of the mid-cheek; the
nasojugal, palpebromalar and mid-cheek grooves.4 This ‘segmentation’ of the mid-cheek has a profound impact on appearance that is responsible for giving the ‘tired’ look we associate
with aging.
The soft tissues of the mid-cheek are structurally composed
of three segments or “modules”, with each overlying a speciﬁc part of the mid-cheek skeleton (Fig. 6.16). The lid-cheek
segment overlies the prominence of the inferior orbital rim,
the malar segment overlies the body of the zygoma and the
nasolabial segment overlies the anterior surface of the maxilla.
The skeletal foundation of the mid-cheek borders the three
bony cavities of the anterior face, the orbital, nasal and oral
cavities. Because of the many spaces and limited bony support
available, the mid-cheek has some intrinsic structural weaknesses. Three factors make the mid-cheek susceptible to aging
changes. These are: (1) the wedge shape of the soft tissue
of the mid-cheek, which are thin above and thicker below;
(2) the natural posterior incline of the mid-cheek skeleton,
from the relative prominence of the infra-orbital rim; and
(3) the signiﬁcant retrusion as a result of resorption of the
maxilla with aging. This is not uniform, as the maxilla recedes
more medially and inferiorly.58–61 With early aging, the retrusion of the maxilla, along with a slight descent of the wedge
shaped cheek soft tissue results in an appreciable reduction
of volume of the upper cheek. The result is that the small
amount of orbital fat over the prominent edge of the infraorbital rim, (originally concealed by the volume of the upper

The mid-cheek

orbicularis oculi act in concert to depress the medial brow and
produce oblique glabella frown lines. The procerus, also a
brow depressor causes transverse nasal skin lines. Laterally,
the action of the lateral ﬁbers of the orbicularis oculi with the
transverse head of the corrugator supercilii promotes lateral
brow ptosis. The ptosis of the lateral brow together and to a
lesser extent, the laxity of the skin with aging produces
a pseudoexcess of the upper eyelid skin. Frontalis muscle
hypertonicity from lateral brow skin hooding and its reaction
to the action of antagonistic muscles (corrugator supercilii,
orbicularis oculi and procerus) results in the development
of transverse forehead skin lines.18,65 The medial brow in contrast, seldom descends with aging and in fact, may rise.66,67
The mechanism responsible for this includes the chronic activation of the frontalis muscle. This may either be to elevate
the brow/eyelid complex associated with clinical or subclinical levator system weakness or to relieve visual ﬁeld obstruction due to excess lateral upper eyelid skin.65 Anatomically,
the frontalis muscle ends at approximately the temporal
fusion line (superior temporal septum). Lateral to this, there
is no upward vector to counteract the downward pull of brow
depressors and gravity on the lateral brow. This may explain
why descent preferentially occurs at the lateral brow.

cheek), now becomes revealed, especially the underside of the
lid fat bulge over the middle part. The visual impression is of
a ‘lengthened’ lower lid.47 At the same time, the increased
thickness of the soft tissue mass over the lower cheek tends
to conceal the degree of maxillary resorption and gives the
profound visual impression that the soft tissue mass has
descended into the lower part of the mid-cheek.
Of the three segments of the mid-cheek, the lower lid
segment changes the most dynamically with aging. It has two
distinct grooves across its surface, which vary in their expression during the aging process, often co-existing. The upper is
the infratarsal groove at the junction of the pretarsal and
preseptal parts of the eyelid. The groove is deﬁned by the
lower boundary of the pretarsal muscle bulge. The pretarsal
bulge in youth is the visual separation of the lid above and
the cheek below. This so-called “high lid-cheek junction” is
located well above the infraorbital rim and is a characteristic
of youth. The infratarsal groove location does not change with
aging, although its contour usually fades. The lower groove
is the lid-cheek junction that relates to the lower edge of the
preseptal part of the lid. It is not usually present in youth and
appears with aging and then progressively deepens and
descends slightly over time. Its shape when it ﬁrst appears is
a gentle C contour but as it “descends”, particularly in its
central portion, its shape changes to a progressively more
angulated V shape with the medial side being formed by the
developing nasojugal groove and the lateral side by the palpebromalar groove. The center of the V, the lowest and deepest
part has the nasojugal groove continuing down the cheek as
the mid cheek groove that separates the cheek into the malar
and nasolabial segments. The reason why this contour demarcation changes while the skin itself does not descend is

Fig. 6.16 The mid-cheek has three segments, the lid-cheek segment (blue) and
the malar segment (green) are within the periorbital part and are adjacent to the
nasolabial segment (yellow) in the perioral part, which overlies the vestibule of
the oral cavity. The three grooves deﬁne the boundaries of the three segments
and interconnect like the italic letter Y. The palpebromalar groove (1) overlies the
inferomedial orbital rim and the nasojugal groove (2) which overlies the inferolateral
orbital rim, then continues into the mid-cheek groove (3). (© Dr Levent Efe, CMI.)

89

The subcutaneous plane of dissection (level 2) is the most commonly used plane in facelifts, either in isolation or more commonly with some form of SMAS management from the
superﬁcial aspect (Fig. 6.17).69–71 A distinction should be drawn
between subcutaneous dissection over the lateral face from
that over the anterior face. This plane of dissection is perceived to be “safe” as dissection remains superﬁcial to the
facial nerve branches at all times and is the main appeal of
level 2 dissection. The subcutaneous dissection can be

Dissection planes

Considerations for correcting aging
changes of the face based on the
anatomy of the aging face

The jowl and the labiomandibular fold in the lower face are
not present in youth, and develop with aging. With the
description of the concept of soft tissue spaces of the face, and
speciﬁcally the premasseter space, the mechanism for the formation of the jowl can now be understood on an anatomical
basis.68 With the onset of aging, laxity develops in the roof of
the premasseter space associated with attenuation of the anterior and inferior boundaries. The major retaining ligaments
(the key masseteric and mandibular) in contrast remain
relatively strong and at these locations the superﬁcial fascia
remains ﬁrmly ﬁxed to the underlying deep fascia. Distension
of the weaker masseteric ligaments at the anterior border of
the lower premasseter space (below the key masseteric ligament) and inferior displacement of the buccal fat (within the
buccal space) is the anatomical basis for the development of
the labiomandibular fold. The mandibular ligament demarcates the transition from the labiomandibular fold above and
the jowl below. The jowl develops as a result of distension of
the roof of the lower premasseter space with resultant descent
of the tissues below the body of the mandible. The more
prominent the jowl, the more apparent will be the cutaneous
tethering provided by the mandibular ligament. Accordingly,
the anatomical solution to correcting these aging changes is
to reduce the inferiorly displaced buccal fat and to tighten the
roof of the premasseter space.

Lower face

explained by difference in the tissue layers. In level 4, the
orbicularis retaining ligament is not rigid where it is over the
center of the inferior orbital rim, so distension results in relative sliding between it and layer 3, the orbicularis oculi. As
the lid-cheek junction becomes more prominent, it visually
takes over from the infratarsal groove and becomes the new
separation between the lower eyelid and the cheek. This is the
basis for the commonly used but misleading phrase “lengthening of the lid cheek junction with aging”, which is in fact
the result of a visual shift from the prominence of the infratarsal groove in youth to the lid-cheek junction with age.
Correction of the aging of the lid cheek segment of the midcheek, the visibly descended contour of the lid cheek junction
and long lower lid, has gained the colloquial name of “blending the lid cheek junction.”

Considerations for correcting aging changes of the face based on the anatomy of the aging face

SECTION I •

6

• Anatomy of the aging face

performed either in the superﬁcial subcutaneous or deep subcutaneous level. In the former, there is more density of the
retinacular cutis ﬁbres as the multi-linked ligaments branches
out before inserting into the dermis. In the latter on the outer
surface of the SMAS, there are fewer ﬁbres, which tend to be
thicker and stronger. The deep subcutaneous layer is not
uniform in its tenacity: some areas, as over the facial spaces
are inherently easier to dissect, while others that overlie the
ligament are more adherent and require sharp release.7,72 For
example, over the malar eminence at McGregor’s patch,
where the zygomatic ligaments are located, sharp release is
often needed as is required over the mandibular ligament. In
contrast, in the lower face over the premasseter space, the
subcutaneous layer separates quite readily, requiring only
blunt ﬁnger dissection.
SubSMAS dissection (level 4): in the scalp, this is the preferred tissue plane for dissection as the scalp readily separates
from the underlying periosteum (level 5) through the avascular areolar tissue with ease and inherent safety. Bruising and
swelling is kept to a minimum because of this anatomy. In the
face proper, while the anatomical principles remain the same,
level 4 is potentially the most risky plane to dissect because
of the facial nerve branches which transition through this
level, from level 5, to supply the facial muscles in level 3.
However, it should be noted that similar to the situation in
the scalp where raising the ﬂap at level 4 gives a robust and
structurally integrated composite ﬂap that can be effectively
tightened, subSMAS dissection in the face has the same
advantages and potential beneﬁts.73,74 Dissection can be performed safely in level 4 by applying the understanding of the
three-dimensional anatomy of the face described earlier; the
key being the facial spaces, which provide safe access through
this layer. Because these spaces are ‘pre-dissected’, access is
quick, atraumatic, and easy. An example of this is the lower
premasseter space. Subcutaneous dissection is performed to
approximately 30 mm anterior to the tragus through the zone
of ﬁxation, the platysma auricular fascia (PAF), where the
SMAS is fused to the deep fascia including the parotid capsule.
Because the objective of the surgery is to correct laxity in the
mobile anterior face, the level of dissection used in the lateral
face is of secondary importance. A further beneﬁt of leaving

90

1

the PAF intact is that it is strong and can be used for suture
ﬁxation.75 Once dissection has proceeded beyond the PAF
(indicated by the posterior border of the platysma), the SMAS
should then be incised to gain direct access into the lower
premasseter space. The space can then be opened by gentle
blunt dissection only, to deﬁne the boundaries of the space.
The premasseter space below and the prezygomatic space
above form a series of spaces in the anterior face (Fig. 6.18).
The boundaries of the spaces, reinforced by retaining ligaments, are where the important anatomy is located. These
need to be precisely released to eliminate their tethering effect
on the soft tissues,76 which is more difﬁcult in younger patients
as the ligaments are denser and stronger. Clear visualization,
optimized by lifting the opened adjacent facial spaces, is beneﬁcial. When blunt scissors are used with gentle vertical
spreading of the blades the surrounding fat and areolar tissue
separate to reveal the ligaments and the facial nerve branches
in relation to them. With further lifting, the ligaments become
more certainly deﬁned as they tighten further, at which time
they can be safely released while the nerves, being obliquely

Fig. 6.18 Using the facial spaces for safe and anatomical access to subSMAS
dissection in facelifts. (1) Premasseter space. (2) Prezygomatic space. (3) Upper
temporal space.

3

2

Fig. 6.17 Alternative levels for dissection and
redraping in facelifts. Dissection can be performed
through any one of three alternative layers, namely
subcutaneous (level 2), subSMAS (level 4) and
subperiosteal for the upper two-thirds of the face.
(© Dr Levent Efe, CMI.)

4. Mendelson BC, Jacobson SR. Surgical anatomy of the
mid-cheek; facial layers, spaces, and mid-cheek
segments. Clin Plast Surg. 2008;35:395–404.
5. Stuzin JM, Baker TJ, Gordon HL. The relationship of
the superﬁcial and deep facial fascias: relevance to
rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3):
441–449.
A discussion of the concept of facial soft tissue being arranged
in concentric layers, and the SMAS as the “investing” layer
of the superﬁcial mimetic muscles of the face. The relationship
between the deep and superﬁcial fascias is described, with
acknowledgement of “areola” planes and areas of dense
ﬁbrous attachments, including true osteocutaneous ligaments
and other coalescences representing the retaining ligamentous
boundaries of the face. Age-associated laxity of the retaining
ligament was noted to be a key component of facial aging.
7. Furnas DW. The retaining ligaments of the cheek. Plast
Reconstr Surg. 1989;83:11.
10. Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg. 2007;119(7):2219–2227.
13. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical
anatomy of the ligamentous attachments of the lower
lid and lateral canthus. Plast Reconstr Surg. 2002;110(3):
873–884.

91

This chapter has been structured to assist the reader to develop
a conceptual understanding of facial anatomy and how it
changes with aging. It is the framework that uniﬁes the
detailed anatomical information now available in the literature. Once understood, this knowledge provides the anatomical foundation for the logical and sound selection of surgical
techniques for rejuvenation of the aging face.

Summary

and tenacity of the superﬁcial fascia is not uniform. The areas
where the retaining ligaments are located have inherent ligamentous reinforcement, making them ideal for suture placement. It is also the location in which traction gives the most
natural appearance, as these are the natural suspension sites
of the face. Accordingly, the suture ﬁxation should be placed
where the retaining ligaments are located. Where ﬁxation
sutures are placed in the anterior face in subSMAS surgery,
they function as replacements for the retaining ligaments that
have weakened or have been divided in order to mobilize the
composite ﬂap. Accordingly, the replacement sutures should
replicate the quality of support provided by the original ligaments as the “mobile” spaces remain. In this respect braided
permanent sutures are advantageous as they stimulate collagen and elastic deposition within the suture similar to a ligament.81 The platysma auricular fascia, a diffuse ligamentous
area on the lateral face, provides an ideal area both anatomically and physically to ﬁx the facelift ﬂap, due to its inherent
strength.

14. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy
of the ligamentous attachments in the temple and
periorbital regions. Plast Reconstr Surg. 2000;105(4):
1475–1490.
A thorough description of the retaining ligaments of the
temporal and periorbital regions is given. The term
“ligamentous adhesion” is introduced to increase the
understanding of the system, and there is emphasis on the
relations of the temporal branch of the facial nerve and the
trigeminal branches to structures visualized in surgery rather
than to less useful landmarks which are not. A discussion of
age related changes to the region compliments one of surgical
approach with respect to the anatomy described.
16. Mendelson BC, Muzaffar AR, Adams WP Jr. Surgical
anatomy of the mid-cheek and malar mounds. Plast
Reconstr Surg. 2002;110(3):885–911.
18. Knize DM. Anatomic concepts for brow lift procedures.
Plast Reconstr Surg. 2009;124(6):2118–2126.
68. Mendelson BC, Freeman ME, Wu W, et al. Surgical
anatomy of the lower face: the premasseter space, the
jowl, and the labiomandibular fold. Aesthetic Plast Surg.
2008;32 (2):185–195.
Introduces the concept of the “premasseter” space,
age-related changes, and utility for safe subSMAS
dissection. Distinction is made between this space,

Access the complete references list online at http://www.expertconsult.com

While adequate surgical release is needed for mobility, it is
the surgical ﬁxation that achieves the desired effect by holding
the mobilized soft tissue in its new position.76 The strength

Placement of sutures

orientated, dislodge out of the way, unaffected by the controlled stretching. The subSMAS spaces can be used to safely
and atraumatically access various part of the face, the
deep temporal space to the lateral brow,13 the preseptal space
to the lower eyelid, and the prezygomatic space to the
mid-cheek.15,16
Level 5: subperiosteal “lifts” have the appeal of safety as far
as the facial nerve risk is concerned as they are superﬁcial and
the remote nerves never cross this plane.77–79 However, there
are inherent limitations to subperiosteal lifts.. The accumulated aging changes across all ﬁve layers are elevated as part
of the subperiosteal lift. Overcorrection is required to effect
the desired changes of soft tissue shape and skin tone, to
compensate for the “lift-lag” phenomenon, which is in proportion to the soft tissue thickness and laxity. Accordingly,
subperiosteal lifts work best in areas where the layers are
more compacted as the lift-lag is minimized. An example
being in the brow where subperiosteal lifts are effective and
popular.80 Where the layers are thicker, such as the nasolabial
segment of the mid-cheek, the lift-lag phenomenon signiﬁcantly limits the improvement that can be achieved. Because
of the unyielding nature of the periosteum, extensive undermining beyond the target area is needed or alternatively a
“periosteal release” immediately beyond the area that requires
lifting to isolate the area to a limited island of periosteum

Summary

SECTION I •

6

• Anatomy of the aging face

over the lower part of the masseter, and another space
overlying the upper part of the masseter where the
neurovascular structures, the accessory lobe of the parotid
gland and duct are located. The true shape of the anterior
border of the masseter muscle is described, with the border
ending anteroinferiorly at the mandibular ligament. This
description completes the picture of the retaining ligaments
as a continuous border separating the anterior and lateral
parts of the face. The relations of the facial nerve branches,
particularly that of the lower buccal trunk, to the masseter
and its fascia is described.
75. Mendelson BC. Surgery of the superﬁcial
musculoaponeurotic system: principles of release,
vectors and ﬁxation. Plast Reconstr Surg. 2001;107(6):
1545–1552.

92

This article highlights the importance of adequate release
of retaining ligaments of the SMAS in repositioning of the
composite ﬂap. Inadequate release can lead to suboptimal
advancement of the ﬂap, and worse, distortion of the ﬂap if
the direction of pull is incorrect, due to unwanted rotation
about the parts of the retaining ligamentous system which
have been left intact. The biomechanical function of the
retaining ligaments is described as “quarantining” sections
of the SMAS with less substantial ﬁxation (areas now
appreciated as subSMAS facial soft tissue spaces), preventing
unwanted traction on areas of the face distant to the desired
action in facial expression. There is discussion on the
advantage of extensive SMAS mobilization in allowing
multiple and varied force vectors to be applied, which allows
proper anatomical repositioning of the soft tissue of the face.
1. Mendelson BC. Facelift anatomy, SMAS, retaining
ligaments and facial spaces. In: Aston J, Steinbrech DS,
Walden JL, eds. Aesthetic plastic surgery. London:
Saunders Elsevier; 2009:53–72.
2. Nahai F, ed. Clinical decision making in face lift and
neck lift. In: The art of aesthetic surgery: principles and
techniques. St Louis: Quality Medical; 2005:898–926.
3. Mendelson BC. Correction of the nasolabial fold:
extended SMAS dissection with periosteal ﬁxation.
Plast Reconstr Surg. 1992;89(5):822–833.
4. Mendelson BC, Jacobson SR. Surgical anatomy of the
mid-cheek; facial layers, spaces, and mid-cheek
segments. Clin Plast Surg. 2008;35:395–404.
5. Stuzin JM, Baker TJ, Gordon HL. The relationship of
the superﬁcial and deep facial fascias: relevance to
rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3):
441–449.
A discussion of the concept of facial soft tissue being arranged
in concentric layers, and the SMAS as the “investing” layer
of the superﬁcial mimetic muscles of the face. The relationship
between the deep and superﬁcial fascias is described, with
acknowledgement of “areola” planes and areas of dense
ﬁbrous attachments, including true osteocutaneous ligaments
and other coalescences representing the retaining ligamentous
boundaries of the face. Age-associated laxity of the retaining
ligament was noted to be a key component of facial aging.
6. Mendelson BC. Advances in the understanding of the
surgical anatomy of the face. In: Eisenmann-Klein M,
Neuhann-Lorenz C, eds. Innovations in plastic and
aesthetic surgery. New York: Springer Verlag; 2007:
141–145.
7. Furnas DW. The retaining ligaments of the cheek. Plast
Reconstr Surg. 1989;83:11.
8. Furnas D. The superﬁcial musculoaponeurotic plane
and the retaining ligaments of the face. In: Psillakis JM,
ed. Deep face-lifting techniques. New York: Thieme
Medical; 1994.
9. Rohrich RJ, Pessa JE. The retaining system of the face:
histologic evaluation of the septal boundaries of the
subcutaneous fat compartments. Plast Reconstr Surg.
2008;121(5):1804–1809.
10. Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg. 2007;119(7):2219–2227.
11. Rohrich RJ, Pessa JE. The anatomy and clinical
implications of perioral submuscular fat. Plast Reconstr
Surg. 2009;124(1):266–271.
12. Mitz V, Peyronie M. The superﬁcial musculoaponeurotic system (SMAS) in the parotid and cheek
area. Plast Reconstr Surg. 1976;58:80.
13. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical
anatomy of the ligamentous attachments of the lower
lid and lateral canthus. Plast Reconstr Surg. 2002;110(3):
873–884.
14. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of
the ligamentous attachments in the temple and

References

30.

29.

28.

27.

26.

25.

24.

23.

22.

21.

20.

19.

18.

17.

16.

15.

92.e1

periorbital regions. Plast Reconstr Surg. 2000;105(4):
1475–1490.
A thorough description of the retaining ligaments of
the temporal and periorbital regions is given. The term
“ligamentous adhesion” is introduced to increase the
understanding of the system, and there is emphasis on the
relations of the temporal branch of the facial nerve and the
trigeminal branches to structures visualized in surgery rather
than to less useful landmarks which are not. A discussion of
age related changes to the region compliments one of surgical
approach with respect to the anatomy described.
Ghavami A, Pessa JE, Janis J, et al. The orbicularis
retaining ligament of the medial orbit: closing the circle.
Plast Reconstr Surg. 2008;121(3):994–1001.
Mendelson BC, Muzaffar AR, Adams WP Jr. Surgical
anatomy of the mid-cheek and malar mounds.
Plast Reconstr Surg. 2002;110(3):885–911.
Yousif NJ, Mendelson BC. Anatomy of the midface.
Clin Plast Surg. 1995;22(2):227–240.
Knize DM. Anatomic concepts for brow lift procedures.
Plast Reconstr Surg. 2009;124(6):2118–2126.
Kahn JL, Wolfram-Gabel R, Bourjat P. Anatomy and
imaging of the deep fat of the face. Clin Anat. 2000;13(5):
373–382.
Zhang HM, Yan YP, Qi KM, et al. Anatomical structure
of the buccal fat pad and its clinical adaptations.
Plast Reconstr Surg. 2002;109(7):2509–2518.
Baker DC, Conley J. Avoiding facial nerve injuries
in rhytidectomy: anatomic variations and pitfalls.
Plast Reconstr Surg. 1979;64:781.
Gosain AK. Surgical anatomy of the facial nerve.
Clin Plast Surg. 1995;222:241.
Seckel BR. Facial danger zones. Avoiding nerve injury in
facial plastic surgery. St Louis: Quality Medical; 1994.
Owsley JQ, Agrawal CA. Safely navigating around
the facial nerve in three-dimensions. Clin Plast Surg.
2008;35:469–477.
Lowe JB 3rd, Cohen M, Hunter DA, et al. Analysis of
the nerve branches to the orbicularis oculi muscle of
the lower eyelid in fresh cadavers. Plast Reconstr Surg.
2005;116(6):1743–1749.
Furnas DW. Landmarks for the trunks and the
temporofacial division of the facial nerve. Br J Surg.
1965;52:694–696.
Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy
of the frontal branch of the facial nerve: the signiﬁcance
of the temporal fat pad. Plast Reconstr Surg. 1989;83(2):
265–271.
Ramirez OM, Maillard GF, Musolas A. The extended
subperiosteal face lift: a deﬁnitive soft-tissue remodeling
for facial rejuvenation. Plast Reconstr Surg. 1991;88(2):
227–236.
Trussler AP, Stephan P, Hatef D, et al. The frontal
branch of the facial nerve across the zygomatic arch:
anatomical relevance of the high-SMAS technique.
Plast Reconstr Surg. 2010;125(4):1221–1229.
Agarwal CA, Mendenhall SD 3rd, Foreman KB, et al.
The course of the frontal branch of the facial nerve in

References

48.

47.

46.

45.

44.

43.

42.

41.

40.

39.

38.

37.

36.

35.

34.

33.

32.

31.

SECTION I •

6

• Anatomy of the aging face

relation to fascial planes: an anatomic study.
Plast Reconstr Surg. 2010;125(2):532–537.
Montagna W, Carlisle K. Structural changes in the aging
skin. Br J Dermatol. 1990;122(Suppl 35):61–70.
Ramirez OM, Santamaria R. Spatial orientation of motor
innervation of the lower orbicularis oculi muscle.
Aesthetic Surg J. 2000;20:107.
Ruess W, Owsley JQ. The anatomy of the skin and
fascial layers of the face in aesthetic surgery. Clin Plast
Surg. 1987;14(4):677–682.
Byrd HS, Andochick SE. The deep temporal lift: a
multiplanar, lateral brow, temporal, and upper face lift.
Plast Reconstr Surg. 1996;97(5):928–937.
Dingman RO, Grabb WC. Surgical anatomy of the
mandibular ramus of the facial nerve based on the
dissection of 100 facial halves. Plast Reconstr Surg.
1962;29:266.
Conley J, Baker DC. Paralysis of the mandibular branch
of the facial nerve. Plast Reconstr Surg. 1982;70:569.
Nelson DW, Gingrass RP. Anatomy of the mandibular
branches of the facial nerve. Plast Reconstr Surg. 1979;
63:479.
Pitanguy I, Ramos AS. The frontal branch of the facial
nerve: the importance of its variations in facelifting.
Plast Reconstr Surg. 1966;38:352–356.
Wulf HC, Sandby-Moller J, Kobayashi T, et al. Skin
aging and natural photoprotection. Micron. 2004;35:
185–191.
Hall G, Phillips TJ. Estrogen and skin: the effects of
estrogen, menopause and hormone replacement therapy
on the skin. J Am Acad Dermatol. 2005;53; 555–568.
Sander CS, Chang H, Salzmann S, et al. Photoaging is
associated with protein oxidation in human skin in
vivo. Invest Dermatol. 2002;118(4):618–625.
Chung JH, Seo JY, Choi HR, et al. Modulation of skin
collagen metabolism in aged and photoaged human
skin in vivo. J Invest Dermatol. 2001;117(5):1218–1224.
Freiman A, Bird G, Metelitsa AI, et al. Cutaneous effects
of smoking. J Cutan Med Surg. 2004;8(6):415–423.
Gosain AK, Klein MH, Sudhakar PV, et al. A volumetric
analysis of soft-tissue changes in the aging midface
using high-resolution MRI: implications for facial
rejuvenation. Plast Reconstr Surg. 2005;115(4):1143–1155.
Gosain AK, Amarante MT, Hyde JS, et al. A dynamic
analysis of changes in the nasolabial fold using
magnetic resonance imaging: implications for facial
rejuvenation and facial animation surgery. Plast Reconstr
Surg. 1996;98(4):622–636.
Lambros V. Observations on periorbital and midface
aging. Plast Reconstr Surg. 2007;120(5):1367–1376.
Faulkner JA, Larkin LM, Claﬂin DR, et al. Age-related
changes in the structure and function of the skeletal
muscles. Clin Exp Phamacol Physiol. 2007;34:1091–1096.
Pottier F, El-Shazly NZ, El-Shazly AE. Aging of
orbicularis oculi: anatomophysiologic consideration in
upper blepharoplasty. Arch Facial Plast Surg. 2008;10(5):
346–349.

92.e2

49. Penna V, Stark GB, Eisenhardt SU, et al. The aging
lip: a comparative histological analysis of age-related
changes in the upper lip complex. Plast Reconstr Surg.
2009;124(2):624–628.
50. Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and
facial aging: nonlinear aspects of youthfulness and
skeletal remodeling, and why, perhaps, infants have
jowls. Plast Reconstr Surg. 1999;103(2):635–644.
51. Schwartz GE, Fair PL, Mandel MR, et al. Facial
electromyography in the assessment of improvement in
depression. Psychosom Med. 1978;40:355.
52. Hellman M. Changes in the human face brought about
by development. Int J Orthod. 1927;13:475.
53. Todd TW. Thickness of the white male cranium.
Anat Rec. 1924;27:245.
54. Lasker GW. The age factor in bodily measurements of
adult male and female Mexicans. Hum Biol. 1953;25:50.
55. Garn SM, Rohmann CG, Wagner B, et al. Continuing
bone growth during adult life: A general phenomenon.
Am J Phys Anthropol. 1967;26:313.
56. Kahn DM, Shaw RB Jr. Aging of the bony orbit: a
three-dimensional computed tomographic study.
Aesthet Surg J. 2008;28(3):258–264.
57. Pessa JE, Chen Y. Curve analysis of the aging orbital
aperture. Plast Reconstr Surg. 2002;109(2):751–755.
58. Pessa JE, Zadoo VP, Mutimer KL, et al. Relative
maxillary retrusion as a natural consequence of aging:
combining skeletal and soft-tissue changes into an
integrated model of midfacial aging. Plast Reconstr Surg.
1998;102(1):205–212.
59. Pessa JE. An algorithm of facial aging: veriﬁcation of
Lambros’s theory by three-dimensional
stereolithography, with reference to the pathogenesis of
midfacial aging, scleral show, and the lateral suborbital
trough deformity. Plast Reconstr Surg. 2000;106(2):
479–488.
60. Shaw RB Jr, Kahn DM. Aging of the midface bony
elements: a three-dimensional computed tomographic
study. Plast Reconstr Surg. 2007;119(2):675–681.
61. Mendelson BC, Hartley W, Scott M, et al. Age-related
changes of the orbit and mid-cheek and the implications
for facial rejuvenation. Aesthetic Plast Surg. 2007;31(5):
419–423.
62. Zadoo VP, Pessa JE. Biological arches and changes to
the curvilinear form of the aging maxilla. Plast Reconstr
Surg. 2000;106(2):460–466.
63. Pessa JE, Slice DE, Hanz KR, et al. Aging and the shape
of the mandible. Plast Reconstr Surg. 2008;121(1):
196–200.
64. Shaw RB Jr, Katzel EB, Koltz PF, et al. Aging of the
mandible and its aesthetic implications. Plast Reconstr
Surg. 2010;125(1):332–342.
65. Knize DM. Muscles that act on glabella skin: A closer
look. Plast Reconstr Surg. 2000;105:350.
66. Matros E, Garcia JA, Yaremchuk MJ. Changes in
eyebrow position and shape with aging. Plast Reconstr
Surg. 2009;124(4):1296–1301.
67. Jelks GW, Jelks EB. The inﬂuence of orbital and eyelid
anatomy on the palpebral aperture. Clin Plast Surg.
1991;18(1):183–195.
68. Mendelson BC, Freeman ME, Wu W, et al. Surgical
anatomy of the lower face: the premasseter space, the
jowl, and the labiomandibular fold. Aesthetic Plast Surg.
2008;32(2):185–195.
Introduces the concept of the “premasseter” space, age-related
changes, and utility for safe subSMAS dissection. Distinction
is made between this space, over the lower part of the
masseter, and another space overlying the upper part of the
masseter where the neurovascular structures, the accessory
lobe of the parotid gland and duct are located. The true shape
of the anterior border of the masseter muscle is described,
with the border ending anteroinferiorly at the mandibular
ligament. This description completes the picture of the
retaining ligaments as a continuous border separating the
anterior and lateral parts of the face. The relations of the
facial nerve branches, particularly that of the lower buccal
trunk, to the masseter and its fascia is described.
69. Baker DC. Lateral SMASectomy. Plast Reconstr Surg.
1997;100:509–513.
70. Tonnard P, Verpaele A. The MACS-lift short scar
rhytidectomy. Aesthet Surg J. 2007;27(2):188–198.
71. Aston SJ, Walden JL. Facelift with SMAS techniques
and FAME. In: Aston SJ, Steinbrech DS, Walden JL, eds.
Aesthetic plastic surgery. London: Saunders Elsevier;
2009;73–86.
72. Labbé D, Franco RG, Nicolas J. Platysma suspension
and platysmaplasty during neck lift: anatomical
study and analysis of 30 cases. Plast Reconstr Surg.
2006;117(6):2001–2007.
73. Hamra ST. Deep-plane rhytidectomy. Plast Reconstr
Surg. 1990;86:53.
74. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg.
1992;90:1.
75. Mendelson BC. Surgery of the superﬁcial
musculoaponeurotic system: principles of release,
81.

80.

79.

78.

77.

76.

92.e3

vectors and ﬁxation. Plast Reconstr Surg. 2001;107(6):
1545–1552.
This article highlights the importance of adequate release
of retaining ligaments of the SMAS in repositioning of the
composite ﬂap. Inadequate release can lead to suboptimal
advancement of the ﬂap, and worse, distortion of the ﬂap if
the direction of pull is incorrect, due to unwanted rotation
about the parts of the retaining ligamentous system which
have been left intact. The biomechanical function of the
retaining ligaments is described as “quarantining” sections
of the SMAS with less substantial ﬁxation (areas now
appreciated as subSMAS facial soft tissue spaces), preventing
unwanted traction on areas of the face distant to the desired
action in facial expression. There is discussion on the
advantage of extensive SMAS mobilization in allowing
multiple and varied force vectors to be applied, which allows
proper anatomical repositioning of the soft tissue of the face.
Le Louarn C. The concentric malar lift: malar and lower
eyelid rejuvenation. Aesthetic Plast Surg. 2004;28(6):
359–372.
Sullivan SA, Dailey RA. Endoscopic subperiosteal
midface lift: surgical technique with indications and
outcomes. Ophthal Plast Reconstr Surg. 2002;18(5):
319–330.
Ramirez OM. Three-dimensional endoscopic midface
enhancement: a personal quest for the ideal cheek
rejuvenation. Plast Reconstr Surg. 2002;109(1):329–340.
Rowe DJ, Guyuron B. Optimizing results in endoscopic
forehead rejuvenation. Clin Plast Surg. 2008;35(3):
355–360.
Huggins RJ, Freeman ME, Kerr JB, et al. Histologic and
ultrastructural evaluation of sutures used for surgical
ﬁxation of the SMAS. Aesthetic Plast Surg. 2007;31(6):
719–724.
Freilinger G, Gruber H, Happat W, et al. Surgical
anatomy of the mimic muscle system and the facial
nerve: Importance for reconstructive and aesthetic
surgery. Plast Reconstr Surg. 1987;80:686.

References

http://www.expertconsult.com

Access the Historical Perspective section online at

Detailed knowledge of forehead anatomy is the basis for
rejuvenation strategies of the forehead region.
Eyebrow position is the net result of forces which depress the
brow, forces which raise the brow and the structures which tether
the eyebrow in place.
Brow depression is caused by glabellar frown muscles, the
orbicularis and gravity. Frontalis is the only effective brow elevator.
Attractiveness of the periorbital region is intimately related to
eyebrow shape and eyebrow position as it relates to the upper
eyelid and the upper lid sulcus.
Aging causes enlargement of the orbital aperture as well as
changes in eyebrow shape. In a subset of individuals there is
ptosis of the entire forehead complex.
Key elements of forehead rejuvenation are the attenuation of frown
muscle action and the repositioning of ptotic eyebrow elements.
The lateral eyebrow is often the only portion requiring elevation.
Forehead rejuvenation can be accomplished using a combination
of surgical and non-surgical techniques.
If surgical elevation of the brow complex fails early, it is usually
due to lack of soft tissue release. If it fails late, is usually due to
failure of ﬁxation.
Many methods of soft tissue ﬁxation and bony ﬁxation have been
proven effective in maintaining the position of the surgically
elevated brow.

©

2013, Elsevier Inc. All rights reserved.

The periorbital region is the most expressive part of the
human face. The eyes are central, framed above by the eyebrows, and below by the cheek. Alteration in components
of the orbital frame, as well as the eyelids themselves, will

Introduction

䊏

䊏

䊏

䊏

䊏

䊏

䊏

䊏

䊏

SYNOPSIS

Richard J. Warren

Forehead rejuvenation

7

Aesthetic Surgery of the Face

The frontal bone is crossed laterally by a curved ridge called
the temporal crest (also called the temporal ridge or the superior temporal fusion line of the skull). This is a palpable landmark which separates the temporal fossa and the origin of the
temporalis muscle from the forehead portion of the frontal
bone (Fig. 7.1). It also marks a change in nomenclature as
tissue planes transition from lateral to medial. The deep temporal fascia covering the temporalis muscle attaches along the
temporal ridge and continues medially as the periosteum
which covers the frontal bone. Similarly, the superﬁcial temporal fascia (also known as the temporal parietal fascia) continues medially as the galea aponeurotica which encompasses
the frontalis muscle.
The surgical signiﬁcance of the temporal crest line is that
all fascial layers are tethered to bone in a band approximately
5 mm wide immediately medial to the palpable ridge. This
has been called the zone of ﬁxation.22,23 Where this zone
approaches the orbital rim at its inferior end, the fascial attachment widens and becomes more dense, forming the orbital
ligament (Fig. 7.2). All fascial attachments in this region must

Anatomy

profoundly affect facial appearance. The aesthetic balance
created by surgery can project strong human emotions,
ranging from joy to sadness and from restfulness to fatigue.
In the younger individual, aesthetic alteration of the forehead is generally limited to the nonsurgical alleviation of
glabellar frown lines and lateral orbital wrinkles. These issues
are discussed in Chapters 3 and 4. Occasionally, surgery is
indicated to change the basic shape of a youthful eyebrow. In
the older individual, the forehead typically becomes ptotic
laterally, while in the orbit, there is a relative loss of orbital
fat together with an accumulation of loose eyelid skin.
Understanding the interplay between these complex anatomical changes is critical in choosing an appropriate surgical
strategy to rejuvenate the upper third of the face.

SECTION I

The history of aesthetic brow surgery was thoroughly
reviewed by Paul in 2001.1
The ﬁrst description of brow elevation surgery was a publication by the French surgeon Passot in 1919.2 His technique
involved the removal of multiple small skin ellipses, positioning scars in the forehead crease lines and at the frontal hairline. In 1926, Hunt described what appears to have been a full
anterior hairline incision for brow lifting access.3 In 1931,
Lexer published a combined forehead and open brow lift with
a hairline incision,4 and in 1933, Claoue published a similar
extensive approach.5 Interestingly, forehead lifting then fell
into disfavor for several decades until 1962 when GonzalezUlloa published in the English literature an open coronal
brow lift combined with facelift.6 Shortly thereafter, in Brazil,
Vinas presented (1965)7 and subsequently described (1976)8
his advanced concepts of brow elevation. He suggested

History

93.e1

making a concerted effort to elevate the lateral portion of the
brow. He also described a local method of direct brow lifting
for certain patients. In 1984, Papillon and colleagues presented a subcutaneous dissection plane from the anterior hairline approach.9 In 1989, Paul described a transblepharoplasty
approach.10
The original description of endoscopic brow lifting is
attributed to two surgeons, Isse and Vasconez, both of whom
presented their method at different venues in 1992.11,12 The
ﬁrst publication of this method was by Chajchir in 1993.13
In 1996, Knize published his “limited incision forehead
lift”,14 using a short temple incision without endoscopic assist.
By 2003, a reduction in the number of endoscopic brow lifts
being done was documented due to uncertainty over the stability of endoscopic brow lifting.15 In the ﬁrst part of the 21st
century, other methods appeared to deal with lateral brow
relapse.16 Numerous reports demonstrated the success of
endoscopic brow lifting using measurements from the brow
to the pupil.17–21

History

SECTION I •

7

• Forehead rejuvenation

Lateral orbital thickening Periorbital septal
of periorbital septum
attachment

Orbital ligament

be released from bone when a full thickness forehead ﬂap is
being repositioned.
Some fascial structures in this area have been named by
different authors, generating some confusion. The superior
temporal septum24 and the zone of adhesion16 are alternate
terms used to describe the zone of ﬁxation. The temporal
ligamentous adhesion24 describes the lower portion of the
zone of ﬁxation and the orbital ligament. The inferior temporal septum24 and the orbicularis-temporal ligament25 both

Fig. 7.2 Fascial attachments around the orbital rim. The inferior end of the zone of
ﬁxation is the orbital ligament. The lateral orbital thickening is a lateral extension of
the septum which extends across the lateral orbital rim onto deep temporal fascia.

Temporal branches
of the facial nerve

Inferior temporal
septum

Sentinel vein

Zone of fixation
(zone of adhesion)

Superior temporal septum

Fig. 7.1 Bony anatomy of the forehead and temporal fossa. The palpable temporal
ridge separates the temporal fossa from the forehead. The zone of ﬁxation (aka zone
of adhesion, superior temporal septum) is a 5 mm wide band along the temporal
ridge where all layers are bound down to periosteum.

Temporal ridge
(temporal crest)

Zone of fixation
(zone of adhesion)

Superior temporal
fusion line

94

Knize has described galeal anatomy in detail.26 In the forehead, the galea aponeurotica splits into a superﬁcial and deep

Galea

describe the criss-crossing white ﬁbers which loosely attach
the superﬁcial to the deep temporal fascia.
The inferior temporal septum is a useful landmark during
endoscopic dissection from above, because it separates the
safe upper zone containing no vital structures from the lower
zone where facial nerve branches travel in the cavity’s roof.
The medial zygomatic temporal vein (sentinel vein) is also
present in this lower zone, adjacent to the lateral orbital rim.
The temporal branches pass immediately superior to this vein
(Figs 7.3, 7.4).

Fig. 7.4 Endoscopic view of the medial zygomaticotemporal vein (sentinel vein),
right side.

Fig. 7.3 Endoscopic view of the inferior temporal septum, right side.

layer encompassing the frontalis muscle (Fig. 7.5). Inferiorly,
the deep galea layer separates further into three separate
layers: one layer immediately deep to the frontalis forming
the roof of the galeal fat pad, a second layer forming the
ﬂoor of the galeal fat pad but not adherent to bone, and a third
layer adherent to periosteum. The two deepest layers deﬁne
the glide plane space between the galeal fat pad and the
skull. Inferiorly, the septum orbitale divides orbital fat from
PreSeptal fat (also known as retro orbicularis oculi fat or
ROOF).
When the eyebrow is raised by frontalis contraction, the
soft tissue slides over the glide plane space. The galeal fat pad
extends across the entire width of the lower 2 cm of the forehead; medially it surrounds the supra orbital and supra trochlear nerves as well as portions of the frown musculature.
The galeal fat pad is separated from the preseptal fat (ROOF)

Fig. 7.5 Relationship of galea to surrounding tissue as it splits to encompass the
frontalis muscle, the galeal fat pad, and the glide plane space. The corrugator
supercilii traverses through the galeal fat pad as it courses from its deep bony
origin to its superﬁcial insertion in the orbicularis and dermis.

Orbital septum

Obicularis oculi muscle

Suborbital fascia

Preseptal fat (ROOF)

Periosteum

Orbital rim

Corrugator supercilii muscle

Glide plane space

Galeal fat pad

Deep galea

Fontalis muscle

Superficial galea

Periosteum

Subgaleal space

Galeal aponeurosis

Lateral orbital rim with
deep galeal attachment

B

Lateral orbital rim with
no galeal attachment

95

Orbicularis oculi

Procerus

Corrugator supercilii

Eyebrow level is the result of a balance between the muscular forces which elevate the brow, the muscular forces
which depress the brow, and the universal depressor: gravity
(Fig. 7.7).
Brow depressors in the glabella originate from bone medially, inserting into soft tissue. The procerus runs vertically, the
depressor supercilii and orbiculars run obliquely, and the corrugator mostly runs transversely. The transverse corrugator

Muscle

by a reﬂected layer of galea. Laterally, this separation is
thought to be variable, with some individuals having a continuous layer of fat from galeal fat pad to the preseptal fat
(Fig. 7.6).26

Fig. 7.7 Glabellar frown muscles.

Depressor supercilii

Fig. 7.6 Lateral orbital rim variation. On the left, galeal attachment tethers the
overlying brow. On the right, the galeal fat pad is contiguous with retro orbicularis
oculi fat, potentially making the lateral brow prone to ptosis.

A

Orbital septum

Preseptal fat

Obicularis
oculi muscle

Galeal
attachment

Galeal
fat pad

Fontalis
muscle

Anatomy

SECTION I •

7

• Forehead rejuvenation

supercilii is the largest and most powerful of these muscles.
It originates from the orbital rim at its most supero-medial
corner, with the large transverse head later passing through
galeal fat becoming progressively more superﬁcial until
it interdigitates with the orbicularis and frontalis at a skin
dimple which is visible when the patient frowns.27
The orbicularis encircles the orbit acting like a sphincter.
Medially and laterally the orbicularis ﬁbers run vertically and
act to depress brow level. Laterally, orbicularis is the only
muscle which depresses brow position (Figs 7.8, 7.9).
Frontalis is the only elevator of the brow. It originates from
the galea aponeurotica superiorly, and interdigitates inferiorly
with the orbicularis. Contraction raises this muscle mass,
and in so doing, lifts the overlying skin which contains the
eyebrow. Due to its deﬁciency laterally, the primary effect of
frontalis contraction is on the medial and central portions of
the eyebrow.

Fig. 7.9 Frontalis acts to raise the eyebrow complex. On contraction, most
movement occurs in the lower third of the muscle, and action is strongest on the
medial and central eyebrow.

Orbicularis occuli
muscle

Temporal crest line

Frontalis muscle

Fig. 7.8 Lateral orbicularis acts like a sphincter, depressing the lateral brow.

96

Innervation to the upper periorbita is supplied by the supraorbita and supratrochlear nerves, as well as two lesser nerves,
the infratrochlear, and zygomaticotemporal (Fig. 7.10).
The infratrochlear nerve exits the orbit medially supplying
sensation to the nasal dorsum and medial orbital rim. It is
seldom damaged and rarely a cause of postoperative concern.
The zygomaticotemporal nerve exits posterior to the lateral
orbital rim piercing the deep temporal fascia just inferior to
the sentinel vein. In brow lifting, with complete release of the
lateral orbital rim, it is often avulsed. Consequences of this
are minimal and temporary.
The supratrochlear nerve usually exits the orbit superomedially although this is variable, and it occasionally will exit
near the supraorbital nerve. It immediately divides into 4–6
branches which can pass superﬁcial (anterior) to the corrugator, or more frequently, directly through the substance of the
corrugator. These branches then become more superﬁcial,
innervating the central forehead.
The supraorbital nerve exits the superior orbit either
through a notch in the rim, or through a foramen superior to
the rim. Much variation occurs with foramina present about
20% of the time.28 The location of the notch or foramen is
between 16 and 42 mm from the midline, with a mean of
25 mm. A useful landmark for this is a palpable notch, or
failing that, the mid-papillary line. When a foramen is present,
it has been found as far as 19 mm above the rim. Because of
such variation, blind dissection from above should be discontinued at least 2 cm above the orbital rim.

Sensory nerves

Fig. 7.10 Sensory nerves.

Infraorbital nerve

Zygomaticofacial nerve

Zygomaticotemporal nerve

Deep branch of
supraorbital nerve

Superficial branch of
supraorbital nerve

Infratrochlear nerve

Supratrochlear nerve

The temporal branch of the facial nerve is the only motor
nerve of concern in this area. Loss of this branch would result
in a brow ptosis and asymmetry due to impaired frontalis
action (Fig. 7.12). The anatomy of this nerve has been well
described.30–33
The temporal branch enters the temporal fossa as multiple
(2–4) ﬁne branches which lie on the periosteum of the middle
third of the zygomatic arch. Between 1.5 cm and 3.0 cm above
the arch, these branches become more superﬁcial, entering the
superﬁcial temporal fascia (temporoparietal fascia), traveling
on to innervate the frontalis, superior orbicularis and glabellar
muscles.34
A number of different landmarks are commonly used to
predict the course of the temporal branches. These include:
1. The middle third of the palpable zygomatic arch
2. 1.5 cm lateral to the tail of the eyebrow

Motor nerves

The supraorbital nerve immediately divides into two distinct segments: superﬁcial and deep. The superﬁcial branch
pierces orbicularis and frontalis, dividing into several smaller
branches which travel on the superﬁcial surface of the frontalis to innervate the central forehead as far posteriorly as the
ﬁrst 2 cm. of hair. The rest of the scalp, as far back as the
vertex, is innervated by the deep branch. The deep branch
courses superiorly in a more lateral location, remaining
between the periosteum and the deepest layer of galea. As it
travels superiorly, it becomes more superﬁcial, piercing frontalis to innervate the skin.
It is a double branch approximately 60% of the time.29 An
important fact during endoscopic brow lifting is that the deep
branch runs in a 1 cm wide band, which is between 5 mm and
15 mm medial to the palpable temporal ridge (Fig. 7.11).

Supraorbital
nerve,
deep branch

97

Fig. 7.11 The deep branch of the supraorbital nerve travels
in a 1 cm wide band between 5 and 15 mm medial to the
temporal ridge.

3. Parallel and adjacent to the inferior temporal septum
4. Immediately superior to the sentinel vein (medial
zygomaticotemporal vein).
In all forehead lift procedures, dissection planes are
designed to protect the temporal branches. This can be done
by staying deep to them, which requires dissecting directly on
deep temporal fascia in the temple and in the subgaleal or

Fig. 7.12 Facial nerve branches in the periorbital region. Note the corrugator has
dual innervation from the temporal branch and the zygomatic branch. The temporal
branch crosses the middle third of the zygomatic arch as 2–4 branches.

Facial nerve, zygomatic branch

Facial nerve, temporal branch

Supraorbital
nerve,
superficial
branches

Anatomy

SECTION I •

7

• Forehead rejuvenation

Fig. 7.14 Patient raising eyebrows. The transverse forehead lines are caused by the
frontalis.

Fig. 7.13 Patient frowning. The paired vertical folds are caused by the corrugator
supercilii and the transverse lines at the nasal radix are caused by the procerus.
The paired oblique lines are caused by the depressor supercilii and the medial
orbicularis oculi. Laterally the “crow’s feet” lines are caused by the vertically
running ﬁbers of the orbicularis oculi.

Historically, the visible signs of forehead aging have been
described in two ways. First, and most obvious are the furrows
caused by the repetitive action of underlying muscles: transverse lines are due to the eyebrow lifting action of the frontalis, while glabellar frown lines are due to the corrugator,
depressor supercilii, and the procerus. The corrugator, being
the most transverse of these muscles causes vertical frown
lines, the depressor supercilii, being oblique, causes oblique
folds which cut across the orbital rim, and the vertically
running procerus causes transverse lines at the radix (Figs
7.13, 7.14).
Second, it has been assumed that the forehead/eyebrow
complex becomes ptotic with age, encroaching on the orbit,
causing a pseudo-excess of upper eyelid skin. While consistent with the age-related ptosis of most other body parts, the

Forehead aging

Patient presentation

subperiosteal planes over the frontal bone. Alternatively, dissection can be kept superﬁcial to the frontalis, the orbicularis,
and the superﬁcial temporal fascia.

98

Fig. 7.16 From age 25–50, photographs demonstrate a 3–4 mm rise in the medial
and central brows.

Fig. 7.15

facts are not so clear. Some studies actually suggest that eyebrows may rise with age, at least in the medial and central
portions (Figs 7.15, 7.16).35–37
Logically, the medial and central eyebrows could rise over
time through the action of frontalis. This may be caused by
a subconscious reaction to excess upper lid skin or to early
eyelid ptosis caused by senile levator disinsertion. Both phenomena will stimulate frontalis contraction to open the line
of sight. Also at play is personal habit, exhibited by the brow
elevation seen when most individuals are confronted with a
mirror, or on facing a camera. Closing the eyes will usually,
but not always, relax the frontalis, causing the eyebrows to
drop. Frontalis paralysis due to facial nerve injury or botulinum toxin will always drop the level of the eyebrow, indicating that some resting tone is normal.
A ﬁnal factor is the shape of the orbital aperture which
appears to enlarge with age, the superomedial brow rising,
and the inferolateral orbital rim dropping and receeding.38,39
This could contribute to a rising medial brow, because of soft
tissue attachment and the soft tissue support provided by the
trunk of the supraorbital nerve (Fig. 7.17).
As described earlier, the level and shape of the eyebrow is
the result of a balancing act between the many forces of brow
depression and the only elevator, which is the frontalis muscle.
The lateral portion of the brow is particularly sensitive to this
interplay because frontalis action is attenuated laterally.40
Against the unrelenting force of gravity and the lateral orbicularis oculi, the principle resistance to lateral brow decent is
soft tissue attachment. This attachment is variable and may
be absent, leaving the lateral brow free to move.41 The result
is often a gradual ptosis of the lateral third of the brow, relative to the medial brow. This effect will be accentuated if a
patient also has a rising medial brow. The resulting downturned lateral brow imparts a look of sadness, tiredness
and age.
B

Traditional teaching has been that the correct eyebrow position is at or above the supra orbital rim. While usually true,
this axiom is overly simplistic, because eyebrow height is only
one of many variables. In many individuals, the lateral brow
becomes more ptotic than the medial brow, altering brow
shape. Studies have demonstrated that our impression of
people can be affected by altering the shape of their eyebrows,
implying that the shape of the brow is more important than
its absolute height.43,44 Also, age related changes in eyebrow
position do not occur in isolation. The upper lid sulcus may
become more hollow as fat is lost, upper lid skin may become
more redundant, and there may be a modest degree of senile
eyelid ptosis. As mentioned earlier, reﬂex brow raising is often
the result, with a rising medial brow in relation to the lateral
brow (Fig 7.16).
Gunter observed that the eyebrow and naso-jugular fold
create an oval shape, and that in an attractive eye, the pupil
will lie at the equator of that oval (Fig. 7.18).45 Applying this
analysis is a useful exercise to determine if brow position is
an issue (Fig. 7.19).
Ovals which are vertically wide look aged, while vertically
narrow ovals look youthful.
There is an intimate relationship between eyebrow position
and the eyelid. The ratio of the visible eyelid from the lashes
to the palpebral fold should be one-third, and at most one
half the distance from the lashes to the lower border of the

Aesthetics

Another effect of a dropping lateral brow is a bunching up
or a pseudoexcess of lateral upper eyelid skin. In response to
this, Flowers and Duval have described the phenomenon of
compensated brow ptosis where patients subconsciously contract the frontalis to open their line of sight.42 This further
exacerbates the appearance of a downturned lateral brow.
Many patients recognize these changes and treat themselves to eyebrow plucking, make-up or tattooing in order to
make the lateral brow appear higher. Alternatively, they may
seek blepharoplasty to deal with lateral soft tissue hooding,
unaware that the ptotic lateral brow is the most signiﬁcant
factor. The unsuspecting surgeon who performs blepharoplasty in this circumstance will see the frontalis relax, unmasking the compensated brow ptosis, causing the medial and
central brow to fall.

A

99

Fig. 7.19 On oval analysis of this case, the pupil lies above the natural equator of
the oval. This conﬁrms a low lying eyebrow plus or minus a low lying nasojugular
fold.

Fig. 7.18 An oval formed by the eyebrow above, and the nasojugular fold below,
should have the pupil at its equator. (Adapted from: Gunter J, Antrobus S. Aesthetic
analysis of the eyebrows. Plast Reconstr Surg 1997; 99:1808–1816.)

Fig. 7.17 Orbital changes with age: orbital
volume expands, most marked superomedial and
inferolateral. (With permission from Kahn DM, Shaw
RB. Aging of the bony orbit. A three-dimensional
computed tomographic study. Aesthet Surg J 2008;
28(3):258–264.)

Patient presentation

Peak

1/

2/

SECTION I •

3

3

7

• Forehead rejuvenation

Most patients are not aware of the many variables involved
in periorbital rejuvenation, and they may not want the multiple procedures required to treat all of these components. For

Patient selection

eyebrow (Fig. 7.20).45 A number of different factors may
change this ratio:
• Changing eyebrow height
• Lid ptosis or lid retraction
• Redundant upper eyelid soft tissue
• Loss of upper sulcus fat.
Any one of these issues can be treated independently or in
conjunction with a brow lift. Brow repositioning is a powerful
tool but it must be considered in the context of other possibilities such as ptosis repair, blepharoplasty, and fat grafting to
the upper lid sulcus.
Individualization is a key component to any periorbital
rejuvenation. Gender, ethnicity, eye prominence and overall
facial proportions must be considered. For example, Oriental
faces look attractive with higher eyebrows than would seem
appropriate for the Caucasian face. Complicating matters, the
“ideal” eyebrow has also changed over time. Renaissance
painters tended to portray their subjects with normal eyebrows and relatively hollow upper sulci, while in the 1950s,
eyebrows became very high and arched.44 Individual variation aside, there are certain themes which deﬁne “the ideal
eyebrow” (Fig. 7.20) in the era when this text is being written:
1. The medial eyebrow level should lie over the medial
orbital rim
2. The medial border of the eyebrow should be vertically in
line with the medial canthus
3. The eyebrow should rise gently, peaking slightly at least
two-thirds of the way to its lateral end; typically this
peak lies vertically above the lateral limbus
4. The lateral tail of the brow should be higher than the
medial end
5. The male brow should be lower and less peaked.

Fig. 7.20 The modern ideal brow/upper eyelid complex.

100

The coronal approach was long considered the “gold standard” against which other techniques must be measured. Many
surgeons still consider it to be the most effective method for
modiﬁcation of the forehead. The principal advantage of this
approach is the unparalleled surgical exposure which facilitates release and mobilization of brow soft tissues, as well as
the modiﬁcation of glabellar muscles under direct vision.
Surgical results are stable, and long lasting.
The technique involves an incision over the top of the head,
classically about 6–8 cm behind the anterior hairline, although
this incision can be placed almost anywhere in the hairbearing scalp (Fig. 7.21). An incision as far back as the vertex

Open coronal approach

Surgical rejuvenation of the forehead has changed dramatically from the one-size-ﬁts-all approach of an earlier era. As
our understanding of anatomy and aging has improved, our
available surgical techniques have also evolved. Alongside
this evolution, the introduction of botulinum toxin for aesthetic indications has changed many of our fundamental
concepts.

Surgical techniques

that reason, identifying the main component of every patient’s
periorbital aging is important. Old photographs are very
helpful in determining which aging changes predominate.
Such a review will also help to focus patients’ perspectives on
exactly how they have aged, and what, if any, rejuvenation
they would like to undergo.
Assessment of the patient should be done with the patient’s
head in the vertical position; the patient will be sitting or
standing. The following issues are evaluated: visual acuity;
eyebrow and orbital symmetry; position of anterior hairline;
thickness of scalp hair; transverse forehead lines; glabellar
frown lines; thickness of eyebrow hair; eyebrow height; axis
of the eyebrow (downward or upward lateral tilt); shape of
the eyebrow (ﬂat or peaked); passive and active eyebrow
mobility, and the presence of old scars or tattoos. The upper
eyelids should be assessed for soft tissue redundancy, for hollowness and for lid level (ptosis versus lid retraction). The
patient should be examined with eyes open and eyes closed.
With the eyes closed, the frontalis can usually be made to
relax, revealing the true position and shape of the eyebrows.
If the brow is held in this position when the patient opens
their eyes, the eyebrow/eyelid relationship without frontalis
effect will be revealed. The surgeon can then manually reposition the eyebrows, experimenting with various positions and
different vectors of mobilization.
Patients may be a candidate to have their entire brow
complex lifted, or more commonly to have only part of the
eyebrow raised, thus improving eyebrow shape. Occasionally,
this may involve raising the medial brow only, but most
typically it involves raising the lateral third to half of the
brow, with little or no lift of the medial portion. Weakening
or eliminating the glabellar frown muscles is a useful parallel
objective. Numerous methods are available, ranging from
botulinum toxin, to surgical techniques which may weaken,
or completely eliminate the glabellar frown muscles.

will be at the watershed between posterior and anterior
running sensory nerves, thus reducing scalp numbness.
However, a more anterior incision involves less scalp dissection, better visibility, and a closer point of traction on the
eyebrows (Figs 7.21–7.23).
The incision is made full-thickness down to periosteum,
and the anterior ﬂap can then be raised in either the subperiosteal, or more commonly, the subgaleal plane. Under direct
vision, the ﬂap is elevated down to the orbital rim. If glabellar
muscles are to be exposed, the galea must be breached on its
deep surface, entering the galeal fat pad for access to the
muscles (Fig. 7.22). The frown muscles, corrugator, depressor
supercillii and procerus can be removed or weakened as necessary (Fig. 7.23). Typically, resection of the corrugator requires
dissection of the supratrochlear nerve branches which course
through the substance of this muscle. It is often advantageous

Fig. 7.22 Open coronal ﬂap dissection shown in the subgaleal plane.

Fig. 7.21 Coronal and anterior hairline approaches.

101

This incision is usually placed along the anterior hairline,
until it reaches the hairline laterally, where it transitions into
the hair-bearing temporal scalp. Alternatively, it can follow
the hairline over its entire extent (Fig. 7.21). Certain technical
details help minimize scar visibility. These include placing the
incision within or just posterior to the ﬁne hair of the anterior
hairline, and beveling the incision parallel to the hair follicles.
Alternatively, the principle of cutting across the hair follicles
may be used in order to promote growth of hairs through the
resulting scar.46 The incision, when made as a slightly wavy
line, tends to create a less visible scar. Skin tension is minimized by approximating the galea, and doing a meticulous
skin closure.
From the anterior hairline incision, dissection of the forehead ﬂap can be done in one of three different planes: subperiosteal, subgaleal, and subcutaneous. Regardless of the plane
being used, the anterior hairline approach offers the same
advantage as the coronal approach, namely excellent surgical
exposure, without the disadvantage of moving the anterior

Anterior hairline approach

to leave some galeal attachment medially to prevent overelevation of the medial scalp. Otherwise, for proper brow
elevation, there must be a thorough release of the galeal
attachments along the central and lateral orbital rims. The
zone of ﬁxation will be released as dissection progresses laterally over the deep temporal fascia. The trunk of the supraorbital nerve is identiﬁed and preserved. To reposition the
brows, the ﬂap is drawn supero-laterally, and a full-thickness
strip of scalp is excised. Laterally, scalp excision will range
from 1 to 3 cm, but centrally, little or no scalp is excised. The
scalp is closed directly, approximating galea and skin.
Although deeper ﬁxation can be added, the classic open
coronal lift relies on scalp excision alone to maintain brow
position.
Disadvantages of the open coronal approach include scalp
numbness, which may be permanent, a long scar, disruption
of hair follicles, and scalp dysesthesia. Inevitably, the anterior
hairline will be raised and some hair-bearing scalp will be
sacriﬁced. This technique should be used cautiously or not at
all in patients with a high anterior hairline, with thin hair, or
in patients who may eventually lose their hair.

Fig. 7.23 Coronal approach showing corrugator muscles.

Surgical techniques

7

Fibers of frontalis muscle

SECTION I •

• Forehead rejuvenation

More than any other innovation, the introduction of endoscopy to facial aesthetic surgery stimulated the quest for better
understanding of forehead and temple anatomy. Basic anatomic principles are integral to the theory of endoscopic brow
lifting. Laterally, brow lifting is accomplished by releasing all
galeal attachments and relying on some method of mechanical ﬁxation to maintain the scalp in a higher position. Medially,
brow lifting happens passively by removing muscular depressors, and allowing the frontalis to lift unopposed.
The principle advantages of the endoscopic brow lift are a
very good surgical exposure, magniﬁcation of the surgeon’s

Endoscopic approach

hairline posteriorly. In addition, there are two unique
advantages.
Because there is no undermining of hair follicles, the
surgeon has the option of a subcutaneous dissection plane
which is done on the superﬁcial surface of the frontalis muscle.
This allows brow elevation without the need to divide any
sensory nerves, and also provides a potential effacement of
deep transverse forehead lines. A popular modiﬁcation of this
method is a short incision in the widow’s peak, which is used
to target only the lateral brow (Fig. 7.24).47
The anterior hairline approach can also be used to lower
an excessively high anterior hairline or to lower overly high
eyebrows. These problems may be congenital but often are the
result of previous brow lift surgery. Hairline lowering involves
a posterior dissection past the vertex of the skull, in order to
extensively mobilize the scalp. Releasing incisions are made
in the galea, and the scalp is advanced, utilizing bony ﬁxation
to maintain the new hairline position (Figs 7.25, 7.26). If the
anterior approach is used to lower the eyebrows, bony ﬁxation is done at the supraorbital rim (Figs 7.25, 7.26).48–50
The main disadvantage of the anterior hairline incision is
the presence of a permanent scar along the anterior hairline.
In addition, if the scalp incision is full-thickness, the resulting
scalp denervation will be worse than with the coronal
approach because the posterior running sensory nerves are
transected closer to their origin. Lastly, a full dissection of
forehead skin may compromise cutaneous blood ﬂow leading
to partial skin necrosis.

Fig. 7.24 Limited hairline subcutaneous approach.

102

view, and short, undetectable incisions. In addition, the scalp
denervation associated with the open coronal approach is
largely avoided (Fig. 7.27).
Access for the procedure is through 3–5 small (1–2 cm)
incisions placed within the hair-bearing scalp. Forehead ﬂap
dissection is done to the same extent as with the open coronal
lift. Medial to the zone of ﬁxation, the dissection plane can be
subgaleal, or the more popular subperiosteal approach. Flap
dissection can be done blindly at ﬁrst, but is completed under
endoscopic control when approaching the orbital rim in order
to avoid damaging the supraorbital nerve. Lateral to the zone
of ﬁxation, dissection is done against the deep temporal fascia,
with the inferior temporal septum and the sentinel vein used
as landmarks for the position of the overlying temporal nerve
branches. The medial and lateral dissection pockets are then
joined by going from lateral to medial. Soft tissue attachments
along the lateral orbital rim and the supraorbital rim are then
visualized and released. Dissection down the lateral orbital
rim may be preperiosteal or subperiosteal. The supraorbital
nerve is visualized during orbital rim release. If glabellar musculature is to be removed, the supratrochlear nerves are visualized as they pass through the substance of the corrugator

Fig. 7.26 Hairline lowering.

Fig. 7.25 Anterior hairline incision to lower the anterior hairline.

A temple approach involves a full-thickness scalp incision in
the temple, lateral to the temporal crest line.53 Knize improved
and popularized this approach with dissection on the deep
temporal fascia, releasing of the lateral orbital rim, the
supraorbital rim, and the zone of ﬁxation with using an endoscope (Fig. 7.28).14 After ﬂap mobilization, ﬁxation is done
with sutures between the superﬁcial and deep temporal
fascia. If surgical modiﬁcation of glabellar frown muscle modiﬁcation is desired, a transpalpebral approach can be used.
Disadvantages of this method include limited visibility of
the central and medial supraorbital rim, and the fact that the
ﬁxation vector applied to the lateral eyebrow is oblique, rather
than vertical, which may be inappropriate for some patients
(Fig. 7.28).

Temple approach

supercilii. Care is taken to avoid excessive release of the ﬂap
medially to prevent over-elevation medially and to avoid
separation of the eyebrows. Once dissected, the forehead ﬂap
is drawn superiorly and somewhat laterally. Speciﬁc vectors
have been described in this regard,51 but the surgeon can make
an artistic decision during preoperative planning, with appropriate vectors customized for each individual patient. While
some authors have suggested that no ﬁxation is necessary,17
two methods of ﬁxation are usually employed: suture ﬁxation
in the lateral dissection pocket from the superﬁcial to the deep
temporal fascia, and bony ﬁxation in the medial dissection
pocket. In an attempt to make the operation more predictable,
a wide variety of ﬁxation devices and techniques have been
described.52
The main disadvantages of endoscopic brow lifting are:
the technical demands of using endoscopic equipment, the
potential of overly elevating or separating the medial eyebrows, and some uncertainty about maintaining adequate
ﬁxation.15

Fig. 7.27 Five port endoscopic approach.

Frontal pocket – subperiosteal

Temporal pocket – against deep temporal fascia

103

The lateral brow approach utilizes a more medial incision
than the temple approach. Its location is based on the observation that the most effective vector for lateral brow lifting
seems to be directly along the temporal crest line (Fig. 7.30).

Lateral brow approach

Using the upper lid blepharoplasty approach, the glabellar
frown muscles can be approached directly.54,55 This is an excellent method to attenuate glabellar frown lines in patients who
do not require a forehead lift. It can also be used as an adjunct
to the patient undergoing an isolated elevation of the lateral
third of the brow. The advantage of this method is a hidden
incision, which may be used for two purposes, blepharoplasty
and frown muscle ablation.
Through an upper blepharoplasty incision, dissection proceeds superiorly deep to the orbicularis oculi, but superﬁcial
to the orbital septum. Over the supraorbital rim, the transverse running ﬁbers of the corrugator supercilii will be found.
The muscle becomes more superﬁcial as it coursed laterally
through the galeal fat pad, eventually combining with the
orbicularis oculi and the lower frontalis. The muscle can be
removed, although care must be taken to protect supra trochlear nerve branches which travel through the substance of the
muscle or around its inferior border. Medially in the wound,
the depressor supercilii can be seen coursing almost vertically,
and the orbicularis oculi courses obliquely. Portions of these
muscles are removed. The procerus can be transected by dissecting across the root of the nose.
The main disadvantages of this approach include potential
damage to sensory nerves (supraorbital and supratrochlear),
and increased bruising and edema compared to an isolated
upper lid blepharoplasty (Fig. 7.29).

Transpalpebral approach –
muscle modiﬁcation

Fig. 7.28 Temple approach.

Surgical techniques

1

Video

SECTION I •

7

Depressor
supercilli

Corrugator
supercilli

Septum
orbitale

A variety of ﬁxation methods can then be used including
simple scalp excision, deep temporal sutures, or ﬁxation to
bone.56 The modiﬁed lateral brow lift is a hybrid procedure
utilizing a 5–6 cm incision in the scalp, approximately 1 cm
behind the hairline.16 Because the desired vector is directly
along the course of the deep branch of the supraorbital nerve,
this procedure is designed to be nerve sparing. Orbital rim
release can be done with or without an endoscope. A fullthickness excision of scalp is done (like an open coronal lift),
but nerve branches are preserved as a neurovascular bundle.
Fixation is accomplished with deep temporal sutures and by

Fig. 7.30 Preoperative marking for modiﬁed lateral brow lift. The planned vector
of pull is marked. Laterally, the purple dashed lines mark the expected course of
the facial nerve temporal branches. The purple dot represents the sentinel vein. The
curved purple line marks the temporal crest line which is accentuated when the
patient clenches her teeth, contracting the temporalis. Medial to the crest line,
the black cross hatched band is the expected course of the deep branch of the
supraorbital nerve, in purple. The corrugator supercilii, depressor supercilii and
procerus are marked in black.

Supraorbital
nerve branches

Supratrochlear
nerve branches

• Forehead rejuvenation

Fig. 7.29 Transpalpebral exposure of the frown musculature.

104

During upper lid blepharoplasty, the ptotic lateral brow can
be addressed through the same upper lid incision.57,58 The
lateral portion of the superior orbital rim is easily exposed,
and dissection proceeds superiorly over the frontal bone,
superﬁcial to the periosteum. Dissection should continue for
2–4 cm above the orbital rim, or at least 1 cm above the level

Transpalpebral browpexy

Because the eyebrow is a cutaneous structure, the most effective method to lift it would theoretically be a subcutaneous
approach done adjacent to the eyebrow itself. This simple
technique was described almost a century ago. An excision
of full-thickness skin is done along the upper margin of
the eyebrow, or alternatively within a deep forehead crease.
On closure, there is initially a 1 : 1 relationship between the
amount of skin removed and brow elevation, but the surgeon
should plan for a 50% relapse in the ﬁrst few months following the procedure. The closer the incision is to the eyebrow,
the less will be the relapse. The principle advantages of this
technique are: the surgery is easy; it is well tolerated by the
patient; there is no scalp denervation; there is no risk to motor
nerves, and the result is relatively predictable.
The principle disadvantages of this method are the visible
scar it creates and that fact that over time, brow depressing
forces will once again stretch out the skin, causing a recurrence of brow ptosis. Certain individuals, especially older
men with deep forehead creases, or thick eyebrows may
be good candidates for this procedure, which can easily be
repeated if necessary.

Direct suprabrow approach

galeal closure. The main advantages of this method are those
of the endoscopic approach, plus the same strength of ﬁxation
provided by a coronal lift. The main disadvantage, compared
with the pure endoscopic approach, is a slightly longer
incision (Fig. 7.31).

Fig. 7.31 The neurovascular bundle of the deep branch of the supraorbital nerve.
The subperiosteal pocket has been developed medially and the temporal pocket
against the deep temporal fascia has been developed laterally. The two pockets are
joined along the temporal crest line. When the lateral brow is raised, the
neurovascular bundle will telescope up under the scalp closure.

The surgical result of forehead rejuvenation depends on the
type of deformity, the procedure done and the quality of its
execution.
Lesser procedures generally produce lesser results, but for
the individual patient with appropriate expectations, this may
be adequate.
More involved procedures afford the opportunity for
greater anatomic intervention, more dramatic results and
potentially greater longevity. However, as our understanding
of the aging brow has progressed, it is clear that brow ptosis
is not as signiﬁcant a factor as was once thought, and therefore, overly aggressive surgery can produce an exaggerated,
un-aesthetic result. Historically, the main problems encountered by surgeons performing browlift procedures have been
aesthetic – in some cases overdoing the surgery and in other
cases, failing to achieve a predictable long term result.
Every patient presents with a different set of challenges, the
most important of which is to ﬁrst make a proper aesthetic

Outcomes and complications

Postoperative care for minor brow procedures is limited
to head elevation, cold packs, ointment application, and
analgesics.
More extensive procedures (e.g., open coronal lift, endoscopic lift) will require dressings and the possibility of drains
for 24 h. Use of bupivacaine to block the supraorbital and
supratrochlear nerves is very helpful in decreasing the incidence of postoperative headache. Patients can shower after
48 h, with scalp suture removal in 7–10 days.
After initial healing, measures can be adopted to prevent
relapse of lateral brow ptosis. The use of botulinum toxin in
the lateral orbicularis is helpful, as is the use of sunglasses
and sun avoidance to prevent squinting in the ﬁrst postoperative month.

Postoperative care

A number of methods have been developed to elevate the
brow only using sutures, with no dissection at all. Methods
include barbed sutures or suture loops which are placed
blindly through subcutaneous tunnels. The obvious advantage of these methods is extreme simplicity and relative safety,
while the principle drawback is their limited effect, and poor
longevity.60

Suture suspension browpexy

of planned ﬁxation. Several sutures are then used to tether
the mobilized brow in a more superior position, ﬁxating the
underside of the orbicularis to the periosteum. Alternate
methods of ﬁxation to bone can also be used. Overly tight
sutures must be avoided because of suture dimpling in the
eyebrow. A more modest pexy is achieved if the cut edge of
orbicularis oculi is simply suture to the orbital rim, with no
superior dissection at all.59 Advantages of transpalpebral
browpexy are the ease of the procedure and a hidden scar. The
principle disadvantage is the limited effect achieved and
questionable longevity.

105

diagnosis. Once the decision has been made to raise all or part
of the brow complex, a myriad number of surgical procedures
are available. No one method can be considered best, but
rather, the surgical procedures must be chosen based on the
individual patient’s needs. In addition, every surgeon will
have greater comfort with some procedures compared with
others, and it is incumbent on surgeons to carefully analyze
their results in order to give patients a realistic idea of what
can be expected.
In addition to the aesthetic issues mentioned above, surgical complications of brow rejuvenation include scar alopecia, hematomas, infections, contour deformities, and nerve
damage (Fig. 7.32).
Signiﬁcant problems with brow positioning and shape may
be treated with secondary procedures. Alopecia due to hair
follicle damage may be temporary, but if permanent can be
treated with scar excision or hair grafting.
Hematomas are uncommon, but if they occur, are treated
with drainage. Infections are rare, consistently reported at less
than 1%, and are treated with wound care and appropriate
antibiotics.18 Contour deformities can occur in areas of muscle
excision; these problems are ideally prevented by the intraoperative utilization of ﬁlling material such as fat or temporal
fascia. If identiﬁed late, similar tissue can be added at a separate procedure.
Sensory nerve damage is a common problem, and is universal with some types of procedures. With coronal incisions,
all posterior running sensory nerves are routinely transected.
The resulting scalp denervation will extend to the vertex,
but will gradually improve, sometimes over several years.
With limited incisions, sensory nerves may be traumatized

Fig. 7.32 Scar alopecia after coronal brow lift.

Outcomes and complications

SECTION I •

7

• Forehead rejuvenation

overly aggressive brow lift surgery can create an unaesthetic
eyebrow shape, most frequently an over-elevation of the
medial brow (Fig. 7.34).
Minimal deformities can be corrected with botulinum
toxin in the central frontalis. If the medial brow has been
aesthetically over-elevated, but the lateral brow remains
unelevated, the lateral brow can be elevated as a separate
maneuver.
Alternatively, the medial brow can be lowered, a procedure
which involves a full release of the scalp’s attachment to the
underlying skull, lowering of the medial brow, and bone
anchoring to the medial orbital rim.50
If there is simply a loss of effect from brow lift surgery, the
situation can often be resolved to the patient’s satisfaction
with a conservative upper lid blepharoplasty. However, if the
loss of effect is signiﬁcant, repeat brow lifting may be necessary, preferably using a different technique and a different
dissection plane.
In the case of a temporal branch palsy which does not
improve with time, treatment options include applying botulinum toxin to the normal side, or alternatively, performing
another brow lift on the affected side.

Fig. 7.34 Over elevated medial brow after endoscopic brow lift.

1. Paul, MD. The evolution of the brow lift in aesthetic
plastic surgery. Plast Reconstr Surg. 2001;108(5):
1409–1424.
In this paper, the author thoroughly reviews the published
history of brow lift surgery, from 1919 to 2001.
14. Knize DM. Limited incision foreheadplasty. Plast
Recontstr Surg. 1999;103:271–284.
16. Warren RJ. The modiﬁed lateral brow lift. Aesthetic Surg
J. 2009;29(2):158–166.
20. Guyuron B, Kopal C, Michelow BJ. Stability after
endoscopic forehead surgery using single-point
fascia ﬁxation. Plast Reconstr Surg. 2005;116:
1988.

22. Knize DM. An anatomically based study of the
mechanism of eyebrow ptosis. Plast Reconstr Surg.
1996;97(7):1321–1333.
In this paper, the author presents the results of careful
anatomic dissections to delineate the fascial structures which
govern eyebrow stability. Surgical implications are described
in the second paper in the same journal.
24. Moss CJ, Mendelson BC, Taylor I. Surgical anatomy
of the ligamentous attachments in the temple and
periorbital regions. Plast Reconstr Surg. 2000;105:4:
1475–1490.
The authors describe a different way of describing fascial
structures surrounding the orbit and creating structural

Access the complete references list online at http://www.expertconsult.com

As mentioned above, minor issues such as areas of alopecia
and contour deformities in the glabella, can be treated with
simple procedures.
The most common reason for revision surgery after brow
surgery is to correct aesthetic deformities. Not infrequently,

Secondary procedures

due to traction, cautery, or instrumentation. Temporary neurapraxia of the supratrochlear nerves after frown muscle
ablation is almost universal, with sensory return typically
appearing by 2–3 weeks. Similarly, temporary neurapraxia of
the supraorbital rim is very common after a thorough release
of the supraorbital rim.
The only motor nerve in the forehead is the temporal
branch of the facial nerve, and damage to this nerve is the
most worrisome complication. Temporary neurapraxias are
relatively common, but permanent damage to the temporal
branch is fortunately very rare. Should a neurapraxia develop,
watchful waiting is a must (Fig. 7.33).

Fig. 7.33 Temporary neurapraxia of left temporal branch after coronal brow lift.

106

layers in the temple. A number of anatomic terms are
introduced for the ﬁrst time.
26. Knize DM. Galea aponeurotica and temporal fascias. In:
Knize DM, ed. Forehead and temporal fossa: anatomy and
technique. Philadelphia: Lippincott Williams & Wilkins;
2001:45.
This text thoroughly presents the anatomy of the temporal
fossa, the forehead and the soft tissues which relate
to the eyebrows. Knize combines several anatomical
studies to summarize this anatomy, while several
additional authors contribute to the technique portions
of the book.

107

36. Matros E, Garcia JA, Yaremchuk MJ. Changes in
eyebrow shape and position with aging. Plast Reconstr
Surg. 2009;124(4):1296–1301.
41. Knize DM. Muscles that act on glabellar skin: A closer
look. Plast Reconstr Surg. 2000;105:350.
45. Gunter J, Antrobus S. Aesthetic analysis of the
eyebrows. Plast Reconstr Surg. 1997;99:1808–1816.
The authors analyze the features of periorbital attractiveness.
They conclude that eyebrow aesthetics must be considered in
concert with the entire periorbital area, including the eyelids.
They describe novel ways to analyze eyes for attractiveness
and identify eight features of attractive eyes.

Secondary procedures

1. Paul MD. The evolution of the brow lift in aesthetic
plastic surgery. Plast Reconstr Surg. 2001;108(5):
1409–1424.
In this paper, the author thoroughly reviews the published
history of brow lift surgery, from 1919 to 2001.
2. Passot R. La chururgie esthetique dew rides du visage.
Presse Med. 1919;27:258.
3. Hunt HL. Plastic surgery of the head, face, and neck.
Philadelphia: Lea & Febiger; 1926.
4. Lexer E. Die Gesamte Wiederherstellungs-Chirurgie.
Vols. 1 and 2. Leipzig: Jahann Ambrosius Barth; 1931.
5. Claoue C. La ridectomie cervico-faciale par accrochage
parieto-temporo-occipital et resection cutanee. Bull Acad
Med (Paris). 1933;109:257.
6. Gonzalez-Ulloa M. Facial wrinkles: integral elimination.
Plast Reconstr Surg. 1962;29:658.
7. Vinas JC. Plan general de la ritidoplastia y zona tabu.
Transactions of the 4th Brazilian Congress on Plastic
Surgery, Porto Alegre, October 5–8, 1965:32.
8. Vinas JC, Caviglia C, Cortinas JL. Forehead
rhytidoplasty and brow lifting. Plast Reconstr Surg.
1976;57:445.
9. Papillon J, Perras C, Tirkanits B. A comparative analysis of
forehead lift techniques. Presented at the Annual Meeting
of the American Society for Aesthetic Plastic Surgery,
Boston, 1984.
10. Paul MD. The surgical management of upper eyelid
hooding. Aesthetic Plast Surg. 1989;13:183.
11. Isse NG. Endoscopic forehead lift. Presented at the Annual
Meeting of the Los Angeles County Society of Plastic
Surgeons, Los Angeles, September 12, 1992.
12. Vasconez LO. The use of the endoscope in brow lifting.
A video presentation at the Annual Meeting of the
American Society of Plastic and Reconstructive
Surgeons, Washington, DC, 1992.
13. Chajchir A. Endoscopia en cirugia plastica y estetica.
In: Gonzalez Montaner LJ, Huriado Hoyo E, Altman R,
et al. eds. El Libro de Oro en Ho- menaje al Doctor Carlos
Reussi. Buenos Aires: Associacion Medica Argentina;
1993:74.
14. Knize DM. Limited incision foreheadplasty.
Plast Recontstr Surg. 1999;103:271–284.
15. Chiu ES, Baker DC. Endoscopic brow lift: A
retrospective review of 628 consecutive cases
over 5 years. Plast Rectonstr Surg. 2003;112:628.
16. Warren RJ. The modiﬁed lateral brow lift. Aesthetic Surg
J. 2009;29(2):158–166.
17. Troilius C. Subperiosteal brow lifts without ﬁxation.
Plast Reconstr Surg. 2004;114:1595.
18. Jones BM, Grover R. Endoscopic brow lift: a personal
review of 538 patients and comparison of ﬁxation
techniques. Plast Reconstr Surg. 2004;113(4):1242–1250.
19. Swift RW, Nolan WB, Aston SJ, et al. Endoscopic brow
lift: objective results after 1 year. Aesthetic Surg J.
1999;19:287–292.

References

107.e1

20. Guyuron B, Kopal C, Michelow BJ. Stability after
endoscopic forehead surgery using single-point fascia
ﬁxation. Plast Reconstr Surg. 2005;116:1988.
21. Graf RM, Tolazzi ARD, Mansur AEC, et al. Endoscopic
periosteal brow lift: evaluation and follow-up of
eyebrow height. Plast Reconstr Surg. 2008;121(2):609.
22. Knize DM. An anatomically based study of the
mechanism of eyebrow ptosis. Plast Reconstr Surg.
1996;97(7):1321–1333.
In this paper, the author presents the results of careful
anatomic dissections to delineate the fascial structures which
govern eyebrow stability. Surgical implications are described
in the second paper in the same journal.
23. Knize DM. Limited-incision forehead lift for eyebrow
elevation to enhance upper blepharoplasty. Plast
Reconstr Surg. 1996;97(7):134.
24. Moss CJ, Mendelson BC, Taylor I. Surgical anatomy
of the ligamentous attachments in the temple and
periorbital regions. Plast Reconstr Surg. 2000;105:4:
1475–1490.
The authors describe a different way of describing fascial
structures surrounding the orbit and creating structural
layers in the temple. A number of anatomic terms are
introduced for the ﬁrst time.
25. Isse N. Endoscopic anatomy of the forehead and
temporal fossa. In: Knize DM, ed. Forehead and temporal
fossa: anatomy and technique. Philadelphia: Lippincott
Williams & Wilkins; 2001:73.
26. Knize DM. Galea aponeurotica and temporal fascias. In:
Knize DM, ed. Forehead and temporal fossa: anatomy and
technique. Philadelphia: Lippincott Williams & Wilkins;
2001:45.
This text thoroughly presents the anatomy of the temporal
fossa, the forehead and the soft tissues which relate to the
eyebrows. Knize combines several anatomical studies to
summarize this anatomy, while several additional authors
contribute to the technique portions of the book.
27. Janis JE, Ghavami A, Lemmon JA, et al. Anatomy of
the corrugator supercilii muscle: Part I. Corrugator
topography. Plast Reconstr Surg. 2007;120(6):1647–1653.
28. Beer GM, Putz R, Mager K, et al. Variations of the
frontal exit of the supraorbital nerve: an anatomic study.
Plast Reconstr Surg. 1998;102(2):334–341.
29. Knize DM. A study of the supraorbital nerve.
Plast Reconstr Surg. 1995;96:564.
30. Furnas DW. Landmarks for the trunk and the
temporofacial division of the facial nerve. Br J Surg.
1965;52:694.
31. Pitanguy I, Ramos AS. The frontal branch of the facial
nerve: the importance of its variation in face lifting.
Plast Reconstr Surg. 1966;38:352.
32. Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy
of the frontal branch of the facial nerve: the signiﬁcance
of the temporal fat pad. Plast Reconstr Surg. 1989;83:256.
33. Gosain AK, Sewall SR, Yousif NJ. The temporal branch
of the facial nerve: how reliably can we predict its path?
Plast Reconstr Surg. 1997;99:1224.
34. Agarwa CA, Mendenhall MS, Foreman KB, et al. The
course of the frontal branch of the facial nerve in

References

46.

45.

44.

43.

42.

41.

40.

39.

38.

37.

36.

35.

SECTION I •

7
• Forehead rejuvenation

relation to fascial planes: an anatomic study.
Plast Reconstr Surg. 2010;125:532.
Van Den Bosch W, Leenders I, Mukler P. Topographic
anatomy of the eyelids and the effects of sex and age.
Br J Ophthamol. 1999;83:348–352.
Matros E, Garcia JA, Yaremchuk MJ. Changes in
eyebrow shape and position with aging. Plast Reconstr
Surg. 2009;124(4):1296–1301.
Lambros V. Observations on periorbital and midface
aging. Plast Reconstr Surg. 2007;120:1367–1376.
Pessa JE, Chen Y. Curve analysis of the aging orbital
aperture. Plast Reconstr Surg. 2002;109:751–755.
Kahn DM, Shaw RB. Aging of the bony orbit:
a three-dimensional computed tomographic study.
Aesthetic Surg J. 2008;28(3):258–264.
Lemke BN, Stasior OG. The anatomy of eyebrow
optosis. Arch Ophthalmol. 1982;100:981.
Knize DM. Muscles that act on glabellar skin: A closer
look. Plast Reconstr Surg. 2000;105:350.
Flowers RS, Duval C. Blepharoplasty and periorbital
aesthetic surgery. In: Aston SJ, Beasley RW, Thorne
CH, eds. Grabb and Smith’s plastic surgery. 5th ed.
Philadelphia: Lippincott-Raven; 1997:612.
Knoll BI, Attkiss KJ, Persing JA. The inﬂuence of
forehead, brow, and periorbital aesthetics of perceived
expression in the youthful face. Plast Reconstr Surg.
2008;121:1793–1802.
Warren RJ. Endoscopic Brow lift: Five-portal approach.
In: Nahai F, Saltz R, eds. Endoscopic plastic surgery. 2nd
ed. St Louis, MO: Quality Medical; 2008:212.
Gunter J, Antrobus S. Aesthetic analysis of the
eyebrows. Plast Reconstr Surg. 1997;99:1808–1816.
The authors analyze the features of periorbital attractiveness.
They conclude that eyebrow aesthetics must be considered in
concert with the entire periorbital area, including the eyelids.
They describe novel ways to analyze eyes for attractiveness
and identify eight features of attractive eyes.
Camirand A, Doucet J. A comparison between parallel
hairline incisions and perpendicular incisions when
performing a face lift. Plast Reconstr Surg. 1997;99(1):
10–15.

107.e2

47. Miller TA, Rudkin G, Honig J, et al. Lateral
subcutaneous brow lift and interbrow muscle resection:
clinical experience and anatomic studies. Plast Reconstr
Surg. 2000;105(3):1120–1127.
48. Guyuron B, Belmand RA, Green R. Shortening the long
forehead. Plast Reconstr Surg. 1990;103; 218–223.
49. Marten T. Hairline lowering during foreheadplasty.
Plast Reconstr Surg. 1999;103:224–236.
50. Yaremchuk MJ, O’Sullivan N, Benslimane F. Reversing
brow lifts. Aesthetic Surg J. 2007;27:367–375.
51. Eaves FF. Endoscopic brow lift surgery. In: Bostwick J,
Eaves FF, Nahai F, et al., eds. Endoscopic plastic surgery.
St Louis, MO: Quality Medical; 1994.
52. Rohrich RJ, Beran SJ, Evolving ﬁxation methods
in endoscopically assisted forehead rejuvenation:
controversies and rationale. Plast Reconstr Surg.
1997;100(6):1575.
53. Gleason MC. Brow lifting through a temporal scalp
approach. Plast Reconstr Surg. 1973;52:141–144.
54. Knize DM. Transpalpebral approach to the corrugator
supercilii and procerus muscles. Plast Reconstr Surg.
1995;95(1):52–62.
55. Guyuron B, Michlow BJ, Thomas T. Corrugator
supercilii muscle resection through blepharoplasty
incision. Plast Reconstr Surg. 1995;96:691.
56. Tucillo F, Jacovella P, Zimman O, et al. An alternative
approach to brow lift ﬁxation: temporoparietalis fascia,
galeal, and periosteal imbrication. Plast Reconstr Surg.
2007, 120(5):1433–1434.
57. Sokol AB, Sokol TP. Transblepharoplasty brow
suspension. Plast Reconstr Surg. 1982;69:940.
58. McCord CD, Doxanas MT. Browplasty and browpexy:
an adjunct to blepharoplasty. Plast Reconstr Surg.
1990;86(2):248–254.
59. Zarem HA, Resnick RM, Carr DG. Browpexy: Lateral
orbicularis muscle ﬁxation as an adjunct to upper
blepharoplasty. Plast Reconstr Surg. 1997;100(5):
1258–1261.
60. Ruff GL. Suture suspension for face and neck. In: Aston
SJ, Steinbrech DS, Walden JL, eds. Aesthetic plastic
surgery. London: Saunders Elsevier; 2009.

Access the Historical Perspective section online at

http://www.expertconsult.com

2013, Elsevier Inc. All rights reserved.

©

Properly performed aesthetic periorbital surgery is one of the
most rejuvenating of all facial surgeries performed today.
Properly conceived and executed, it proves a tremendous
source of joy for both surgeon and patient. Done poorly, it can
lead to a lifetime of disﬁgurement and functional problems
for the patient, sleepless nights for the surgeon, and dissatisfaction for both participants. The problem is magniﬁed
because aesthetic periorbital surgical procedures are among
the most commonly performed in plastic surgery practices.
Traditional methods of aesthetic periorbital surgery often
produce suboptimal results. A departure from the standard
techniques of the past is recommended. Most plastic surgeons
know there is a better way, and those who persist with

The orbits are pyramids formed by the frontal, sphenoid,
maxillary, zygomatic, lacrimal, palatine, and ethmoid bones
(Fig. 8.1). The periosteal covering or periorbita is most ﬁrmly
attached at the suture lines and the circumferential anterior
orbital rim. The investing orbital septum in turn attaches to
the periorbita of the orbital rim, forming a thickened perimeter known as the arcus marginalis. This structure reduces the

Osteology and periorbita

It is an absolute necessity that the surgeon understands the
essential and dynamic periorbital anatomy to effect superior
aesthetic and functional surgical results. No surgeon should
perform surgery without fully understanding the aesthetic
and functional consequences of the choices.2–5

Essential and dynamic anatomy

Basic science/disease process

traditional techniques may soon be deviating from a new
standard of surgical care. It is this new standard that is advocated in this chapter. When they are understood and adopted,
these new standards eliminate the classic complications and
risks associated with traditional techniques.
Instead of the common practice of excising precious upper
and, to a somewhat lesser degree, lower eyelid tissue, it is
preferable to focus on restoration of attractive, youthful
anatomy. To expect that the simple removal of tissue will
always result in beautiful or youthful eyes is unrealistic
because this may not fully correct the aging eye deformity.
One should ﬁrst conceptualize the desired outcome, then
select and execute procedures accurately designed to achieve
those speciﬁc goals. For this task to be accomplished, several
important principles are advocated (Box 8.1). Enthusiastically
embraced, this approach is likely to result in excellent aesthetic quality of surgical outcomes.

Aesthetic Surgery of the Face

Blepharoplasty is a vital part of facial rejuvenation. The traditional
removal of tissue may or may not be the preferred approach when
assessed in relation to modern cosmetic goals.
A thorough understanding of orbital and eyelid anatomy is
necessary to understand aging in the periorbital region, and to
devise appropriate surgical strategies.
Preoperative assessment includes a review of the patient’s
perceptions, assessment of the patient’s anatomy, and an
appropriate medical and ophthalmologic examination.
Surgical techniques in blepharoplasty are numerous and should
be tailored to the patient’s own unique anatomy and aesthetic
diagnosis.
Interrelated anatomic structures including the brow and the
infraorbital rim may need to be surgically addressed for an optimal
outcome.

SYNOPSIS

Introduction

䊏

䊏

䊏

䊏

䊏

Julius Few Jr. and Marco Ellis

Blepharoplasty

8

SECTION I

As far back as the 10th and 11th centuries, Arabian surgeons,
Avicenna and Ibn Rashid, described the signiﬁcance of excess
skin folds in impairing eyesight.1 Even at an early date, surgeons had excised upper eyelid skin to improve vision. Texts
published in the 18th and 19th centuries were the ﬁrst to
describe and illustrate the upper eyelid aging deformities. The
term, blepharoplasty, was coined by Von Graefe in 1818 to
describe reconstructive procedures employed following oncologic excisions. Several European surgeons developed reconstructive techniques for eyelid defects in the latter half of the
19th century. Graefe and Mackenzie would be credited with

History

108.e1

applying these reconstructive principles and publishing the
ﬁrst, reproducible cases of upper blepharoplasty. The concepts of herniated orbital fat pads were described shortly
thereafter by Sichel and Bourguet, respectively. Orbital fat
pads were originally considered to be “circumscribed tumors”
of fat that made movement of the upper lid more difﬁcult. It
was a rare condition found “most often in children”. Cosmetic
blepharoplasty entered a period of rapid growth and research
in the 1920–1930s. Contributions were made that described
nearly 13 different approaches and closure methods. Recent
variations in technique appear to have a basis in these early
techniques, which have cycled in popularity over the last
decade.

History

Frontal bone

perimeter and diameter of the orbital aperture and is thickest
in the superior and lateral aspects of the orbital rim.6
Certain structures must be avoided during upper lid
surgery. The lacrimal gland, located in the superolateral orbit
deep to its anterior rim, often descends beneath the orbital
rim, prolapsing into the postseptal upper lid in many persons.
During surgery, the gland can be confused with the lateral
extension of the central fat pad destined for removal during
aesthetic blepharoplasty. The trochlea is located 5 mm posterior to the superonasal orbital rim and is attached to the
periorbital. Disruption of this structure can cause motility
problems.7

• Control of periorbital aesthetics by proper brow positioning,
corrugator muscle removal, and lid fold invagination when
beneﬁcial.
• Restoration of tone and position of the lateral canthus and, along
with it, restoration of a youthful and attractive intercanthal axis tilt.
• Restoration of the tone and posture of the lower lids.
• Preservation of maximal lid skin and muscle (so essential to lid
function and aesthetics) as well as orbital fat.
• Lifting of the midface through reinforced canthopexy, preferably
enhanced by composite malar advancement.
• Correction of suborbital malar grooves with tear trough (or
suborbital malar) implants, obliterating the deforming tear trough
(bony) depressions that angle down diagonally across the cheek,
which begin below the inner canthus.
• Control of orbital fat by septal restraint or quantity reduction.
• Removal of only that tissue (skin, muscle, fat) that is truly
excessive on the upper and lower lids, sometimes resorting to
unconventional excision patterns.
• Modiﬁcation of skin to remove prominent wrinkling and excision
of small growths and blemishes.

Box 8.1 Principles for restoration of youthful eyes

Infraorbital foramen

Optic foramen
Ethmoid
Lacrimal bone
and fossa
Maxilla

Supraorbital foramen
Superior orbital ridge

Fig. 8.1 Orbital bones. Frontal view of the orbit with foramina.

Zygomaticofacial foramen

Greater wing
of sphenoid
Zygomatic
Infraorbital
fissure

Supraorbital fissure

Lateral rectus and sheath
Periorbita

Tenon’s capsule

Orbicularis
Lateral canthal tendon
Lateral check retinaculum

109

Anchored to the lateral orbit is a labyrinth of connective
tissues that are crucial to maintenance of the integrity, position, and function of the globe and periorbital. Understanding
how to effectively restore these structures is key to periocular
rejuvenation by canthopexy. These structures, known as the
lateral retinaculum, coalesce at the lateral orbit and support
the globe and eyelids like a hammock (Fig. 8.2).8–10 The lateral
retinaculum consists of the lateral canthal tendon, tarsal strap,
lateral horn of the levator aponeurosis, the Lockwood suspensory ligament, Whitnall’s ligament, and check ligaments of
the lateral rectus muscle. They converge and insert securely
into the thickened periosteum overlying the Whitnall
tubercle. Controversy exists surrounding the naming of the
components of the lateral canthal tendon. Recent cadaveric
dissections suggest that the lateral canthal tendon has dual
insertions. A superﬁcial component is continuous with the
orbicularis oculi fascia and attaches to the lateral orbital rim
and deep temporal fascia by means of the lateral orbital thickening. A deep component connects directly to the Whitnall
tubercle is classically known as the lateral canthal tendon
(Fig. 8.3).11
In addition, the tarsal strap is a distinct anatomic structure
that inserts into the tarsus medial and inferior to the lateral
canthal tendon.12 In contrast to the canthal tendon, the thick
tarsal strap is relatively resistant to laxity changes seen with
aging. The tarsal strap attaches approximately 3 mm inferiorly and 1 mm posteriorly to the deep lateral canthal tendon,
approximately 4–5 mm from the anterior orbital rim. It shortens in response to lid laxity, beneﬁting from release during
surgery to help achieve a long-lasting restoration or elevation
canthopexy (Fig. 8.4). Adequate release of the tarsal strap
permits a tension-free canthopexy, minimizing the downward
tethering force of this ﬁbrous condensation. This release along
with a superior reattachment of the lateral canthal tendon is
key to a successful canthopexy.

Lateral retinaculum

Fig. 8.2 Horizontal section of the orbit showing the lateral retinaculum formed by
the lateral horn of the levator, lateral canthal tendon, tarsal strap, the Lockwood
suspensory ligament, and lateral rectus check ligaments.

Medial rectus and sheath

Medial canthal tendon
Medial check retinaculum
Fossa for lacrimal sac

Basic science/disease process

Temporalis
Zygomatic bone

SECTION I •

• Blepharoplasty

Maxilla bone
Tarsal plates

Frontal bone

Orbicularis fascia
Lateral orbital thickening
Lateral canthal tendon

8

Tarsus

Procerus

Superciliary corrugator

Forehead and temporal region
The forehead and brow consist of four layers: skin, subcutaneous tissue, muscle, and galea. There are four distinct brow
muscles: frontalis, procerus, corrugator superciliaris, and
orbicularis oculi (Fig. 8.6). The frontalis muscle inserts predominately into the medial half or two-thirds of the eyebrow
(Fig. 8.7), allowing the lateral brow to drop hopelessly ptotic
from aging, while the medial brow responds to frontalis activation and elevates, often excessively in its drive to clear the
lateral overhand. Constant contraction of the frontalis will

A hammock of ﬁbrous condensations suspends the globe
above the orbital ﬂoor. The medial components of the apparatus include medial canthal tendon, the Lockwood suspensory ligament and check ligaments of the medial rectus. The
medial canthal tendon, like the lateral canthal tendon, has
separate limbs that attach the tarsal plates to the ethmoid and
lacrimal bones.13 Each limb inserts onto the periorbital of the
apex of the lacrimal fossa. The anterior limb provides the bulk
of the medial globe support (Fig. 8.5).

Fig. 8.6 Facial muscles of the orbital region. Note that the preseptal and pretarsal
orbicularis muscles fuse with the medial and lateral canthal tendons.

Preseptal
orbicularis

Pretarsal
orbicularis

Orbicularis oculi

Frontalis

Fig. 8.4 The deep portion of the lateral canthal tendon inserts securely into the
thickened periosteum overlying Whitnall’s tubercle. The tarsal strap is a distinct
anatomic structure that suspends the tarsus medial and inferior to the lateral canthal
tendon to lateral orbital wall, approximately 4–5 mm from the orbital rim.

Orbital septum

‘Tarsal strap’

Whitnall’s tubercle
Lateral canthal tendon

Medial orbital vault

Fig. 8.5 The medial canthal tendon envelops the lacrimal sac. It is tripartite, with
anterior, posterior and superior limbs. Like the lateral canthal tendon, its limbs are
continuous with tarsal plates. The components of this tendon along with its lateral
counterpart are enveloped by deep and superﬁcial aspects of the orbicularis
muscle. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular
Surgery. Philadelphia: Saunders; 2004:13.)

Anterior and posterior lacrimal crests

Lacrimal fossa

Anterior limb, medial canthal tendon

Superior limb, medial canthal tendon

Posterior limb, medial canthal tendon

Fig. 8.3 Lateral canthal tendon has separate superﬁcial and deep components. The
deep component attaches inside the orbital rim at Whitnall’s tubercle. The
superﬁcial component passes from the tarsal plates to the periosteum of the lateral
orbital rim and lateral orbital thickening. Both components are continuous with both
superior and inferior lid tarsal plates. (Adapted from Muzaffar AR, Mendelson BC,
Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid
and lateral canthus. Plast Reconstr Surg 2002; 110(3):873–884.)

Coronoid process of mandible

110

give the appearance of deep horizontal creases in the forehead
(Fig. 8.8).3
The vertically oriented procerus is a medial muscle, often
continuous with the frontalis, arising from the nasal bones
and inserting into the subcutaneous tissue of the glabellar
region. It pulls the medial brow inferiorly and contributes to

Fig. 8.8 Frontalis action. The frontalis muscle inserts into the medial two thirds of
the brow. Exaggerated medial brow elevation is required to clear the lateral
overhang and to eliminate visual obstruction. Constant contraction of the frontalis
will give the appearance of deep horizontal creases in the forehead. This necessarily
means that when the lateral skin is elevated or excised, the over-elevated and
distorted medial brow drops profoundly.

Diagonal lines

Fig. 8.7 The frontalis muscle inserts predominantly into the medial half or
two-thirds of the eyebrow. The medial brow responds to frontalis activation and
elevates, often excessively, in its drive to clear lateral overhang.

Frontalis

Orbicularis oculi

Capsulopalpebral fascia
Lockwood’s ligament

Upper tarsal plate

Muller’s muscle

111

The orbital septum originates superiorly at the arcus and
forms the anterior border of the orbit. It joins with the levator
aponeurosis, just superior to the tarsus. The sling formed by
the union of these two structures houses the orbital fat.

Upper eyelid

The eyelids are vital, irreplaceable structures that serve to
protect the globes. Their shutter-like mechanism is essential
to clean, lubricate, and protect the cornea. Any disruption or
restriction of eyelid closure will have signiﬁcant consequences
for both the patient and the surgeon.
There is much similarity between upper and lower eyelid
anatomy. Each consists of an anterior lamella of skin and
orbicularis muscle and a posterior lamella of tarsus and conjunctiva (Fig. 8.9).15
The orbicularis muscle, which acts as a sphincter for the
eyelids, consists of orbital, preseptal, and pretarsal segments.
The pretarsal muscle segment fuses with the lateral canthal
tendon and attaches laterally to Whitnall tubercle. Medially it
forms two heads, which insert into the anterior and posterior
lacrimal crests (Fig. 8.6).

Eyelids

the horizontal wrinkles at the root of the nose. More commonly, these wrinkles result from brow ptosis and correct
spontaneously with brow elevation.
The obliquely oriented corrugators muscle arises from
the frontal bone and inserts into the brow tissue laterally,
with some extensions into orbicularis and frontalis musculature, forming vertical glabellar furrows during contraction.
Wrinkles from procerus and corrugators contraction can
worsen signiﬁcantly after upper lid tissue excision as a result
of the frontalis muscle’s relaxing after being relieved of the
need to clear the obstructing lid skin.14

Fig. 8.9 Eyelid anatomy. Each eyelid consists of an anterior lamella of skin and
orbicularis muscle and a posterior lamella of tarsus and conjunctiva. The orbital
septum forms the anterior border of the orbital fat.

Inferior rectus

Levator palpebrae
Superior rectus

Basic science/disease process

SECTION I •

8
• Blepharoplasty

The anatomy of the lower eyelid is somewhat analogous to
that of the upper eyelid. The retractors of the lower lid, the
capsulopalpebral fascia, correspond to the levator above. The
capsulopalpebral head splits to surround and fuse with
the sheath of the inferior oblique muscle. The two heads fuse
to form the Lockwood suspensory ligament, which is analogous to Whitnall’s ligament. The capsulopalpebral fascia
fuses with the orbital septum 5 mm below the tarsal border
and then inserts into the anterior and inferior surface of the
tarsus.18 The inferior tarsal muscle is analogous to Muller’s
muscle of the upper eyelid and also arises from the sheath of
the inferior rectus muscle. It runs anteriorly above the inferior
oblique muscle and also attaches to the inferior tarsal border.
The combination of the orbital septum, orbicularis, and
skin of the lower lid acts as the anterior barrier of the orbital
fat. As these connective tissue properties relax, the orbital fat
is allowed to herniate forward, forming an unpleasing, full
lower eyelid. This relative loss of orbital volume leads to a
commensurate, progressive hollowing of the upper lid as
upper eyelid fat recesses.19
The capsulopalpebral fascia and its overlying conjunctiva
form the posterior border of the lower orbital fat. Transection

Lower eyelid

The orbital septum has an adhesion to the levator aponeurosis
above the tarsus. The septum continues beyond this adhesion
and extends to the ciliary margin. It is superﬁcial to the
preaponeurotic fat found at the supratarsal crease. The septal
extension is a dynamic component to the motor apparatus, as
traction on this ﬁbrous sheet reproducibly alters ciliary margin
position (Fig. 8.11). The septal extension serves as an adjunct
to, and does not operate independent of, levator function, as
mistaking the septal extension for levator apparatus and plicating this layer solely results in failed ptosis correction.17

Septal extension

The levator palpebrae superioris muscle originates above
the annulus of Zinn. It extends anteriorly for 40 mm before
becoming a tendinous aponeurosis below Whitnall’s ligament.7,16 The aponeurosis fans out medially and laterally to
attach to the orbital retinacula. The aponeurosis fuses with the
orbital septum above the superior border of the tarsus and at
the caudal extent of the sling, sending ﬁbrous strands to the
dermis to form the lid crease. Extensions of the aponeurosis
ﬁnally insert into the anterior and inferior tarsus. As the
levator aponeurosis undergoes senile attenuation, the lid
crease rises into the superior orbit from its remaining dermal
attachments while the lid margin drops.
Müller’s muscle, or the supratarsal muscle, originates on
the deep surface of the levator near the point where the muscle
becomes aponeurotic and inserts into the superior tarsus.
Dehiscence of the attachment of the levator aponeurosis to the
tarsus results in an acquired ptosis only after the Müller’s
muscle attenuates and loses its integrity.14
In the Asian eyelid, fusion of the levator and septum commonly occurs at a lower level, allowing the sling and fat to
descend farther into the lid.15,16 This lower descent of fat
creates the characteristic fullness of their upper eyelid. In
addition, the aponeurotic ﬁbers form a weaker attachment
to the dermis, resulting in a less distinct lid fold (Fig. 8.10).

112

The trigeminal nerve along with its branches provides sensory innervations to the periorbital region (Fig. 8.15). The
ophthalmic division enters the orbit and divides into the
frontal, nasociliary, and lacrimal nerves. The terminal branch
of the nasociliary nerve, the infratrochlear nerve, supplies
the medial conjunctiva, and lacrimal sac. The lacrimal nerve
supplies the lateral conjunctiva and skin of the lateral upper
eyelid. The frontal nerve, the largest branch, divides into
the supraorbital and supratrochlear branches. The supraorbital nerve exits through either a notch or a foramen and
provides sensory innervations to the skin and conjunctiva
of the upper eyelid and the scalp. The supratrochlear nerve
innervates the skin of the glabella, forehead, medial upper
eyelid, and medial conjunctiva. A well-placed supraorbital

Innervation: trigeminal nerve and facial nerve

The internal and external carotid arteries supply blood to the
orbit and eyelids (Fig. 8.14). The ophthalmic artery is the ﬁrst
intracranial branch of the internal carotid; its branches supply
the globe, extraocular muscles, lacrimal gland, ethmoid,
upper eyelids, and forehead. The external carotid artery
branches into the superﬁcial temporal and maxillary arteries.
The infraorbital artery is a continuation of the maxillary artery
and exits 8 mm below the inferomedial orbital rim to supply
the lower eyelid.22
The arcade of the superior and inferior palpebral arteries
gives a rich blood supply to the eyelids. The superior palpebral artery consists of a peripheral arcade located at the
superior tarsal border – the area where surgical dissection
occurs to correct lid ptosis and to deﬁne lid folds. Damage to
a vessel within this network commonly results in a hematoma of Müller’s muscle, causing lid ptosis for 2–8 weeks
postoperatively. Likewise, on the lower lid, the inferior palpebral artery lies at the inferior border of the inferior tarsus.
The supratrochlear, dorsal nasal, and medial palpebral
arteries all traverse the orbit medially. Severing these arteries
during fat removal, without adequately providing hemostasis, may lead to a retrobulbar hematoma, a vision-threatening
complication of blepharoplasty.

Blood supply

A network of ligaments serves as a scaffold for the skin and
subcutaneous tissue surrounding the orbit. The orbital retaining ligament directly attaches the orbicularis at the junction
of its orbital and preseptal components to the periosteum of
the orbital rim and, consequently, separates the prezygomatic
space from the preseptal space. This ligament is continuous
with the lateral orbital thickening, which inserts onto the
lateral orbital rim and deep temporal fascia. It also has attachments to the superﬁcial lateral canthal tendon (Figs 8.3, 8.12,
8.13).20 Attenuation of these ligaments permit descent of
orbital fat onto the cheek. A midfacelift must release these
ligaments to achieve a supported, lasting lift.21

Retaining ligaments

of the capsulopalpebral fascia during lower lid procedures,
particularly transconjunctival blepharoplasty, releases the
retractors of the lower eyelid, which can reduce downward
traction and allow the position of the lower lid margin to rise.

0 to minimum

0 to minimum

8–13mm

6–8mm

Fig. 8.10 The anatomic variations in the upper eyelid displayed by different ethnic groups and the changes associated with senescence within each group allow for a
convergence of anatomy. (A) The occidental upper eyelid has levator extensions inserting onto the skin surface to deﬁne a lid-fold that averages 6–8 mm above the lid
margin. The position of the levator-skin linkage and the anteroposterior relationship of the preaponeurotic fat determine lid-fold height and degree of sulcus concavity or
convexity (as shown on the right half of each anatomic depiction). (B) In the case of levator dehiscence from the tarsal plate, the upper lid crease is displaced superiorly.
The orbital septum and preaponeurotic fat linked to the levator are displaced superiorly and posteriorly. These anatomic changes create a high lid crease, a deep superior
sulcus, and eyelid ptosis. (C) In the aging eyelid, the septum becomes attenuated and stretches. The septal extension loosens, and this allows orbital fat to prolapsed
forward and slide over the levator into an anterior and inferior position. Clinically, this results in an inferior displacement of the levator skin attachments and a low and
anterior position of the preaponeurotic fat pad. (D) The youthful Asian eyelid anatomically resembles the senescent upper lid with a low levator skin zone of adhesion and
inferior and anteriorly located preaponeurotic fat. The characteristic, but variable, low eyelid crease and convex upper eyelid and sulcus are classic. (Adapted from Spinelli
HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:59.)

D

Asian

C

Baggy eyelid

B

Deep set
(levator dehiscence)

A

Occidental

SECTION I •

8
• Blepharoplasty

Tarsus

Septal
extension

Levator
aponeurosis

Muller’s muscle

Orbital
septum

Orbicularis

Fig. 8.13 The orbital retaining ligament (ORL) directly attaches the orbicularis oris
(OO) at the junction of its pars palpebrarum and pars orbitalis to the periosteum
of the orbital rim and, consequently, separates the prezygomatic space from the
preseptal space. (Adapted from Muzaffar AR, Mendelson BC, Adams WP Jr.
Surgical anatomy of the ligamentous attachments of the lower lid and lateral
canthus. Plast Reconstr Surg 2002; 110(3):873–884.)

Orbicularis oculi

Pre-zygomatic space

Orbitomalar ligament

Septum orbitale

Globe

Fig. 8.11 The orbital septum has an adhesion to the levator aponeurosis above the
tarsus. The septal extension begins at the adhesion of the orbital septum to the
levator and extends to the ciliary margin. It is superﬁcial to the preaponeurotic fat
found at the supratarsal crease. (Adapted from Reid RR, Said HK, Yu M, et al.
Revisiting upper eyelid anatomy: introduction of the septal extension. Plast Reconstr
Surg 2006; 117(1):65–70.)

114

Lateral orbital thickening

Zygomatic bone

Nasal bone

Maxilla bone

Orbicularis retaining ligament

Orbicularis retaining
ligament

Orbicularis oculi

Infraorbital artery

Facial artery

Fig. 8.15 Sensory nerves of the eyelids.

Zygomaticofacial
nerve

Zygomaticotemporal
nerve

Lacrimal nerve

Infraorbital nerve

Infratrochlear nerve

Supraorbital nerve
Supratrochlear nerve

Angular artery
Medial palpebral artery
(inferior)
Lateral nasal artery
Inferior palpebral artery

Dorsal nasal artery

Supratrochlear artery

Medial palpebral artery (superior)
1. Peripheral arcade
2. Marginal arcade

Fig. 8.14 Arterial supply to the periorbital region.

Transverse facial artery

Zygomaticofacial artery

Superficial temporal
artery
Lacrimal artery

Supraorbital artery

Fig. 8.12 The orbicularis muscle fascia attaches to the skeleton along the orbital
rim by the lateral orbital thickening (LOT) in continuity with the orbicularis retaining
ligament (ORL). (Adapted from Ghavami A, Pessa JE, Janis J, et al. The orbicularis
retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg 2008;
121(3):994–1001.)

Frontal bone

Corrugator supercilii

surgical maneuvers. Attractive, youthful eyes are bright eyes.
Bright eyes have globes framed in generously sized horizontal
apertures (from medial and lateral), often accentuated by a
slight upward tilt of the intercanthal axis (Fig. 8.17). The aperture length should span most of the distance between the
orbital rims. In a relaxed forward gaze, the vertical height of
the aperture should expose at least three-quarters of the
cornea with the upper lid extending down at least 1.5 mm
below the upper limbus (the upper margin of the cornea) but
no more than 3 mm. The lower lid ideally covers 0.5 mm of
the lower limbus but no more than 1.5 mm.4,15
In the upper lid, there should be a well-deﬁned lid crease
lying above the lid margin with lid skin under slight stretch,
slightly wider laterally. Ideally, the actual pretarsal skin visualized on relaxed forward gaze ranges from 3 to 6 mm in
European ethnicities. The Asian lid crease is generally 2–3 mm
lower, with the distance from lid margin diminishing as
the crease moves toward the inner canthus. Patients of IndoEuropean and African decent show 1 to 2 mm lower than
European ethnicities. The ratio of distance from the lower
edge of the eyebrow (at the center of the globe) to the open
lid margin to the visualized pretarsal skin should never be
less than 3–1 (Fig. 8.1), preferably more.
Scleral show is the appearance of white sclera below
the lower border of the cornea and above the lower eyelid
margin. In general, sclera show is contradictory to optimal
aesthetics and may be perceived as a sign of aging, previous
blepharoplasty, or orbital disease (e.g., thyroid disease).
More than 0.5 mm of sclera show beneath the cornea on
direct forward gaze begins to confer a sad or melancholy
aura to one’s appearance. However, in some youthful persons, the largeness of these apertures gives dramatic emphasis
to the eyes and may be considered a strong and positive
feature.
The intercanthal axis is normally tilted slightly upward
(from medial to lateral) in most populations. Exaggerated
tilts are encountered in some Asian, Indo-European and

block will anesthetize most of the upper lid and the central
precoronal scalp.6,14,23
The maxillary division exits the orbit through one to three
infraorbital foramina. It provides sensation to the skin of the
nose, the lower eyelids, and the upper lid. Dissection is necessary lateral to the infraorbital nerve for successful midfacelifting and around the nerve for placement of tear trough
implants.
The facial nerve exits the stylomastoid foramen and divides
in the substance of the parotid gland into the superior temporofacial and inferior cervicofacial branches (Fig. 8.16). The
temporofacial nerve divides into the frontal, zygomatic, and
buccal nerves; the cervicofacial nerve divides into the buccal,
mandibular, and cervical nerves. There are signiﬁcant variations in the branching of the facial nerve, which is responsible
for facial expression. Innervation of facial muscles occurs on
their deep surfaces. Interruption of the branches to the orbicularis muscle from the periorbital surgery or facial surgery may
result in atonicity due to partial denervation of the orbicularis
with loss of lid tone or anomalous reinnervation and possibly
undesirable eyelid twitching.15
The frontal branch of the facial nerve courses immediately above and attached to the periosteum of the zygomatic
bone. It then courses medially approximately 2 cm above the
superior orbital rim to innervate the frontalis, corrugators,
and procerus muscles from their deep surface. A separate
branch travels along the inferior border of the zygoma to
innervate the inferior component of orbicularis oculi.24 The
surgeon should take great care when operating in this area
to avoid damaging this nerve during endoscopic and open
brow lifts.

The characteristics of youthful, beautiful eyes differ from one
population to another but generalizations are possible and
provide a needed reference to judge the success of various

Youthful, beautiful eyes

Fig. 8.17 On relaxed forward gaze, the ideal upper lid should rest approximately
2 mm below the upper limbus. The lower lid ideally covers 0.5 mm of the lower
limbus. The ratio of distance from the lower edge of the eyebrow to the open lid
margin to the pretarsal skin ratio should be greater than 3.

X

3–5X

115

Fig. 8.16 Anatomy of the brow and temporal region. The light green opaque area
denotes the deep temporal fascia and the periosteum where sutures may be used to
suspend soft tissue. Wide undermining, soft tissue suspension and canthopexy are
safely performed here.

Zygomatic branches (facial nerve VIII)

Temporal branches (facial nerve VIII)

Basic science/disease process

SECTION I •

8
• Blepharoplasty

Fig. 8.18 Morphed digital photography (split right half = current preoperative
photograph, split left half = photograph 20 years ago), demonstrating descent of
periorbital fat and skin during the aging process. (From Odunze MO, Reid RR, Yu M,
et al. Periorbital rejuvenation and the African-American patient: a survey approach.
Plast Reconstr Surg 2006; 118:1011–1018.)

In the upper lid, excessive skin due to loss of elasticity and
sun damage is one of the major causes of an aged appearance
in the periorbital area. If there is an excess of skin that hangs
over the lid or the upper eyelid appears to have multiple
folds, it is difﬁcult to have a rejuvenated appearance with
cosmetics alone. In addition to relaxed skin changes, excessive
fat herniation can cause bulging, resulting in a heavy appearance to the upper lid area. Although this fat is normal orbital
fat, it appears to be protruding outward because of the laxity
of the orbital septum, which holds the fat in place. Theoretically,
replacement of the fat into a position that maintains a normal
level of fat in the orbital area seems an optimal solution.
However, this is not easily accomplished and may result in
complications that are difﬁcult to correct. Therefore, the skin
and fat that seem to be in apparent excess should be treated
accordingly.
The etiology of aging changes in the lower lids is similar
in some ways but quite different in others. Aging changes
include relaxation of the tarsal margin with scleral show,
rhytides of the lower lid, herniated fat pads resulting in
bulging in one or all of the three fat pocket areas, and hollowing of the nasojugal groove and lateral orbital rim areas.
Hollowing of the nasojugal groove area appears as dark
circles under the eyes, mostly because of lighting and the
shadowing that result from this defect (Fig. 8.18).26 It is clear
that evaluation of all aspects of aging changes in the lids is
important so the surgeon can plan the most effective operative
procedure.

Etiology of aging

African-American populations. Such upward tilt of the lateral
canthal axis may give the eye a youthful appearance, which
is aesthetically pleasing in any ethnic group. The lower lid
that droops in its lateral aspect and the eye with a downward
tilt generally convey to the viewer an aging, ill-health distortion or unattractiveness.25

116

A thorough history and physical examination should be
performed before surgery (Box 8.2). In addition, an adequate
eye history encourages positive outcomes and reduces eye
complications.
Contact lens wear poses particular risks when eyelid
surgery is performed. The natural progression of aging dries
the eyes out, and long-term contact lens wearing hastens this
process considerably. Traditional blepharoplasty techniques

Medical and ophthalmic history

The ﬁrst essential step is to look at the patient carefully, thoroughly, and critically. The surgeon should be seated directly
in front of the prospective patient with the patient’s eyes at
his or her eye level. Note the general impression and feeling
generated from looking at this person (Fig. 8.19).
One should also look for areas of symmetry or asymmetry.
Notice the shape of the eye; the prominence or asymmetry of
the globes; and evidence of exposure, dryness, or injection of
vessels. Look for evidence of decreased tone and dropped
posture of the lower lids. What is the posture of the upper lid?
Are the upper lids symmetric? Is there lid ptosis? At what
level does the upper lid traverse the globe? What levels do
the upper and lower lids sit in relation to the limbus?
Next, have the patient relax the brow and close the eyes.
Do the lids close? Then ask the patient to open the eyes. Is it
necessary to raise the brows to effect comfortable forward
vision? Does the corrugator frown increase in prominence
with the eyes closed and the forehead relaxed? Is there transverse brow wrinkling? Is one brow lower? Which one and
how much? Is there a prominent frown?
Assess the lower lid tone by pulling the lid away from the
globe and releasing, making sure the patient does not blink
(modiﬁed snap test). Does each lid spring back immediately,
reluctantly, or not at all? Is it held against the globe by only
the tear seal? Most people presenting for blepharoplasty
have a signiﬁcant decrease in their lower lid tone, often
asymmetric.
What, if anything, would improve the aesthetic appearance
of the eyes and periorbital region? Are there festoons or deep
grooves (i.e., nasojugal grooves or tear trough deformities)?
Is there excess skin, muscle, or fat? Quantitate any excess soft
tissue on a simple eye diagram. Does restoration of lateral
canthal posture correct the illusion of excess skin on the lower
eyelid? Does it diminish it? Does the orbital septum appear
to be excessively relaxed? Note the tilt of the intercanthal axis
or lack thereof.
The “four-ﬁnger lift” is performed by encircling the outer
orbit with the tips of the index, middle, ring and little ﬁngers
on one hand. With the index and middle ﬁngers above the
lateral brow, place the ring ﬁnger lateral to the canthus and
little ﬁnger beneath the lateral canthus just lateral to the malar
prominence. Gently move the four ﬁngers posteriorly and
superiorly to lift the lateral brow, canthus, and cheek. If this
test restores youthfulness and attractiveness, a canthopexy,
brow lift, and midfacelift may be beneﬁcial.

Evaluation basics

Diagnosis/patient presentation

• Medication use: particularly anticoagulants, anti-inﬂammatory
and cardiovascular drugs, and vitamins (especially vitamin E).
• Herbal supplement use: herbs represent risks to anesthesia
and surgery, particularly those affecting blood pressure, blood
coagulation, the cardiovascular system, and healing.
• Allergies: medication and type.
• Past medical history: especially hypertension, diabetes,
cardiovascular and cerebrovascular disease, hepatitis, liver
disease, heart disease or arrhythmias, cancer, thyroid disease,
and endocrine disease.
• Bleeding disorders or blood clots.
• Psychiatric disease.
• Alcohol and smoking history.
• Recreational drug use, which may interact with anesthesia.
• Exposure to human immunodeﬁciency virus and hepatitis virus.
• Any history of facial herpes zoster or simplex.

Box 8.2 Important information to obtain during history
and physical examination

117

consistently produce vertical dystopia with increased scleral
exposure, making the lens wear difﬁcult if not dangerous.
Ptosis and canthopexy surgery may alter the corneal curvature and require that contacts be reﬁtted. The patient should
discontinue contact lens wear in the perioperative period to
allow healing without the need to manipulate the eyelids.
Levator dehiscence or attenuation commonly accompanies
long-term hard contact lens wear, caused by the mechanical
stresses posteriorly from the rigid lens rubbing against the
posterior lamella of the lid.27
The same population that seeks aesthetic surgery also gravitates toward refractive surgery, such as LASIK (laser-assisted
in situ keratomileusis). A history of such surgery is necessary
information because periorbital surgery particularly canthopexies and levator surgery, can affect the refractive characteristics, cause mechanical irritation of the conjunctiva
and cornea, or affect the corneal ﬂap.28 Ptosis repair or debulking of heavy upper lids can change the corneal curvature,
resulting in the need for a new prescription for eyeglasses.
Canthopexy normally raises the contact point of the lid with
the globe and can increase the tension of the lid with the globe

Fig. 8.19 Mid cheek deﬂation due to loss of superﬁcial and deep fat. SMAS, superﬁcial musculoaponeurotic system. (Adapted from Rohrich RJ, Pessa JE. The fat
compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219-2227.)

Jowl formation

Deepening of the nasolabial fold

Laxity of the SMAS covering zygomaticus muscles
and other elevators of the upper lip

Descent of the check fat pad with laxity of the orbitomalar ligament

Descent of the lid-cheek junction

Laxity and descent of the orbicularis oculi

Laxity of the orbital septum

Diagnosis/patient presentation

SECTION I •

8
• Blepharoplasty

The periorbital skin and tissues are examined for benign or
malignant lesions, including xanthelasma, syringoma, basal
cell carcinoma, benign moles, skin tags, and chalazia. Marked
anesthetic improvement results from removal of benign

External examination

The most essential preoperative test is assessment of visual
acuity, by the surgeon or ophthalmic colleague. Document the
vision with patient wearing glasses or contact lenses if they
are needed. Note any vision deﬁcits and have them evaluated
before surgery. The most common cause of unrecognized loss
of vision is amblyopia (lazy eye), which is present in 2% of
the general population. A patient may often be unaware of the
unilateral amblyopia (or any loss of vision) until the eyes are
tested individually.

Visual acuity

An ocular examination before elective periorbital aesthetic
surgery should include all of the elements covered in the
following sections (Fig. 8.20).

Ocular examination

and can increase the tension of the lid against the cornea,
affecting corneal curvature. It can cause conjunctival chemosis
or produce corneal erosion early postoperatively. Dry eye
exposure problems are most prevalent in patients who have
undergone LASIK surgery because the ﬂap disrupts corneal
innervations, forming an anesthetic effect that suppresses
tear production. When in doubt, such patients should be
reviewed by their refractive surgeon before undergoing
blepharoplasty.
One should check for a history of other eye procedures,
including glaucoma surgery (forms a bleb of conjunctival
tissue on the superior limbus), retinal, strabismus, and cataract surgery. Evaluate carefully for a history as well as physical evidence of facial muscle weakness, extraocular muscle
imbalance, Bell palsy, or trauma in addition to orbicularis
hyperactivity such as blepharospasm or hemifacial spasm.
Any ocular condition may affect the type or result of eyelid
surgery.29
Superior or lateral visual ﬁeld loss suggests functional
ptosis or pseudoptosis. A 12–20 degree or a 30% improvement
of the superior visual ﬁeld, between a taped and untaped
upper lid, may qualify for medical necessity.
Chronic eye irritation, such as tearing, dryness, excessive
blinking, discharge, eyelid margin inﬂammation, crusting,
burning, or itching, must be brought under control before any
surgery. Dry eyes should be aggressively sought out and
treated before surgery.
Dry irritated eyes before surgery will lead to irritated eyes
after surgery, and the surgeon may be blamed. On questioning, most patients will rarely admit to dry eyes, although it is
known that the eyes dry out considerably throughout our
lifetime. Treatment options include artiﬁcial tears, ointment,
anti-inﬂammatory drops, and punctal plugs or punctal
closure.29,30
Exophthalmos, unilaterally or bilaterally, associated with a
thyroid disorder should be completely stabilized for approximately 6 months before elective aesthetic surgery. However,
there may be an urgent requirement in active Graves’ disease
to perform procedures to protect the globe or the vision.13

118

lesions about the eyes, especially those that rise above the lid
margin. Any cancerous (or precancerous) lesions must be
removed before any aesthetic procedure is performed to preserve eyelid skin for reconstruction, if needed.
Eyelid measurements are documented for use during ptosis
surgery and, if necessary, for insurance purposes. In the
eyelid of the white individual, the aperture (distance between
the upper and lower eyelids) average 10–12 mm. The margin
reﬂex distance (MRD), measured from the light reﬂex on the
center of the cornea to the upper eyelid margin, ranges from
3 to 5 mm. True blepharoptosis is deﬁned by the degree
of upper lid infringement upon the iris and pupil. As the
MRD decreases towards zero, the severity of blepharoptosis
increases. Before method selection, the levator function must
be determined by measuring the upper eyelid excursion from
extreme downward gaze to extreme upward gaze; it generally
ranges from 10 to 12 mm. If ptosis exists, the type of repair
depends upon the severity of the ptosis and the reliability
of the levator to recreate smooth, upper lid elevation. A deep
upper lid sulcus with a high lid fold in the presence of a
droopy eyelid usually indicated a levator dehiscence, which
is often unilateral or asymmetric.31,32
Pseudoptosis occurs when excess upper lid skin covers the
eyelid, depressing the eyelashes, forming hooding and simulating ptosis. It is easily differentiated from true ptosis by
simply elevating the brow or the hooded skin itself to determine the true resting lid level.33 Photographic evidence of this
is often necessary for insurance purposes when a levator
aponeurosis repair or a excisional blepharoplasty is planned.
When the hooded skin hangs over the lashes, the lashes turn
downward and sometimes interfere with vision or rub against
the cornea. True trichiasis (misdirected lashes) may also exist,
but inward-turning lashes can be trained to return to their
natural posture after eyelid repair with lash rotation.
Brow ptosis is a common aspect of facial aging. It adds
weight and volume to the upper eyelid to develop, or exacerbate, eyelid ptosis. The more ptotic brow is often selectively
elevated or over-elevated by frontalis muscle contraction,
which may confuse the surgeon as to whether eyelid ptosis
or retraction exists. The ability to differentiate the causes of
droopy eyelids – brow ptosis (brow weight resting on the
eyelids), dermatochalasis (excess skin), and blepharoptosis
(levator attenuation or dehiscence) – will enable the surgeon
to select the proper correction.
Unilateral as well as bilateral upper eyelid retraction is
commonly associated with prominent globes, which are often
asymmetrically proptotic. Most commonly, it is the result of
Graves’ ophthalmopathy, which can lift the lid above the
superior limbus. A thyroid evaluation is appropriate before
any surgery to correct retraction. If it is stable for more than
6 months, levator recession surgery can be combined with fat
reduction blepharoplasty, but lid skin should rarely if ever
removed.
Long-term soft contact lens wear is also a common cause
of lid retraction that raises the lid to the superior limbus or
above. Congenitally shallow or traumatically small orbits are
also a cause of lid retraction, as is idiopathic retraction.27 If the
retraction persists in spite of taping the brow or lid tissue out
of the way of vision, the surgery to correct the retraction must
either precede or accompany the eyelid or brow surgery.
Retraction can also be accompanied contralateral blepharoptosis according to Hering’s Law.

Negative vector

E Tear film break up time

B Schirmer’s test

Fig. 8.20 (A–E) Evaluation of the patient should include an appreciation of visual acuity (with and without correction), baseline tear production, intrinsic lid tone, lower
eyelid support, and tear ﬁlm quality. The tests performed and their interpretation should be tailored by the clinician within the context of each patient and applied on an
individual basis. (Adapted from Spinelli HM. Atlas of aesthetic eyelid and periocular surgery. Philadelphia: Saunders; 2004:31.)

D Malar support

Positive vector

C Snap back lost

A Visual acuity via Snellen chart

Diagnosis/patient presentation
119

SECTION I •

8

Levator labii superioris

Levator labii superioris
alaeque nasi

Tear trough

Orbicularis oculi

• Blepharoplasty

The pupils are evaluated for direct and consensual response
to light. An abnormal result indicates a problem behind the
globe (i.e., the optic nerve or brain). Refractive errors, amblyopia, and corneal or retinal problems will not present with an
abnormal papillary response.

Pupils

The relative position of the globe to orbital anatomy greatly
inﬂuences appropriate surgical technique. There is a normal
10–12 mm projection of the globe seen in a lateral, as measured from the lateral orbital rim at the level of the canthal
tendon to the pupil. Proptosis and enophthalmos are relative
anterior and posterior displacement of the globe, respectively.
Hertel exophthalmometry can be used to quantitate the degree
of relative projection for documentation purposes.15,24
The tear trough is at the inferior orbital rim most medially,
triangulated by the orbicularis, levator labii superioris alaeque
nasi and levator labii superioris muscles (Fig. 8.21). The
indentation is at the junction of the thin eyelid skin above and
the thicker and different nasal and cheek skin below, with
attenuated subcutaneous tissue overlying the maxillary bone.
It is the deepening of this groove that leads to true indentation
and signiﬁcantly impacts facial appearance. The relative lack
of subcutaneous tissue in this area is subject to worsening
concavity with aging. The cause of the deformity is due to a
combination of orbital fat herniation, skin laxity and malar
volume loss and ptosis of skin and subcutaneous tissue.26 The
ability to place the side of the ﬁnger into the bony furrow
under the nasojugal grooves suggests a potential beneﬁt from
a tear trough implant or the addition of soft tissue augmentation (Fig. 8.22).34

Orbits and malar eminence

Fig. 8.21 The anatomy of the tear trough deformity demonstrates the muscular
triangle formed by the orbicularis oculi, levator labii superioris, and levator labii
superioris alaeque nasi. (Adapted from Hirmand H. Anatomy and nonsurgical
correction of tear trough deformity. Plast Reconstr Surg 2010; 125(2):699–708.)

120

Assessment of tear production is a necessary but unreliable
task. Schirmer testing consists of placing ﬁlter paper strips in
the lateral third of the lower eyelid. The irritation of any
foreign object against the globe stimulates reﬂex tearing,

Tear ﬁlm

The globe is examined for clarity of the cornea, iris, and lens.
The corneal light reﬂex should be sharp and no lesions noted
anywhere on the globe. If there is any question of a corneal
defect, a slit-lamp examination is needed, either by a surgeon
or by an ophthalmologist on referral. Any whitening of the
cornea is possibly an infectious inﬁltrate and should be treated
aggressively with antibiotics.

Globe

The extraocular muscles are tested for deviations, motility
problems, or restrictions. Eye deviations often present with
amblyopia unilaterally and corresponding reduced vision.
One should examine the patient for the presence of an intact
Bell’s phenomenon, an upward and outward rotation of the
cornea with lid closure. This can be accomplished by gently
forcing the upper eyelids open during closure. The presence
of an intact Bell reﬂex affords protection for the eye and cornea
in the event of incomplete eyelid closure. If the eyelid fails to
close during sleep, the cornea may remain uncovered and dry
out. Thus, the absence of Bell phenomenon raises the risk for
postoperative problems, especially in those with preexisting
problems or dry eyes.29

Extraocular muscles

Fig. 8.22 Tear trough test. The ability to place the side of a ﬁnger into the bony
furrow under the nasojugal groove suggests a potential beneﬁt from tear trough
augmentation.

Tear trough

Before surgical planning, one must have a meaningful conceptualization of the desired result. Only then can the surgical

Operative planning

Patient selection

There is a natural phenomenon that prevents surgeons from
fully appreciating the potential adverse effects of the surgery.
Women, and some men to whom appearance is important,
subconsciously and automatically modify their appearance
when they are confronted with a mirror, a camera, or someone
carefully examining their appearance. They lift the chin, tilt
the head backwards, elevate the eyebrows, and smile slightly.
This gives the illusion of elevated lower eyelids (although it
alters the intercanthal axis, turning it downward), and it
cleans the upper lids. These unintentional changes simulate a
brow lift, although the medial brow is typically disproportionately elevated. This disguises from the surgeon, both on
direct inspection and in photographs, the accurate preoperative appearance and true outcome of the surgery. When the
mirror and camera disappear, the brow drops, the corrugators
contract, and the lower lids drop to their natural posture. This
then, is the face the real world is seeing.

Unintentional deception in eye appearance

No other area of cosmetic surgery is more dependent on accurate photography than the periorbital region (Box 8.3). It is
essential in documenting existing anatomy and pathologic
changes. Accurate photography assists in surgical planning,
intraoperative decision-making, and documentation of results,
and it may be necessary for legal protection.35

Photographic documentation

121

In patients with unilateral eyelid ptosis, one may be tempted
to operate on the normal eye, which may appear to be
retracted, instead of the “disguised” ptotic eye. As a

Eyelid ptosis or retraction

The presence of atonic lower lids and lateral canthal laxity
may give the impression that there is excess skin requiring
removal. However, lower lid posture and optimal lateral
canthal position should be restored manually before determining the amount of skin and other tissues to be removed.
Lid and canthal restoration frequently eliminates skin excess.
When skin removal is indicated, the surgeon will often need
to remove skin more centrally than laterally.9,36

Lower eyelid tonicity

In the typical person with the brow in an aesthetically pleasing position, 20 mm of upper lid skin must remain between
the bottom of the central eyebrow and the upper lid margin
to allow adequate lid closure during sleep, a well-deﬁned lid
crease, and an effective and complete blink.

Upper eyelid position

Anatomic-directed therapy

maneuvers required be organized in a meaningful way
(Box 8.4).35 Preoperative planning should take place with the
patient upright under good lighting and with complete facial
relaxation. It is also important to document the brow, canthus,
and upper and lower eyelid posture and position and all other
desired alterations preoperatively. The preoperative photographs and surgical plan should be easily visible to the
surgeon during the entire surgery.
Skin and muscle are quantiﬁed for excision in millimeters
or any standardized system comfortable to the surgeon. Fat
excision is measured in terms of cubic centimeters (cc) or
milliliters (mL). A pea-sized amount is roughly equivalent
to 0.5 ccs or 0.5 mL. Determination of fat excision should
be approximated in multiples of this standard measure.
Measurements should be consistent with the patient in a vertical position to avoid lid hollowness or concave depressions.
In proptotic patients, more aggressive fat excision offers the
possibility of reduction of globe projection, but skin removal,
of any quantity, is most likely contraindicated.

The preoperative periorbital plan should include the following:
• The patient’s speciﬁc concerns and desires for improvement
• Brow position
• Lower eyelid tonicity
• Eyelid ptosis, retraction, or levator dehiscence
• Exophthalmos or enophthalmos
• Supraorbital rim prominence or hypoplasia
• Suborbital malar and tear trough deformities
• Excision of necessary skin, muscle, and fat – only if necessary.

• Full face, upright (at rest) frontal, oblique, and lateral views.
• Full face, upright and smiling.
• Direct periorbital views in upward gaze and downward gaze and
with eyes gently closed.
• A view with a ﬁnger slightly elevating the brows with the eyes
open and another with the eyes closed.

possibly yielding a deceptively good test result. A topical
anesthetic (tetracaine or proparacaine) eases discomfort and
reﬂex tearing, giving a better assessment of basal tear secretion. After 5 min, normal tear production should be greater
than 15 mm; 5–10 mm indicates borderline tear secretion, and
below 5 mm is hyposecretion.
Basal tear production diminishes with age in all persons to
a degree that usually becomes symptomatic by 50 years of
age. In contact lens wearers, allergy sufferers, arthritics, and
people with autoimmune diseases, this process accelerates
and often becomes symptomatic in their 30s. It is important
for patients to be aware of this age-related decrease in tear
production preoperatively.

Box 8.4 Preoperative periorbital plan

Box 8.3 Recommended photographic views

Patient selection

SECTION I •

8
• Blepharoplasty

The position of the globe greatly affects the procedural choices
and quality of outcome in periorbital surgery. The high frequency of asymmetry in globe prominence is often not appreciated in aesthetic periorbital surgery. Unless it is recognized
and treated appropriately, unfortunate outcomes are almost
inevitable.
In patients with infraorbital malar hypoplasia or tear
trough deformity, it is not possible to achieve optimal aesthetic results without some contour correction. If the globe
extends anteriorly past the inferior orbital rim, lower lid
surgery will increase scleral show and lid deformity unless
the lid and canthal posture are raised, the orbital rim-malar
complex is enhanced, or the prominent globe is retropositioned. This bone deﬁcit of the lower orbit, which occurs
most commonly in men, creates an exophthalmos of the
lower half of the globe. The patients can be described as
vector-negative or having hemiexophthalmos. A youthful,
vector-positive proﬁle consists of an inferior orbital rim and
malar soft tissue that are in the same plane of the globe (see
Fig. 8.20).39
When a vector-negative proﬁle exists, there is a relative
scarcity of lower eyelid skin. Lids must not be shortened
either by blepharoplasty. To do so causes the lid margins to
ride down the globe surface, resulting in more scleral show
and pathologic exposure. Similar to proptotic patients, suspension canthopexy must be placed more superiorly and
anteriorly to prevent scleral show. This relative lack of lower
lid skin can also increased with lower lid spacers, canthal
tendon elongation or orbital fat reduction.
In exophthalmos, tightening the lower lid, even when it is
repositioned with a canthopexy or a lid shortening, may cause
some severe potential problems. When it is horizontally tightened, the lid takes the course of least resistance and migrates
under the proptotic globe, especially when the canthal attachment is not lifted. To overcome this, the canthopexy attachment commonly needs to be placed higher than is aesthetically
most desirable. In addition, the canthal ﬁxation must be
placed more anteriorly to accommodate the proptotic globe,
and occasionally the canthus needs an extension to reach the
bone or augmentation of the orbital rim.

Globe position and malar prominence

consequence of Hering’s law, both levators are energized
equally in an attempt to clear the visual axis of the ptotic lid,
thereby making the normal lid appear retracted. Covering
each eye separately and observing the lid position often lead
to the discovery of the ptotic eye as the pathologic source. The
retracted eye will drop to its normal position once the ptotic
eye is covered, only to have the ptotic eye rise when it is
uncovered. Symmetric elevation of the brow is similarly
helpful in patients in whom asymmetric brow pseudoptosis
obstructs peripheral vision.
It is easy to correct existing true ptosis, or true retraction,
at the time of blepharoplasty surgery. Even when ptosis is
mild, correction avoids the probable worsening of the ptosis
by the additional insults of a weakened levator due to surgical
trauma, an edematous or bruised lid, a hematoma in the
levator muscle, a cicatrix associated with even the smallest
amount of orbital bleeding, or a simple asymmetric surgical
rendering.37,38

122

Aesthetic surgery of the forehead is thoroughly reviewed in
Chapter 7. Brow positioning is a cornerstone of blepharoplasty surgery. The majority of aesthetic improvement of the
upper orbital region comes from proper brow positioning and
canthopexy. When advocating periorbital rejuvenation, it is
therefore appropriate to consider repositioning the resting
brow position when considering blepharoplasty.41
A low resting brow is extremely common and occurs in
people of all ages. The lateral overhang of the eyebrow, upper
eyelid and juxtabrow skin can cause visual ﬁeld obstruction.
These tissues progress downward from degenerative changes
resulting in stretching of the forehead and brow tissues. The
recurring pull of the orbicularis, corrugator, and procerus
muscles contributes to descent of the brow. Many adults
presenting for aesthetic surgery have signiﬁcant – but often
undetected – “resting” brow ptosis. This phenomenon has
been termed “compensated brow ptosis”, where brow ptosis
remains undetected because of the compensatory activation of
the frontalis muscles to clear the obstructing lid overhang.42
If the brow is simply elevated to its proper position, the
seemingly elevated upper lid tissue either disappears or
diminishes dramatically, leaving most if not all of the irreplaceable eyelid skin. Furthermore, any scars resulting from
skin excision, when it is required, remain short and need not
extend beyond the orbital rim.
If a blepharoplasty alone is performed in these patients, the
visual incentive to elevate the brow disappears. The frontalis
relaxes and the brow drops – exaggerating the aged, tired look
that the blepharoplasty was supposed to correct (Fig. 8.24). In
addition, the weakened frontalis now fails to oppose the corrugators and relaxes its pull on the glabellar and interbrow
skin, thereby accentuating the glabellar crease and frown – a
heavy price to pay for an aesthetic procedure designed to
rejuvenate the face. These features can be prevented by a
concomitant or preceding temporal brow lift that restores
the eyebrows to their proper position and checks against
a profound drop in the resting posture of the brow after
blepharoplasty.

Optimal brow positioning

The tear trough deformity is a type of relative infraorbital
malar hypoplasia, where there is an asymmetric bony depression along the medial infraorbital rim. Tear trough implants
(Fig. 8.19) are reserved for severe deformities where the
volume of surgical fat repositioning is inadequate and cost of
ﬁller exceptional.34,40
If the surgeon can place the side of his or her ﬁnger into
this diagonally recessed bone, augmentation of the concavity
should be considered. Factors such as age, skin quality and
severity of the hollowing dictate the appropriate procedure.
Young patients with good skin quality will beneﬁt from
hyaluronic acid ﬁllers placed between the deep dermis and
orbicularis oculi fascia. This outpatient procedure can be performed concomitantly or weeks after blepharoplasty once
perioperative swelling subsides (Fig. 8.23). Older patients
require orbital fat repositioning from the medial and central
compartments during a transconjunctival blepharoplasty.
Alternative soft tissue injectables include autogenous fat,
hydroxyapatite and micronized acellular dermis.

Tear trough deformities

B

123

The goal of the eyelid surgeon when evaluating patients is to
develop an individualized treatment plan for the classic
symptoms of periorbital aging. While surgical techniques
deliver the most dramatic and lasting results, these procedures are not without inherent risks and postoperative recovery. Surgery is not always the ﬁrst and immediate response.
Patients in their 30s and 40s will frequently beneﬁt from
ofﬁce-based, nonsurgical care. Chemodenervation can minimize the early appearance of brow ptosis and ﬁne-line rhytides

Continuum of aesthetic enhancement

Treatment/technique

The most common approach to upper blepharoplasty has
been the en block excision of skin, muscle, and fat in an attempt
to debulk the eyelid. However, traditional blepharoplasty
may not always fulﬁll the promise of producing youthful,
aesthetically pleasing eyelids. In particular, aggressive upper

Upper eyelid surgery

along the lateral orbital rim. Fillers, which range in cost and
resorption rates, can augment the infraorbital rim in negative
vector patients. Photodynamic and laser therapy are alternatives to treat minor skin excess. It is prudent to develop lasting
relationships with patients and provide the least invasive,
targeted procedure needed for rejuvenation.

Fig. 8.24 Compensated brow ptosis – continuous obligatory frontalis muscle contraction to clear the periorbital tissues (and to affect comfortable and unobstructed forward
vision).

Fig. 8.23 (A) Preoperative and (B) postoperative photograph demonstrating tear trough augmentation with ﬁllers.

A

Treatment/technique

1

Video

SECTION I •

8
• Blepharoplasty

Anchor blepharoplasty involves the creation of an upper
eyelid crease by attaching pretarsal skin to the underlying
aponeurosis. The advantage of an anchor blepharoplasty is a
crisp, precise, and well-deﬁned eyelid crease that persists
indeﬁnitely. Such lids are more desirable in women than in
men because they tend to glamorize the orbital region. The
disadvantage is that it is more time-consuming, requires
greater surgical skills and expertise, and encourages greater
frontalis relaxation as a result of more effective correction of
the overhanging pseudoptotic skin. It accomplishes that task
while minimizing upper lid skin removal.43

Anchor (or invagination blepharoplasty)

Preserving orbicularis muscle and preaponeurotic fat has
been shown to enhance aesthetic outcomes for a variety of
presentation. Many who present for upper blepharoplasty
hope for a result that is aesthetically enhancing yet avoids
a “surgical appearance” or hollowed upper periorbital.
Volume-maintaining methods by preserving the orbicularis
muscle can be used to preserve or restore a youthful convexity of the upper eyelid-brow junction. Excessive skin and
facial soft-tissue descent may rest more on the deﬂationary
effects of regional volume loss rather true, gravitational
descent.
A youthful appearance is gained with maintenance or
enhancement of volume, and a shorter pretarsal fold. Closure
of the skin ellipse after skin resection and orbicularis preservation can improve supratarsal and infrabrow volume. The
effects of muscle preservation can be similar to results achieved
by soft-tissue ﬁller. Muscle resection should be reserved for
patients with orbicularis redundancy or relative hypertrophy.
The primary indication for selective myectomy is upper eyelid
fold disparities and mild lid ptosis.
When skin-only excision is elected, it should occur above
the supratarsal fold or crease, leaving that structure intact.
This retains most of the deﬁnition of an existing lid fold. If
eyelid skin containing the crease is part of the excision, the
lid fold becomes ill-deﬁned, indistinct, and irregular. The
supratarsal fold is located approximately 7–8 mm above the
ciliary margin in women and 6–7 mm in men. The upper
marking must be at least 10 mm from the lower edge of the
brow and should not include any thick brow skin. The use of
a pinch test for redraping the skin is helpful.
The shape of the skin resection is lenticular in younger
patients and more trapezoid-shaped laterally in older patients.
The incision may need to be extended laterally with a larger
extension, but extension lateral to the orbital rim should be
avoided if possible, to prevent a prominent scar (Fig. 8.25).
Similarly, the medial markings should not be extended
medial to the medial canthus because extensions onto the
nasal side wall result in webbing. At the conclusion of
the case, the patient should have approximately 1–2 mm of
lagophthalmos bilaterally. Figure 8.26 displays the predictable, restorative outcomes that can be achieved with skin
excision alone.

Simple skin blepharoplasty

lid skin excision performed as standard procedure is both a
functionally and aesthetically harmful form of upper eyelid
blepharoplasty.

124

During upper blepharoplasty, with the septum open and the
aponeurosis and superior tarsus exposed, there is an ideal
opportunity to adjust the level of the aperture. Inappropriate
aperture opening can be due to upper lid ptosis or upper lid
retraction. It is not uncommon for there to be ptosis of only
the medial portion or retraction of only the lateral portion. A
surgeon should not hesitate to take advantage of this opportunity for repair. True ptosis repair involves reattachment
of the levator aponeurosis to the tarsus, with or without shortening of applicable structures (e.g., aponeurosis, Müller’s
muscle, and tarsus).32,33
Approximately half of all patients presenting for periorbital aesthetic surgery have one brow that is several
millimeters lower than the other. Half of those have signiﬁcant unilateral ptosis on the side of the lower brow from
the “mechanical weight” of the excess skin. Half of those
patients’ ptosis will be corrected by manually raising the brow
on the affected side. The other half have true ptosis, which
most likely has gone undiagnosed because of overhanging
tissue.

Blepharoptosis

A relative excess of retroseptal fat may be safely excised
through an upper eyelid blepharoplasty incision. A small septotomy is made at the superior aspect of the skin excision into
each fat compartment in which conservative resection of
redundant fat has been planned. The fat is teased out bluntly
and resected using pinpoint cautery. This fat usually includes
the medial or nasal compartment, which contains white fat.
Yellow fat in the central compartment is usually more superﬁcial and lateral. Gentle pressure on the patient’s globe can
reproduce the degree of excess while the patient lies recumbent on the operating room table (Fig. 8.28). Overall, undercorrection is preferred to prevent hollowing, which can be
dramatic and recognized as an A-frame abnormality.
The attenuated orbital septum may be addressed by using
selective diathermy along the exposed caudal septum.
Inﬂammation-mediated tightening can enhance septal integrity. Septal plication aid is unnecessary and may induce a
brisk, restrictive inﬂammatory response.

Orbital fat excision

Key components of the anchor blepharoplasty include
minimal skin excision (2–3 mm) extending cephalad from the
tarsus. A 1–2 mm sliver of orbicularis must be removed in
proportion to the amount of skin removed. A small pretarsal
skin and muscle ﬂap are dissected from the aponeurosis and
septum adhesion. After sharply disinserting the aponeurosis
from the tarsus, pretarsal fatty tissue can be removed to
debulk the pretarsal skin. Key components of the anchor
blepharoplasty include minimal skin excision (2–3 mm)
extending cephalad from the tarsus. A 1–2 mm sliver of orbicularis must be removed in proportion to the amount of skin
removed. A small pretarsal skin and muscle ﬂap are dissected
from the aponeurosis and septum adhesion. After sharply
detaching the septal extension from the tarsus, pretarsal fatty
tissue can be removed to debulk the pretarsal skin. Mattressed
anchor sutures are placed connecting the tarsus to the aponeurosis and pretarsal skin (Fig. 8.27). Finally, a running suture
approximates the preseptal skin incision.

A

Pressure on globe causes
medial fat pad bulge

Skin and orbicularis muscle resection

B

Fig. 8.25 Simple skin excision blepharoplasty. (A) Digital traction and light pressure
by the surgeon allow smooth quick incisions. (B) The skin may be elevated with the
orbicularis muscle in one maneuver, proceeding from
lateral to medial. (C) The orbital septum is then opened, exposing the preaponeurotic
space. The underlying levator aponeurosis is protected by opening the septum as
cephalad as possible. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and
Periocular Surgery. Philadelphia: Saunders; 2004:64.)

B

Orbital septum

125

Fig. 8.26 (A) Preoperative and (B) postoperative photograph depicting predictable results with simple skin excision blepharoplasty anchor technique in addition to levator
advancement with reinsertion into tarsus.

C

Central fat pad (preaponeurotic)
on levator aponeurosis

A

Incision

Levator aponeurosis

Treatment/technique

SECTION I •

8
• Blepharoplasty

There are a variety of techniques to address blepharoptosis
but they are outside the scope of this chapter. We will thus
present our preferred technique for uncomplicated involutional ptosis. A ptosis repair may be undertaken in combination with a skin excision upper blepharoplasty. The difference
is adjusting (or advancing) the point of attachment of the
levator aponeurosis to the tarsus. There is a signiﬁcant learning curve to performing a ptosis repair, and even then, the
ability to get perfect symmetry is elusive.
In the setting of mild upper eyelid ptosis (approx. 1 mm),
where the decision has been made to avoid a formal lid ptosis
procedure, selective myectomy of the upper eyelid orbicularis
can be performed to widen the lid aperture. The amount of
muscle to be resected depends on a host of factors, including
the severity of relative lid ptosis, brow position, and fold
disparity (Fig. 8.29). The orbicularis muscle is then resected
selectively using cautery that strips orbicularis muscle from
the underlying orbital septum. The amount of resection is
titrated depending on the amount of effect desired. For 1 mm
or less of relative upper lid ptosis, resection of at least 3–4 mm
of orbicularis is required. The effects are more powerful the
closer the resection is to the inferior edge of the elliptical
wound. No attempt is made to close orbicularis muscle in
this resection, which could increase the risk of lagophthalmos.
On the opposite side, which is likely retracted, a slight ptosis
can be induced by resecting a larger degree of orbicularis

Surgical technique

Fig. 8.27 Anchor blepharoplasty technique. Attaching the dermis of the
pretarsal skin ﬂap to the superior aspect of the tarsus and to the free edge of the
aponeurosis. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular
Surgery. Philadelphia: Saunders; 2004:69.)

126

Closure

Medial fat pad removed
Intracuticular running
suture

Levator aponeurosis

and/or lowering the upper eyelid margin. Placing the upper
eyelid incision and crease 2 mm or higher on the relatively
retracted side can also reduce the need for formal lid retraction surgery.38
The key components of formal lid ptosis correction include
correct identiﬁcation of the distal extensions of the aponeurosis and the orbital septal extension.12 The superior edge of
the tarsus is freed from any dermal or tendinous extensions.
Leaving a small cuff of ﬁlmy connective tissue (approx. 1 mm)
on the tarsus will minimize bleeding from the richly vascularized area. Ensure that there is complete hemostasis by use of

Fig. 8.28 Simple skin excision blepharoplasty. (A) The medial fat pad may require
digital pressure to expose and grasp; however, care should be taken not to overly
resect fat when using digital pressure techniques. (B) Closure may then be
performed with a combination of interrupted and running intracuticular sutures.
(Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery.
Philadelphia: Saunders; 2004:65.)

B

Interrupted sutures

A

Whitnall’s ligament

B

127

a ﬁne forceps cautery, lifting all lid tissues away from the
cornea and globe before cauterizing. Anchor the upper third
of the tarsus to the remaining levator with 5–0 silk suture,
placed as a horizontal mattress. The lid should be ﬂipped to
ensure that the suture is not exposed posteriorly on the tarsus,
which could cause a troublesome corneal abrasion. The level
should be checked by having the patient open the eye. Some
coaxing helps the patient open the eye gently rather than
maximally, which the patient has been used to doing consistently to compensate for ptosis. The patient should blink frequently and look superiorly to ensure that the lid never rises
above the superior limbus. For cases under general anesthetic,
one should attempt to create one to two times the amount of
lagophthalmos relative to the preoperative ptosis.
If there is any medial or lateral retraction or ptosis, the
central suture should be repositioned medially or laterally as
many times as needed, with adjustment to a pleasing lid
height and contour. Both sides should be completed before
the suture is permanently tied. Once the desired lid height
and contour of both eyes are achieved, the patient should be
asked to open and close the eyes to ensure symmetry.
Anchoring the tarsus, dermis, and aponeurosis at the right
level keeps the pretarsal skin taut and ﬂat, prevents lash eversion, and forms a neat, crisp lid crease that will persevere for
many years.
Lower blepharoplasty has evolved substantially. There are
two trends in blepharoplasty, one towards more aggressive
techniques to maximize the aesthetic outcome and the
other towards more conservative techniques to minimize the
risk of complications. Although excellent aesthetic results
can be achieved with transcutaneous lower blepharoplasty,
lid retraction and ectropion are concerning complications.
Conservative excisional techniques center on the concept
of fat preservation. Transconjunctival lower blepharoplasty,
although more conservative, does not eliminate the risk of lid
malposition. An effective, lasting procedure should address
the extrinsic and intrinsic support of the eye, which is weakened during the aging process.
In the classic concept of lower lid blepharoplasty, the
concern of the surgeon who resects lid fat is the difﬁculty of
estimating the correct amount of fat to remove.44 If this is not
done correctly, this miscalculation may lead to asymmetry,
hollowing, or a sunken lid appearance. Relative enophthalmos is an obvious sign of aging because the volume of fat
decreases due to involution and herniation within the bony
orbit. By extension, rejuvenation proceeds by maintaining the
fatty volume and strengthening the globe’s extrinsic support
by canthopexy and orbicularis and midface suspension.

Lower lid blepharoplasty

Fig. 8.29 (A,B) Once the upper lid is incised, the levator may be modiﬁed (shortened/lengthened) in a number of ways, including simple plication. A suborbicularis skin
ﬂap can also be developed allowing access to preaponeurotic fat. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders;
2004:69.)

A

Levator aponeurosis

Orbital septum
and underlying
(preaponeurotic) fat

Levator plication

Treatment/technique

SECTION I •

8
• Blepharoplasty

A subciliary incision can be used to develop a skin ﬂap or a
skin-muscle ﬂap. With either method, pretarsal orbicularis
ﬁbers should remain intact. For the skin-muscle ﬂap, skin and
preseptal orbicularis are elevated as one ﬂap, while with a
skin ﬂap, the muscle and its innervation can be preserved.14
Periorbital fat, muscle, and skin can be addressed with either
approach. Once the plane deep to the orbicularis is entered,
dissection continues between the muscle and the orbital
septum down to the level of the orbital rim. Periorbital fat can

Transcutaneous blepharoplasty

Transconjunctival blepharoplasty is the preferred procedure
for fat reduction in patients without excess skin and with
good canthal position. A transconjunctival approach is less
likely to lead to lower lid malposition than is a transcutaneous
approach. It minimizes but does not eliminate postoperative
lower lid retraction; transection of the lower lid retractors
can cause a temporary rise in the lid margin, especially if
they are suspended during the healing period. Previously
suspected septal scarring through transconjunctival fat excision has not been shown to signiﬁcantly alter lid posture or
tonicity.45
The lower lid retractors (capsulopalpebral fascia and
inferior tarsal muscle) and overlying conjunctiva lie directly
posterior to the three fat pads of the lower lid. A broad and
deep transconjunctival incision severs both conjunctiva and
retractors but typically should not incise the orbital septum,
orbicularis, or skin. The conjunctival incision is made with a
monopolar cautery needle tip at least 4 mm below the inferior
border of the tarsus – never through the tarsus (Fig. 8.30). A
preseptal approach is obtained by entering the conjunctiva
above the level of septal attachment to the capsulopalpebral
fascia. A retroseptal approach involves a 1.5–2 cm incision
lower down in the fornix, and is typically used to excise fat.
There are differences of opinion about whether to leave the
transconjunctival incision open or to close it; however, it is
preferable to leave it open. Suturing the wound may trap
bacteria or cause corneal irritation. Conjunctival closure,
when it is elected, is simpliﬁed by a monoﬁlament pull-out
suture that enters the eye externally, closes the conjunctiva,
and exits through the skin and is taped.
The incision through the conjunctiva and retractors gives
excellent access to the orbital fat. A 6–0 silk traction suture
passed through the inferior conjunctival wound and retracted
over the globe gives wide access to the orbital fat, even helping
to prolapse the fat into the wound. The thin ﬁlm of synoviumappearing capsule encasing the orbital fat is opened, releasing
the fat to bulge into the operative ﬁeld (Fig. 8.31).
Once fat is removed or repositioned through a transconjunctival incision, excess skin can be removed through a subciliary position. Fat reduction may leave skin excess, leading
to wrinkling. A conservative “skin pinch” can be done to
estimate skin removal, or alternatively, skin can be tightened
by skin resurfacing with chemical or laser peels (Fig. 8.32).
One should be careful not to incise the orbital septum, which
leads to increased postoperative retraction. This procedure
works particularly well when there is an isolated fat pad,
especially medially, accessed through a single stab incision
through the conjunctiva.

Transconjunctival blepharoplasty

128

In this procedure, the herniated septum is plicated and repositioned to its normal anatomic site within the orbit. The fat
is replaced in the retroseptal position to regain its original
anatomic integrity (Fig. 8.33). Three to four 5–0 polyglycolic
acid sutures are placed in a vertical fashion from medial to
lateral. The protruding fat pads are invaginated and the integrity of the thin, ﬂaccid septum is restored. Additional support
may be gained with septo-orbitoperiostoplasty variation.48
This technique plicates the ﬂaccid septum and secures it to
the periosteum of the inferior orbital rim. Because of no disruption of the eyelid anatomy occurs, complications of related
to lid malposition such as lid retraction, scleral show, and
ectropion are reduced.49

Orbital septum plication

The fundamental agreement among surgeons who practice
plication is that bulging of orbital fat is the major component
in most cases of eyelid aging deformity. The conclusion is that
most cases of baggy eyelids occur from a true herniation
of the orbital fat out of the bony orbit. Consequently, rejuvenation centers on re-establishing the normal position of the
globe orbital fat. Plication offers the advantages of prevention
of depletion of the orbita, achievement of a homogeneous
and natural eyelid, avoiding local hollowing and sunken lid
appearance, and no risk of infraorbital hematomas. Access is
through a transcutaneous approach, which gives superior
exposure.

Plication techniques

An alternative to excising prominent orbital fat is to redrape
the pedicled fat onto the arcus marginalis. Patients with tear
trough deformities who have prominent medial fat pads are
excellent candidates.46 Access to the medial and central fat
pads is by the subciliary or transconjunctival incision.47 The
minor degree of lateral fat pad prominence is generally
insufﬁcient to affect any change with repositioning. A supraperiosteal or a subperiosteal dissection for 8–10 mm caudal to
the inferior orbital rim permits tension-free placement. The fat
can be secured in place with interrupted absorbable sutures.
This technique can be used as an alternative to fat grafting or
ﬁller injection. Patients must be warned that various degrees
of fat loss and hardening are possible. There is also a rare
but described possibility of restrictive strabismus related to
aggressive fat mobilization and ﬁxation.

Orbital fat transposition

The relative excess of orbital fat may be handled in several
ways. Most commonly, surgeons choose to excise the herniated fat with meticulous attention to hemostasis. Additional
techniques exist to reposition the fat to create periorbital
harmony.

Orbital fat

be excised through small incisions in the septum. The fat can
also be retropositioned using capsulopalpebral fascia placation, or it can be transferred into the naso-jugular fold.
Orbicularis muscle ﬁbers and skin can be excised at closure.
However, care must be taken with muscle excision, which can
lead to orbicularis denervation and lid malposition.

C

Inferior tarsal plate

Orbital septum

129

Anatomical dissection suggests that the Lockwood suspensory ligament descends with aging that leads to relative
enophthalmos and fat herniation. Moreover, simply plicating
the orbital septum, which is an acellular membrane with little
tensile strength, will not restore the globe’s position. The capsulopalpebral fascia can be plicated to the orbital rim either
through a transcutaneous or a transconjunctival approach. In

Capsulopalpebral fascia plication
the transcutaneous method, dissection is carried out between
the orbicularis and the septum down to the orbital rim; the
capsulopalpebral fascia is then sutured to the orbital rim. In
the transconjunctival method, the capsulopalpebral fascia is
divided from the tarsus, and orbital fat is retroplaced, its position maintained by suturing the capsulopalpebral fascia to
the periosteum of the orbital rim using a continuous running

Fig. 8.30 (A) The transconjunctival approach to the retroseptal space may be in one of two ways: preseptal or retroseptal. The preseptal route requires entry into the
suborbicularis preseptal space above the fusion of the lower lid retractors and the orbital septum. This will allow direct visualization of the septum, and each fat pad can be
addressed separately in a controlled fashion. (B) A conjunctival stay suture is placed deep in the fornix and traction is applied superiorly while the lid margin is everted.
This causes the inferior edge of the tarsal plate to rise toward the surgeon. (C) The conjunctiva and lower lid retractors are incised just below the tarsal plate entering the
suborbicularis preseptal space. This plane is developed to the orbital rim with the assistance of the traction suture and a nonconductive instrument. (Adapted from Spinelli
HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:86.)

B

Conjunctiva is divided longitudinally
just below the tartsal plate

Conjunctiva is tented and secured with a stay suture

A

Nonconductive retractor

Pretroseptal (suborbicularis) approach

Retroseptal approach

Treatment/technique

8

Orbital septum opened

A

B

Remove fat pads if they bulge

• Blepharoplasty

Inferior oblique muscle

SECTION I •

Reposition fat pads transconjunctivally

Lateral, central and medial fat pads (left to right)

Conjunctiva retracted superiorly

6–0 nonabsorbable suture. The conjunctival gap of a few
millimeters is allowed to reepithelialize (Fig. 8.34).50–52 One
advantage of the transconjunctival approach is the division of
lower eyelid depressors, which helps maintain the lower
eyelid at an elevated level due to the unopposed action of
the pretarsal orbicularis. Several series have shown this
disruption does not interfere with lower eyelid or globe
function.48,50

Orbicularis repositioning can be used to eliminate hypotonic
and herniated orbicularis muscle, soften palpebral depressions, and shorten the lower lid to cheek distance. The main
steps include elevation of a skin muscle ﬂap, release of the
orbicularis retaining ligament and resuspension of the orbicularis – frequently after lateral canthopexy. Along the entire

Orbicularis suspension

Fig. 8.31 (A) The orbital septum may then be punctured and the inferior oblique muscle identiﬁed and preserved. (B) The fat pad may be addressed individually in-keeping
with preoperative plans with either resection, repositioning, conservation or any combination of the these techniques. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid
and Periocular Surgery. Philadelphia: Saunders; 2004:87.)

130

A

B

Inferior orbital rim

Inferior orbital rim
B

Inferior orbital septum

131

As the lateral canthal tendon lengthens, it shortens the aperture and allows the lid posture to drop to give the illusion of

Canthopexy

infraorbital rim, the orbicularis retaining ligament is divided.
Additional medial dissection is performed to release the
levator labii when a tear trough deformity is present.
The skin muscle ﬂap is draped in a superior lateral vector
rather than a pure vertical vector. Excision of skin and muscle
are performed by removing a triangle of tissue lateral to the
canthus, thereby minimizing the amount of tissue removed
along the actual lid margin. The lateral suspension of the
orbicularis is to the orbital periosteum. Lower lid support is
gained by resuspension of the anterior (skin and muscle) and
posterior lamellae (tarsus by canthopexy).
This technique is best suited for patients with scleral show,
lid laxity, and a negative vector, which put them at risk for lid
malposition in the postoperative period. Its drawback is that
it inherently disrupts the orbicularis, which may lead to denervation. Mobilization of the levator labii muscles also may
put the buccal branch of the facial nerve at risk.

excess lower lid skin as the tissues accordion inferiorly. With
restoration of the normal intercanthal axis tilt, lid tone, and
septal integrity, the appearance of excess skin and herniated
fat disappears with minimal tissue excision and, in many
patients, without the need for any muscle, skin, or fat excision
(Fig. 8.35).37,53
A lateral canthopexy can establish an aesthetically and
functionally youthful eyelid and reduce the incidence of lower
lid malposition and scleral show (Fig. 8.36). It has become
an integral part of a lower lid blepharoplasty and midfacelifting.36 It is increasingly appreciated that good and longlasting surgical results in lower lid surgery are rarely possible
without an effective canthopexy.
A lasting canthopexy involves more than a simple stitch
into the periosteum. A properly executed canthopexy restores
the tone, posture, and tilt to the lower lid and serves as the
fulcrum point for rejuvenation of the entire midface. In addition, it raises the Lockwood suspensory ligament (and the
entire retinacular complex), lifting orbital structures upward,
reducing lower lid fat herniation, and reducing upper lid
hollowing – all an essential part of a youthful periorbital
restoration.

Fig. 8.33 (A,B) Schematic representation of procedure for lower eyelid. Note that only the inferior orbital septum is plicated and sutured to the inferior orbital rim. (Adapted
from Sensöz O, Unlu RE, Percin A, et al. Septoorbitoperiostoplasty for the treatment of palpebral bags: a 10-year experience. Plast Reconstr Surg 1998; 101(6):1657–1663.)

A

Capsulopalpebral fascia

Capsulopalpebral fascia

Protruding inferior orbital fat
Inferior orbital septum

Fig. 8.32 (A) Simple skin excision lower eyelid blepharoplasty. (B) Typical removal of redraped skin or skin-muscle from the lower lid, which can be the shape of an
obtuse triangle, with the largest amount sacriﬁced laterally.

Treatment/technique

Inferior orbital septum

SECTION I •

8
• Blepharoplasty

B

Lower (ocular) flap made up
of conjunctiva inferior tarsal
muscle capsulopalpebral fascia

Upper (ciliary) flap

The degree of laxity predetermines the type of lateral
canthal support. A lateral canthopexy is recommended for
moderate lid laxity, which is considered <6 mm of lid
distraction away from the globe. This technique takes advantage of a bluntly dissected tunnel extending from the lateral
upper lid blepharoplasty incision into the lateral aspect of a
lower lid incision. Next, the lateral retinaculum and tarsal
strap are bluntly dissected off the periosteum 5 mm in both
directions (Figs 8.4, 8.37).
A double-armed 4–0 Prolene or Mersilene is used to suture
the tarsal plate and lateral retinaculum to the inner aspect of
the lateral orbital rim periosteum above the Whitnall tubercle.
Periosteum is thickest at the superior and lateral orbital rim,
making it a secure suture site. The mattress suture is placed
through the periosteum within the lateral orbital rim to
maintain the posterior position of the lid margin against
the globe.
Bone canthopexy is technically possible through upper
and lower lid incisions but is technically demanding. Wide
exposure through a coronal brow lift provides the ideal environment and access. Bone ﬁxation gives a profoundly longer
lasting result than does periosteal ﬁxation. Drill holes (1.5 mm
drill bit) are placed 2–3 mm posterior to the lateral orbital rim.
The inferior and superior holes are separated by 5–10 mm to
allow suture separation and ligation (Fig. 8.38).
The vertical position of the lateral canthal suture is dependent on eye prominence and preexisting canthal tilt. Patients
with prominent eyes and negative vector morphology are at
higher risk for lid malposition and require additional vertical

Patients will frequently complain that they would like the
lower skin to be smoother and tighter, the fatty pads to be
eliminated, and the tissues of the malar eminence to be fuller.
Midface descent occurs in the spectrum of periorbital aging,
clinically apparent in the 4th decade (Fig. 8.39). The orbicularis muscle and suborbicularis oculi fat (SOOF) descend in
an inferonasal direction and, in conjunction with descent
of the malar fat pad, results in the fullness of the nasolabial
fold frequently seen with the aging face. This inferonasal
vector of aging also creates a visual lengthening of the lower

Midfacelifting

support of the lateral canthus. While the standard position of
the lateral canthopexy suture is most commonly at the lower
level of the pupil, patients with prominent eyes or negative
vectors require additional vertical positioning of the lateral
canthal support suture at the superior aspect of the pupil.
Lateral canthoplasty, which includes surgical division of
the lateral canthus, is recommended for more signiﬁcant
lower lid laxity, deﬁned by lid distraction >6 mm away from
the globe. Lateral canthotomy, cantholysis of the inferior limb
of the lateral canthal tendon, and release of the tarsal strap are
performed. This dissection is followed by a 2–3 mm fullthickness lid margin resection, depending on the degree of
tarsoligamentous laxity. The lateral commissure is carefully
reconstructed by aligning the anatomical grey line with 6–0
plain gut. Final ﬁxation to the lateral orbital periosteum can
be as described above.

Fig. 8.34 (A,B) Suturing the lower capsulopalpebral ﬂap to the arcus marginalis to reduce and contain the herniated fat. (Adapted from Camirand A, Doucet J, Harris J.
Anatomy, pathophysiology, and prevention of senile enophthalmia and associated herniated lower eyelid pads. Plast Reconstr Surg 1997; 100(3):1535–1538.)

A

Fascioseptal triangular space

132

0˚

0˚

lids beyond the orbital margin. Lastly, relative loss of soft
tissue secondarily skeletonizes the inferior orbital rim and
zygoma, deepening the tear trough and diminishing the malar
prominence.54,55
The middle third of the face, or midface, lies between the
lateral canthal angle and the top of the nasolabial fold. It

Fig. 8.35 (A) Attenuation with aging produces a descent of the lateral canthus.
(B) The end result is a lateral canthus that is linear or declined compared with the
medial canthus. As the lateral canthus sags, the intercommissure distance shortens
and the lower lid and inferior lateral septum become lax. This produces sclera
show, lid malposition and orbital fat prominence laterally and tear drainage
problems. With restoration of the normal intercanthal axis tilt, lid tone, and septal
integrity, the appearance of excess skin and herniated fat disappears with minimal
tissue excision and, in many, without the need for any muscle, skin, or fat excision.
(Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery.
Philadelphia: Saunders; 2004:35.)

B

+10 - 15˚

A

-10 - 15˚

133

includes the lateral canthal tendon, the medial canthal tendon,
the skin, fat, and orbicularis oculi muscle of the lower eyelids,
the sub–orbicularis oculi fat pad, the malar fat pad, the orbitomalar ligament (orbicularis ligament), the orbital septum,
and origins of the zygomaticus major and minor muscles
and levator labii superioris. When evaluating the midface
for aesthetic surgery, all the structures listed above must be
considered.
The author’s preferred technique includes approaching
the midface through a transconjunctival incision. After repositioning or resection of orbital fat, the midface is elevated in
a supraperiosteal plane. The attachment of the orbicularis
oculi muscle to the orbital septum is preserved. Adequate
release of the remaining, lax orbitomalar ligament then
permits malar fat pad suspension in a superolateral vector to
the lateral orbital rim and temporoparietal fascia (Fig. 8.40).
Canthopexy is then performed to redrape lower eyelid skin
and recreate a youthful intercanthal angle. Finally, a skin only
resection of the lower lid may be necessary to address any
redundancy.

Fig. 8.36 (A) Preoperative and (B) 5-year postoperative photograph of a patient
with a lower lid blepharoplasty and canthopexy.

B

A

Treatment/technique

SECTION I •

8
• Blepharoplasty

Fig. 8.37 (A–C) Periosteal canthopexy. The inferior ramus of the lateral canthal
tendon is secured and elevated to a raised position inside the orbital rim. Tension
free suspension occurs with release of the tarsal strap and lateral orbital thickening.

C

B

A

134

E

B

D

tahir99 - UnitedVRG
vip.persianss.ir

All patients are advised to expect swelling, bruising, some
degree of ptosis, and tugging sensation on gazing upward.
Although complete recovery takes months, patients generally
look presentable approximately 2–3 weeks after surgery.

Postoperative care

Fig. 8.38 The canthopexy suture series for a two-layered canthopexy. (A) The
canthopexy suture ﬁxating the tarsal tail into the drilled hole. (B) The second-layer
orbicularis suture. (C) Lateral sutures ﬁx the lateral orbicularis to the deep temporal
fascia. (D) If a midfacelift is elected, an inferior drill hole can be made to ﬁxate the
midface tissues. (E) Bury the knot into drill hole.

C

A

Surgical literature has not advocated compression bandaging of the eyes after surgery. The concern is an undetected
retrobulbar hemorrhage that results in vision loss. However,
the reality is that the risk for hemorrhage, chemosis, and other
problems is more likely in an eye that has no compression.
Retrobulbar hemorrhage is likely to induce orbital pain, which
should never be ignored, alerting the surgeon to the potential
vision-threatening complication. If one chooses not to use
gently compressive bandages, postoperative edema can be
reduced with cool compresses for up to 20 min intermittently
during the initial 36 hours postoperatively. Patients are
advised against using frozen compresses directly over their
face in the setting of previous anesthetic use and pain
medication.29
Additional recommendations include having the patient lie
in a semi-recumbent position while resting and to avoid
bedrest. Prescriptions for rewetting drops, Lacri-Lube® and
antibiotic ophthalmic ointment can be given to reduce the
incidence of exposure keratoconjunctivitis and dry eye symptoms in the immediate postoperative period. Patients are permitted to shower the next day and use antibiotic ointments as
needed, for routine incisional care. Avoiding direct sun exposure with sunglasses may reduce the severity of sunburn and
the formation of irregular, darkened pigmentation. It is also
suggested that patients refrain from using contacts and to
minimize the use of prescription eyeglasses.30

Fig. 8.39 (A) Preoperative and (B) postoperative photograph demonstrating the
beneﬁt of midfacelift in the setting of blepharoplasty.

B

A

135

tahir99 - UnitedVRG
vip.persianss.ir

Even the most carefully planned procedures will have a small
percentage of complications. The possibility of such complications and a realistic appraisal of likely outcome should be
discussed with the patient before surgery.
Asymmetry is common postoperatively and can be caused
by edema, bruising, and asymmetric sleep posture, but it also
predictably follows undiagnosed preoperative asymmetry,
including mild ptosis, made worse by the weight of postoperative edema. Patients should be advised that no reoperations are indicated before 8 weeks, and then only if the lids
have stabilized and no edema or bruising is seen. The need for
reoperations is infrequent, but when ptosis or exophthalmos
is involved, incidence increases signiﬁcantly to 10–30%.45
Retrobulbar hemorrhage is the most feared complication of
eyelid surgery. Any complaint of severe orbital pain needs to
be examined immediately, especially that of sudden onset.
Acute management involves immediate evaluation, urgent
ophthalmologic consultation and a return to the operation for
evacuation of the hematoma. Medical treatments, in addition
to operative exploration, include administration of high ﬂow
oxygen, topical and systemic corticosteroids and mannitol.
Acute loss of vision mandates bedside suture removal and
decompressive lateral canthotomy. Hospitalization with head
elevation and close observation may be necessary to supplement the described measures.29 Peribulbar hematoma, in contrast, does not threaten vision. It usually results from bleeding
of an orbicularis muscle vessel. Small hematomas may resolve
spontaneously, though larger hematomas can be evacuated in
the ofﬁce.
Visual changes, including diplopia, are generally temporary and can be attributed to wound reaction, edema and
hematoma. Any damage to the superﬁcial lying oblique
muscles can be permanent and lead to postoperative strabismus. Conservative management is recommended; refractory
cases should be referred to an ophthalmologist.
The most common complication after blepharoplasty is
chemosis. Disruption of ocular and eyelid lymphatic drainage
leads to development of milky, conjunctival and corneal
edema. Chemosis can be limited by atraumatic dissection,
cold compresses, elevation and massage. It is usually selflimited and resolves spontaneously, though prolonged chemosis can be treated with topical steroids.
Dry eye symptoms are also frequently cited in the post
operative phase. Patients may complain of foreign body sensation, burning, secretions and frequent blinking. Preexisting

Complications

When no canthopexy is performed, half-inch Steri-Strips,
retracted superiorly, are applied as a “cast” (with benzoin or
Mastisol for security). This treatment tends to reduce lid
retraction. Alternatively, a Frost suture placed in the lower lid
margin and ﬁxed to the brow suspends the lid during early
healing. Temporary medial or lateral limbus tarsorrhaphies
were previously popular after aggressive skin excision blepharoplasty techniques. These sutures were primarily used to
minimize chemosis during the ﬁrst 48 h. Discomfort, restricted
vision and secondary ofﬁce visits for suture removal have led
to their limited use today. However, the best support during
healing is a secure extended canthopexy.45

Complications

C

Cheek flap is elevated and
sutured to deep temporal fascia or
periosteum of lateral orbital rim

Extent of sub-orbicularis muscle/
malar fat pad/SMAS undermining

Malar fat pad

SOOF

Orbitomalar ligament

Malar bag

Orbital fat
Orbital septum
Orbicularis oculi

• Blepharoplasty

Zygomaticus

8

Buccal fat pad

SMAS

SECTION I •

A

Single mattress suture repair

Access via upper or lower blepharoplasty incision

dry eyes may be aggravated by postoperative lagophthalmos.
Ocular protection can achieved medically with liberal use of
corneal lubricants.
Additional complications such as lower lid malposition,
lagophthalmos, undercorrection, asymmetry, and iatrogenic

tahir99 - UnitedVRG
vip.persianss.ir

ptosis all require careful observation and photographic
documentation. Reoperation should be performed no earlier
than 3 months later. Secondary blepharoplasty can range
from simple ofﬁce-based procedures to extremely challenging
interventions.

Fig. 8.40 Midfacelift. (A) The arrow in red depicts the plane of dissection to the midfacial structures in the cheek in a supraperiosteal approach. (B) Wide undermining of
the periorbital ligamentous structures and lateral retinaculum may be transconjunctival or through the upper blepharoplasty incision. (C) Canthopexy and cheek suspension
then proceed sequentially. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:129.)

B

136

12. Flowers RS, Nassif JM, Rubin PA, et al. A key to
canthopexy: the tarsal strap. A fresh cadaveric study.
Plast Reconstr Surg. 2005;116(6):1752–1758.
Flowers and colleagues detail the anatomy of the lateral
orbital retinaculum and highlight the importance of full
dissection to achieve a tension-free canthopexy.
14. Spinelli HM. Atlas of aesthetic eyelid and periocular
surgery. Philadelphia: Saunders; 2004.
15. Zide BM. Surgical anatomy around the orbit: the system
of zones. ed 2. Philadelphia: Lippincott, Williams &
Wilkins; 2006.
17. Reid RR, Said HK, Yu M, et al. Revisiting upper eyelid
anatomy: introduction of the septal extension. Plast
Reconstr Surg. 2006;117(1):65–70.
This cadaveric and histologic study identiﬁes an extension of
the orbital septum that must be identiﬁed and spared when
performing a levator advancement for blepharoptosis.
21. Muzaffar AR, Mendelson BC, Adams Jr WP. Surgical
anatomy of the ligamentous attachments of the lower
lid and lateral canthus. Plast Reconstr Surg.
2002;110(3):873–884.
26. Hirmand H. Anatomy and nonsurgical correction of
tear trough deformity. Plast Reconstr Surg. 2010;125(2):
699–708.

137

American Society for Aesthetic Plastic Surgery, there was a
293% increase in the number of African-American patients
who underwent cosmetic plastic surgery from 1997 to 2004.58
The awareness of the beneﬁts of cosmetic plastic surgery is
becoming ever-present to a patient population which transcends cultural and racial boundaries.
African-American patients pursuing eyelid rejuvenation
have preconceived notions and concerns distinct from their
Caucasian counterparts, thereby demanding a different
surgical strategy. African-Americans are twice as likely as
Caucasians to be afraid of losing their ethnic identity and 10
times as likely to choose a surgeon with special interests in
ethnic plastic surgery. There are several features that make the
African-American eye ethnically unique. The lateral canthus
is cephalad to the medial canthus in great frequency. In addition, there is a tendency for a more oval, Asian-like palpebral
aperture, as opposed to the more rounded Caucasian palpebral ﬁssure. The supratarsal fold distance tends to be shorter
than in the Caucasian eyelid but longer than the Asian eyelid.
The lateral orbit and cheek skin is more sebaceous, and there
is a decreased tendency toward rhytid formation. Finally,
African-Americans tend to be poor candidates for lower
eyelid resurfacing because of pigmentation risk. The preferred
surgical approach includes canthopexy to restore lateral
canthal position, preservation of the majority of orbicularis to
restore supratarsal contour and avoidance of cephalad malposition of the upper eyelid incision to preserve limited pretarsal show. These subtleties are discussed preoperatively,
often with the aid of youthful photographs, to appropriately
plan surgery.25,59
The unique characteristics of the Asian blepharoplasty will
be thoroughly discussed in Chapter 10.

tahir99 - UnitedVRG
vip.persianss.ir

30. Rohrich RJ, Coberly DM, Fagien S, et al. Current
concepts in aesthetic upper blepharoplasty. Plast
Reconstr Surg. 2004;3:32e–42e.
This continuing medical education article provides a concise
description of upper eyelid aging and a step-by-step guide to
popular rejuvenation techniques.
36. Flowers RS. Canthopexy as a routine blepharoplasty
component. Clin Plast Surg. 1993;20(2):351–365.
44. Mendelson BC. Fat preservation technique of lower-lid
blepharoplasty. Aesthet Surg J. 2001;21(5):450–459.
Results shown in Mendelson’s article demonstrate the safe,
reproducible outcomes of a skin-only blepharoplasty and help
swing the pendulum away from aggressive, fat excisional
techniques.
45. Codner MA, Wolﬁ J, Anzarut A. Primary transcutaneous
lower blepharoplasty with routine lateral canthal
support: a comprehensive 10-year review. Plast Reconstr
Surg. 2008;121(1):241–250.
59. Few JW. Rejuvenation of the African American
Periorbital Area: Dynamic Considerations. Semin Plast
Surg. 2009;23(1):198–206.
Few’s survey-based study shows that one must prioritize a
patient’s ethnic identity and heritage when approaching the
periorbital area in African-Americans.

Access the complete references list online at http://www.expertconsult.com

Patients who identify themselves other than Caucasian now
account for 27% of all cosmetic procedures. Hispanics, AfricanAmericans and Asian-Americans have seen a steady rise in
their market share over the last 10 years. According to the

Blepharoplasty in people of color

In the United States, 16% of blepharoplasties are performed
on men, and blepharoplasty is the second most common
cosmetic surgery performed on male patients.56 Men tend to
seek out blepharoplasty more for functional reasons than
women, but this difference has become less and less distinct
in recent years. A more natural look is preferred, and the
“operated look” will not be tolerated well by most male
patients. Men typically do not use cosmetics, so all scars
must be carefully concealed. This also makes male patients
suboptimal candidates for laser resurfacing. The lateral incision should rarely be extended beyond the later orbital rim.
In men with heavy brows, resection of upper eyelid skin only
will result in profoundly ptotic brows. Therefore, one should
consider combined brow surgery with upper blepharoplasty.
Many men are reluctant to have cosmetic surgery to correct
brow ptosis, so careful preoperative counseling is needed to
prevent a dissatisﬁed patient with worse brow ptosis postoperatively.30,57 Often, conservative eyelid resection is all that is
required.

Male blepharoplasty

Special considerations

Special considerations

1. Dupuis, C, Rees, TD. Historical notes on blepharoplasty.
Plast Reconstr Surg. 1971;47(3):246–251.
2. Flowers RS. The art of eyelid and orbital aesthetics. Clin
Plast Surg. 1987;14(4):709–721.
3. Nesi FA, Levine MR, Lisman RD. Smith’s Ophthalmic
Plastic and Reconstructive Surgery. ed 2. St. Louis, MO:
Mosby; 1997.
4. Putterman AM. Cosmetic Oculoplastic Surgery: Eyelid,
Forehead, and Facial Techniques. ed 3. Philadelphia: WB
Saunders; 1999.
5. Flowers RS. Advanced blepharoplasty: principles of
precision. In: Zaoli G, Meyer R, Gonzales-Ulloa M, et al,
eds. Aesthetic Plastic Surgery. vol II. Padova: Piccin Press;
1987.
6. Wolff E. The Anatomy of the Eye and Orbit. Philadelphia:
WB Saunders; 1976.
7. Doxanas MT, Anderson RL. Clinical Orbital Anatomy.
Baltimore, MD: Williams & Wilkins; 1984.
8. Stewart TD. The points of attachment of the palpebral
ligaments: their use in facial reconstructions of the skull.
J Forensic Sci. 1983;28(4):858–863.
9. Jelks GW, Jelks EB. The inﬂuence of orbital and eyelid
anatomy of the palpebral aperture. Clin Plast Surg.
1991;18:183–195.
10. Couly G, Hureau J, Tessier P. The anatomy of the
external palpebral ligament in man. J Maxillofac Surg.
1976;4(4):195–197.
11. Whitnall SE. Anatomy of the Human Orbit and Accessory
Organs of Vision. New York: Oxford University Press;
1932.
12. Flowers RS, Nassif JM, Rubin PA, et al. A key to
canthopexy: the tarsal strap. A fresh cadaveric study.
Plast Reconstr Surg. 2005;116(6):1752–1758.
Flowers and colleagues detail the anatomy of the lateral
orbital retinaculum and highlight the importance of full
dissection to achieve a tension-free canthopexy.
13. Ghavami A, Pessa JE, Janis J, et al. The orbicularis
retaining ligament of the medial orbit: closing the circle.
Plast Reconstr Surg. 2008;121(3):994–1001.
14. Spinelli HM. Atlas of aesthetic eyelid and periocular
surgery. Philadelphia: Saunders; 2004.
15. Zide BM. Surgical anatomy around the orbit: the system
of zones. ed 2. Philadelphia: Lippincott, Williams &
Wilkins; 2006.
16. Fralick FB. Anatomy and physiology of the eyelid.
Ophthalmology. 1962;66:575–581.
17. Reid RR, Said HK, Yu M, et al. Revisiting upper eyelid
anatomy: introduction of the septal extension. Plast
Reconstr Surg. 2006;117(1):65–70.
This cadaveric and histologic study identiﬁes an extension of
the orbital septum that must be identiﬁed and spared when
performing a levator advancement for blepharoptosis.
18. Jones LT. The anatomy of the lower eyelid and its
relation to the cause and cure of entropion. Am J
Ophthalmol. 1960;49:29–36.

References

137.e1

tahir99 - UnitedVRG
vip.persianss.ir

19. Hawes MJ, Dortzbach RK. The microscopic anatomy
of the lower eyelid retractors. Arch Ophthalmol.
1982;100(8):1313–1318.
20. Gioia VM, Linberg JV, McCormick S. The anatomy
of the lateral canthal tendon. Arch Ophthalmol.
1987;105(4):529–532.
21. Muzaffar AR, Mendelson BC, Adams Jr WP. Surgical
anatomy of the ligamentous attachments of the
lower lid and lateral canthus. Plast Reconstr Surg.
2002;110(3):873–884.
22. Jones LT, Mustarde JC, Callahan A. Ophthalmic Plastic
Surgery. New York: Aesculapius; 1970.
23. Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy.
Philadelphia: WB Saunders; 1994.
24. Beard C, Quickert MH. Anatomy of the Orbit. New York:
Aesculapius; 1969.
25. Odunze MO, Reid RR, Yu M, et al. Periorbital
Rejuvenation and the African American Patient:
A Survey Approach. Plast Reconstr Surg.
2006;118(4):1011–1018.
26. Hirmand H. Anatomy and nonsurgical correction
of tear trough deformity. Plast Reconstr Surg.
2010;125(2):699–708.
27. Zinkernagel MS, Ebneter A, Ammann-Rauch D. Effect
of upper eyelid surgery on corneal topography. Arch
Ophthalmol. 2007;125(12):1610–1612.
28. Lee WB, McCord Jr CD, Somia N, et al. Optimizing
blepharoplasty outcomes in patients with previous
laser vision correction. Plast Reconstr Surg.
2008;122(2):587–594.
29. Rohrich RJ, Trussler AP. MOC-PS CME article:
Blepharoplasty. Plast Reconstr Surg. 2008;1:1–10.
30. Rohrich RJ, Coberly DM, Fagien S, et al. Current
concepts in aesthetic upper blepharoplasty. Plast
Reconstr Surg. 2004;3:32e–42e.
This continuing medical education article provides a concise
description of upper eyelid aging and a step-by-step guide to
popular rejuvenation techniques.
31. McCord CD, Tanenbaum M. Oculoplastic Surgery. New
York: Raven Press; 1987.
32. Beard C. Ptosis. St. Louis, MO: Mosby; 1976.
33. Anderson RL, Dixon RS. Aponeurotic ptosis surgery.
Arch Ophthalmol. 1979;97(6):1123–1128.
34. Flowers RS. Tear trough implants for correction of tear
trough deformity. Clin Plast Surg. 1993;20(2):403–415.
35. Flowers RS. Precision planning in blepharoplasty: the
importance of preoperative mapping. Clin Plast Surg.
1993;20(2):303–310.
36. Flowers RS. Canthopexy as a routine blepharoplasty
component. Clin Plast Surg. 1993;20(2):351–365.
37. Ortiz-Monasterio F, Rodriguez A. Lateral canthoplasty
to change the eye slant. Clin Plast Surg. 1985;75(1):1–10.
38. Fagien S. The role of the orbicularis oculi muscle and
the eyelid crease in optimizing results in aesthetic upper
blepharoplasty: a new look at the surgical treatment of
mild upper eyelid ﬁssure and fold asymmetries. Plast
Reconstr Surg. 2010;125(2):653–656.

References

SECTION I •

8

• Blepharoplasty

39. Flowers RS. Orbital rim contouring. In: Ousterhout D,
ed. Aesthetic Contouring of the Craniofacial Skeleton.
Boston, MA: Little, Brown; 1991.
40. Yaremchuk MJ. Secondary malar implant surgery. Plast
Reconstr Surg. 2008;121(2):620–628.
41. Flowers RS. Blepharoplasty and brow lifting. In:
Roenigk RK, Roenigk HH, eds. Principles of Dermatologic
Surgery. New York: Marcel Dekker; 1989.
42. Flowers RS. The biomechanics of brow and frontalis
function and its effect on blepharoplasty. Clin Plast Surg.
1993;20(2):255–268.
43. Flowers RS. Upper blepharoplasty by eyelid
invagination: anchor blepharoplasty. Clin Plast Surg.
1993;20(2):303–307.
44. Mendelson BC. Fat preservation technique of lower-lid
blepharoplasty. Aesthet Surg J. 2001;21(5):450–459.
Results shown in Mendelson’s article demonstrate the safe,
reproducible outcomes of a skin-only blepharoplasty and help
swing the pendulum away from aggressive, fat excisional
techniques.
45. Codner MA, Wolﬁ J, Anzarut A. Primary transcutaneous
lower blepharoplasty with routine lateral canthal
support: a comprehensive 10-year review. Plast Reconstr
Surg. 2008;121(1):241–250.
46. Loeb R. Naso-jugal groove leveling with fat tissue. Clin
Plast Surg. 1993;20(2):393–400.
47. Goldberg RA. Transconjunctival orbital fat
repositioning: transposition of orbital fat pedicles
into a subperiosteal pocket. Plast Reconstr Surg.
2000;105(2):743–748.
48. Sensöz O, Unlu RE, Percin A, et al. Septoorbitoperiostoplasty for the treatment of palpebral
bags: a 10-year experience. Plast Reconstr Surg.
1998;101(6):1657–1663.
49. Huang T. Reduction of lower palpebral bulge by
plicating attenuated orbital septa: a technical
modiﬁcation in cosmetic blepharoplasty. Plast Reconstr
Surg. 2000;105(7):2552–2558.
50. Camirand A, Doucet J, Harris J. Anatomy,
pathophysiology, and prevention of senile enophthalmia
and associated herniated lower eyelid pads. Plast
Reconstr Surg. 1997;100(3):1535–1538.

137.e2

tahir99 - UnitedVRG
vip.persianss.ir

51. de la Plaza R, Arroyo JM. A new technique for the
treatment of palpebral bags. Plast Reconstr Surg.
1998;81(5):677–687.
52. Parsa AA, Lye KD, Radcliffe N, et al. Lower
blepharoplasty with capsulopalpebral fascia
hernia repair for palpebral bags: a long-term
prospective study. Plast Reconstr Surg. 2008;121(4):
1387–1397.
53. Jelks GW, Glat PM, Jelks EB, et al. The inferior
retinacular lateral canthoplasty: a new technique. Plast
Reconstr Surg. 1997;100(8):1262–1266.
54. Patipa M. Transblepharoplasty lower eyelid and
midface rejuvenation: Part I. Avoiding complications
by utilizing lessons learned from the treatment of
complications. Plast Reconstr Surg. 2004;113(5):
1459–1468.
55. Paul MP, Calvert JW, Evans GR. The evolution of the
midface lift in aesthetic plastic surgery. Plast Reconstr
Surg. 2006;117(7):1809–1827.
56. American Society of Plastic Surgeons. Gender
distribution: cosmetic surgery 2008. Arlington Heights:
American Society of Plastic Surgeons; 2010. Online.
Available at: http://www.plasticsurgery.org/Media/
stats/2008-top-5-male-cosmetic-surgery-proceduresgraph.pdf
57. Flowers RS. Periorbital aesthetic surgery for men:
eyelids and related structures. Clin Plast Surg.
1991;18(4):689–729.
58. American Society of Plastic Surgeons. Cosmetic
demographics 2008. Arlington Heights: American
Society of Plastic Surgeons; 2010. Online. Available at:
http://www.plasticsurgery.org/Media/stats/
2008-cosmetic-procedure-demographics-ethnicity.pdf;
http://www.plasticsurgery.org/Media/stats/
2008-cosmetic-procedure-demographics-ethnicity.pdf
(Accessed March 1).
59. Few JW. Rejuvenation of the African American
Periorbital Area: Dynamic Considerations. Semin Plast
Surg. 2009;23(1):198–206.
Few’s survey-based study shows that one must prioritize a
patient’s ethnic identity and heritage when approaching the
periorbital area in African-Americans.

Aesthetic Surgery of the Face

Serious complications of primary blepharoplasty surgery are rare,
but should they occur, can be difﬁcult to correct and be potentially
disastrous.
Some serious complications which develop early, such as corneal
exposure, require aggressive treatment, but lesser complications
such as minor lid malpositions should be dealt with after time has
passed to allow for scar maturation.
The eyelids can be divided into four anatomic zones.
Upper eyelid problems include ptosis and lid retraction. An
understanding of Herring’s law is necessary to diagnose the
problem responsible for lid level asymmetry.
Lower lid malposition is a common problem after primary
blepharoplasty, and is due to an interplay between the patient’s
unique orbital and eyelid anatomy, and the cicatricial forces. There
are a number of predisposing factors.
Lower lid evaluation should address the presence of cicatricial
contraction, a vector analysis of the globe in relation to the malar
eminence, a soft tissue to bone distance at the lateral canthus,
tarsoligamentous integrity (distraction and snap tests), lower lid
eversion, and the level of the malar fat pad.
Lower lid malposition can be treated with various methods,
including a wide variety of canthopexy and canthoplasty
procedures, vertical spacer grafts and midface elevation.
In severe cases, a combination of modalities is often indicated.

2013, Elsevier Inc. All rights reserved.

©

Each year, over 200 000 people in the United States have
a blepharoplasty operation.1 These operations are generally
very successful with a high level of patient satisfaction.
Successful operations are the result of thorough preoperative
evaluation, skillfully performed customized surgical procedures, uneventful anesthesia, proper surgical venue and

Introduction

䊏

䊏

䊏

䊏

䊏

䊏

䊏

SYNOPSIS

tahir99 - UnitedVRG
vip.persianss.ir

individualized postoperative management. Although rare,
complications and unfavorable results may occur following
blepharoplasty. It has been estimated that the complication
rate following blepharoplasty is 2%.2–21 Minor complications
are temporary and self-limiting with minimal visual disturbance or aesthetic consequence (Table 9.1). Major complications are deﬁnitely undesirable and potentially disastrous.
They include visual loss, ﬁxed eyelid deformities, corneal
decomposition, and signiﬁcant aesthetic compromise (Table
9.2). In addition, an apparent technically successful operation
may produce a very unhappy patient.
Once the complication is discovered, a careful and thorough evaluation of the patient’s anatomical deformity and its
prognosis is essential. If impending visual compromise is
apparent, early emergent intervention may be warranted.
Most lid malpositions are temporary and resolve within 4–6
weeks postoperatively. It is important to protect the cornea
during this time. If the lid malpositions aggravate and contribute to corneal decompensation, they should be corrected
as soon as possible. However, lid malpositions that do not
compromise visual function may be corrected after scar maturation. In general, a delay in secondary surgical procedures to
address the problem is recommended. Secondary surgery is
more predictable in a surgical environment that is less inﬂammatory. Better results are obtained if secondary surgery can
be postponed for at least 6 months and preferably 1 year following the initial surgery.
The effect of blepharoplasty procedure complications on
patient and physician can be profound. When the results of
an elective aesthetic surgical procedure are suboptimal, the
patient usually becomes more difﬁcult to manage. It is easier
to manage a dissatisﬁed patient when there has been a thorough preoperative discussion of risks resulting in a signed
informed consent to the procedure. It is imperative to have a
handwritten note by the operating surgeon in the patient’s
chart documenting the explanation of the proposed surgical
procedures including any risks or complications to their
surgery. In addition, the alternatives to surgery should be
discussed.

Glenn W. Jelks, Elizabeth B. Jelks, Ernest S. Chiu, and Douglas S. Steinbrech

Secondary blepharoplasty: Techniques

9

SECTION I

Inﬂammatory conditions
Infectious
Cellulitis
Abscess
Hordeolum
Chalazion
Blepharitis
Noninfectious
Allergic
Chemical
Blepharitis

Eyelid deformities
Hematoma
Epicanthal folds
Cysts
Wound separation
Eyelid numbness
Eyelid discoloration
Scars
Loss of eyelashes

Eyelid malposition
Upper eyelid
Ptosis
Retraction
Contour change
Marginal rotation
Lower eyelid
Scleral show
Lid retraction
Lid paresis
Marginal rotation
Ectropion or entropion

Once a complication occurs, more time and effort by the
physician and his support staff will be required. This often
translates into arranging for more frequent ofﬁce visits. The
physician must devote more time to help the patient through
this disappointing situation. Reassurance by the surgeon in
the face of temporary complications will aid in patient acceptance of prolonged healing.
The easiest complication to avoid is failure to recognize a
pre-existing condition that would increase the likelihood of
an unfavorable result from standard blepharoplasty (Table
9.3).22–25 The pre-existing conditions include: (1) medical or
ophthalmological conditions that may increase the risk of
visual impairment; (2) morphological variants that predispose
the patient to post-blepharoplasty eyelid malpositions;

139

tahir99 - UnitedVRG
vip.persianss.ir

(3) anatomical variations that may be accentuated after
eyelid skin, muscle; and fat removal and, most importantly,
(4) the psychological status of the patient and assessment
of their expectations of surgery. The presence of a preexisting condition does not preclude cosmetic blepharoplasty;
however, the surgical timing, venue, and technique may have
to be altered.
The following discussion contains relevant information
regarding anatomical zones of the eyelids as well as prevention, diagnosis, and management of complications in the postblepharoplasty patient. Although malposition of both the
upper and lower eyelid are presented, a particular emphasis
is placed on unnatural distortion of the lower eyelid as these
are the most common types of defects encountered.

From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.27

Conjunctival changes
Chemosis
Prolapse
Incarceration
Hemorrhage

Lacrimal disorder
Dry eye
Epiphora
Tear ﬁlm abnormality
Reﬂexly stimulated tears
Tear distribution abnormalities
Lid margin eversion
Lid retraction
Lid ectropion
Lid entropion
Lid paresis
Tear drainage abnormalities
Punctal eversion
Obstruction of nasolacrimal system
Lid paresis
Dacryocystitis

Corneal changes
Exposure
Keratitis
Erosion
Ulcer
Refractive
Astigmatism
Edema
Tear ﬁlm abnormality
Basement membrane disorder

Extraocular muscle disorder

Glaucoma

Pupil changes

Retrobulbar hemorrhage without visual loss

Table 9.1 Minor blepharoplasty complications

Introduction

SECTION I •

9

Contour changes
Margin abnormalities
Lower eyelid
Scleral show
Retraction
Laxity
Paralysis
Margin abnormalities
Ectropion
Entropion

In both primary and secondary surgery of the eyelids and
orbital region, protection of the cornea is essential. Specially
designed, protective contact lenses should be routine (Fig.
9.3).27 Colored lenses are preferred as they ﬁlter bright operating light if the procedure is performed under local anesthesia,
and they are also less often inadvertently left on the cornea
postoperatively. The contact shell prevents desiccation and
inadvertent corneal injury by an instrument or gauze. In order
to avoid postoperative corneal abrasions, deep sutures on or
near the conjunctival surface should be placed in such a
manner that the knots are buried in the tissue or placed externally. A continuous buried suture that may be pulled out after
healing is particularly useful in the approximation of tissue
over the cornea. Skin grafts should not be placed in the conjunctival sac if they are to be in contact with the cornea; only
conjunctival or other mucosal tissue is tolerated by the cornea.

To facilitate complete and thorough anatomical analysis, the
eyelids are divided into zones (Fig. 9.1).22,26 Zone 0 includes
the ocular globe and orbital structures behind the arcus marginalis, posterior lacrimal crest, and lateral retinaculum.
Zones I and II include the upper eyelid and lower eyelid,
respectively, from the lateral commissure to the temporal
aspect of canalicular puncti. Zone III is the medial canthus
with the lacrimal drainage system. Zone IV is the lateral
retinaculum. Zones I–IV are further subdivided into structures that are anterior (preseptal) or posterior (postseptal) to
the orbital septum. Zone V includes the contiguous periorbital
structures of nasal, glabella, brow, forehead, temple, malar,
and nasojugal regions which merge with zones I–IV (Fig. 9.2).
The diagnosis and management of upper eyelid (zone I) and
lower eyelid (zone II) complications that occur as a result of
blepharoplasty procedures will be discussed in detail.

tahir99 - UnitedVRG
vip.persianss.ir

Corneal protection

Anatomical zones

From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.27

Permanent eyelid deformities and functional disorders
Lacrimal disorders
Dry eye
Epiphora
Tear ﬁlm abnormalities (reﬂexly stimulated)
Tear distribution abnormalities
Lid eversion
Lid retraction
Ectropion
Entropion
Tear drainage abnormalities
Lid paralysis
Medial punctal eversion
Obstruction of nasolacrimal system
Eyelid malpositions
Upper eyelid
Ptosis
Retraction

Visual loss or alteration
Globe penetration
Retrobulbar hemorrhage
Glaucoma
Extraocular muscle disorder
Corneal
Exposure
Ulcer
Filaments
Scar
Neovascularization
Refractive
Astigmatism
Tear ﬁlm abnormality
Contact lens intolerance
Basement membrane disorder
Eyelid deformities
Palpebral aperture asymmetry
Unveiled pre-existing condition
Iatrogenic
Upper eyelid fold
Asymmetric
Absent
High
Low
Multiple
Epicanthal folds
Cicatrix
Inadequate fat removal
Excessive fat removal
Suture tunnels
Dermal pigmentary changes
Festoons
Malar pads

• Secondary blepharoplasty: Techniques

Table 9.2 Major blepharoplasty complications

140

IV

II

I

V

III

Fig. 9.1 Surgical zones of the eyelids and periocular structures. Zone I, upper
eyelid; zone II, lower eyelid; zone III, medial canthal structures including the
lacrimal drainage system; zone IV, lateral canthal area; zone V, periocular
contiguous area-glabella, eyebrow, forehead, temple, malar, nasojugal and nasal
areas. (From Spinelli HM, Jelks GW. Periocular reconstruction: a systematic
approach. Plast Reconstr Surg 1993;91:1017.)

V

Pre-existing conditions
Medical conditions
Hypertension
Diabetes
Bleeding disorders
Inﬂammatory skin condition
Asthma
Sulﬁte allergy
Venous thrombosis
Cardiac disorders
Atherosclerosis
COPD
Emphysema
Sleep apnea
Ophthalmological conditions
Amblyopia
Diplopia
Strabismus
Glaucoma
Corneal disease
Eyelid disorder
High myopia
Contact lens wearer
Retinal disorders
Uveitis
Dry eye
Tear ﬁlm dysfunction
Refractive surgery

5

3

141

tahir99 - UnitedVRG
vip.persianss.ir

Fig. 9.2 Topographic anatomy of the eyelids and cheeks. (1) Superior eyelid fold;
(2) inferior eyelid fold; (3) malar fold; (4) nasojugal fold; (5) nasolabial fold.
(Modiﬁed from Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications
and problems in aesthetic plastic surgery. New York: Gower Medical Publishing;
1992.)

4

2

1

Psychological
Realistic outcome expectations
Ability to deal with vision loss, deformity
Body dysmorphic disorder
Body image

Anatomical variations
Tear trough deformity
Malar pads
Festoons
Cheek-lid interface deformity
True ptosis
Look ptosis
Frontalis spasm
Corrugator hyperactivity
Crow’s feet
Punctal eversion
Ectropion
Entropion

Morphology
Negative vector
Malar hypoplasia
High myopia
Small orbital volume
Horizontal lid laxity
Involutional
Cicatricial
Ectropion
Entropion

Table 9.3 Prevention of blepharoplasty complications: preoperative evaluation

Corneal protection

SECTION I •

9

Posterior lamella

Middle lamella

Anterior lamella

Palpebral conjunctiva

Fat

Levator function (measurement)

Lid levels

Normal

Normal

0–3 mm

Equal

Normal
Symmetric

Palpebral aperture

Normal

Lash position

Lid fold position

Normal

Skin
Scars

Absent
Normal

Lagophthalmos

Table 9.4 Secondary blepharoplasty candidate evaluation: upper eyelid

Abnormal

Abnormal

3–10 mm

Ptosis
Unilateral
Bilateral
Cicatricial
Mechanical
Involutional

Asymmetric

Abnormal

Abnormal

Abnormal

Abnormal

Present

tahir99 - UnitedVRG
vip.persianss.ir

Excess
removal
Retention

>10 mm

Retraction
Physiologic
Thyroid
Bell’s
Cicatricial

High
Low
Absent
Multiple

Position
Quality

Over-resection
Excess

A thorough evaluation of the upper eyelid (zone I) level is
facilitated by dividing the structure into anterior, middle, and
posterior lamella (Table 9.4). The anterior lamella is composed
of upper lid skin and orbicularis muscle. The middle lamella
is composed of the tarsus, levator mechanism, orbital septum,
and fat. The posterior lamella consists of the conjunctiva. The
palpebral aperture is primarily inﬂuenced by the upper eyelid
levels (Fig. 9.4). The palpebral aperture usually varies in
shape, size, and obliquity due to hereditary, racial, traumatic,
or other acquired situations. The surrounding bony orbital
anatomy, the internal orbital volume, and the integrity of the
eyelids, with their muscular and tarsoligamentous supports,
are some of the factors that inﬂuence the palpebral aperture
(Figs 9.5, 9.6). It is also inﬂuenced by the relative amount of
associated periorbital skin, fat, and soft tissues. Unique individual combinations of eyelid and orbital anatomy can cause
variations in the palpebral aperture (Fig. 9.4).28
The eyelid fold position should also be evaluated. In the
occidental patient, the upper eyelid fold is normally 8–10 mm
above the lid margin. This corresponds to the superior attachments of the levator aponeurosis to the subcutaneous tissue
of the eyelid. Above the lid fold, the aponeurosis does not
attach to the preseptal or orbital subcutaneous tissue, and the
overhanging skin forms a fold. Inferior to the lid fold there

Upper eyelid malposition: evaluation
and management

Upper eyelid

• Secondary blepharoplasty: Techniques

Fig. 9.3 Corneal protective shields manufactured with a steep central radius of
curvature and a ﬂat peripheral radius of curvature. This conﬁguration prevents direct
contact. Colored lenses are preferred as they ﬁlter bright operating light if the
procedure is performed under local anesthesia, and they are also less often
inadvertently left on the cornea postoperatively. (From Jelks GW, Jelks EB.
Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic
surgery. New York: Gower Medical Publishing; 1992.)

142

Normal

B

Ptosis

C
Lid retraction

143

Fig. 9.5 Sagittal section through the upper eyelid showing the relationship of
the orbicularis oculi muscle, septum orbitale, levator palpebrae superioris, and
Mueller’s muscle. (Modiﬁed from Jelks GW, Smith BC. Reconstruction of the
eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery.
Philadelphia: WB Saunders; 1990:1671.)

Tarsus

Attachments
to skin

Attachments
to tarsus

Cul-de-sac of
conjunctiva

Müller’s muscle

Levator tendon

Orbital septum

Obicularis

Skin

Ptosis is the abnormally low level of the upper eyelid.28–31
Ptosis of the upper eyelid can result from damage to the
levator complex during retroseptal dissection by direct
trauma, hematoma, edema, or septal adhesions.28,32–38 The
normal upper eyelid level covers 2–3 mm of the superior
limbus or lies at the level midway between the superior edge
of a 4 mm pupil and the superior corneal limbus (Fig. 9.4).
Preoperative variations in upper eyelid levels may result from
the level of alertness, pharmacologic agents, direction of gaze,
size of the ocular globe, orbital volume, visual acuity, and
extraocular muscle balance.28 Occasionally, unrecognized
ptosis manifests itself in the postoperative blepharoplasty
patient. Review of the preoperative examination records and
medical photography usually reveals the etiology. When no
presenting condition can be documented, a surgical misadventure is implicated in the etiology.
Mechanical ptosis due to postoperative edema is symmetric and transient and usually resolves spontaneously within
48–72 h. A hematoma in the retroseptal space can cause
impairment of levator muscle function, maintaining the upper
eyelid in a ptotic position. Resorption of the hematoma may
produce secondary ﬁbrosis of the levator with persistent
ptosis. Attempts to create high upper eyelid supratarsal
folds involve ﬁxing the skin muscle edges to the levator
aponeurosis. This can lead to tractional ptosis if the lid fold is

Ptosis

are levator attachments to the subcutaneous tissue overlying
the tarsus. In the Asian patient, the orbital septum inserts
more inferiorly onto the distal expansion of the levator aponeurosis, which allows more preaponeurotic fat to descend
into the upper eyelid and the resultant lower eyelid crease.
Blepharoplasty in Asians requires the identiﬁcation of suborbicular fat. Dissection through this fat layer provides access
to the orbital septum and the retroseptal (preaponeurotic) fat.
Ptosis and lid retraction are conditions that alter the palpebral aperture by affecting the anatomic position of the upper
eyelid. Localization of any major eyelid pathology facilitates
the delineation of corrective procedures. The most commonly
seen upper eyelid complications requiring secondary correction are ptosis and lid retraction.

Fig. 9.4 (A) Normal palpebral aperture. The upper eyelid is normally 1–2 mm below the superior corneal limbus. (B) Ptosis is seen when the upper eyelid level is below
that seen in (A), interfering with the superior visual ﬁeld. (C) Lid retraction is seen when the elevation of the upper lid is at or above the superior corneal limbus. (Modiﬁed
from Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

A

Upper eyelid

Levator

SECTION I •

9

B

Tarsus

Conjunctiva

Müller’s smooth muscle

Levator aponeurosis

Obicularis
Orbital septum

Skin

• Secondary blepharoplasty: Techniques

C

Fig. 9.6 Sagittal section illustrating the structures of
the upper eyelid, including the levator muscle, its
aponeurosis, and its relationship with Mueller’s muscle
and the septum orbitale. (Modiﬁed from Jelks GW,
Smith BC. Reconstruction of the eyelids and associated
structures. In: McCarthy JG, ed. Plastic surgery.
Philadelphia: WB Saunders; 1990:1671.)

placed too high. The medial and lateral retinaculae become
tense and lower the upper lid level. Treatment consists of
observation and massage of the upper eyelid. If ptosis persists
more than several weeks, removal of the supratarsal ﬁxation
sutures is necessary. Ptosis may also occur when adhesions
develop between the orbital septum and the levator aponeurosis at a level higher than the original septal origin.
Ptosis is classiﬁed as mild at 1–2 mm, moderate at 2–3 mm,
and severe at ≥4 mm.4,22,28 The amount of ptosis is documented
by measuring the vertical dimensions of the palpebral apertures at the midpupillary line. The amount of levator function
in millimeters is measured whenever ptosis is diagnosed in
order to plan a surgical correction. The test is performed by
examining the upper eyelid excursion from complete down
gaze to up gaze, while blocking any contribution to upper
eyelid elevation by the eyebrow (Fig. 9.7). Asymmetric or
absent lid creases must be identiﬁed, because asymmetry can
be accentuated with standard blepharoplasty techniques. The
vertical dimensions of the palpebral apertures at the midpupillary line are also measured.23

Aponeurosis disinsertion, or dehiscence, is the most
common form of acquired ptosis. The typical clinical presentation is a mild (1–2 mm) to moderate (2–3 mm) case of ptosis
associated with thin upper eyelids, high lid folds, and good
levator excursion (Figs 9.8, 9.9).28 The levator muscle originates from the apex of the orbit and passes anteriorly, becoming aponeurotic at the superior orbital margin to insert onto
the anterior two-thirds of the anterior tarsal surface. Some
ﬁbers of the aponeurosis extend to the orbicularis fascia to
attach to the dermis of the upper eyelid, forming the upper
lid crease. The anterior orbital fat removed during upper
blepharoplasty lies posterior to the septum and anterior to
the levator aponeurosis. Inadvertent penetration or detachment injury to the levator aponeurosis can occur during
removal of the preseptal orbicularis oculi muscle or retroseptal fat (Fig. 9.9A).
The condition is repaired by levator exploration and
advancement of the aponeurotic structures to the anterior
tarsus.32–38 Patients with levator detachment should be
repaired by levator advancement to the anterior tarsus. The

Fig. 9.7 (A) Patient with acquired ptosis of the left upper lid. (B,C) Levator function of 15 mm was measured with a ruler from down gaze to up gaze while manually
blocking brow elevation of the upper eyelid. Levator function >10 mm is considered good. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and
problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

A

Lateral canthal tendon

Lateral rectus

Lateral horn of
levator aponeurosis

Globe

Superior rectus

144

B

Retraction in the upper eyelid may also present as a result of
ptosis in the contralateral eye (Fig. 9.13). This type of retraction can be explained by Herring’s law of equal innervation,43
which states that both the levator palpebrae muscles receive
the same level of innervation (for motor power), regardless of
whether they are asymmetric. Therefore, if one eyelid is ptotic,
when the body produces a reﬂex action to overstimulate the
eyelid to improve the ptotic eyelids position, the contralateral
eye will then appear retracted. Herring’s law is an important
consideration in both ptosis repair and lid retraction repair.
By covering each eye independently during evaluation, the
true amount of retraction may be revealed. Treatment consists
of repair of the ptotic eyelid which should ultimately correct
the asymmetry (Fig. 9.13).

Herring’s law

Lid retraction of the upper eyelid is an elevation of the upper
eyelid margin above the superior corneal limbus. Lid retraction may be unilateral or bilateral, giving the patient a staring
appearance and the illusion or accentuation or exophthalmos.
Excessive skin removal from the upper eyelid may result in
lagophthalmos and lid retraction which prevents complete
closure of the eyelids (Fig. 9.11A). Varying amounts of lid
margin eversion may also be present (Fig. 9.11B). Surgical
correction requires release of the retraction through application of a retro- or preauricular full-thickness skin graft (Fig.
9.11C,D).37–42
Adhesion, ﬁbrosis, and foreshortening of the mid-lamellar
structures of the upper lid (levator aponeurosis, orbital
septum, and tarsus) can cause upper eyelid retraction (Fig.
9.12A). Treatment requires surgical release of the adhesion,
levator aponeurosis recession, interpositional fascial grafts,
and lid traction sutures, which should establish a minimal
amount of ptosis of the involved lids (Fig. 9.12B).27,37–42
Subsequent ptosis correction by a levator aponeurosis
advancement or partial tarso-mullerectomy usually produces
an acceptable result (Fig. 9.12C).27,37

Retraction

Fig. 9.9 (A) Patient who underwent cosmetic blepharoplasty with inadvertent disinsertion of the right levator aponeurosis during orbicularis oculi and retroseptal fat removal
resulting in a right upper eyelid ptosis. (B) Patient following cosmetic blepharoplasty with a left upper eyelid ptosis from inadvertent levator aponeurosis detachment.

A

Fig. 9.8 Levator aponeurosis dehiscence produces a high upper lid fold, thin upper
eyelid, and ptosis. (Modiﬁed from Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC,
ed. Complications and problems in aesthetic plastic surgery. New York: Gower
Medical Publishing; 1992.)

Ptosis

Skin

Tarsus

Thin lid

Conjunctiva

Müller’s smooth
muscle

Levator aponeurosis

High lid fold

Orbital septum

Preaponeurotic fat

Levator
aponeurosis

Obicularis oculi

145

Fasanella–Servat38 technique and its various modiﬁcations
(Fig. 9.10), or variations of a tarso-mullerectomy are also
excellent approaches to correct minimal ptosis.

Upper eyelid

SECTION I •

9

D

• Secondary blepharoplasty: Techniques

D

B

E

C

Fig. 9.10 The Fasanella–Servat technique. (A) The eyelid is everted. (B) Two thin, curved hemostatic forceps are placed on the lower edge of the everted lid ≤3 mm from
the upper border of the tarsus. The ﬁrst of the interrupted incisions is made. The interrupted incisions are extended in steps of 4–5 mm. A mattress suture is placed after
each incision. (C) The sutures are tied so as to hold the tissues ﬁrmly yet allow the lid to be returned to its normal position at the end of the procedure. (D) Fasanella’s
alternative method of suturing a running continuous or “serpentine” fashion. (E) The running continuous or “serpentine” suture is returned, and the suture is tied on the
temporal side. (Modiﬁed from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders;
1990:1671.)

A

Fig. 9.9, cont’d (C,D) Patients with left upper eyelid cicatricial ptosis due to adhesions between the levator aponeurosis, orbital septum, and skin. (From Jelks GW, Jelks
EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

C

146

D

C

147

B
C

B
C

Fig. 9.13 (A) Patient presents with left t upper lid retraction and right lid ptosis secondary to purulent granulation tissue in the right upper eyelid. (B) By covering the right
ptotic eye, the retracted eye exhibits a normal lid level due to Herring’s law of equal innervation. (C) Following excision of granulation tissue and correction of ptosis, the
patient exhibits normal lid levels bilaterally.

A

Fig. 9.12 (A) Patient 2 months postoperatively with right upper eyelid cicatricial retraction of the midlamellar structures (tarsus, orbital septum, and levator aponeurosis. (B)
Patient 6 months after the release of lid adhesions and a levator recession of the right upper eyelid. Minimal ptosis of the right upper eyelid was deliberately produced. (C)
Patient 6 months after ptosis correction by tarso-mullerectomy. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic
surgery. New York: Gower Medical Publishing; 1992.)

A

Fig. 9.11 (A) Patient with excessive skin removal from the upper eyelid and lagophthalmos. Bell’s reﬂex is fair. (B) Patient with upper eyelid retraction, lid margin eversion,
and exposure keratopathy due to excessive upper eyelid skin excision. Note the surgical marking for the proposed incision to release the scar and establish a wide defect.
(C) Retroauricular full-thickness skin graft sutured to the defect. (D) Patient 9 months postoperatively. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed.
Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

B

A

Upper eyelid

Upper pretarsal

Upper preseptal

Orbital

SECTION I •

9
• Secondary blepharoplasty: Techniques

B

Lower preseptal

Lower
pretarsal

Upper
pretarsal

Lateral canthal
tendon

Upper preseptal

Lateral horn of levator

Upper tarsus

The complications of primary blepharoplasty have been
described in Chapter 6. Asymmetry is a common problem and
distortion of lower lid position is a common contributor to
this phenomenon.2–4,7–10,13,18–21
This malposition is often due to an interplay of the patient’s
unique periorbital anatomy with mechanical distraction due
to gravitational and cicatricial forces of the skin, muscle, and
septum displacing the lid inferiorly following blepharoplasty
procedures.22,23 Canthal and eyelid laxity, edema, hematoma,
excessive resection of skin and fat, or impaired orbicularis
oculi muscle function may also contribute to the disruptive
forces.
The lower eyelids (zone II) extend from the lid margin to
the cheek area (Fig. 9.1). The medial canthus zone (zone III),
is a complex region containing the origins of the orbicularis
oculi muscle, the lacrimal collecting system, and associated
neurovascular structures. The lateral canthus (zone IV) is an
integral anatomic unit of the temporal aspects of the eyelids.
The lateral canthus zone, which is more correctly termed
lateral retinaculum, consists of: (1) the lateral horn of the
levator palpebrae superioris muscle; (2) the continuation of
the preseptal and pretarsal orbicularis oculi muscle (the lateral
canthal tendon); (3) the inferior suspensory ligament of the
globe (Lockwood’s ligament); and (4) the check ligaments of
the lateral rectus muscle (Fig. 9.14).22,23,26,27 The lateral retinaculum structures attach to a conﬂuent region of the lateral bony
orbital wall on a small promontory just within the lateral
orbital rim known as Whitnall’s tubercle (Figs 9.2, 9.15).23,27
Similar to the upper lid, the lower lid is also divided
into structural layers, consisting of the anterior, middle, and
posterior lamella. The anterior lamella is composed of the
lower lid skin and orbicularis muscle. The middle lamella (or
midlamellar) structures include the tarsus, capsulopalpebral

Evaluation

Lower eyelid malposition

Lower eyelid

Upper
preseptal
Upper
pretarsal

Lower
pretarsal
Lower
preseptal

Levator palpebrae superioris

Fig. 9.15 The lateral extension or horn of the levator aponeurosis (upper arrow)
splits the lacrimal gland into its orbital (O) and palpebral (P) lobes and extends
inferolaterally to join the lateral retinaculum. The lateral portion of Whitnall’s
ligament (W) inserts into the orbital lobe of the gland by way of the interglandular
fascial septa. The inferolateral pole of the palpebral lobe of the lacrimal gland
usually rests at the level of the lateral retinaculum (lower arrow). The lateral
retinaculum is a conﬂuence of the lateral horn of the levator, the lateral canthal
tendon, Lockwood’s suspensory ligament of the globe, and check ligaments from
the lateral retinaculus muscle. (Modiﬁed from Jelks GW, Smith BC. Reconstruction
of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery.
Philadelphia: WB Saunders; 1990:1671.)

Lateral canthal
tendon

Lateral horn
of levator

Lateral rectus

Superior rectus

Fig. 9.14 (A) The lateral palpebral raphe. (B) The lateral canthal tendon and the anatomy of the structures of the lateral canthus. (Modiﬁed from Jelks GW, Smith BC.
Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1990:1671.)

A

Lateral palpebral raphe

148

Absent

Lagophthalmos

Palpebral conjunctiva

Yes

No

No

Lateral canthal laxity

Symmetric

Palpebral aperture

Asymmetric

Abnormal

High

>1 cm

Negative

fascia, and orbital septum. The posterior lamella is the
conjunctiva.
Anatomical analysis, especially of the lateral canthal region,
and a thorough understanding of lower eyelid malposition
etiology are required to choose and perform the appropriate, corrective secondary blepharoplasty procedure in
the lower lid (Tables 9.5, 9.6). Predisposing factors for postblepharoplasty eyelid malposition include: hypotonicity/
involutional changes, malar hypoplasia, shallow orbit, thyroid
ophthalmopathy, unilateral high myopia, and patients undergoing secondary blepharoplasty.3,22
A thorough clinical assessment should include evaluation
of: (1) pretarsal orbicularis oculi muscle function; (2) presence
of vertical midlamellar cicatricial lid retraction/excessive skin
resection; (3) morphology: vector analysis and soft tissue to
bone distance; (4) tarsoligamentous integrity; (5) presence
of lower margin eversion; (6) posterior lamellar integrity;
and (7) presence of malar fat pad descent.
Signiﬁcant deformities may occur when excess skin and
muscle are excised during a blepharoplasty procedure.

Equal

Medial to lateral canthal
position

Medial canthal laxity

Normal

Snap test

Abnormal

Yes

Normal

Distraction test

Abnormal
(>8 mm)

<1 cm

Soft tissue: bone
distance

Tarsoligamentous integrity

Neutral

Positive

<1 cm

Vector analysis

Anatomical morphology

Abnormal

Abnormal

Absent

Present

Present

Abnormal

Present

Present

Excess removal
Retention

LME I
LME II (w/scleral show)
LME III (w/lash rotation)
Ectropion

Over-resection
Excess

Position
Severity

149

Scarring of the pretarsal orbicularis oculi muscle to the middle
lamella can result in lower lid malposition and scleral show.
Denervation of the orbicularis oculi muscle leads to ﬂattening
of this area resulting in an aged, unnatural look. More importantly, denervation or damage to orbicularis oculi muscle can
lead to an incomplete blink mechanism, lack of tone, laxity of
the lower lid and scleral show.
During the evaluation of the patient with lower eyelid malposition it is important to determine if there is any element of
midlamellar (tarsus, capsulopalpebral fascia, orbital septum)
cicatricial retraction (Fig. 9.16). If lid retraction is present, then
surgical management may require lysis of the adhesions,
interpositional grafts (cartilage, palatal mucosal), and other
grafts, ﬂaps, and procedures for correction. Ordinarily, when
upward traction is placed on the lower eyelid, it is easily
displaced to the level of the mid-pupil or above. When midlamellar retraction is present, the eyelid will have restricted
upward mobility (Fig. 9.17).
The lateral view reveals the vector relationship of the (1)
ocular globe to (2) the lower lid and (3) the malar eminence
(Fig. 9.18).22,44–46 A positive vector relationship is when the most
anterior projection of the globe lies behind the lower eyelid
margin, which lies behind the anterior projection of the malar
eminence. It is a favorable anatomic situation because there is
good bony, eyelid, and tarsoligamentous support with normal
eyelid contours and levels. A neutral vector relationship is
when the most anterior projection of the globe is in a vertical
relationship with the lower lid and malar eminence. Like the
positive vector relationship, it has minimal risk for lower
eyelid malposition following aesthetic blepharoplasty. The
negative vector relationship is when the most anterior projection of the globe lies anterior to the lower lid and malar eminence These patients often have scleral show. They have a
hypoplastic malar relationship which increases the risk for an
unfavorable result, and requires alteration in the aesthetic
blepharoplastic procedure to prevent postoperative lower
eyelid malposition (Fig. 9.19).
The soft tissue to bone distance is measured from the lateral
canthus to orbital rim (Fig. 9.20). This distance is important
for determining what type of lower lid support procedure is
necessary to deliver acceptable results. If the distance is <1 cm,

Normal

Normal

Absent

Lid margin eversion

Fat

Normal

Skin

Present

Absent

Scars

Vertical cicatricial midlamellar retraction

Absent

Pretarsal orbicularis oculi function

Table 9.6 Lateral canthal zone evaluation

Posterior lamella

Middle lamella

Anterior lamella

Table 9.5 Secondary blepharoplasty candidate evaluation: lower eyelid

Lower eyelid

SECTION I •

9
• Secondary blepharoplasty: Techniques

Lower pretarsal
obicularis oculi
Mid-lamellar cicatrix
Lower preseptal
obicularis oculi

Tarsus

B

the patient usually presents with deep set eyes (i.e., positive/
neutral vector). Tarsal strip lateral canthoplasty and inferior
retinacular lateral canthoplasty/canthopexy are effective procedures to address this problem. If the distance is >1 cm and
the patient presents with prominent eyes (i.e., negative vector),
inferior retinacular lateral canthoplasty, dermal orbicular
pennant lateral canthoplasty, and midfacial elevation are
effective procedures in the surgical armamentarium to correct
lower lid malposition in these patients.
The tarsoligamentous integrity is determined by three components: lower lid laxity, medial canthal laxity, and lateral
canthal laxity. Horizontal lower lid laxity is diagnosed by
“distraction” and “snap” test (Fig. 9.21).3,22,37 In the distraction
test, the lower lid is grasped with the thumb and index ﬁnger
and displaced anteriorly. In the post-blepharoplasty patient,
when the lower lid can be distracted laterally >8 mm, there
should be concern for compromised tarsoligamentous integrity. The snap test is performed by pulling the eyelid inferiorly
to the level of the inferior orbital margin and then releasing it
to judge the speed at which it returns to a normal level. A lid

with a slow snap back or a persistent eversion may have
eyelid and canthal laxity requiring correction (Fig. 9.22). If the
lateral canthus is higher than or equal to the level of the
medial canthus, one may elect to perform horizontal lid shortening with a wedge resection alone or in combination with
lateral canthoplasty. If, however, the lateral canthus is lower
than the medial canthus, a lateral canthoplasty procedure is
necessary for optimal correction.
Another component of the evaluation of the secondary
blepharoplasty patient involves lower lid eversion, which is
divided into four subtypes. The four types of lower lid eversion are as follows: (I) lid margin eversion (LME) with scleral
show; (II) LME with scleral show and horizontal lid laxity;
(III) LME with lash rotation; and (IV) ectropion – involutional
or cicatricial (Fig. 9.23). The term ectropion denotes an outward
turning or eversion of the eyelid. Ectropion may be classiﬁed
as either involutional or cicatricial.5,22,37 A common factor
in all forms of ectropion is conjunctival hyperemia or keratinization, punctual occlusion, and inﬂammatory changes
that become progressively worse. Involutional ectropion (aka,

Fig. 9.17 (A) Patient with vertical displacement of the right lower eyelid demonstrates movement of the eyelid to the mid-pupillary level. (B) Same patient with
displacement of the left lower eyelid demonstrating midlamellar cicatricial changes preventing movement of the lid (lid retraction). (From Jelks GW, Jelks EB. Blepharoplasty.
In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

A

Fig. 9.16 Midlamellar cicatricial retraction is one of the most common indications for secondary blepharoplasty. Correction requires lysis of adhesions in conjunction with
lateral canthoplasty with or without spacer grafts.

Orbital rim

Inferior oblique

Orbital septum
Conjunctiva

Lateral canthal tendon

150

3

1
2

H

E

B

3

1
2

F

C

3

2

1

151

senile ectropion) is caused by horizontal lid laxity of the eyelid
supportive structures and usually begins with scleral show
(Fig. 9.24). Cicatricial ectropion is caused by a deﬁciency of
the skin or skin and muscle of the lid. In secondary blepharoplasty patients, cicatricial ectropion is seen following excess
skin removal and/or multiple previous blepharoplasty procedures and resultant scarring (Fig. 9.24).
Patients with lower lid retraction often have a descent of
the malar fat pad.7,9 A procedure such as a subperiosteal
midface suspension techniques may be required to elevate
the malar fat pad to a position that will assist in supporting
the lower eyelids. A transblepharoplasty subperiosteal
midface elevation in conjunction with lateral canthoplasty
(with or without a spacer graft) may be required in patients
who present with lagophthalmos from multiple procedures
and excessive skin resection to obviate or reduce a full
Several surgical procedures are available to provide excellent
lower eyelid function and contour in the secondary blepharoplasty patient requiring correction of lower lid derformities.2,3,8,9,16,48–57 As mentioned previously, careful evaluation of
the etiology of the lower eyelid defect as well as a thorough
morphological anatomical examination will assist the surgeon
in determining the optimal procedure(s) to perform to best
address the defect or defects (Fig. 9.25, Table 9.7).

Management

thickness skin grafting requirement. This is partially covered
in Chapter 11.1.22,47
Finally, examination of the inner component of the posterior lamella should be conducted to determine if ﬁbrosis,
infection, inadequate blood supply, etc., is present.

Fig. 9.18 Comparison of the variable anatomic relationships of the orbital region that inﬂuence the palpebral aperture. (1) Ocular globe; (2) lower lid; (3) malar eminence.
Cosmetic blepharoplasty may have to be combined with other surgical procedures to prevent complications. (A,B) Young woman with high lid folds, deep set eyes (large,
bony orbital volume with small ocular globes), and well-developed malar eminences. The most anterior projection of the ocular globe lies behind the lower eyelid margin
and the malar eminence. This positive vector relationship is a favorable anatomic situation as there is good eyelid and tarsoligamentous integrity with normal eyelid contours
and levels. (C,D) Woman presenting for cosmetic blepharoplasty with prominent ocular globes and increased periorbital skin and fat. The most anterior projection of her
ocular globes are posterior to the lower eyelid margin and inferior orbital margin (malar eminence). This is a neutral vector relationship with a minimum risk for lower eyelid
malposition. (E,F) Woman with prominent ocular globes, slight scleral show, and malar hypoplasia. The lateral view demonstrates the inﬂuence of the globe on the lower
eyelid position and the lack of eyelid support from the inferior orbital rim. This patient has a negative vector relationship with the most anterior portion of portion of the globe
anterior to the lower lid and malar eminence. This negative vector relationship requires alterations in the cosmetic blepharoplastic procedure to prevent lower eyelid
malposition. (G,H) Middle-aged woman with excess eyelid skin and fat, normal ocular globe position, marked inferior scleral show, lower eyelid laxity, and malar hypoplasia.
This woman has a negative vector relationship and is at risk for an unfavorable result from lower eyelid surgery. A lower eyelid and lateral canthal tightening with
repositioning (lateral canthalplasty) should be combined with the cosmetic blepharoplasty. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and
problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

G

D

A

1
2
3

Lower eyelid

SECTION I •

9

D

• Secondary blepharoplasty: Techniques

B

Fig. 9.20 Lateral bone to canthus relationship. (A) Patients with <1 cm distance exhibit a positive/neutral vector. (B) Patients with >1 cm exhibit an negative vector.

A

Fig. 9.19 Eyelid malpositions following lower eyelid blepharoplasty. (A) Patient with bilateral lid margin eversion, round of the lateral canthi, and scleral show. (B) Patient
with lower eyelid horizontal laxity as well as the ﬁndings shown in (A). Note the malar hypoplasia. (C,D) Patient with marked lower eyelid malpositions and corneal exposure.
Note the malar hypoplasia with inadequate bony support to the lower eyelid and ocular globe. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and
problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

C

B

A

152

B

portion of lateral retinaculum, the lid is elevated far enough
to cover 1–2 mm of the inferior limbus (Fig. 9.26B). The level
of ﬁxation to the inner aspect of the orbital rim should correspond to a point level with the superior aspect of the pupil
in primary position (Fig. 9.26C). Finally, upon closure of the
lateral canthal skin incisions, the angle of the divergence from
the original horizontal orientation must be equal and symmetric from one side to the other to ensure lateral canthal and
lower eyelid symmetry (Fig. 9.26D).

D

B

lateral orbital rim periosteum. However, in some patients, the
soft, connective tissue of the periosteum has lost its integrity
due to damage from scarring or trauma. In patients with
milder damage, the ﬁxation may be supplemented with a
local periosteal ﬂap58–60 or a fascial graft.61 However, patients
who have undergone multiple procedures with extensive
damage to the orbital rim periosteum may require drill hole
ﬁxation.52,62 Drill hole ﬁxation of the lateral canthus is accomplished by determining the desired point of ﬁxation in the
lateral orbital rim. The point of ﬁxation is determined by

It is not advisable to rely on horizontal lid shortening with
simple wedge resections for lower lid support or to preserve
the lateral canthal anatomy. Pentagonal resection of the lower
eyelid only addresses one aspect of the lower lid malposition,
namely excess horizontal length. Optimal correction should
address all aspects of the pathology, in particular the
restoration/preservation of canthal anatomy to maximize
postoperative success.
Fixation of a lateral canthoplasty or canthopexy may be
accomplished by directly suturing the lateral canthus to the

B

Fig. 9.25 Etiology of the lower eyelid defect versus the optimal procedure to
address the defect.

A

Increasing technical complexity

Fig. 9.24 Classiﬁcation of ectropion: (A) cicatricial or (B) involutional. (Modiﬁed
from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures.
In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1990:1671.)

mild lid margin eversion

horizontal lid laxity

severe horizontal lid
laxity & retraction

severe lid malposition with
mid face decent

We already know the trends

e

The lateral canthoplasty and its various modiﬁcations are
useful in addressing lower eyelid malposition.48–57 The procedures described in the following text require a precise knowledge of the orbital anatomy and the desire to preserve the
external commissure. There are key surgical points that should
be kept in mind when performing a lateral canthoplasty to
achieve symmetric lateral canthal repositioning. The lateral
canthal and lower eyelid incision should be horizontal (Fig.
9.26A). After selective release of the lower eyelid with its

• Secondary blepharoplasty: Techniques

lon

Fig. 9.22 Medial canthus to lateral canthus relationship. (A) If the lateral canthus is higher than or equal to the level of the medial canthus, one may elect to perform
horizontal lid shortening with a wedge resection alone or in combination with lateral canthoplasty. (B) If, however, the lateral canthus is lower than the medial canthus, a
lateral canthoplasty procedure is necessary for optimal correction.

9

ya

B

C

A

SECTION I •

Fig. 9.23 Lower lid eversion divided into four types subtypes: (A) lid margin eversion (LME) with scleral show; (B) LME with scleral show and horizontal lid laxity; (C) LME
with lash rotation; (D) ectropion – involutional or cicatricial.

154

pex

A

Fig. 9.21 Distraction and snap test. (A) In the distraction test, the lower lid is grasped with the thumb and index ﬁnger and displaced anteriorly. In the post-blepharoplasty
patient, when the lower lid can be distracted laterally >8 mm there should be concern for compromised tarsoligamentous integrity. (B) The snap test is performed by pulling
the eyelid inferiorly to the level of the inferior orbital margin and then releasing it to judge the speed at which it returns to a normal level. A lid with a slow snap back or a
persistent eversion may have eyelid and canthal laxity.

A

153

Increasing severity of defect

Lower eyelid

+
er n
pac sio
+ s pen
sty us
pla eek s
l
ch
ica
ert
+ v ft
sty gra
pla acer
trip
sp
al s
ars
/- t
+
sty
pla

Bone to soft tissue distance of
<1 cm, minimal distraction, +
snap test

Vertical deﬁciency from release
of midlamellar cicatrix or skin
deﬁciency

Multiple previous procedures
– recruitment of skin and
tissue

Inferior retinacular lateral
canthoplasty

Inferior retinacular lateral
canthopexy

Vertical spacer graft

Subperiosteal midface
elevation

Symmetry of closures
B

C

Fig. 9.28 Tarsal strip lateral canthoplasty. The lower portion of the lateral
retinaculum is divided and development of a tarsal element for ﬁxation is formed by
excising the temporal lid margin, cilia, conjunctiva, and skin. The tarsal strip is then
ﬁxed in position to the lateral orbital periosteum with sutures. (Modiﬁed from Jelks
GW, Smith BC. Reconstruction of the eyelids and associated structures. In:
McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1990:1671.)

Lateral canthal tendon

The inferior retinacular lateral canthoplasty/canthopexy
(IRLC) was developed for secondary blepharoplasty patients
requiring correction of lower lid malposition and lateral
canthal deformities without the problems associated with
the tarsal strip lateral canthoplasty and DOPLC (Fig. 9.34).55
The IRLC is indicated in the secondary or primary blepharoplasty patient with a negative vector analysis, but with a

Inferior retinacular lateral canthoplasty/canthopexy
and midface elevation

Fig. 9.29 (A) Patient exhibiting post-blepharoplasty complications of scleral show, temporal bowing, and mild ectropion that is greater on the right side than on the left. (B)
The tarsal strip ready for periosteal ﬁxation. (C) At 6 months after bilateral tarsal strip procedures. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications
and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

A

Fig. 9.27 Drill hole ﬁxation of a lateral canthopexy. Following determination of the
proper point of ﬁxation, a single drill hole is made no less than 1 mm and generally
approximately 4 mm posterior to the lateral orbital rim. A double-armed 4–0
Mersilene (ME-2) suture is used for ﬁxation. In a canthopexy procedure (no lysis
of the lateral canthus) the suture is double-looped into the canthal tissue and both
suture arms are brought through the single hole. (From Aston, Aesthetic Plastic
Surgery, 2009, Saunders.)

The dermal orbicular pennant lateral canthoplasty (DOPLC) was
developed to reduce the incidence of tarsal strip lateral

Lid elevation

B

Dermal orbicular pennant lateral canthoplasty

canthoplasty contour complications (Fig. 9.31).3,54 This procedure uses an extension of the lower lid in the form of a deepithelialized pennant of skin and underlying orbicularis muscle,
but it does not divide the lateral palpebral commissure (Fig.
9.32). This method maintains the horizontal dimension of the
palpebral aperture while allowing for tightening of the lower
lid as well as lateral suspension (Fig. 9.33).
The DOPLC is useful in post-blepharoplasty patients with
lower lid malposition, especially in patients with a bone to
soft tissue relationship (Fig. 9.20) of >1 cm. However, because
the incision between the upper and lower lids has a very
narrow skin bridge, persistent edema between the upper and
lower lids may occur laterally with this technique.

• Secondary blepharoplasty: Techniques

Early in the senior author’s experience, the procedure of
choice for post-blepharoplasty lower lid malposition was
the tarsal strip lateral canthoplasty48–51,54 combined with horizontal lid shortening and lateral support with or without
vertical spacer grafts of skin, cartilage, or mucosa (Fig. 9.28).
The tarsal strip lateral canthoplasty procedure divides the
lateral palpebral commissure and selectively releases the
lower lid. The amount of horizontal lid shortening can be
varied with the suture placement and ﬁxation in the orbital
periosteum. The tarsal strip procedure, and its many variations is useful for secondary correction of the lax lower eyelid,
however, this technique produces a decrease in the horizontal
dimension of the palpebral aperture which may cause deformities of the lower lid and a rounding of the external commissure (Fig. 9.29).
If midlamellar cicatricial retraction is present, then surgical
correction may only require incising the midlamellar
cicatricial adhesion. However, if the vertical lid defect is excessive, an interpositional graft composed of palatal mucosa,
cartilage, or a ﬂap of de-epithelialized lateral canthal dermis
(dermal pennant ﬂap) may be required (Fig. 9.30).3,53,54 The
preferred graft is palatal mucosa.3,27,37 The graft donor site is
between the gingival and the midline which is a location of
well-deﬁned submucosa for easy separation of the graft from
the fat and periosteum. When performing bilateral retraction
repair, it is preferable to take two grafts from both sides of the
mouth rather than one large graft; this will encourage more
rapid healing. Once the graft has been thinned and all

9

Tarsal strip lateral canthoplasty and vertical spacer grafts

SECTION I •

remaining fatty tissue excised, it is sutured into the lower
eyelid. A 6–0 mild chromic suture is used to attach the graft(s)
to the inferior tarsal edge and the recessed conjunctiva and
capsulopalpebral fascia.

156

a canthoplasty procedure (lysis of the lateral canthus) a single
loop of suture is brought through the canthal edges of the lids,
and the arms are brought out through the single hole. Both
arms of the suture are secured to the deep temporal fascia.62

155

Fig. 9.26 Key points to achieve symmetric lateral canthal repositioning. (A) The lateral canthal and lower eyelid incision should be horizontal. (B) The lid is elevated to
cover 1–2 mm of the inferior limbus. (C) The level of ﬁxation to the lateral orbital periosteum is at a level corresponding to the superior aspect of the pupil in primary
position. (D) On closure of the lateral canthal skin incisions, the angle of divergence from the original horizontal orientation must be equal and symmetric to ensure lateral
canthal and lower eyelid symmetry. (Modiﬁed from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery.
Philadelphia: WB Saunders; 1990:1671.)

C

Level of fixation

Bone to soft tissue distance of
<1 cm

Dermal-orbicular pennant
lateral canthoplasty

D

Bone to soft tissue distance of
>1 cm

Tarsal strip lateral canthoplasty
with horizontal lid shortening

Horizontal incision

Lid laxity or ectropion

Tarsal strip lateral canthoplasty

A

Indications

Lower lid canthal malposition
without lid laxity or ectropion

Canthoplasty technique

Table 9.7 Canthoplasty techniques and indications

tucking the lateral canthus against the orbital rim until it corresponds with the vertical level of the superior aspect of the
pupil. This position is marked with surgical ink, and a single
drill hole with is made no less than 1 mm and generally
approximately 4 mm posterior to the lateral orbital rim. A
double-armed 4–0 Mersilene (ME-2) suture is used for ﬁxation. In a canthopexy procedure (no lysis of the lateral canthus)
the suture is double-looped into the canthal tissue and both
suture arms are brought through the single hole (Fig. 9.27). In

Lower eyelid

Spacer graft
B

Dermal pennant as spacer graft

157

Transblepharoplasty subperiosteal midface elevation is useful
in conjunction with lateral canthoplasty with or without
spacer grafts for patients who have undergone multiple cosmetic procedures who present with lower eyelid and midface

Midface elevation and ﬁxation

favorable bone to soft-tissue relationship (<1 cm discrepancy)
(Figs 9.18, 9.20).3,54–57
The IRLC is performed through the lateral aspect of the
upper eyelid blepharoplasty incision. A skin-muscle ﬂap is
elevated along the lateral orbit extending onto the lateral
aspect of the inferior orbital rim. This maneuver exposes the
lower lid lateral fat pad that lies behind the orbital septum.
The inferior aspect of the lateral retinaculum lies immediately
superior to this fat. The lateral fat pad can be removed to
better expose the lateral retinaculum. Following removal of
the fat pad, the suborbicularis plane will be elevated to the
level of the lateral retinaculum. The lower lid component of
the lateral retinaculum may then be identiﬁed.
In the canthoplasty procedure, the lateral retinaculum is
released completely from all lateral attachments to the orbit
and allows free movement of the lower orbit. A canthopexy
procedure is a non-lysis canthoplasty in which the lower
lid component of the lateral retinaculum is plicated and
anchored to the lateral orbital rim. A canthopexy is only
appropriate for those patients with minimal distensibility and
a ﬁrm snap test.
Both needles of a 4–0 Polydek suture are then passed into
a hitching stitch. The suture is passed through the lateral
orbital rim periosteum at a level corresponding to the superior edge of the pupil with the globe in primary gaze. The
Polydek suture is adjusted and tightened so that the lower lid
covers 1–2 mm of the inferior cornea. The lower lid component of the lateral retinaculum is ﬁxed in its newly elevated
position on the lateral orbital rim. The position of the lateral
canthus will appear over-corrected, and there may be some
initial bunching of the soft tissue at the lateral canthal region.
This relaxes to a normal contour over 2–4 weeks postoperatively as the lateral canthus settles inferiorly.
Careful evaluation of speciﬁc indications in regard to the
patient’s anatomy as well as their speciﬁc defect, enable the
surgeon to choose the optimal lateral canthoplasty procedure
(Table 9.7). In patients with a bony (lateral orbital rim) to softtissue (external commissure) distance of ≥1 cm, the dermal
orbicular pennant lateral canthoplasty has become the procedure of choice for correction of lower lid malposition.
The dermal orbicular pennant lateral canthoplasty (DOPLC)
allows for correction of the lateral canthal angle, while preserving the external commissure.54 Lid laxity or ectropion are
indications for canthoplasty, however, it is still preferable to
utilize some form of horizontal lid shortening (usually with a
tarsal strip). This maneuver allows for correction of the laxity
while allowing for canthal resuspension.

Choosing the appropriate technique(s)

malposition with a deﬁciency of lower lid skin.9,47,56,63 Proper
midface ﬁxation and canthoplasty prevent lower lid descent
in the ﬁrst critical weeks of postoperative healing.
Subperiosteal midface elevation is achieved through a
lower blepharoplasty incision. A skin-muscle ﬂap is dissected
down to the infraorbital rim. Periosteum at the anterior
margin of the infraorbital rim is elevated with a subperiosteal
pocket. The periosteum is released laterally over the inferior
lateral rim followed by release of the entire subperiosteal
ﬂap so it can be mobilized superiorly. The midfacial ﬂap is
suspended with using two 4–0 Vicryl sutures on half-circle
cutting needles that are used to purchase the suborbicularis
oculi fat and the malar fat pad. The sutures are then tied to a
titanium screw placed on the anterior surface of the lateral
orbital bone (zygomatic bone) (Fig. 9.35). The screw is tightened until the head is ﬂush with the bone surface. Alternate
methods which can be used to elevate the midface include a
preperiosteal dissection from the lower lid,64 the concentric
malar lift,65 and the endoscopic, subperiosteal approach from
the temple (covered further in Chapter 11.8).
The elevated and stabilized structures support the repositioned lower lid and the recruited and elevated cheek skin
and tissue help replace deﬁcient posterior lamella.

Fig. 9.30 Lower eyelid spacer grafts. (A) A spacer graft of autogenous palatal mucosal or auricular cartilage, or a (B) vascularized, de-epithelialized lateral canthal dermal
pennant ﬂap may be used to increase vertical height of the retracted or deﬁcient lower eyelid in conjunction with a lateral canthoplasty. Spacer grafts are useful in enhancing
the results in post-blepharoplasty patients with defects secondary to cicatricial retraction or excessive skin resection.

A

Lower eyelid

C

Protective contact lens

Orbicularis muscle

Canthal angle remains intact
E

D

Spacer graft

Suture fixation is to lateral rim corresponding to the upper
level of the pupil with the patient in the primary gaze

Strumming inferior retinaculum
with Colorado needle to release lower lid

• Secondary blepharoplasty: Techniques

De-epithelialized dermal flap

9

Mobilize flap to pretarsal muscle

Dermis

Cut to fascia

Periorbital fascia

B

A

Scratch through dermis

SECTION I •

Fig. 9.31 Dermal-orbicular pennant lateral canthoplasty (DOPLC). (A) Patient is illustrated with a protective, colored contact lens in place. The dermal-orbicular ﬂap is
outlined at the lateral canthus. Note the horizontal alignment and the maintenance of the external commissure. An incision is made through the superﬁcial layers. (B) The
ﬂap is de-epithelialized preserving the underlying dermis. The superﬁcial border of the ﬂap is incised to the suborbicularis muscle plane. (C) The inferior border of the
dermal-orbicular pennant is elevated to the external commissure, which remains intact. The lower lid component of the lateral retinaculum is divided by “strumming”
the structure with a Colorado needle. (D) The ﬁxation of the suture is to the lateral orbital rim corresponding to the upper level of the pupil with the patient in primary gaze.
(E) A spacer graft can be added as necessary. (Modifed from Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg 1993; 20:417–421.)

158

Closure

ME-2 needles

Suture into tarsus

Alternate suture placement

Bilaterally symmetrical angles

Fixation suture inside periosteum of orbital rim

Fig. 9.32 Dermal-orbicular pennant lateral canthoplasty (DOPLC) ﬁxation and
closure. (A) Both arms of an ME-2 4–0 Polydek suture are passed through
periosteum from the inner to the outer aspect of the orbital rim. The needles are
passed through the loop, and cinched tightly down, hugging the inner aspect of the
orbital rim. (B) Most commonly, periosteal ﬁxation is to the lateral edge of the
tarsus. Fixation of the lower lid to the orbital rim should result in an over-correction
such that the lower lid covers 1–2 mm of the inferior cornea. (C) Upon closure,
elevation causes inferior angulation of the original horizontal incision. (D) When
bilateral procedures are performed, care is taken to obtain symmetry of closure.
(Modifed from Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg
1993; 20:417–422.)

D

C

B

A

159

Fig. 9.33 (A) Patient with bilateral lower eyelid malposition after blepharoplasty.
(B) The patient is seen 9 months following bilateral dermal-orbicular pennant
lateral canthoplasties. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed.
Complications and problems in aesthetic plastic surgery. New York: Gower Medical
Publishing; 1992.)

B

A

Lower eyelid

9

C

Cave from inside orbit

B

D

Canthoplasty

• Secondary blepharoplasty: Techniques

Removal of fat pad to reveal ‘cave’

SECTION I •

Canthopexy

In patients with lid retraction, a DOPLC may be sufﬁcient
to correct the problem if there is associated soft-tissue to
bony disparity. If release of midlamellar (orbital septum, lid
retractors) cicatricial retraction is the cause of the vertical deﬁciency, the use of autogenous palatal mucosal or auricular
cartilage as a spacer graft is recommended. Spacer grafts
should also be utilized when release of the posterior lamella
(conjunctiva) produces a vertical deﬁcit. In patients with multiple previous procedures presenting with deﬁcient lower
eyelid skin and tissue, midface elevation techniques may also
be necessary for an optimal result. Finally, for secondary or
primary blepharoplasty patients with negative vectors and

Excessive fat resection is a most disturbing problem, especially
when associated with lower eyelid malposition. Autogenous
fat pad sliding, fat grafting (Fig. 9.36), and fat injection
have been utilized to correct this deformity with variable

Miscellaneous complications

favorable bony to soft-tissue relationships (<1 cm), the inferior retinacular lateral canthoplasty/canthopexy (IRLC) is
recommended.22,44,45,54–57 The IRLC procedure avoids the pitfalls of horizontal lid shortening and the edema associated
with DOPLC.

Fig. 9.34 Inferior retinacular lateral canthoplasty (IRLC) technique. (A) The IRLC is performed through the lateral aspect of an upper eyelid blepharoplasty incision. A
skin-muscle ﬂap is elevated along the lateral orbit exposing the lower lid lateral fat pad. The inferior aspect of the lateral retinaculum lies immediately superior to this fat.
The lateral fat pad can be removed to better expose the lateral retinaculum. Inset: following removal of the fat pad, a “cave” is revealed superior to the lateral retinaculum.
The illustration reveals this area as it would be visualized from inside the orbit. (B) Canthoplasty procedure with lysis of the lateral retinaculum. Inset: canthopexy, or
non-lysis procedure in which the lower lid component of the lateral retinaculum is plicated and anchored to the lateral orbital rim. (C) Both needles of 4–0 Polydek suture
have been passed into a hitching stitch. The suture has been passed through the lateral orbital rim periosteum (as denoted by the arrow) at a level corresponding to the
superior edge of the pupil with the globe in primary gaze. (D) The Polydek suture is adjusted and tightened so the lower lid covers 1–2 mm of the inferior cornea. The lower
lid component of the lateral retinaculum is then ﬁxed in its elevated position to the lateral orbital rim. (Modifed from Jelks GW et al. The inferior retinacular lateral
canthoplasty: a new technique. Plast Reconstr Surg 1997; 100:1262–1265.)

A

160

X

B

Cutting edge
on outside of curve

Mitek screw

Cutting edge
on outside

C

B

C

B
C

Fig. 9.38 (A) Patient seen following blepharoplasty with persistent malar excess skin. (B) Immediately after direct excision. (C) A satisﬁed patient seen 9 months
postoperatively. (From Jelks, GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing;
1992.)

A

Fig. 9.37 (A) Blepharoplastic patient preoperatively. (B) At 2 months postoperatively with evidence of inadequate resection of fat from the right lower eyelid medial
compartment. (C) The fat is removed via a small stab incision through skin, muscle, and orbital septum. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed.
Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

A

161

Fig. 9.35 Mitek screw ﬁxation in subperiosteal midface
elevation. Following elevation of the subperiosteal midface ﬂap,
ﬁxation is achieved by suspending the ﬂap using two 4-0 Vicryl
sutures on half-circle cutting needles. The sutures are then tied
to a titanium screw placed on the anterior surface of the lateral
orbital bone (zygomatic bone). The screw is tightened until the
head is ﬂush with the bone surface. The elevated and stabilized
structures support the repositioned lower lid and the recruited
and elevated cheek skin and tissue help replace deﬁcient
posterior lamella. (From Aston, Aesthetic Plastic Surgery, 2009,
Saunders.)

Fig. 9.36 (A) Patient with excessive lower lid fat resection with associated lower eyelid malposition. (B) The supplementary submental autogenous fat grafts are shown
before their placement into a retroseptal position through a lateral canthal incision. Lateral canthoplasties were also performed. (C) Patient seen one year postoperatively.
(From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

A

Screw locations

X

X

X

Lower eyelid

SECTION I •

9

3. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin
Plast Surg. 1993;20:417.
5. Jelks GW, Jelks EB. Preoperative evaluation and
treatment of lower lid ectropion following
blepharoplasty. Plast Reconstr Surg. 1990;85:
971.
Preoperative identiﬁcation of a predisposition to ectropion is
the ﬁrst step in preventing this complication after
blepharoplasty. The authors discuss surgical techniques to
avoid this common adverse outcome and address procedures
designed to reverse ectropion if it does occur.
7. Patipa M. The evaluation and management of lower
eyelid retraction following cosmetic surgery. Plast
Reconstr Surg. 2000;106:438.
Causes of lower eyelid retraction are discussed from an
anatomical perspective. The author then presents etiologybased corrective procedures.
12. Lisman RD, Hyde K, Smith B. Complications of
blepharoplasty. Clin Plast Surg. 1988;15:309.
24. Zide BM, Jelks GW. Surgical anatomy of the orbit. Plast
Reconstr Surg. 1984;74:301.
43. Carraway JH. The impact of Herring’s law on
blepharoplasty and ptosis surgery. Aesthetic Surg J.
2004;24:275.

45. Pessa JE, Desvigne LD, Lambros VS, et al. Changes
in ocular globe-to-orbital rim position with age:
implications for aesthetic blepharoplasty of the lower
eyelids. Aesthetic Plast Surg. 1999;23(5):337–342.
The authors present ﬁndings from CT scans assessing the
relationship of the globe to surrounding anatomy throughout
the aging process. Their ﬁndings inform recommendations for
lower lid blepharoplasty and are incorporated into a model of
craniofacial aging.
51. Rees TD. Prevention of ectropion by horizontal
shortening of the lower lid during blepharoplasty.
Ann Plast Surg. 1983;11:17.
57. Fagien S. Algorithm for Canthoplasty. The lateral
retinacular suspension: a simpliﬁed suture canthopexy.
Plast Reconstr Surg. 1999;103:2042.
Methods to provide canthal support and avoid lower lid
malposition in midface/lower eyelid rejuvenation are
presented. The author describes his novel transpalpebral
lateral retinacular suspension in this context.
61. McCord CD Jr, Ellis DS. The correction of lower lid
malposition following lower lid blepharoplasty. Plast
Reconstr Surg. 1993;92:1068.
Methods to correct lower lid malposition are presented based
on the underlying anatomical pathology.

Access the complete references list online at http://www.expertconsult.com

results.66–72 A lateral canthoplasty should be performed at the
time of fat augmentation.
Inadequate fat resection most commonly occurs in the upper
and lower medial and lower lateral compartments. A small
stab incision through the skin, muscle, and septum can be
utilized to deliver the residual fat for excision (Fig. 9.37).27
In the lower lid, the transconjunctival approach may also
be used.
Persistent malar bags, or excess skin that presents without
lower lid cicatricial retraction can be directly excised and carefully closed to produce acceptable results (Fig. 9.38).27
Chemosis is a milky edema of the subconjunctival tissues. It
results from obstruction of the lymphatic drainage channels
of the periorbital area (Fig. 9.39). Repositioning the eyelids
over the chemotic conjunctiva and patching usually resolve
the situation. If the chemosis becomes more marked or there
is actual incarceration by the eyelids, temporary suture tarsorrhaphy may be required.3,27,37

• Secondary blepharoplasty: Techniques

Fig. 9.39 Patient with persistent chemosis.

162

1. ASAPS. Statistical data for 2003. Online. Available at:
http://www.surgery.org
2. McCord CD Jr. The correction of lower lid malposition
following blepharoplasty. Plast Reconstr Surg. 1999;102:
2471.
3. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin
Plast Surg. 1993;20:417.
4. Gradinger GP, Jelks GW. Blepharoplasty: anatomic
considerations and common problems. Perspect Plast
Surg. 1992;6:90.
5. Jelks GW, Jelks EB. Preoperative evaluation and
treatment of lower lid ectropion following
blepharoplasty. Plast Reconstr Surg. 1990;85:971.
Preoperative identiﬁcation of a predisposition to ectropion
is the ﬁrst step in preventing this complication after
blepharoplasty. The authors discuss surgical techniques to
avoid this common adverse outcome and address procedures
designed to reverse ectropion if it does occur.
6. Bartley GB. The differential diagnosis and classiﬁcation
of eyelid retraction. Ophthalmology. 1996;103:168.
7. Patipa M. The evaluation and management of lower
eyelid retraction following cosmetic surgery. Plast
Reconstr Surg. 2000;106:438.
Causes of lower eyelid retraction are discussed from an
anatomical perspective. The author then presents etiologybased corrective procedures.
8. Patipa M. Transblepharoplasty lower eyelid and
midface rejuvenation: part I. Avoiding complications
by utilizing lesson learned from the treatment of
complications. Plast Reconstr Surg. 2004;113(5):
1459–1468.
9. Yaremchuk MJ. Restoring palpebral ﬁssure shape after
previous lower blepharoplasty. Plast Reconstr Surg.
2003;111(1):441–450.
10. Carraway JH, Mellow CG. The prevention and
treatment of lower lid ectropion following
blepharoplasty. Plast Reconstr Surg. 1990;85:971.
11. Levine MR, Boynton J, Tenzel RR, et al. Complications
of blepharoplasty. Ophthal Surg. 1975;6:53.
12. Lisman RD, Hyde K, Smith B. Complications of
blepharoplasty. Clin Plast Surg. 1988;15:309.
13. McCord CD Jr, Shore JW. Avoidance of complications
in lower lid blepharoplasty. Ophthalmology. 1983;90:
1039.
14. McCord CD Jr. Complications of upper lid
blepharoplasty. In: Putterman AM, ed. Cosmetic
oculoplasty surgery. New York: Grune & Stratton; 1982.
15. Rafety FM. Complications of cosmetic blepharoplasty.
Cos Surg. 1983;2:17.
16. Kim YW, Park HJ, Kim S. Secondary correction of
unsatisfactory blepharoplasty: removing multilaminated
septal structures and grafting of preaponeurotic fat.
Plast Reconstr Surg. 2000;106(6):1399–1404.
17. Rocca R, Nesi FA, Lisman RD, eds. Ophthalmic plastic
and reconstructive surgery. St. Louis: CV Mosby;
1987.

References

162.e1

18. Jelks GW, Jelks EB. Prevention of ectropion in
reconstruction of facial defects. Clin Plast Surg.
2001;28(2):297.
19. Edgerton MT. Causes and prevention of lower lid
ectropion following blepharoplasty. Plast Reconstr Surg.
1972;49:367.
20. Tenzel RR. Complications of blepharoplasty: orbital
hematoma, ectropion, and scleral show. Clin Plast Surg.
1981;7:797.
21. Tenzel RR. Surgical treatment of complications of
cosmetic blepharoplasty. Clin Plast Surg. 1978;5:517.
22. Jelks GW, Jelks EB. Preoperative evaluation of the
blepharoplasty patient: bypassing the pitfalls. Clin Plast
Surg. 1993;20:213.
23. Zide BM, Jelks GW. Surgical anatomy of the orbit. New
York: Raven Press; 1985.
24. Zide BM, Jelks GW. Surgical anatomy of the orbit. Plast
Reconstr Surg. 1984;74:301.
25. Doxanas MT, Anderson RL. Clinical orbital anatomy.
Baltimore: Williams and Wilkins; 1984.
26. Spinelli HM, Jelks GW. Periocular reconstruction: a
systematic approach. Plast Reconstr Surg. 1993;91:1017.
27. Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed.
Complications and problems in aesthetic plastic surgery.
New York: Gower Medical Publishing; 1992.
28. Jelks GW, Jelks EB. The inﬂuence of orbital and eyelid
anatomy on the palpebral aperture. Clin Plast Surg.
1991;18:183.
29. de la Tore JL, Martin SA, De Cordier B, et al. Aesthetic
eyelid ptosis correction: a review of technique and
cases. Plast Reconstr Surg. 2003;112:655.
30. Beard C. Ptosis, 3rd ed. St. Louis: CV Mosby; 1981.
31. Frueh BR. The mechanistic classiﬁcation of ptosis.
Ophthalmology. 1980;87:1019.
32. Patipa M. Levator ptosis in patients undergoing upper
lid blepharoplasty. Ann Ophthalmol. 1984;16:270.
33. Anderson RL, Dixon RS. Aponeurotic ptosis surgery.
Arch Ophthalmol. 1979;97:1123.
34. Flowers RS. Comments on blepharoplasty –
management of complications and patient
dissatisfaction. In: Goldwyn RN, ed. The unfavorable
result in plastic surgery, 2nd ed. Boston: Little, Brown;
1984.
35. McCulley TJ, Kersten RC, Kulwin DR, et al. Outcomes
and inﬂuencing factors of external levator palpebrae
superioris aponeurosis advancement for blepharoptosis.
Ophthal Plast Reconstr Surg. 2003;19:388.
36. Rohrich RJ, Coberly DM, Fagien S, et al. Current
concepts in aesthetic upper blepharoplasty. Plast
Reconstr Surg. 2004;113(3):32e.
37. Jelks GW, Smith BC. Reconstruction of the eyelids and
associated structures. In: McCarthy JG, ed. Plastic
surgery. Philadelphia: WB Saunders; 1990:1671.
38. Fasanella RM, Servat J. Levator resection for minimal
ptosis: another simpliﬁed operation. Arch Ophthalmol.
1961;65:493.
39. Shorr N, Goldberg, RA, McCann JD, et al. Upper eyelid
skin grafting, an effective treatment for lagophthalmos

References

56.

55.

54.

53.

52.

51.

50.

49.

48.

47.

46.

45.

44.

43.

42.

41.

40.

SECTION I •

9

57. Fagien S. Algorithm for Canthoplasty. The lateral
retinacular suspension: a simpliﬁed suture canthopexy.
Plast Reconstr Surg. 1999;103:2042.
Methods to provide canthal support and avoid lower lid
malposition in midface/lower eyelid rejuvenation are
presented. The author describes his novel transpalpebral
lateral retinacular suspension in this context.
58. Dryden RM, Edelstein JP. Lateral palpebral tendon
repair for lower eyelid ectropion. Ophthalmol Plast
Reconstr Surg. 1988;4:115.
59. McCord CD Jr. Lateral canthal reconstruction. In:
McCord CD, Codner MA, Hester TR, eds. Eyelid surgery:
principles and techniques. Philadelphia: Lippincott-Raven;
1995:294.
60. Sassoon E, McCord CD Jr, Codner MA, et al. Periosteal
strip for correction of complications following lower
lid blepharoplasty. Paper presented at the Aesthetic
Meeting of the American Society for Aesthetic Plastic
Surgery, San Diego, California, 2000.
61. McCord CD Jr, Ellis DS. The correction of lower lid
malposition following lower lid blepharoplasty. Plast
Reconstr Surg. 1993;92:1068.
Methods to correct lower lid malposition are presented based
on the underlying anatomical pathology.
62. McCord CD Jr, Boswell CB, Hester TR. Lateral canthal
anchoring. Plast Reconstr Surg. 2003;112:222.
63. Hester TR, Codner MA, McCord CD. Subperiosteal
malar cheek lift with lower blepharoplasty. In: McCord
CD, Codner MA, Hester TR, eds. Eyelid surgery:
principles and techniques. Philadelphia: Lippincott-Raven;
1995.
64. Moelleken B. The superﬁcial subciliary cheek lift, a
technique for rejuvenating the infraorbital region and
nasojugal groove: a clinical series of 71 patients. Plast
Reconstr Surg. 1999;104(6):1863–1876.
65. Le Louarn C. The concentric malar lift: malar and lower
eyelid rejuvenation. Aesthetic Plast Surg. 2004;28(6):
359–374.
66. Loeb R. Fat pad sliding and fat grafting for leveling lid
depression. Clinics in plastic surgery, Vol. 8, No. 4.
Philadelphia: WB Saunders; 1981.
67. Silkiss RZ, Baylis HI. Autogeneous fat grafting
by injection. Ophthal Plast Reconstr Surg. 1987;3:
71–75.
68. Coleman SR. Structural fat grafts: the ideal ﬁller? Clin
Plast Surg. 2001;28(1):111–119.
69. Coleman SR. Facial recontouring with lipostructure.
Clin Plast Surg. 1997;24(2):347–367.
70. Coleman SR. Long-term survival of fat transplants:
controlled demonstrations. Aesthetic Plast Surg.
1995;195(5):421–425.
71. Kanchwala SK, Bucky LP. Facial fat grafting: the search
for predictable results. Facial Plast Surg. 2003;19(1):
137–146.
72. Ellenbogen R. Free autogenous pearl fat grafts in the
face-a preliminary report of a rediscovered technique.
Ann Plast Surg. 1986;16:3.

• Secondary blepharoplasty: Techniques

following blepharoplasty. Plast Reconstr Surg.
2003;112:1444.
Baylis HI, Cies WA, Kamin DF. Correction of upper
eyelid retraction. Am J Ophthalmol. 1976;82:790.
Fagien S. Advanced rejuvenative upper blepharoplasty:
enhancing aesthetics of the upper periorbita. Plast
Reconstr Surg. 2002;110:278.
Gradinger GP. Cosmetic upper blepharoplasty. Clin Plast
Surg. 1988;15:289.
Carraway JH. The impact of Herring’s law on
blepharoplasty and ptosis surgery. Aesthetic Surg J.
2004;24:275.
Pessa JE, Chen Y. Curve analysis of the aging orbital
aperture. Plast Reconstr Surg. 2002;109(2):751–755.
Pessa JE, Desvigne LD, Lambros VS, et al. Changes
in ocular globe-to-orbital rim position with age:
implications for aesthetic blepharoplasty of the lower
eyelids. Aesthetic Plast Surg. 1999;23(5):337–342.
The authors present ﬁndings from CT scans assessing the
relationship of the globe to surrounding anatomy throughout
the aging process. Their ﬁndings inform recommendations for
lower lid blepharoplasty and are incorporated into a model of
craniofacial aging.
Yaremchuk MJ. Improving periorbital appearance
in the “morphologically prone.” Plast Reconstr Surg.
2004;114(4):980–987.
Hester TR, Codner MA, McCord CD. The centrofacial
approach for correction of facial aging using the
transblepharoplasty subperiosteal cheek lift. Aesthetic
Surg Quart. 1996;16:51.
Anderson RL, Gordy DD. The tarsal strip procedure.
Arch Ophthalmol. 1979;97:2192.
Jordan DR, Anderson RL. The lateral tarsal strip
revisited: The enhanced tarsal strip. Arch Ophthalmol.
1989;107:604.
Marsh JL, Edgerton MT. Periosteal pennant lateral
canthoplasty. Plast Reconstr Surg. 1979;64:24.
Rees TD. Prevention of ectropion by horizontal
shortening of the lower lid during blepharoplasty. Ann
Plast Surg. 1983;11:17.
Flowers RS. Canthopexy as a routine blepharoplasty
component. Clin Plast Surg. 1993;20:351.
Patel BC, Patipa M, Anderson RL, et al. Management of
postblepharoplasty lower eyelid retraction with hard
palate grafts and lateral strip. Plast Reconstr Surg.
1997;99(5):1251–1260.
Jelks GW, Glat PM, Jelks EB, et al. The evolution of the
lateral canthoplasty: techniques and indications. Paper
presented at the American Association of Plastic
Surgeons, 74th Annual Meeting, San Diego, April 30
to May 3, 1995.
Jelks GW, Glat PM, Jelks EB, et al. The inferior
retinacular lateral canthoplasty: a new technique. Plast
Reconstr Surg. 1997;100:1262.
Hester R Jr, Codner MA, McCord CD. Discussion:
The inferior retinacular lateral canthoplasty: a new
technique. Plast Reconstr Surg. 1997;100:1271.

162.e2

©

2013, Elsevier Inc. All rights reserved.

The face, while only a single part of the body, is the icon of
self-identity and can be easily recognized among hundreds
of thousands of faces. Asian and Caucasian faces each have
unique features. It is generally accepted that Asians have
small, puffy eyes with an epicanthal fold, shallow orbits, a
low proﬁle nasal dorsum with thick skin, ﬂat faces with large
cheekbones and broad width. This is especially true for East
Asians, including people from China, Japan, Mongolia, North
Korea, South Korea and Taiwan.1 Asia is the largest continent,
and has numerous ethnic groups.1,2 Southern Asians have
darker, thicker skin, larger eyes with double folds and smaller,
narrower facial skeletons compared to northern Asians,
whereas western Asians have quite different facial features

(Cicero)

Everything is in the face

The Asian’s concept of beauty has changed over time. Currently,
most Asians want to improve their appearance while preserving
their ethnic identity.
Asian cosmetic surgery is not simply Western cosmetic surgery
applied to Asians. Rather, cosmetic surgery in Asians must
account for the underlying differences in anatomy and aesthetic
proportions between Asians and Caucasians.
Asian blepharoplasty and augmentation rhinoplasty are two of the
most popular facial cosmetic procedures in Asia today. Facial bone
contouring and aesthetic orthognathic surgery are also becoming
more common in certain parts of Asia.
Since there is no perfect way to deﬁne beauty, one must use both
subjective and objective tools for analyzing facial proﬁles according
to ethnic standards.

Introduction

䊏

䊏

䊏

䊏

SYNOPSIS

Aesthetic Surgery of the Face

from other Asians. Although there are some constants, the
standard of beauty varies among countries. Anatomic characteristics and cultural differences, including trends in each
ethnic group, should be considered before performing facial
cosmetic surgery.
Much controversy surrounds the concept of universal
beauty. Humans, even babies, have an innate afﬁnity for beautiful people.3 Symmetry and a healthy, young-looking appearance make a face more attractive, regardless of ethnic
background. A key feature of beautiful faces is the quality
known as youthfulness.4 In Caucasian women, high cheekbones are an important factor, whereas Asian women with
round or oval-shaped faces are considered more beautiful.
When Asians see facial photographs of themselves alongside
Caucasians, they, especially younger individuals, are sometimes disappointed with their appearances. In general, Asian
faces tend to look broader with a ﬂatter contour to their eyes,
nose, and face. We live in a three-dimensional world, and the
faces we observe directly are three-dimensional. Facial cosmetic surgery is a three-dimensional procedure, and more
emphasis is being placed on facial contour changes.
Over the past two decades, many countries in East Asia,
including South Korea, China, Taiwan, and Japan, have
emerged as strong economies. More people in these countries
can now afford to spend money on items that are not considered basic necessities, including cosmetic and luxury items.
These items usually come from wealthier countries with wellestablished economies, mostly located in Europe and North
America. People in East Asia have adopted Western habits, as
“westernization” has progressed into these countries. Among
the items brought to East Asia is a new concept of beauty for
young female adults and teenagers. Due to globalization,
Western and Eastern cultures interact to a greater degree than
ever before, indirectly or directly. Thus, people from both
cultures have become familiar with each other’s looks.
Young female Asians have become acutely interested in
their appearance, creating a boom in cosmetic surgery. This
phenomenon has created a new standard of beauty. Females
in East Asia seek larger eyes, a higher nose, and a smaller face,

Kyung S. Koh, Jong Woo Choi, and Clyde H. Ishii

Asian facial cosmetic surgery

10

SECTION I

SECTION I •

10 • Asian facial cosmetic surgery

Few young Caucasians undergo cosmetic procedures for their
upper eyelids. Most of these individuals have large eyes with
crisp, tall upper lid creases. In contrast, Asians are described
by westerners as having puffy, small eyes, epicanthal folds,

Introduction

Asian blepharoplasty

which are not traditional to “Asian” beauty but have been
inﬂuenced by Western countries. It is incorrect to simply
assume that Asians seek to “westernize” their faces. Although
westernization of the Asian face seemed to be a goal in the
past, most patients now want to preserve their ethnic identity,
while at the same time improving their appearance.1,2,5 This
has reached a point where people wonder if the concept of
traditional beauty no longer exists in these Asian countries
and traditional beauty is no longer deemed beautiful. Some
patients in cosmetic surgery clinics want to look like celebrities in their respective countries. These celebrities have beautiful and attractive faces that are popular not only in their own
countries but in neighboring countries. Patients seeking cosmetic surgery must be properly counseled in order to avoid
disappointment from unrealistic expectations.
Following the introduction of Western medicine in Asia,
aesthetic surgery was disorganized and sporadic. Although
the history of aesthetic surgery in Japan has been described,
the exact details are not known due to lack of documentation.
This is also true in other Asian countries. Modern concepts of
facial cosmetic surgery, including double fold and augmentation rhinoplasty, began and were developed in Japan in the
late 19th and 20th centuries. In South Korea, facial cosmetic
surgery ﬂourished following the Seoul Olympics in 1988.
With economic development, cosmetic surgery in China has
grown rapidly. Due to the increased scientiﬁc knowledge and
training of board-certiﬁed plastic surgeons in East Asia, facial
cosmetic surgery has advanced rapidly. These plastic surgeons have also played a key role in introducing new ideas
and techniques about Asian facial plastic surgery.
Double eyelid surgery and augmentation rhinoplasty are
two of the most popular facial cosmetic procedures throughout Asia. Facial bone contouring is also becoming another
common procedure in East Asia. Experience with orthognathic surgery/craniofacial surgery initiated facial bone
operations like mandible angle contouring and zygoma
reduction. Development of special bone surgery tools, such as
a variety of electrical saws and burrs has expanded the scope
of cosmetic facial bone surgery, with favorable results.
Some Asians have attractive facial traits, including large
eyes, a well-balanced nose with a good proﬁle, and small
lower faces.6 Individuals who regard their facial features as
falling short of the mainstream ideals of beauty are willing to
undergo facial cosmetic surgery. Younger individuals, for
example, wish to undergo facial bone contouring to make
their faces smaller. These individuals do not have “below
average faces”.1 Rather, they want to look above average,
sometimes chic and stylish, not merely natural. Most patients
who want facial cosmetic procedures like double eyelids and
augmentation rhinoplasty are women, but these cosmetic procedures are also requested by men.

164

Multiple theories exist regarding the formation of the supratarsal crease or fold (Fig. 10.1). First, Sayoc explained the
presence of double fold based on anatomic differences between
Caucasian and East Asian eyelids. Expansions of the levator
palpebrae superioris muscle penetrating through the septum
and orbicularis oculi muscle to the overlying dermis were
thought to be present in Caucasian eyelids and less so in
Asians (Fig. 10.2A).14 The presence of such attachments
between the levator aponeurosis and skin was established by
Cheng and Xu through scanning electron microscopy studies.15
Another concept is the role of ﬁbrous septa between the tarsal
plate and pretarsal skin. The adherence between the tarsal
plate and pretarsal skin is loose in the single eyelid and tight
in the double eyelid.4,16 Therefore, both explanations focus on
the connection between the levator mechanism and the pretarsal skin.
An important factor contributing to supratarsal crease formation is the level of fusion of the orbital septum and the
levator aponeurosis. The supratarsal crease is formed by the
dermal insertion at the conﬂuence of the septum and levator
aponeurosis.13 The level of adhesion between the orbital
septum and levator aponeurosis deﬁnes the superior palpebral crease in most Caucasian eyelids,17 whereas lower fusion
of the orbital septum to levator aponeurosis results in a low
lying or absent crease in the Asian eyelid (Fig. 10.2B). Asians
with naturally occurring superior palpebral folds have a relatively higher fusion of the orbital septum and levator aponeurosis (Fig. 10.3).18 The preaponeurotic orbital fat present in the
pretarsal space eliminates the formation of double fold in
Asians. Among Asians, it is not unusual for the upper lids to
vary, being double and single in the same individual, depending on such variables as fatigue, diurnal variations of eyelid
swelling, and weight change.
The epicanthal fold is also a characteristic feature of Asian
upper lid. It hides the medial part of eye, including the

Anatomic considerations

and lack of supratarsal folds. However, this is not true of all
Asians. About 50% of women in East Asia have these features.1,2 Many Asian women wish to enhance their appearance
but they do not want Caucasian eyelids.1,2,7 Asian blepharoplasty or “double eyelid” surgery is the most common cosmetic operation in Asia, with some reports suggesting that
30–60% of Asians undergo this procedure.8 If these women
have deep-set, large eyelids with high folds like Caucasians,
they look unnatural, as such eyelids do not match the
shape of their faces. Therefore, ethnic differences should be
considered.
The ﬁrst procedure to create a supratarsal fold or “double
eyelid” was described by Mikamo in 1896.9 The procedure
was performed on a patient who lacked a fold in one of her
upper eyelids. Shirakabe et al. made a historical review of 32
surgical techniques reported in Japan.10 In the western countries, Sayoc reported anatomic differences of upper eyelids
between Caucasians and East Asians. The anatomic differences and their implications regarding double eyelid surgery
were discussed.11 Fernadez and Flowers in Hawaii, where
East meets West, published papers about double eyelid
surgery for Asians.4,12 Newer techniques seeking to be more
reﬁned and less invasive while imitating the natural fold are
being reported.13

Caucasian

B

Tarsal plate

Orbital septum

Caucasian

Levator aponeurosis

Puffy asian eyelid without double fold

Levator aponeurosis

Müller muscle

Retromuscular fat

Orbital fat

Orbital septum

Müller muscle

Orbicularis oculi

Orbital fat

caruncle and lacrimal lake and increases the intercanthal distance. In East Asians, at least 50% of adults have epicanthal
fold. If slight traces are included, almost all East Asians retain
epicanthal folds, and a mild epicanthus is not an unusual
feature for them.1 There has been a recent trend to eliminate
or loosen the epicanthal fold as part of the double eyelid

165

operation. This medial epicanthoplasty will decrease the wide
intercanthal distance and increase the horizontal width of
the palpebral apertures. However, surgeons should be very
cautious about total elimination of epicanthal folds, because
this can leave a noticeable scar and result in loss of ethnic
identity.

Fig. 10.2 (A) The cross-sectional anatomy of the Caucasian upper eyelid. (B) The cross-sectional anatomy of the Asians with puffy eyelid.

A

Tarsal plate

Asian

Orbicularis oculi

Fig. 10.1 Anatomy of upper eyelid in Caucasians and Asians.

Conjunctiva

Tarsal plate

Dermal attachment of
levator apon

Orbicularis muscle

Levator aponeurosis

Submuscular fat

Septum orbitale

Müller muscle

Orbital fat

Asian blepharoplasty

Tarsal plate

Levator aponeurosis

Müller muscle

Retromuscular fat

Orbital septum

Orbital fat

Orbicularis oculi

10 • Asian facial cosmetic surgery

Thin asian eyelid

SECTION I •

c

d

b

a

Most Asian patients desiring double eyelids no longer want
a westernized appearance, but rather an appearance more
appropriate for Asians. Because the anatomy of the orbit
differs greatly between Asians and Caucasians, Asian blepharoplasty should be performed in accordance with the orbital
anatomy of Asians. Previously, most young Asians seeking
upper blepharoplasty have done so only for double fold formation. More recently, Asians have undergone upper blepharoplasty to achieve a more attractive eyelid shape by reducing
the pufﬁness in their eyelids, obtaining a double fold, and
increasing the palpebral ﬁssure length.18 These patients also
prefer a ﬂat upper eyelid which looks young and stylish, not
sunken or deﬂated.4
The height of double eyelid is an important issue. In young
Caucasians, the superior palpebral fold is small and the height
of the pretarsal skin exposure is similar to te height of the
superior palpebral crease.18 In contrast, the Asian lid crease is
generally 2–3 mm lower, and a large superior palpebral fold
hangs over the pretarsal skin.7 Thus, exposure of pretarsal
skin is less than in Caucasians. The lower border of the fold
is called the double eyelid line, and the distance between this
line and the margin of the lid at primary gaze is pretarsal
exposure (Fig. 10.4). After blepharoplasty, the pretarsal exposure is determined by several factors, such as the height of
incision, the amount of pretarsal skin excision, the height of

Preoperative considerations and diagnosis

Fig. 10.4 The mechanism of double eyelidplasty in North-East Asians. a, Double eyelid line, lower border of fold; b, upper lid margin; c. pretarsal exposure; d, lower lid
margin.

Fig. 10.3 The cross-sectional anatomy of the Asians with thin eyelid.

166

Fig. 10.5 “Inside” vs “outside” fold in Asian blepharoplasty.

Outside fold

Inside fold

167

Conjunctiva

Tarsal plate

Connective tissue

Fig. 10.6 Nonincisional double eyelidplasty (single stitch method).

Numerous nonincisional methods have been described.21–26
These methods are used primarily for young people who do
not require skin excision and for patients with thin upper Video
1
eyelid tissue who do not have an excess of fat. The advantages
of these minimally invasive techniques must be balanced
against the knowledge that the ﬁxation may not be as durable
over time when compared with the incisional methods. Nonincisional methods can be categorized as single stitch and
multiple stitch methods, both of which have advantages and
disadvantages.
In these techniques, stitches are simply inserted through
the skin at the level of the preferred lid crease, traversing the
full thickness of the lid tissues down to and including either
the levator aponeurosis or the tarsal plate. The stitches are tied
in such a way that the knots are buried.
• Single stitch nonincisional methods have many
modiﬁcations.21 Figure 10.6 shows a nonincisional single
stitch method. Fixation through the levator aponeurosis
can result in a more natural appearance and minimal

Nonincisional methods

Generally, surgical techniques for double fold formation
can be categorized as incisional and nonincisional methods,
although some authors have advocated partial incisional
methods.

Incisional versus nonincisional methods

Although procedures for blepharoplasty in Asians have a
number of similarities to those in Caucasians, it is important
to recognize that upper blepharoplasty in Asians is not a westernization procedure. Thus, surgical techniques should differ
in some respects from a Caucasian blepharoplasty.

Treatment/surgical technique

are uncomfortable with this conﬁguration, since it appears
unnatural to them. They prefer a fold that for most part is
parallel to the lid margin. Laterally, the crease may have a
slight ﬂare, in that the crease lies farther from the lash line
than the central third. Medially, the crease may taper toward
the medial canthus (“inside fold”) or run outside the epicanthus (“outside fold”) (Fig. 10.5).20

Orbicularis muscle

Skin

ﬁxation, and levator function.18 Currently, the preference for
most Asians is a pretarsal exposure <3 mm, and as little as
1 mm.7 These desires have geographical variation (Fig. 10.4).
Another preoperative consideration is the shape of the
desired crease. Caucasians typically have a semilunar shaped
crease where the central third of the crease lies farther from
the lash line than the medial and lateral thirds.19 Most Asians

Asian blepharoplasty

SECTION I •

2

frequently.28,29 These procedures have evolved to overcome
disadvantages of the above two methods. Partial incisional
methods can result in moderate tissue adhesions, preventing
the early relapse observed using nonincisional methods.
Moreover, partial incision can result in a more natural appearance, minimizing scarring of the upper lid. Using the partial
incisional approach, preaponeurotic fat can be easily removed
to correct puffy eyelids.

Video Partial incisional methods (Fig. 10.8) are being used more

Partial incisional methods

postoperative edema, but relapse can sometimes occur.
Fixation through the upper portion of the tarsal plate can
result in a more deﬁnite eyelid crease with minimal
relapse, but postoperative edema can occur more
frequently than in levator ﬁxation methods.
• Multiple stitch nonincisional methods can be
performed, usually with 3–5 stitches on each side
(Fig. 10.7).27
Several factors should be considered when performing
nonincisional double fold formation. First, the conjunctival
side of the stitches should not be exposed, since this exposure
can result in corneal damage postoperatively and second, the
possibility of relapse should be considered and mentioned
preoperatively to all patients.

Fig. 10.7 Nonincisional double eyelidplasty (multiple stitch method).

For double fold formation in the upper lid, traditional tarsodermal ﬁxation through incisional methods (Fig. 10.9A,B)
has been an effective standard method.30 In patients with
redundant eyelid skin, the incisional approach is unavoidable.
There are as yet no deﬁnite standards for incisional blepharoplasty, but the common procedures will be described. The
placement of the double fold on the upper lid should be
decided preoperatively according to each patient’s appearance and preference utilizing forceps or a probe.
The skin incision marking tapers closer to the lash line as
it progresses medially towards the epicanthal fold. Some
patients may prefer that the medial portion of the crease lies
outside the epicanthus. The superior incision is marked such
that the skin to be excised will also taper, usually measuring
1 mm medially, 2 mm centrally, and 3 mm laterally. The skin
incision is then made and the strip of skin excised. A strip of
orbicularis oculi wider than the skin strip is then removed in
order to create a sharp lid crease. Leaving excess orbicularis
can result in a puffy appearance. The septum is then entered,
and a variable amount of retroseptal fat may be either excised
or released, allowing it to ride up superiorly. The levator
aponeurosis is exposed as it approaches the tarsal plate. The
Asian tarsal plate typically measures 6–7 mm in height.
Fixation of the new upper lid crease is then done. Various
methods of suture ﬁxation involving internal buried sutures
have been described. One method is to use 3–7 sutures passing
through the aponeurosis and the dermis-muscle of the inferior
skin edge. The skin is thus anchored to the levator mechanism, creating the new lid crease, which will be hidden by the
overhanging tissue of the palpebral fold. Alternatively, ﬁxation can be done to the superior edge of the tarsal plate, a
procedure which is thought to create a more static and deﬁned
upper lid crease (Fig. 10.9B–D).

Incisional methods

In the partial incision method, one or more small stab incisions can be made in the planned upper eyelid crease, and
after going through orbicularis, the preaponeurotic fat is
removed. A permanent suture material is then placed between
the skin edges and the underlying aponeurosis or superior
edge of the tarsal plate. The lid should be inverted to conﬁrm
that the suture has been placed to catch the upper border of
the tarsal plate, and to ensure that the suture has not pierced
the conjunctiva.

Conjunctiva

Tarsal plate

Connective tissue

Orbicularis muscle

Skin

10 • Asian facial cosmetic surgery

Fig. 10.8 Partial incisional double eyelidplasty with fat removal.

168

A

Skin

D

B

169

Medial epicanthoplasty (Figs 10.10–10.12) is a very important
component of Asian eyelid surgery.36 Various methods were
originally introduced for the correction of blepharophimosis
in Western countries. In Asia, however, these procedures

Medial epicanthoplasty

Many Asian people who want more attractive looking eyelids
are not satisﬁed with the creation of a simple double crease.31
They may have a low resting level of their eyelids, which if
corrected will give them a more open and attractive palpebral
ﬁssure.32 These patients have a tendency for upper eyelid
ptosis, and are deﬁned as having “subclinical ptosis”. They
may be candidates for the same procedures utilized in cases
of mild ptosis, including Müllerectomy, or levator aponeurosis plication or advancement.33–35

Subclinical ptosis repair
have been used for the correction of average Asian medial
epicanthal folds. Although traditional methods, including
the Mustarde technique,37,38 have been used, these procedures may result in bad scars on the medial canthal area.
These problems may be overcome by the half Z-plasty technique.37,39,40 Nevertheless, the amount of release is limited and
a moderate scar remains. Many Asian patients have complained about these scars. New methods, including skin
redraping methods, have therefore been developed to eliminate the possibility of scarring of the medial canthal area.36,41
These skin redraping methods, which have become very
popular in Asia, include a medial subciliary incision on the
lower eyelid which makes a nonvisible scar and resection/
releaser of medial epicanthal adhesions, procedures that can
minimize medial epicanthal scars and correct medial epicanthus quite well (Figs 10.11 and 10.12).
These methods, however, can also have side-effects, including unnatural dimpling at the releasing points of medial epicanthal adhesions.

Fig. 10.9 (A) Incisional method: skin–aponeurosis. (B) Incisional method: skin–tarsus. (C) Double eyelidplasty: preoperative view. (D) Double eyelidplasty: postoperative
view.

C

Upper tarsus

Levator

Asian blepharoplasty

A

A

E

D

Park Z epicanthoplasty

B

B

D

SECTION I •

A
C

C

B

C

C

B

D

D

A

B

C

B

C

D

D

Postoperative care for Asian blepharoplasty patients is similar
to that for Caucasians. Scarring is generally not a problem,
although excessive swelling can result in a higher crease

Postoperative care

Lateral canthoplasty (Figs 10.13, 10.14) may increase the horizontal length of the palpebral ﬁssure and result in a more
natural appearance around the lateral canthus.42 Although
currently controversial, these procedures are being used for
these purposes.

Lateral canthoplasty

Fig. 10.11 Medial epicanthoplasty with skin redraping method: planning.

A

A

A

A

D

Skin redraping method

B

10 • Asian facial cosmetic surgery

Fig. 10.10 Various methods of medial epicanthoplasty.

C

C

170

A

A
B

B

D

D

A

Root Z epicanthoplasty

E

B
C
D

A

B
C

D

Complications are similar to those observed during routine
blepharoplasty procedures. These complications include

Outcomes, prognosis, and complications

height than is desired. Postoperative instructions are as
follows:
1. Cold compresses, as tolerated, for 24 h
2. Antibiotic ointment for the suture lines
3. Cleanse the wound with clean water
4. The external sutures may be removed in 4–5 days.

D

B

C

C

B

C

D

B

C

*

5mm

3mm

2mm

Fig. 10.13 Lateral canthoplasty technique.

B

Cornea

A

C

Fig. 10.12 Medial epicanthoplasty with skin redraping method: completion.

C

A

A

A
D

D

B

A

B

*

C
D

D

Palpebral conjunctiva

A
B

*

C

Asian blepharoplasty

D

171

Von ammon method

Conjunctiva

SECTION I •

B

2

1

Blair method

a

b

c

d

10 • Asian facial cosmetic surgery

Augmentation rhinoplasty is one of the most common aesthetic plastic surgery procedures in Asian countries. Whereas
most Western literature addresses issues related to rhinoplasty in Caucasians, such as reduction and corrective rhinoplasty procedures, augmentation of the nasal dorsum and tip
remain key issues for Asian plastic surgeons.43 In the past,
most of these operations consisted of simple augmentation
rhinoplasty. More recently, however, the needs of patients
have become more complex, requiring more meticulous preoperative diagnosis and more involved surgical techniques.
Ideally, rhinoplasty should enhance the harmony between the
nose and face, thus requiring general evaluation of the entire
face. For this purpose, the entire face must be evaluated. The
general principles for rhinoplasty in Asians are quite similar
to those in Caucasians. However, rhinoplasties in Asians and
Caucasians have different characteristics. This section will
describe various aspects of rhinoplasty in Asians, as well as
commonly encountered problems and solutions.

Introduction

Asian rhinoplasty

asymmetry, prolonged swelling, multiple folds, infection and
hematoma.
Asymmetry is the most common problem after Asian
blepharoplasty, especially when combined with levator plication or advancement. Revision surgery may be required for
patients with major and persistent asymmetry. Patients should
be informed of this preoperatively.

A

3

2

1

172

Blaskovics method

Fig. 10.14 Lateral canthoplasty: other
techniques.

The nasal proﬁle of Asians is quite different from that of
Caucasians. The Asian nose has a shorter height, less tip
projection, and a wider nasal base when compared to the
Caucasian nose. The Asian nose has a similar height and narrower width than the African nose.44 The overlying soft tissue
enveloping Asian noses consists of a dense ﬁbromuscular
layer along with a fatty layer, especially over the alar lobule.
The linear dimensions of the nose are smaller in Asians than
in Caucasians, but their noses are wider, although their nostril
ﬂoor widths are quite similar. These ﬁndings can be attributed
to the thicker, ﬂaring alar lobule in Asians.45 A comparison of
the aesthetic proportions of Asian and Caucasian noses found
that Asian noses projected less from the face and were broader
at the intercanthal level and alar base, but not at the bony
base. Moreover, Asian noses projected less at all levels, including the nasion projection and tip projection.46
Although there are racial variations among Asians, nasal
skeletons are generally smaller and weaker in Asians than in
Caucasians.47 The shape of the nasal bone in Germans has
been classiﬁed into eight types, whereas the width of the nasal
bones was shorter and the width of the pyriform aperture
was wider in Asians than in Germans. The nasal base width
in Asians is greater than in Caucasians but less than in
Africans. Asian noses have been found to be wider at the nasal
base, but similar or shorter in the height of the nasal base
(tip projection), than in Caucasians.48 Contrary to popular
thought, the alar cartilage in Asians is not markedly smaller
than in Caucasians, although there are differences in the

Differences in nasal soft tissue and skeletons
between Asian and Caucasian noses

C

3

2

1

173

Low proﬁle nasal dorsum augmentation

Most Asian people have a relatively low nasal dorsum compared with Caucasians. In recent years, many Asian patients
have requested augmentation of their dorsal nasal contour, as
well as increased projection of their nasal tip. It has therefore
become important to diagnose the height of the nasal dorsum
in the context of the entire lateral proﬁle involving the forehead, lip, and chin point. The thickness of the nasal skin must

Although autogenous cartilage remains the material of choice
for rhinoplastic grafts, an alternative grafting material is often
required. For cosmetic surgery, most patients desire simple
procedures that avoid the additional scarring associated with
autogenous graft harvesting. In Asians, and especially in

Surgical techniques and treatment

Surgery in Asians to augment their dorsum and increase tip
projection can result in cephalic tip rotation with exposure
of the nostrils. This is distressing to most people including
Asians. Lengthening an over-shortened nose is one of the
most challenging of rhinoplasty procedures. Therefore, it
is important to prevent shortening of the nose during augmentation rhinoplasty. It is also important to have the means
to correct the short Asian nose which presents either as
a primary condition or secondary to previous surgery. The
short nose can be deﬁned as congenital, postoperative or
posttraumatic, with procedures individualized according to
etiology. Frequent problems include paucity of the nasal
lining, contracture of the skin envelope and limitation in
expansion of the osteocartilaginous framework of the nose.
These three components should be corrected simultaneously.58
Recently, the release of ﬁve ﬁbrous connections has been
emphasized. The most effective length was reported to be
gained by severing the lateral crus from the upper lateral
cartilages, with moderate gain from release at the pyriform
aperture and the mucoperichondrium of the upper lateral
cartilage. Release of other tip-deﬁning structures was not statistically effective.59

Short or contracted nose

The nasal skin envelope is thicker in Asians than in Caucasians.
This thickness can obscure the underlying nasal cartilaginous
framework which is often ﬂimsy. To overcome these issues,
two problems must be addressed: (1) Can the thick skin be
altered? (2) How much can the cartilaginous framework be
manipulated?

Blunt nasal tip

The cartilaginous framework in most Asians is relatively
weak, resulting in an underprojected nasal tip. Asians seeking
rhinoplasty desire more nasal tip projection along augmentation of the dorsum.
Various methods exist for determining nasal tip projection.57 The ideal tip projection will be different for each patient
and must be balanced with the remainder of the face. Many
Asians have varying degrees of dentoalveolar protrusion. If
this is minimal, increased nasal tip projection may be desirable, but when it is severe, rhinoplasty alone will not solve the
patient’s problem.

Underprojection of the nasal tip

also be considered, especially if an alloplastic augmentation
is planned. Although the thick skin of Asians is better able to
endure dorsal implants, a tight skin envelope may limit the
possibility of a thick dorsal implant.

Low proﬁle and broad nasal dorsum

Nasal analysis in Asians is similar to that in Caucasians. The
universal standards for rhinoplasty do not differ greatly. The
following is a discussion of the most frequent ﬁndings and
strategies when dealing with Asian noses.

Diagnosis

Rhinoplasty in Asians was ﬁrst reported in 1964 by Khoo BooChai.51 He demonstrated augmentation rhinoplasty in Asians
using autogenous materials and silicone implants. He proposed the “golden point”, midway between the orbital ridge
and the intercanthal line, which is the optimal starting point
for the end of a silicone implant on the nasal dorsum. He also
proposed the importance of both dorsal and nasal tip augmentation in Asian rhinoplasty. In 1974, Furukawa summarized the important aspects of Asian rhinoplasty.16 He reported
anthropometric data of Japanese, identiﬁed the ideal Asian
proﬁle and described unique techniques for the Asian nose.
Moreover, diverse-shaped silicone dorsal implants were introduced. In 1986, McCurdy showed the aesthetic goals of rhinoplasty in the non-Caucasian nose are similar to those in the
Caucasian nose.52 He also noted that technical modiﬁcations
are needed when performing a non-Caucasian rhinoplasty. In
1990, Parsa’s report showed nasal augmentation with split
calvarial grafts in Orientals.53 Shin and Lee reported, in 1993,
columella lengthening in nasal tip plasty of Orientals.54
Watanabe analyzed the alar structure of the Oriental nose in
1994.55 In 1996, Han and Kang reported a custom-made nasal
implant prefabricated from the curing of silicone adhesive,
demonstrating satisfactory results in Asian noses.56 Since
then, different rhinoplasty techniques, depending on anatomy,
have been investigated in Asian patients. This was followed
by aesthetic modiﬁcations and techniques to minimize complications. Finally, advanced techniques have been developed
for complicated cases and difﬁcult situations.

History

conﬁguration and thickness of the cartilage and the length of
the foot plate of the medial crus. Moreover, nostril shape was
found to be affected mainly by the volume of the dilator naris
anterior/posterior muscular components, the depressor septi
nasi muscle, the shape of the lateral crus and the footplate
segment ratio.49 In Asians, there is also a loose connection
between the domes of the middle crura and the absence of
attachment of the medial crura to the caudal septum. This
might explain, at least in part, why the nasal tip is broad, and
underprojected, while its base is wide. Moreover, the lateral
crus is usually concave in Asians, but convex in Caucasians.50
Findings such as these have led to signiﬁcant advancements
in Asian rhinoplasty.

Asian rhinoplasty

3

Video

SECTION I •

B

10 • Asian facial cosmetic surgery

C

In the two-piece technique (Fig. 10.16), an alloplastic implant
is used to augment the dorsum as far down as the supratip
break. The tip is augmented using the cartilage techniques
described below. There is no connection between the silicone
implant and the cartilage used to augment the nasal tip;
unlike the one-piece method, this may lead to a discontinuity
between the tip and the new dorsum, necessitating additional
cartilage grafting.64 In placing the dorsal alloplastic implant,

Two-piece augmentation rhinoplasty

L-shaped silicone implants were originally used for augmentation rhinoplasty in Asian patients. However, these implants
were associated with many complications.60,61 Over the long
term, placement of a single L-shaped piece of alloplastic material can result in problems at the nasal tip, such as skin thinning, redness, transparency, tip deformation, implant
extrusion, and compression of the cartilaginous framework.62
An alternative to the L-shaped implant is a straight silicone
implant designed to only augment the dorsum; this technique
is much less problematic than the L-shaped implant. This
“one piece augmentation” implies a prosthetic implant which
extends to the nasal tip. For this classiﬁcation, the one piece
augmentation implies a prosthetic implant which extends to
the nasal tip. A variation of this technique is to attach a cartilage graft at the distal end of the straight silicone implant.63
Despite the use of such cartilage grafts on implants, similar
long-term complications can occur in the nasal tip area.
Because of these problems, many Asian plastic surgeons
prefer a two-piece augmentation rhinoplasty.

One-piece augmentation rhinoplasty

Korea, the use of synthetic nasal implants is well- established,
especially in the dorsum (Fig. 10.15).
The need for an implant material that is readily available,
not associated with donor site morbidity, offering ease of
sculpting, and with smooth contours, has led to the introduction of alloplastic materials such as: silicone; nylon
(Supramid mesh); PTFE (Teﬂon®, Gore-Tex®, Proplast®); polyester (Mersilene®); polyethylene (Medpor®), and hydroxyapatite. Silicone remains the most widely used material in Asia,
although its use can be associated with problems such as
extrusion, translucency, displacement, and infection.

D

Many Asian people have a relatively underprojected nasal tip
compared with Caucasians, making projection of the nasal tip

Underprojected nasal tip

a no-touch technique is used as much as possible, decreasing
the chance for contamination. For ideal positioning of the
nasal implant, the uppermost level is determined by the midpupillary level or by the midpoint between the eyebrow and
medial canthus. The underside of the implant is contoured
into a concave shape to ﬁt the contour of the nasal dorsum.
The implant is scored or perforated to allow tissue ingrowth
and thereby minimize movement of the implant.65 Interdomal
and transdomal sutures are often added to improve nasal tip
projection.

Fig. 10.16 Two piece augmentation rhinoplasty: alloplastic material for dorsal
augmentation; cartilage graft and suturing method for tip augmentation.

Columella strut

Shield graft

Alloplastic material for
dorsal augmentation
(mainly with silicone implant)

Fig. 10.15 (A,B) Preoperative view. Flat forehead and nose proﬁle. (C,D) Postoperative view. After augmentation of forehead and nose.

A

174

Although there have been many attempts to correct the
bulbous nose (Fig. 10.18), complete correction is usually not
achieved. Skin thinning procedures are possible in patients

Bulbous nose

Septal extension grafts (Fig. 10.17) were originally developed for correction of contracted noses. In Asian patients,
indications for such grafts have been expanded to improve
nasal tip projection without cephalic rotation of the nasal tip
and derotation of short noses.67,68 Since many Asians have a
thin septal cartilage, additional support with batten type cartilage may be required. Long-term stability of septal extension
grafts requires secure ﬁxation and complete release of soft
tissue constraints

Septal extension graft

Onlay cartilaginous grafting in the nasal tip can result in an
additional projection. Such onlay grafts may be visible in thin
skinned patients. However, such grafts are successful in most
Asian patients due to the thickness of their skin in this area.

Onlay graft

Although various suture methods based on tripod concepts
can be applied to Asian patients, most Asian noses are relatively short. Thus, creating tip projection using a suture
method can result in an up-turned nose. To prevent this sideeffect, derotation of the nasal tip is frequently required during
the procedure to increase tip projection. One method to
accomplish this involves placement of cartilage grafts on the
caudal surface of the nasal tip cartilages. These grafts slightly
lengthen the cartilage framework in the tip, causing the
appearance of tip derotation.
The other effective way to do this is to release the ﬁbrous
attachments between the upper and lower lateral cartilages.
After this procedure, the nasal tip could be projected effectively with various nasal tip suture techniques including
transdomal, interdomal sutures without fearing the cephalic
rotation of the nasal tip.

Cartilaginous work for nasal tip projection

Although AlloDerm or polytetraﬂuoroethylene is sometimes
used for nasal tip projection, these materials are associated
with many potential problems. Furthermore, while, porous
polyethylene (Medpor) can be used for columellar strut or
septal extension, it has been associated with long-term complications, including infection and tissue contracture, perhaps
due to exposure of the porous polyethylene through the thin
membranous septum.66 Due to long-term complications of
alloplastic materials around the nasal tip, few Asian plastic
surgeons use these materials. Over the past 20–30 years in
Korea, nasal tip plasty has been performed mainly using
autologous materials, including conchal and septal cartilage.

Alloplastic materials around the nasal tip

a key factor in Asian rhinoplasty. As mentioned earlier, one
potential side-effect of increasing projection of the nasal tip
is cephalic rotation and nasal shortening. This should be
avoided, especially because visibility of the nostrils on the
frontal view is considered a sign of bad luck in many Asian
countries.

175

Septal extension grafts are commonly utilized in Korea for
correction of short noses. Septal extension grafts were ﬁrst
introduced in 1997 and categorized into three types: direct
extension, paired spreader, and paired batten grafts.69 Because
most Asians have smaller septal cartilages, the efﬁcient usage
of this graft material is very important. Along with septal
extension, the lower lateral cartilage must be released from
the upper lateral cartilage in order to allow inferior displacement of the tip. Without this procedure, a septal extension
graft can result in a hanging columella. Occasionally, spacer
grafts are necessary between the separated upper and lower
cartilages in order to prevent alar retraction.
Due to the prevalent use of alloplastic material in the nose
and/or illegal administration of liquid alloplastic materials by
nonmedical personnel, a contracted nose is an iatrogenic
deformity common throughout Asia. Chronic inﬂammation
along the implant after rhinoplasty can result in a contracted
nose.70 This may be corrected by complete removal of the scar
tissue around the implant and followed by the complete
release of the soft tissue envelope from the nasal skeleton.
Without the latter, the contracted soft tissue envelope cannot
be lengthened, despite lengthening of the cartilaginous framework. After removal of the implant from the nose, other alloplastic materials can be used for dorsal augmentation, but
their use may result in other complications. Therefore, autologous tissue such as dermal-fat grafts, rib cartilage, calvarial

Short or contracted nose

with very thick skin, but the risk of necrosis of the skin envelope is relatively high. Thus, many Asian plastic surgeons
choose to augment the skeletal framework to camouﬂage
bulbous skin.

Fig. 10.17 Septal extension graft in oriental nose for preventing or correcting the
short nose.

Septal extension graft

Asian rhinoplasty

SECTION I •

B

10 • Asian facial cosmetic surgery

Lower lateral cartilage

Derotation (Fig. 10.19) of the nasal tip requires wide dissection
of the skin envelope, with release of the ﬁbrous tissue
between the caudal portion of the upper lateral cartilage and
the cephalic portion of the lower lateral cartilage. During this
procedure, the nasal mucosa must be preserved. Cymba

Derotation graft

The procedure is quite similar to that used for correction of
short noses. However, mucosal release may be difﬁcult in
contracted noses complicated by infection or severe scar contractures. Complete meticulous release of soft tissue including
the mucosa may be needed. Moreover, since excessive caudal
extension can result in soft tissue thinning on the nasal tip
area, the soft tissue envelope around the nasal tip should be
considered during lengthening procedures.

Septal extension graft

bone grafts and diced cartilage may provide better results.
The cartilage framework may be lengthened using a septal
extension graft, a derotation graft with conchal cartilage or a
rib osteochondral graft.

Fig. 10.19 Substantial lengthening with septal or conchal cartilage graft for
prevention of contracted nose.

Upper lateral
cartilage

Fig. 10.18 Bulbous nose in Asians. (A,B) preoperative view; (C,D) postoperative view.

A

176

D

Alloplastic materials should be removed from patients with
implant infections, with revision rhinoplasty performed after
a minimum delay of 3 months.

Implant infection

Visibility, redness, infection, and skin thinning may indicate
future implant exposure. Because this may be aggravated by
implantation of another alloplastic material, autogenous
tissue should be considered. In Korea, dermal-fat grafts are
most frequently used. Other types of autogenous grafts
include rib cartilage, bone and diced cartilage.

Implant exposure

This is the most common complication after augmentation
rhinoplasty in the Asian nose. It typically occurs with alloplastic materials, which have been placed through a unilateral
vestibular incision into a deviated pocket. This may be prevented by bilateral incisions, even when using the closed
approach. In the open approach, implant ﬁxation on the
midline portion of the cartilaginous framework may prevent
deviation of the implant.

Implant deviation

Outcomes, prognosis, and complications

Rib osteochondral grafts were originally designed for the
reconstruction of saddle nose deformities. This procedure
has been used primarily for the secondary correction of contracted noses, for which there were no other options.72
Although some authors advocate the primary usage of rib
cartilage graft on short noses, this is considered controversial.
Dermal-fat grafts can be very helpful in secondary revision of
contracted nose.

Rib cartilage or dermal-fat graft

concha is used for columellar struts and derotation grafts,
whereas cavum concha is used for onlay grafts.71 Derotation
grafting with conchal cartilage is relatively easy to perform
and can yield stable results with nasal tip lowering. However,
supratip bulging can occur after this procedure.

C

Although the standards of facial beauty have changed
over time, certain features remain constant. Many studies have
shown that symmetry and averageness could be the overall
standards for beauty proﬁles.74 Throughout history, humans
have attempted to deﬁne beauty objectively. Beauty can be
measured by various methods, including artistic standards,
cephalometric standards and anthropometric analysis.75
By using the golden ratio, Leonardo Da Vinci employed
artistic standards to try and explain facial beauty

Introduction

Asian facial bone surgery

As in Caucasian patients, chin projection should always be
considered in relation to nasal tip projection and the overall
proﬁle of the face. Osseous genioplasty or augmentation genioplasty with alloplastic materials are both successful in Asian
patients.

Genioplasty

Many Asians are also concerned about the width of their nasal
base. The very real risk of visible scarring must be carefully
discussed with the patient before proceeding with any modiﬁcation of the alar base.

Alar base surgery

In Asia, augmentation rhinoplasty combined with paranasal
augmentation has become quite popular. Paranasal augmentation is performed using PTFE (Gore-Tex®), silicone or polyethylene (Medpor) implants. Since this procedure can result
in inﬂammation or chronic infection, patients should be
informed preoperatively. Microfat grafts with the Coleman
technique may also be used for paranasal augmentation.

Paranasal augmentation

Augmentation rhinoplasty can make the lateral proﬁle more
attractive. However, patients with a ﬂat forehead proﬁle
may beneﬁt from a simultaneous forehead augmentation.
Traditionally, custom-made silicone or Gore-Tex® implants
have been used for forehead augmentation despite the possibility of seroma or infection of the implant.73 This may be
due to the ease of the technique and the more natural contour
of the forehead resulting from the use of these implants.
Microfat grafting with the Coleman technique or augmentation with various cements may also be used to improve the
forehead proﬁle.

Forehead augmentation (Fig. 10.15)

Secondary procedures

Capsular contractures may occur around any alloplastic
implant and cause deformity and possible implant extrusion.
Treatment of this complication is similar to that advocated for
implant exposure.

Capsular contracture around implants

177

Reduction malarplasty, ﬁrst reported at 1983 by Onizuka
and colleagues, was based on underpositioning of the osteotomized zygoma through an intraoral approach.82 In 1988,

Malar reduction

History

mathematically. The golden ratio, which was originally used
in architecture, geometry and other areas is deﬁned by a line
divided into two unequal segments, where the ratio of the
entire line to the longer segment is identical to the ratio of the
longer to the shorter segment, or 1.618.76 The golden ratio has
been used in planning correctional surgery for a facial deformity, creating a line drawing of a mask outlining ideal facial
proportions.77 Although others have claimed that this mask
does not describe an ideal facial shape, the facial golden mask
has been used as an objective index for facial analysis, with
some correlation to the degree of facial attractiveness.78 In
view of artistic standards, the Asian is known to have a relatively wider mid and lower face, based on the golden ratio.
These ﬁndings may explain why many Asians request facial
reduction procedures, including the malar reduction, mandible angle reduction and maxillomandibular setback procedures. In addition, Asian people have smaller noses and
greater bizygomatic and bigonial widths, according to the
golden ratio.79 Reduction of the mandible angle and/or
zygoma reduction is regarded by many Asian women as a
means of becoming more attractive.
The second tool for measuring the facial proﬁle is cephalometric analysis.75 This method, along with other analytic
methods, has been the standard until now for facial analysis.
However, these analytic methods have their shortcomings.
Thus, it has been concluded that clinical aesthetic evaluations
are more valuable than cephalometric standards, and that
strict adherence to cephalometric standards does not lead to
either harmonious or more beautiful faces. Despite these controversies, cephalometric analysis has been the standard tool
for analysis of facial growth and orthognathic surgery.
McNamara et al. reported a study of the lateral proﬁle of 60
Koreans and 42 European–American adults with normal
occlusion.80 Their study showed that the Koreans had a lower
angle of nasal inclination and a higher degree of lip protrusion, whereas the slope of the forehead did not differ signiﬁcantly. Dentoalveolar protrusion is another characteristic of
Asian people. Thus, many of orthognathic procedures in Asia
are done to setback of dentoalveolar complex and maxillomandibular complex.81
Anthropometry, a method by which direct measurements
are taken on live subjects, offers numerous advantages: these
measurements are easy to take, noninvasive, and inexpensive,
as well as being suitable for a wide variety of purposes. In
order to be meaningful, there must be an adequate number
of subjects representing all ethnic groups and different social
backgrounds. In addition, well-trained examiners should
use sophisticated measurement tools. Honn and Goz used this
method to investigate differences between female KoreanAmericans and Caucasian–Americans.75
The above discussion suggests that there is no perfect way
to deﬁne beauty. Therefore, it would be wise to use the both
subjective and objective tools for analysis of facial proﬁles
according to the ethnic standards.

Asian facial bone surgery

SECTION I •

10 • Asian facial cosmetic surgery

The presence of prominent mandibular angles in Asians suggests a harsh and masculine appearance. This led to the design
of procedures for aesthetic contouring of the mandible. The
square facial appearance in Asians is not only due to masseteric hypertrophy but also to a posterior projection and lateral
ﬂaring of the mandibular angle. In 1989, Baek et al. reported
the mandible angle ostectomy in 42 Asian patients.89 In 1994,
technical reﬁnements were reported,5 which classiﬁed the
prominent mandible angle according to the anatomic type of
mandibular angle: lateral bulging in frontal view and posteroinferior projection in lateral view, or a combination of these
types. Curved and/or tangential osteotomy of the lateral
ﬂaring was performed based on the category. Mandible contouring surgery could be performed with an oscillating saw,
and multiple mandible angle ostectomy was found to result
in a smoother contour of the mandible angle postoperatively.
In 1994, Kyutoku et al. invented the gonial angle stripper for
treatment of prominent gonial angle.90 Satoh reported mandibular contouring surgery by angular contouring combined
with genioplasty in orientals.91 In 1997, Deguchi et al. reported
angle-splitting ostectomy for reducing the width of the lower
face.92 In 2005, Gui and colleagues reported intraoral onestage curved osteotomy in 407 cases.93 Among the methods
described to reduce the bigonial width were external corticotomy with a sagittal split which involved removal of the
external cortex of the mandibular ramus, thus reducing the
bigonial angle. Han and Kim reported reduction mandibuloplasty, which he described as ostectomy of the lateral cortex
around mandibular angle.94 Lo et al. showed the high satisfaction rates after zygoma and mandible reduction surgery in
outcome assessments. He also showed the signiﬁcant volume
change in osseous mandible and masseter muscle after the
mandibular contouring surgery.95 Hong and colleagues threedimensionally analyzed the relationship among lower facial
width, bony width, and masseter muscle volume in prominent mandible angles.96 Long curved osteotomy was recently
introduced in Korea to reduce the mandibular body as well

Mandible angle reduction

Baek et al. reported 94 cases using a technique involving the
coronal approach followed by either an in situ transposition
osteoplasty or the removal of the malar complex and contouring of the bone with replacement as a free bone graft.83 In 1991,
Uhm and Lew classiﬁed zygoma prominence into three categories, including true zygoma protrusion, pseudozygomatic
protrusion and combination.84 Yang and Park reported, in
1992, an infracture technique for the zygomatic body and arch
reduction, which he postulated could minimize the agerelated ptosis of soft tissues of the cheek. Surgical procedures
for zygomatic reduction in Orientals have also been described,
as has an “infracture technique for zygomatic osteotomy and
arch reduction.”85 In 1993, Satoh and Watanabe showed the
results using the tripod osteotomy via the coronal approach
and simultaneous frontoperiorbital lifting in oriental patients.86
Cho compared the results of the intraoral and bicoronal
approaches.87 Baek and Lee showed that intraoral malar
reduction could result in cheek drooping. Thus, the combination of reposition malarplasty and facelift proved to be a satisfactory method.88 Many reports for simultaneous mandibular
contouring and zygoma reduction have been reported for
balanced facial contours.

178

Genioplasty in Asian people, either for setback or advancement, is a similar procedure to that in Caucasians. Recently, a
narrowing genioplasty has been introduced in Korea. This is
often done in conjunction with mandible angle reduction.
Park reported the narrowing genioplasty, either as a single
procedure or in combination with mandible reduction, making
the lower face appear slender and produces a more feminine

Chin

Most Asian people have prominent cheekbones. Prominent
cheekbones are considered attractive in Western women. This
is not true in eastern societies, where prominent cheekbones
are indicative of strength and considered undesirable in
Asian women. Thus, most Asian women want less prominent
zygomas. However, in performing zygoma reduction surgery,
the bitemporal widths should be considered. Overcorrected
zygoma widths can result in an unnatural appearance, removing the soft contour of the face. Moreover, the anterior part of
the zygoma should be preserved in most patients. Without
this protrusion, patients tend to look older. Therefore, to preserve a youthful appearance, only the anterolateral and lateral
parts of the zygoma should be reduced.

Zygoma

Many Asian people want to improve their square face appearance by reducing the size of their prominent mandible angles.
Therefore, mandibular angle reduction is a popular procedure
in Asia. An acute gonial angle can be corrected by mandible
angle ostectomy (bone removal). Mandible angle reduction
results in a narrower bigonial distance. Moreover, the lateral
ﬂaring in frontal view can be corrected with external corticotomy and angle reduction. If, in addition, a patient has
masseteric hypertrophy, it can be corrected with Botox injection, but only with temporary effects. Thus, an alternative in
such patients is to combine an osseous mandibular angle
reduction and resection of the masseter muscle. These combined procedures are still controversial.

Mandible angle

Diagnosis and indications

Proﬁloplasty of the lower face by maxillary and mandibular
anterior segmental osteotomies (ASO) was ﬁrst described in
1993.97 Taiwanese plastic surgeons YuRay Chen, Philip Chen,
and LunJou Lo have played important roles in developing
orthognathic surgery suitable for Asians. Recently in Korea,
orthognathic surgery is being performed for purely aesthetic
reasons. Although maxillo-mandibular complex clockwise
rotation has been found quite helpful for skeletal class III
patients, the true indications for these procedures have not
yet been clariﬁed.

Orthognathic surgery and anterior
segmental ostectomy

as the mandibular angles. Sometimes, these procedures are
performed simultaneously with narrowing genioplasty,
resulting in a smaller lower face.

Traditionally, mandible angle ostectomy has been performed
with an oscillating saw. An external approach was previously
used because it allowed direct access to the mandibular angle.
However, this procedure is now usually performed using an
intraoral approach. In the latter, meticulous subperiosteal dissection is important to minimize bleeding and postoperative
edema. Mandible angle ostectomy with an oscillating saw
requires the somewhat blind removal of the mandible angle
area. In patients with inwardly curved angles, ostectomy may
be facilitated by burring on the ramus area or by the use of
indirect mirrors. Important anatomical structures must be
respected. In women, the average distances of the inferior
alveolar nerve from the mandibular angle are 23.69 mm for
square faces versus 20.66 mm for normal faces. In men, these
distances are 27.30 mm and 23.28 mm, respectively.99 During
this procedure, the facial artery and the retromandibular vein
are the most vulnerable vessels and should therefore be
avoided. Following ostectomy, the secondary angle should
also be manipulated by burring or doing multiple ostectomies

Mandible angle ostectomy (Figs 10.20, 10.21)

Facial contouring surgery

Surgical techniques and treatments

Orthognathic surgery was originally designed to correct dentofacial deformities in patients with angle classiﬁcation II or
III. In Asia, the indications for orthognathic surgery have
recently been extended to patients with almost normal occlusion and mild skeletal dentofacial disharmony. Although
standard protocols have not yet been deﬁned, orthognathic
surgery has been found to change the facial proportions more
ideally and reduce the size of the face. Since many Asian
people have a mild skeletal class III pattern, many orthognathic surgery procedures in Asia involve class III corrections.
Moreover, recent trends in facial bone surgery in Asia include
the reduction of the facial contour, making it smaller than
Asian average. In 2006, Jin et al. showed that orthognathic
surgery for correction of occlusal class I in skeletal class III
cases is effective in some patients. This report showed that it
is possible to enhance the aesthetic outcome in this subset
of Asians by changing skeletal characteristics so that the
facial measurements more closely approach normal values.98
However, the indications for orthognathic surgery in this
group of patients remain controversial.

Facial proﬁles

Anterior segmental setback ostectomy (ASO) is indicated in
Asians with bimaxillary protrusions. Many Asian people have
a tendency towards dentoalveolar protrusion, which may
require orthodontic treatment or ASO. The latter procedure,
however, should be limited to patients with large protrusions.
Mild dentoalveolar protrusion might be better treated with
orthodontic treatment alone. Excessive dentoalveolar setback
with ASO can result in an unnatural appearance in Asians.

Dentoalveolar protrusion

chin contour. Trapezoid or broad chins can be reduced by
narrowing genioplasty.

B

Multiple ostectomy

179

on the mandible body area. If not, patients may complain of
irregular mandibular contours postoperatively. Three different ostectomy patterns may be performed:
• Curved ostectomy with an oscillating saw: This procedure
is indicated in most patients with prominent mandible
angles. It especially helps in reducing posteroinferior
ﬂaring in the lateral view.
• Tangential ostectomy with a reciprocating saw: With this
procedure, the external cortex of the mandibular ramus
is removed. Tangential ostectomy is performed to narrow
the bigonial distance in mandibles with lateral ﬂaring in
the frontal view. This procedure alone, however, may not
make the lateral contour smooth.100
• Long-curved ostectomy: This procedure is indicated in
patients with a prominent mandible angle and wide
mandibular body. Simultaneous reduction of the
mandibular angle and body can result in a much
smaller lower facial contour. Recently in Korea, this
procedure is often performed along with narrowing
genioplasty.

Fig. 10.20 (A–C) Various methods for mandibular reduction.

C

Long-curved ostectomy
and narrowing genioplasty

A

External corticotomy

Asian facial bone surgery

SECTION I •

B

10 • Asian facial cosmetic surgery

A

B

Infracture
technique

C

Superior
repositioning

Malar reduction (Fig. 10.22) was ﬁrst performed in the early
1980s to reduce the bizygomatic width. While the malar
complex can be approached through intraoral, bicoronal, or
preauricular incisions, the intraoral approach is often preferred. This approach to malar reduction begins with an oral
incision and subperiosteal dissection. The osteotomy line is
usually between the most concave line to the maxillary buttress, but may vary according to the preference of the surgeon.
A higher position on the upper osteotomy site can result
in greater malar reduction. Exposure of the maxillary sinus
does not usually lead to infection, but avoiding an excessive
anterior osteotomy is important in order to achieve good
bony contact. Intraoral malar reduction has some pitfalls, the

Malar reduction surgery

ﬁrst of which is soft tissue ptosis. Wide periosteal dissection
involves detachment of the zygomatico-cutaneous ligaments.
Postoperatively, soft tissue tends to displace downwards.
The implication is that minimal dissection over the maxilla is
preferred. The second pitfall is nonunion. With the intraoral
approach, high ﬁxation of the zygomatic segments is not easy.
The masseteric power is quite great so postoperative downward displacement of the zygomatic bone may occur. Without
bone union, the masseter muscle tends to displace the zygomatic complex. These problems may be overcome by using a
bicoronal approach, an infracture technique with incomplete
osteotomy, or by minimizing dissection during malar reduction. For osteotomy of the zygomatic arch, a small incision
around the hairline is usually made, allowing for use of a
reciprocating saw or a small osteotome. Use of the former may

Fig. 10.22 (A–C) Various methods for malar reduction. (A) Typical L-shape ostectomy. (B) Green stick fracture. (C) Superior repositioning of malar complex via the
bicoronal approach.

L-shape
ostectomy

Fig. 10.21 (A,B) Prominent mandible angle: mandible angle ostectomy and external corticotomy with microfat graft in older ages.

A

180

The standard approach in management of class III dentofacial
deformity in Caucasian patients is simultaneous maxillary
advancement and mandibular setback. This procedure is
indicated when maxillary hypoplasia exists relative to

Orthognathic surgery: jaw rotation

Lip and chin proﬁles differ considerably between Asian and
Western populations. Asians tend to have bimaxillary protrusion and a class III skeletal pattern, which have made ASO
setback and class III correction with orthognathic surgery
quite popular in Asian countries.

Orthognathic surgery and anterior
segmental ostectomy

Narrowing genioplasty (Fig. 10.23), either as a single procedure or in combination with mandible reduction, makes the
lower face appear slender and produces a more feminine chin
contour. Soft tissue attachment of the chin is maintained to
produce a maximum narrowing effect and maintain the blood
ﬂow to bony segments. Horizontal osteotomy and two vertical osteotomies are designed as shown in ﬁgure. The amount
of resection in the central segment is determined preoperatively, depending on the width of chin and the patient’s desire.
The two segments are approximated centrally and ﬁxed with
microplates and screws. Advancement of the two segments is
also possible if correction of the proﬁle is required. The resection of the central strip has ranged from 6 to 12 mm.

Narrowing genioplasty

For purely aesthetic reasons, this procedure is not wellaccepted. However, in complicated cases, malar reduction via
bicoronal approach can give the best results in ﬁxation and
precise correction of the malar complex. This approach may
be advantageous in middle age or older patients because a
forehead lift can be done simultaneously without additional
incisions.

Bicoronal approach

To overcome the limits of intraoral malar reduction, this procedure may be useful (Figs 10.22B). Infracture with green stick
fracture of the malar bone can minimize the incidence of postoperative soft tissue ptosis and malar nonunion. Additional
burring is often needed to decrease the bony step in the malar
area. Also, secure zygomatic arch ﬁxation may be needed.

Intraoral infracture technique with incomplete osteotomy

This is the traditional method of malar reduction (Fig.
10.22A). Segmental resection of the malar bone decreases
the bizygomatic width and often results in an unnatural
appearance.

Intraoral L-shaped ostectomy

sometimes involve a temporal approach with a small incision.
Some surgeons perform intraoral osteotomy on the zygomatic
arch area without making any incision on the preauricular
area. The optimal procedure for malar reduction in Asians
has not been determined, but may depend primarily on
each patient’s condition and the surgeon’s preferences
(Fig. 10.22). Possible approaches to malar reduction include
the following.

181

This procedure is designed to osteotomize the anterior portions of the Lefort I segment and mandible and move them
posteriorly. Preoperatively or intraoperatively, the ﬁrst or
second premolar is extracted for ASO setback. For anterior
segmental ostectomy of the maxilla, two different pedicles can
be used, with the palatal pedicle commonly used with the
buccal approach. This approach provides improved exposure
and easier performance of surgery. During these procedures,
care must be taken to preserve the palatal mucosa. Preoperative

Bimaxillary protrusion: anterior segmental
setback ostectomy

mandibular prognathism in class III dentofacial deformities.
However, many Asian patients have a varying degree of dentoalveolar protrusion which makes the Asian face look different from their Caucasian counterparts. In Asians, the maxillary
advancement procedures may sometimes cause the aggravation of dentoalveolar protrusion or widening of alar base,
both of which would be detrimental to their facial appearance.
Moreover, Asian females tend to have a ﬂat occlusal plane and
a prominent mandibular angle which results in a square
appearance. For these reasons, a posterior maxillary impaction without any maxillary advancement would be the preferable in some Asian class III patients (Figs 10.24–10.27).
However, caution must be exercised because excessive posterior impaction of maxilla along with the mandibular set back
may impair the airway or change the shape of the smile.
In some cases, total maxillary setback is needed for simultaneous correction of a dentoalveolar protrusion. The vascular
plexus should be avoided during this procedure and the total
amount of total maxillary setback is limited compared to that
with ASO (Fig. 10.27).

Fig. 10.23 Narrowing genioplasty for the correction of the chin width.

Narrowing genioplasty

Asian facial bone surgery

PP

PP

SECTION I •

B

Many complications from mandible angle reduction have been
reported.101 The most critical complications include the condyle
fracture caused by a wayward osteotomy, massive bleeding
from the retromandibular vein or facial vessels and damage to
the mental nerve. During angle reduction, precise ostectomy
around the mandible posterior border is important in order to
avoid a condylar fracture. When using the oscillating saw,
adequate periosteal dissection is needed to allow visualization
of the posterior mandibular border. If the retromandibular
vein is torn during the procedure, direct coagulation or other
means of hemostasis is not easy. Therefore, manual compression for at least for 30 min can help. The facial artery is sometimes injured during periosteal dissections. This problem can
be addressed by manual compression or direct ligation of
vessel. Fortunately, damage to the facial nerve is rare.

Mandible angle reduction

Intraoperative complications are rare. However, long-term
complications include drooping of cheek tissues and malar
bone nonunion. Excessive wide dissection can release the
zygomatico-cutaneous ligaments leading to soft tissue ptosis.
Poor ﬁxation of the osteotomy can lead to nonunion.
Unfortunately, intraoral ﬁxation of the malar complex in the
superior-medial direction is not easy. The bicoronal approach
can solve this problem by providing access for secure ﬁxation.
Alternatively, an infracture technique with a green stick fracture can be done. Finally, in order to minimize complications,
less invasive approaches with minimal dissection are being
introduced.

Zygoma reduction

Outcomes, prognosis, and complications

and postoperative orthodontic treatment is mandatory to
obtain predictable results.

Fig. 10.25 (A,B) Preoperative and postoperative lateral cephalometry. The lateral cephalometry shows the rotational movements of maxilla and mandibular complex (MMC).
In these cases, the maxillary advancement procedures may cause aggravation of dentoalveolar protrusion or widening of alar base and these changes are harmful to the
aesthetics of Asian face. Moreover, Asian females tend to have a ﬂat occlusal plane and a prominent mandibular angle which causes their faces to look square. For these
reasons, a large amount of posterior maxillary impaction without any maxillary advancement would be the preferable in Asian class III patients.

A

PP

10 • Asian facial cosmetic surgery

Fig. 10.24 Two jaw rotational setback.

182

B
C

D

B

C
D

183

4. Flowers RS. The art of eyelid and orbital aesthetics:
multiracial surgical considerations. Clin Plast Surg.
1987;14(4):703–721.
Basic and original article for orbital aesthetics.
28. Lam SM, Kim YK. Partial-incision technique for
creation of the double eyelid. Aesthet Surg J.
2003;23(3):170–176.
41. Oh YW, Seul CH, Yoo WM. Medial epicanthoplasty
using the skin redraping method. Plast Reconstr Surg.
2007;119(2):703–710.
This technique has changed the concept of medial
canthoplasty.
43. Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast
Surg Clin North Am. 2007;15(3):293–307.
50. Han SK, Lee DG, Kim JB, et al. An anatomic study
of nasal tip supporting structures. Ann Plast Surg.
2004;52(2):134–139.
64. Rohrich RJ, Deuber MA. Nasal tip reﬁnement in
primary rhinoplasty: the cephalic trim cap graft.
Aesthet Surg J. 2002;22(1):39–45.

85. Yang DB, Park CG. Infracture technique for the
zygomatic body and arch reduction. Aesthetic Plast
Surg. 1992;16(4):355–363.
89. Baek SM, Kim SS, Bindiger A. The prominent
mandibular angle: preoperative management,
operative technique, and results in 42 patients. Plast
Reconstr Surg. 1989;83(2):272–280.
The pioneer article for Asian mandible angle
ostectomy.
97. Baek SM, Baek RM. Proﬁloplasty of the lower face
by maxillary and mandibular anterior segmental
osteotomies. Aesthetic Plast Surg. 1993;17(2):
129–137.
First article for Asian proﬁloplasty.
100. Jin H, Park SH, Kim BH. Sagittal split ramus
osteotomy with mandible reduction. Plast Reconstr
Surg. 2007;119(2):662–669.
New concept of mandible angle ostectomy.

Access the complete references list online at http://www.expertconsult.com

Fig. 10.27 (A,B) Preoperative view. Jaw rotation in skeletal class III proﬁles. Combined maxillary posterior impaction and mandibular rotation. (C,D) Postoperative view.
Jaw rotation in skeletal class III proﬁles. Combined maxillary posterior impaction and mandibular rotation.

A

Fig. 10.26 (A,B) Class III dentofacial deformity: preoperative view. (C,D) Postoperative view. Two jaw surgery with jaw rotational setback procedure.

A

Asian facial bone surgery

1. Ohmori K. Esthetic surgery in the Asian patient.
In: McCarthy JG, ed. Plastic surgery. Philadelphia:
Saunders; 1990:2415–2426.
2. Kang J. Basic principles of aesthetic surgery. In:
McCarthy JG, ed. Plastic surgery. Philadelphia:
Saunders; 2004:829–836.
3. Rubenstein AJ, Kalakanis L, Langlois JH. Infant
preferences for attractive faces: a cognitive explanation.
Dev Psychol. 1999;35(3):848–855.
4. Flowers RS. The art of eyelid and orbital aesthetics:
multiracial surgical considerations. Clin Plast Surg.
1987;14(4):703–721.
Basic and original article for orbital aesthetics.
5. Baek SM, Baek RM, Shin MS. Reﬁnement in aesthetic
contouring of the prominent mandibular angle.
Aesthetic Plast Surg. 1994;18(3):283–289.
6. Park S, Noh JH. Importance of the chin in lower facial
contour: narrowing genioplasty to achieve a feminine
and slim lower face. Plast Reconstr Surg.
2008;122(1):261–268.
7. Flowers RS, Nassif JM. Aesthetic periorbital surgery.
In: Mathes SJ, ed. Plastic surgery. 2nd ed. Philadelphia:
Saunders; 2006:77–78.
8. Hiraga Y. The double eyelid operation and
augmentation rhinoplasty in the oriental patient.
Clin Plast Surg. 1980;7(4):553–568.
9. Sergile O. Mikamo’s double eyelid operation: The
advent of Japanese aesthetic surgery. Plast Reconstr
Surg. 1997;99:662–667.
10. Shirakabe Y, Kinugasa T, Kawata M, et al. The
double-eyelid operation in Japan: its evolution as
related to cultural changes. Ann Plast Surg. 1985;15(3):
224–241.
11. Sayoc BT. Plastic construction of the superior palpebral
fold. Am J Ophthalmol. 1954;38(4):556–559.
12. Fernandez LR. Double eyelid operation in the Oriental
in Hawaii. Plast Reconstr Surg Transplant Bull. 1960;25:
257–264.
13. Cho BC, Byun JS. New technique combined with
suture and incision method for creating a more
physiologically natural double-eyelid. Plast Reconstr
Surg. 2010;125(1):324–331.
14. Sayoc BT. Anatomic considerations in the plastic
construction of a palpebral fold in the full upper
eyelid. Am J Ophthalmol. 1967;63(1):155–158.
15. Cheng J, Xu FZ. Anatomic microstructure of the upper
eyelid in the oriental double eyelid. Plast Reconstruct
Surg. 2001;107:1665–1668.
16. Furukawa M. Oriental rhinoplasty. Clin Plast Surg.
1974;1(1):129–155.
17. Siegel R. Surgical anatomy of the upper eyelid fascia.
Ann Plast Surg. 1984;13(4):263–273.
18. Yoon KC, Park S. Systematic approach and selective
tissue removal in blepharoplasty for young Asians.
Plast Reconstr Surg. 1998;102(2):502–508.

References

183.e1

19. Chen WPD. Upper lid crease terminology and
conﬁgurations. Asian blepharoplasty and the eyelid crease,
2nd ed. Philadelphia: Butterworth Heinemann/
Elsevier; 2006.
20. Zubiri JS. Correction of the oriental eyelid. Clin Plast
Surg. 1981;8(4):725–737.
21. Baek SM, Kim SS, Tokunaga S, et al. Oriental
blepharoplasty: single-stitch, nonincision technique.
Plast Reconstr Surg. 1989;83(2):236–242.
22. Liu D. Oriental blepharoplasty. Plast Reconstr Surg.
1989;84(4):698–699.
23. Hin LC. Oriental blepharoplasty – a critical review
of technique and potential hazards. Ann Plast Surg.
1981;7(5):362–374.
24. Weingarten CZ. Blepharoplasty in the Oriental eye.
Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol.
1976;82(4):442–446.
25. Dresner SC. Oriental blepharoplasty: anatomic
considerations. Plast Reconstr Surg. 1989;84(6):1003.
26. Choi AK. Oriental blepharoplasty: nonincisional suture
technique versus conventional incisional technique.
Facial Plast Surg. 1994;10(1):67–83.
27. Wong JK. A method in creation of the superior
palpebral fold in Asians using a continuous buried
tarsal stitch (CBTS). Facial Plast Surg Clin North Am.
2007;15(3):337–342.
28. Lam SM, Kim YK. Partial-incision technique for
creation of the double eyelid. Aesthet Surg J. 2003;23(3):
170–176.
29. Yang SY. Oriental double eyelid: a limited-incision
technique. Ann Plast Surg. 2001;46(4):364–368.
30. McCurdy JA. Upper lid blepharoplasty in the Oriental
eye. Facial Plast Surg. 1994;10(1):53–66.
31. Park SH, Shim JS. Classiﬁcation of blepharoptosis by
etiology. J Korean Soc Plast Reconst Surg. 2008;35(4):
455–460.
32. Baik BS, Choi WS, Yang WS. Treatment of
blepharoptosis by the advancement procedure
of the Müller’s muscle-levator aponeurosis composite
ﬂap. J Korean Soc Plast Reconstr Surg. 2009;36(2):
200–2004.
33. Ben Simon GJ, Lee S, Schwarcz RM, et al. Müller’s
muscle-conjunctival resection for correction of upper
eyelid ptosis: relationship between phenylephrine
testing and the amount of tissue resected with ﬁnal
eyelid position. Arch Facial Plast Surg. 2007;9(6):
413–417.
34. de la Torre JI, Martin SA, De Cordier BC, et al.
Aesthetic eyelid ptosis correction: a review of
technique and cases. Plast Reconstr Surg. 2003;112(2):
655–662.
35. Kim Y. Correction of blepharoptosis using posterior
check ligament sling. J Korean Soc Aesthetic Plast Surg.
2009;15(3):228–233.
36. Uchida J. [Triangular ﬂap method in medial and lateral
canthotomy]. Keisei Geka. 1967;10(2):120–123.
37. Lessa S, Sebastia R. Z-epicanthoplasty. Aesthetic Plast
Surg. 1984;8(3):159–163.

References

SECTION I • 10 • Asian facial cosmetic surgery

38. Mulliken JB, Hoopes JE. W-epicanthoplasty.
Plast Reconstr Surg. 1975;55(4):435–438.
39. Park JI. Z-epicanthoplasty in Asian eyelids.
Plast Reconstr Surg. 1996;98(4):602–609.
40. Park JI. Root Z-epicanthoplasty in Asian eyelids.
Plast Reconstr Surg. 2003;111(7):2476–2477.
41. Oh YW, Seul CH, Yoo WM. Medial epicanthoplasty
using the skin redraping method. Plast Reconstr Surg.
2007;119(2):703–710.
This technique has changed the concept of medial
canthoplasty.
42. Jang H, Chung YJ, Kang DH, et al. Cosmetic
lengthening and repositioning of the lateral canthal
angle with skin muscle redraping methods. J Korean
Society Aesthetic Plast Surg. 2009;15(3):208–212.
43. Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast
Surg Clin North Am. 2007;15(3):293–307.
44. Farkas LG, Deutsch CK, Hreczko TA. Asymmetries in
nostrils and the surrounding tissues of the soft nose
– a morphometric study. Ann Plast Surg. 1984;12(1):
10–15.
45. Aung SC, Foo CL, Lee ST. Three dimensional laser
scan assessment of the Oriental nose with a new
classiﬁcation of Oriental nasal types. Br J Plast Surg.
2000;53(2):109–116.
46. Leong SC, White PS. A comparison of aesthetic
proportions between the Oriental and Caucasian nose.
Clin Otolaryngol Allied Sci. 2004;29(6):672–676.
47. Abdelkader M, Leong S, White PS. Aesthetic
proportions of the nasal aperture in 3 different racial
groups of men. Arch Facial Plast Surg. 2005;7(2):111–113.
48. Lee SH, Yang TY, Han GS, et al. Analysis of the nasal
bone and nasal pyramid by three-dimensional
computed tomography. Eur Arch Otorhinolaryngol.
2008;265(4):421–424.
49. Dhong ES, Han SK, Lee CH, et al. Anthropometric
study of alar cartilage in Asians. Ann Plast Surg.
2002;48(4):386–391.
50. Han SK, Lee DG, Kim JB, et al. An anatomic study
of nasal tip supporting structures. Ann Plast Surg.
2004;52(2):134–139.
51. Khoo BC. Augmentation rhinoplasty in the Orientals.
Plast Reconstr Surg. 1964;34:81–88.
52. McCurdy JA Jr. Aesthetic rhinoplasty in the nonCaucasian. J Dermatol Surg Oncol. 1986;12(1):38–44.
53. Parsa FD. Nasal augmentation with split calvarial
grafts in Orientals. Plast Reconstr Surg. 1991;87(2):
245–253.
54. Shin KS, Lee CH. Columella lengthening in nasal tip
plasty of Orientals. Plast Reconstr Surg. 1994;94(3):
446–453.
55. Watanabe K. New ideas to improve the shape of
the ala of the Oriental nose. Aesthetic Plast Surg.
1994;18(4):337–344.
56. Han K, Kang J. A custom-made nasal implant:
prefabrication from curing of silicone adhesive.
Plast Reconstr Surg. 1996;97(2):436–444.

183.e2

57. Gunter JP, Hackney FL. Clinical Assessment and Facial
Analysis. In: Gunter JP, Rohrich RJ, Adams WP, eds.
Dallas rhinoplasty: nasal surgery by the Masters. St Louis:
Quality Medical; 2002.
58. Gruber RP. Surgical correction of the short nose.
Aesthetic Plast Surg. 2002;26(Suppl 1):S6.
59. Han SK, Ko HW, Lee DY, et al. The effect of releasing
tip-supporting structures in short-nose correction. Ann
Plast Surg. 2005;54(4):375–378.
60. Jung DH, Kim BR, Choi JY, et al. Gross and pathologic
analysis of long-term silicone implants inserted into
the human body for augmentation rhinoplasty: 221
revision cases. Plast Reconstr Surg. 2007;120(7):
1997–2003.
61. Lam SM, Kim YK. Augmentation rhinoplasty of the
Asian nose with the “bird” silicone implant. Ann Plast
Surg. 2003;51(3):249–256.
62. Sun AK, Xu F, Liu WZ, et al. [The long-term effect of
augmentation rhinoplasty with silicone]. Lin Chuang Er
Bi Yan Hou Ke Za Zhi. 2000;14(11):501–502.
63. Ahn J, Honrado C, Horn C. Combined silicone and
cartilage implants: augmentation rhinoplasty in Asian
patients. Arch Facial Plast Surg. 2004;6(2):120–123.
64. Rohrich RJ, Deuber MA. Nasal tip reﬁnement in
primary rhinoplasty: the cephalic trim cap graft.
Aesthet Surg J. 2002;22(1):39–45.
65. Lam SM. Revision rhinoplasty for the Asian nose.
Facial Plast Surg. 2008;24(3):372–377.
66. Turegun M, Acarturk TO, Ozturk S, et al. Aesthetic and
functional restoration using dorsal saddle shaped
Medpor implant in secondary rhinoplasty. Ann Plast
Surg. 2008;60(6):600–603.
67. Han K, Jin HS, Choi TH, et al. A biomechanical
comparison of vertical ﬁgure-of-eight locking suture
for septal extension grafts. J Plast Reconstr Aesthet Surg.
2010;63(2):265–269.
68. Kim JS, Han KH, Choi TH, et al. Correction of the
nasal tip and columella in Koreans by a complete
septal extension graft using an extensive harvesting
technique. J Plast Reconstr Aesthet Surg. 2007;60(2):
163–170.
69. Byrd HS, Salomon J, Flood J. Correction of the
crooked nose. Plast Reconstr Surg. 1998;102(6):
2148–2157.
70. Jung DH, Moon HJ, Choi SH, et al. Secondary
rhinoplasty of the Asian nose: correction of the
contracted nose. Aesthetic Plast Surg. 2004;28(1):1–7.
71. Paik M. Correction of short nose. J Korean Soc Aesthet
Plast Surg. 2005;11(1):22.
72. Lee Y, Kim J, Lee E. Lengthening of the postoperative
short nose: combined use of a gull-wing concha
composite graft and a rib costochondral dorsal onlay
graft. Plast Reconstr Surg. 2000;105(6):2190–2201.
73. Wong JK. Forehead Augmentation with Alloplastic
Implants. Facial Plast Surg Clin North Am.
2010;18(1):71–77.
74. Rhodes G, Yoshikawa S, Clark A, et al. Attractiveness
of facial averageness and symmetry in non-western
89.

88.

87.

86.

85.

84.

83.

82.

81.

80.

79.

78.

77.

76.

75.

cultures: in search of biologically based standards of
beauty. Perception. 2001;30(5):611–625.
Honn M, Goz G. [The ideal of facial beauty: a review].
J Orofac Orthop. 2007;68(1):6–16.
Piehl J. The golden section: the “true” ratio? Percept
Mot Skills. 1978;46(3 Pt 1):831–834.
Marquardt SR, Dr. Stephen R. Marquardt on the
Golden Decagon and human facial beauty. Interview
by Dr. Gottlieb. J Clin Orthod. 2002;36(6):339–347.
Holland E. Marquardt’s Phi mask: pitfalls of relying on
fashion models and the golden ratio to describe a
beautiful face. Aesthetic Plast Surg. 2008;32(2):200–208.
Mizumoto Y, Deguchi T Sr, Fong KW. Assessment of
facial golden proportions among young Japanese
women. Am J Orthod Dentofacial Orthop. 2009;136(2):
168–174.
Hwang HS, Kim WS, McNamara JA Jr. Ethnic
differences in the soft tissue proﬁle of Korean and
European-American adults with normal occlusions and
well-balanced faces. Angle Orthod. 2002;72(1):72–80.
Soh J, Chew MT, Wong HB. An Asian community’s
perspective on facial proﬁle attractiveness. Community
Dent Oral Epidemiol. 2007;35(1):18–24.
Onizuka T, Watanabe K, Takasu K, et al. Reduction
malar plasty. Aesthetic Plast Surg. 1983;7(2):121–125.
Baek SM, Chung YD, Kim SS. Reduction malarplasty.
Plast Reconstr Surg. 1991;88(1):53–61.
Uhm KI, Lew JM. Prominent zygoma in Orientals:
classiﬁcation and treatment. Ann Plast Surg. 1991;26(2):
164–170.
Yang DB, Park CG. Infracture technique for the
zygomatic body and arch reduction. Aesthetic Plast
Surg. 1992;16(4):355–363.
Satoh K, Watanabe K. Correction of prominent
zygomata by tripod osteotomy of the malar bone. Ann
Plast Surg. 1993;31(5):462–466.
Cho BC. Reduction malarplasty using osteotomy and
repositioning of the malar complex: clinical review
and comparison of two techniques. J Craniofac Surg.
2003;14(3):383–392.
Baek RM, Lee SW. Face lift with reposition malarplasty.
Plast Reconstr Surg. 2009;123(2):701–708.
Baek SM, Kim SS, Bindiger A. The prominent
mandibular angle: preoperative management,
operative technique, and results in 42 patients. Plast
Reconstr Surg. 1989;83(2):272–280.
The pioneer article for Asian mandible angle ostectomy.

183.e3

90. Kyutoku S, Yanagida A, Kusumoto K, et al. The gonial
angle stripper: an instrument for the treatment of
prominent gonial angle. Ann Plast Surg. 1994;33(6):
672–676.
91. Satoh K. Mandibular contouring surgery by angular
contouring combined with genioplasty in orientals.
Plast Reconstr Surg. 1998;101(2):461–472.
92. Deguchi M, Iio Y, Kobayashi K, et al. Angle-splitting
ostectomy for reducing the width of the lower face.
Plast Reconstr Surg. 1997;99(7):1831–1839.
93. Gui L, Yu D, Zhang Z, et al. Intraoral one-stage curved
osteotomy for the prominent mandibular angle: a
clinical study of 407 cases. Aesthetic Plast Surg.
2005;29(6):552–557.
94. Han K, Kim J. Reduction mandibuloplasty: ostectomy
of the lateral cortex around the mandibular angle.
J Craniofac Surg. 2001;12(4):314–325.
95. Lo LJ, Mardini S, Chen YR. Volumetric change of
the muscles of mastication following resection of
mandibular angles: a long-term follow-up. Ann Plast
Surg. 2005;54(6):615–622.
96. Hong HJ, Hong JW, Koh SH, et al. A three-dimensional
analysis of the relationship among lower facial width,
bony width, and masseter muscle volume in subjects
with prominent mandible angles. J Craniofac Surg.
2009;20(4):1114–1119.
97. Baek SM, Baek RM. Proﬁloplasty of the lower face
by maxillary and mandibular anterior segmental
osteotomies. Aesthetic Plast Surg. 1993;17(2):129–137.
First article for Asian proﬁloplasty.
98. Jin H, Kim BH, Woo YJ. Three-dimensional mandible
reduction: correction of occlusal class I in skeletal class
III cases. Aesthetic Plast Surg. 2006;30(5):553–559.
99. Lo LJ, Wong FH, Chen YR. The position of the inferior
alveolar nerve at the mandibular angle: an anatomic
consideration for aesthetic mandibular angle reduction.
Ann Plast Surg. 2004;53(1):50–55.
100. Jin H, Park SH, Kim BH. Sagittal split ramus
osteotomy with mandible reduction. Plast Reconstr
Surg. 2007;119(2):662–669.
New concept of mandible angle ostectomy.
101. Hwang K, Han JY, Kil MS, et al. Treatment of condyle
fracture caused by mandibular angle ostectomy.
J Craniofac Surg. 2002;13(5):709–712.

References

http://www.expertconsult.com

Access the Historical Perspective section online at

Age-related changes occur in all layers of the face, including skin,
superﬁcial fat, SMAS, deep fat, and bone.
Patients presenting for facial rejuvenation surgery are usually
middle aged or older, thus increasing the chance of underlying
medical problems. Risk factors such as hypertension and smoking
should be dealt with prior to facelift surgery.
A careful preoperative assessment will provide the surgeon with an
aesthetic diagnosis regarding the underlying facial shape, the age
related issues which predominate and the appropriate surgical
procedures for every individual patient.
Almost all facelift techniques begin with a subcutaneous facelift
ﬂap. Careful incision placement, tissue handling, and ﬂap
repositioning are important in order to avoid the obvious stigmata
of facelift surgery.
Volume augmentation, and in some locations volume reduction,
should be considered in all cases of facelift surgery.
Facial aging is usually a pan-facial phenomenon. Therefore, in
order to obtain a harmonious result, patients will often beneﬁt from
surgery to other components of their face.
The most common complication of facelift surgery is hematoma.
This problem should be dealt with promptly.

2013, Elsevier Inc. All rights reserved.

©

A complete discussion of facial rejuvenation would involve
the periorbital region, forehead, cheek, neck, and perioral
region. (The periorbital zone is reviewed in Chapter 8 and
the forehead in Chapter 7.) In this chapter, we will be dealing
with the middle and lower thirds of the face – the cheek
and neck. Terminology for procedures which address these
areas include rhytidectomy, rhytidoplasty, meloplasty and

Introduction

䊏

䊏

䊏

䊏

䊏

䊏

SYNOPSIS

Richard J. Warren

Facelift: Principles

䊏

The classic stigmata of the aging face include:
• Visible changes in skin, including folds, wrinkles,
dyschromias, dryness and thinning
• Folds in the skin and subcutaneous tissue created
by chronic muscle contraction: glabellar frown lines,
transverse forehead lines, and crow’s feet over the lateral
orbital rim.
• Deepening folds between adjoining anatomic units:
the nasojugular fold (tear trough), nasolabial folds,
marionette lines and submental crease
• Ptosis of soft tissue, particularly in the lower cheek, jowls
and neck
• Loss of volume in the upper two-thirds of the face which
creates hollowing of the temple, the lateral cheek and the
central cheek. The result is a more skeletal appearance in
the temple, the periorbita and the malar region
• Expansion of volume in the neck and lateral jaw line
which leads to the formation of jowls and fullness of the
neck (Fig. 11.1.1).
The driving force behind our ability to explain these many
changes has been an improved understanding of facial
anatomy and the way this anatomy changes over time. Aging

Anatomy and patient presentation

facialplasty, although in this text, the more common term,
“facelift” will be used.
Facelift surgery was originally conceived as a method of
placing traction on the aging face by excising skin in the
periphery of the face and closing the resulting defect under
tension. Since that simple beginning over 100 years ago, the
procedure has evolved to encompass a wide range of techniques which lift, augment, and rearrange facial tissues in an
attempt to rejuvenate the aging face.
Despite the development of many less invasive technologies, nothing can match a facelift in its ability to globally treat
the face, returning its basic architecture to a more youthful
conﬁguration.

Aesthetic Surgery of the Face

11.1

SECTION I

Facelift surgery dates from the early part of the 20th century.
Its colorful history has been thoroughly reviewed by Stuzin,1
whose summary is reproduced here.
In the past, the history of aesthetic facial surgery has been
reported by a number of authors, including: Rogers,2,3 Rees
and Wood-Smith,4 Gonzalez-Ulloa,5 Rees6 and Barton.7,8
There is still doubt as to who performed the ﬁrst facelift,
but most sources date it to the ﬁrst decade of the 20th
century.3,9,10 According to Rogers,3 Hollander11 reported in a
chapter entitled “Cosmetic Surgery” in Handbuch der Kosmetik
that “as a victim of the art of feminine persuasion,” he removed
pieces of skin at the margins of the hairline and in the natural
aging skinfolds of a woman to freshen up “her wrinkles and
drooping cheeks”. In this chapter, Hollander did not date the
procedure, but in 1932 he stated that his original procedure
had been performed in 1901 for a Polish aristocrat.12 Lexer,10
however, reported in 1931 that he had performed a facelift for
an actress in 1906 and that he was unaware of any such operation before that date. Joseph9 reported in 1921 that he had
performed an operation in 1912 for correction of aging cheek
tissues in a 48-year-old woman. By the time Hollander, Lexer,
and Joseph reported their ﬁrst procedures, a number of other
prominent surgeons in Europe, such as Noel, Passot, Morestin,
Bourguet, and Lagarde, were busy performing cosmetic surgical procedures. In the United States, Miller and Kolle had
large cosmetic surgery practices. Passot13 in 1919 published an
illustrated article showing sites of elliptic skin excision of the
hairline, the forehead, and the temporal and preauricular
areas to tighten the skin and an elliptic excision of skin and
fat to reduce submental fat deposits. Bourguet14 reported
elliptic skin excisions similar to those of Passot. He was the
ﬁrst to report fat excisions to correct herniated periorbital fat
pads (1924)15 and to publish preoperative and postoperative
photographs of fat pad excision (1925).16 Noel published a
book in 1926,17 La Chirurgie Esthetique: Son Role Social, describing facialplasty, blepharoplasty, forehead lifting, and correction of loose skin of the neck, burns, scars, protruding ears,
and laxity of the upper arms. Although her procedures were
not aggressive by modern standards, Noel was a true master
of that era.
Miller18 published the ﬁrst book in medical history devoted
entirely to the subject of cosmetic surgery. Miller was described
by Rogers3 as a “quack” on one hand and at the same time,
“a surgical visionary years ahead of his academic colleagues
… medicine’s ﬁrst truly cosmetic surgeon.” Miller was a proliﬁc writer. In 1906, he wrote the ﬁrst article in the medical
literature describing an attempt to remove excess skin from
the eyelids.19 In 1907, he published the ﬁrst article with a
photograph illustrating lower eyelid incisions,20 and he also
published three cosmetic surgery textbooks.18,21,22 Kolle was
born in Germany and practiced in New York. His book Plastic
and Cosmetic Surgery23 represented the second description of
cosmetic surgery in medical history. The book was more than
500 pages in length and contained hundreds of illustrations,
including preoperative and postoperative photographs of
protruding ears; it took a rather aggressive surgical approach
to the correction of excess skin of the eyelids. Bettman24 was
the ﬁrst to publish preoperative and postoperative facelift
photographs and to describe a continuous temporal scalp,

History

184.e1

preauricular, postauricular, and mastoid area incision. With
modiﬁcations, his incision is essentially that used for facialplasty today. Hunt25 published a book, Plastic Surgery of the
Head, Face and Neck, that included facelifting and forehead/
browlifting operations.
All the early facialplasty procedures were limited to skin
excision and wound closure without subcutaneous undermining. Bames26 described subcutaneous face and neck undermining, skin redraping, and excision of excess skin. The
continuous incision described by Bettman24 and subcutaneous
undermining recommended by Bames26 essentially established the basic facelift procedure for the next 40 years. As
discussed by Rees,6 a great deal of secrecy surrounded early
facelift procedures. Surgeons were reluctant to share their
techniques because of professional jealousy and greed. The
disdain for “vanity” surgery by both the medical profession
and the public restricted most facelift procedures to private
ofﬁces and small clinics. The extent of surgery in such settings
was necessarily limited. Many prominent plastic surgeons in
major medical centers were forced to perform their facelifts in
small clinics or to hide their cases by misnaming the procedures on the operating schedule. Renowned plastic surgeons
after the First and Second World Wars, such as Gillies, Blair,
Davis, Pierce, McIndoe, Mowlem, Conway, and others, did a
great deal of cosmetic surgery but were reluctant to publish
on the subject.6 The conventional facelift operation (skin dissection only) failed to address the effect of aging and the force
of gravity on the structures (e.g. muscle, fat, and superﬁcial
fascia) deep to the skin. Likewise, the classic skin dissection
facialplasty failed to account for the wide variation in facial,
jaw line, and cervical deformities; in the location of fat deposits; in the asymmetry of anatomic structures; and in the genetically determined deformities, such as microgenia and the
obtuse cervicomental angle.
Aufricht27 discussed the limitations of the subcutaneous
facelift, particularly its failure to correct submental fat deposits and platysma bands. Adamson and colleagues28 discussed
correction of the platysma bands in the submental area, and
Millard and co-workers29 recommended extensive submental
defatting. Pennisi and Capozzi30 and Baker and Gordon31
described suture plication of the deep tissues of the cheek and
lateral neck. Tipton32 challenged the deep suture techniques
in a study of 33 patients in whom he performed unilateral
plication. Two years postoperatively, there was no obvious
difference in the two sides of the face. Skoog33,34 described a
technique of dissection of the superﬁcial fascial layer in the
face, in continuity with the platysma muscle in the neck and
advancement of the myofascial unit in a cephaloposterior
direction. This was the beginning of the modern era in facelifting. Mitz and Peyronie35 used cadaver dissections to deﬁne
the limits of the superﬁcial musculoaponeurotic system
(SMAS) in the face and noted that tightening of this layer
would be beneﬁcial in facialplasty. SMAS-platysma facelifting, wide skin undermining, and extensive fat removal soon
gained worldwide popularity. Surgery of the tissue layers
deep to the skin of the face and neck is now established as an
essential part of cervical and facialplasty operations. Many
surgeons have described different SMAS-platysma techniques
to improve the cervicofacial area and to remedy problems not
corrected by conventional facialplasty.36–44 Furnas,45 in 1989,
described the retaining ligaments of the midface, which led to
a better understanding of anatomic areas where facial soft

History

SECTION I •11.1• Facelift: Principles

tissue is supported and the involvement of these ligaments in
leading to the anatomic changes that occur with aging. These
ligaments were further deﬁned by others46,47 who thought that
loss of the support from the retaining ligament system allowed
facial fat to descend inferiorly in the face, deepening the
nasolabial fold and forming facial jowls with aging. The
importance and location of the retaining ligaments led to
modiﬁcations in procedures involving retaining ligament

184.e2

release in sub-SMAS dissection,47–56 the primary goal of these
procedures being to reposition descended facial fat to the
anatomic location of youth. Other surgeons, preferring subperiosteal rather than sub-SMAS dissection to reposition
fat, developed procedures whose similar goal is to resuspend
descended malar fat to the malar eminences using the subperiosteal plane.57–59 A combination of subperiosteal and
subcutaneous lifting has also been described.60

Platysma muscle laxity

Excess preplatysmal and
subplatysmal fat

Expansion and ptosis of jowl fat

Elongating upper lip
Peri oral wrinkles
Buccal fat pad ptosis

Malar fat descent

Obicularis contracture
Lower lid laxity
Obicularis oculi laxity
Loss of midface fat

Lateral brow ptosis

Temporal fat pad atrophy

Frontalis contraction

Normal skin is directly adherent to underlying fat via the
retinacular cutis system. In certain predictable areas the skin
is tethered to bone or underlying muscle by condensed areas
of connective tissue. In some places, these are string-like cutaneous ligaments, and in other areas, these are ribbon-like
septae. Because nerves and vessels often reach the skin adjacent to these vertically running ﬁbrous structures, dissection
of skin is more difﬁcult and bloody where the skin is tethered;
McGregor’s patch is such an area because of its association
with the zygomatic cutaneous ligaments and a perforating

Skin

of the face occurs in all its layers, from skin down to bone; no
tissue is spared. For the purposes of this discussion, the face
will be viewed as a ﬁve-layer structure as described in Chapter
6: skin, subcutaneous fat, the superﬁcial musculoaponeurotic
system (SMAS) and muscles of facial expression, fascial
spaces, and deep fascia. Underlying everything is bone, except
over the oral cavity. The surgical signiﬁcance of this concentric
layer arrangement is that dissection can be done in the planes
between the layers. Also, anatomical changes in each of the
layers can be addressed independently, as required to treat
the presenting problem.

185

branch of the transverse facial artery. Changes in the skin
of the face are some of the most obvious signs of aging.
Skin aging over time is both intrinsic and extrinsic. Intrinsic
aging is the result of genetically determined apoptosis. The
skin becomes thinner; there is a decrease in melanocytes, a
reduced number of ﬁbroblasts and a loss of skin appendages.
In the dermal matrix, there is fragmentation of the dermal
collagen and impairment of ﬁbroblast function.61,62 As the skin
weakens and thins, the underlying contraction of facial
muscles creates permanent skin folds in predictable locations
(see Fig 11.1.5).
Extrinsic forces include sun exposure, cigarette smoke,
extreme temperatures and weight ﬂuctuations. The net result
is that facial skin loses its ability to recoil, a condition called
elastosis. This has surgical implications, because ﬁrm tight
skin is youthful, and to varying degrees, the tightening of
loose facial skin is part of a good surgical result. However, a
facelift does not appreciably improve the quality or texture of
the skin. Therefore, patients with good quality skin are likely
to enjoy a better result from facelift surgery than the patient
with poor quality skin. Alternatively, when skin quality is
poor, other options such as injectable ﬁllers and skin resurfacing may be more important for rejuvenation than facelift
surgery. In most cases of facial rejuvenation, medical and surgical therapies can work in concert for a more complete result.

Figure 11.1.1 The aging face exhibits changes in the skin, superﬁcial wrinkles, deeper folds, soft tissue ptosis, loss of volume in the upper third and middle third and
increased volume in the lower third.

Platysma bands
Vertical neck pleats

Transverse neck folds

Jowls

Thinning lips
Marionette lines

Tear trough
Midface flattening
Cheek descent
Nasolabial folds

Crow’s feet

Upper lid sulcus hollowing

Temporal wasting

Transverse forehead creases

Anatomy and patient presentation

SECTION I •11.1• Facelift: Principles

The face is carpeted in a layer of superﬁcial fat which lies
immediately deep to the dermis. Between individuals, there
is much variability in the thickness of the superﬁcial fat layer.
This has surgical implications, because a heavier patient will
have thicker, heavier tissues to reposition, but the dissection
of the facelift skin ﬂap will be easier. Conversely in a thin
patient, facial layers are packed closely together, like an onion,
necessitating greater care if the surgeon wishes to separate
skin from SMAS and SMAS from underlying structures.
Superﬁcial facial fat also varies in thickness depending on the
area of the face. The most important area of thickened subcutaneous fat is the malar fat pad.54 This is a triangular shaped
mass of fat bordered by the nasolabial fold, the infraorbital
arch and a diagonal line across the mid-cheek. Its apex is over
the malar eminence. The malar fat pad is present throughout
life (Fig. 11.1.2).
One study looked at fat volume in the cheek area and
found 56% of the fat superﬁcial to the SMAS and 44% was
deep to the SMAS and the muscles of facial expression.63 The
superﬁcial fat is separated by vertical septae into ﬁve distinct
compartments: nasolabial, medial cheek, middle cheek, lateral
temporoparietal, and the inferior orbital fat (Fig. 11.1.3A).64
The two central fat compartments (medial and middle) are
the primary components of the Malar Fat Pad.
The deep fat is also divided into compartments (Fig.
11.1.3B). The most signiﬁcant is the deep medial fat compartment, which lies directly against bone and is bordered above
by the orbicularis retaining ligament, laterally by the zygomaticus major and buccal fat pad and medially by the pyriform aperture65 (Fig. 11.1.3C).
The authors who identiﬁed this compartment propose that
age related deﬂation of deep medial fat compartment leads
to “pseudoptosis” of the overlying superﬁcial fat and skin –
ptosis which is real, but which is caused by lack of underlying
support.65
This in turn is thought to cause deepening of the nasolabial
fold and development of the “inverted V deformity” inferior
to the infraorbital rim.66 Adjacent and lateral to the deep
medial fat is the suborbicularis oculi fat (SOOF), which itself
is divided into a medial and lateral component.
Generally in youth, facial fat is tightly packed, creating
surface contours which undulate smoothly from convexity to
concavity. Cosmetic highlights rise above areas of depression.
The malar fat pad which extends over the body of the zygoma
creates the principle cosmetic highlight zone in the youthful
face, immediately above the normal depression overlying the
buccal recess. Make-up artists accentuate this zone by highlighting the apex and simulating a depression immediately
below. In the aging face, fat is less tightly packed, and facial
contours become more abrupt. In areas of tight ligamentous
attachment, such as the preparotid area, the anterior jowl
border and the zygomatic ligament insertions, there appears
to be an acceleration of volume loss with indenting of the
surface contour.67 With more advanced aging, there is malar
fat atrophy, leading to a more skeletal appearance of the

Facial fat: ptosis, volume loss and
volume gain

(These complementary therapies are reviewed in Chapters 4
and 5.)

186

zygoma. Simultaneously there is an apparent ptosis of the
malar fat pad which causes bunching of fat and deepening
of the nasolabial fold. Surgeons have traditionally viewed
superﬁcial fat in the cheeks as a ptotic layer which requires
correction for facial rejuvenation to occur. In support of this
theory, it has been demonstrated that the primary muscles of
facial expression in the mid-cheek (zygomaticus major and
minor) do not change in length, while the overlying fat
appears to migrate inferiorly.68 Another study, using CT scans,
conﬁrmed the presence of facial fat compartments and identiﬁed age related inferior migration of the midfacial fat compartments as well as inferior volume shift within the individual
compartments.68a
At the time of writing, it is unclear whether the cause of
superﬁcial fat ptosis is gravitational due to relaxed ﬁxation,
or if it relates to pseudoptosis caused by the loss of volume
in the deep fat compartments. Also, it is uncertain whether
volume of facial fat is lost equally from the deep and

Figure 11.1.2 The malar fat pad is a triangular area of thickened superﬁcial fat
with its base along the nasolabial fold, and its apex over the superolateral malar
prominence.

Malar fat pad

Zygomaticus major

Orbicularis oculi

A

SOOF

ZM

Nasolabial

ORL
ORL

Medial

Lateral

Nasolabial

Middle

Medial

Middle

SCS

Lateral

187

Figure 11.1.3 (A) Superﬁcial
facial fat is compartmentalized by
vertically running septae. In the
mid-cheek, from medial to lateral,
these compartments are the
nasolabial, medial, middle, and
lateral compartments.

Anatomy and patient presentation

SECTION I •11.1• Facelift: Principles

C

B

superﬁcial fat layers, or if it lost equally or differentially from
the various fat compartments which have been identiﬁed.65
In the lower face, the area of the jowl just posterior to the
marionette lines appears to become thicker with age, making
the mandible appear wider. This phenomenon has been called
“radial expansion” (Lambros, pers. comm. 1999).69 This may
be due to fat accumulation, or it may be caused by soft tissue
ptosis within the premasseteric space, a natural glide plane.69a
Below the mandible, a similar expansion occurs in the neck
as soft tissue falls away from deep tissue attachments and fat
tends to accumulate.

The loss of facial volume is an important phenomenon which
surgeons recognized much later than the more obvious ptosis
of soft tissue. To arrive at this conclusion, astute observations
were made about changes in surface contours which lead to
inferences about internal volume loss.65,67,70,71
The combination of volume loss in some areas, volume
gain in others, and soft tissue ptosis creates a cascade
effect which results in the loss of natural youthful curves
(Fig. 11.1.4).

Change in facial shape

Figure 11.1.4 This healthy 72-year-old woman has never undergone facial surgery, has gained 10 pounds, but has aged 50 years. She appears to have lost fat in the
periorbital region and middle third of her face, revealing underlying bone. The orbit seems to have enlarged. Overall volume has been lost in the middle third of the face. The
soft tissues which remain appear to be ptotic, ﬂattening her cheeks, and widening her jaw line. The heart-shaped face of youth has become more rectangular.

A

Fig. 11.1.3, cont’d The nasolabial and medial compartments make up the malar fat pad. (B) The deep facial fat is also compartmentalized by septae. The deep medial fat
pad (here stained blue) is bounded above by the orbicularis retaining ligament, medially by the pyriform aperture, and laterally by the zygomaticus major (labeled ZM)
muscle and the buccal fat pad (labeled B). (C) Over the body of the zygoma, the sub orbicularis oculi fat (SOOF) is deep fat. It is seen here with a medial portion (yellow)
and a lateral portion (stained blue). It is bounded medially by deep medial fat pad (stained red). (A, Courtesy of Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227; B,C Courtesy of Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and
the deep medial fat compartment. Plast Reconstr Surg. 2008;121(6):2107–2112).

B

188

The muscles of facial expression are found in a superﬁcial
layer and a deep layer. The superﬁcial muscles are orbicularis
oculi, orbicularis oris, zygomaticus major, zygomaticus minor,
levator labii superioris, risorius, and depressor anguli oris. All
of these muscles are innervated on their deep surface by
branches of the facial nerve (VII). Consequently, surgical dissection on the superﬁcial surface of these muscles will not
endanger their innervation. The only facial muscles innervated on their superﬁcial surface are the muscles in the deep
layer: levator anguli oris, mentalis and buccinator. The three
facial muscles which are most important to surgeons are
orbicularis oculi and platysma, because they are often
manipulated during facelift surgery, and zygomaticus major

Facial muscles

Immediately deep to the subcutaneous fat is the superﬁcial
musculoaponeurotic system (SMAS), described by Mitz and
Peyronie in 1976.73 The SMAS, or its analogues can be thought
of as a continuous fascial sheath which encompasses the
entire face and neck. Superiorly, it continues into the temple
as the superﬁcial temporal fascia (temporoparietal fascia) and
then into the scalp as the galea aponeurotica.74 Inferiorly, into
the neck, the SMAS becomes the superﬁcial cervical fascia
which envelopes the platysma muscle. Clinically, the thickness and strength of the SMAS varies between patients, and
also varies in every individual face, being thicker and adherent over the parotid, and thinner anteriorly. The SMAS is most
tenuous under the malar fat pad where it splits to encompass
the zygomaticus major and the orbicularis oculi.53,75 The SMAS
has important surgical implications because its ﬁbrous attachments to skin allow it to act as a carrier for overlying subcutaneous fat; also it has been shown to be much more resistant
to stretch than skin.76 Furthermore, below the zygomatic arch,
all branches of the facial nerve are deep to the SMAS.
The relationship of the SMAS (superﬁcial fascia of the
face) to the deep fascial structures of the face, involves areas
of mobility interspersed between areas of attachment. The
superﬁcial fascia is tethered to the deep fascia by retaining
ligaments in the following locations: over the parotid gland,
at the inferior border of the zygomatic body, and along the
anterior edge of the masseter. (These ligaments are described
in Chapter 6 and are reviewed later in this chapter.) Between
areas of ﬁxation the SMAS is free to move over the underlying deep fascia. These are the suprazygomatic zone where
superﬁcial temporal fascia slides over the deep temporal
fascia, the mid-cheek, where SMAS rides over the parotid
masseteric fascia (premasseteric space), and the neck where
the platysma overlies the underlying strap muscles.

Superﬁcial musculoaponeurotic system

Gradually, there is a reversal of facial shape as the cheek
prominence of youth gives way to the jowl prominence of age.
Effectively, in youth, the cheeks are full, but with age, the
jowls and neck become full. The face changes from a heart
shape to a more rectangular shape, or from an egg sitting on
its narrow end to an egg resting on its broad end. This change
has been called losing the “inverted cone of youth”, and has
been likened to a reversal of the “Ogee” curve, a natural
S-shaped curve seen in architecture.60,72

189

Facial soft tissue and skin is held in place by retaining ligaments which run from underlying ﬁxed structures through
facial fat, inserting into the dermis.45,48,80 Effectively, these ligaments attach the superﬁcial fascia (SMAS) and the overlying
skin to the underlying deep fascia and bone (Fig. 11.1.6).
There are two ligament systems. The ﬁrst group is true
osteocutaneous ligaments, which tether skin to bone: the
orbital, zygomatic and the mandibular ligaments. The orbital
ligament is found at the junction of the superior and lateral
orbital rims and constitutes the inferior thickening of the temporal crest line zone of ﬁxation (zone of adhesion). (This area

Retaining ligaments

because it is used as a landmark in certain facelift techniques
(Fig. 11.1.5).
Most muscles of facial expression take their origins from
bone and insert into the dermis thus allowing for voluntary
and involuntary movement of facial soft tissues. The platysma
is a purely subcutaneous muscle which takes its origin from
the fascia of the pectoralis, and inserts into soft tissue of the
face, with a small bony insertion on the anterior mandible.
The platysma interdigitates with the depressor labii inferioris
which in some individuals, gives it some effect on the depression of the lower lip. In the neck the platysma is thicker,
forming visible bands; superiorly the platysma thins dramatically as it crosses the mandibular border, but continues superiorly, often visible during surgical dissection well into the
mid-cheek, at times approaching the lower ﬁbers of the orbicularis oculi.
While most muscles of facial expression do not change
appreciably with age, the orbicularis oculi and the platysma
are thought to undergo age-related changes. Both of these
muscles have a large surface area but are relatively thin – a
conﬁguration which lends them to potential redundancy if
they lose tone or if there is attenuation of their deep tissue
attachment. For example, in some individuals redundancy
develops in the lower half of the orbicularis, a condition
which has been speculated to cause lower eyelid festoons.77
Some have suggested that it is the loss of support of the
orbicularis through attenuation of the orbicularis retaining
ligament (orbitomalar ligament), which contributes to deformities of the lower eyelid/cheek junction.66 Similarly, the paired
platysma muscles, which are encased by SMAS, appear to
gradually fall away from their deep cervical attachment carrying the overlying fat and skin. The net result is a more
obtuse cervico-mental angle and the development of visible
platysma bands at the anterior platysmal border. Another
issue common to orbicularis oculi and platysma is that these
are the only facial muscles which are undermined during
certain surgical procedures, thus imperiling some of their
motor innervation. Fortunately, the orbicularis has multiple
motor nerve branches which provide a level of collateral
innervation.78 There is a less elaborate innervation to the
platysma; two or three cervical branches can be identiﬁed just
inferior and anterior to the angle of the mandible in the plane
between the deep cervical fascia and the undersurface of the
platysma. Preservation of these branches is potentially important because the platysma acts as a support structure and also
inﬂuences lower lip depression, especially in those individuals with a “full dentition” smile.79

Anatomy and patient presentation

SECTION I •11.1• Facelift: Principles

Platysma

Figure 11.1.5 Muscles of facial expression. The solid
lines demonstrate overlying skin creases caused by
repeated contraction of the underlying muscles. (Netter
illustration from www.netterimages.com. © Elsevier Inc.
All rights reserved.)

the posterior border of the platysma, the superﬁcial fascia is
ﬁrmly attached to the deep fascia. A number of authors have
identiﬁed the importance of this area, and with some subtle
differences, a number of different names have been applied
to the same soft tissue attachment: platysma-auricular fasica,81
platysma-auricular ligament,45 parotid cutaneous ligament,80
and a localized area called Lore’s fascia.82,83 In this zone, the
SMAS and the overlying skin are tethered to such a degree
that soft tissue in this area does not become ptotic with age.
A prime surgical signiﬁcance is that the “ﬁxed SMAS” of the
posterior cheek can be used to support the surgically mobilized portion of the more anterior “mobile SMAS”. A number
of facelift techniques depend on this concept (Fig. 11.1.7).
The importance of retaining ligaments in the aging process
is potentially two-fold. One theory holds that with age, ligaments relax, leading to a gravitational shift of overlying
superﬁcial fat and skin. In youth, the superﬁcial fat and skin
appear to be ﬁrmly adherent to underlying bone and deep
fascia, while with age the same soft tissue appears to become
ptotic. One area where this has been proposed is along the
infraorbital rim, where the orbicularis retaining ligament may
relax, leading to the V-deformity at the lid cheek junction.66,84–86
Over the malar highlight area, the ligament relaxation theory
suggests that the zygomatic ligaments become attenuated and
the malar fad pad becomes ptotic, causing a migration of fat
medially and inferiorly, deepening the nasolabial fold.
The second way that retaining ligaments become an issue
with aging is through their tethering effects. The concept of
“pseudoptosis” holds that it is primarily the loss of facial fat

Orbicularis oculi, orbital portion
Orbicularis oculi, preseptal portion
Orbicularis oculi, pretarsal portion
Nasalis
Levator labii superioris alaeque nasi
Levator labii superioris
Auricularis anterior
Zygomaticus minor
Zygomaticus major
Levator anguli oris
Masseter
Buccinator
Depressor septi nasi
Risorius
Orbicularis oris
Depressor anguli oris
Depressor labii inferioris
Mentalis

Corrugator supercilii

Procerus

Frontalis

Galea aponeurotica

is reviewed in Chapter 7.) The zygomatic ligament is actually
a group of ligaments which originate from the lower half of
the zygomatic body where it joins the zygomatic arch. The
zygomaticus major inserts into bone at this location. These
ligaments stabilize the overlying malar fat pad, going through
this structure to the overlying skin. In this area, a perforating
branch of the transverse facial artery courses from deep to
superﬁcial, contributing to the clinical bleeding seen when the
zygomatic ligaments are released in this area during superﬁcial skin ﬂap dissection (McGregor’s patch). A branch of the
zygomaticofacial nerve also accompanies the ligaments in this
area, coursing directly from bone to skin providing sensation
to the skin of the malar cheek prominence. As described
in Chapter 6, the zygomatic ligaments constitute the lower
border of the prezygomatic space and must be released if the
malar fat pad is to be fully mobilized and elevated. The mandibular ligament is a short but strong structure originating
from the parasymphysial mandible, which tethers the overlying skin and contributes to formation of the marionette lines.
The second ligament system involves tethering structures
which do not originate from bone, but rather, tether the
superﬁcial fascia (SMAS) to the deep fascia. Along the anterior border of the masseter, the masseteric ligaments extend
in a line from the zygoma down to the lower cheek.80 These
ligaments support the anterior cheek and are more clinically
signiﬁcant superiorly, where they intermingle with the zygomatic ligaments. The most superior ﬁbers of the platysma can
also be seen terminating in the most superior masseteric ligaments. Over the parotid gland with an extension down along

190

Mandibular ligament

Buccinator
Risorius
Obicularis oris
Depressor anguli oris
Mentalis

Nasalis
Zygomatic ligaments
Zygomaticus major
Zygomaticus minor
Masseteric ligaments

Orbital ligament
Obicularis oculi
Temporal fat pad

Temporalis

Temporal crest

Frontalis

191

Figure 11.1.7 Mendelson’s interpretation of soft tissue attachments (Ch. 6). The
ﬁxed posterior soft tissue is held in place by the platysma auricular fascia (large
red area). The anterior face is ﬁxed by a vertical column of attachments: orbital
ligament, lateral orbital thickening (superﬁcial canthal tendon), zygomatic
ligaments, masseteric ligaments, mandibular ligament). In the mid-cheek, there is
some mobility of these ligaments, while there is limited mobility over the platysma
auricular fascia. The so-called “ﬁxed SMAS” is that portion attached to the parotid
and the posterior border of the platysma. Anterior to this, is the “mobile SMAS”.
(Courtesy of Dr Levent Efe, CMI.)

The deepest layer of the face is the deep fascia, which covers
deep muscles and overlies the oral cavity (Ch. 6). In the face,
this fascia is a continuation of the deep cervical fascia in the
neck which covers the superﬁcial surface of the strap muscles
and the sternocleidomastoid. The equivalent layer in the
temple is the deep temporal fascia covering the temporalis. In
the cheek, this fascia is found covering the masseter muscle,
where it is called masseteric fascia, and covering the parotid

Deep fascia

volume which leads to ptosis, but the ligaments tether the
skin, leading to depressions and grooves in the surface contour
of the face. Examples of tethering include: the mid-cheek
groove, caused by the zygomatic ligaments, the nasojugular
groove, partly caused by the orbicularis retaining ligament
(orbitomalar ligament) and the jowl/marionette line caused
by the mandibular ligament.81–83,85
It is likely that both of these theories are in play – ptosis
and deﬂation, although conclusive proof of how face age is
not available at the time of this writing. Either way, the tethering structures play an important role in determining the way
a face will age. Furthermore, these same tethering structures
can be manipulated during facelift surgery, depending on the
speciﬁc indication.

Figure 11.1.6 Facial soft tissue is tethered to underlying bone by the orbital, zygomatic and mandibular ligaments. Soft tissue is tethered to underlying deep fascia by the
masseteric cutaneous ligaments and by an area of attachment anterior and inferior to the earlobe, known by a number of different terms: platysma auricular ligament
(Furnas), platysma auricular ligament (Mendelson), parotid cutaneous ligament (Stuzin), and a distinct area anterior to the earlobe known as Lore’s fascia.

Platysma

Sternocleidomastoid

Platysma auricular fascia

Tympanoparotid
(Lore’s) fascia

Occipitalis

Upper edge of temporal fat

Superficial layer of deep
temporal fascia

Anatomy and patient presentation

SECTION I •11.1• Facelift: Principles

The facial nerve exits the stylomastoid foramen, and separates
into an upper and lower division within the parotid glad.
Classically, there are ﬁve branches which arise and exit the
cover of the superﬁcial lobe of the parotid: temporal, zygomatic, buccal, marginal mandibular, and cervical. There are
typically 2–3 temporal branches; 4–5 zygomatic branches;
3 buccal branches; 2–3 mandibular branches, and 2–3 cervical
branches.
In fact, there is considerable variation in the anatomy
of facial nerve branches. One study identiﬁed up to eight
branches exiting the parotid, with multiple connections
between these branches.95–97
The temporal branches exit the parotid superiorly, coursing
obliquely and superiorly across the middle-third of the
zygomatic arch. Like all other facial nerve branches, the temporal branches start out deep to the deep fascia of the midcheek (parotid masseteric fascia), but unlike all other facial
nerve branches in the cheek, they become more superﬁcial. At

Facial nerve

Nerve anatomy

The bony skeleton of the face was once thought to be quite
stable in volume and shape as the body aged. However, there
is ample evidence that atrophy in certain portions of the facial
skeleton is a signiﬁcant factor in facial aging.88–93
Computed tomography of young and old skulls has shown
a retrusion of the infraorbital rim as well as recession of the
maxillary face below the infraorbital rim (Fig. 11.1.8).90
This has been conﬁrmed by others who have demonstrated
an enlarging orbital aperture (Fig. 11.1.9).94
The loss of bone has surgical implications because it contributes to an overall loss of volume, and more speciﬁcally, to
loss of soft tissue support in critical areas such as the infraorbital rim. This contributes to development of the tear trough
deformity and age related ﬂattening of the anterior midface.
Following the principle of replacing like with like, bone loss
can be replaced with solid objects such as facial implants (Ch.
15), or with soft tissue volume enhancement such as with fat
grafting (Ch. 14).

Bone

gland, where it is called the parotid fascia or capsule; the
combined complex is called the parotid masseteric fascia
(parotidomasseteric fascia). When the SMAS is raised surgically, just anterior to the parotid gland in the premasseteric
space, the parotid masseteric fascia can be seen as a thin shiny
membrane – an important landmark, because in the cheek
(unlike the neck and temple), all branches of the facial nerve
are deep to this deep fascial layer. Superﬁcial to this layer, but
deep to the SMAS, there is often an additional thin layer of
fat, the sub – SMAS fat, which adds further protection to the
Video underlying nerves when the SMAS is raised. In the neck along
1 the posterior border of the platysma, the SMAS becomes
fused with the deep cervical fascia where the deep fascia
covers the sternocleidomastoid muscle. This is important,
because a surgeon planning to mobilize a platysma ﬂap to
address the neck, will have to release the platysma’s attachment to the deep cervical fascia in this area.87

192

a point 1.5–3.0 cm superior to the zygomatic arch, the temporal branches transition from deep to superﬁcial, travelling at
ﬁrst on the undersurface and then within the superﬁcial temporal fascia (temporoparietal fascia), staying there until they
terminate in the frontalis muscle, upper orbicularis and frown
musculature. The surgical implication is that a SMAS ﬂap can
be safely raised from a point just superior to the zygomatic
arch providing that surgical dissection does not extend superiorly to the level where the temporal branch transitions
superﬁcially.98
A classic external landmark for the course of the temporal
branch has been along a line drawn from a point 0.5 cm below
the tragus to a point 1.5 cm lateral to the lateral eyebrow.99
More recent studies have found that the temporal branch
actually consists of 2–5 individual branches which do not
adhere completely to this landmark. One study found that
these branches cross the middle-third of the zygomatic arch,
with a posterior safe zone 1 cm anterior to the acoustic meatus,
and an anterior safe zone 2 cm posterior to the lateral orbital
rim. Once above the zygomatic arch, these branches were

Figure 11.1.8 Computed tomography of young and old skulls has demonstrated a
retrusion of the infraorbital rim. (Courtesy of Pessa JE. An algorithm of facial aging:
veriﬁcation of Lambros’s theory by three-dimensional stereolithography, with
reference to the pathogenesis of midfacial aging, scleral show, and the lateral
suborbital trough deformity. Plast Reconstr Surg. 2000;106:479.)

consistently found anterior and inferior to the anterior branch
of the temporal artery, a palpable landmark in the temple.100
The zygomatic and buccal branches, all exit the parotid
gland deep to the parotid masseteric fascia. As they travel
anteriorly, they often arborize with each other. Zygomatic
branches course parallel to the transverse facial artery. When
they reach the area of the zygomatic retaining ligament,
they travel to the undersurface of the muscles which they
innervate: zygomaticus major, zygomaticus minor, and
orbicularis oculi. Deep to the parotid masseteric fascia, within
the premasseteric space, the parotid duct courses anteriorly
along an imaginary line from the tragus to the corner of the
mouth. Accompanying the duct is normally a buccal branch.
Beyond the anterior border of the masseter, a buccal branch
can normally be seen crossing the buccal fat pad (fat pad of
Bichat). At this level, the portion of buccal fat seen is the
buccal extension, which is the most inferior portion of the
buccal fat pad.101
The mandibular branches exit the parotid approximately
near the angle of the mandible. They then travel anteriorly
near the border of the mandible, until they encounter the
facial artery and vein, crossing those vessels and then turning

Figure 11.1.9 Computed tomography scan of (A) a male patient in the young
age group and (B) a male patient in the older age group. The image from the
older age groups shows signiﬁcant bony remodeling (arrows) both superomedially
and inferolaterally. (Courtesy of Kahn DM, Shaw RB. Aging of the bony orbit: a
three-dimensional computed tomographic study. Aesthetic Surg J. 2008;28:258.)

B

A

193

Like any elective surgical procedure, a prerequisite is to
conﬁrm that a patient’s physical status and mental status
are appropriate to withstand the rigors of surgery, the recovery phase and any potential complications. The patient’s
expectations must be explored to determine if they are realistic, and if they are technically achievable. The quality of surgical result will be affected by many patient related factors
including the facial skeleton, the weight of facial soft tissue,
the depth and location of folds, and the quality of the skin.

Patient selection

The great auricular nerve, a branch of the cervical plexus, is
sensory to the earlobe and lateral portion of the pinna. This
nerve wraps around the posterior border of the sternocleidomastoid, and courses obliquely across the muscle in a superior
direction. The classic landmark for this nerve is at the mid
portion of the sternocleidomastoid, 6.5 cm. below the external
auditory canal (Fig. 11.1.11).
It runs parallel and about 1 cm posterior to the external
jugular vein which also crosses the sternocleidomastoid
roughly along the same vector. The nerve is deep to the superﬁcial cervical fascia, but the platysma is usually absent over
the posterior sternocleidomastoid. Hence, the nerve is at risk
of injury during surgical dissection along the posterior border
of the sternocleidomastoid, because with lack of fascial cover,
it is technically subcutaneous.104,105
The auriculotemporal nerve, a branch of the trigeminal is
sensory to the preauricular skin and the lesser occipital nerve
is sensory to the retroauricular scalp. The zygomaticofacial
nerve exits through its foramen in the body of the zygoma,
piercing the malar fat pad to provide sensation to the skin of
the malar prominence; this nerve is often transected when the
malar fat pad is surgically mobilized (Fig. 11.1.12).

Sensory nerves

more superiorly. In Chapter 6, facial spaces are described,
with the mandibular branches coursing at the lower border of
the premasseteric space, which displaces inferiorly with age.
Consequently, in elderly patients in the supine position, they
have been found coursing well inferior to the mandibular
border.102
The cervical branches are the most inferior, exiting the
parotid at its inferior border and always coursing below
the mandibular border. The cervical branches innervate the
platysma. There are usually two or three branches with
considerable variation in branching patterns. A contribution
from the sensory transverse cervical nerve has also been
described.79
Because the buccal and zygomatic branches are multiple
and interconnected, there is a reserve capacity in the event of
a single branch injury; therefore, permanent injury is uncommon. However, the temporal and marginal mandibular
branches enjoy less collateral innervation making permanent
loss much more likely if these branches are injured. Damage
to the cervical branches can lead to a “pseudo paralysis”
of the lower lip because in some patients the platysma
contributes to depression of the corner of the mouth
(Fig. 11.1.10).103

Patient selection

B

SECTION I •11.1• Facelift: Principles

Cervical branch

Marginal mandibular
branch

Buccal branches

Parotid gland

Temporofacial divison
Cervicofacial division

Posterior
auricular nerve

Zygomatic branches

Temporal branches

Some issues can be reversed, others attenuated, and some
may not be correctable at all.
The patient presenting for facial rejuvenation will usually
be middle age or older, thus increasing the chances of underlying medical problems. In an otherwise apparently healthy
individual, speciﬁc issues which must be addressed are blood
pressure, smoking history and the use of medications or supplements which can promote surgical bleeding.
Incipient hypertension is common in the general population and can promote postoperative hematomas if it is
not identiﬁed prior to surgery. Hematoma is by far the commonest complication in facelift surgery. Uncontrolled hypertension is a contraindication for surgery, while controlled
hypertension is not a contraindication. The labile hypertensive can be the most insidious situation; if possible it should
be identiﬁed preoperatively and controlled. If patients have
intermittent hypertension (the white coat syndrome), or they
are simply type A individuals who are easily excitable, perioperative treatment with medications such as Clonidine
should be considered
Smokers have been shown to exhibit delayed wound
healing due to microvasoconstriction and abnormal cell function.106 One study reported a 12.5 times greater chance of
having skin ﬂap necrosis in a smoking patient compared with
a non-smoker.107 Long-term smokers have a reduction in
arteriole function, which may never return to normal.
Nevertheless, there are signiﬁcant short-term effects which
can be reversed by abstaining from tobacco use for 2–3 weeks
prior to surgery. Tests for the metabolites of nicotine in the
blood are available to conﬁrm abstinence from smoking.
Commonly used non-steroidal anti-inﬂammatory medications (NSAIDs) and the consumption of certain dietary supplements may promote intraoperative and postoperative
bleeding based on platelet function inhibition. Patients should
avoid these medications for 3 weeks prior to surgery.
Female patients in the facelift age group may be on hormone
replacement and are therefore at increased risk for developing
postoperative deep vein thrombosis (DVT) and a potentially
lethal pulmonary embolism. For these patients, in addition to
all recognized preventative measures, consideration should
be given to stopping hormonal replacement 3 weeks prior to
surgery.
With respect to the surgical objectives in facelift surgery,
aging causes fundamental anatomical changes in all parts
and in all tissues of the face. However, patients will typically
present with speciﬁc concerns about speciﬁc areas – often
the ptosis of soft tissue in the neck or jowls, or the visible
wrinkles and folds in the cheek and neck. Patients are usually
unaware of the underlying anatomic changes which are
causing the problems they can see in the mirror. Nevertheless,

Figure 11.1.10 (A) A cadaveric dissection of the facial nerve. Note three temporal branches crossing the middle third of the zygoma, the arborization between zygomatic
and buccal branches, the marginal mandibular branch running along the mandibular border, and two cervical branches innervating the platysma. (Courtesy of Dr Julia Terzis).
(B) Diagram of the facial nerve. The facial nerve exits the stylomastoid foramen and normally divides within the parotid gland into a superior and inferior division. Classically,
ﬁve groups of branches are seen: temporal, zygomatic, buccal, mandibular, and cervical. There is arborization between branches, particularly between the zygomatic and
buccal branches.

A

194

it is important to recognize what the patient can see is the
patient’s primary concern. To help focus the discussion, old
photographs are very useful in determining which aging
changes predominated and what features the patient would
most like corrected. This will help improve patients’ understanding of exactly how they have aged, and what, if any,
rejuvenation they would like to undergo. They will also gain
a better understand of the magnitude of surgery which may
be required to accomplish what they desire.
Prior to surgery, the entire face should be properly assessed.
This examination is conducted in a well lit room with the
patient sitting vertically in a comfortable position. Examination
should proceed in an orderly fashion so that nothing is missed.
The face is examined with the patient in repose as well as
in animation. In doing so, facial nerve function is clinically
assessed. The face should be assessed as a whole – looking for
the equality of facial thirds, the degree of symmetry, and the
overall shape (round, thin, wide). Underlying skeletal form
will potentially inﬂuence the choice of surgical procedure; for
example, a wide full face will not be as amenable to malar fat
pad repositioning as a narrow, long face. Conversely, a thin
face will require the preservation of all soft tissue, overlapping it rather than excising it, and potentially adding

Figure 11.1.11 The great auricular nerve crosses the midportion of the
sternocleidomastoid at McKinney’s point, which is 6.5 cm inferior to the external
auditory canal. It usually travels about 1 cm posterior to the external jugular vein.
Anterior to McKinney’s point, the nerve is covered by the superﬁcial cervical fascia
and the platysma (SMAS), but at the posterior border of the sternocleidomastoid,
the nerve is effectively subcutaneous. The most common point of injury is at the
posterior border of the sternocleidomastoid muscle.

External jugular vein

McKinney’s point
Great auricular nerve

6.5cm

195

additional volume. Any asymmetry should be pointed out to
the patient because facelift surgery will make some asymmetries more obvious.
Surgeons should develop an organized way to examine all
the zones of the face: forehead, eyelids, cheeks, the perioral
area, and the neck. In certain individuals, the appropriate
procedure will be a correction of only one of these areas, but
more commonly, all or most or the zones should be addressed
in order to achieve a harmonious result. Assessment of the
forehead and orbital area are discussed in Chapters 7 and 8.
In the cheeks, the surgeon should assess the shape and prominence of the underlying skeleton, the volume and distribution
of facial fat, the degree of soft tissue atrophy and ptosis
and the relative mobility of the subcutaneous (superﬁcial) fat.
Any signiﬁcant hollowing or ﬂattening should be noted, and
conversely, any radial expansion in the jowl and neck should
be noted. With the diversity of surgical techniques available,
a surgeon should think like a sculptor – considering the face
in three dimensions with a view to adding tissue in some
areas, removing tissue in other areas, and repositioning tissue
where indicated. In the perioral area, the plumpness of the
lips should be assessed, and any elongation of the upper lip
should be noted. On smiling, the amount of dental show is
observed. The skin should be assessed, with its quality noted,
along with the depth of wrinkles and folds, including the
nasolabial fold and the marionette lines.
Assessment of the neck is discussed in Chapter 13, but in
general, the neck should be examined in various positions:
neutral, ﬂexion, and turning side-to-side. The patient is asked
to contract the platysma by clenching the teeth and grimacing.
This will help identify the degree of platysma laxity, the
strength of platysma bands and the amount of subcutaneous
fat superﬁcial to the platysma. The amount of subplatysma
fat is also estimated. Ptosis of the submandibular gland should
be noted and pointed out to the patient preoperatively; this
condition, if untreated, will be more obvious after facelift
surgery than before.
The ear should be examined with a thought to the potential
placement of incisions. Important factors include the size and
orientation of the earlobe, the angle of attachment of the
tragus, the difference in character of the cheek skin and tragal
skin, and the size of the tragus. Also inﬂuencing the choice of
incisions are the density of the hair surrounding the ear and
the location of the hairline in the temple, the sideburn, and
posterior to the ear.
A careful assessment of the overlying skin is also important
to determine if anything of a non-surgical nature is indicated
either before, during or after facelift surgery. Assessment will
include skin type, skin quality, skin excess, the depth of folds,
the degree of ﬁne wrinkling and the amount of photo-aging.
In particular, perioral rhytides should be examined as they are
often a signiﬁcant concern for the patient. Issues with the skin
should be pointed out to the patient, and options discussed
because facelift surgery itself will not improve the texture and
quality of the skin – a common misconception.
Excellent photographic documentation of the preoperative
face is very important, and should include frontal, oblique,
and proﬁle views. Other optional views include the smile and
close up views of the neck in repose and with platysma contracture. Changes in the face from facelift surgery may be
more subtle than other aesthetic procedures, so a reliable
record of the surgical starting point is imperative.

Patient selection

SECTION I •11.1• Facelift: Principles

Historically, surgeons have been guided by the empirical
ﬁnding that people look younger when soft tissue of the lower

Technique

A facelift is a signiﬁcant operation. It should be done under
excellent conditions with appropriate medical staff, appropriate equipment and adequate back up. Anesthesia can be safely
done with many different approaches, including local anesthetic with different levels of intravenous sedation and with
varying levels in the spectrum of general anesthesia. An
anesthesiologist, if involved, can decide in consultation with
the surgeon what form of anesthesia is preferred for an
individual patient. There should be proper intraoperative
patient positioning, intraoperative monitoring, intraoperative
warming, and intraoperative DVT prophylaxis.

Surgery

Figure 11.1.12 Major sensory nerves of the face.

Mandibular nerve V3

Maxillary nerve V2

Ophthalmic nerve V1

196

cheek is shifted into the middle and upper cheek. Patients see
the same thing in a mirror when they manually lift their cheek
or if they lie on their back. Effectively, by shifting lower facial
fat superiorly, volume is restored to the midface while simultaneously, ptotic tissue is lifted. As we have seen, changes in
volume are a signiﬁcant part of facial aging. Surgeons have
been able to improve the lower third of the face and neck by
removing excess volume, and in recent years, surgeons have
demonstrated that people may look younger with volume
augmentation alone.108,109 By combining these approaches –
adding volume in some areas, subtracting volume in others,
and by repositioning ptotic tissue, the surgeon has the ability
to sculpt facial shape and more accurately restore the contours
of youth.
The repositioning of ptotic tissue is the principle objective
which has interested surgeons since facelift surgery began.
Many methods have been described. The choice of technique
will depend on the individual patient’s aesthetic diagnosis,
the patient’s desires, and the surgeon’s comfort level with a
certain procedure. While differences between surgical techniques can be signiﬁcant, many commonalities exist. In this
section, the classic subcutaneous facelift will be described and

Mental nerve

Buccal nerve

Infra-orbital nerve

Infratrochlear nerve
External nasal nerve
Zygomaticofacial nerve
Auriculotemporal nerve

Zygomaticotemporal nerve

Lacrimal nerve

Supratrochlear nerve
Supra-orbital nerve

The purpose of a facelift incision is two-fold. First, the incision
allows elevation of a ﬂap which provides access for surgical
manipulation of the deep tissues of the face. Second, the
resulting skin ﬂap can be repositioned with excess skin being
removed along the incision line; this is the primary goal of
a skin-only subcutaneous facelift. Generally, the incision is
hidden by the hair and by contours of the ear.
In the temple area, the incision can be placed in the hair, at
the anterior hairline, or a hybrid of the two, with an incision
in the hair plus a transverse extension at the base of the sideburn (Fig. 11.1.13A,B).
The advantage of the incision in the hair is that it is hidden,
but when the ﬂap is drawn up, the anterior hairline and sideburn will shift, the degree of this depending on skin laxity.
If the incision is placed at the anterior hairline, the scar is
potentially more visible, but there will be no shift of the hairline. A transverse incision at the base of the sideburn is a
compromise solution, which ameliorates much of the hairline
shift, while preserving a largely hidden scar. Other compromises have been described.110 Several factors should be
assessed before committing to an incision within the temple
hair. First, a preoperative estimate of skin redundancy will
give the surgeon some sense of how far the skin ﬂap will
move. The distance between the lateral orbital rim and the
temporal hairline should be assessed. In youth, this distance
is generally <4–5 cm, while in older patients, the distance
increases.111 If the distance is already excessive, or if the
expected movement of the temporal hairline will create a
distance over 5 cm, then an incision in the hair should be
avoided (Fig. 11.1.13C). On the other hand, patients must be

Facelift incisions

The ﬁrst facelift, which dates from the early 20th century, was
a simple skin incision at the temporal hairline and anterior to
the ear; several authors lay claim to this innovation.9–11 This
method soon evolved into a subcutaneous dissection of a
large random pattern skin ﬂap which was shifted in a superiorlateral direction.24,26 Still used today, this classic procedure
tightens excess skin, and relies completely on skin tension to
shift underlying facial soft tissue against the force of gravity.
The advantages of the subcutaneous facelift are that it is relatively safe, it is easy to do, and patient recovery is rapid. For
the thin patient with excess skin, and minimal ptosis of deep
soft tissue, this procedure is effective. However, the reverse,
namely a heavier patient with signiﬁcant ptosis of deep tissue,
is a poor candidate. The inherent disadvantage of the “skinonly” facelift is that skin placed under tension to support
heavy underlying soft tissue will stretch, leading to a loss of
surgical effect. An attempt to overcome this problem with
excess skin tension may lead to distortion of facial shape,
abnormal re-orientation of wrinkles, and local problems at
the incision line including stretched scars and distorted
earlobes.

Subcutaneous facelift

the fundamental issues which pertain to all facelift techniques
will be reviewed. (The various methods speciﬁcally designed
to manipulate the deep tissues of the face will be described
later, in Chapters 11.2–11.8.)

197

informed that the alternative incision along their temporal
hairline may result in a more visible scar. Because of this
problem a number of solutions have been devised along the
temple hairline including beveling the incision to encourage
growth of hair through the scar and the use of zig-zag
incisions.112,113 In any circumstance, the anterior hairline incision should be meticulously sutured under minimal tension.
Also, the patient’s wishes should be taken into consideration
prior to surgery, because the location of the incision in the
temple is inevitably a compromise and the patient may have
preferences which will inﬂuence the surgeon’s choice.
Anterior to the ear, the incision can be pre-tragal, or along
the tragal edge (Fig. 11.1.13D,E). The advantage of the tragal
edge incision is that it is hidden, but care must be taken to
thin the ﬂap covering the tragus in order to simulate a normal
tragal appearance. Furthermore, as pointed out by Connell,111,114
the tragus looks like a rectangle, with a top and a bottom, and
to preserve a distinct lower border, a short transverse cut at
the inferior end of the tragus (the incisura) should be done.
Before committing to a tragal edge incision, the quality of
tragal skin and that of facial skin must be compared; if
the difference is too great, drawing thick cheek skin onto the
tragus may be problematic because the skin covering the
tragus will not be anatomically appropriate. Therefore, in
certain cases, a pretragal incision is preferred. For example, in
men, the pretragal approach may be beneﬁcial if it appears
that thick-bearded skin will be drawn up onto the tragus
and the surgeon is concerned that removing hair follicles and
thinning the ﬂap will not ameliorate the appearance of cheek
skin on the tragus. Elsewhere in front of the ear, the superior
portion of the incision should follow a curved line along the
helix, and a slightly straighter curve along the anterior attachment of the earlobe; a long, straight line incision in front of Video
2
the ear should be avoided.
Around the earlobe, the incision can be place either in
the cleft of earlobe attachment or 1–2 mm distal to the cleft,
leaving a cuff of skin along the earlobe. This cuff will ease the
process of insetting the earlobe on skin closure.
In the retroauricular sulcus, the incision can be placed
directly in the conchal groove as it courses superiorly. Various
landmarks have been described to determine how high to
carry this incision. These include the level of the external auditory canal, or slightly higher, at the level of the antihelix.
A signiﬁcant surgical decision is whether to extend the
postauricular incision across the non hair baring skin into
the occipital region. Generally speaking, the occipital incision
should be made when there is a need to remove excess redundant neck skin. A “short scar” facelift is one which avoids
the occipital incision, and will sufﬁce for many patients.115 If
the incision is kept short, the lateral neck is accessed from the
earlobe and retroauricular incision, and any bunching of skin
is redistributed within the retroauricular sulcus. Disadvantages
of the short scar technique are that access to deep tissues is
somewhat limited, there is a tendency to draw the skin ﬂap
in a more superior direction possibly requiring a pre-hairline
incision in the temple, and the fact that excess neck skin, if
there is any, must be gathered up in the retroauricular sulcus,
often creating pleats.
If the decision has been made to extend the incision beyond
the retroauricular sulcus, many variations are described,
ranging from an incision which goes vertically into the scalp116
to an incision which courses inferiorly along the hairline of

Technique

SECTION I •11.1• Facelift: Principles

D

B

E

the neck. Most commonly, surgeons use an incision which
is between these two extremes. The principle objectives for
the occipital incision are to gain access to the neck in order
to take up redundant neck skin, while making the incision
as invisible as possible with little or no distortion of the occipital hairline. If a small amount of skin is going to be removed,

the retroauricular incision can curve posteriorly into the
occipital hair from the retroauricular sulcus. If more skin from
the neck is going to be removed, this approach could create a
notch in the posterior hairline, so a called “lazy S” pattern can
be used, where the incision follows the occipital hairline for
1–2 cm, before angling more posteriorly into the scalp. A

Figure 11.1.13 (A) The traditional hidden incision in the temple hair is appropriate when the temporal hairline will not be shifted adversely. (B) A temple incision along the
hairline is used if a hidden incision will adversely shift the hairline. (C) The distance from the lateral orbital rim to the temporal hairline should not exceed 5 cm (D) The
retrotragal incision follows the edge of the tragus. (E) The pretragal incision is placed in the pretragal sulcus.

C

A

198

rough guide is to use the lazy S approach if 2 cm or more of
neck skin is to be removed at the incision line.117 This approach
allows an adequate excision of skin without a stair-step
deformity, while hiding the lower, potentially most visible
Video part of the scar in the wispy hair of the lower occipital scalp
3 (Figs 11.1.14, 11.1.15).
Either the temple dissection or the post-auricular dissection
can be done ﬁrst, depending on surgeon preference. The dissection is usually begun with a scalpel, for the ﬁrst 1–2 cm, at
which point many surgeons switch to scissors. In the postauricular area, the ﬂap is ﬁrmly attached to the deep cervical
fascia of the sternocleidomastoid and the mastoid. Also, this
is the most common location to see skin ﬂap necrosis, so the
ﬂap should be raised sharply under direct vision, keeping the
dissection against the underlying deep fascia in order to maintain ﬂap thickness. As the dissection continues inferior to the
earlobe level, the surgeon must be cognizant of the great auricular nerve, where it is most at risk over the posterior border of
the sternocleidomastoid. By keeping the dissection in the subcutaneous plane, the great auricular nerve will be protected.
In the temple, if the incision has been made along the anterior hairline, dissection is begun directly in the subcutaneous
plane. If the incision has been made in the hair baring scalp
of the temple, dissection can be carried out in one of two
planes: superﬁcial to the superﬁcial temporal (temporoparietal fascia) which will continue directly into the subcutaneous
facelift plane, or between the superﬁcial temporal fascia
and the deep temporal fascia. If the deeper approach is used,
the dissection proceeds quickly against deep fascia, but at the

Figure 11.1.14 When there is minimal skin shift expected, the incision is limited
to the retro-auricular sulcus only (“short scar” technique). When more skin shift is
expected, especially from the neck, the incision is extended across nonhair-baring
skin into the occipital hair. A wide range of patterns for this extension have been
described, ranging from a vertical incision down to an incision that follows the
hairline. Most surgeons follow a course somewhere in between, as in this photo
where a “lazy S” follows the occipital hairline for 1 or 2 cm before entering the
occipital hair.

199

anterior hairline, the dissection plane must transition into the
subcutaneous facelift plane. This change of plane results in a
narrow ribbon of superﬁcial temporal fascia which will
contain the superﬁcial temporal artery and vein and branches
of the auriculotemporal nerve. This is known as the “mesotemporalis”, and must be divided, often requiring ligation of
the superﬁcial temporal vessels. The argument in favor of the
deeper dissection is to protect temporal hair follicles, although
vessels and a nerve must be sacriﬁced (Fig. 11.1.16A). The
superﬁcial plane has the reverse attributes: vessels and nerves
within the superﬁcial temporal fascia are preserved, but the
hair follicles can be injured during the dissection unless care
is taken (Fig. 11.1.16B).
Anterior to the anterior hairline, the subcutaneous plane is
then developed. Commonly referred to as the “facelift plane”,
the level of dissection normally leaves about 2 mm of fat on
the dermis. This results in a large random pattern skin ﬂap
the survival of which will entirely depend on the subdermal
plexus. In the upper face, this dissection continues anteriorly
until the orbicularis oculi is encountered where it encircles the
lateral orbital rim. Depending on the type of deep plane
surgery planned, the mid-cheek dissection may stop short of
the malar fat pad (see Ch. 11.7), or alternatively, carry on over
the fat pad, freeing it from the overlying skin in the temple
and cheek (see Ch. 11.6). Lower in the cheek, immediately
anterior to the ear and the earlobe, the skin is tethered to
underlying structures by secure fascial attachments (variously
named: platysma auricular fascia, parotid cutaneous ligament, and Lore’s fascia). Beyond this area, the subcutaneous

Figure 11.1.15 The traditional incision for a facelift ﬂap curves vertically or
slightly anteriorly in the temple, follows the contours of the ear, both anteriorly and
posteriorly, and then angles into the posterior scalp.

Technique

4

Video

B

SECTION I •11.1• Facelift: Principles

Once the deep tissues have been managed, skin ﬂap mobilization and closure must be done accurately and with care.
Despite masterful deep tissue surgery, errors made on skin
closure can create some of the most obvious of facelift deformities. At all times, the skin should be considered a covering
layer, not a structural one. Therefore, skin ﬂap repositioning
should be seen as a removal of redundancy rather than a
method to hold up ptotic soft tissue. Most techniques advance

Skin ﬂap mobilization and closure

The subcutaneous facelift ﬂap does two things – it allows for
reposition and removal of excess facial skin, and it provides
access to the deep tissues of the face. Techniques to address
the deep tissues of the face will be reviewed in Chapters
11.2–11.8. These will include: SMAS plication, loop sutures
(MACS lift), SMASectomy, subSMAS with skin attached, sub
SMAS with separate skin ﬂap, and subperiosteal.

Deep tissue surgery

dissection proceeds relatively easily. Once the skin ﬂaps anterior and posterior to the ear have been raised, the two dissections are joined. The extent of the facelift ﬂap dissection into
the cheek and neck will depend on the type of deep tissue
technique being employed (see Ch. 11.2). When a submental
incision is done with midline platysma muscle plication (Ch.
13), there will be traction on the cervical skin toward the
midline of the neck. In that circumstance it is important to
widely mobilize the cervical skin from the underlying
platysma in order to allow the cervical skin to be redraped
along a vector opposite to that in which the platysma is being
moved. If, on the other hand, there is no submental incision,
the neck dissection can be more limited (Figs 11.1.17, 11.1.18).

A

200

Figure 11.1.17 Subcutaneous facelift ﬂap has been raised.

Figure 11.1.16 (A) Facelift ﬂap has been
raised in two different planes, initially deep
to the superﬁcial temporal fascia, against the
deep temporal fascia (seen as an oval
window), with a change of planes near the
anterior temporal hairline into the
subcutaneous plane. The “mesotemporalis”
is a bridge of tissue which develops between
these two planes. In order to unify the
planes, it has been divided with ligation of
the superﬁcial temporal artery. (B) Facelift
ﬂap has been raised in a single
subcutaneous plane, with dissection directly
on the superﬁcial temporal fascia and deep
to the hair follicles of the scalp. The purple
line outlines the course of the anterior
branch of the superﬁcial temporal artery.

C

D

B

the skin ﬂap along an oblique vector which is slightly less
vertical than the vector for repositioning deep tissues. In
certain techniques, surgeons employ a nearly vertical vector
to the skin ﬂap (Ch. 11.4). One concept is to place the skin ﬂap
“where it lies”, using the vector which facial skin naturally
assumes when the patient is lying in the supine position. This
is based on the theory that we all look better lying on our back
with facial skin redraping itself in a natural direction (Fogli,
pers. comm.). A common guide is to advance the skin ﬂap
toward the temple along a vector which is perpendicular to
the nasolabial fold. This is also approximately along the line
of the zygomaticus major muscle. A skin ﬂap marker can be
very useful in determining where the skin should be incised.
The anterior anchor point is immediately adjacent to helix of
the ear at the junction of the hair baring scalp. This will be the

201

ﬁrst of two anchor points; it can be held in place with a half
buried mattress suture in order to minimize the chance of a
visible suture mark (Fig. 11.1.19).
Posteriorly, the skin ﬂap should be drawn along a vector
which roughly parallels the body of the mandible. The second
anchor point will be at the superior most extent of the postauricular sulcus at the point where the incision starts to transition posteriorly. Once again, a half buried mattress suture can
be used. At this point, trimming of the overlapping ﬂap and
suturing can be done in the temple and in the occipital region;
the order is based on surgeon’s preference. During this
process, the facelift ﬂap is redraped in the desired direction
with gentle tension. Attention is then turned to trimming
excess skin around the ear, with absolutely no tension on the
closure. If a tragal edge incision is used, the tragal ﬂap is

Figure 11.1.18 (A) Traditional subcutaneous ﬂap dissection with no submental incision. (B) Traditional subcutaneous ﬂap dissection with submental incision.

A

Technique

SECTION I •11.1• Facelift: Principles

The basic principles of neck surgery will be covered here.
(Surgical rejuvenation of the neck is reviewed in Chapter 13.)
Like the face, the layers of the aging neck must be assessed
independently in order to devise an appropriate surgical plan.
Superﬁcially, the skin of the neck is typically thinner and
less elastic than facial skin. With age, further skin laxity develops, causing vertical wrinkles and pleats. These can be corrected by tightening the skin in a posterior oblique direction.
Some surgeons believe that such a correction should be
accompanied by superior oblique repositioning of the underlying platysma.118,119 With age, subcutaneous fat usually

Neck surgery

thinned and hair follicles are removed. In the retroauricular
sulcus, there is normally little or no skin to be trimmed if the
posterior ﬂap has been correctly positioned. Earlobe inset is
done last and is designed to angle 15° posterior to the long
access of the ear (Fig. 11.1.20).114,117
Skin trimming around the ear should be guided by having
no tension on the sutures when the wound is closed. Tension
on the earlobe can lead to distortions such as the pixy ear
deformity and the malpositioned earlobe, both of which are
difﬁcult to correct (see Ch. 12).

Figure 11.1.19 Diagram shows typical skin ﬂap redraping along an oblique
direction which is slightly less vertical than the vector along which deep tissues are
moved. There is considerable variation in this however; some techniques involve a
more horizontal vector (dual plane extended SMAS, see Ch. 11.6), while other
techniques utilize a nearly vertical vector (MACS, see Ch. 11.4).

202

centrally and to do a partial transaction of the muscle inferiorly. Some surgeons advocate multiple rows of sutures to
aggressively advance the platysma muscles medially: the
corset platysmaplasty.124 Deep to the platysma, excess subplatysmal fat may be removed, hypertrophic digastric muscles
can be thinned and ptotic submandibular glands can be corrected by repositioning or by partial excision.125,126
In some facelift cases, only minimal correction of the neck
is required and a facelift with deep tissue advancement will
supply adequate correction. Conversely, in patients concerned
only with the neck, this can be treated as an isolated procedure utilizing a number of different techniques: isolated liposuction, liposuction plus platysma plication and transection,
or a retroauricular approach to tighten the platysma posteriorly.127 If after submental surgery, there is skin laxity, it can be
tightened with an isolated retroauricular incision, or with a
full subcutaneous facelift.
In some older males, the preferred procedure may be a
direct neck excision of excess skin, leaving a scar in the
midline. This can be done with a zig-zag pattern or with a
vertical ellipse broken up with two or more Z-plasties.128
In the typical case of the aging neck, there is usually a
combination of factors (skin laxity, excess fat, and lax platysma
muscle). In such a scenario, there is controversy as to how
aggressive to be with surgical treatment. While most surgeons
agree that a youthful neck contour is one of the principle
objectives of facelift surgery, many fear the possibility of creating the “overdone” neck. And while some surgeons feel that
any platysma banding warrants open surgery, others virtually
never do an open neck procedure, relying instead on liposuction and posterior-superior platysma traction. Some surgeons
feel that ptotic submandibular glands should always be
addressed while others feel it need never be done. The implication of these opposing opinions is that a perfect, universal
procedure for the neck probably does not exist, and surgeons
must individualize their approach to variations in anatomy
and patient expectations.

No platysma interdigitation

203

Long-term experience with elevating deep facial tissues has
shown this approach to add some fullness to the middle third
of the face (see Chs 11.2–11.8). However, a more complete
result can be obtained if speciﬁc volume augmentation is
done. The addition of volume can be accomplished with a
number of different methods including: synthetic implants

Volume augmentation

With radial expansion of the lower third of the face, many
patients require fat removal. Subcutaneous fat can be removed
either by direct excision or with liposuction. In the cheek, this
is often done on a limited basis for the jowls, especially in
cases where jowls cannot be corrected by soft tissue elevation
alone. Removal of deep fat can be done by partially removing
the buccal fat pad, which can be approached through a facelift
dissection or through an incision in the upper buccal sulcus.
In the neck, superﬁcial fat can be removed using liposuction
or by direct excision through a submental or a facelift incision.
Fat deep to the platysma can be removed using direct excision
through the submental approach. In all cases of fat removal,
caution is advised because of the potential defects which can
be produced when too much fat is removed.

Volume removal

Facial aging rarely occurs in a regional fashion, and is typically a pan-facial phenomenon. Therefore, a comprehensive
approach to facial rejuvenation is normally required to achieve
a harmonious result. For many patients, surgery for the brow
(Ch. 7) and the eyelids (Ch. 8) are critical components of a
global approach for which a facelift would be only part of the
solution.

Browlift surgery and blepharoplasty

Ancillary techniques

Extensive platysma interdigitation

accumulates in the anterior neck, although this is highly variable; in some thin individuals, there may be little or no subcutaneous fat in the neck. If subcutaneous fat is the only
problem, and the skin is ﬁrm, or will be surgically tightened,
the fat can be simply removed with closed liposuction.120
Deep to the fat, the paired platysma muscles have well
recognized variations in their anatomy. The majority (roughly
75%) of necks exhibit interdigitation of the platysma muscles
in the submental region for the ﬁrst 1–2 cm behind the
chin.121,122 The remaining 25% either overlap extensively, or do
not overlap at all (Fig. 11.1.21).
With age, there appears to be a loss of tethering of the
platysma muscles to the deep cervical fascia, analogous to the
loss of tethering of the orbicularis oculi along the infraorbital
rim. As a result, the platysma seems to fall away from the
cervical mandibular angle and the sharp angle of youth gives
way to the obtuse angle of age. The visible bands, which
develop with age, are normally the leading edge of the paired
platysma muscles, but clinical experience has demonstrated
these visible bands may also represent pleats in the redundant
muscle just posterior to their leading edge. Bands are considered either static (present at rest), or active (only present on
animation). There are two different surgical options to deal
with platysma bands in the anterior neck. One approach
involves mobilizing the posterior borders of the paired
platysma muscles, drawing them in a superior oblique direction and ﬁxating the muscle to ﬁrm fascia (platysma auricular
fascia, or the Lore’s fascia component).83,118
Alternatively, the paired platysma muscle can be drawn
medially, and approximated in the midline of the neck.28,123
Access for this is through a 2–3 cm incision placed adjacent to
or in the submental fold. Through this submental incision,
several anatomical structures can be addressed directly:
subcutaneous fat, subplatysma fat, the platysma muscles,
digastric muscles, and the submandibular glands. A common
approach is to remove excess subcutaneous and subplatysma
fat, to approximate the anterior platysma muscle edges

Limited platysma interdigitation

Figure 11.1.21 Three types of platysma anatomy.

B

Thyroid cartilage

Mandibular
symphysis

Figure 11.1.20 The earlobe should be inset with the long axis of the earlobe
(dotted line) about 15° posterior to the long axis of the ear itself. If the earlobe is
pulled forward, an unnatural appearance results.

A

Proper insetting of the ear lobe

Technique

SECTION I •11.1• Facelift: Principles

The aging face often develops changes in the perioral region,
but a facelift will not affect the perioral region to any appreciable degree. Common changes include elongation of the
upper lip as measured from Cupid’s bow to the base of the
columella, a thinning of the vermillion, and the development
of perioral rhytides.
Elongation of the upper lip is highly variable, but if present,
tends to hide the upper teeth, in some cases almost eliminating the normal upper dental show on smiling. It has been
estimated that the ideal distance from Cupid’s bow to the base
of the columella is 15 mm.136,137
The upper lip can be shortened by performing a skin
excision along the contours of the base of the nose (bull horn
pattern). Skin is excised, with the direct approximation of
skin acting as a subcutaneous lift. Disadvantages include a

Lip procedures

In an attempt to lift the tissue immediately inferior to the
infraorbital rim (the midface), an approach through the lower
lid was developed.132 This involves a subciliary or a transconjunctival blepharoplasty type incision followed by a dissection down over the face of the maxilla. This procedure can be
done in the subperiosteal plane, which requires an inferior
periosteal release, or it can be done in a supraperiosteal
plane.133 After mobilization of the cheek mass the soft tissue
is ﬁxated superiorly, either laterally along the lateral orbital
rim,132 or more vertically with anchoring to the bone of the
infraorbital rim.134 Disadvantages have included the learning
curve necessary for surgeons to feel comfortable with this
approach and a signiﬁcant incidence of revisions for malposition of the lower eyelid.135 An alternative approach to the
midface is endoscopically through the temple. This procedure
is described in detail in Ch. 11.2.

Midfacelift (blepharoplasty approach)

(cheek implants, submalar implants, orbital rim implants),
injectable synthetic ﬁllers, hydroxy appetite granules or
injected fat (all of which are reviewed in Chs, 4, 14, and 15).
In particular, the harvesting, processing and injection of
micro-droplet fat grafts (lipoﬁlling) have undergone great
technical improvements.70,129
This technology is now reproducible, and for many surgeons is a major component of their facelift technique.130,131
There is a high rate of fat graft take after fat injection in the
middle third and upper third of the face; in fact signiﬁcant
over-grafting should be avoided in the periorbital area because
of the propensity for visible ridges and lumps if excess fat
grafting has been done. Fat grafting is less reliable around the
vascular, mobile lips. Speciﬁc areas which are commonly
grafted in conjunction with facelift surgery fat are the periorbita (orbital rim, upper lid sulcus, and the tear trough), the
mid-facial groove, and the malar prominence. The depth of
injection can be in the superﬁcial fat layer (superﬁcial to
SMAS), or in the deep fat layer. As mentioned above, it has
been proposed that the deep medial fat compartment may
play a unique role in support of soft tissue in the mid face,
suggesting the beneﬁts of fat grafting this zone.64 Fat injection
can be done independently, or in combination with facelift
Video surgery. When done in conjunction with facelifting, it is
5 usually done ﬁrst, before the facelift ﬂap has been raised.

204

potentially visible scar and a certain degree of relapse making
revisions common (Fig. 11.1.22).
Alternatively, a strip of skin can be removed along the
vermillion border, advancing the vermillion superiorly. This
has the advantage of immediately increasing the apparent
width of the vermillion lip, but the disadvantages that the
white roll is eliminated and a permanent scar will be left along
the vermilion border. Women can deal with this by using
lipstick, but this is usually a life-long commitment when the
scar is visible.
Lip augmentation can be done with many different techniques. Commonly used methods include: injectable ﬁllers
(Ch. 4), injected fat, dermal fat graft, acellular dermis and
SMAS grafts. Many different human tissues, and many synthetic materials have been used to thicken lips. Depending on
the technique used, problems have included resorption and
loss of effect, permanently over ﬁlled lips, distorted shaped
lips, immobile lips, and in some cases tissue necrosis from
vascular compromise. Attempts to augment the lip along the
vermillion border lead to a duck like appearance, while augmentation along the wet dry junction is more likely to achieve
a normal appearing lip.
Perioral rhytides are a common ﬁnding in the facelift age
group. They can be effectively treated at the time of surgery

Figure 11.1.22 Pre- and postoperative photographs of a lip-shortening procedure
using a bullhorn-shaped incision along the nostril sill.

B

A

Postoperative hematoma is the most common facelift complication, and has a reported incidence of 2–3% in women. The
incidence in men has been reported up to 8%, although this
can be decreased to 4% through meticulous surgery and postoperative blood pressure control.138,139 Numerous variables

Hematoma

Surgical complications

In the initial postoperative period, the patient is kept still and
blood pressure is monitored closely. Any signs of blood pressure increase should be taken very seriously; the patient is
examined for possible causes (pain, anxiety, urinary retention)
and appropriate measures taken. If the increase in blood pressure is endogenous, it should be treated pharmacologically. If
the surgical procedure has been long (>3 h), sequential compression devices are kept on the legs in recovery room until
the patient can ambulate normally. The patient is then encouraged to get out of the bed with assistance, in order to walk to
the bathroom. The patient’s positioning involves keeping the
head of the bed elevated, but avoiding ﬂexion of the neck.
Avoiding the use of a pillow for 10–14 days will help keep the
patient’s head in a neutral, non-ﬂexed position. Cool packs to
the face will increase comfort and help decrease swelling.
Analgesics and antinauseants are used as necessary. In some
jurisdictions, patients are discharged home, but in other settings, patients are kept under the care of a medically trained
individual for the ﬁrst night after surgery. On the ﬁrst postoperative day, the patient is reviewed, paying particular attention to the possibility of a hematoma, the dressings are
changed or removed, and drains are removed. After the ﬁrst
day, options include another light dressing, a commercially
available “chin strap”, or no dressing at all. Patients are
usually permitted to have a shower and wash their hair when
the incisions are sealed from the environment – usually 2–4
days postoperatively. Subsequently, patients are seen for
dressing changes, suture remove and wound inspection, at
intervals up to 7–9 days when the ﬁnal sutures are removed.
Typically, there is a return visit at 2–3 weeks and then again
between 6 and 8 weeks. Photographic documentation of the
surgical result should be deferred for at least 6 months to
allow for all postoperative swelling to settle completely.

Postoperative care

Some surgeons feel that dressings after facelift surgery are
not necessary, but most surgeons use light dressings to protect
the incisions and to act as an absorbent for wound drainage.
Dressings should not be tight or constrictive, but rather soft
and comfortable. The initial dressing is normally removed on
the ﬁrst postoperative day.

Dressings

with resurfacing procedures. Options include chemical peel,
surgical dermabrasion or laser treatment. (These techniques
are discussed in Chapter 5.) The most common problem is
permanent depigmentation when the resurfacing has been
overly aggressive.

205

Damage to a facial nerve branch can easily go unnoticed by
the surgeon until muscle paralysis is identiﬁed postoperatively. Immediately after surgery, in the recovery room setting,
facial nerve paresthesias are extremely common and are
usually caused by the lingering effects of local anesthetic.
Once the temporary anesthetic effects are gone (approx. 12 h
for bupivacaine), persisting dysfunction may be due to

Motor nerve injury

The terminal branches of sensory nerves to a facelift ﬂap are
routinely divided when the ﬂap is raised. The consequence is
a self-limiting paresthesia which usually recovers completely
in 6–12 months. The great auricular nerve is the major sensory
nerve at greatest risk for damage during facelift surgery.
Transection will lead to numbness of the lateral portion of the
external ear as well as skin anterior and posterior to the ear.
A painful neuroma can also develop. If knowingly transected
during facelift surgery, either partial or complete, it should be
repaired intraoperatively. A portion of the zygomaticofacial
nerve is often transected when the malar fat pad is lifted; this
will lead to numbness of the lateral cheek, which will continue
to improve for over a year. In this area, some permanent
numbness is possible.

Sensory nerve injury

have been explored, including dressings, drains, ﬁbrin glue,
and platelet gel. A positive association has been found when
simultaneous open neck surgery is done, with patients taking
platelet inhibitors such as Aspirin and anti-inﬂammatories,
with hypertension in the postoperative period, and with the
rebound effect when the epinephrine wears off postoperatively.140,141 Hematoma prevention involves avoiding these
variables as much as possible. Hematomas typically develop
in the ﬁrst 12 h after surgery. If an expanding hematoma is
identiﬁed it should be promptly drained. If skin ﬂap compromise is suspected and there is a delay in returning to the
operating, a temporary solution can be the removal of sutures
in order to relieve pressure (Fig. 11.1.23).

Figure 11.1.23 Postoperative hematoma in a hypertensive male. Note the
ineffective suction drain.

Surgical complications

SECTION I •11.1• Facelift: Principles

64. Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg. 2007;119:2219–2227.
Anatomic dissections are presented which demonstrate
how the subcutaneous fat of the face is partitioned
into multiple, independent anatomical compartments.

In some locations, the septae dividing the fat
compartments are aligned with retaining
ligaments.
65. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and
the deep medial fat compartment. Plast Reconstr Surg.
2008;121(6):2107–2112.

Access the complete references list online at http://www.expertconsult.com

Conclusion
Facelift surgery has evolved in parallel with our more advanced
understanding of the anatomy of facial aging. For over a
century, innovative surgeons have developed a wide variety
of approaches to treat age related changes. In this chapter we
have reviewed surgical anatomy as it relates to facial aging.
We have introduced the classic skin-only facelift along with
the issues which pertain to preoperative and postoperative
patient care. In the coming chapters, various methods of handling the deep facial tissues will be discussed.

Facelift dissection creates a large relatively thin random
pattern skin ﬂap which is then placed under tension; it has a
remarkable ability to survive. Factors which can contribute to
the avascular loss of skin include excessive tension, an overly
thin ﬂap, hematoma, constrictive dressings, and perhaps the
most damaging of all – smoking. Established skin necrosis
should be dealt with conservatively; the majority of such cases
will eventually heal spontaneously. Scar revision can be done
at a later date.

Infection is reported to be rare in facelift surgery, with various
series indicating an incidence of less than 1%.143–145
However, most authors with published series have only
counted cases requiring surgical drainage or hospitalization. Minor cases of cellulitis and stitch abscesses are likely
more common. Should an infection occur, treatment is with
surgical drainage, antibiotics and appropriate wound care
(Fig. 11.1.24).

Infection

Skin loss

Loss of hair can occur along the incision line or within the hair
baring scalp which has been raised as a ﬂap. The usual cause
is excess tension at the incision line. However, if a ﬂap of hair
baring skin is raised, follicles can also be damaged by the dissection itself, by cautery, or by traction on the ﬂap. Permanent
hair loss can be treated in some cases by mobilization of an
adjacent ﬂap of hair baring scalp. However, for signiﬁcant
alopecia, achieving adequate coverage with hair growth in the
proper direction is best achieved with micro-hair-grafting
(Ch. 23).

Alopecia

80.

73.

70.

Figure 11.1.24 Abscess under cervical portion of facelift ﬂap, 1 week after a
facelift. This was treated with drainage and antibiotics.

69.

Depending on the incision chosen, scars can potentially be
obvious and deforming. Improper placement of incisions can
lead to distortion of the ear and unnatural shifting of the
hairline. Excessive tension can lead to loss of hair, depigmentation and widened scars. Some scars can be improved with
scar revision at a later date. Hypertrophic scars can be dealt
with by steroid injection, and scar revision if necessary. (These
issues are discussed in Chapter 12.)

68.

Unsatisfactory scars

surgical traction or the effect of cautery near a nerve branch;
these issues can be expected to resolve spontaneously over
days or weeks. If a facial nerve branch has been transected or
wrapped in a suture, complete functional recovery may still
be possible if the target muscle receives collateral innervation.
The anatomic issues were discussed earlier. The most commonly injured branches are thought to be the buccal branches,
although long-term sequelae are rare due to multiple interconnections between nerve branches. Damaged temporal
or marginal mandibular branches are less likely to recover
because they are terminal branches with less collateral
support. Fortunately, permanent paralysis of any degree is a
rare event, and has been reported as being less than 1%.142

206

Anatomic dissections of deep facial fat are presented (fat
which is deep to the muscles of facial expression). The deep
fat is compartmentalized by septae, creating the deep medial
fat pad, and the suborbicularis oculi fat.
Gosain AK, Amarante MTJ, Hyde JS, et al. A dynamic
analysis of changes in the nasolabial fold using
magnetic resonance imaging: Implications for facial
rejuvenation and facial animation surgery. Plast
Reconstr Surg. 1996;98:622.
A comparative MRI study demonstrates the changes in
subcutaneous fat which develop with age. The authors
conclude that superﬁcial fat in the cheek becomes ptotic
while the underlying elevators of the lip do not elongate
with age.
Stuzin J. Restoring facial shape in facelifting: the role
of skeletal support in facial analysis and midface
soft-tissue repositioning (Baker Gordon Symposium
Cosmetic Series). Plast Reconstr Surg. 2007;119:362.
This review discusses the changes in facial shape which
occur with aging, the surgical means we have to correct
these changes, and alterations which should be made with
different degrees of underlying skeletal support.
Coleman SR. Facial recontouring with lipostructure.
Clin Plast Surg. 1997;24(2):347.
A pioneer of facial fat grafting presents early experience
with lipoinjection of the face.
Mitz V, Peyronie M. The superﬁcial
musculoaponeurotic system (SMAS) in the parotid
and cheek area. Plast Reconstr Surg. 1976;58:80.
This paper is the ﬁrst description of the superﬁcial
musculoaponeurotic system.
Stuzin JM, Baker TJ, Gordon HL. The relationship
of the superﬁcial and deep facial fascias: relevance
to rhytidectomy and aging. Plast Reconstr Surg.
1992;89:441.
141.

129.

111.

96.

95.

207

Anatomic dissections conﬁrm the presence of retaining
ligaments previously described by other authors as well as
newly described masseteric ligaments. The authors discuss
the support these structures supply between ﬁxed bone and
deep fascia and the superﬁcial fascia.
Tzafetta K, Terzis J. Essays on the facial nerve: Part I.
Microanatomy. Plast Reconstr Surg. 2010;125(3):
879–889.
The authors review facial nerve anatomy and present
anatomic ﬁndings which conﬁrm extensive arborization
between facial nerve branches. The discussion by Stuzin96
highlights clinically important issues.
Stuzin JM. Discussion: essays on the facial nerve: Part
I. Microanatomy. Plast Reconstr Surg. 2010;125(3):
890–892.
Marten TJ. Facelift planning and technique. Clin Plast
Surg. 1997;24(2):269–308.
This review article covers the planning, surgical
marking and technical details of two layer facelift
surgery. Details regarding the skin incisions are
emphasized.
Coleman SR. Structural fat grafting. St Louis: Quality
Medical; 2004.
This text is a comprehensive review of the history, basic
science and technical details of fat harvest and fat injection.
Jones BM, Grover R. Avoiding hematoma in
cervicofacial rhytidectomy: a personal 8-year
quest. Reviewing 910 patients. Plast Reconstr Surg.
2004;113:381.
The authors review a large facelift series where the most
common complication of facelift surgery, hematoma, is
addressed. Variables thought to inﬂuence the formation of
hematoma were reviewed, including the use of dressings,
drains, soft tissue adhesives and epinephrine.

Conclusion

1. Stuzin J. Aging face and neck. In: Mathes SJ, ed. Plastic
surgery. Philadelphia: Saunders Elsevier; 2006.
2. Rogers BO. A brief history of cosmetic surgery. Surg
Clin North Am. 1971;51:265.
3. Rogers BO. The development of aesthetic plastic
surgery: a history. Aesthetic Plast Surg. 1976;1:3.
4. Rees TD, Wood-Smith D. Cosmetic facial surgery.
Philadelphia: WB Saunders; 1973.
5. Gonzalez-Ulloa M. The history of rhytidectomy.
Aesthetic Plast Surg. 1980;4:1.
6. Rees TD. Aesthetic plastic surgery. Philadelphia: WB
Saunders; 1980.
7. Barton Jr F. Rhytidectomy. Selected Readings in Plastic
Surgery. 1985;3.
8. Barton Jr F. The aging face/rhytidectomy. Selected
Readings in Plastic Surgery 1987;4.
9. Joseph J. Hangewangenplastik (Melomioplastik). Dtsch
Med Wochenschr 1921;47:287.
10. Lexer E. Die Gesamte Wiederherstellungschirurgie, Vol 2.
Leipzig: JA Barth; 1931:548.
11. Hollander E. Die Kosmetische Chirurgie. In: Joseph M,
ed. Handbuch der Kosmetik. Leipzig: Verlag von Veit;
1912:688.
12. Hollander E. Plastische (Kosmetische) Operation:
Kritische Darstellung ihres gegenwartigen Stands. In:
Klemperer G, Klemperer F, eds. Neue Deutsche Klinik,
Vol. 9. Berlin: Urban and Schwarzenberg; 1932:1–17.
13. Passot R. La chirurgie esthetique des rides du visages.
Presse Med 1919;27:258.
14. Bourguet II J. La disparition chirurgicale des rides et
plis du visage. Bull Acad Med (Paris) 1919;82:183.
15. Bourguet JV. Les hernies graisseuses de l’orbite.
Notre traitement chirurgical. Bull Acad Med (Paris)
1924;92:1270.
16. Bourguet J. Chirurgie esthetique de la face. Les nez
concaves, les rides et les “poches” sous les yeux. Arch
Prov Chir 1925;28:293.
17. Noel A. La chirurgie esthetique: son role social. Paris:
Masson et Cie; 1926.
18. Miller CC. The correction of featural imperfections.
Chicago: Oak Printing Company; 1907.
19. Miller CC. The excision of bag-like folds of skin from
the region about the eyes. Med Brief 1906;34:648.
20. Miller CC. Semilunar excision of the skin at the outer
canthus for the eradication of crow’s feet. Am J
Dermatol. 1907;11:483.
21. Miller CC. Cosmetic surgery: the correction of featural
imperfections. Chicago: Oak Printing Company; 1908.
22. Miller CC. Cosmetic surgery: the correction of featural
imperfections, 2nd ed. Philadelphia: FA Davis; 1925.
23. Kolle FS. Plastic and cosmetic surgery. New York:
Appleton; 1911.
24. Bettman AG. Plastic and cosmetic surgery of the face.
Northwest Med 1920;19:205.

References

207.e1

25. Hunt HL. Plastic surgery of the head, face and neck.
Philadelphia: Lea & Febiger; 1926.
26. Bames H. Truth and fallacies of face peeling and
facelifting. Plast Reconstr Surg 1927;126:86.
27. Aufricht G. Surgery for excess skin of the face and
neck. In: Wallace EB, ed: Transactions of the International
Society of Plastic Surgeons, Second Congress. Edinburgh:
E & S Livingstone; 1960:495–502.
28. Adamson JE, Horton CE, Crawford HH. The surgical
correction of the “turkey gobbler” deformity. Plast
Reconstr Surg 1964;34:598.
29. Millard DR, Pigott RW, Hedo A. Submandibular
lipectomy. Plast Reconstr Surg. 1968;41:513.
30. Pennisi VR, Capozzi A. The transposition of fat in
cervicofacial rhytidectomy. Plast Reconstr Surg.
1972;49:423.
31. Baker TJ, Gordon HL. Adjunctive aids to rhytidectomy.
South Med J. 1969;62:108.
32. Tipton JB. Should the subcutaneous tissue be plicated
in a facelift? Plast Reconstr Surg 1974;54:1.
33. Skoog T. Rhytidectomy – a personal experience and
technique. Presented and demonstrated on live
television at the Seventh Annual Symposium on
Cosmetic Surgery at Cedars of Lebanon Hospital,
Miami, FL, February; 1973.
34. Skoog T. Plastic surgery – new methods and reﬁnements.
Philadelphia: WB Saunders; 1974.
35. Mitz V, Peyronie M. The superﬁcial
musculoaponeurotic system (SMAS) in the parotid and
cheek area. Plast Reconstr Surg. 1976;58:80.
36. Guerrero-Santos J, Espaillat L, Morales F. Muscular
lift in cervical rhytidoplasty. Plast Reconstr Surg.
1974;54:127.
37. Peterson R. Cervical rhytidoplasty – a personal
approach. Presented at the Annual Symposium on
Aesthetic Plastic Surgery, Guadalajara, Mexico,
October; 1974.
38. Connell BF. Cervical lifts: the value of platysma muscle
ﬂaps. Ann Plast Surg. 1978;1:34.
39. Guerrero-Santos J. The role of the platysma muscle in
rhytidoplasty. Clin Plast Surg. 1978;5:29.
40. Guerrero-Santos J. Surgical correction of the fatty fallen
neck. Ann Plast Surg. 1979;2:389.
41. Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast
Surg. 1979;3:529.
42. Lemmon ML, Hamra ST. Skoog rhytidectomy: a
ﬁve-year experience with 577 patients. Plast Reconstr
Surg. 1980;65:283.
43. Kaye BL. The extended neck lift: the “bottom line”.
Plast Reconstr Surg. 1980;65:429.
44. Kaye BL. The extended face-lift with ancillary
procedures. Ann Plast Surg. 1981;6:335.
45. Furnas D. The retaining ligaments of the cheek. Plast
Reconstr Surg. 1989;83:11.
46. Stuzin JM, Baker TJ, Gordon HL. The relationship of
the superﬁcial and deep facial fascias: relevance to
rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441.

References

SECTION I •11.1• Facelift: Principles

47. Mendelson BC. Correction of the nasolabial fold:
extended SMAS dissection with periosteal ﬁxation.
Plast Reconstr Surg. 1992;89:822.
48. Bosse JP, Papillon J. Surgical anatomy of the SMAS at the
malar region. Transactions of the 9th International Congress
of Plastic and Reconstructive Surgery. New York:
McGraw-Hill; 1987:348.
49. Hamra S. The deep plane rhytidectomy. Plast Reconstr
Surg. 1990;86:53.
50. Stuzin JM, Baker TJ, Gordon HL. The extended SMAS
ﬂap in the treatment of the nasolabial fold. Presented
at the American Society for Aesthetic Plastic Surgery
meeting, Chicago, IL; 1990.
51. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS
dissection as an approach to midface rejuvenation. Clin
Plast Surg. 1995;22:295.
52. Mendelson BC. Extended sub-SMAS dissection and
cheek elevation. Clin Plast Surg. 1995;22:325.
53. Barton Jr FE. Rhytidectomy and the nasolabial fold.
Plast Reconstr Surg. 1992;90:601.
54. Owsley Jr JQ. Lifting the malar fat pad for correction
of prominent nasolabial folds. Plast Reconstr Surg.
1993;91:463.
55. Connell BF, Marten TJ. The trifurcated SMAS ﬂap:
three-part segmentation of the conventional ﬂap for
improved results in the midface, cheek and neck.
Aesthetic Plast Surg. 1995;19:415.
56. Aston SJ. Facelift with FAME technique. Presented at
the Thirty- Second Annual Baker Gordon Symposium
on Cosmetic Surgery, Mercy Hospital, Miami, FL,
February; 1998.
57. Tessier P. Facelifting and frontal rhytidectomy. In: Ely
JF, ed. Transactions of the Seventh International Congress
of Plastic and Reconstructive Surgery, Rio de Janeiro;
1980:393.
58. Psillakis JM, Rumley TO, Camargos A. Subperiosteal
approach as an improved concept for correction of the
aging face. Plast Reconstr Surg. 1988;82:383.
59. Ramirez OM, Maillard GF, Musolas A. The extended
subperiosteal facelift: a deﬁnitive soft tissue
remodeling for facial rejuvenation. Plast Reconstr Surg.
1991;88:227.
60. Little JW. Three-dimensional rejuvenation of the
midface: volumetric resculpture by malar imbrication.
Plast Reconstr Surg. 2000;105:267.
61. Fitzgerald R, Graivier MH, Kane M, et al. Update on
facial aging. Aesthetic Surg J. 2010;30(Suppl 1):11S–23S.
62. Kligman LH. Photoaging. Manifestations, prevention,
and treatment. Dermatol Clin. 1986;4(4):517.
63. Raskin E, LaTrenta GS. Why do we age in our cheeks?
Aesthetic Surg J. 2007;27(1):19.
64. Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg. 2007;119:2219–2227.
Anatomic dissections are presented which demonstrate how
the subcutaneous fat of the face is partitioned into multiple,
independent anatomical compartments. In some locations,
the septae dividing the fat compartments are aligned with
retaining ligaments.

207.e2

65. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and
the deep medial fat compartment. Plast Reconstr Surg.
2008;121(6):2107–2112.
Anatomic dissections of deep facial fat are presented (fat
which is deep to the muscles of facial expression). The deep
fat is compartmentalized by septae, creating the deep medial
fat pad, and the suborbicularis oculi fat.
66. Muzaffar AR, Mendelson BC, Adams WP. Surgical
anatomy of the ligamentous attachments of the
lower lid and lateral canthus. Plast Reconstr Surg.
2002;110:873.
67. Lambros V. Models of facial aging and implications for
treatment. Clinics Plast Surg. 2008;35(3):319–327.
68. Gosain AK, Amarante MTJ, Hyde JS, et al. A dynamic
analysis of changes in the nasolabial fold using
magnetic resonance imaging: Implications for facial
rejuvenation and facial animation surgery. Plast
Reconstr Surg. 1996;98:622.
A comparative MRI study demonstrates the changes in
subcutaneous fat which develop with age. The authors
conclude that superﬁcial fat in the cheek becomes ptotic
while the underlying elevators of the lip do not elongate
with age.
68a. Gierloff M, Stöhring C, Buder T, et al. Aging changes
of the midfacial fat compartments: A computed
tomographic study. Plast Reconstr Surg.
2012;129(1):263–273.
69. Stuzin J. Restoring facial shape in facelifting: the role
of skeletal support in facial analysis and midface
soft-tissue repositioning (Baker Gordon Symposium
Cosmetic Series). Plast Reconstr Surg. 2007;119:362.
This review discusses the changes in facial shape which
occur with aging, the surgical means we have to correct
these changes, and alterations which should be made with
different degrees of underlying skeletal support.
69a. Mendelson BC, Freeman ME, Wu W, Huggins RJ.
Surgical anatomy of the lower face: The premasseter
space, the jowl, and the labiomandibular fold. Aesthetic
Plast Surg. 2008;32:185.
70. Coleman SR. Facial recontouring with lipostructure.
Clin Plast Surg. 1997;24(2):347.
A pioneer of facial fat grafting presents early experience
with lipoinjection of the face.
71. Lambros V. Observations on periorbital and midface
aging. Plast Reconstr Surg. 2007;120:1367.
72. Little JW. Volumetric perceptions in midfacial aging
with altered priorities for rejuvenation. Plast Reconstr
Surg. 2000;105:252.
73. Mitz V, Peyronie M. The superﬁcial
musculoaponeurotic system (SMAS) in the parotid
and cheek area. Plast Reconstr Surg. 1976;58:80.
This paper is the ﬁrst description of the superﬁcial
musculoaponeurotic system.
74. Gosain AK, Yousif NJ, Madiedo G, et al. Surgical
anatomy of the SMAS: a reinvestigation. Plast Reconstr
Surg. 1993;92:1254.
75. Barton Jr FE. The SMAS and the nasolabial fold. Plast
Reconstr Surg. 1992;89:1054.

76. Saulis AS, Lautenschlager EP, Mustoe TA.
Biomechanical and viscoelastic properties of skin,
SMAS, and composite ﬂaps as they pertain to
rhytidectomy. Plast Reconstr Surg 2002;110:590.
77. Furnas DW. Festoons, mounds, and bags of the eyelids
and cheek. Clin Plast Sur. 1993;20:367–385.
78. Lowe JB, Cohen M, Hunter RT, Mackinnon SE.
Analysis of the nerve branches to the orbicularis oculi
muscle of the lower eyelid in fresh cadavers. Plast
Reconstr Surg. 2005;116(6):1743.
79. Salinas NL, Jackson O, Dunham B, Bartlett SP.
Anatomical dissection and modiﬁed Sihler stain of the
lower branches of the facial nerve. Plast Reconstr Surg.
2009;124(6):1905–1915.
80. Stuzin JM, Baker TJ, Gordon HL. The relationship
of the superﬁcial and deep facial fascias: relevance
to rhytidectomy and aging. Plast Reconstr Surg.
1992;89:441.
Anatomic dissections conﬁrm the presence of retaining
ligaments previously described by other authors as well as
newly described masseteric ligaments. The authors discuss
the support these structures supply between ﬁxed bone and
deep fascia and the superﬁcial fascia.
81. Mendelson BC, Jacobson SR. Surgical anatomy of the
midcheek; facial layers, spaces, and midcheek
segments. Clin Plast Surg. 2008;35:395–404.
82. Lore JM. An atlas of head and neck surgery, Vol. 2, 2nd
ed. Philadelphia: Saunders; 1973:596–597.
83. Labbe, D, Franco, RG, Nicolas J. Platysma suspension
during neck lift. Plast Reconstr Surg.
2001;117(6):2001–2010.
84. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of
the superﬁcial musculoaponeurotic system and
characterization of the orbitomalar ligament. Ophthal
Plast Reconstr Surg. 1996;12:77.
85. Mendelson BC, Muzaffar AR. Surgical anatomy of the
midcheek and malar mounds. Plast Reconstr Surg.
2002;119:885.
86. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy
of the ligamentous attachments in the temple and
periorbital regions. Plast Reconstr Surg 2000;105:1475.
87. Mustoe, TA, Rawlani V, Zimmerman H. Modiﬁed deep
plane rhytidectomy with a lateral approach to the
neck: an alternative to submental incision and
dissection. Plast Reconstr Surg. 2011;127(1):357–370.
88. Jelks GW, Jelks EB. The inﬂuence of orbital and eyelid
anatomy on the palpebral aperture. Clin Plast Surg.
1993;02:275.
89. Pessa JE, Desvigne LD, Lambros VS, et al. Changes in
ocular globe-to-orbital rim position with age:
implications for aesthetic blepharoplasty of the lower
eyelids. Aesthet Plast Surg 1999;23(5):337.
90. Pessa JE, Chen Y. Curve analysis of the aging orbital
aperture. Plast Reconstr Surg. 2002;109(2):751–755.
91. Pessa JE. An algorithm of facial aging: veriﬁcation of
Lambros’s theory by three-dimensional
stereolithography, with reference to the pathogenesis
of midfacial aging, scleral show, and the lateral
107.

106.

105.

104.

103.

102.

101.

100.

99.

98.

97.

96.

95.

94.

93.

92.

207.e3

suborbital trough deformity. Plast Reconstr Surg.
2000;106:479.
Bartlett SP, Grossman R, Whitaker LA. Age-related
changes of the craniofacial skeleton: an anthropometric
and histologic analysis. Plast Reconstr Surg. 1992;90:592.
Shaw RB, Katzel E, Koltz P, et al. Aging of the
mandible and its aesthetic implications: a three
dimensional CT study. Plat Reconstr Surg.
2010;125:332–342.
Kahn DM, Shaw RB. Aging of the bony orbit: a
three-dimensional computed tomographic study.
Aesthetic Surg J. 2008;28(3):258–264.
Tzafetta K, Terzis J. Essays on the facial nerve: Part I.
Microanatomy. Plast Reconstr Surg. 2010;125(3):
879–889.
The authors review facial nerve anatomy and present
anatomic ﬁndings which conﬁrm extensive arborization
between facial nerve branches. The discussion by Stuzin96
highlights clinically important issues.
Stuzin JM. Discussion: essays on the facial nerve: Part
I. Microanatomy. Plast Reconstr Surg.
2010;125(3):890–892.
Davis RA, Anson BJ, Budinger JM, et al. Surgical
anatomy of the facial nerve and parotid gland based
upon a study of 350 cervicofacial halves. Surg Gynecol
Obstet. 1956;102:385–412.
Agarwal CA, Mendenhall 3rd SD, Foreman KB, et al.
The course of the frontal branch of the facial nerve in
relation to fascial planes: an anatomic study. Plast and
Reconstr Surg. 2010;125:532–537.
Pitanguy I, Ramos AS. The frontal branch of the facial
nerve: the importance of its variations in facelifting.
Plast Reconstr Surg. 1966;38:352–256.
Gosain AK, Sewall SR, Yousif NJ. The temporal branch
of the facial nerve: how reliably can we predict its
path? Plast Reconstr Surg 1997;99:1224.
Stuzin JM, Wagstrom L, Kawamoto HK, et al. The
anatomy and clinical applications of the buccal fat pad.
Plast Reconstr Sur. 1990;85:29.
Nelson DW, Gingrass RP. Anatomy of the mandibular
branches of the facial nerve. Plast Reconstr Surg
1979;64:479.
Ellenbogen R. Pseudo-paralysis of the mandibular
branch of the facial nerve after platysmal face-lift
operation. Plast Reconstr Surg. 1997;63:364–368.
Rohrich R, Taylor NS, Ahmad J, et al. Great auricular
nerve injury, the “subauricular band” phenomenon,
and the periauricular adipose compartments. Plast
Reconstr Surg. 2011;127:835–843.
McKinney P, Katrana DJ. Prevention of injury to the
great auricular nerve during rhytidectomy. Plast
Reconstr Surg. 1980;66:675.
Kruger JK, Rohrich RJ. Clearing the smoke: the
scientiﬁc rationale for tobacco abstention with plastic
surgery. Plast Reconstr Surg. 2001;108:1063–1073.
Rees TD, Liverett DM, Guy CL. The effect of cigarette
smoking on skin ﬂap survival in the facelift patient.
Plast Reconstr Surg. 1984;73:911.

References

SECTION I •11.1• Facelift: Principles

108. Coleman SR. Long-term survival of fat transplants:
controlled demonstrations. Aesthetic Plast Cur.
1995;19:421.
109. Lambros V. Fat injection for aesthetic facial
rejuvenation. Aesthetic Surg J. 1997;17(3):190–191.
110. Guyuron B, Watkins F, Totonchi A. Modiﬁed temporal
incision for facial rhytidectomy: an 18 year experience.
Plast Reconstr Surg. 2005;115(2):609–616.
111. Marten TJ. Facelift planning and technique. Clin Plast
Surg. 1997;24(2):269–308.
This review article covers the planning, surgical marking
and technical details of two layer facelift surgery. Details
regarding the skin incisions are emphasized.
112. Camirand A, Doucet J. A comparison between parallel
hairline incisions and perpendicular incisions when
performing a facelift. Plast Reconstr Surg. 1997;99(1):
10–15.
113. Tonnard PL, Verpaele AM. The MACS-lift short scar
rhytidectomy. St Louis: Quality Medical; 2004.
114. Connell BF, Marten TJ. Deep layer techniques in
cervicofacial rejuvenation. In: Psillakis J, ed. Deep
face-lifting techniques. New York: Thieme; 1994.
115. Baker DC. Minimal incision rhytidectomy (short scar
facelift) with lateral SMASectomy. Aesthet Surg J.
2001;21(1):68–79.
116. Marchac D, Brady J, Chiou P. Facelifts with hidden
scars: the vertical U incision. Plast Reconstr Surg.
2002;109(7):2539–2551.
117. Marten TJ. Facelift. Planning and technique. Clin Plast
Surg. 1997;24(2):269–308.
118. Fogli A. Skin and platysma muscle anchoring. Aesthetic
Plast Surg. 2008;32(3):531–541.
119. Tonnard P, Verpaele A, Monstrey S, et al. Minimal
access cranial suspension lift: a modiﬁed S-lift. Plast
Reconstr Surg 2002;109:2074–2086.
120. Courtiss EH. Suction lipectomy of the neck. Plast
Reconstr Surg. 1985;76:882.
121. Vistnes AM, Souther SG. The anatomical basis for
common cosmetic anterior neck deformities. Ann Plast
Surg. 1979;2:381.
122. DeCastro CC. The anatomy of the platysma muscle.
Plast Reconstr Surg. 1980;66(5):680.
123. Knize DM. Limited incision submental lipectomy and
platysmaplasty. Plast Reconstr Surg. 1998;101:473.
124. Feldman JJ. Neck lift. St Louis: Quality Medical; 2007.
125. Sullivan PK, Freeman MB, Schmidt S. Contouring the
aging neck with submandibular gland suspension.
Aesthetic Surg J. 2006;4:465–471.
126. Singer, K, Sullivan P. Submandibular gland, and
anatomic evaluation and surgical approach to
submandibular gland resection for facial rejuvenation.
Plast Reconstr Surg 2003;112:1150–1154.
127. Zins J, Fardo D. The “anterior-only” approach to neck
rejuvenation: an alternative to facelift surgery. Plast
Reconstr Surg. 2005;115(6):1761–1768.
128. Gradinger GP. Anterior cervicoplasty in the male
patient. Plast Reconstr Surg 2000;106:1146.
129. Coleman SR. Structural fat grafting. St Louis: Quality
Medical; 2004.

207.e4

This text is a comprehensive review of the history, basic
science and technical details of fat harvest and fat injection.
130. Trepsat F. Volumetric facelifting. Plast Reconstr Surg.
2001;108(5):1358.
131. Roberts TL, Pozner JN, Ritter E. The RSVP facelift: A
highly vascular ﬂap permitting safe, simultaneous,
comprehensive facial rejuvenation in one operative
setting. Aesthetic Plast Surg. 2000;24:313.
132. Hester TR, Codner MA, McCord CD. Subperiosteal
malar cheeklift with lower lid blepharoplasty. In: Eyelid
surgery: principles and techniques. New York: LippincottRaven; 1995.
133. Moelleken B. The superﬁcial subciliary cheeklift, a
technique for rejuvenating the infraorbital region and
nasojugal groove: a clinical series of 71 patients. Plast
Reconstr Surg. 1999;104:1863.
134. Le Louarn C. The concentric malar lift: malar and
lower eyelid rejuvenation. Aesthetic Plast Surg.
2004;28(6):359–372.
135. Hester Jr TR, Codner MA, McCord CD, et al. Evolution
of technique of the direct transblepharoplasty
approach for the correction of lower lid and midfacial
aging: maximizing results and minimizing
complications in a 5-year experience. Plast Reconstr
Surg. 2000;105:393.
136. Austin HW. The lip lift. Plast Reconstr Surg. 1986;77:990.
137. Austin HW, Weston GW. Rejuvenation of the aging
mouth. Clin in Plast Surg. 1992;19:511.
138. Baker DC, Aston SJ, Guy CL, et al. The male
rhytidectomy. Plast Reconstr Surg. 1977;60:514.
139. Baker DC, Stafani W, Dhiu ES. Reducing the incidence
of hematoma requiring surgical evacuation following
male rhytidectomy: a 30 year review of 985 cases. Plast
Reconstr Surg. 2005;116(7):1973–1985.
140. Grover R, Jones BM, Waterhouse N. The prevention of
haematoma following rhytidectomy: a review of 1078
facelifts. Br J Plast Surg. 2004;54:481.
141. Jones BM, Grover R. Avoiding hematoma in
cervicofacial rhytidectomy: a personal 8-year quest.
Reviewing 910 patients. Plast Reconstr Surg.
2004;113:381.
The authors review a large facelift series where the most
common complication of facelift surgery, hematoma, is
addressed. Variables thought to inﬂuence the formation of
hematoma were reviewed, including the use of dressings,
drains, soft tissue adhesives and epinephrine.
142. Baker DC, Conley J. Avoiding facial nerve injuries in
rhytidectomy. Anatomic variations and pitfalls. Plast
Reconstr Surg. 1979;64:781.
143. Zoumalan RA, Rosenberg DB. Methicillin-resistant
staphylococcus aureus-positive surgical site infections
in face-lift surgery. Arch Facial Plast Surg.
2008;10(2):116–123.
144. Ullman Y, Levy Y. Superextended facelift: our
experience with 3,580 patients. Ann Plast Surg.
2003;52:8.
145. Matarasso A, Elkwood A, Rankin M, Elkowitz M.
National Plastic Surgery Survey: face lift techniques
and complications. Plast Reconstr Surg.
2000;106(5):1185–1195.

Aesthetic Surgery of the Face

In its pure form, the subcutaneous, skin-only facelift has a limited
effect on the position of heavier deep tissue.
In SMAS plication, a skin ﬂap is created with suture manipulation
of the superﬁcial fat and the underlying SMAS/platysma.
In loop suture techniques (MACS lift), a skin ﬂap is created with
long suture loops taking multiple bites of superﬁcial fat and
platysma – ﬁxed to a single point on the deep temporal fascia.
The supraplatysma plane creates a single ﬂap of skin and
superﬁcial fat mobilized and advanced along the same vector.
SMASectomy involves a skin ﬂap plus excision of superﬁcial fat
and SMAS from the angle of the mandible to the malar
prominence, with direct suture closure of the resulting defect.
A SMAS ﬂap raised with skin attached (deep plane) creates a ﬂap
of SMAS/platysma, superﬁcial fat and skin, all mobilized and
advanced along the same vector.
A separate SMAS ﬂap (dual plane) creates two ﬂaps, the skin ﬂap
and the superﬁcial fat/SMAS/platysma, which are advanced along
two different vectors.
The subperiosteal lift involves dissection against bone, with
mobilization and advancement of all soft tissue elements.

2013, Elsevier Inc. All rights reserved.

©

In the previous chapter, the generic subcutaneous “skin-only”
facelift was described. However, as reviewed in Chapter 6, the
anatomy of facial aging is a complex process involving all
layers of the face from the skin through to the bone. Logically,
surgical rejuvenation of the aging face should address all or
most of these tissue layers. To this end, rejuvenation of the
skin is reviewed in Chapter 5. Within the soft tissue of the
face, the two principle age-related changes are loss of midface
volume and soft tissue descent. (Surgical methods to add
volume are described in Chapters 14 and 15.) With regard to
soft tissue descent, a host of surgical approaches have been

Introduction

䊏

䊏

䊏

䊏

䊏

䊏

䊏

䊏

SYNOPSIS

Richard J. Warren

The “skin-only” facelift (Fig. 11.2.1) is used to tighten loose
facial skin by advancing a random pattern skin ﬂap and
removing the excess. By deﬁnition, there is nothing done to
the deep facial tissues. A tried and true technique, this method
can be effective when the only signiﬁcant problem is loose
skin. For example, some patients with very thin faces and little
or no subcutaneous fat may present with loose skin only. It is
also useful in secondary or tertiary situations where deep
tissues have previously been repositioned and the presenting
problem is a recurrence of skin laxity. In that setting, a short
scar approach will often sufﬁce. Advantages of the skin-only
facelift include its simplicity, a rapid postoperative recovery,
and the use of a dissection plane which does not risk damage
to the facial nerve or other deep structures. Disadvantages
include: a minimal effect on underlying facial shape and the
inherent disadvantage that skin is an elastic structure which
will stretch when tension is applied. Therefore, the longevity
of effect is in question, especially when the skin is used to
reposition heavy facial tissues. Unfortunately, if the surgeon
increases skin tension in a misguided attempt to reposition
ptotic deep tissue, the shape of the face can be distorted. Skin
tension will ﬂatten facial shape, negating the rounded contours of youth. Also patients in the facelift age group have
usually lost elasticity in their skin and therefore, with tension,
are prone to a stretched look with wrinkles re-oriented in
abnormal directions. Lastly, excess skin tension at the incision

Subcutaneous facelift

described. In this chapter the standard methods available to
elevate and rearrange the deep soft tissues of the face are
outlined; in the coming chapters, they will be described in
detail by authors who developed these techniques, or by
authors who use them routinely. The subcutaneous facelift
is included here for comparison purposes, although in its
classic form, there is no attempt to address the deeper tissues
of the face.

Facelift: Introduction to deep tissue techniques

11.2

SECTION I

After surgeons learned to raise a large random pattern skin
ﬂap, it became apparent that facial shape could be changed
by using sutures to manipulate the underlying soft tissue.1
Suture plication creates an infolding of the superﬁcial fat,
drawing fat from the lower in the face up to the point
where the sutures are placed. Areas of ﬁxed tissue, such as the
ﬁxed SMAS (Fig. 11.2.2) over the parotid gland are less
movable, and can act as an anchoring point; anterior to the
parotid, mobile tissues can be easily manipulated.2 Multiple
sutures with customized vectors can be used allowing reshaping of the superﬁcial facial fat. The technique is relatively easy
to master; it can be customized for the individual case, and
can be modiﬁed intraoperatively by removing and replacing
sutures as necessary. The superﬁcial fat can be shifted in a
different direction than the skin. When plication sutures are
placed properly, there is little or no risk to branches of the
facial nerve. Proponents of plication claim long-lasting results
without the need for invasive and potentially dangerous dissections.3 The primary concern with plication is the potential
loss of effect if sutures cut through the soft tissue (the “cheese
wire” effect). Another concern is that the degree of improvement may be limited by the tethering effect of the retaining

SMAS plication

line can cause malposition of the hairline, alopecia, distorted
earlobes, widened scars, and the potential for skin ﬂap
necrosis.

Fig. 11.2.1 Subcutaneous facelift.

209

A variation of suture plication is the loop suture method
(Fig. 11.2.3), for which the main variant is the MACS
lift (minimal access cranial suspension). This procedure,
which itself was derived from the “S-lift”, relies on long
suture loops which take multiple small bites of soft tissue.4,5
Some of these bites are strategically placed into the SMAS
and platysma. The loop sutures are ﬁxated to the deep
temporal fascia at a point just superior to the zygomatic
arch and anterior to the ear. The theoretical explanation
for the efﬁcacy of this technique relates to the use of multiple
bites of tissue which the developers of the technique
feel creates “microimbrications” of the superﬁcial fat and
SMAS.5 Anteriorly, a third suture can be placed to advance
the malar fat pad, although the fat pad is not surgically
released and its repositioning depends on its own intrinsic
mobility. Treatment of the neck usually involves closed
liposuction. Proponents of this technique recommend a nearly
vertical vector for the skin ﬂap, with a short scar incision.
The advantages with this technique are similar to those of
plication, although proponents point to the added beneﬁt of
using a more ﬁrm point of ﬁxation (deep fascia) and the

Loop sutures (MACS lift)

ligaments which in this technique are not released. When the
subcutaneous fat is fragile, suture ﬁxation may fail, and plication may have a limited effect in patients with heavy jowls
and ptotic tissues in the neck.

Subcutaneous facelift

The supra-platysmal plane facelift (Fig. 11.2.4) involves a deep
subcutaneous dissection carried out immediately superﬁcial
to the SMAS and platysma. Originally described as the
extended supra-platysmal (ESP) dissection plane, this procedure raises the superﬁcial fat and skin as a single layer, leaving
the SMAS layer untouched. The zygomatic ligaments are
released as dissection of the superﬁcial facial fat extends over
the malar prominence as far forward as the nasolabial folds.
The theory behind this technique is the belief that the superﬁcial fat is a ptotic structure, but the underlying SMAS and
platysma are not.6 After the ﬂap has been raised, the fat on
the underside of the ﬂap can by contoured and sutures can
also be placed from this fat to underlying ﬁxation points. This
technique provides good mobilization because ligaments are

Supra-platysmal plane facelift

improved effect of micro-imbrications. Disadvantages are the
same as SMAS plication: potential loss of effect if the sutures
pull through, the lack of ligamentous release and concerns
about the effectiveness of sutures holding heavy jowls and
ptotic neck tissues against gravity. Lastly, surgeons must
address the tendency for loop sutures to cause fat to bunch
up, potentially leaving bulges which can be visible through
the skin.

In the SMASectomy procedure (Fig. 11.2.5), a strip of SMAS
and overlying fat is removed with direct suture closure of the
resulting defect.7 The excised strip angles obliquely across the
cheek from the angle of the mandible to the lateral malar
eminence at the edge of the malar fat pad. The procedure has
been described after using either a conventional facelift incision or a short scar approach. Advantages include the fact that
the location of traction is close to the ptotic lower facial tissues,
and therefore potentially more effective than a SMAS ﬂap
raised at a higher level. The technique allows for skin and
SMAS to be moved along different vectors. By suturing two
opposing freshly cut edges, ﬁxation is potentially more secure
than plication alone. The cut edges being sutured have not
been undermined, potentially making them more viable, and
the resulting ﬁxation more secure than undermined ﬂaps.

Subcutaneous facelift with SMAS
removal (SMASectomy)

released, and it produces a thick very robust ﬂap. Also, with
no surgical penetration of the underlying SMAS, there is theoretically no risk to branches of the facial nerve. Concerns
about this method are that the ﬂap is unidirectional (the skin
and fat move en bloc), and the fact that repositioning the
weight of this ﬂap depends primarily on skin tension at the
suture line.

Fig. 11.2.3 Subcutaneous ﬂap with loop sutures (MACS lift).

SECTION I •11.2• Facelift: Introduction to deep tissue techniques

Fig. 11.2.2 Subcutaneous ﬂap with SMAS plication.

210

Tord Skoog, in 1974, published his method of raising skin,
subcutaneous fat, and the SMAS as a single layer which
created a thick robust ﬂap with excellent blood supply. It also
contained a stretch-resistant structure (the SMAS), with the
promise of a long-lasting result.8 Originally, there was limited
improvement in the anterior face with little or no change to
the nasolabial fold. This lack of anterior movement was
later found to be due to tethering of the SMAS to the lip elevators: zygomaticus major and minor, and levator labii superioris.9 In order to overcome some of these shortcomings,
multiple variations have been developed (Barton: high SMAS;
Hamra: deep plane) (Fig. 11.2.6).10–13 The skin is normally
raised for only 2–3 cm anterior to the tragus, the SMAS is then

SMAS ﬂap with skin attached
(deep plane facelift)

Compared with a SMAS ﬂap, the procedure is more rapid,
with less theoretical risk to the facial nerve because there is
no deep plane dissection. Proponents feel that ﬁxation is effective because the location of the SMASectomy resection is
roughly at the junction of the mobile SMAS, which allows
mobile tissue to be sutured to the ﬁxed SMAS. Disadvantages
include the possibility of injuring a facial nerve branch (if the
SMAS removal is done too deeply) and the lack of any ligamentous release, which may limit the movement of certain
tissues such as the malar fat pad.

A

Area of skin and
subcutaneous fat
elevation in extended
supraplatysmal plane (ESP)

B

SMAS/platysma

SMAS/platysma

211

Surgeons wishing to move the SMAS and subcutaneous fat in
a different direction than the skin arrived at the concept of
two separate ﬂaps: the random pattern facelift skin ﬂap and
an SMAS ﬂap carrying the superﬁcial fat (Fig. 11.2.7). Multiple
variations of this popular concept have been developed with
terminology introduced by different authors (extended SMAS:
Stuzin; high SMAS: Connell and Marten; FAME: Aston).14–22
As in plication, MACS and SMASectomy, proponents of this
method feel that that moving the skin and subcutaneous soft

Subcutaneous facelift with separate SMAS
ﬂap (dual plane facelift)

incised, and the rest of the dissection is done deep to the
SMAS as far as the zygomaticus major muscle from which the
SMAS is released. The skin and subcutaneous fat are left
attached to the SMAS and the entire ﬂap is then advanced and
ﬁxated as the surgeon desires. Advantages of this technique
are the robustness and physical strength of the ﬂap, and the
requirement for only one plane of dissection. Ligaments are
also thoroughly released. Certain variations of the technique
also allow for repositioning of the malar fat pad.10,13
Disadvantages include the inherent risk of dissecting under
the SMAS with the potential for damage to the facial nerve.
Also, these procedures are “monobloc” techniques where the
skin, subcutaneous fat and SMAS are generally moved in one
direction.

Fig. 11.2.4 Supra-platysmal plane (ESP lift).

ESP dissection

Superficial fat

Supra-platysmal plane facelift

tissues along different vectors will result in a more accurate
reversal of the aging process. Typically, the deep tissue ﬂap is
shifted more vertically than the skin ﬂap. A second advantage
is the ability to reposition deep facial tissues by mobilizing
and ﬁxating the SMAS ﬂap internally without the need to rely
on skin tension for support. Theoretically, the disadvantages
of excess skin tension are therefore avoided. Also, as in the
deep plane technique, ligaments are surgically released,
resulting in excellent mobilization and advancement for the
SMAS and overlying fat. Disadvantages relate to a more timeconsuming procedure because two different surgical planes
are developed. In addition, these two planes introduce the
inherent problems of each: potential damage to deep structure
when doing the SMAS ﬂap dissection, and potential problems
with the skin ﬂap if it is too thinly dissected or if it is placed
on too much tension. In a thin patient, both layers can be quite
thin, which increases the technical demands placed on the
surgeon.

Fig. 11.2.5 Subcutaneous ﬂap with SMAS excision (SMASectomy).

Undermining posterior border
of platysma for advancement
to mastoid

Resection is at interface of
fixed and mobile SMAS.
Width of resection
determined by SMAS laxity
and desired de-bulking

Multiple techniques have been devised to elevate and reposition tissues in the aging face. In the following chapters, leading
surgeons will address two issues: ﬁrst, they describe how they
handle the deep tissues of the face, and second, they explain
the logic behind their own particular technique. This is a ﬁeld
where personal opinions are strong, and at the time of this
writing, the greatest difference of opinion among facelift surgeons relates to the various methods used to manipulate deep
facial tissue. All surgeons have been striving for the same
objective: a procedure which will be effective, have a relatively a long-lasting result, and a high margin of safety. Over
the years, a number of studies have been done to compare
different facelift techniques.31–40 In order to assess the available
data, a systematic review of the world literature over a 60-year
period was made in an attempt to locate reliable studies which
could attest to the efﬁcacy and safety of one method over
another.41 Despite this exhaustive review, no clear indication
could be found that any one facelift technique was superior
to the others. Therefore, surgeons must continue to use their
own judgment for technique selection based on their patient’s
needs, balanced against their personal convictions about
quality, longevity and safety.

Summary

Paul Tessier, in 1979, ﬁrst presented his concept for a subperiosteal approach using craniofacial principles to elevate facial
tissue.23,24 Variations were developed,25,26 but it was not until
the introduction of the endoscope that surgeons widely
adopted this concept (Fig. 11.2.8).
Approaching from the temple, the midface can be dissected
in either the subperiosteal27,28 or supra-periosteal plane.29,30
Added exposure can be achieved with a lower eyelid or an
intra-oral incision. The advantages are a dissection which is
deep to all vital structures, a relatively short incision, and
harmonious lifting of the midface and lateral brow. There is
little or no tension on the skin thus eliminating problems from
excess tension on the skin. Some surgeons feel this technique
is uniquely advantageous for the patient requiring improvement in the infraorbital midface in conjunction with lateral
browlifting. The younger patient who requires midface
improvement without skin tightening has been proposed as a
good candidate for this technique. Disadvantages of subperiosteal lifting include the additional technology and equipment
involved, a limited effect in the lower face/neck region and
limited effect on superﬁcial structures, particularly loose skin.
Furthermore, the early aging midface which seems suited to
this technique may in fact be due to volume loss, a problem
which can be correctable with less invasive procedures such
as fat grafting.

Subperiosteal facelift

SECTION I •11.2• Facelift: Introduction to deep tissue techniques

Lateral SMASectomy
extends from tail of
parotid to lateral
canthus

212

Fig. 11.2.6 SMAS ﬂap with skin attached (deep plane facelift).

SMAS incision

Upper lateral
corner of SMAS
remains attached
to skin

Subcutaneous
dissection 4cm

Subgaleal
dissection

Marginal mandibular
branch of facial nerve

Dissection from
beneath SMAS
over zygomaticus
major thus releasing
restraint of investing
fascia

Temporal branch,
facial nerve

Subcutaneous dissection of neck from
mastoid to midline superficial to platysma

Only skin expected
to be removed is undermined

Subcutaneous tunnel
superior to arch

Summary

213

Fig. 11.2.8 Subperiosteal facelift.

Submental approach

Intraoral approach

Fronto-temporal approach
Subcutaneous
dissection

SECTION I •11.2• Facelift: Introduction to deep tissue techniques

Fig. 11.2.7 Subcutaneous facelift with separate SMAS ﬂap (dual plane facelift).

214

BF

Intraoral
incision

SOOF

6. Hoefﬂin SM. The extended supraplatysmal plane (ESP)
face lift. Plast Reconstr Surg. 1998;101:494.
The author presents his logic behind using a facelift ﬂap,
which contains skin and all the subcutaneous fat down to,
but not including the SMAS. The technique is described
in detail and the results with a series of 300 patients are
presented. There was high patient satisfaction reported, no
nerve injuries and relatively rapid recovery.
7. Baker D. Lateral SMASectomy. Plast Reconstr Surg.
1997;100(2):509.
The author presents his personal evolution in arriving at the
SMASectomy technique, describing his logic in doing so,
and reports a series of 1500 cases over 5-year period. One
transient buccal branch injury was encountered. The author
feels this technique affords a safe, effective technique, but
acknowledges that other techniques also produce excellent
results.
8. Skoog T. Plastic surgery. Philadelphia: WB Saunders;
1974.
In this classic text, the author describes the ﬁrst technique to
utilize the sub-SMAS plane to elevate ptotic facial tissue.
Illustrations effectively convey the basics of this new
technique.
13. Barton FE Jr, Hunt J. The high-superﬁcial aponeurotic
system technique in facial rejuvenation: an update. Plast
Reconstr Surg. 2003;112:1910.
This is a follow-up of a previous publication by Barton, which
described his variation for a SMAS-based facelift technique
called the high SMAS technique. In this paper, 267 patient

The authors report that in 1999, they modiﬁed the previously
described S-lift to include improved suture ﬁxation and soft
tissue elevation, which they named the MACS lift, an
acronym for minimal access cranial suspension. Two long
loop sutures are used to elevate facial soft tissue with ﬁxation
to the deep temporal fascia above the zygomatic arch and a
third suture is used for the malar fat pad in the extended
version of the procedure. A total of 88 patients over 20
months were presented with a low complication rate. The
operative technique is described in detail.

5. Tonnard P, Verpaele A, Monstrey S, et al. Minimal
access cranial suspension lift: a modiﬁed S-Lift. Plast
Reconstr Surg. 2002;109:2074.

3. Berry MG, Davies D. Platysma-SMAS plication Facelift.
J Plast Reconstr Aesthetic Surg. 2010;63(5):793–800.
The authors describe their logic for using soft tissue plication
and describe their particular method, called the PSP lift
(platysma SMAS plication). A series of 117 consecutive
patients is reported, all of whom were followed objectively
with a 5-point scale. There was excellent improvement with a
low complication rate: 3.4% hematoma and 3.4% transient
facial nerve palsies.

215

This paper presents the results of a systematic review
that assessed all studies in the English language literature
from 1950 until 2009 in which there was a comparison
of facelift techniques. There were 57 studies identiﬁed;
only 10 of these directly compared the efﬁcacy of different
facelift techniques. The study found there to be a lack of
quality data regarding the efﬁcacy and safety of facelift
techniques and concluded that there was no evidence
to support the use of any one facelift technique over
another.

41. Chang S, Pusic A, Rohrich RJ. A systematic review of
comparison of efﬁcacy and complications rates among
face-lift techniques. Plast Reconstr Surg. 2011;127(1):
423–433.

The authors’ experience with subperiosteal facelift techniques
is reviewed. Pertinent points include: (1) using an
interconnected subperiosteal approach which involve the
entire zygomatic arch; (2) utilizing upward pull of the
muscles of facial expression to elevate the mouth; (3) keeping
the dissection deep in the temple to protect the temporal
branch, and (4) utilizing the temporal fascia as a lifter and
anchoring point.

28. Ramirez OM, Maillard GF, Musolas A. The extended
subperiosteal face lift: A deﬁnitive soft-tissue
remodeling for facial rejuvenation. Plast Reconstr Surg.
1991;88:227.

records were reviewed using the nasolabial fold as an
indicator of surgical result 6 months after surgery. Using this
hard endpoint, improvement was almost universally achieved
with a low complication rate. Recommendations are made as
to the extent of dissection required based on depth of the
nasolabial fold.
17. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS
dissection as an approach to midface rejuvenation. Clin
Plast Surg. 1995;22(2):295.
This review article outlines the authors’ understanding
of facial anatomy as it pertains to facelift surgery, their
understanding of facial aging, and it describes their surgical
procedure in detail. The procedure is called the extended
SMAS dissection because it involves raising the malar fat
pad in conjunction with the SMAS ﬂap. The authors
emphasize the importance of ﬂap ﬁxation in order to create
a long lasting result.
18. Marten TJ. High SMAS facelift: combined single ﬂap
lifting of the jawline, cheek, and midface. Clin Plast
Surg. 2008;35(4):569–603.
The review article outlines the author’s logic in utilizing
a two layer facelift, emphasizing that skin has a covering
function, and that deep tissue manipulation is necessary for
facial reshaping. The high SMAS facelift is described in
detail, with emphasis on skin incisions, and the proper
selection of vectors.

Access the complete references list online at http://www.expertconsult.com

Summary

1. Aufricht G. Surgery for excess skin of the face. In:
Transactions of the Second International Congress of Plastic
and Reconstructive Surgery. Edinburgh: E& S Livingstone;
1960.
2. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS
plication for the treatment of prominent
nasomandibular folds and restoration of normal cheek
contour. Plast Reconstr Surg. 1995;96(6):1279–1287.
3. Berry MG, Davies D. Platysma-SMAS plication Facelift.
J Plast Reconstr Aesthetic Surg. 2010;63(5):793–800.
The authors describe their logic for using soft tissue plication
and describe their particular method, called the PSP lift
(platysma SMAS plication). A series of 117 consecutive
patients is reported, all of whom were followed objectively
with a 5-point scale. There was excellent improvement with
a low complication rate: 3.4% hematoma and 3.4% transient
facial nerve palsies.
4. Saylan Z. The S-lift: less is more. Aesthetic Surg J.
1999;19:406.
5. Tonnard P, Verpaele A, Monstrey S, et al. Minimal
access cranial suspension lift: a modiﬁed S-Lift. Plast
Reconstr Surg. 2002;109:2074.
The authors report that in 1999, they modiﬁed the previously
described S-lift to include improved suture ﬁxation and soft
tissue elevation, which they named the MACS lift, an
acronym for minimal access cranial suspension. Two long
loop sutures are used to elevate facial soft tissue with ﬁxation
to the deep temporal fascia above the zygomatic arch and a
third suture is used for the malar fat pad in the extended
version of the procedure. A total of 88 patients over 20
months were presented with a low complication rate. The
operative technique is described in detail.
6. Hoefﬂin SM. The extended supraplatysmal plane (ESP)
face lift. Plast Reconstr Surg. 1998;101:494.
The author presents his logic behind using a facelift ﬂap,
which contains skin and all the subcutaneous fat down to,
but not including the SMAS. The technique is described
in detail and the results with a series of 300 patients are
presented. There was high patient satisfaction reported, no
nerve injuries and relatively rapid recovery.
7. Baker D. Lateral SMASectomy. Plast Reconstr Surg.
1997;100(2):509.
The author presents his personal evolution in arriving at the
SMASectomy technique, describing his logic in doing so,
and reports a series of 1500 cases over 5-year period. One
transient buccal branch injury was encountered. The author
feels this technique affords a safe, effective technique, but
acknowledges that other techniques also produce excellent
results.
8. Skoog T. Plastic surgery. Philadelphia: WB Saunders;
1974.
In this classic text, the author describes the ﬁrst technique
to utilize the sub-SMAS plane to elevate ptotic facial tissue.
Illustrations effectively convey the basics of this new
technique.

References

215.e1

9. Barton FE Jr. The SMAS and the nasolabial fold. Plast
Reconstr Surg. 1992;89:1054.
10. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg.
1992;90:1.
11. Hamra ST. The zygorbicular dissection in composite
rhytidectomy: an ideal midface plane. Plast Reconstr
Surg. 1998;102:1646.
12. Barton FE Jr. Rhytidectomy and the nasolabial fold.
Plast Reconstr Surg. 1992;90:601.
13. Barton FE Jr, Hunt J. The high-superﬁcial aponeurotic
system technique in facial rejuvenation: an update.
Plast Reconstr Surg. 2003;112:1910.
This is a follow-up of a previous publication by Barton, which
described his variation for a SMAS-based facelift technique
called the high SMAS technique. In this paper, 267 patient
records were reviewed using the nasolabial fold as an
indicator of surgical result 6 months after surgery. Using this
hard endpoint, improvement was almost universally achieved
with a low complication rate. Recommendations are made
as to the extent of dissection required based on depth of the
nasolabial fold.
14. Owsley JQ. Platysma-fascial rhytidectomy. Plast Reconstr
Surg. 1977;60:843.
15. Connell BF. Eyebrow, face, and neck lifts for males.
Clin Plast Surg. 1978;5(1):15–28.
16. Connell BF, Marten TJ. The trifurcated SMAS ﬂap:
three-part segmentation of the conventional ﬂap for
improved results in the midface, cheek, and neck.
Aesthetic Plast Surg. 1995;19(5):415–420.
17. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS
dissection as an approach to midface rejuvenation. Clin
Plast Surg. 1995;22(2):295.
This review article outlines the authors’ understanding
of facial anatomy as it pertains to facelift surgery, their
understanding of facial aging, and it describes their surgical
procedure in detail. The procedure is called the extended
SMAS dissection because it involves raising the malar
fat pad in conjunction with the SMAS ﬂap. The authors
emphasize the importance of ﬂap ﬁxation in order to create
a long lasting result.
18. Marten TJ. High SMAS facelift: combined single ﬂap
lifting of the jawline, cheek, and midface. Clin Plast
Surg. 2008;35(4):569–603.
The review article outlines the author’s logic in utilizing
a two layer facelift, emphasizing that skin has a covering
function, and that deep tissue manipulation is necessary for
facial reshaping. The high SMAS facelift is described in
detail, with emphasis on skin incisions, and the proper
selection of vectors.
19. Mendelson BC. Correction of the nasolabial fold
extended SMAS dissection with periosteal ﬁxation. Plast
Reconstr Surg. 1992;89:822.
20. Aston SJ. The FAME Technique. Presented at the Aging
Face Symposium. Waldorf Astoria Hotel, New York, NY,
1993.
21. Aston SJ, Walden J. Facelift with SMAS technique and
FAME. In: Aston SJ, Steinbrech DS, Walden JL, eds.
Philadelphia: Saunders Elsevier; 2009.

References

41.

40.

39.

38.

37.

36.

35.

34.

33.

ﬁxation in face lifts. Plast Reconstr Surg. 1977;60:
851–859.
Webster RC, Smith RC, Papsidero MJ, et al. Comparison
of SMAS plication with SMAS imbrication in face
lifting. Laryngoscope. 1982;92:901–912.
Ivy EJ, Lorenc ZP, Aston SJ. Is there a difference?
A prospective study comparing lateral and standard
SMAS face lifts with extended SMAS and composite
rhytidectomies. Plast Reconstr Surg. 1996;98:1135–1147.
Kamer FM, Frankel AS. SMAS rhytidectomy versus
deep plane rhytidectomy: An objective comparison.
Plast Reconstr Surg. 1998;102:878–881.
Becker FF, Bassichis BA. Deep-plane face-lift vs
superﬁcial musculoaponeurotic system plication
face-lift: A comparative study. Arch Facial Plast Surg.
2004;6:8–13.
Zager WH, Dyer WK. Minimal incision facelift.
Facial Plast Surg. 2005;21:21–27.
Prado A, Andrades P, Danilla S, et al. A clinical
retrospective study comparing two short-scar face
lifts: Minimal access cranial suspension versus
lateral SMASectomy. Plast Reconstr Surg. 2006;117:
1413–1427.
Antell DE, Orseck MJ. A comparison of face lift
techniques in eight consecutive sets of identical twins.
Plast Reconstr Surg. 2007;120:1667–1673.
Alpert BS, Baker DC, Hamra ST, et al. Identical twin
face lifts with differing techniques: A 10-year follow-up.
Plast Reconstr Surg. 2009;123:1025–1036.
Chang S, Pusic A, Rohrich RJ. A systematic review of
comparison of efﬁcacy and complications rates among
face-lift techniques. Plast Reconstr Surg. 2011;127(1):
423–433.
This paper presents the results of a systematic review that
assessed all studies in the English language literature from
1950 until 2009 in which there was a comparison of facelift
techniques. There were 57 studies identiﬁed; only 10 of these
directly compared the efﬁcacy of different facelift techniques.
The study found there to be a lack of quality data regarding
the efﬁcacy and safety of facelift techniques and concluded
that there was no evidence to support the use of any one
facelift technique over another.

SECTION II •11.2• Facelift: Introduction to deep tissue techniques

22. Warren RJ. The oblique SMAS with malar fat pad
elevation. Presented at the Canadian Society for
Aesthetic Plastic Surgery 29th Annual Meeting, Toronto,
Ontario, 2002.
23. Tessier P. Facial lifting and frontal rhytidectomy. In:
Fonseca J, ed. Transactions of the VII International
Congress of Plastic and Reconstructive Surgery. Rio de
Janeiro: Cartgraf; 1979:393–396.
24. Tessier P. The subperiosteal facelift. Ann Chir Plast
Esthet. 1989;34:193.
25. Psillakis JM, Rumley TO, Camargos A. Subperiosteal
approach as an improved concept for correction of the
aging face. Plast Reconstr Surg. 1988;82:383.
26. De la Plaza R, Valiente E, Arroyo JM. Supraperiosteal
lifting of the upper two-thirds of the face. Br J Plast
Surg. 1991;44:325.
27. Hinderer UT. The sub-SMAS and subperiosteal
rhytidectomy of the forehead and middle third of the
face: a new approach to the aging face. Facial Plast Surg.
1992;8:18.
28. Ramirez OM, Maillard GF, Musolas A. The extended
subperiosteal face lift: A deﬁnitive soft-tissue
remodeling for facial rejuvenation. Plast Reconstr Surg.
1991;88:227.
The authors’ experience with subperiosteal facelift techniques
is reviewed. Pertinent points include: (1) using an
interconnected subperiosteal approach which involve the
entire zygomatic arch; (2) utilizing upward pull of the
muscles of facial expression to elevate the mouth; (3) keeping
the dissection deep in the temple to protect the temporal
branch, and (4) utilizing the temporal fascia as a lifter and
anchoring point.
29. Byrd HS, Andochick SE. The deep temporal lift: a
multiplanar, lateral brow, temporal, and upper face lift.
Plast Reconstr Surg. 1996;97:928.
30. Hunt JA, Byrd HS. The deep temporal lift: a multiplanar
lateral brow, temporal, and upper face lift. Plast Reconstr
Surg. 2002;110(7):1793.
31. Tipton JB. Should the subcutaneous tissue be plicated in
a face lift? Plast Reconstr Surg. 1974;54:1–5.
32. Rees TD, Aston SJ. A clinical evaluation of the
results of submusculoaponeurotic dissection and

215.e2

Aesthetic Surgery of the Face

Allows multi-vector traction to individualise the facelift.
Sutures placed closer to the point of lift have the best effect.
Delivers a good malar auto-augmentation.
Reduced downtime.
Safe and ideal for thin, attenuated SMAS layers or repeat facelifts.

2013, Elsevier Inc. All rights reserved.

©

As summarized in Chapter 11.2, facelifting has evolved appreciably from the simple, skin-only procedures of the early 20th
century. Today, we have an almost bewildering array of techniques and tissue planes from which to choose. While each
proponent may provide convincing support for their particular technique, most are in agreement about the central role of
the superﬁcial musculoaponeurotic system (SMAS), originally highlighted by Skoog in the 1970s1 and detailed in Mitz
and Peyronie’s now classic treatise.2 The question remains
precisely what to do with the SMAS in order to balance
invasiveness, and thus tissue trauma from which the patient
must recover, in addition to potential complications, and its
longevity.
The SMAS may be simply elevated and advanced,3 dissected at various planes,4,5 rolled upon itself with mesh to
augment malar projection,6 excised,7 or plicated.8 The multiplicity of techniques bears testament to the fact that a universal and standard procedure eludes us still. There is also some
evidence that there may be little actual difference, in either
the short9 or the long term, between techniques of varying
aggressiveness10,11; therefore, procedures with less inherent
risk to important structures, such as the facial nerve may
be safer. Problems noted include inconsistent results, a

Introduction

䊏

䊏

䊏

䊏

䊏

SYNOPSIS

Dai M. Davies and Miles G. Berry

less-than-impressive effect on the nasolabial folds and jowls
and long operating times, requiring extended periods of
careful surgery, particularly with anterior SMAS dissection.
Furthermore, the SMAS is relatively avascular,12 behaving
more as a graft in certain circumstances, and may be thin and
attenuated, thus holding sutures poorly. During revision or
secondary surgery, the poverty of vascular supply to the
undermined SMAS may present the surgeon with a mass of
scar tissue.
Given the recent paradigm shift towards minimallyinvasive techniques, to limit facial nerve complications and
reduce recovery time, the minimal access cranial suspension
(MACS) lift was initially popularly accepted.13 Since its
description in 2002, the MACS has proven effective, particularly for younger patients concerned with early jowling,
minimal neck ptosis and the desire for minimal downtime.
Itself a derivation of Saylan’s ‘S-lift’,14 the MACS lift focussed
on the anatomical basis, suture anchoring position and skin
excision, but certain limitations have been shown by experience. One of these, the relative lack of malar augmentation
was addressed by the addition of a third suture and quickly
became commonly applied.15 However, precise purse-string
suture placement is not always easy and subcutaneous irregularities may not settle as well as described. Whilst good for
younger patients, the authors feel it does not always have a
sufﬁciently strong effect on the lateral neck of older patients,
and is painful in the initial postoperative period, with a limitation of mouth-opening, acknowledged by the originators.13
Finally, there are two areas of tissue excess, or dog-ears, in
pure vertical-vector lifts, which may fail to settle satisfactorily.
The ﬁrst is infero-posterior to the lobule. The second, cutaneous bunching at the lateral canthus, is particularly pronounced
with the powerful suture of the extended MACS15 and may
be addressed through a lower lid blepharoplasty incision,
however, not all patients require this additional procedure. It
has been demonstrated that by utilizing tension in the SMAS
rather than the skin, both cutaneous dog-ears and scar stretch3
are minimized.

Facelift: Platysma-SMAS plication

11.3

SECTION I

1

Video

As required
Yes
Direct (infralobular
excision)
SMAS-SMAS
Yes
Cephaloposterior
Tailored, no tension
Multiple procedures
Yes

Skin ﬂap
Dissection into neck
Platysmaplasty
SMAS ﬁxation
Malar augmentation
Vector
Skin excision
Neck
Ancillary procedures

No

Liposuction in >95%

Tailored, high tension

Predominantly
vertical

No

SMAS-DTF

Indirect

No

Limited to 5 cm oval

Inverted L (anterior
only)

MACS

The surgical procedure is as follows: patients are prepared as
for a standard facelift with tumescent inﬁltration (20 mL 0.5%
bupivacaine and 1 mL 1 : 1000 adrenaline in 200 mL normal
saline) into the subcutaneous plane. The incision extends vertically in the temporal scalp, along the anterior helical sulcus
then passes post-tragal, and on occasion into the post-auricular

Technique

Experience with these limitations led the authors to the
use of sutures to plicate the SMAS; a procedure termed
the ‘platysma-SMAS plication’ (PSP) lift. Its advantages
(Table 11.3.1) include the application of a postero-superior, as
opposed to purely vertical, vector, which allows a lift tailored
to each individual. The vertically-extended skin incision
permits synchronous temporal lift and reduces sideburn elevation and a visible scar.16,17 While concealing the scar within
temporal hair risks alopecia, it allows greater ﬂexibility with
no risk of highly visible alopecia between the helical root and
hairline. A post-auricular extension, not employed in all cases,
is important to ameliorate the post-auricular skin dog-ear,
which adds to down-time and has been reported as a problem
with the MACS.9
With no sub-SMAS dissection, PSP is safer, particularly
with respect to the facial nerve, and quicker. It is also beneﬁcial where SMAS vascularity is poor. Large bites of SMAS
allow greater security, and therefore potential longevity. A
second layer of ﬁner imbrication sutures is used, producing
both a smooth ﬁnish and perhaps additional strength. It is, of
course, not without sequelae and does produce two dog-ears
in the subcutaneous layer. Fortunately, the ﬁrst, overlying the
malar prominence, has the effect of auto-augmentation and
assists with the overall rejuvenation by reversion of the aged
“square” to a youthful “triangular” face. The second, in the
sub-lobule region is not so beneﬁcial, but is simply excised; a
manoeuvre common to both Baker’s7 and Waterhouse’s modiﬁed SMASectomy procedures.18

Vertical temporal
(± post-auricular
extension)

Incision

PSP

Table 11.3.1 Comparison of chief features for the PSP and
MACS facelifts

217

In the authors’ practice, the PSP-lift was initiated in 2004 and
an initial evaluation was performed on a consecutive cohort

Patients and methods

Evaluation

sulcus (Fig. 11.3.1). A post-auricular extension is used where
required and subcutaneous dissection tailored to each patient.
The anterior SMAS is grasped in a postero-superior direction
to provide a satisfactory effect on the jowl (Fig. 11.3.2). The
key suture, using 2-0 PDS (Johnson & Johnson Medical Ltd),
is then inserted to attach this SMAS to the relatively immobile
pre-auricular parotid-masseteric fascia. Further sutures complete plication of the cervical platysma, below the mandibular
angle, to the mastoid fascia (Fig. 11.3.3) and any surface irregularities are addressed by suture imbrication with 3-0 Vicryl
(Johnson & Johnson). Excess SMAS in the infra-lobular region
is excised, following hydrodissection, and closed with 3-0
Vicryl. Following meticulous haemostasis, excess skin, with
low tension only, is trimmed and the wound closed over a
small suction drain with 4-0 and 6-0 nylon. A light, compressive facelift dressing remains overnight and is removed with
the drain the following morning. These can be similarly
removed immediately prior to discharge in day-case patients.
Sutures are removed at 4–6 days.

Fig. 11.3.1 Incision and area of subcutaneous dissection employed with the
PSP-lift. Note that the posterior extension is not always required, but is useful where
excess skin remains in the neck after SMAS plication.

Evaluation

SECTION I •11.3• Facelift: Platysma-SMAS plication

Of the original cohort, ﬁve were lost to follow-up or had insufﬁcient data for analysis. Of the remaining 117, all but eight
were women (two male-female transgender patients were
analyzed as biologically male). Mean age was 55 (range
29–79). General anesthesia was employed in the majority
with three undergoing local anesthesia-sedation. Additional
aesthetic procedures were performed in 104 patients
(Table 11.3.3). The neck was addressed with a variety of procedures in 92 (78.6%) patients (Table 11.3.4).
Overall, there was a high correlation (r = 0.76) between the
assessments of patient and surgeon. Mean scores of 4.45

Results

between August 2004 and May 2007. During this time, 122
patients were followed prospectively and speciﬁc assessment
of outcome was performed. While speciﬁc, validated evaluation systems are available for surgical correction of the breast19
and upper limb,20 there is little available for evaluation of
cosmetic facial surgery. Thus, a simple proforma (Table 11.3.2)
was established allowing both patient and surgeon to contribute to the assessment employing a linear analogue scale
(LAS), whereby poor and excellent results scored 1–5, respectively. Statistical analysis was performed with Kappa’s
correlation.

Fig. 11.3.2 Placement of the ﬁrst and key suture, which takes a generous bite of
anterior SMAS and tractions it postero-superiorly onto the parotido-masseteric
fascia. It can be trialled and its effect easily measured externally by observing
reduction of the jowl and effacement of the nasolabial fold as the SMAS is
tractioned and the suture tied.

218

Happy

Very happy

4
Happy

5
Very happy

Patient assessment

4

5

Surgeon assessment

Corneal symptoms

Subconjunctival

Eye closure

Scars

Unevenness

Asymmetry

Nerve damage

OK

3

OK

3

Unhappy

2

Unhappy

2

Right

Very unhappy

1

Very unhappy

1

Left

Table 11.3.2 Example of assessment proforma (blank)

Fig. 11.3.3 Tying the key suture produces a ‘dog-ear’ of SMAS that produces a
convenient malar autoaugmentation. A second suture passes between the posterior
platysma and the mastoid fascia to complete the effect on the jowl and commence
the necklift.

5
6

Face + 4 additional
Face + non-face additional

1
1

Platysmaplasty alone

The commonest complication was hematoma requiring a
return to theatre which was required in four patients (3.4%);
one following drain removal. All underwent evacuation
under local anesthesia without apparent adverse effect on
outcome (mean score 4.75). Some degree of nerve dysfunction
was noted in ﬁve patients. Of the four with motor symptoms,
only one lasted more than 6 weeks and was associated with
ipsilateral infection. One with unilateral dysesthesia was
followed-up at the chronic pain clinic after 3 months. The rate
of temporary nerve injury overall was therefore 4.3%, motor
3.4%, and sensory 0.85%. Five patients experienced delayed
wound healing, but all settled conservatively; oral antibiotics
being required in one case, and the longest healed by 8 weeks.
Two received intralesional steroid therapy for mild scar
hypertrophy. One complained of a small area of alopecia, not

Complications

(range 2–5) and 4.49 (3–5) were obtained for patients and
surgeon, respectively initially and 4.43 (2–5) and 4.45 (3–5),
ﬁnally. The same score was given at both stages in 42.9%,
improved with time in 39.3%, and deteriorated in 17.8%.

92

1

Liposuction + lipectomy + band division
Total

1

Liposuction + lipectomy + platysmaplasty

Band division alone
Liposuction + lipectomy

2
2

Lipectomy + platysmaplasty

Lipectomy + band division + platysmaplasty

3

6

Liposuction + band division + platysmaplasty

2

9

Band division + platysmaplasty

Liposuction + lipectomy + band division + platysmaplasty

11

Liposuction alone

Liposuction + platysmaplasty

n
54

Management of the neck

Table 11.3.4 Type and number of options employed in
management of the neck

117

Facial rejuvenation is increasingly viewed by patients as a
suitable recourse in a more ageist society that lives both longer
and more healthily. Interestingly, studies directly comparing
highly invasive with less aggressive procedures have shown
no signiﬁcant differences between the two10,11 and more afﬂuent, younger patients are requesting procedures with as little
“down-time” as possible. The PSP facelift was designed to
address these issues.
It must be remembered that SMAS advancement, whether
composite or independent, exerts uniform traction, much
like braces on trousers. Studies by Rohrich have elegantly
demonstrated discrete facial partitions that go a long way to
explaining why simple SMAS elevation-advancements often
provide only partial correction.21 PSP exploits the fact that
the optimal effect from a suture derives from its proximity to
the point of lift, and plication sutures can be placed wherever
they are required. This answers one of the drawbacks of
SMASectomies and conventional SMAS ﬂaps where the excision is remote from both the jowl and nasolabial fold (NLF).
With plication, the SMAS is sutured directly, rather than in
a purse-string fashion used with the MACS lift, and has the
potential for an inﬁnite multiplicity of vectors, to obtain
the precise effect tailored to the individual. This differs from
Robbins’ anterior plication, which employs a vertical row of
SMAS sutures lateral to the NLF.8 While addressing the NLF,
this anterior only approach obliges antero-inferior traction on
both lateral SMAS and malar fat thus counterbalancing malar
augmentation.
Many have reported that the SMAS progressively thins
anteriorly,3,7,10 particularly in secondary surgery.17 Saulis et al.
demonstrated both the weakness and reduced suture-retention
of the SMAS when raised alone,22 as compared to an SMAS
ﬂap raised in continuity with the skin, a feature which has
been cited by supporters of composite ﬂaps. However, they
also demonstrated less tissue creep and stress relaxation in the
SMAS ﬂap as compared to skin ﬂaps, lending credence to
SMAS tightening procedures such as plication, in the pursuit
of surgical longevity. The degree of skin ﬂap undermining is
also much greater in the PSP than with procedures such as the
MACS in observance of Baker’s philosophy that SMAS vectoring to give maximal anatomic improvement is not adversely
affected by employing a separate vector for skin redraping.23
Minimal access supporters stress the importance of vertical
vectors in contemporary facelifts,13 however, in our view,
facial ageing occurs in multiple directions, according to
gravity, the locations of retention ligaments, and local muscular forces,16 and senescence is characterized by antero-inferior
descent.7 It seems counter-intuitive to disregard some vectors
at the expense of others.10
Additionally, traditional SMAS techniques in which the
malar fat is not speciﬁcally dissected, have a limited effect on
both malar ptosis and the NLF.3 As shown in Figure 11.3.4,

41
12

Face + 2 additional
Face + 3 additional

Total

Discussion

13
40

Face + 1 additional

n

visible socially, in the temporal incision that improved spontaneously. A single patient underwent corrective fat transfer
for a persistent surface irregularity. There was no statistically
signiﬁcant relationship between any complication and hypertension, smoking or secondary surgery.

219

Face alone

Procedure

Table 11.3.3 Number of procedures synchronous with the
PSP-lift

Discussion

SECTION I •11.3• Facelift: Platysma-SMAS plication

PSP can exert a powerful effect on the malar prominence and
NLF due to individualized plication. Another advantage of
the PSP lift is that after initial plication any residual SMAS
irregularities are addressed with secondary imbrication to
leave a smooth surface, this second layer further contributing
to the integrity of the SMAS ﬁxation. Personal experience has
shown that the purse-string technique may lead to irregularities, which do not always resolve as claimed and can lead to
patient dissatisfaction. Debate continues as to where the
advanced SMAS should be ﬁxed.24 Deep ﬁxation can also
leave the patient with “marked pain and restricted mouth
opening.”13 The success of SMASectomy procedures attests to
the strength of SMAS-SMAS ﬁxation.7,18 Furthermore, there is
the added beneﬁt of autologous malar augmentation as proposed by Baker.7 The infra-lobular platysma-SMAS excess is
excised (Fig. 11.3.5), and the defect closed, to remove the
lateral swelling beneath the ear lobe, a feature typical of more
minimal techniques.
Nerve dysfunction, particularly motor, remains the most
feared complication of any facelift and in our series, none
were permanently affected. Of note, half underwent synchronous endoscopic browlifts that more likely caused the frontal
branch palsies. Interestingly, all nerve complications occurred
in the ﬁrst third of the study indicating a learning curve. That
all motor function in this series recovered fully and rapidly
indicates the inherent safety of PSP and assuages critics’ fears
that blind needle insertion into the pre-masseteric SMAS is
dangerous.

Fig. 11.3.4 Completion of the face and necklift, leaving the beneﬁcial malar
dog-ear and the undesirable infero-posterior lobule dog-ear.

220

The neck continues to be a problem area for several reasons:
swelling and scarring always seem to mature slowly and correction of platysmal bands is often incomplete. In addition,
aggressive submental lipectomy may leave irregularities and
exacerbates the appearance of any residual jowling. Finally,
seroma and excess skin are a frequent source of complaint
and secondary surgery. The neck is a deﬁning feature as small
remnant anomalies can spoil an otherwise excellent result in
the face. Management of the neck, therefore, remains controversial with supporters at both minimal and aggressive ends
of the spectrum. That such a range and difference of opinion
exists indicates the universal procedure remains elusive,
although the pendulum appears to be swinging towards minimalism due to the limited margin for technical error and
healing irregularities.11,13 The viscoelastic properties of cervical ﬂaps have been demonstrated to be inherently different
from facial ﬂaps with greater creep and stress-relaxation
thereby allowing increased relapse, although the reason
for this remains unclear.22 The importance of the posterosuperior region of the neck’s anterior triangle has been highlighted in a recent publication, which demonstrated a gliding
plane between the platysma and the sternocleidomastoid

The neck

Fig. 11.3.5 Following the platysma-mastoid suture tying, the infero-posterior
lobule excess is (A) marked and (B) excised. The cut SMAS edges are then
sutured.

B

A

B

Conclusion

C

D

The use of suture plication of the SMAS has been encouraging both for aesthetic outcome (Figs 11.3.6–11.3.8) and
complication rate. The PSP-facelift seeks to combine the
advantages of SMAS advancement with those of plication
whilst minimizing complications and maximizing outcome.
It has a sound anatomical basis, allowing individual, and differential, SMAS and skin vectoring that provides speciﬁc
anatomical correction and ameliorates asymmetry. Moreover,
the technique is safe to perform and easily acquired by trainees and less experienced aesthetic surgeons. The skin incision
is standard and allows optimal access to the relevant anatomy.
It is suitable for day-case surgery as a single procedure or
with multiple concomitant aesthetic facial procedures and is
particularly good for autologous malar augmentation. It
works particularly well where the facial ptosis is concentrated primarily in the midface and at the jowl and has been
noted by our patients to settle rapidly and thereby minimize
“downtime”.

221

B

C

D

Fig. 11.3.7 Preoperative views (A,C) in a woman who underwent PSP-lift. Postoperative images (B,D) underline the malar autoaugmentation in addition to jowl
diminishment and a good result in the cervical region.

A

Fig. 11.3.6 A 67-year-old female shown 12 months following PSP-lift demonstrating its effect, particularly on jowl and cervical skin excess reduction. She also underwent
synchronous bilateral upper and lower blepharoplasties and peri-oral CO2 laser treatment. (A,C) preoperative; (B,D) postoperative.

A

such that supero-lateral traction exerts a powerful effect on
both lateral and anterior platysma.25 Waterhouse emphasized
a similar concept18 for optimal results in the neck, which we
fully endorse. It is worth reiterating the advantage of infralobular dissection, with or without a posterior incision, which
allows SMAS anchoring to the mastoid fascia for a strong
lateral platysmaplasty. A little over three-quarters of our
patient cohort underwent some additional management of the
neck, the majority (54 of 92) receiving liposuction alone.
Following our assessment, nine (7.7%) were felt to have suboptimal neck outcomes. Distribution was equal in the ﬁrst and
second halves of the study with no obvious features to assist
in the preoperative selection of such patients.
Patient satisfaction was high with scores of 4.45. Interobserver correlation was also high, lending some credence to
what is effectively a subjective assessment. With respect to
those who downgraded their scores, 75% had experienced a
problem of some kind, including persistent dysesthesia, postoperative hematoma and skin ﬂap telangiectasia; all were
considered by the surgeon to have achieved at least a grade 4
surgical outcome.

Conclusion

B

SECTION I •11.3• Facelift: Platysma-SMAS plication

C

2. Mitz V, Peyronie M. The superﬁcial musculoaponeurotic system (SMAS) in the parotid and cheek
area. Plast Reconstr Surg. 1976;58:80–88.
A classic facelift paper in which the SMAS was described. It
opened up a new ﬁeld for surgery and study in addition to
the beneﬁts of much improved longevity over skin-only lifts.
5. Hamra ST. The zygorbicular dissection in composite
rhytidectomy: An ideal midface plane. Plast Reconstr
Surg. 1998;102:1646–1657.
6. Stuzin JM, Baker TJ, Baker TM. Reﬁnements in face
lifting: enhanced facial contour using Vicryl mesh
incorporated into SMAS ﬁxation. Plast Reconstr Surg.
2000;105:290–301.
The use of Vicryl mesh to both improve the ﬁxation and
enhance overall contour. This technique excises no SMAS,
but utilizes the excess to augment the malar area.
8. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS
plication for the treatment of prominent
nasomandibular folds and restoration of normal cheek
contour. Plast Reconstr Surg. 1995;96:1279–1287.
10. Ivy EJ, Lorenc PZ, Aston SJ. Is there a difference? A
prospective study comparing lateral and standard
SMAS facelifts with extended SMAS and composite
rhytidectomies. Plast Reconstr Surg. 1996;98:1135–1143.
A study with the dual interest of both being able to undertake
different procedures on opposite sides, in addition to the
ﬁnding that signiﬁcant differences were hard to detect.

D

11. Alpert BS, Baker DC, Hamra ST, et al. Identical twin
face lifts with differing techniques: a 10-year follow-up.
Plast Reconstr Surg. 2009;123:1025–1033.
13. Tonnard P, Verpaele A, Monstrey S, et al. Minimal
access cranial suspension lift: a modiﬁed S-lift. Plast
Reconstr Surg. 2002;109:2074–2086.
16. Mendelson BC. Surgery of the superﬁcial
musculoaponeurotic system: principles of release,
vectors, and ﬁxation. Plast Reconstr Surg. 2001;107:
1545–1552.
The scholarly treatise of anatomy and vectors now
accepted as a benchmark of the principles underpinning
facelifting.
20. The Institute for Work & Health. The disabilities of the
arm, shoulder and hand (DASH) outcome measure. Toronto:
The Institute for Work & Health; 2005.
22. Saulis AS, Lautenschlanger EP, Mustoe TA.
Biomechanical and viscoelastic properties of skin, SMAS
and composite ﬂaps as they pertain to rhytidectomy.
Plast Reconstr Surg. 2002;110:590–598.
25. Labbé D, Franco RG, Nicolas J. Platysma suspension
and platysmaplasty during neck lift: anatomical study
and analysis of 30 cases. Plast Reconstr Surg. 2006;117:
2001–2007.
A beautifully conducted and illustrated paper that goes a long
way to explaining why the neck is frequently the most
disappointing part of a facelift.

Access the complete references list online at http://www.expertconsult.com

Fig. 11.3.8 This ﬁgure demonstrates both the acceptability of PSP in the male and its ability to ameliorate deep-set nasolabial folds.

A

222

1. Skoog T. Plastic surgery. Philadelphia: WB Saunders;
1974:300–330.
2. Mitz V, Peyronie M. The superﬁcial musculoaponeurotic system (SMAS) in the parotid and cheek
area. Plast Reconstr Surg. 1976;58:80–88.
A classic facelift paper in which the SMAS was described.
It opened up a new ﬁeld for surgery and study in addition
to the beneﬁts of much improved longevity over skin-only
lifts.
3. Owsley JQ. Platysma-fascial rhytidectomy:
a preliminary report. Plast Reconstr Surg. 1977;59:
843–850.
4. Hamra ST. The deep plane rhytidectomy. Plast Reconstr
Surg. 1990;86:53–61.
5. Hamra ST. The zygorbicular dissection in composite
rhytidectomy: An ideal midface plane. Plast Reconstr
Surg. 1998;102:1646–1657.
6. Stuzin JM, Baker TJ, Baker TM. Reﬁnements in face
lifting: enhanced facial contour using Vicryl mesh
incorporated into SMAS ﬁxation. Plast Reconstr Surg.
2000;105:290–301.
The use of Vicryl mesh to both improve the ﬁxation and
enhance overall contour. This technique excises no SMAS,
but utilizes the excess to augment the malar area.
7. Baker DC. Lateral SMASectomy. Plast Reconstr Surg.
1997;100:509–513.
8. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS
plication for the treatment of prominent
nasomandibular folds and restoration of normal cheek
contour. Plast Reconstr Surg. 1995;96:1279–1287.
9. Prado A, Andrades P, Danilla S, et al. A clinical
retrospective study comparing two short-scar face lifts:
minimal access cranial suspension versus lateral
SMASectomy. Plast Reconstr Surg. 2006;117:
1413–1425.
10. Ivy EJ, Lorenc PZ, Aston SJ. Is there a difference?
A prospective study comparing lateral and standard
SMAS facelifts with extended SMAS and composite
rhytidectomies. Plast Reconstr Surg. 1996;98:
1135–1143.
A study with the dual interest of both being able to undertake
different procedures on opposite sides, in addition to the
ﬁnding that signiﬁcant differences were hard to detect.
11. Alpert BS, Baker DC, Hamra ST, et al. Identical twin
face lifts with differing techniques: a 10-year follow-up.
Plast Reconstr Surg. 2009;123:1025–1033.

References

222.e1

12. Whetzel TP, Stevenson TR. The contribution of the
SMAS to the blood supply in the lateral face lift ﬂap.
Plast Reconstr Surg. 1997;100:1011–1018.
13. Tonnard P, Verpaele A, Monstrey S, et al. Minimal
access cranial suspension lift: a modiﬁed S-lift.
Plast Reconstr Surg. 2002;109:2074–2086.
14. Saylan Z. Purse string-formed plication of the SMAS
with ﬁxation to the zygomatic bone. Plast Reconstr Surg.
2002;110:667–671.
15. Verpaele A, Tonnard P, Guerao FP, et al. The third
suture in MACS-lifting: making midface-lifting simple
and safe. J Plast Reconstr Aesthet Surg. 2007;60:
1287–1295.
16. Mendelson BC. Surgery of the superﬁcial
musculoaponeurotic system: principles of release,
vectors, and ﬁxation. Plast Reconstr Surg. 2001;107:
1545–1552.
The scholarly treatise of anatomy and vectors now accepted as
a benchmark of the principles underpinning facelifting.
17. Guyuron B. Secondary rhytidectomy. Plast Reconstr
Surg. 2004;114:797–800.
18. Waterhouse N, Vesely M, Bulstrode NW. Modiﬁed
lateral SMASectomy. Plast Reconstr Surg. 2007;119:
1021–1026.
19. Pusic AL, Klassen AF, Scott AM, et al. Development
of a new patient-reported outcome measure for breast
surgery: the BREAST-Q. Plast Reconstr Surg. 2009;124:
345–353.
20. The Institute for Work & Health. The disabilities of the
arm, shoulder and hand (DASH) outcome measure. Toronto:
The Institute for Work & Health; 2005.
21. Rohrich RJ, Pesa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg. 2007;119:2219–2227.
22. Saulis AS, Lautenschlanger EP, Mustoe TA.
Biomechanical and viscoelastic properties of skin, SMAS
and composite ﬂaps as they pertain to rhytidectomy.
Plast Reconstr Surg. 2002;110:590–598.
23. Baker TJ. Rhytidectomy: a look back and a look
forward. Ann Plast Surg. 2005;55:565–570.
24. Baker TJ, Stuzin JM. Personal technique of face lifting.
Plast Reconstr Surg. 1997;100:502–508.
25. Labbé D, Franco RG, Nicolas J. Platysma suspension
and platysmaplasty during neck lift: anatomical study
and analysis of 30 cases. Plast Reconstr Surg. 2006;117:
2001–2007.
A beautifully conducted and illustrated paper that goes a long
way to explaining why the neck is frequently the most
disappointing part of a facelift.

References

©

2013, Elsevier Inc. All rights reserved.

Facial rejuvenation surgery has had an interesting evolution
over the last 75 years. It is an interesting exercise to examine
the chronicle of progress of facial rejuvenation surgery and at
the same time, critically ask ourselves: “What were they
thinking when they came up with that particular procedure
for facial rejuvenation?” Our concept regarding facial

rejuvenation has evolved beyond surgical technique to now
encompass facial aesthetics, ancillary treatments, biomechanics of facial rejuvenation, and consumer preferences for lesserinvasive procedures with rapid recovery.
In retrospect, we have moved back and forth between a
variety of technical solutions versus a more holistic process
of how to optimally deliver operational excellence in facial
rejuvenation for a diverse patient population. As a surgeon,
it is sometimes easier to fall in love with a single technique of
facial rejuvenation and not engage in critical thinking about
the shortcomings and tradeoffs of that particular technique.
At the same time, when confronted with newer techniques
and concepts for facial rejuvenation, many surgeons adopt a
defensive reasoning mindset that prevents adoption of these
approaches.
MACS-lift is an acronym for “minimal access cranial suspension”.1 The ﬁrst time that I (the author) read the MACS
short-scar rhytidectomy paper by Tonnard et al.,2–5 it seemed
a puzzling principle which relied on suture loop suspension
to a cranial anchoring point, far different that the sheet tightening approach of the classic SMAS-lift that I was performing
at the time. It took a trip to the anatomy lab and a visit with
Tonnard and Verpaele in Belgium to convince me that there
was something different (and possibly better) about the
MACS-lift. Once this approach for facial rejuvenation was
examined in light of other publications by Labbé,6 Mendelson,7
Besins,8 Pessa/Rohrich,9 and Gardetto,10 there actually appears
to be a unifying concept that has scientiﬁc and biomechanical
validity as a mainstay technique for facial rejuvenation.
First, we should ask ourselves, “Why do we think that it is
necessary to delaminate the face in order to rejuvenate? Can
we accomplish volume redistribution/repositioning without
having to engage in complex, deep anatomic dissections?
What is the validity of using a cranial suspension platform
to re-suspend facial structures over traditional ways?” And
ﬁnally: “Can we innovate a less-invasive procedure for facial
rejuvenation that gives a durable outcome and allows for
future revisions?”

Mark Laurence Jewell

Facelift: Facial rejuvenation with loop sutures,
the MACS lift and its derivatives

Limit undermining of skin to planned areas for suture loops or for
redraping of skin. The indiscriminate delamination of skin of neck
structures or in the post-auricular region can unduly inﬂuence
outcomes. Undermine only as necessary to accomplish the lift,
not more.
Ensure that the neck loop suture has a good bite of platysma
fascia. This is important to prevent failure of the neck-lifting
component.
Do not make the cheek loop too small. This can result in a wad of
tissue that cannot be made smooth.
Understand the ability that you have to innovate with the MACS-lift,
based on your patient’s individual needs. Too often, we become
wedded to a sequence of techniques and ancillary procedures
that limits our ability to individualize and adapt for each of your
patients.
The MACS suture loop suspension approach works nicely in
secondary or revisionary situations, where there has been earlier
deep layer work and repeat deep layer dissections could be both
challenging and risky. MACS loop sutures hold well in scar from
previous surgery.
Critical evaluation of outcomes is part of the learning process
in terms of determining what went right and areas that require
improvement. Reﬁnement of technique comes with an honest
analysis of the outcome.

SYNOPSIS

Introduction

䊏

䊏

䊏

䊏

䊏

䊏

Aesthetic Surgery of the Face

11.4

SECTION I

The surgical foundation for facial rejuvenation should address
the biomechanical effects of facial aging and volume loss for
each patient, depending on their particular needs. Surgeons
must be faulted in the past for not having a fundamental
understanding of facial aging, volume loss, laminar anatomy,
and biomechanical engineering. Our current understanding
of the anatomy of facial aging is thoroughly reviewed in
Chapter 10, giving insight into the complex biomechanics of
facial aging. Aging involves the gravimetric effects on skin
and SMAS, loss of elastic property of tissue, volume loss and
descent within in fat compartments, and extrinsic effect of
sun, genetics, weight loss/gain, and smoking.11–13 Fat within
the face does not exist as a conﬂuent mass, but in discreet
compartments separated by septae, formerly known as ligaments. Facial anatomy involves a laminar concept in which,
movement between layers is possible without surgical delamination. Proponents of ligament release feel that such movement is inadequate for facial rejuvenation, but experience
with the MACS-lift provides evidence that sufﬁcient interlayer movement is, indeed possible and surgically effective.
From the perspective of biomechanics, surgical approaches
that rely on sheet tightening of attenuated facial structures
(SMAS) may not produce a long-term effect due to the loosening of this layer over time (shear-yield). Suture line repairs
such as linear plication or excision techniques (plication or
SMASectomy) remain vulnerable to disruption (shear failure
and “cheese wiring”) by down-pulling the platysma whose
fascia is contiguous with the SMAS facial rejuvenation, is
therefore an exercise in biomechanical engineering in terms of
how much force is required to vertically lift facial and neck
structures and suspend them in place with approaches that
are less prone to failure. Surgery is part of the solution for
facial rejuvenation, but ancillary procedures found in cosmetic medicine such as medical skin care, ﬁllers, neurotoxins,
and light-based treatments work synergistically to produce a
“wow effect” when used masterfully.
The MACS-lift concept involves the use of suture loops
placed in a purse-string fashion in order to elevate deep facial
tissue by anchoring to a ﬁxed point. In the basic MACS-lift,
there is one anchoring point on the deep temporal fascia, just
above the lateral zygoma, and posterior to the passage of the
temporal branch of the facial nerve. This is a very robust
anchor point that will hold a 0-0 or 2-0 suture without a pullout failure The “CS” part of the MACS-lift is “cranial suspension”, which refers to the deep temporal fascia’s attachment
to the cranium along the temporal crest line. The MACS-lift
does not utilize sheet tightening of the SMAS, SMAS plication,
or SMASectomy, but relies purely on specialized suture suspension. The basic MACS-lift involves two suture loops, one
vertical and one oblique, while the “extended MACS-lift”
involves an additional suture to elevate the malar fat to a more
anterior anchoring point (Figs 11.4.1, 11.4.2). Suture loops
placed within facial tissues results in a gathering and suspension of tissue. Tonnard and Verpaele describe this as “microimbrication” (Fig. 11.4.3).
How the loops are designed and sequenced is crucial, as
once the platysma is pulled upward, it is possible to rotate the
layers of the face without a downward traction component of
the platysma. By not dissecting skin off the platysma, there is

tightening of the neck skin when the platysma is tightened.7
The zone of adherence just anterior to the earlobe, called
Lore’s fascia, can be used as a ﬁxed structure to pull against
in order to achieve vertical tightening of the platysma as
described by Labbé.5
The traditional skin incision for the MACS-lift utilizes a
“short scar” anterior hairline approach with no retroauricular
dissection. After deep tissue reposition, skin redraping is
designed in a purely vertical direction (Fig. 11.4.4).
The amount of skin excision with the vertical approach of
the MACS-lift is much less than seen with the classic SMASlift. Attention must be paid to a tension-free skin closure in
order to promote excellent healing and avoid earlobe distortion. In a divergence of philosophy and practice from Tonnard
and Verpaele, patients with greater facial and neck laxity will
require extending the incision into the retroauricular area in
order to manage lax skin (Fig. 11.4.5).
Therefore, the “MA” (minimal access) portion of the MACS
terminology must be expanded to address situations where
there is more tissue laxness necessitating a retroauricular incision. In optimal situations, with younger patients, the short
scar approach is preferable, yet can be modiﬁed when the
amount of loose tissues cannot be managed with a short scar
approach. Extending the incisions into the post-auricular

Fig. 11.4.1 The basic MACS-lift involves two suture loops placed into the SMAS
in a purse-string fashion. The vertical loop captures the platysma muscle below the
angle of the mandible, elevating soft tissues of the neck. The cheek loop captures
and elevates soft tissue of the mid cheek and jowl.

SECTION I •11.4• Facelift: Facial rejuvenation with loop sutures, the MACS lift and its derivatives

Surgical foundation for the MACS-lift

224

region resolves bunching of loose skin at the level of the
earlobe.
There are numerous advantages of the MACS-lift. Deep
tissues are readily repositioned without deep plane dissection, which risks injury to the facial nerve. Less dissection is
also likely to result in faster recovery. The short scar approach
avoids dissection over the sternocleidomastoid muscle and
therefore removes the potential for injury to the great auricular nerve. MACS sutures are anchored at ﬁxed points which
avoid the temporal branches of the facial nerve (Fig. 11.4.6).
It has outcomes that are acceptable over time, and favorable biomechanics that address volume redistribution and

Fig. 11.4.3 MACS sutures result in a bunching up of soft tissue. This has been
termed microimbrication.

Fig. 11.4.2 The extended MACS-lift adds a third suture to elevate the malar fat
pad.

225

Each patient is unique with respect to their particular needs
for facial rejuvenation. It then is incumbent on the surgeon to
formulate a strategy that will provide solutions for each
patient. In the author’s experience, a more holistic approach
works best in his own patient population. This involves both
cosmetic medicine and aesthetic plastic surgery, allowing for
care to be ongoing and to advantage each patient with adjunctive services of medical skin care, ﬁllers, neurotoxins, and
light-based treatments.
The following components of a patient’s face require evaluation and strategy.

Patient evaluation

facial tightening without deep layer work. This technique
appears very adaptable to most patients seeking primary and
secondary facial rejuvenation. It also has the advantage of
being reversible during surgery, as suture loops can be
changed or the entire technique be abandoned for a more
traditional approach. The learning curve for successful adoption of the MACS-lift is something that can be mastered by
most surgeons who are willing to invest the time required to
learn a new approach to surgical facial rejuvenation.

Fig. 11.4.5 Vertical skin advancement in the standard short scar approach for a
MACS-lift.

Fig. 11.4.4 The short scar incision used in the standard MACS-lift.

Patient evaluation

1.8

2.0

2.0

Assessment of the loss of facial volume is done. Volume
enhancement in the submalar sulcus may be done with
surgery, autologous fat grafts, or synthetic ﬁllers. The recognition of volume loss that occurs due to attritional lipoatrophy
is underestimated.

Facial volume

Forehead rejuvenation may involve the use of neurotoxins, or
rejuvenation surgery through the endoscopic, or transpalpebral approach.

Forehead and glabellar rhytides

Photodamage and photoaging must be addressed and consideration given for medical skin care or light-based treatments.
Rhytides and looseness in the perioral area cannot be resolved
with rhytidectomy.

Skin quality, character, and looseness

Structural needs such as cheek or chin deﬁciency must be
addressed. Evaluate for facial nerve function, muscular function, any asymmetry.

Facial skeletal structure and asymmetry

The management of patient expectations becomes a major
part of facial rejuvenation, whether surgical or medical. It
is essential that patients see themselves for who they are
before treatment and that realistic portrayal of outcomes be
communicated. Occasionally, there is the need for revisionary
surgery/procedures that must be addressed prior to treatment versus afterwards. Revision surgery may not be
successful.
The better informed that patients are regarding their particular needs and your recommendations, both surgical and

Patient expectations

Patients seeking facial rejuvenation may have medical conditions that can inﬂuence their safety during facial rejuvenation.
Not everyone seeking facial rejuvenation surgery is a candidate for surgery, based on chronic medical disorders. Attention
should be paid to a thorough review of systems with emphasis on cardiac and circulatory issues. Unique subsets of
patients with surgical weight loss procedures may present
with additional factors such as facial lipoatrophy, tissue
wasting, and obstructive sleep apnea. DVT risk must be
assessed and managed.

Medical history

Patients seeking additional reﬁnements or “maintenance” of
facial rejuvenation from previous surgical procedure may
present with distorted changes due to conﬂicting traction
vectors or ineffectual outcomes. This type of patient requires
thoughtful consideration of what can be safely addressed
with reoperative surgery.

Previous surgery

The squareness of the jaw line is largely inﬂuenced by the
downward descent of facial structures. Depending on the
severity, dissection into the pre-masseteric space may be
required.

Jowls

Neck laxness and platysmal banding will inﬂuence the need
to consider extended incisions and possibly a submental
approach for direct work on platysma banding. The presence
of submental fat may be addressed either through lipoplasty
if superﬁcial or direct excision if submuscular.

Neck

Dermatochalasis, brow position, brow ptosis, fat bags, lower
eyelid looseness requiring lateral canthal work, lower eyelid
skin, and malar bags should all be assessed. Given the substantive lift of the MACS-lift, a lower eyelid blepharoplasty is
often an integral part of this approach.

Ocular region

SECTION I •11.4• Facelift: Facial rejuvenation with loop sutures, the MACS lift and its derivatives

Fig. 11.4.6 The temporal branches of the facial nerve course over the middle third
of the zygomatic arch. The MACS suture anchor points are designed to avoid
damage to these nerve branches.

226

1

Video

The patient is marked before the start of the procedure; key
points are the planned incision, the degree of undermining,
and the location of suture loops The degree of skin ﬂap undermining typically extends inferiorly just past the mandibular
angle and anteriorly 5–6 cm in front of the ear. If an extended
MACS-lift is planned, undermining is marked over the malar
prominence. The sequence of performing a MACS-lift is
straightforward. If autologous fat grafting is considered, the

Surgical sequence

The use of worksheets and templates has proven useful in
many areas of aesthetic surgery and cosmetic medicine. A
simple form based on your practice helps you develop your
surgical strategy for each patient’s care. It allows you to make
notes, show speciﬁc details, and more importantly determine
the tradeoffs involved. Such a form is a nice ﬁt with your
informed consent(s) for the surgical procedure or cosmetic
treatments (ﬁllers, neurotoxins, etc.).
How you choose to communicate your strategy with the
patient is also important. Simple aids such as a 10 × 15 cm
print from a digital camera on which you can draw, can be
useful. Other approaches involve drawing on the patient with
an eyeliner marker (easily removed) and taking a photograph.
Both of these are good communication tools to make certain
that your plans are in alignment with the patient’s expectations and needs. Even something as simple as displaying a
digital photograph on a large-screen LCD television works far
better than using a hand mirror.
Anesthesia for the MACS-lift can be minimalistic: local
anesthetic with conscious sedation; more complex with monitored anesthesia care – deep sedation (MAC) or general
anesthesia (GA). If general anesthesia is contemplated, the
author prefers an endotracheal tube (ET) over the laryngeal
mask (LMA) device because of less neck distortion with the
ET. Other important considerations would be DVT prophylaxis and a warming blanket for prevention of hypothermia.
Although some surgeons consider chemoprophylaxis with
fractionated heparin on long cases, there are reasonable concerns of increased risk of hematoma incidence. Some anesthesiologists prefer GA over MAC because of better airway
management and the ability of a gas analyzer to measure end
tidal CO2 as an index of ventilation.
Care should be given during the procedure to installing
protective eye ointment in order to prevent corneal exposure
problems. Sterile tape strips may also be used to prevent
eyelid opening. Individuals with a history of LASIK procedures are especially at risk for corneal problems due to diminished corneal sensory innervations that triggers tearing. When
operating on a post-LASIK patient, consider an evaluation by
an ophthalmologist for adequacy of tear production and tear
ﬁlm quality.

Surgical strategy

nonsurgical, they will be able to obtain the best outcome.
If a patient does not appear to be capable of obtaining an
outcome from treatments/procedures, it is better to communicate this up front and avoid the vexing problem of a dissatisﬁed patient who had unrealistic expectations.

227

The suture loop for the neck is placed ﬁrst. Going inferiorly
in the natural sulcus that is anterior to the tragus, ﬁrm bites
between 1 cm and 1.5 cm long are taken into the SMAS.
Progressing inferiorly past the angle of the mandible, two
or three suture bites are taken into the platysma before the
suturing is directed upward and back to the anchor point.
A U-shape loop about 1 cm wide is created and the knot is
then tied at the anchor point under tension. The suture loop
is tied without any instrument that might be used to hold the
ﬁrst knot. This diminishes the possibility of suture damage

The neck suture

The deep temporal fascia anchor point is chosen to avoid
the superﬁcial temporal vessels and the temporal branch of
the facial nerve. Small scissors are used to create a window
in the subcutaneous tissue approximately 1 cm above the
zygomatic arch and 1 cm in front of the helical rim in order
to expose the deep temporal fascia (Fig. 11.4.7).
When placing the suture into the temporalis fascia, the
author sews away from the temporal vessel location. A single
anchor point is used for both the neck loop and the cheek loop
in order to diminish the amount of suture used and the palpability of knots. Absorbable monoﬁlament sutures such as
0-polydiaxonone are preferred over nonabsorbable polypropylene or braided polyester suture.

Anchor point

Local anesthetic containing epinephrine is injected along the
incision line. In the area of ﬂap undermining, the author
prefers lipoplasty wetting solution that contains epinephrine
1 : 500 000. The short scar incision extends from the earlobe
below to the anterior hairline above. It follows the attachment
of the earlobe from the retroauricular crease, around to the
anterior attachment of the earlobe, following the tragal edge,
the anterior helical attachment to the root of the helix, then
across the lower portion of the sideburn and up the anterior
hairline. Anteriorly, the incision is made in a zigzag pattern
1–2 mm within the hairline. The zigzag incision effectively
increases the length of the temporal incision to better receive
the elevated cheek ﬂap. In the standard MACS-lift, the incision is carried up to the level of the lateral canthus, while in
the extended MACS-lift, the incision extends up to a point
opposite the tail of the eyebrow. Flap elevation is accomplished with scissor dissection. If an extended incision in the
retroauricular zone is required, this is done early in the procedure as it generally facilitates suture loop placement and
skin redraping when the neck is tightened vertically.

Skin incision and undermining

author harvests and processes fat at the beginning, followed
by injection prior to the incisions for the MACS-lift. It is preferred not to store AFT graft tissue at ambient temperature for
long periods during the procedure. Any anterior neck surgery,
such as lipoplasty is performed ﬁrst. The cheek ﬂap is then
dissected and the loop sutures are placed. If a temporal lift or
endobrowlift is contemplated, it is done next. A blepharoplasty, if planned, is done last.

Surgical strategy

The cheek loop is placed next. It originates at the same anchor
point from the deep temporal fascia. Taking bites of the SMAS,
suturing progresses inferiorly just anterior to the ﬁrst loop
and then curves more anteriorly, creating a wider loop above
the jowl extending anteriorly as far as the skin ﬂap has been
raised. The author has found that the loop works best when
it is in the conﬁguration of a logarithmic spiral, like a Nautilus
shell. This allows for upward rotation of facial structures and
volume repositioning. The overall angle of the cheek loop is
approximately 30° across the cheek, as compared to the vertical neck loop. The suture is then tied under tension. Novice
MACS-lift surgeons tend to make too small of a cheek loop
and are then faced with a situation of a peculiar wad of tissue
when the loop is tied. Experience teaches that if a suture loop
appears unsatisfactory, the best strategy is to take it out and
replace it.

The cheek suture

and breakage. In my (the author) ﬁrst few cases, I found that
I did not have an adequate grip on the platysma fascia and
that neck tightening was not optimal; for neck tightening to
occur, adequate suture purchase of the platysma below the
angle of the mandible is imperative. When performing the
short scar variation, a ﬁberoptic retractor is helpful to visualize correct suture placement in the depth of the dissection.
Should additional reinforcement of the neck be desired, 2-0
polydioxanone sutures can be placed from the platysma into
the fascial zone of adherence just below the tragus (Lore’s
fascia) or from the platysma to the mastoid fascia. Suture
knots in this area should be inverted to avoid knot palpability
through the skin (Fig. 11.4.8).

Once the cheek loop is tied, it is possible to add a third loop
for elevation of the malar fat; this constitutes the “extended
MACS-lift” variant. A different anchor point is used anterior
to the temporal branch of the facial nerve. This point can
either be the deep temporal fascia just lateral to the lateral
orbital rim, or the periosteum of the zygoma, approximately
1.5 cm lateral to the lateral canthal area. Access to either of
these anchor points requires a small window in the orbicularis
muscle where the ﬁbers run vertically. This purse-string
suture travels obliquely toward the malar fat pad where at a
point 2 cm below the lateral canthus, the direction is reversed,
creating a narrow U-shaped loop that is tight under tension.
In my experience, the direction of pull will be oblique, but
ideally should be as vertical as possible. If the surgeon is dissatisﬁed with the placement of the loops, it is easy to cut and
replace the loops until satisﬁed with their placement and
tissue gathering.
Tissue bunching is an integral problem with the MACS
suture loops. It is resolved with imbrications with 4-0

The malar suture

Fig. 11.4.8 (A,B) Cadaveric example demonstrating placement and the effect of
the vertical neck suture. The orientation is vertical, and neck traction depends on
achieving excellent suture purchase of the platysma muscle below the angle of the
mandible.

B

A

SECTION I •11.4• Facelift: Facial rejuvenation with loop sutures, the MACS lift and its derivatives

Fig. 11.4.7 The short scar incision has been made, and the skin ﬂap raised. The
zygomatic arch is marked in purple. Note the marks on the skin designating the
location of the suture loops. The scissors are dissecting a window down to the deep
temporal fascia which will be used as the anchor point for the vertical and cheek
suture loops.

228

E

D

F

C

The skin ﬂap is then redraped along a vertical axis and the
excess skin is resected. If there is excess skin at the level of the
ear lobe, it must be resolved by incisions in the posterior ear
region. My philosophy is to resolve this skin by extending my
incisions in the posterior sulcus of the ear, instead of dealing
with skin bunching post surgery. If necessary, the author uses
a classic rhytidectomy incision in the post-auricular region,
depending on the patient’s neck laxity. The goal for skin

Skin advancement and resection

229

tahir99 - UnitedVRG
vip.persianss.ir

Fig. 11.4.9 (A–F) A 61-year-old woman who underwent a 3-loop extended MACS-lift, submental liposuction, autologous fat graft to submalar region, and hyaluronic acid
ﬁllers to the perioral area. The result shown is at 12 months.

B

A

polyglactin braided suture. The author prefers the version of
this suture that contains triclosan, an antibacterial agent in
order to diminish risk of stitch abscess. Before leaving the
deep tissue, it is necessary to place the skin ﬂap over the tissue
and observe for unresolved bunching and tissue tethering at
the margins of the undermined area. Scissor removal of protruding fat may be needed in order to produce a smooth tissue
surface inside the loops. Imbrication of tissue in the region
just anterior to the tragus is important in order to preserve
this normal sulcus.

Surgical strategy

E

B

F

C

tahir99 - UnitedVRG
vip.persianss.ir

Fig. 11.4.10 (A–I) This 56-year-old woman developed a relapse of neck soft tissue laxity after a MACS-lift. She underwent a secondary procedure with the placement of
both neck and cheek sutures. The result shown is at 12 months after the revision surgery.

D

A

Wound closure is also straightforward with absorbable
5-0 monoﬁlament in the deeper layers and 5-0 and 6-0
polypropylene skin sutures places as interrupted and continuous (horizontal mattress).
Dressings involve customary facelift dressings. The author
personally prefers some silicone-backed foam for the anterior
neck if lipoplasty has been performed. Otherwise, aftercare is
similar to standard facelift procedures.

SECTION I •11.4• Facelift: Facial rejuvenation with loop sutures, the MACS lift and its derivatives

excision is to have a tension free closure with wound margins
coapted against each other.
The author’s personal technique uses approximately 1 cc
of ﬁbrin glue (5 units/mL dilution) that is sprayed on the ﬂaps
and held for 3 min. I ﬁnd that this diminishes ecchymosis
formation and eliminates the requirement for drains. Care
must be given to not apply excessive ﬁbrin glue as it can
interfere with revascularization of the ﬂaps.

230

G

H

1. Tonnard P, Verpaele A, Monstrey S, et al. Minimal
access cranial suspension lift: a modiﬁed S-lift. Plast
Reconstr Surg. 2002;109(6):2074–2086.
2. Tonnard P, Verpaele A. The MACS-lift short-scar
rhytidectomy. St Louis: Quality Medical; 2004.
3. Tonnard P, Verpaele A, Gaia S. Optimising results from
minimal access cranial suspension lifting (MACS-lift).
Aesthetic Plast Surg. 2005;29:213.
4. Tonnard P, Verpaele A. Short scar face lift, operative
strategies and techniques. St Louis: Quality Medical
Publishing, 2007.

References

The MACS-lift is a facelift technique which is ideally suited
for the lower and middle third of the face. By using strategically placed sutures, deep tissues are repositioned without the
dangers of deeper dissection. The vertical vector ensures that
many patients beneﬁt from a short scar approach with a faster
recovery. The technique is adaptable to a wide cross section
of patients, and it can be mastered by most surgeons who are
willing to learn a new technique.

Summary

Three representative cases utilizing the MACS-lift concept
are shown in Figures 11.4.9 and 11.4.10.

Fig. 11.4.10, cont’d

231

tahir99 - UnitedVRG
vip.persianss.ir

5. Aston S, Steinbrech, D, Walden J. MACS facelift.
In: Tonnard P, ed. Aesthetic plastic surgery. Philadelphia:
Saunders-Elsevier; 2009:137–149.
6. Labbé D, Franco R, Nicolas J. Platysma suspension and
platysmaplasty during neck lift: anatomical study and
analysis of 30 cases. Plast Reconstr Surg. 2006;117(6):
2001–2007.
7. Mendelson B, Muzaffar AR, Adams WP Jr. Surgical
anatomy of the midcheek and malar mounds. Plast
Reconstr Surg. 2002;110(3):885–896.
8. Besins T. The ‘R.A.R.E.’ technique (reverse and
repositioning effect): the renaissance of the aging
face and neck. Aesthetic Plast Surg. 2004;28(3):
127–142.
9. Rohrich RJ, Pessa, J E. The fat compartments of the face.
Plast Reconstr Surg. 2007;119:2219–2227.
10. Gardetto A, Dabernig J, Rainer C, et al. Does a
superﬁcial musculoaponeurotic system exist in the
face and neck? An anatomical study by the tissue
plastination technique. Plast Reconstr Surg. 2003;111(2):
673–675
11. Mazza E, Papes O, Rubin MB, et al. Simulation of the
aging face. J Biomech Eng. 2007;129(4):619–623.
12. Barbarino G, Jabareen M, Trzewik J, et al. Biomedical
Simulation: Physically based ﬁnite element model of the face.
Berlin: Springer-Verlag; 2008:1–10.
13. Barbarino G, Jabareen M, Trzewik J, et al. Development
and validation of a three-dimensional ﬁnite element
model of the face. J Biomech Eng. 2009;131:1–10.

I

References

2013, Elsevier Inc. All rights reserved.

©

Rhytidectomy is a procedure that continues to evolve as surgeons seek to offer patients natural rejuvenation with reduced
morbidity. Over the years, we have witnessed an evolution of
techniques ranging from basic skin lifts to superﬁcial musculoaponeurotic system (SMAS) procedures to even more
complex, deep-plane operations in search of an operation that
reliably restores facial form with minimal morbidity.1 More
recently, the need for extensive incisions for rhytidectomy has
also been questioned. It has become increasingly clear that not
all patients require the full classic temporal preauricular and
retroauricular incisions.2 The incision, as well as the planes or
levels of facial dissection, should be individualized for each
patient, in-keeping with the physical changes related to aging
and the desired result. As more patients seek facial rejuvenation at an earlier age, the need for surgical solutions that are

Introduction

SMASectomy advantages
䊏 Minimal SMAS dissection
䊏 Greater tension can be put on SMAS re-approximation
䊏 Malar fat pad can be elevated
䊏 Reduces skin undermining
䊏 Reduces tension of skin ﬂap
䊏 Simple and direct.
Avoiding SMASectomy pitfalls
䊏 Keep parotid fascia intact
䊏 Maintain correct plane from parotid edge to malar eminence
䊏 Suture at proper level
䊏 Feather all irregularities.

SYNOPSIS

Daniel C. Baker

tahir99 - UnitedVRG
vip.persianss.ir

less invasive and that involve less downtime is becoming
increasingly important.3
When SMAS dissection ﬁrst became popularized after
the work of Mitz and Peyronie in 1976, many surgeons
dissected the SMAS directly overlying the parotid gland
developing a SMAS ﬂap which was rotated to elevate the
deeper tissue. I (the author) initially utilized this form of
SMAS dissection beginning in the late 1970s and continued
with it into the mid-1980s but overall, was disappointed with
the effects of a simple elevation and tightening of the lateral
superﬁcial fascia. Speciﬁcally, there was little difference in
overall facial contour whether I had performed a SMAS ﬂap
or plication.
As greater experience was gained with SMAS dissection, it
became obvious that for the superﬁcial fascia to produce any
effective contour change in facelifting, it was necessary to
elevate the SMAS anterior to the parotid gland. The problem
of more extensive SMAS dissection is that facial nerve branches
are placed in greater jeopardy.4,5 It was also noted that the
superﬁcial fascia tends to thin out as it is dissected more
anteriorly, making the SMAS easy to tear. A SMAS dissection
that is not raised as a continuous fascial sheet but rather is
raised with several tears in it is a poor substrate for holding
the tension of contouring the face. For these reasons, the
author felt that an extensive SMAS dissection was often not
warranted in most patients and offered little long-term beneﬁt
when compared with SMAS plication.
In 1992, the author realized that an alternative to formal
elevation of the SMAS was to perform a “lateral SMASectomy”,
removing a portion of the SMAS in the region directly overlying the anterior edge of the parotid gland at the interface of
the ﬁxed and mobile SMAS.6 Excision of the superﬁcial fascia
in this region secures mobile anterior SMAS to the ﬁxed
portion of the superﬁcial fascia overlying the parotid. The
direction in which the SMASectomy is performed is oriented
so that vectors of elevation following SMAS closure are perpendicular to the nasolabial fold or even more vertical, thereby

Aesthetic Surgery of the Face

Facelift: Lateral SMASectomy

11.5

SECTION I

Virtually all of the author’s procedural facelifts are performed
with the patient under monitored intravenous propofol sedation. Patients are given oral clonidine, 0.1–0.2 mg, 30 min
before surgery to control their blood pressure. The face
and neck are inﬁltrated with local anesthesia, 0.5% lidocaine
with 1:200 000 epinephrine, through use of a 22-gauge spinal
needle. The author injects the face before scrubbing to provide
the requisite 10 min for vasoconstriction.

Anesthesia

Operative technique

producing improvement not only of the nasolabial fold but
also of the jowl, jaw line, and midface.
The advantages of lateral SMASectomy are several when
compared with formal SMAS elevation.7 First, since the procedure does not require a formal SMAS ﬂap elevation, there
are fewer concerns about tearing of the superﬁcial fascia.
Second, the potential for facial nerve injury is less because the
majority of the dissection is carried over the parotid gland. If
the SMASectomy is performed anterior to the parotid, the
deep fascia (parotid masseteric fascia) similarly will provide
protection for the facial nerve branches as long as the resection of the superﬁcial fascia is done precisely and the deep
facial fascia is not violated. Third, because SMAS ﬂaps have
not been elevated, they tend to be more substantial in terms
of holding suture ﬁxation, and the problems of developing
postoperative dehiscence and relapse contour are reduced.
Because of the design of the lateral SMASectomy along the
anterior border of the parotid, the SMASectomy is performed
at the interface of the superﬁcial fascia ﬁxed by the retaining
ligaments and the more mobile anterior superﬁcial facial
fascia. On closure, this brings the mobile SMAS up to the
junction of the ﬁxed SMAS, producing a durable elevation of
both superﬁcial fascia and facial fat. In contrast, simple plication pulls on unreleased facial fascia (still bound by the retaining ligaments) such that proper vectors of elevation and
obtaining long-lasting ﬁxation can be problematic.
In the author’s practice, utilizing the lateral SMASectomy
technique, we are conﬁdent that we can obtain consistently
good results with minimal risk, complications, and morbidity,
and a speedy postoperative recovery. This method represents
a rapid, safe, and reproducible operation, allowing the surgeon
the versatility obtained with formal SMAS ﬂap undermining
while producing both the safety and rapidity of SMAS plication. However, we not apply this technique in every patient,
and patients with a thin face, where fat needs to be preserved,
get an excellent result with just a skin undermining, SMAS
plication and redraping.
There are certainly other rhytidectomy techniques that
produce excellent results.8 Each surgeon must adopt a technique that serves his or her patients best. Ideally, the technique should be safe, consistent, easily reproducible, and
applicable to a variety of anatomic problems. The surgeon
must also have the versatility to adapt and modify his or
her technique to the needs and desires of each patient. At
present, the lateral SMASectomy provides this for many of
my patients.

233

tahir99 - UnitedVRG
vip.persianss.ir

All skin ﬂap undermining is performed under direct
vision (with scissors dissection) to minimize trauma to the
subdermal plexus and preserve a signiﬁcant layer of subcutaneous fat on the undersurface of the ﬂap. Subcutaneous
dissection in the temporal region is preferable, because
the skin seems to redrape better. (I believe that hair loss
results primarily from tension rather than superﬁcial undermining.) Therefore, dissection in this area is done directly
against superﬁcial temporal fascia (temporoparietal fascia.)
Subcutaneous dissection in the temporal region must be performed carefully to avoid penetrating the superﬁcial temporal
fascia that protects the frontal branch of the facial nerve. All
dermal attachments between the orbicularis oculi muscle and
the skin are separated up to the lateral canthus.
Dissection extends across the zygoma to release the zygomatic ligaments but stops several centimeters short of the
nasolabial fold. I have never believed that further dissection
provides signiﬁcant beneﬁts; on the contrary, the only result
is increased bleeding. In the cheek, dissection releases the

Skin ﬂap elevation

When the temporal hairline shift is assessed as minimal, the
preferred incision is well within the temporal hair. With
this incision, it is often necessary to excise a triangle of skin
below the temporal sideburn at the level of the superior
root of the helix in order to prevent over elevation of the
sideburn.
When a larger skin shift is anticipated or the distance
between the lateral canthus and temporal hairline is >5 cm,
the author prefers an incision a few millimeters within the
temporal hairline. Although this is a compromise, the alternative of a receding temporal hairline is rarely acceptable to a
female patient. When the incisions are executed properly,
these scars heal well and are easy to revise or camouﬂage. The
only exception might be in a patient who has deeply pigmented skin in whom the scar will contrast and appear as a
white line. The temporal hairline incision should be made
parallel to the hair follicles and no higher than the frontotemporal hairline.
The temporal hairline incision allows for more vertical
elevation of the facial ﬂap without changing the hairline.
Other indications for this incision are a receding hairline from
previous facelifts and a ﬁne, fragile hairline.
The choice of preauricular incision is up to the surgeon.
When executed properly, all of these incisions heal well
and are imperceptible. I (the author) usually prefer a curved
incision anterior to the helix and continue inferiorly anterior
to the tragus in a natural skin fold. This practice preserves
the thin, pale, hairless tragal skin and its demarcation from
the usual coarser, thicker, darker cheek skin with its lanugo
hairs. I perform intratragal incisions in patients in whom
the cheek and tragal skin are similar and the tragal cartilage
is not sharp or prominent. Closure must be without tension
and the ﬂap overlying the tragus should be defatted to
dermis.
In short scar facelifting, efforts are made to end the incision
at the base of the earlobe, but sometimes a short retroauricular
incision is often necessary to correct a dog-ear after the facial
ﬂap rotation (Fig. 11.5.1).

Incisions

Operative technique

SECTION I •11.5• Facelift: Lateral SMASectomy

The author opens the neck in patients who had active platysma
bands on animation, and therefore, the medial approximation

Open submental incision with medial
platysma approximation

Whenever possible, I prefer closed suction assisted Lipoplasty
in the neck and jowls. I use a 2.4 mm Mercedes tip cannula,
keeping it under constant, steady motion in the subcutaneous
space. I attempt to leave a layer of fat subcutaneous fat on the
undersurface of the cervical skin. If I suction the jowls, this is
always done conservatively. I rarely suction or remove subplatysmal fat because: (1) the facial nerves run just beneath
the platysma, and (2) any patient who has signiﬁcant subplatysmal fat probably has a fat, round face, so removing
subplatysmal fat could create an over-operated look.
I usually perform lipoplasty before elevating the skin ﬂaps.
In doing so, I am careful not to over-suction the portion of the
SMAS platysma that will be elevated over the mandible with
the lateral SMASectomy.

Defatting the neck and jowls

masseteric-cutaneous ligaments and, if necessary, the mandibular ligaments.
Subcutaneous dissection continues over the angle of the
mandible and sternocleidomastoid for 5–6 cm into the neck,
which exposes the posterior half of the platysma muscle. If a
submental incision has been made, the facial and lateral neck
dissection is connected through and through to the submental
dissection.

Usual lower border of
undermining

Subcutaneous undermining
into neck allows for
exposure of platysma
and skin redraping

Optional preauricular
or intratragal incision

Preferred incision

234

Fig. 11.5.1 Incisions and extent of skin undermining.

tahir99 - UnitedVRG
vip.persianss.ir

The outline of SMASectomy is marked on a tangent from
the lateral malar eminence to the angle of the mandible, essentially in the region along the anterior edge of the parotid
gland. In most patients, this involves a line of resection
extending from the lateral aspect of the malar eminence
toward the tail of the parotid gland. Usually, a 2–4 cm segment
of superﬁcial fascia is excised, depending on the degree of
SMAS-platysma laxity (Fig. 11.5.3).

Lateral SMASectomy including
platysma resection

provides another vector to enhance the cervicomental recontouring (Fig. 11.5.2).
The submental incision is made either in the submental
crease or just anterior to it. The subcutaneous dissection is
performed with the neck hyperextended, and undermining is
usually to the level of the thyroid cartilage and angle of the
mandible. Suction-assisted lipoplasty is then performed with
a large, single-hole cannula under direct vision. Direct fat
excision is performed if necessary, but to avoid depressions,
subplatysmal fat is rarely removed.
The medial borders of the platysma muscle are identiﬁed
and elevated for several centimeters. To break the continuity
of the bands, a wedge of muscle is removed at the level of the
hyoid. The medial borders of the muscle are then sutured
together with interrupted buried 4-0 PDS (Ethicon Inc.,
Somerville, NJ).
The submental incision is left open to allow for ﬁnal hemostasis and recontouring after communication with the facial
dissection and completion of the lateral SMASectomy.

Submental incision
in normal skin crease.
Undermining
connects laterally

Usual extent of
subcutaneous
undermining to
lateral canthus
and release of
malar ligaments

Optional temporal
incision for
recessed hairlines

Fig. 11.5.3 Lateral SMASectomy.

Undermining posterior border
of platysma for advancement
to mastoid

Resection is at interface of
fixed and mobile SMAS.
Width of resection
determined by SMAS laxity
and desired de-bulking

Lateral SMASectomy
extends from tail of
parotid to lateral
canthus

Wedge resection of
4-5cm medial
platysma border
to interrupt bands

Platysma flap
sutured to mastoid
periosteum (lateral
oblique vector)

Suture from submandibular
platysma SMAS to anterior
tympano-parotid fascia
(vertical vector)

SMAS and platysma
approximation suspension.
Suture is just beneath
SMAS

Fig. 11.5.2 Platysmaplasty and SMASectomy advancement
vectors.

235

tahir99 - UnitedVRG
vip.persianss.ir

The various vectors accomplish corrections of the anterior
neck, the cervicomental angle, the jowls, and the nasolabial
fold. The ﬁrst key suture grasps the platysma at the angle of
the mandible and advances it in a posterosuperior direction;
it is secured with 2-0 Maxon (United States Surgical Corp.,
Norwalk, CT) to the ﬁxed lateral SMAS overlying the parotid
(see Fig. 11.5.2). This action lifts the cervical platysma and
cervical skin.
After SMAS resection, interrupted 3-0 PDS buried sutures
are used to close the SMASectomy, ﬁxed lateral SMAS being
evenly sutured to more mobile anterior superﬁcial fascia
(see Fig. 11.5.2). Vectors are usually perpendicular to the
nasolabial fold. The last suture lifts the malar fat pad, securing
it to the malar fascia. It is important to obtain a secure ﬁxation
to prevent postoperative dehiscence and relapse of facial
contour.

Vectors

In SMAS resection, the author likes to pick up the superﬁcial fascia region of the tail of the parotid, extending the resection from inferior to superior in a controlled fashion. When
SMAS resection is being performed, it is important to keep
the dissection superﬁcial to the deep fascia and avoid dissection into the parotid parenchyma. Note that the size of the
parotid gland varies from patient to patient; consequently, the
amount of protection for the underlying facial nerve branches
also varies. Despite this, as long as one carries the dissection
superﬁcial to the deep facial fascia, ensuring that only the
superﬁcial fascia is resected, facial nerve injury and parotid
injury will be prevented. In essence, this is a resection of the
superﬁcial fascia in the same plane of dissection in which one
would normally raise a SMAS ﬂap.

Medial and lateral
platysma vectors create
a muscular hammock
support and define
the jawline

Submandibular
vertical vector

Facial vectors

Malar fat pad vector

Operative technique

B

SECTION I •11.5• Facelift: Lateral SMASectomy

If ﬁrm monoﬁlament sutures are used, such as PDA or
Maxon, the sutures should be buried and sharp ends on the
knot trimmed. Final contouring of any SMAS or fat irregularities along the suture line is completed with scissors. Fat can
also be trimmed at the sternomandibular trough, ﬁnal contouring being accomplished with lipoplasty.
In the thin face where facial soft tissue should be preserved,
SMAS plication is a viable alternative. Instead of an incision
line into the SMAS, a row of plication sutures is placed, utilizing the same vectors, the same suture tension and the same
suture material as with the SMASectomy. Skin redraping completes the procedure (Fig. 11.5.4).

Fig. 11.5.5 (A–D) A 79-year-old: face and neck, platysmaplasty, chin implant.

A

Zygomatic arch

Temporalis fascia

236

D

Fig. 11.5.4 Optional plication of SMAS, for thin
faces when debulking is not indicated.

tahir99 - UnitedVRG
vip.persianss.ir

After SMAS and platysma approximation, some tethering
of the skin might appear at the anterior and submandibular
skin. Suture ﬁxation is at the level of the insertion of the superior helix. The author prefers to use a buried 3-0 PDS through
the temporal fascia with a generous bite of dermis on the
skin ﬂap. Closure is under minimal to moderate tension.
Staples are used to close any incisions in the hair. A wedge
is usually removed at the level of the sideburn to preserve

Skin closure, temporal and
earlobe dog-ears

C

Plication of
mobile to fixed SMAS

Last suture lifts
malar fat pad

B

B

C

C

1. Baker DC. Deep dissection rhytidectomy: A plea for
caution. Plast Reconstr Surg. 1994;93:1498–1499.

References

the hairline. If an anterior hairline incision has been made,
I like to close it with buried 5-0 Monocryl sutures (Ethicon,
Inc.) and 5-0 nylon sutures. Extra time and attention must be
sent on this closure to eliminate any dog-ears and obtain the
ﬁnest scar.
Excess skin is then trimmed from the facial ﬂap so that
there is no tension on the preauricular closure. Wound edges
should be “kissing” without sutures. Trimming at the earlobe
must also be without tension, and the skin ﬂap is tucked
under the lobe with 4-0 PDS sutures, taking a bite of the
earlobe dermis, cheek ﬂap dermis, and conchal perichondrium to minimize any tension (if a short scar facelift is performed a small dog-ear might be present behind the earlobe;
this is easily trimmed and tailored into a short incision in the
retroauricular sulcus). A closed suction drain is usually
brought out through a separate stab in the retroauricular
sulcus (Figs 11.5.5–11.5.7).

D

D

237

tahir99 - UnitedVRG
vip.persianss.ir

2. Baker DC. Lateral SMASectomy, placation and short scar
facelifts: indications and techniques. Clin Plast Surg.
2008;35:533–550.
3. Baker DC. Short scar facelift. In: Aston SJ, Steinbrech D,
Walden J, eds. Advances in Aesthetic Surgery London:
Elsevier; 2009.
4. Baker DC, Conley J. Avoiding facial nerve injuries in
rhytidectomy. Anatomical variations and pitfalls. Plast
Reconstr Surg. 1979;64:781.
5. Baker DC. Complications of cervical rhytidectomy. Clin
Plast Surg. 1983;10:543–562.
6. Baker DC. Lateral SMASectomy. Plast Reconstr Surg.
1997;100:509–513.
7. Baker DC. Lateral SMASectomy. Semin Plast Surg. 2002;16:
417–422.
8. Alpert BS, Baker DC, Hamra ST, et al. Identical twin face
lifts with differing techniques: a 10-year follow-up. Plast
Reconstr Surg. 2009;123:1025–1036.

Fig. 11.5.7 (A–D) A 68-year-old: face and neck, platysmaplasty, chin implant, excise buccal fat.

A

Fig. 11.5.6 (A–D) A 62-year-old: face and necklift-platysma, peel face.

A

References
Aesthetic Surgery of the Face

2013, Elsevier Inc. All rights reserved.

©

Surgical rejuvenation of the aging face has evolved into one
of the most frequently performed surgical procedures in the
United States. Facelifting, initially performed as a skin tightening procedure since the early 1900s, has technically matured
during the last quarter of a century. This evolution is directly
related to the scientiﬁc investigation of facial soft tissue
anatomy, resulting in a better understanding of the facial anatomic changes which occur with aging. Over the last 30 years,
a plethora of procedures have evolved which utilize a variety
of technical approaches, having as a common goal the reconstruction of aging-related anatomic changes.
Both the public’s perception as well as the aesthetic concepts in facelifting have similarly evolved over time. Initially,
both patients and surgeons focused solely on the laxity which
occurs with facial aging, attempting to tighten what was
loose rather than shape the face. Hence the term “facelift” (as
opposed to “facialplasty”), a mechanical term implying a procedure, the goal of which is to lift what has fallen. Unfortunately,
this mechanical approach to facial rejuvenation often produced a tight-appearing, operated look, the stigma of the
“wind-tunnel appearance” so often associated with surgical
rejuvenation of the aging face. Nonetheless, based on a better
understanding of facial soft tissue anatomy and the anatomic
changes which occur in aging, facelifting has developed into
both a reconstructive procedure (whose goal is to reconstruct
the anatomic changes which occur in aging) as well as a more
artistically deﬁned technique, which attempts to enhance
facial appearance while minimizing signs that a surgical procedure, has been performed.
There are many treatment goals in facelifting besides
simply correcting the hallmarks of the aging face, including
improvement of the nasolabial folds, facial jowling and correction of obliquity of cervical contour. As important as the
mechanical aspects of tightening a loose, aged face, are the

Introduction

James M. Stuzin

vip.persianss.ir

aesthetic concepts of improving facial shape and bringing out
the beauty in the face which existed during youth. To these
goals, the surgeon attempting facial rejuvenation must have
a thorough understanding of facial soft tissue anatomy, comprehend the anatomic changes which occur in aging which
produce a change in facial shape, and understand the ideal
facial shape which can be obtained for a particular patient.
Artistic design of surgical access incisions to minimize scar
perceptibility, as well as prevent hairline distortion, is also key
in preventing surgical stigmata.
The evolution of aging in the human face is complex
and multifactorial. Problems that the plastic surgeon confronts in midface rejuvenation include: (1) the dermal component of aging related to intrinsic and extrinsic skin changes
(dermal elastosis); (2) facial fat descent; (3) facial deﬂation,
which tends to be regionally speciﬁc; (4) radial expansion
as facial fat becomes situated centrifugally away from the
facial skeleton; and (5) the degree of skeletal support of the
soft tissue which inﬂuences both loss of volumetric highlights,
as well as the descent of facial fat.1–4 All of these factors
inﬂuence facial shape changes with aging. Individual patients
will exhibit various degrees of these problems at the time
they request surgery, and each component of the aging
face should be addressed according to individual patient
needs.
Evaluation of patient photographs taken during youth and
middle age are helpful in determining how a speciﬁc patient
has aged. Young photographs will usually demonstrate the
location of the volumetric highlights present in youth, or
serve to document areas which have deﬂated over time, delineating both the position and vector of facial fat descent. These
factors illustrate patient-speciﬁc changes in facial shape from
youth to middle age, as well as clarifying the possibilities of
methods which facial fat repositioning can improve and
restore shape. From my perspective, the restoration of facial
shape is a more worthy aesthetic goal than attempting to
tighten a loose face.

Facelift: The extended SMAS technique in facial rejuvenation

11.6

SECTION I

The communication between the superﬁcial and deep facial
fascia occurs at the level of the retaining ligaments which are
discussed in Chapter 11.1. These structures ﬁxate facial soft
tissue in normal anatomic position, resisting gravitational
forces.1,7 In the evolution of midface aging, the zygomatic
and masseteric cutaneous ligaments bear particular attention.
The zygomatic ligaments originate from the periosteum of the
malar region. Their function is to ﬁxate the malar pad to the
underlying zygomatic eminence in the youthful face.
Support of the soft tissues of the medial cheek is provided
from a series of ﬁbrous bands that extend along the entire
anterior border of the masseter muscle. These are the “masseteric cutaneous ligaments”, and are identiﬁed superiorly in
the malar area where they mingle with the zygomatic ligaments and extend along the anterior border of the masseter
as far inferiorly as the mandibular border. These ﬁbers represent a coalescence between the superﬁcial and deep fascia,
extending from the masseter muscle vertically to insert into
the overlying dermis. These masseteric ligaments support the
soft tissues of the medial cheek superiorly above the mandibular border in youth.
The surgical signiﬁcance of the retaining ligaments is that
they represent the anatomic communication between superﬁcial and deep facial fascia. As this support system becomes

Retaining ligaments

The anatomic basis that allows rhytidectomy to be performed
safely is that the facial soft tissue is arranged as a series of
concentric layers. This concentric arrangement allows dissection within one anatomic plane to proceed completely separate from structures lying within another anatomic plane.
The layers of the face are the: (1) skin; (2) subcutaneous
fat; (3) SMAS (superﬁcial facial fascia); (4) mimetic muscles;
(5) parotidomasseteric fascia (deep facial fascia); and (6) plane
of the facial nerve, parotid duct, buccal fat pad, and facial
artery and vein. (This information is thoroughly reviewed in
Chapter 6.)
In an overview of the architectural arrangement of the
facial soft tissue, the essential point is that there is a superﬁcial
component of the facial soft tissue which is deﬁned by the
superﬁcial facial fascia and includes the SMAS and those anatomic components which move facial skin (including superﬁcially situated mimetic muscle invested by SMAS, the
subcutaneous fat, and skin). This is in contrast to the deeper
component of the facial soft tissue, which is deﬁned by the
deep facial fascia and those structures related to the deep
fascia (including the relatively ﬁxed structures of the face,
such as the parotid gland, masseter muscle, periosteum of the
facial bones, and facial nerve branches). As the human face
ages, many of the stigmata which are typically seen in aging
relate to a change in the anatomic relationship which occurs
between the superﬁcial and deep facial fascia. With aging,
facial fat descends in the plane between superﬁcial and deep
facial fascia, and the radial expansion of the superﬁcial soft
tissue away from the facial skeleton occurs within this plane.
In the author’s opinion, these anatomic changes justify repositioning facial fat through subSMAS dissection to restore
facial shape.5,6

Anatomic considerations

239

tahir99 - UnitedVRG
vip.persianss.ir

Youthful faces are full of well supported facial fat. Over time,
deﬂation occurs, and tends to be most apparent in regions of
the face with a high density of retaining ligaments. For this
reason, the areas which are noted to be volumetrically full in

Volume loss and facial deﬂation

As the human face ages, facial fat descends and with it facial
shape changes. Typically, the youthful face is full of wellsupported fat. Volumetric highlights are located within facial
aesthetic subunits, which have a high density of retaining
ligaments (zygomatic eminence and zygomatic arch, preparotid, orbital rim) and serve to ﬁxate this volume of fat to
underlying structures. Juxtaposed to the volumetric fullness
(or convexity) of the malar and preparotid region is commonly a concavity within the submalar region, overlying
the buccinator muscle and buccal recess. The combination
of fullness in the malar region and lateral cheek, associated
with submalar concavity and a well-deﬁned mandibular
border, accounts for the angular, tapered appearance of the
youthful face.
With aging, facial fat can descend and produce signiﬁcant
changes in facial shape. In middle-age, as ligamentous support
becomes attenuated, facial fat volumetrically becomes situated anteriorly and inferiorly in the cheek, producing a
contour that is square and bottom heavy with little differential
between malar highlights and submalar fat. As facial fat is
situated more inferiorly in the face, middle-aged faces appear
vertically longer than young faces (Fig. 11.1.4).3,4

Descent of facial fat

As the human face ages, facial shape changes, morphologic
facial changes are multifactorial. Some of these changes are
straightforward to address, while others remain difﬁcult
technical challenges. A paradox has always been that facial
anatomy (in terms of basic soft tissue architecture) is essentially unchanged from youth to middle-age, but facial appearance changes greatly over time and is patient speciﬁc.
Although each face ages differently, there are common themes
noted in all aging faces.

Aesthetic analysis and
treatment planning

attenuated, facial shape changes. The position of the retaining
ligaments also dictates the degree of dissection required in a
facelift. To adequately mobilize the skin ﬂap, the dissection
needs to be carried at least to the peripheral extent of the
retaining ligament system, speciﬁcally dissecting the skin ﬂap
into the malar region, as well as past the anterior border of
the masseter. Similarly, the location and restrictiveness of the
retaining ligaments dictates the degree of SMAS elevation
required to adequately release the superﬁcial fascia. In general,
this requires the surgeon to extend the SMAS dissection into
the malar region, releasing the superﬁcial fascia from the
restraint of the zygomatic ligaments, the upper masseteric
ligaments, as well as medial to the anterior border of the
parotid.

Aesthetic analysis and treatment planning

youth (malar, preparotid, lateral and infraorbital rim, lateral
chin) become volumetrically deﬂated over time. With deﬂation, soft tissue becomes less supported and therefore appears
lax. Youthful faces have a smooth blending of contour between
the aesthetic subunits of the face. Middle-aged faces, secondary to both deﬂation and facial fat descent, develop lines of
demarcation between one region of the face and another,
which is intuitively identiﬁed as old. An accurate aesthetic
treatment plan to improve facial shape requires repositioning
descended soft tissue into areas of facial deﬂation to improve
shape, not only by restoring volume to the position noted in
youth, but also serving to blunt the lines of demarcation
between aesthetic subunits. Volumetric augmentation through
autologous fat injection or other injectable soft tissue ﬁllers
are ancillary agents, which can be useful in augmenting areas
of deﬂation.
Deﬂation in the aging face is a complex process which tends
to be regional and age-speciﬁc. Key elements in understanding how deﬂation occurs have been enlightened following an
elucidation of the compartmentalization of subcutaneous fat
within the cheek as deﬁned by Rohrich and Pessa.8 What these
investigators realized was that the cheek subcutaneous fat,
rather than being homogeneous, is compartmentalized, with
each facial fat compartment surrounded by speciﬁc septal
membranes and with each compartment having an independent perforator blood supply. Aesthetically, the signiﬁcance of
compartmentalization of facial fat is that deﬂation tends to
occur within a speciﬁc region of the cheek, explaining why
the entire cheek does not deﬂate homogeneously (Fig. 11.6.1).

At the risk of over-simpliﬁcation, one key to understanding
facial deﬂation is the recognition of the location of zygomaticus major muscle, which traverses from the malar eminence
to the oral commissure. Deﬂation of the cheek lateral to the
zygomaticus major muscle tends to occur independently from
deﬂation in the malar region, medial to the zygomaticus
major. For many patients, lateral cheek deﬂation develops at
an earlier age than malar pad deﬂation, and is often noted in
patients in their forties. Medial cheek and malar pad deﬂation
tend to occur later in life and is responsible not only for the
loss of volumetric support within the anterior cheek, but also
leads to the development of what has been termed the infraorbital V-deformity. Deﬂation in this region results in an apparent increase in the vertical length of the lower lid, as the
lid–cheek junction visually descends inferiorly into the poorly
supported anterior cheek (Fig. 11.6.2).
An interesting region of deﬂation develops in some patients
in the submalar region lateral to the oral commissure. In these
patients, deﬂation can result in accentuation of the submalar
concavity, which can become more obvious following the vertical soft tissue shifts associated with facelifting procedures.
An accentuation of submalar depression lateral to the oral
commissure can result in the development of what has been
termed “joker lines” or cross-cheek depressions, which are
a typical stigmata that a patient has undergone a facelift.
Avoidance of vertical soft tissue repositioning in conjunction
with volume addition in the submalar recess lateral to the oral
commissure is useful in preventing the accentuation of postoperative cross-cheek depressions (Fig. 11.6.3).9

Fig. 11.6.1 (A) Preoperative appearance of a 42-year-old patient with early facial aging resulting primarily from deﬂation. Note the hollowing effect within the lateral cheek
and preparotid region. Deﬂation in this young patient has occurred in the fat compartments lateral to the zygomaticus major muscle. (B) Postoperative result following face
and necklift. Note, as anteriorly situated fat is brought into the upper lateral midface, it ﬁlls the areas of deﬂation, thereby blunting the lines of demarcation between aesthetic
subunits which develop with age. Notice also the change in facial shape, which now appears more structured and supported following facial fat repositioning.

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

SECTION I •11.6• Facelift: The extended SMAS technique in facial rejuvenation

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

240

241

Fig. 11.6.3 A cadaver dissection illustrates the muscular insertions into the oral
commissure and modiolus. The small arrow overlies the facial portion of the
platysma, and points to the risorius muscle. The large arrow points to the depressor
anguli oris in the region where it merges with the platysma. Superiorly, note the
insertion of the zygomaticus major into the lateral commissure with a slip of
muscle inserting inferiorly into the modiolus. Following deﬂation in this area,
the medial component of the cross cheek depression develops in the watershed
between the elevator and the depressors of the lip. (From Lambros V, Stuzin JM.
The cross-cheek depression: surgical cause and effect in the development of the
“Joker Line” and its treatment. Plast Reconstr Surg 2008;122:1543.)

Not all facial aging is vertical and a major challenge in facial
rejuvenation is the radial expansion of facial soft tissue which
occurs along speciﬁc areas of the midface. In youth, the skin
and underlying subcutaneous fat are densely attached to the
deep facial fascia by retinacular ﬁbers which transverse
between skin, subcutaneous fat, superﬁcial fascia and insert
into the deep fascia and facial musculature. Over time, with
prolonged animation such as smiling, the skin along the
nasolabial line is forced deep to the subcutaneous fat, positioned lateral to the nasolabial fold, attenuating these retinacular attachments. Prolonged animation therefore forces
the skin and fat lateral to the nasolabial fold to expand radially and prolapse outward from the facial skeleton, accounting for much of the nasolabial fold prominence in the aging
face. Radial expansion lateral to the oral commissure and
marionette line similarly accounts for the prominence of the
jowl in many middle-aged patients, making the older face
appear square in shape and bottom heavy.4,10
Radial expansion is technically difﬁcult to correct, as there
are few surgical solutions to re-establish the retinacular attachments between skin, subcutaneous fat and deep fascia.
Nonetheless, repositioning of facial fat through some form of
support to the superﬁcial fascia will not only reposition fat
vertically, but will also provide some degree of internal repositioning such that the superﬁcial facial soft tissues lie closer
to the facial skeleton. As the soft tissues become situated
closer to the underlying deeper structures of the face, facial
morphology tends to be restored to a more youthful conﬁguration. Because of the technical difﬁculty to completely treat
radial expansion in many faces, incomplete correction of both
the jowl and nasolabial fold resulting in under-correction can

Radial expansion

Fig. 11.6.2 (A,B) Preoperative appearance of a 59-year-old male following a 90 pound weight loss from a gastric bypass procedure. Notice the signiﬁcant areas of facial
deﬂation along the infraorbital rim, lateral orbital rim and malar region. Also note the apparent length of the lower lid as the infraorbital V-deformity develops in association
with malar pad deﬂation. Note also the radial expansion of skin and fat lateral to the nasolabial fold, most marked on the right side. Not only does malar fat deﬂate and
descend, but attenuation of the retinacular connections between skin, fat and deep facial fascia lateral to the nasolabial line allows centrifugal prolapse of soft tissue which
accentuates nasolabial prominence. (C,D) Postoperative result. The areas of deﬂation along the infraorbital rim, lateral orbital rim, and malar region are improved as facial fat
has been repositioned into these regions. The nasolabial folds are somewhat improved following malar pad repositioning, but correction is incomplete, especially on the
right. Malar pad elevation helps to ﬂatten the prominent nasolabial fold, and improve the infraorbital V-deformity, but does little to correct radial expansion, with the skin
lateral to the nasolabial line remaining prolapsed from its attachments to the facial skeleton. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal
support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.)

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

Radial expansion

In youth, facial fat is situated overlying the malar and preparotid region. This malar fullness is juxtaposed to a concavity

Convexity of the malar region juxtaposed to
the concavity of the submalar region

Compared with wide faces, patients who present with vertical
maxillary excess often have long, thin faces on front view. As
facial fat descends in middle age, it becomes situated anteriorly and inferiorly in the face, and the face appears even
longer with age. Malar pad elevation and enhancing malar
volume in these types of patients is usually beneﬁcial. As
malar volume is enhanced and bizygomatic diameter is
increased, the face appears wider on the front view, detracting
from relatively excessive facial length (Fig. 11.6.5).

Facial length and the relative vertical heights of
the lower and middle-third of the face

The emphasis in facelifting over the last 30 years has focused
on malar pad elevation.2,11–19 While malar pad elevation and
restoration of malar highlights is an important factor in
improving facial shape, it needs to be patient-speciﬁc. Many
patients present preoperatively with wide faces, strong malar
eminences and large malar volume, with little evidence of
malar fat descent. In these individuals it is necessary to evaluate preoperatively the degree of malar pad elevation required
to improve facial shape. While limited degrees of malar pad
elevation can be helpful in patients who present with wide
bizygomatic diameters, in general, if the malar volume is signiﬁcantly enhanced in these types of individuals, the aesthetic
effect is to make a wide face appear even wider on the front
view postoperatively. In patients with adequate facial width,
the author tends to limit both SMAS release and malar pad
elevation to the lateral aspect of the zygomatic eminence such
that bizygomatic diameter is not increased postoperatively
(Fig. 11.6.4).

Facial width, bizygomatic diameter,
and malar volume

Facial shape and contour is intuitively evaluated when analyzing a patient for facial rejuvenation. Often the twodimensional considerations seen in photographs are the
easiest aspects of aging to identify, and such factors as nasolabial fold depth, jowl prominence, and cervical contour
become the primary objectives to improve appearance in the
middle-aged face. While these factors are certainly important
considerations in treatment planning, the more subtle threedimensional qualities of facial shape are equally important to
evaluate, and are greatly inﬂuenced by underlying skeletal
support.
In evaluating facial shape during preoperative analysis,
there follow some of the major factors which are helpful to
consider.4

Role of skeletal support in formulating
a surgical treatment plan

within the submalar region overlying the buccinator. As
patients age, the relationship between the malar and submalar
regions changes and with it, facial shape changes. As facial fat
descends and facial deﬂation occurs, there is less volume
overlying the malar eminence and an associated increase in
fullness resulting from radial expansion within the submalar
region. As the aesthetic relationship between the malar and
submalar region becomes modiﬁed with time, there is a loss
of the angular, tapered conﬁguration in shape noted in youth,
and middle-aged faces often appear oval. With greater facial
fat descent, and an increase in submalar fullness, older faces
appear square.
Preoperatively, an evaluation of the relationship between
the malar and submalar region on front view is an essential component of aesthetic treatment planning. For many
patients, a restoration in this relationship by increasing
malar highlights and malar volume, in association with a
restoration of concavity in the submalar region through
repositioning fat internally overlying the buccinator muscle
becomes a central component in improving facial shape
(Figs 11.6.6, 11.6.7).

Fig. 11.6.4 Facial width and bizygomatic diameter reﬂect the underlying degree of
skeletal support. Patients who exhibit strong malar eminences and wide bizygomatic
diameter often beneﬁt from having malar highlights restored, but usually do not
require signiﬁcantly enhancing malar volume (which will cause a wide face to
appear wider postoperatively). Shaping considerations in these types of faces
usually focus on improving the appearance of the lower two-thirds of the cheek,
speciﬁcally addressing jowl fat repositioning, as well as creating submalar
hollowing which improves the aesthetic relationship between malar and submalar
regions. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal
support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg
2007;119:362.)

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

SECTION I •11.6• Facelift: The extended SMAS technique in facial rejuvenation

be noted postoperatively despite heroic efforts at repositioning descended facial fat.

242

243

Fig. 11.6.6 (A) Preoperative appearance.
Note that facial shape is oval, secondary to
malar deﬂation associated with an increase
in submalar fullness. (B) Postoperatively,
following malar pad elevation, malar volume
is enhanced in association with a restoration
of submalar concavity, producing a more
angular appearance to facial shape. (From
Stuzin JM. Restoring facial shape in
facelifting: The role of skeletal support in
facial analysis and midface soft-tissue
repositioning. Plast Reconstr Surg
2007;119:362.)

excellent skeletal support for soft tissue repositioning and are,
therefore, less of a surgical challenge. In contradistinction,
patients with a short mandibular ramus, an open mandibular
plane angle and a short length of the mandibular body typically have poor skeletal support for midface and perioral soft
tissue repositioning. These patients are a greater surgical challenge in restoring facial shape, and often beneﬁt from volumetric augmentation, either alloplastic or autogenous, to
enhance skeletal support.

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

The vertical height of the mandibular ramus and the horizontal length of the mandibular body provide skeletal support
for the lower two-thirds of the face. Patients who present
with a normal mandibular ramus height, as well as adequate
horizontal length of the mandibular body, usually have

The vertical height of the mandibular
ramus and the horizontal length of
the mandibular body

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

Fig. 11.6.5 Long, thin faces often beneﬁt from an enhancement of malar volume. SMAS dissection and facial fat repositioning carried anteriorly over the zygomatic
eminence allows the surgeon to restore malar volume, thereby increasing bizygomatic diameter. When malar volume is enhanced, the face appears wider, detracting from the
relatively excessive facial length. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning.
Plast Reconstr Surg 2007;119:362.)

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

Radial expansion

All modern techniques share a commonality in that postoperative contour is largely dependent on facial fat repositioning
through some form of SMAS manipulation. The advantage
of formal SMAS ﬂap elevation lies in its aesthetic versatility. Once the superﬁcial fascia has been freed from the
restraint of the retaining ligaments, it offers the surgeon
several advantages, including: (1) vector versatility; (2) greater
control in terms of long-term vertical facial fat repositioning;
and (3) greater control in terms of long-term internal facial fat
repositioning.
Regarding vector versatility, dermal elastosis and skin
laxity in the aging face often does not occur in the same direction nor at the same rate as aging related to the descent of fat.
The main advantages of performing skin dissection separate
from SMAS dissection is that it allows these two layers to be
draped along vectors which are independent of one another
(Fig. 11.6.8).2,19–21 Another advantage of a two-layer SMAS
facelift is that the tension of contouring is placed on the superﬁcial fascia, thereby allowing the surgeon to use less tension
for skin closure. This improves control regarding scar perceptibility.20,21 In terms of vectors, in the author’s experience,
facial fat is commonly repositioned in a more vertical vector
than skin ﬂap redraping. Strong vertical shifting of the cervicofacial ﬂap is a maneuver that has traditionally been utilized
in many facelift techniques. While skin tightening can produce
a dramatic effect in terms of improvement of facial laxity, the

The aesthetic advantages of formal
SMAS elevation in a two-layer dual
plane SMAS facelift

Restoration of support to the underlying deeper facial soft
tissues has become the key ingredient to the approach to
improve facial aging. If the SMAS is thin, plication is an alternative method. Nonetheless, better contouring and longer
lasting results are obtained following a formal dissection
of the superﬁcial fascia. In the author’s experience, after the
superﬁcial fascia is freed from the restraint of the retaining
ligament, it slides freely, allowing greater control in vertically
repositioning of facial fat. Full release of the SMAS also allows
the superﬁcial fascia to better conform internally to the underlying deeper facial soft tissue and facial skeleton. Greater
control of internal fat repositioning provides for more complete correction of radial expansion.

Surgical technique: extended
SMAS dissection

aesthetic effects of vertical skin vectoring unfortunately have
been poorly delineated. Speciﬁcally, when skin is shifted in a
cephalad direction, the effect of skin tension commonly produces an accentuation of ﬂatness in the preparotid region, an
area that typically deﬂates with aging. In my opinion, vertical
skin shifting can produce an unnatural tightness to facial
shape, producing some of the typical stigmata associated with
rhytidectomy. If the surgeon has been successful in repositioning descended facial fat, the use of strong vertical skin tension
is neither desirable nor required to enhance the postoperative
result (Fig. 11.6.9).

Fig. 11.6.7 (A) Preoperatively, the patient shows a similar blunting of the relationship between the malar and submalar regions. (B) Postoperative appearance. Enhancing
malar volume (and bizygomatic diameter) and restoring the concavity within the submalar region make the face appear more angular, as well as vertically shorter. (From
Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.)

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

SECTION I •11.6• Facelift: The extended SMAS technique in facial rejuvenation

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

244

1

Video

The key to performing successful dissection of an extended
SMAS ﬂap is precise dissection of the skin ﬂaps during subcutaneous undermining, with care to leave a moderate amount
of fat intact on the superﬁcial surface of the SMAS, especially
in the regions where the SMAS is to be dissected. If the skin
ﬂaps are dissected so that little fat is left along the superﬁcial
surface of the SMAS, the SMAS becomes more difﬁcult to
raise, appearing thin, tenuous and prone to tearing. In a
SMAS-type facelift, much of the contouring that is obtained
is due to elevation and ﬁxation of the SMAS layer. The more
substantial the SMAS ﬂap, often the better long-term results
that can be obtained in terms of facial contouring. The use of
contralateral transillumination is helpful in providing a
clearer deﬁnition of the interface between subcutaneous fat
and superﬁcial fascia, allowing for greater precision in skin
ﬂap elevation.
Preoperatively, I (the author) decide the extent of subcutaneous skin ﬂap undermining based on the most medial aspect
of where I want to end the SMAS dissection, which typically
is situated just medial to the retaining ligaments. I prefer to

Fig. 11.6.8 The direction of SMAS redraping in the face tends to be cephalad in
its orientation as opposed to skin ﬂap redraping, which is oriented along a more
horizontal vector. The aesthetic versatility of vectoring the SMAS in a direction
independent of skin ﬂap redraping is a major advantage of a two-layer SMAS-type
facelift.

245

The dissection of the superﬁcial fascia allows the surgeon to
re-elevate jowl and descended malar fat back upwards into
the face toward their previous, normal anatomic location.2,5
In patients with prominent nasolabial folds and signiﬁcant
infraorbital hollowing, it is my feeling that the SMAS dissection should extend into the malar region in an effort to
re-elevate the malar fat pad back upward overlying the zygomatic eminence. An added beneﬁt of performing a more
extensive anterior dissection of the SMAS is that it frees this
layer from the restraint of both the zygomatic and masseteric
ligaments, and this anterior release provides for a more complete elevation of the facial fat below the oral commissure and
along the anterior portion of the jowl.
The incisions (Fig. 11.6.11) for extended SMAS dissection
begin approximately 1 cm inferior to the zygomatic arch to
ensure frontal branch preservation. This horizontal incision
is continued several centimeters forward to the region where
the zygomatic arch joins the body of the zygoma. At this
point, the malar extension of the SMAS dissection begins
with the incision angling superiorly over the malar eminence
toward the lateral canthus for a distance of 3–4 cm. On reaching the edge of the subcutaneous skin ﬂap in the region
of the lateral orbit, the incision is carried inferiorly at a 90°
angle toward the superior aspect of the nasolabial fold. A
vertical incision is designed along the preauricular region,
extending along the posterior border of the platysma to a
point 5–6 cm below the mandibular border. In essence, the
malar extension of the SMAS dissection simply represents
an extension of a standard SMAS dissection into the malar
region in an attempt to obtain a more complete form of deep
layer support.
The SMAS in the malar region is then elevated in continuity with the SMAS of the cheek. When elevating this ﬂap,
the ﬁbers of the orbicularis oculi, as well as the zygomaticus major and minor, are usually evident and the ﬂap is elevated directly along the superﬁcial surface of these muscles.
It is important to carry the dissection directly external to
these muscle ﬁbers, where a natural plane exists, remembering that the facial nerve branches lie deep to these muscular
bellies. The malar SMAS is then elevated until the ﬂap is
freed from the underlying zygomatic prominence. Freeing
of the SMAS completely from the zygomatic attachments is

SMAS elevation

limit the skin undermining several centimeters lateral to the
nasolabial fold rather than undermining the skin to this facial
landmark. The reason is that if one limits the dissection of the
skin ﬂap in the medial aspect of the cheek, this will preserve
some of the attachments that go from the deep fascia through
the SMAS to facial skin. The preservation of these attachments, followed by adequate undermining of the superﬁcial
facial fascia (SMAS), will allow the surgeon to re-elevate anteriorly displaced fat and skin through SMAS rotation rather
than to redrape the superﬁcial fascia completely independent
of skin ﬂap redraping. The ability to re-elevate and resuspend
facial soft tissue through SMAS rotation produces a more
pleasing aesthetic result and a greater degree of correction of
radial expansion within the cheek, as the facial fat is brought
internally to conform to the underlying buccinator muscle
(Fig. 11.6.10).

Surgical technique: extended SMAS dissection

an important technical point in obtaining the mobility necessary to reposition the malar soft tissue superiorly. To obtain
this mobility usually also requires a division of the upper
ﬁbers of the masseteric cutaneous ligaments, which will
expose the underlying body of the buccal fat pad. The cheek
portion of the SMAS dissection is performed beginning
directly overlying the parotid gland and then extending this
dissection anterior to the parotid utilizing a combination
of sharp and blunt dissection toward the anterior border of
the masseter.
In most patients, following extended SMAS dissection
of the cheek and malar regions, mobility of the soft tissues
lying lateral to the nasolabial fold remain restricted unless
the dissection is carried more medially. This restriction in
movement results from the undivided retaining ligaments
which originate medial to the zygomaticus minor. To improve
mobility, I commonly continue malar pad elevation medially in an area where I have not subcutaneously undermined
the skin. This dissection is carried directly in the plane between the malar fat and the superﬁcial surface of the elevators
of the upper lip. It is usually quite easy to delineate this
level of dissection after the malar SMAS elevation is complete,
and the superﬁcial surface of the elevators of the upper
lip visualized. The scissors are then inserted directly superﬁcial to the elevators of the upper lip and blunt dissection
is quickly performed by pushing the scissors in a series
of passes bluntly toward the nasolabial fold. I ﬁnd that when
we insert the scissors in the proper plane, the dissection
quickly glides through the malar soft tissues and I usually
will feel a “snap” as we dissect through the remaining

Repositioning and closure of the SMAS is then performed.
The malar SMAS ﬂap is advanced superio-laterally over the
zygomatic prominence in a direction perpendicular to the
nasolabial fold, and usually paralleling the zygomaticus
major muscle. After superior and lateral advancement, if a
malar augmentation is not planned, the excess tissue can be
excised and the ﬂap securely ﬁxated to the zygomatic periosteum with interrupted sutures (Fig. 11.6.13).
Once the malar ﬂap is secure, the cheek-SMAS ﬂap is
rotated superiorly perpendicular to the mandibular border.
This portion of the SMAS ﬂap is used to contour jawline and
jowl. The SMAS overlying the preauricular region and ear is
then treated as a transposition ﬂap and carried posteriorly
behind the ear, helping to restore tone to the submental region
and neck. Following trimming, the SMAS ﬂap is carefully
secured with multiple interrupted sutures. Occasionally, skin
dimpling is noted after securing the SMAS ﬂap and this
results from the forces of SMAS rotation on resuspended
facial skin. Skin dimpling is treated by simply performing
a bit more subcutaneous undermining prior to skin ﬂap
redraping.

SMAS ﬁxation

retaining ligaments. Once these structures are divided,
one notes greater mobility when traction is applied to the
malar portion of the SMAS ﬂap, translating into greater movement along the uppermost portion of the nasolabial fold
(Fig. 11.6.12).

Fig. 11.6.9 These two patients show the effect of vertical rotation of the cervicofacial ﬂap associated with hairline distortion. A skin ﬂap that is overly rotated in a cephalad
direction not only can compromise the temporal hairline, but also tends to produce ﬂatness in the lateral midface overlying the masseter and parotid. This imparts a tight,
unnatural appearance to the face. Also notice the effect of scar perceptibility when strong skin tension is used in an attempt to contour the aging face. (From Baker TJ,
Gordon HL, Stuzin JM. Surgical rejuvenation of the aging face, 2nd edn. St Louis: CV Mosby; 1995.)

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

SECTION I •11.6• Facelift: The extended SMAS technique in facial rejuvenation

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

246

B

247

Following proper contouring of the SMAS dissection, the
facial skin ﬂaps are rotated and closed in the direction decided
upon, based on preoperative evaluation. In general, these skin
ﬂaps are inset with a minimum degree of tension placed along
the key sutures and then the skin ﬂaps are trimmed with a
degree of redundancy between the key sutures to minimize
tension along the incision sites.
To summarize, the key points in mobilizing the superﬁcial
fascia from the restraint of the retaining ligaments of the cheek
are as follows:
1. The SMAS overlying the parotid gland and malar
eminence tends to be substantial and easy to dissect,
with both the parotid and zygomaticus major and
minor muscles protecting the underlying facial nerve
branches. These areas are very safe regions to begin
SMAS elevation and delineate the subSMAS plane.
2. The thinnest fascial component of an extended SMAS
dissection is in the region just lateral to the zygomaticus
major muscle, where the SMAS splits to invest the
3. The most difﬁcult portion of an extended SMAS
dissection is freeing the superﬁcial fascia from the
restraint of the superior masseteric ligaments, which
are lateral to the zygomaticus major muscle. If these
ligaments are not mobilized, restricted movement is
noted in the portion of superﬁcial fascia that affects
contouring along the lower nasolabial fold, oral
commissure and anterior jowl. The zygomatic branches
of the facial nerve are in close proximity to the upper
masseteric ligament. At times it can prove difﬁcult
to differentiate between ligaments and facial nerve
branches. Caution is stressed in this region of
dissection.

elevators of the upper lip. Dissecting the skin ﬂap
thinly in this region leaves a substantial amount of
subcutaneous fat intact along the surface of the
superﬁcial fascia, providing greater ease in SMAS
dissection and minimizing the possibility of tearing
this layer.

Fig. 11.6.10 (A) If an extended SMAS dissection is to be performed, it is important not to widely undermine the skin all the way to the nasolabial fold, but rather to
preserve some of the attachments that exist between the skin and the SMAS (the limit of subcutaneous undermining is the shaded area). If these attachments are left intact,
this allows the surgeon to simultaneously re-suspend undissected anterior facial skin at the time of SMAS rotation and ﬁxation. (B) It is important to understand which
portion of the SMAS ﬂap will affect facial contouring. In this diagram, the most superomedial aspect of the SMAS dissection affects contour along
the nasolabial fold, whereas the more lateral portion of the SMAS dissection is used to re-elevate jowl fat upward into the cheek. A portion of the SMAS ﬂap is rotated into
the postauricular region with the vector of rotation of this portion of the SMAS dissection affecting submental and cervical contouring.

A

Surgical technique: extended SMAS dissection

B

SECTION I •11.6• Facelift: The extended SMAS technique in facial rejuvenation

The biomechanics of SMAS repositioning have been previously described and are inﬂuenced by the degree of release,
vector of fat repositioning and how the superﬁcial fascia is
ﬁxated.22 As postoperative contour is dependent on each of
these factors, preoperative planning needs to be patientspeciﬁc in terms of the degree of SMAS release required, the

Variations in extended SMAS technique
to affect a restoration in facial shape

The incision design of an extended SMAS dissection allows
for complete release of the SMAS from its underlying retaining ligamentous attachment in the lateral midface. As surgeons, there is a tendency to believe that a greater degree
of SMAS dissection equates with a better result, but this

Release

vectors in which facial fat is repositioned, and the location and
method for SMAS ﬁxation.

Fig. 11.6.11 (A) In patients with malar deﬂation or malar pad descent, the author typically performs what is termed an extended SMAS dissection. By this, I mean I extend
the SMAS dissection into the malar region in an attempt to re-elevate ptotic malar fat back upward over the zygomatic prominence. The incisions begin at the junction
where the zygomatic arch joins the body of the zygoma. From this point, the incision in the SMAS is angled superiorly toward the lateral canthus and along the lateral
orbital rim. The incision in the SMAS is then carried medially and inferiorly toward the peripheral extent of skin ﬂap undermining, angling toward the uppermost portion
of the nasolabial fold (the amount of subcutaneous undermining is shaded in pink, whereas the amount of SMAS undermining is shaded in yellow.) (B) The malar-SMAS
dissection is then performed in continuity with the cheek-SMAS dissection. Dissecting in the malar region carries the dissection directly along the superﬁcial surface of
the zygomaticus major and usually exposes the lateral aspects of the zygomaticus minor as well. To obtain adequate mobility in terms of SMAS dissection, it is necessary
to elevate the malar portion of the dissection completely from the zygomatic eminence and free it from the zygomatic ligaments. To obtain mobility in terms of SMAS
movement affecting the jowl contour, the uppermost portions of the masseteric cutaneous ligament commonly are divided, especially where they merge with the zygomatic
ligaments of the malar area. If these ﬁbers are not divided, they will restrict the upward redraping of jowl fat. On division of the upper portion of the masseteric cutaneous
ligaments, the buccal fat pad becomes evident, and commonly the zygomatic nerve branches traversing toward the undersurface of the zygomaticus major muscle are
visualized. This diagram illustrates the typical degree of mobilization performed in our extended SMAS dissection.

A

248

has not been my experience. Rather, precision in the degree
of SMAS dissection and its release from the retaining ligaments as dictated by the aesthetic needs of a patient increases
surgical control and consistency in while minimizing
morbidity.3
How much to release the SMAS, and how high and anterior
to carry the SMAS dissection, needs to be decided preoperatively. As discussed previously, in patients who present with
adequate malar volume, wide bizygomatic diameter and little
evidence of malar pad descent, it is usually unnecessary to
carry the SMAS dissection medial to the lateral orbital rim
(although the author usually carries the dissection high within
the malar eminence to allow fat repositioning along the

Fig. 11.6.12 It is commonly necessary to extend the malar SMAS dissection more
peripherally than the subcutaneous dissection to obtain adequate ﬂap mobility of
the soft tissues lateral to the nasolabial fold. This portion of the dissection is easily
performed by simply inserting the scissors in the plane between the superﬁcial
surface of the elevators of the upper lip and the overlying subcutaneous fat. Once
the scissors are inserted in the proper plane, the surgeon bluntly dissects in a
series of passes past the nasolabial fold (area marked in green). As long as the
scissors remain superﬁcial to the elevators of the upper lip, motor nerve injury will
be prevented. Usually three or four passes are required to obtain adequate ﬂap
mobility.

249

All patients exhibit some degree of facial asymmetry.
Commonly, one side of the face is vertically longer and the

Vectors of fat elevation:
facial asymmetry

infraorbital and lateral orbital rims). Most commonly, these
types of patients require only a restoration of malar highlight
and not signiﬁcant anterior malar volume enhancement.
Limiting the SMAS dissection to the lateral aspect of the malar
eminence will not increase facial width on the front view.4
Typically, the shaping considerations for these patients is
focused on reducing fullness in the submalar region (Fig.
11.6.14).
Vertically long faces often beneﬁt from carrying the malar
portion of the extended SMAS dissection anteriorly, medial to
the lateral orbital rim so that malar volume restoration is
performed along the anterior aspect of the zygomatic eminence. Carrying the SMAS dissection more medially allows
the surgeon to enhance malar volume and restore malar
highlights anteriorly over the zygomatic eminence, thereby
increasing facial width on the front view (Fig. 11.6.15).

Fig. 11.6.13 The vectors of redraping of the extended SMAS ﬂap are determined
according to the preoperative evaluation of the patient and are generally more
cephalad than skin ﬂap redraping.

Vectors of fat elevation: facial asymmetry

Rights were not granted to include
this figure in electronic media.
Please refer to the printed publication.

SECTION I •11.6• Facelift: The extended SMAS technique in facial rejuvenation

Rights were not granted to include
this figure
in electronic media.
Please refer to the printed publication.

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

Fig. 11.6.15 Faces which are more dominated by their facial length (especially the lower third of the face) usually beneﬁt from malar volume restoration. To enhance malar
volume requires the SMAS dissection be carried toward the anterior aspect of the zygomatic eminence, such that malar volume is increased in this region. (From Stuzin JM.
Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.)

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

Fig. 11.6.14 Patients with wide bizygomatic diameters and good underlying skeletal support typically do not require a signiﬁcant anterior malar dissection to improve facial
shape. Most commonly, the SMAS dissection in these patients (while kept high), is extended only as medial as the lateral orbital rim, so that malar volume restoration is
limited to the lateral aspect of the zygomatic eminence. The shaping considerations for these types of faces usually emphasize reducing fullness within the submalar area,
as well as jowl fat elevation. Notice that postoperatively the patient’s face appears more tapered and thinner in morphology through facial fat repositioning without removal
of facial fat. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg
2007;119:362.)

$

250

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

251

short side of the face is usually wider than the long side. Malar
highlights are typically more superiorly located on the long
side of the face and, with age, facial fat tends to descend in a
more vertical direction on the long side. As facial asymmetry
and facial skeletal conﬁguration are asymmetric in most individuals, it follows that the vectors of fat elevation (SMAS
repositioning) should be speciﬁc for the right and the left side
of the face.
The vector in which the SMAS is repositioned has a signiﬁcant impact on the location and volume of elevated facial fat,
thereby inﬂuencing facial shape. Decisions regarding the
direction of SMAS vectoring for the right and left side of the
face are best determined preoperatively, as it is very difﬁcult
to make aesthetic vector judgments intraoperatively with the
patient recumbent.
SMAS vectors inﬂuence postoperative facial shape. Vertical
SMAS repositioning typically provides a larger amount of fat
for malar eminence enhancement, as well as allowing for a
reduction in fullness within the sub-malar region as fat is
forced internally along the concavity of the buccinator. For
this reason, vertical SMAS vectors are often indicated to
reshape round, full faces, allowing them to appear more
tapered and thinner postoperatively (Fig. 11.6.16). If the
SMAS is vectored more obliquely, there is less volume of fat
brought into the malar region and a greater volume of fat
repositioned into the submalar region. Oblique SMAS repositioning is therefore helpful in elderly patients who appear
gaunt over the buccal recess, as it allows the surgeon to volumetrically enhance the submalar region (Fig. 11.6.17).
In a two-layer SMAS-type facelift, the tension of contouring
is placed on the superﬁcial fascia rather than the skin envelope. For this reason, the fascial quality and tensile strength
of the superﬁcial fascia has an inﬂuence on both the longevity
of result, as well as the volume of fat which can be repositioned intraoperatively and maintained postoperatively. In
other words, soft tissue quality inﬂuences long term contour,
and is the primary reason why facelifts in young patients are
more predictable.
In an effort to improve fascial quality in a SMAS facelift,
for over a decade I incorporated Vicryl mesh into the SMAS
ﬁxation.3 It was my initial observation that incorporating
Vicryl mesh into ﬁxation improved not only longevity of
result, but greater aesthetic control. Nonetheless, I have
stopped using Vicryl mesh, as I have come to realize that
what was the predominant factor in improving ﬁxation is the
method in which the superﬁcial fascia was secured. Obtaining
a secure ﬁxation utilizing multiple sutures placed deeply
within the superﬁcial fascia allows the surgeon greater control
in postoperative shape. Suturing the SMAS securely under
moderate tension affects facial shape in two ways: (1) adding
more sutures allows the surgeon to stack volume in speciﬁc
areas of the midface, which is useful in augmenting areas
of deﬂation, as well as augmenting volume along the
malar eminence; (2) as the superﬁcial fascia is sutured under
tension, facial fat is not only repositioned vertically, but also

SMAS ﬁxation

Fig. 11.6.16 Vectors of SMAS elevation have a signiﬁcant impact on facial shape. Vertical repositioning of the SMAS allows the surgeon to enhance malar volume and
reduce fullness within the submalar region, as fat is forced up along the concavity of the buccinator. Restoration of submalar hollowing through SMAS vectoring is useful
in contouring full faces, making them appear thinner postoperatively. In this patient, a small amount of jowl defatting through needle aspiration was also performed. (From
Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.)

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

SMAS ﬁxation

Correction of the neck is thoroughly reviewed in Chapter 13.
In the author’s hands, the best approach to the anterior
platysma is via a submental incision, placed just caudal to the
submental skin crease.5,23–26 If this crease is very deep, the skin
cephalad is elevated toward the base of the chin pad and
along the caudal mandibular border to free any retaining
mandibular ligaments, which tend to accentuate the crease.
Following this, the cervical skin is carefully elevated. The
cervical skin is usually undermined at least to the level of
the cricoid.
Upon exposing the platysma muscle anteriorly, most
patients exhibit a decussation of platysmal ﬁbers across the
midline, at least for a few centimeters below the mentum.
When platysma band surgery is contemplated, these decussating ﬁbers must be sharply divided with scissor dissection
directly in the midline. Following this, the medial edge of the
platysma is mobilized from the mentum inferiorly at least to
the hyoid and commonly as caudal as the cricoid cartilage.
Mobilization, usually performed using a combination of sharp
and blunt dissection, separates the platysma from the

Correction of platysma bands and
cervical obliquity

repositioned internally, forcing the soft tissue to conform to
the underlying deep facial structures. This gives the surgeon
greater control in improving radial expansion (Fig. 11.6.18).

underlying subplatysmal fat, the anterior belly of the digastric
muscle, and the strap muscles overlying the thyroid cartilage.
At times, numerous small venules are encountered within the
subplatysmal fat and careful hemostasis must be obtained.
Following mobilization of the medial edges of the platysma,
the subplatysmal fat is conservatively contoured according to
preoperative planning.
Following mobilization, the medial edge of the platysma
muscle is grasped on either side and overlapped in the midline
in order to estimate the amount of excess muscle present.
Muscle excess will vary from patient to patient. A portion of
the medial edge can be excised to remove redundancy within
the platysma. A conservative resection is performed so that
undue tension is not present at the time of suture plication.
Muscular plication consists of edge-to-edge approximation
using multiple interrupted sutures at the mentum and extending at least to the level of the hyoid. Suture placement back
from the leading edge of the muscle, in areas of intact muscular fascia, is an important technical point in preventing
suture pull-through postoperatively.
In most patients, the edge-to-edge suturing below the
hyoid is continued inferiorly toward the cricoid cartilage. The
goal of muscular plication is to produce an even, smooth
contouring of the platysma that is tightly adherent to the
underlying ﬂoor of the mouth and thyroid cartilage, providing a ﬂat framework for redraping of cervical skin. A low
plication joining a widely separated platysma over a prominent thyroid cartilage also tends to blunt a prominent
larynx and produce a rounder, more feminine appearance to
the neck.

Fig. 11.6.17 This patient exhibits asymmetry in the submalar region preoperatively. Notice that she appears hollow and concave on the right, while she is fuller on the left
side. For this reason, the SMAS was vectored obliquely on the right to volumetrically enhance the submalar region, while it was vertically vectored on the left side to restore
submalar hollowing and balance the two sides of her face. (From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface
soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.)

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

SECTION I •11.6• Facelift: The extended SMAS technique in facial rejuvenation

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

252

Following edge-to-edge approximation of the platysma,
some form of muscular release is performed. This muscular
release commonly involves a partial transection of the
platysma muscle with the myotomy performed inferiorly
within the neck.
Platysma transection is an effective technique in the treatment of platysma bands and in obtaining the desired cervical
contour. This procedure must be performed meticulously
because the early experience with transection was fraught
with complications. Speciﬁcally, if the transection is performed at a high level, it can be associated with unveiling of
the submaxillary glands and denervation of the platysma
associated with lower lip dysfunction. Also, obvious contour
depressions associated with divided muscular edges can be
noted in the overly thin neck (Fig. 11.6.19).
The key to platysma transection is that the transection of
the muscle be performed lower in the neck, often as inferior
as the level of the cricoid cartilage. The disadvantage of horizontal transection at this level is that a depression in the neck
can develop if preplatysmal fat has been removed at the level

Fig. 11.6.18 This diagram illustrates how the excess SMAS, rather than being
excised, is rolled onto itself to form a double layer of SMAS thickness. Once the
SMAS has been rolled, it is ﬁxated to the periosteum of the zygomatic eminence.
An added beneﬁt of preserving the excess SMAS rather than excising it is that, as
the thickened SMAS layer is secured to the zygomatic eminence, it highlights the
malar region, serving as an autogenous malar augmentation. Highlighting the malar
area tends to enhance angularity in facial contour. (From Stuzin JM. Restoring facial
shape in facelifting: The role of skeletal support in facial analysis and midface
soft-tissue repositioning. Plast Reconstr Surg 2007;119:362.)

253

1. It alleviates tension along the medial portion of the
platysma transection following plication.
2. It allows the platysma to shift superiorly, producing a
deeper cervicomental angle.
3. It prevents the conversion of two platysmal
bands to a single band following edge-to-edge
approximation, which can be visible when the
neck is extended.

where the transection is performed. Preservation of preplatysmal fat lower in the neck where the transection is to be performed is obviously an important factor in preventing this
problem.
In most patients, only partial division is required. The
myotomy is performed from the midline laterally until the
tension is completely released from the platysmaplasty closure
(approximately the anterior border of the sternocleidomastoid
muscle in most patients).
The muscular release seen following platysma transection
serves many purposes:

Fig. 11.6.19 After edge-edge approximation of the platysma from the mentum to
the cricoid cartilage, some form of muscular release is performed. This usually
consists of a horizontal cut extending from the midline to the anterior border of the
sternocleidomastoid muscle.

Correction of platysma bands and cervical obliquity

Because the SMAS and the platysma represent the same anatomic layer, if platysmaplasty is performed before the SMAS
dissection, it can adversely affect facial contour.3,20,21 Contouring
the neck before the midface can also be problematic. When
the platysmaplasty is performed ﬁrst, the descended jowl fat
is locked down into the neck, and movement of the superﬁcial
fascia diminishes following elevation of the SMAS. This
diminished movement tends to lessen surgical ability to
modify facial shape; it also produces a loss of aesthetic contour.
If the SMAS dissection is performed before platysmaplasty,
descended jowl fat is brought cephalad to the mandibular
border and easily repositioned. After the SMAS has been
securely sutured bilaterally, the mandibular border appears
more distinct, making cervical contouring less demanding.
When performing platysmaplasty subsequent to SMAS

Sequence of SMAS ﬁxation
versus platysmaplasty

In most patients in whom I perform a platysmaplasty, small
drains are placed and left in place until drainage is minimal
and the skin ﬂaps are adherent. In my experience, the use of
drains has lessened postoperative edema, ecchymosis and
seroma formation (Fig. 11.6.20).

Incisions have been reviewed in Chapter 11.1. The importance
of incision quality cannot be over-emphasized in diminishing
signs that the patient has undergone a surgical procedure.
One of the major advantages of a two-layer facelift is that the
tension of contouring is along the superﬁcial fascia and thus
there is less need to redrape the skin ﬂap with great force.
Decreased tension on the key sutures in both the preauricular
and postauricular region provides greater control for scar perceptibility. If the incisions are artistically designed, patients
can typically wear their hair up off their ears without obvious
stigma that a facelift has been performed.21
Whereas many authors have described the salient factors
regarding incision design, we would delineate the main
points:

Incisions

ﬁxation, the surgeon will notice less redundancy along the
medial borders of the platysma; there is also less need to resect
muscle at the time of platysmaplasty. The enhanced contour
effects of extended SMAS dissection, associated with precise
platysmaplasty, tend to diminish the need to remove cervical
fat. In general, the neck and jaw lines appear softer if preplatysmal fat is preserved when contouring the neck (Fig.
11.6.21).

Fig. 11.6.20 (A) Preoperative appearance. Note the hollowed contour in the lateral cheek, which represents the region from which the facial fat has descended and deﬂated,
as well as the marked cervical obliquity. (B) Postoperative result following extended SMAS dissection. If the surgeon can re-elevate descended facial fat back to its previous
anatomic location and secure it there postoperatively, this will help to enhance the mandibular border, providing for predictable cervical contouring through platysmaplasty.
This lessens the need for preplatysmal fat removal. In general, necks look softer if cervical fat is preserved. (From Stuzin JM, Baker TJ, Baker TM. Reﬁnements in facelifting:
Enhanced facial contour using Vicryl mesh incorporated into SMAS ﬁxation. Plast Reconstr Surg 2000;105:290.)

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

SECTION I •11.6• Facelift: The extended SMAS technique in facial rejuvenation

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

254

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

255

There is increasing public demand for natural appearing
results in facial rejuvenation. This places the onus on the
surgeon to create incisions that are imperceptible if these procedures are to be justiﬁed. No matter how well deep-layer
support is obtained, and facial contour improved by SMAS
elevation and platysmaplasty, if the incision is obvious, scar
quality poor, the hairline disturbed, or the earlobe deformed,
the overall result remains disappointing

3. Detached earlobes tend to appear more natural than
attached earlobes. If a small cuff of cheek skin is left
attached to the earlobe, it will allow surgical rotation of
the skin up under the earlobe during skin ﬂap redraping,
suturing the earlobe distinctly from the cheek ﬂap. The
earlobe should be inset in an axis posterior to the axis of
the pinna, thereby avoiding a pixie deformity.

2. Tragal incisions are more demanding than preauricular
incisions, requiring precise design and insert so that the
tragus is not distorted. The aesthetic unit of the tragus
is rectangular as opposed to semilunar. If the surgeon
designs the tragal incision properly, respecting the
incisura of the tragus, the tragus will appear normal
in its shape postoperatively, exhibiting both a visual
beginning at its junction with the helix and a visual
ending along the preserved incisura.

1. The author prefers tragal incisions, performed at the
margin of the tragus, rather than preauricular incisions,
because the color difference between the pale skin of
the ear and the blush skin of the cheek is usually better
camouﬂaged when the incision is brought internally into
the ear.
From a personal perspective, after two decades of striving to
improve techniques in facial rejuvenation, it is my ﬁrm conviction that improving technical control when contouring the
superﬁcial facial fascia and platysma provides for a more
consistent, aesthetically pleasing result, which is non-surgical
in appearance. The difﬁculty in performing a two-layer
SMAS-type facelift is that it requires a commitment on the
part of the surgeon, not only to understand facial soft tissue
anatomy, but also to perform a procedure which demands
technical precision. A two-layer SMAS-type facelift is a time
consuming operation, with both the skin ﬂap elevation, as
well as the dissection of the SMAS, requiring meticulous and
accurate dissection. Obtaining consistency with this procedure is challenging because of the variability in thickness of
subcutaneous fat and the SMAS which exists among individual patients. Following precise dissection, secure ﬁxation
of both SMAS and platysma is mandated to maintain the
shaping desired in postoperative contour. Meticulous hemostasis followed by careful skin ﬂap inset are required to
minimize postoperative scar perceptibility and ensure a rapid
postoperative recovery.
Despite these demands, this author has found the extended
SMAS technique to be personally rewarding, with a high
degree of patient satisfaction. All techniques have advantages
and disadvantages. For me, the biggest advantage of the
extended SMAS technique remains its aesthetic versatility,
allowing the surgeon to vary the contouring aspects of the
procedure according to the aesthetic needs of the patient.

Summary

Fig. 11.6.21 (A) Preoperative appearance. (B) Postoperative appearance. Another example of how facial fat re-elevation inﬂuences cervical appearance. Sequencing errors
can lead to loss in contour; it is my preference to perform SMAS elevation and ﬁxation before performing platysmaplasty. As the facial fat and skin is re-elevated back into
the midface through SMAS rotation, the mandibular border becomes more distinct, making cervical contouring more predictable.

Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.

Summary

8. Rohrich RJ, Pessa JE. The fat compartments of the face:
Anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg. 2007;119:2219.
Cadaveric dissection demonstrated multiple discrete
compartments of subcutaneous fat in the human face.
The clinical signiﬁcance of this ﬁnding is addressed.
10. Lambros V. Fat contouring in the face and neck. Clin
Plast Surg. 1992;19:401.
11. Lemmon ML, Hamra ST. Skoog rhytidectomy: a ﬁveyear experience with 577 patients. Plast Reconstr Surg.
1980;65:283.
14. Barton Jr FE. Rhytidectomy and the nasolabial fold.
Plast Reconstr Surg. 1992;90:601.
The Skoog facelift was modiﬁed to free the SMAS from the
underlying mimetic muscles of the face. A sizeable clinical
series demonstrated improvement in nasolabial fold aesthetics.
15. Owsley Jr JQ. Lifting the malar fat pad for correction
of prominent nasolabial folds. Plast Reconstr Surg.
1993;91:463.
22. Mendelson BC. Surgery of the superﬁcial
musculoaponeurotic system: Principles of release,
vectors, and ﬁxation. Plast Reconstr Surg. 2001;107:1545.

Access the complete references list online at http://www.expertconsult.com

SECTION I •11.6• Facelift: The extended SMAS technique in facial rejuvenation

1. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS
dissection as an approach to midface rejuvenation. Clin
Plast Surg. 1995;22:295.
2. Stuzin JM, Baker TJ, Gordon HL. The relationship of
the superﬁcial and deep facial fascias: Relevance to
rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441.
Facial anatomy is characterized as a series of concentric
layers based on cadaveric and intraoperative dissection. These
ﬁndings inform a discussion of the anatomic basis of facial
aging.
4. Stuzin JM. Restoring facial shape in facelifting: The
role of skeletal support in facial analysis and midface
soft-tissue repositioning. Plast Reconstr Surg. 2007;119:
362.
The authors emphasize the importance of establishing
patient-speciﬁc aesthetic goals in planning a facelift.
Skeletal anatomy is a key component of this analysis.
7. Furnas DW. The retaining ligaments of the cheek. Plast
Reconstr Surg. 1989;83:11.
The anatomy of the facial retaining ligaments is reviewed.
The importance of addressing these structures in facelift
procedures is addressed.

256

1. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS
dissection as an approach to midface rejuvenation. Clin
Plast Surg. 1995;22:295.
2. Stuzin JM, Baker TJ, Gordon HL. The relationship of
the superﬁcial and deep facial fascias: Relevance to
rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441.
Facial anatomy is characterized as a series of concentric
layers based on cadaveric and intraoperative dissection. These
ﬁndings inform a discussion of the anatomic basis of facial
aging.
3. Stuzin JM, Baker TJ, Baker TM. Reﬁnements in
facelifting: Enhanced facial contour using Vicryl mesh
incorporated into SMAS ﬁxation. Plast Reconstr Surg.
2000;105:290.
4. Stuzin JM. Restoring facial shape in facelifting: The
role of skeletal support in facial analysis and midface
soft-tissue repositioning. Plast Reconstr Surg. 2007;119:
362.
The authors emphasize the importance of establishing
patient-speciﬁc aesthetic goals in planning a facelift. Skeletal
anatomy is a key component of this analysis.
5. Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of
the aging face. 2nd ed. St Louis: CV Mosby; 1995.
6. Freilinger G, Gruber H, Happak W, et al. Surgical
anatomy of the mimic muscle system and the facial
nerve: Importance for reconstructive and aesthetic
surgery. Plast Reconstr Surg. 1987;80:686.
7. Furnas DW. The retaining ligaments of the cheek. Plast
Reconstr Surg. 1989;83:11.
The anatomy of the facial retaining ligaments is reviewed.
The importance of addressing these structures in facelift
procedures is addressed.
8. Rohrich RJ, Pessa JE. The fat compartments of the face:
Anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg. 2007;119:2219.
Cadaveric dissection demonstrated multiple discrete
compartments of subcutaneous fat in the human face.
The clinical signiﬁcance of this ﬁnding is addressed.
9. Lambros V, Stuzin JM. The cross-cheek depression:
surgical cause and effect in the development of the
“Joker Line” and its treatment. Plast Reconstr Surg.
2008;122:1543.
10. Lambros V. Fat contouring in the face and neck. Clin
Plast Surg. 1992;19:401.

References

256.e1

11. Lemmon ML, Hamra ST. Skoog rhytidectomy: a ﬁveyear experience with 577 patients. Plast Reconstr Surg.
1980;65:283.
12. Mendelson BC. Correction of the nasolabial fold:
Extended SMAS dissection with periosteal ﬁxation. Plast
Reconstr Surg. 1992;89:822.
13. Hamra S. The deep plane rhytidectomy. Plast Reconstr
Surg. 1990;86:53.
14. Barton FE Jr. Rhytidectomy and the nasolabial fold.
Plast Reconstr Surg. 1992;90:601.
The Skoog facelift was modiﬁed to free the SMAS from the
underlying mimetic muscles of the face. A sizeable clinical
series demonstrated improvement in nasolabial fold
aesthetics.
15. Owsley JQ Jr. Lifting the malar fat pad for correction
of prominent nasolabial folds. Plast Reconstr Surg.
1993;91:463.
16. Connell BF, Marten TJ. The trifurcated SMAS ﬂap:
Three-part segmentation of the conventional ﬂap for
improved results in the midface, cheek and neck.
Aesthet Plast Surg. 1995;19:415.
17. Aston SJ. Facelift with FAME technique. Paper
presented at the 32nd Annual Baker Gordon
Symposium on Cosmetic Surgery, Mercy Hospital,
Miami, FL, February, 1998.
18. Little JW. Three-dimensional rejuvenation of the
midface: Volumetric resculpture by malar imbrication.
Plast Reconstr Surg. 2000;105:267.
19. Owsley Jr JQ. SMAS-platysma facelift: A bidirectional
cervicofacial rhytidectomy. Clin Plast Surg. 1983;10:429.
20. Connell BF. Neck contour deformities: The art,
engineering, anatomic diagnosis, architectural planning,
and aesthetics of surgical correction. Clin Plast Surg.
1987;14:683.
21. Marten TJ. Facelift planning and technique. Clin Plast
Surg. 1997;24:269.
22. Mendelson BC. Surgery of the superﬁcial
musculoaponeurotic system: Principles of release,
vectors, and ﬁxation. Plast Reconstr Surg. 2001;107:1545.
23. Connell BF. Cervical lifts: the value of platysma muscle
ﬂaps. Ann Plast Surg. 1978;1:34.
24. Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast
Surg. 1979;3:529.
25. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg.
1990;85:333.
26. Feldman JJ. Neck lift. St Louis: Quality Medical; 2006.

References

Access the Historical Perspective section online at

http://www.expertconsult.com

©

2013, Elsevier Inc. All rights reserved.

The patient consultation is divided into three portions:
(1) evaluation of the patient’s health; (2) evaluation of the
facial anatomic features; and (3) evaluation of the patient’s
appropriateness.
First and foremost, cosmetic surgery is only appropriate for
healthy patients. As physicians, our overriding responsibility
is to do no harm. A patient’s life should never be placed at
signiﬁcant risk for improvement of appearance. Intercurrent
illnesses such as cardiac disease, cerebrovascular disease,
major organ dysfunction, and potential healing impairment
may preclude safe surgery.
Assuming the patient is healthy, the evaluation turns to the
anatomic analysis. From my perspective, maintaining facial
harmony is paramount. The worst of all outcomes is to look
“operated”. The are a number of causes of an “operated” look,
and these will be addressed in more detail later in the chapter.
But surgical disharmony – that is, correcting one aging feature
while leaving other aged areas uncorrected – is disharmony
by design. Regardless of the effectiveness of the surgical technique, segmental disharmony compromises the result.
Young patients may have only segmental aging. Most commonly, early aging involves the forehead and orbit before the

lower face and neck. If the only disharmony is brow ptosis, a
forehead procedure alone may sufﬁce. The same may be true
regarding the eyelids in young patients. In such a situation,
correcting a single aged feature, so as to match the remaining
youthful features, actually restores facial harmony.
However after the age of 40, most patients have aging
changes throughout multiple areas. They may look slightly
aged, but they look natural, since all areas match. If natural
facial harmony is to be maintained, all aged areas need simultaneous correction.
Such an approach is often met with resistance by patients,
particularly young patients. They are used to the traditional
approach of sequential segmental surgery – an approach that
most of us were trained to do. Adding to the confusion is the
patient’s faulty logic that, by doing less at a single stage, they
are less likely to look operated.
While debate remains regarding the relative roles of deﬂation (loss of fat) and descent, there are several inescapable
truths.
The practical fact is that aging patients have lax facial
tissues. And when standing erect (as most people judge their
appearance), gravity causes the facial tissues to descend. The
second fact is that aged people have excess facial skin.
Re-inﬂating the skin envelope to the point of eliminating
laxity would create an unattractively puffy face. Third, the
descended tissues look better when repositioned superiorly.
Finally, a method of maintaining the tissues in their
upward position has to be found, even if the repair is
non-anatomic.
While the “high SMAS” approach to the cheek is the
assigned focus of this chapter, the need to maintain facial
harmony necessitates a brief description of pan-facial
analysis.
Starting at the top, forehead analysis begins at the hairline.
The determination of hairline height is assessed from midpupil to hairline – not brow to hairline. While forehead rejuvenation is colloquially referred to as a “browlift”, the brow
is actually only one element of forehead improvement. Lateral
brow hooding, corrugator lines, and procerus creases also

Fritz E. Barton Jr.

Facelift: SMAS with skin attached –
the “high SMAS” technique

The patient consultation considers both the potential for anatomic
improvement as well as the patient’s expectations.
Maintenance of facial “harmony” is paramount.
A “high SMAS” facelift vertically repositions the skin and the
subcutaneous tissues as a single unit.

Patient consultation

䊏

䊏

䊏

SYNOPSIS

Aesthetic Surgery of the Face

11.7

SECTION I

Triggered by the appearance of surface laxity, early attempts
at facial rejuvenation focused on skin excision. Since the
surface skin was sufﬁciently mobile to efface anterior redundancy, undermining and release seemed unnecessary. Limited
peripheral skin excisions dominated the gestation period of
facelifts,1–3 in the ﬁrst quarter of the 20th century. While these
procedures yielded improvement, they were limited in anterior effect and temporary in duration.
Seeking greater effect, Lexer4 lengthened and combined the
separate temporal, preauricular and mastoid incisions. Bames5
later added skin undermining to further enhance the result.
This concept of wide skin undermining dominated the thinking of the mid-20th century,6–8 and remains popular today.9,10
The presence of the subcutaneous facial mass may have
been recognized as early as the 1930s by Pires.11 Pires placed

History

257.e1

suspension loops from the preauricular fascial to the anterior
nasolabial fat in an effort to better efface anterior jowling. But
the importance of speciﬁc suspension of the subcutaneous
mass, in addition to skin redraping was best described by
Aufricht in 196012: “In order to understand the mechanics of
the sagging cheek, one must consider the behaviour of the
skin and the areolar fatty layer separately. Both layers are
subject to histo-morphological changes of their own. This
fact is important. It indicates that the surgical correction for
sagging cheeks generally requires a two phase procedure: (1)
subcutaneous suspension (or lift), i.e., suspension of the fatty
areolar layer; and (2) cutaneous suspension after the removal
of excess skin.”
The concepts of removal and/or repositioning of both the
skin as well as the subcutaneous fatty mass remain the cardinal points of modern surgical facial rejuvenation. What to
do is generally agreed upon. How best to do it remains
controversial.

History

Jowl

Nasolabial fold

Malar fat pad

anterior fat accumulates along the jowl at the mandibular
border. The analysis of the individual patient, involves identifying the extent of each of these changes.
Consideration of the degree of facial laxity introduces the
discussion of the ideal age and stage for facial rejuvenation
surgery. The traditional timing for facial rejuvenation was
mid-50s to mid-60s. Timing was based upon the experience
with skin-based facelifts in which signiﬁcant relapse of skin
laxity from dermal stress relaxation was inevitable. Therefore,
if half of the beneﬁt was to be lost quickly, there needed to be
a great deal of laxity present for a net gain. With more powerful fascial (SMAS) based procedures available, the strategy
changes. The author has come to recognize that actually, the
ideal time for facial rejuvenation is when aging changes are
present, but early. The best strategy is to try to maintain
youthful appearance, rather than losing it, then trying to
recapture it. Speciﬁcally, the ideal time for facial rejuvenation
in most women is in her early 40s.
Finally, before formulating a surgical plan, the surgeon
must decide whether the patient’s goals are both achievable
and realistic.
Sometimes, the patient’s analysis of the problem is accurate, but there may not be a predictable correction. Making a
full face thin or permanently removing every wrinkle are
examples. Conversely, the patient may grossly exaggerate a
minor problem and seek an unrealistic result. Surgery should
be avoided in both situations. Often, the accurate evaluation
of the patient’s mind is more difﬁcult than the evaluation of
their anatomy.

Fig. 11.7.1 The superﬁcial subcutaneous fatty mass.

SECTION I •11.7• Facelift: SMAS with skin attached – the “high SMAS” technique

must be addressed. Perhaps most important, the upper lid
cannot be correctly assessed without restoring the brow to
proper position. The upper eyelid and brow thus form a combined unit. A similar combination occurs with the lower
eyelid and cheek. Finally, the neck serves as a relatively independent unit, though its best correction often involves
addressing the lower face. We will focus here in detail on the
lower eyelid and cheek.
The lower eyelid and upper cheek overlap, and as a
result, they should be addressed together in the patient over
the age of 40. The delicate lower eyelid is separated from
the heavier cheek by two fascial partitions. The orbicularis
retaining ligament13 (orbitomalar membrane14) extends from
the junction between the pre-septal and periorbital portions
of the orbicularis muscle to attach to the bony skeleton.
The orbicularis retaining ligament (ORL) inserts into the
orbital rim medially, then courses down and lateral onto the
body of the zygoma. A second fascial partition, the malar
membrane15,16 (zygomaticocutaneous ligament17) extends from
the lower border of the periorbital orbicularis to insert in the
malar bone below. Medially, the malar membrane origins
align with the orbicularis retaining ligament at the medial
tear trough. Laterally, however, it courses obliquely across the
cheek, inserting into bone in the bare area above the deep
origins of the upper lip levators. Together, these two partitions
protect the eyelid suspensory apparatus from the weight of
the cheek.
There are six essential elements of the lower eyelid which
require assessment. Beginning from deep: (1) the prominence
of the orbital bony rim – a positive, negative, or neutral vector
orbit; (2) the prominence of the arcus marginalis insertion; (3)
the competence of the orbital septum and fat herniation; (4)
presence of orbicularis ptosis; (5) skin laxity and wrinkling;
and (6) competence of the lateral canthal tendon. Essentially,
all aging patients develop ptosis of the orbicularis muscle.
They may or may not have abnormalities of any or all of the
other elements.
Likewise, evaluation of the cheek involves six elements: (1)
Skin surface abnormalities (dyschromia, actinic damage, etc.);
(2) dermal quality; (3) degree of skin laxity; (4) facial skeletal
shape; (5) overall facial volume; and (6) contour of the subcutaneous mass.
For the purposes of this chapter, we will focus on the
degree of facial laxity and the variations of contour of the subcutaneous fatty mass.
Variations in the volume, shape and position of the subcutaneous fatty mass inﬂuence the ultimate surgical plan. The
superﬁcial layer of the subcutaneous fatty mass – that portion
external to the superﬁcial layer of the mimetic muscles – is the
portion which inﬂuences facial shape and which is most malleable in facial rejuvenation surgery. The upper border of the
fatty mass is at the lower orbital rim and zygomatic arch; the
lateral border is the auricle, the lower boundary is the mandibular border, and the medial border is the fusion plane at
the nasolabial fold.
The speciﬁc sub-areas to be addressed are the malar prominence, the nasolabial fold, and the jowl (Fig. 11.7.1). The
typical aging face shows descent of the malar portion of the
subcutaneous mass, so that the maximal cheek prominence is
sub-malar, rather than over the body of the zygoma. Anteriorly,
the upper anterior portion of the cheek fat shelves over the
ﬁxed fusion plane at the nasolabial fold. And ﬁnally, the lower

258

The modern “high SMAS” technique evolved from my (the
author) failed experiences with other methods. Early in my
clinical practice, I performed a moderately wide skin undermining with redraping. It yielded good results in younger
patients who had excellent quality skin, thin faces, and good
lower orbits. I believe the procedure can still yield good
results in that sub-group of patients.
But not all of my patients were of that type. As I encountered older patients, those with more jowls and deeper nasolabial folds, my results with skin-only facelifts were often
disappointing and brief in duration. Worst of all, as I became
more aggressive with the procedure to overcome these deﬁciencies, some patients developed a “stretched” look. It was
then that I became acutely aware of the viscoelastic relaxation
(“stress relaxation”) of skin placed under tension.
Aufricht12 and others18 had pointed out the need to directly
address suspension of the subcutaneous facial fat as an essential component of facelifting. I, therefore, went through a
phase of skin dissection followed by suture plication, as
described by Aufricht. My experience was that the initial
facial contours of the nasolabial fold and jowl were improved.
But in follow-up, only about one-half of the patients achieved
a lasting correction. Moreover, using the dermis to secure
the skin advancement still caused many patients to look
“stretched”. My overall results improved, and some patients
maintained a natural improvement, but the results were too
inconsistent for my satisfaction.
In 1974, Tord Skoog published his classic text,19 in which
he described a revolutionary facelift procedure. Undermining
the skin and superﬁcial subcutaneous mass together as a composite, the cheek mass was then re-suspended using the
superﬁcial subcutaneous fascia (later termed the superﬁcial
musculoaponeurotic system or SMAS20). This approach
offered repositioning of the skin along with the superﬁcial
subcutaneous mass as a single unit, without placing tension on
the skin. Unfortunately, Skoog died before he was able to work
out the nuances to develop his concept into maximally effective procedure. But the concept of cheek repositioning while
avoiding skin stretching was very appealing.
Other surgeons21,22 adopted Skoog’s basic idea, and set out
to modify it. Their early attempts focused on the buccal and
mandibular area, where the SMAS was more deﬁned and
more mobile. The upper cheek, or malar area, was left only
dermal support.23 It seemed clear to me that such differential
suspension – fascia in the lower face, and only dermal suspension of the malar portion of the subcutaneous fatty mass –
would give incomplete repositioning of the malar prominence.
And worse, over time, the weak dermal support would relax
faster than would the lower fascial portion.
It was that dilemma that fostered our anatomic dissections
in the late 1970s and early 1980s.24,25 We ﬁrst demonstrated
that the dissected subSMAS cheek ﬂap was supplied as an
axial myocutaneous ﬂap from the anterior facial artery
branches. Second, we found that anteriorly, the SMAS became
the investing layer of the superﬁcial layer of the mimetic
muscles (Fig. 11.7.2). Third, we found that the upper SMAS
did not insert into the zygomatic arch, but rather, continued
over the arch to fuse with the temporoparietal fascia. And
most importantly, the frontal branch of the facial nerve lay

Evolution of the “high SMAS” technique

259

beneath a second fascial layer over the zygomatic arch. This
ﬁnding allowed us to safely divide the SMAS horizontally
above the zygomatic arch to facilitate upward mobilization of
the upper (malar) portion of the fatty mass along with the
lower buccal-mandibular portion.
Anterior release of the SMAS from the zygomatic retaining
ligaments as well as from the investment of the anterior
mimetic muscles, combined with horizontal SMAS division
above the zygomatic arch, provided complete cheek mobilization. This dissection became known as the “high SMAS”
technique.
As my experience with the “high SMAS” technique grew,
I began to make technique variations to match patient variations. Compiling the data of my ﬁrst clinical series,26 it became
clear that dissection completely across the nasolabial fold was
not necessary in every patient. I subsequently developed
three variations, which I will delineate below, in the surgical
planning portion of this chapter. The direct vertical relocation
vector of the technique caused accentuation of the orbicularis
oculi ptosis. Inﬂuenced by the work of others,27–29 I routinely
added correction of the lower eyelid to the cheek procedure.
And ﬁnally, being made aware of the tendency to a rounded
eye in lower blepharoplasty from laxity of the lateral canthal
tendon with aging,30–32 added lateral canthal tightening was

Fig. 11.7.2 Release of the SMAS investment of the zygomaticus major muscle.

SMAS

Evolution of the “high SMAS” technique

Orbicuarlis
moves alone

The initial incision location in the temporal area depends
upon what is to be done with the forehead. If a bicoronal
or hairline incision is to be utilized for the forehead, then
that extension is used for the cheek dissection. If only an

Surgical technique

Surgical planning involves both the surgical sequence as well
as patient preparation. As previously mentioned, in the
patient who has not had previous surgery, I believe a panfacial approach is usually necessary. The actual components
of the procedures of the forehead, orbit and neck vary with
the patient’s anatomy and aging deformity. (Those planning
details are beyond the scope of this chapter, however.)
Preoperative patient preparation means stabilizing any
intercurrent medical problems or medications not serious
enough to preclude surgery. The most common intercurrent
illness to stabilize is hypertension.
Preparation of the healthy facelift patient involves mainly
avoidance of any interference with wound healing. It has
been my observation that the body will heal well if not
interfered with. Avoidance focusses on nicotine products
and medications that interfere with clotting (e.g., Aspirin,
NSAIDs, etc.).

Surgical planning

added. Otherwise, I have remained consistent with the “high
SMAS” technique for over 25 years (Fig. 11.7.3).24,33,34

Fig. 11.7.3 “High SMAS” elevation of the subcutaneous fatty mass with
orbicularis suspension separately.

endoscopic approach or no forehead surgery is planned, then
only a horizontal sideburn incision is done. With use of the
sideburn incision, it is critical to limit the upward extent. The
ﬁne, posterior-directed upper temple hair will not hide an
incision.
A post-tragal auricular incision is used routinely in both
males and females. The only exception is dark skinned males
with very dark, heavy beards. In most males, skin displaced
to the tragus can have the hair follicles excised from beneath
the dermis. Any remaining hair can be controlled with an
Alexandrite laser. The location and extent of the mastoid incision depends upon the amount of neck skin laxity.
Sequencing of the facial units is the next consideration. The
author usually starts at the midline of the neck and works in
an upward sequence. This moves the redundancy upward
through the cheek and eyelid, then out the top. One criticism
of this sequence is that the anterior platysmal closure in the
neck might restrict the upward motion of the platysma
(SMAS) in the cheek. This restriction can be avoided by merely
connecting the medial platysmal borders loosely to each
other in the midline, so as to allow later upward motion in
the cheek.
The cheek dissection is begun by elevating the skin in the
pre-auricular area sharply. Above the level of the tragus, a
subcutaneous tunnel is formed to the lateral border of the
orbicularis oculi muscle. This tunnel will facilitate later horizontal division of the upper SMAS. From the tragus down,
the skin ﬂap is thinly dissected only to the extent of estimated
skin excision (Fig. 11.7.4). Care is taken not to overly separate
the skin from the SMAS, especially at the upper corner where
the previous tunnel was made. The lower extent of the subcutaneous cheek dissection extends below the mandibular
border. If no previous neck skin dissection has been done, the
submandibular skin dissection is carried approximately onehalf way down the neck and one-half way to the midline. This
release is necessary to allow partial division of the lateral
platysma, and its investing fascia, to facilitate upward displacement of the cheek composite tissues.
With the skin dissection complete, attention is turned to the
SMAS. The safest place to penetrate the SMAS is between
the top of the tragus and the bottom of the ear lobule. Here,
the SMAS is the thickest, and the facial nerve lies deep
within the parotid gland. In this location, the SMAS is a multilayer ﬁbro-fatty structure laminated to the parotid capsule.
The proper dissection plane leaves a thin translucent ﬁbrous
layer over the visible parotid acini. As this dissection plane is
extended anteriorly and inferiorly an areolar plane on the
underside of identiﬁable platysma ﬁbers can be visualized.
Once in this areolar plane, dissection is carried to the anterior
border of the parotid gland, and down the anterior border of
the sternocleidomastoid muscle.
At the anterior border of the parotid gland, the dissection
method changes from sharp to blunt spreading in the anterior
areolar plane. Over the parotid gland, the SMAS is ﬁxed to
the gland capsule – the so-called “ﬁxed SMAS”. Anterior to
the parotid gland, in the buccal area, there is an areolar gliding
plane which can be separated bluntly, to avoid any risk to the
underlying facial nerve branches. It is imperative to maintain
the ﬁlmy, near-transparent deep fascia over the masseter
muscle, since the facial nerve branches lie just beneath.
Inferiorly, the dissection continues down the fascial fusion
plane at the anterior border of the sternocleidomastoid muscle.

SECTION I •11.7• Facelift: SMAS with skin attached – the “high SMAS” technique

Malar and
bucccal/mandibular
areas move together

260

Only skin expected
to be removed is undermined

Subcutaneous tunnel
superior to arch

Fig. 11.7.4 The skin ﬂap is thinly dissected
only to the extent of estimated skin excision.

261

dissection also minimized swelling by preserving the anterior
facial venous and lymphatic supply.
In patients with moderately deep nasolabial folds, the same
limited cheek dissection is done, but a ﬁbro-fatty SMAS
graft,35,36 trimmed from the lateral dissection, is tunneled
beneath the nasolabial fold (Fig. 11.7.7). I ﬁnd this graft to
survive most of the time, such that, accurate placement is
critical.
In patients with deep nasolabial folds, usually associated
with a thin face, complete dissection across the nasolabial fold
into the lip is done (Fig. 11.7.8).
In the rare patient, the upper one-third of the nasolabial
fold may be quite deep. In such a case, more anterior cheek
elevation is needed. In this situation, the author combines the
“high SMAS” cheek lift with a subperiosteal “malar lift”.38,39
With the cheek supporting its own weight, rather than being
suspended from the lid, the risk of secondary ectropion is
greatly reduced.
With completion of this release, the entire subcutaneous
cheek mass, from mandible to orbit, will freely move superiorly. It is paramount to mobilize the cheek in a pure vertical – not
horizontal or oblique – direction. The primary vector is vertical
along the lateral orbital rim (Fig. 11.7.9).
Key sutures are placed in the deep temporal fascia and in
the mastoid fascia. The periauricular SMAS is then completely
closed with a continuous suture to disperse the tension from
the key sutures.
Redundant skin is trimmed in place – with no additional
tension. It is paramount to the “high SMAS” concept that all
suspension load is placed on the fascia (SMAS) – the skin is never
placed under greater than normal tension.
This upward cheek mobilization, however, does not elevate
or redrape the ptotic orbicularis oculi. Care is taken not to
undermine the lower orbicularis with the cheek dissection,

Subcutaneous dissection of neck from
mastoid to midline superficial to platysma

Here the cervical investing fascia of the platysma continues
to invest the sternocleidomastoid muscle. Without a “back
cut” in this fascia, upward motion of the platysma (SMAS)
can be restricted. Thus, a short 2–3 cm “back cut” in the
investing fascia and platysma is made about 4 cm below the
mandibular border. The “back cut” is made at this level to
avoid any aberrant branches of the marginal mandibular
facial nerve.
At this point in the dissection, the buccal-mandibular
portion of the cheek will mobilize well, but the upper (malar)
portion of the cheek mass is little affected.
Completion of cheek mobilization is achieved by release of
the anterior ligament and fascial restrictions. The SMAS is
divided horizontally above the zygomatic arch over to the
lateral orbicularis. Using the visible edge of the orbicularis as
a depth marker, the dissection is carried over the malar area
to release the zygomatic retaining ligaments. Again, using the
inferior-lateral border of the orbicularis oculi muscle as a
depth gauge, the dissection is carried over the lateral border
of the zygomaticus major muscle into the subcutaneous plane.
Since the anterior SMAS is attached to the zygomaticus major
as its investing fascia, the muscle attachment will restrict
upward cheek mass mobilization unless released. By making
a transition in the cheek dissection plane from a subSMAS
plane to over the surface of the zygomaticus major muscle,
the investing fascia is released. Dissection is then carried
down the lateral border of the zygomaticus major muscle to
the level of the modiolus (Fig. 11.7.5). The extent of anterior
subcutaneous dissection depends upon the characteristics of
the nasolabial fold.
In patients with minimal nasolabial fold depth, dissection
stops short of the fold to preserve attachment of the fat to the
cheek ﬂap (Fig. 11.7.6). This allows elevation of the cheek
to spread the medial fat away from the fold. The limited

Subcutaneous
dissection 4cm

Subgaleal
dissection

Surgical technique

Stops before anterior
facial vascular and
lymphatic territory

Fig. 11.7.6 Cheek dissection I stops short of the nasolabial fold.

Fig. 11.7.5 Complete release of the SMAS.

SMAS incision

Defatting the face presents a different challenge when using
the “high SMAS” facelift. The dissection plane is deep to the
platysma at the jowl, while the jowl fat lies superﬁcial to the
platysma. The author ﬁnds liposuction, through a nasal vestibule incision, to be most expeditious. A 2.4 mm cannula
works quite well. It should be cautioned, however, that
liposuction the buccal area should be avoided. Secondary
grooving is too likely.
Two areas respond well to fat grafting. There is often a
small redundant strip of excess in the SMAS mobilized to the

Ancillary procedures

in order to avoid denervation. But by leaving the ptotic orbicularis in place, upward cheek movement accentuates the
shelving of the lower orbicularis. It is therefore necessary to
add orbicularis suspension, with or without correction of
other lower lid malformations, to the routine “high SMAS”
cheek lift.
While the cheek mass, including anterior cheek skin, moves
in a vertical direction, correction of neck redundancy necessitates posterior (horizontal) redraping. This is accomplished
by lateral suspension of the SMAS to the mastoid fascia,
accompanied by lateral skin redraping and excision. As
opposed to the cheek, where the skin and subcutaneous fat
are mobilized as a composite, the neck dissection separates
the skin from the underlying platysma. Thus, the redundant
cervical skin can be mobilized horizontally, while the cheek
mass moves vertically.

Marginal mandibular
branch of facial nerve

Dissection from beneath SMAS
over zygomaticus major thus
releasing restraint of investing fascia

Temporal branch,
facial nerve

SECTION I •11.7• Facelift: SMAS with skin attached – the “high SMAS” technique

Upper lateral corner of SMAS
remains attached to skin

262

1

Video

Fig. 11.7.8 Cheek dissection III across the nasolabial fold into the lip.

Dissection across
nasolabial fold onto lip

Fig. 11.7.7 Cheek dissection II stops short of nasolabial fold with tunneled SMAS
graft.

Limited dissection

SMAS fat graft

263

Immediate postoperative care consists of basic post-anesthesia
recovery and avoidance of hematoma. Due to the depth
and precision of dissection, most patients are under general
anesthesia.

Postoperative care

mastoid. This ﬁbrofatty strip can be used to tunnel beneath
the nasolabial fold or to provide lip fullness.35–37 As previously
mentioned, the graft takes reliably in the nasolabial area, but
survives only about 50% of the time in the lips.
Vertical upper lip lengthening is present in some patients.
In the properly selected individual, a “gull wing” excision at
the nostril sill40,41 will provide subtle improvement.
Perioral lines, either from actinic damage or recurrent
orbicularis contraction, are very common in aging patients.
While a number of corrective methods exist, all have limited
beneﬁt. The dilemma is that in order to completely remove
deep wrinkles, you often remove pigment and skin appendages. This can leave the patient with a smooth, but
white, waxy appearance. Lighter peels and fractionated
lasers have fewer side-effects, but less complete correction
(Fig. 11.7.10).

Fig. 11.7.9 The cheek mass is suspended vertically (shown with key sutures),
and the entire SMAS ﬂap is closed with a continuous suture to disperse the
tension from the key sutures. An orbicularis ﬂap is then done to suspend the
orbicularis.

Postoperative care

E

B

F

C

SECTION I •11.7• Facelift: SMAS with skin attached – the “high SMAS” technique

Intraoperatively, a 0.2 mg clonidine dermal patch is placed.
The maximal onset of action coincides nicely with maximum
absorption peak of the adrenalin in the local anesthetic solution, 4–6 h postoperatively. The patch is usually left in place
until the ﬁrst postoperative morning, unless the patient demonstrates hypotension.
Xylocaine 0.5% with 1:400 000 adrenalin is used for local
anesthesia and hemostasis. The 1:400 000 adrenalin strength
seems to provide adequate tissue hemostasis, and results in
less postoperative rebound hypertension than the stronger
dilutions.

The other major element to control in the postoperative period, is swelling. Any facial dissection, whether
subcutaneous or sub-SMAS, temporarily interrupts part of
the lymphatic drainage. While the lymphatics reconstitute
over 3–6 months,42 during that interval, swelling can compromise the result. Even young skin, maintained under stretch,
undergoes stress relaxation. But young patients’ skin can
recoil back to normal dimension. Older patients, however,
do not have skin recoil. If skin is held under stretch from
prolonged edema, the initial surgical improvement can be
compromised.

Fig. 11.7.10 (A–C) This 53-year-old woman underwent hairline browlift, upper and lower blepharoplasty, “high SMAS” rhytidectomy with dissection short of the nasolabial
fold, submental plication and SMAS grafts to the lips. (D–F) The result is shown at 6 months postoperatively.

D

A

264

7. Rees TD, Wood-Smith D. Cosmetic facial surgery.
Philadelphia: WB Saunders; 1973.
12. Aufricht G. Surgery for excess skin of the face. In:
Transactions of the Second International Congress of
Plastic and Reconstructive Surgery. Edinburgh: E & S
Livingstone; 1960.
13. Muzaffar AR, Mendelson BC, Adams WP. Surgical
anatomy of the ligamentous attachments of the lower
lid and lateral canthus. Plast Reconstr Surg. 2002;110(3):
873.
Cadaveric dissections and histological analyses were
performed to characterize the deep attachments of
the lower eyelid region. Surgical considerations are
discussed.
17. Muzaffar AR, Mendelson BC, Adams WP. Surgical
anatomy of the midcheek and malar mounds. Plast
Reconstr Surg. 2002;110(3):885.
The surgical anatomy of the malar region is deﬁned through
cadaveric and clinical dissections. The anatomical basis for
midfacial aging is discussed.
19. Skoog T. Plastic surgery – new methods. Philadelphia:
WB Saunders; 1974.

265

Skin necrosis is quite rare, since the cheek ﬂap is thick and
well vascularized. On rare occasions in previous smokers, a
small patch of skin necrosis can occur in the thin mastoid skin.
While patients can discontinue the immediate exposure to
smoke products, some degree of permanent obliterative
endarteritis always remains.
Incisional infection is also very rare (<2%). Infection is
usually caused by one of two organisms. Many patients, particularly health care workers, may carry Staph. aureus in their
nostrils. If a carrier status is suspected, topical mupirocin
ointment will usually eradicate it. The second problematic
organism is pseudomonas aeruginosa. This organism is most
commonly harbored in the external auditory canal.
The greatest concern of surgeons performing more extensive dissections, is facial nerve injury. In the publication of the
initial clinical series, the author reported a 15% temporary
neurapraxia. All were of the marginal mandibular branch,
and all promptly recovered. In re-examining the cause, it was
realized that the neurapraxias were due to spreading dissection of the platysma over the anterior mandible. It was also
realized that that degree of anterior dissection under the
“mobile SMAS” was unnecessary. Subsequent elimination of
the dissection over the mandible eliminated the temporary
neurapraxias in subsequent patients. The author has never
had a permanent facial nerve injury in his approximately 1000
“high SMAS” dissections.

20. Mitz V, Peyronie M. The superﬁcial musculoaponeurotic
system (SMAS) in the parotid and cheek area. Plast
Reconstr Surg. 1976;58:80.
This seminal study details SMAS anatomy and its clinical
implications.
22. Lemmon ML, Hamra ST. Skoog rhytidectomy: A
ﬁve-year experience with 577 patients. Plast Reconstr
Surg. 1980;65:283.
23. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr
Surg. 1990;86:53.
The subSMAS facelift is discussed as a means to address the
prominent nasolabial fold. Outcomes are reported in over 400
patients.
26. Barton FE Jr. The SMAS and the nasolabial fold. Plast
Reconstr Surg. 1992;89:1054.
37. Hester TR, Codner MA, McCord CD. The “centrofacial”
approach for correction of facial aging using the
transblepharoplasty subperiosteal cheek lift. Aesthetic
Surg Quart. 1996;Spring:51.
The anatomical basis for midface aging is described.
Outcomes in over 750 patients are assessed after direct
transblepharoplasty midface rejuvenation.

Access the complete references list online at http://www.expertconsult.com

As mentioned above, the most common postoperative complication is hematoma. In non-hypertensive patients, the frequency is 3%; in hypertensive patients, the frequency may
approach 8%. Very small collections restricted to the mastoid
may be treated by closed aspiration. But larger collections,
particularly located low in the neck, are best surgically
evacuated.

Complications

Three things are helpful to control postoperative swelling.
First, dexamethasone 8–10 mg is given intravenously prior to
dissection and a Dosepak of dexamethasone or methylprednisolone is continued orally for 4 days to minimize initial
surgical edema. Second, strict control of ﬂuid intake is very
beneﬁcial. Patients are instructed to minimize ﬂuid volume
intake. They can drink when thirsty, but they are cautioned
not to force excess ﬂuids in an attempt to improve health.
Third, strict attention to sodium intake is crucial. A low
sodium diet is very difﬁcult to achieve. All preserved foods,
fast foods, and food sauces are loaded with sodium. Patients
are instructed to calculate sodium intake for 3–6 months.
Ideally, they should restrict sodium intake to <2000 mg/day.
The closer to 1000 mg/day, the better.

Complications

1. Miller CC. Cosmetic surgery. The correction of featural
imperfections. Chicago: Oak Printing; 1908.
2. Bourguet J. Notre traitement chirurgical de “poches”
sous les yeux sans cicatrice. Arch Fr Belg Chir.
1928;31:133.
3. Noel A. La chirurgie esthetique. Clermont (Oise): Theron
et Cie; 1928.
4. Lexer E. Zur Geischtsplastik. Arch klin Chir. 1910;92:749.
5. Bames OH. Truth and fallacies of face peeling and face
lifting. Med J Rec. 1927;126:86.
6. Conway H. The surgical face lift-rhytidectomy. Plast
Reconstr Surg. 1970;45:124.
7. Rees TD, Wood-Smith D. Cosmetic facial surgery.
Philadelphia: WB Saunders; 1973.
8. Stark RB. A rhytidectomy series. Plast Reconstr Surg.
1977;59:373.
9. Hoefﬂin SM. The extended supraplatysmal plane (ESP)
face lift. Plast Reconstr Surg. 1998;101:494.
10. Duffy MJ, Friedland JA. The superﬁcial-plane
rhytidectomy revisited. Plast Reconstr Surg. 1994;93:
1392.
11. Pires D. Kosmetische chirurgie der gesichtsrunzein.
Fortschr Med. 1934;52:576.
12. Aufricht G. Surgery for excess skin of the face. In:
Transactions of the Second International Congress of
Plastic and Reconstructive Surgery. Edinburgh: E & S
Livingstone; 1960.
13. Muzaffar AR, Mendelson BC, Adams WP. Surgical
anatomy of the ligamentous attachments of the lower
lid and lateral canthus. Plast Reconstr Surg. 2002;110(3):
873.
Cadaveric dissections and histological analyses were
performed to characterize the deep attachments of the lower
eyelid region. Surgical considerations are discussed.
14. Kikkawa DO, Lemke BN, Dortzback RK. Relations of
the superﬁcial musculoaponeurotic system to the orbit
and characterization of the orbitomalar ligament.
Ophthal Plast Reconstr Surg. 1996;12:77.
15. Pessa JE, Garza JR. The malar septum: the anatomical
basis of malar mounds and malar edema. Aesthetic Surg
J. 1997;17:11.
16. Pessa JE, Zadoo VP, Adrian EK, et al. Anatomy of a
“black eye”: a newly described fascial system of the
lower eyelid. Clin Anat. 1998:11(3):157.
17. Muzaffar AR, Mendelson BC, Adams WP. Surgical
anatomy of the midcheek and malar mounds. Plast
Reconstr Surg. 2002;110(3):885.
The surgical anatomy of the malar region is deﬁned through
cadaveric and clinical dissections. The anatomical basis for
midfacial aging is discussed.
18. Pangman II WJ, Wallace RM. Cosmetic surgery of the
face and neck. Plast Reconstr Surg. 1961;27:544.
19. Skoog T. Plastic surgery – new methods. Philadelphia: WB
Saunders; 1974.

References

265.e1

20. Mitz V, Peyronie M. The superﬁcial musculoaponeurotic
system (SMAS) in the parotid and cheek area. Plast
Reconstr Surg. 1976;58:80.
This seminal study details SMAS anatomy and its clinical
implications.
21. Owsley JQ. Platysma-fascial rhytidectomy. Plast Reconstr
Surg. 1977;60:843.
22. Lemmon ML, Hamra ST. Skoog rhytidectomy: A
ﬁve-year experience with 577 patients. Plast Reconstr
Surg. 1980;65:283.
23. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr
Surg. 1990;86:53.
The subSMAS facelift is discussed as a means to address the
prominent nasolabial fold. Outcomes are reported in over 400
patients.
24. Barton Jr FE. Facial rejuvenation. St Louis: Quality
Medical; 2008.
25. Barton FE Jr. Rhytidectomy: The anatomical basis for
complete dissection. Presented at the Annual Meeting
of the American Society for Aesthetic Plastic Surgery,
Los Angeles; 1989.
26. Barton Jr FE. The SMAS and the nasolabial fold. Plast
Reconstr Surg. 1992;89:1054.
27. Furnas DW. Festoons of orbicularis as a cause of baggy
eyelids. Plast Reconstr Surg. 1978;61:540.
28. Hamra ST. Repositioning the orbicularis oculi muscle
in composite rhytidectomy. Plast Reconstr Surg.
1992;90:14.
29. Fogli AL. Orbicularis myoplasty and face lift: a better
orbital contour. Plast Reconstr Surg. 1995;96:1560.
30. Ousterhout DK, Weil RB. The role of the lateral canthal
tendon in lower eyelid laxity. Plast Reconstr Surg.
1982;9:620.
31. Flowers RS. Canthopexy as a routine blepharoplasty
component. Clin Plast Surg. 1993;20:351.
32. Heinrichs HL, Kaidi AA. Subperiosteal face lift: a
200-case, 4-year review. Plast Reconstr Surg. 1998;102:
843.
33. Barton Jr FE. Rhytidectomy and the nasolabial fold.
Plast Reconstr Surg. 90:601, 1992.
34. Barton Jr FE, Hunt J. The high-superﬁcial aponeurotic
system technique in facial rejuvenation: an update. Plast
Reconstr Surg. 2003;112:1910.
35. Guyuron B, Michelow B. The nasolabial fold: a
challenge, a solution. Plast Reconstr Surg. 1994;93:522.
36. Lassus CA. A surgical solution to the deep nasolabial
fold. Plast Reconstr Surg. 1996;97:1473.
37. Leaf N, Firouz JS. Lip augmentation with superﬁcial
musculoaponeurotic system grafts: report of 103 cases.
Plast Reconstr Surg. 2002;109:319–326.
38. Hester TR, Codner MA, McCord CD. The “centrofacial”
approach for correction of facial aging using the
transblepharoplasty subperiosteal cheek lift. Aesthetic
Surg Quart. 1996;Spring:51.
The anatomical basis for midface aging is described.
Outcomes in over 750 patients are assessed after direct
transblepharoplasty midface rejuvenation.

References

40. Austin HW. The lip lift. Plast Reconstr Surg. 1986;77:990.
41. Austin HW, Weston GW. Rejuvenation of the aging
mouth. Clin Plast Surg. 1992;19:511.
42. Meade R, Grifﬁths L, Barton FE. Presented at the Annual
Meeting of the American Society for Aesthetic Surgery,
New York; 2006.

SECTION I •11.7• Facelift: SMAS with skin attached – the “high SMAS” technique

39. Hester Jr TR, Codner MA, McCord CD, et al. Evolution
of technique of the direct transblepharoplasty approach
for the correction of lower lid and midfacial aging:
maximizing results and minimizing complications
in a 5-year experience. Plast Reconstr Surg. 2000;105:
393.

265.e2

Subperiosteal dissection is used for preferential rejuvenation of the
central oval of the face: forehead, periorbita, midface, and chin.
The subperiosteal and subcutaneous are the safest plane of
dissection. Both are combined in my biplanar technique.
The biplanar technique maximizes the positive features of the
subperiosteal and subcutaneous plane of dissection to prevent the
windswept appearance and to give a more natural look.
The forehead-upper eyelid, midface-lower eyelid and the lower
face-neck are areas that should be approached as aesthetic units
during facial rejuvenation.
The combination endomidface and lower blepharoplasty makes
surgery on the lower eyelid a lesser procedure with maximal
improvement and minimal complications
The Bichat’s fat pad mobilization as a pedicle ﬂap is the maneuver
that has its maximal effect in the creation of the Ogee of the
midface.
Subperiosteal dissection is the most suitable plane for placement
of facial implants or other skeletal support manipulation at the
same time as the facial rejuvenation is done.

SYNOPSIS

2013, Elsevier Inc. All rights reserved.

©

Although the midface seems to be the area which demonstrates the maximum beneﬁt of the subperiosteal facelift,
impressive results can also be obtained in the forehead and
jaw regions. The reason why the subperiosteal dissection has
more recognition in the midface is because no other technique
in my view can offer the advantages of subperiosteal undermining. Those advantages will be outlined later in the chapter.
Detractors of the subperiosteal approach point out the “tremendous invasiveness” of this surgical approach. They claim
that the periosteum does not age and therefore question the
need of the dissection in this plane. As opposed to those

Introduction

䊏

䊏

䊏

䊏

䊏

䊏

䊏

Oscar M. Ramirez

1. The subperiosteal dissection allows en bloc mobilization
of the soft tissues. Once dissection is done either in the
forehead, the midface or the entire jaw line, the tissues
can be lifted in a vertical or superolateral direction
(Fig. 11.8.1). To maintain soft tissue position, key
suspension sutures are used to maintain the desired
elevation. Some surgeons prefer to use prefabricated
suspension systems (Endotines® by Coapt) or to use

I have been performing subperiosteal facelifts since my years
as a senior Resident of the University of Pittsburgh in 1983–
1984. My preference for this approach has not changed over
the years. I will enumerate the reasons for this:

The advantages of the
subperiosteal facelift

views, the advantages of the subperiosteal dissection will be
outlined in this chapter. Another area of controversy and
poorly understood strategy is the combination of the subperiosteal facelift of the central oval of the face, with the standard maneuvers of the lower face and neck. The rationality and
advantages of such maneuvers will also be described.
The subperiosteal facelift has evolved from the open techniques of the upper face described initially by Paul Tessier to
the endoscopic techniques described in the early 1990s.1,2
In this chapter you will learn the relevant surgical anatomy
of the midface and eyelid to understand the safest plane of
dissection. I (the author) will describe the zygomaxillary
anthropometric point as a key anthropometric structure to
create an esthetically pleasing cheek mound. I will also
describe the methods to efface the tear-trough deformity. I will
emphasize the role of the Bichat’s fat pad and other structures
in creating the “OGEE line” of the midface.3 Finally, you will
learn the anatomical basis and surgical maneuvers to prevent
complications and obtain the best aesthetic and durable
results.

Aesthetic Surgery of the Face

Facelift: Subperiosteal facelift

11.8

SECTION I

barbed sutures for ﬁxation. Over the years, I have tried
these and other methods of suspension. They work
very well but they do not offer signiﬁcant advantages
over the simplest methods of ﬁxation: percutaneous
screw ﬁxation for the forehead and suture suspension
for the midface. Although suture ﬁxation can be used
for the mandible, I reserve this for the most difﬁcult
cases (Fig. 11.8.2). The mandibular soft tissues can be
remodeled without speciﬁc traction sutures by the
insertion of chin and jaw implants, by the indirect
traction of the midfacelift in a vertical direction or
by the traction exerted by the cervicofacial ﬂaps in an
oblique superolateral direction during the biplanar
approach. To allow this type of en bloc mobilization,
it is critical to release periosteal attachments in key
anatomical areas along the lowermost boundaries of
the area of dissection.
2. The subperiosteal dissection facilitates soft tissue
remodeling. This can be accomplished by imbricating the
entire mass of the dissected tissues, by transposition of
vascularized fat ﬂaps and by injection of fat grafting to
the entire thickness of the elevated soft tissues.
3. The subperiosteal dissection leaves exposed the
underlying bony skeleton. This allows skeletal
contouring by bone reduction or by augmentation with
the use of implants. There is no need to open a different
plane of dissection, which is the case with subcutaneous,
subSMAS (sub-Superﬁcial Musculo-Aponeurotic System)
or inter-muscular dissections.

Fig. 11.8.1 During subperiosteal surgery the approach and direction of dissection
are similar for the open or endoscopic methods. The upper face is worked from the
frontal and temporal approaches. The midface is worked via upper sulcus intraoral
incision. The chin and mandible is worked via a submental incision.

Submental approach

Intraoral approach

Fronto-temporal approach

267

When a patient consults for facial rejuvenation, my own personal approach is to perform surgical correction for all the
areas affected by the aging process. I will rarely agree to do
partial rejuvenation unless the patient requires it or refuses
the more extensive approach. At the very least, I will advise
the patient about my philosophy. The consultation therefore
becomes a teaching process for the patient and a sound decision can be made. If any shortcomings or unbalanced looks
occur after the surgery, the patient will be aware of the reasons
for these.
The aging process should be corrected by functional and
anatomical units. From my point of view, the forehead and
upper eyelid is one unit. The lower eyelid and midface is
another unit. The lower face and neck is another unit. Surgery
in one unit usually facilitates and enhances the correction of
the adjacent unit. This will become obvious as we describe
the techniques. I will focus more on the midface which is the
topic of this chapter.

Technique

7. Allows more balanced and natural rejuvenation. The
more superﬁcial planes of dissection usually pull the soft
tissues in a horizontal or oblique direction. Furthermore,
the central midface soft tissues are pulled indirectly by
the tension applied to the peripherally dissected ﬂaps.
These two characteristics create tension bands and more
pull on the periphery than in the centrally located
tissues, giving the typical “windswept” or “motorcyclist”
appearance to the face.

6. It is probably more durable than other more superﬁcial
techniques. Once the block of soft tissues has been
repositioned, and healing has occurred in the elevated
position, it will stay there for a very long time. In over
25 years of performing subperiosteal facelifts (open and
endoscopic), I have seen that the operation on the central
oval of the face (forehead and midface) lasts for over 10
years. The area that tends to relapse earlier is the lower
face and the neck, in which a more superﬁcial dissection
has been done. This usually last 5–7 years.

4. The subperiosteal plane has better visibility and
orientation than the more superﬁcial planes, particularly
when using endoscopic techniques. The bony surface
is a better reﬂector of light, some bone areas are good
landmarks for orientation. As opposed to these, the
supraperiosteal or more superﬁcial planes of dissection
tend to absorb the light and orientation can be more
difﬁcult.
5. The subperiosteal plane is a safer plane for the facial
nerves. Despite the unfounded claims that the
subperiosteal plane of dissection has a high incidence of
nerve injury, I strongly believe that this plane is as safe as
the subcutaneous plane of dissection and safer than the
intermediate plane of dissection. This assumption is
based on my experience over many years. My rate of
nerve injury is about 2%, and the great majority is only
temporary. For this reason, in my biplanar techniques,
I combine the safest planes of dissection: subperiosteal
and subcutaneous (Fig. 11.8.3).

Technique

A

Modiolus suspension

SOOF suspension

B

Mentopexy
suspension

ROOF
suspension

Frontalis-pericranium suspension

Fig. 11.8.3 The safest planes of dissection are the subcutaneous and the
subperiosteal planes. When both approaches are used simultaneously, it is called
the biplanar approach. The intermediate lamella of the face is the area where the
facial mimetic muscles and motor nerves of the face are located. The author prefers
not to work in those planes.

The frontalis muscle and the more superﬁcial periorbital
muscles are functionally and anatomically interrelated. The
frontalis muscle is a brow and forehead elevator, while the
procerus, corrugator, depressor orbicularis and orbicularis
oculi muscles are brow depressors. Gravity and the depressor
muscles will pull down the brow while the frontalis will be
the only muscle to counteract this function. One way to diminish the hyperactivity of the frontalis muscle is to decrease the
counteracting function of the brow depressors, particularly
the more “functionally negative muscles” such as the procerus
and corrugator muscles. This is done with botulinum toxin or
surgery. The endoscopic forehead approach is in my view the
best option to do this. This method obtains a more complete
ablation of the corrugator and the only way to ablate the
procerus is via the approach from the frontal area. The transpalpebral route does not treat the procerus unless the technique described by the author is used.4 Even in those
circumstances, the dissection is bloody and there is not good
control of the resection.
When a patient has brow ptosis and excess eyelid skin that
patient should be assessed preoperatively with the patient in
a sitting position. The amount of excess eyelid skin can be

Forehead and upper eyelid

Fig. 11.8.2 There are many suspension points for the upper, mid and lower face. These are located in the deep planes of dissection: at the periosteal and or deep fat
compartments (midface), cortical tunnel (mentopexy) or at the muscle layer (frontalis/galea/periosteum) during the biplanar forehead rejuvenation. ROOF, retro-orbicularis
oculi fat; SOOF suborbicularis oculi fat.

Mandibular periosteum suspension

Superomedial SOOF

Canthoplasty/
canthopexy

SECTION I •11.8• Facelift: Subperiosteal facelift

Temporal suspension

Intermediate
temporal fascia

268

judged by digitally elevating the brow to an aesthetically
pleasing position. This will give an estimate of the needed
skin excision. If there is any doubt it is better to postpone
the blepharoplasty for a second stage when the brow and
forehead has settled. The combination browlift and blepharoplasty allows the surgeon to be conservative for both procedures: brow positioning and the extent of upper eyelid
excision. The combined procedure prevents over-resection
of eyelid skin that may occur by trying to correct upper
eyelid fullness and excess skin with a blepharoplasty only.
Consequently, the combined procedure will make the upper
blepharoplasty resultant scar shorter and more conﬁned to the
inner orbit. Conversely, if an attempt is made to correct fullness and excess skin with a browlift only, a surprised look by
hyper-elevation of the brow position may be the result.
Dissection in the frontal area is done entirely in the subperiosteal plane and in the temporal area between the superﬁcial temporal fascia and the temporal fascia proper in the
upper temporal area and over the intermediate temporal
fascia in the lower temporal area. Both areas of dissection
(temporal and frontal) are connected across the temporal line
of fusion with the undermining coming from temporal to
frontal orientation (four incision technique, see below). The
lower limit of the temporal dissection is about 1 cm above the
zygomatic arch.
My endoforehead can be done with 2, 3, or 4 incisions,
depending on the complexity of the surgery and the difﬁculty
imposed by the patient’s anatomy. If two incisions are used,
these are located about 3 cm from the midline. If three incisions are used, one is made centrally and the other two are
paramedian, 4 cm from the midline. If four incisions are used,
two are paramedian at 2.5 cm from the midline and the other
two, one on each temporal area, are located 2 cm inside the
temporal scalp in a line tangential to a line extending from the
nasal alae and external canthus.
The more lateral incisions (paramedian or temporal) are
used to do the periosteal release of the lateral brow in cases
of hooding of the brow. The paramedian incisions in general
are used to do corrugator and procerus ablation. The multiple
incisions are utilized for the introduction of two separated
instruments for the standard triangulation technique used in
endoscopic surgery. After the muscle manipulation and periosteal release are done, one “butterﬂy” drain of 2 mm diameter
is introduced to the glabellar area. The drain is introduced
through a separate mini stab wound incision in the scalp
posterior to the entrance ports for dissection. Fixation in the
majority of cases is done with two percutaneous self-retaining
self-stabilizing screws (Synthes®). These are applied at the
superior projection of the tails of the brows in the frontal scalp
with the vector of traction in the superomedial direction
(Fig. 11.8.4). Upper blepharoplasty, if indicated, is done at the
end of the endoforehead procedure. In the majority of cases
the lateral extent of the blepharoplasty excision does not
extend beyond the lateral orbit.
Another important functional interrelation is the function
of the frontalis muscle and the levator muscle. It is important
to understand this critical connection because this will affect
not only function of the eyelid and brow but also will have
very important aesthetic consequences. The basic functional
fact is that the frontalis and levator muscles are agonist
muscles. The frontalis will usually contract forcefully every
time an individual wants to look up or at a distance. Similarly,

269

when eyes are being closed, the frontalis muscle will usually
relax. In patients with congenital unilateral or bilateral weakness of the levator system, the individual will use the frontalis
muscle to compensate for this function. This will create forehead lines and creases. This is more frankly seen in the severe
eyelid ptosis. The same situation is seen in cases of acquired
eyelid ptosis. However, there is a condition of gradual development with aging that at an early stage may not be quite
apparent. In this scenario, there is a gradual weakening of the
aponeurosis insertion into the tarsal plate. This may eventually progress to a frank disinsertion of the levator aponeurosis. To compensate for this weakness, the patient will contract
the frontalis muscle. At an early stage, this will produce a
tonic contraction of the frontalis without the development of
signiﬁcant lines and creases. As the process continues, the
collagen composition of the skin deteriorates and the additive
effect of the brow ptosis occurs, the patient will develop
severe lines and creases in the forehead. During this stage, the
patient will develop a condition that I have coined “spastic
frontalis syndrome”.5 This is characterized by the severe contraction of the frontalis muscle, elevated brows, severe forehead wrinkles and inability of the patient to relax the forehead,
Even when the brow is pushed down digitally this immediately moves upwards like a rubber band. When the patient is
asked to relax the forehead they are unable to do it voluntarily.
Even when they are asked to close the eyes the frontalis
remains spastic. In the early stages however, the diagnosis can
be difﬁcult and ptosis surgery may be a proposition to the
patient that he/she did not expected. The treatment for this
is usually carried out in two stages. Ptosis repair is done ﬁrst
under local anesthesia. The frontalis muscle is allowed to relax
and the brow will subsequently drop. This may take weeks
or months. After the ﬁnal position of the brow is determined,
a decision can be made about how much brow elevation is
required. In this situation, performing both operations

Fig. 11.8.4 The forehead and the upper eyelids are treated as one cosmetic unit.
The forehead is usually approached through four small endoscopic ports. Fixation is
obtained via a suspension of the superﬁcial temporal fascia to the temporal fascia
proper and by percutaneous screws in the frontal area. Direction of traction is
superomedially.

Technique

1

Video

SECTION I •11.8• Facelift: Subperiosteal facelift

The lower eyelid is a structure in which the functional and
aesthetic effect of aging is more critical than in any other
structure in the face. This makes its surgical approach equally
critical.
Although some controversies have arisen in relation to its
innervations, I stand by the original conclusions of my original research in which we showed that the innervations of the
lower orbicularis muscle ﬁbers comes in a perpendicular
direction to its ﬁbers (Fig. 11.8.5).6 If these ﬁbers come from
the zygomaticus branch or the buccal branch or from both, it
is irrelevant as far as the planned incision is made. If the
classic skin-muscle ﬂap is used (the original McIndoe operation), the pretarsal portion of the lower orbicularis oculi
muscle will at its best be temporarily denervated and at worst
will be totally denervated. The degree of denervation will
depend of the extent of the original muscle transection. The
recovery process will also depend of the degree of neurotization of the pretarsal orbicularis. A better chance of neurotization will occur when more contact between the preseptal and
pretarsal segments of the muscle exist at the end of the operation. This is accomplished by preseptal orbicularis suspension
methods, such as the orbicularis “hitch”. Canthopexy methods
will also prevent the ﬂabby tarsal orbicularis to heal in a
relaxed position and will make innervations functionally
more effective. Some of the secondary effects of incomplete
innervations in order of severity are: tilting of the ciliary
border with anterior exposure of the white line of the lower
eyelid, sclera show, bowing of the lateral third of the lower
eyelid and frank ectropion. Lesser degrees of the problem still
will affect how the tear ﬁlm is distributed across the cornea
and from the aesthetic point of view will show an eye that
looks “funny” even if the patient or the surgeon can not pinpoint the exact cosmetic defect.
The midfacelift combined with my functional blepharoplasty is an excellent tool to rejuvenate the lower eyelid while

Midface and lower eyelid

simultaneously becomes a guessing game in determining the
most appropriate brow position.

Fig. 11.8.5 During lower eyelid blepharoplasty, the author avoids transecting the
orbicularis oculi muscle when entering the preseptal-suborbicular plane, because
this will denervate its pretarsal portion. The motor nerves travel perpendicular to the
orientation of the muscle incision.

270

preserving its function. Additional improvements will be seen
with better lower eyelid position, improvement of laxity and
correction of the V deformity of the lower orbit/upper cheek.
The midfacelift begins with Xylocaine 0.5% mixed with
epinephrine at 1/200 000 dilution, which is inﬁltrated in the
temporal and midface areas.
The midface is approached from above through a temporal
incision, and from below through an intraoral buccal mucosal
incision. The length of the incision in the temporal area
will depend on the technique used. In the open approach the
incision is either a coronal incision if the forehead lift is also
done concomitantly or a limited temporal-frontal incision.
Dissection in the temporal area separates the superﬁcial temporal fascia from the temporal fascia proper in the upper
temporal area and the superﬁcial temporal fascia from the
intermediate temporal fascia in the lower temporal area. In
the endoscopic technique, dissection continues in this plane
until the superior border of the zygomaticus arch is reached.
With upward traction of the temporal ﬂap, the periosteum of
the zygomaticus arch is elevated with a sharp periosteum
elevator. In the open approach the intermediate temporal
fascia with its attached intermediate fat pad is elevated 2–3 cm
above the zygomaticus arch and the periosteum is dissected
in continuity.1 This fascial ﬂap will be used as an anchor suspension of the midface. Alternatively, in the open technique
this fascial ﬂap elevation can be avoided and rely on the
suspension points of the midface used in the endoscopic
approach. In either of the alternatives the temporal nerve
branch of the facial nerve is protected in the elevated ﬂap. It
is important although not critical to save the temporal vein #2
(sentinel vein) and the zygomaticus-temporal nerve(s). This
will minimize ecchymosis, swelling, and hypoesthesias.
Next, the intraoral buccal incision is made. This is located
at the level of the ﬁrst premolar and done either vertically or
slightly obliquely. The initial incision is done through the
mucosa only, then the buccinator muscle is spread with the
periosteal elevator and a subperiosteal dissection is carried
out on the maxilla and malar bones. Medially, this extends
to the pyriformis area and laterally underneath the fascia
of the masseter muscle. This lateral extension goes about
2.5 cm over the masseter tendon. Dissection superiorly is
done to separate the orbicularis muscle attachments to the
inferior orbital rim, thus releasing the arcus marginalis. The
attachments around the infraorbital nerve are freed after
the ﬁxation points on the midface are applied and just before
their ﬁxation in the temporal fascia proper. That will avoid
traction neuropathy by excessive manipulation. The zygomaticofacial nerve is also preserved to avoid the occasional
painful neuropathy and/or localized anesthesia. Subperiosteal
dissection of the midface is connected with the temporal
optical cavity over the anterior two-thirds of the zygomatic
arch (Fig. 11.8.6). Dissection includes elevation of the soft
tissues from the external lateral orbital rim.
The sutures applied to the midface have the following
effects: suspension, volumetric remodeling and lifting. I routinely use four sutures per side, although in some particular
cases it may be three or two depending on the aesthetic objectives (Fig. 11.8.7). The ﬁrst one to be applied is to the anterior
central SOOF (suborbicularis oculi fat), which is anchored to
the most anterior portion of the temporal fascia proper near
the lateral orbital rim. This is a 4-0 polydioxanone (PDS)
suture that prior to its passing to the temporal area can be

anchored to the immediately superior arcus marginalis which
will act as a pulley to direct the anterior SOOF towards the
orbital rim area helping to efface the tear trough area. This is
anchored before passing the rest of the sutures to the temporal
area because this does not restrict with the placement of the
rest of the sutures and it may become entangled with the rest
of the other sutures if left for later. The next suture is the
lateral SOOF that is applied to the compound periosteum/
SOOF tissue 3 cm inferior and vertical to the lateral canthal
tendon insertion. This is done with a 3-0 PDS suture. The next
suture is the modiolus suspension. This is applied to the ﬁbroadipose tissue just inferior to the most anterior portion of the
intraoral incision. This is done with 4-0 PDS suture. These two
sutures are tunneled to the temporal area end exited through
the temporal port. The last suture is applied to the Bichat’s
fat pad. This is perhaps the most difﬁcult and the one that
has the steepest learning curve among the different sutures
applied to the midface. Once this technique is mastered, there
is nothing to replace it in the ﬁnesse and beautifying effect of
its mobilization.7 The Bichat’s or buccal fat pad is located in

Fig. 11.8.6 The “endo-midface” is approached by a single temporal and an
intraoral incision. For this reason, it is better called an endotemporo-midface
procedure. The midface and temporal cavities are connected across the zygomatic
arch. The subperiosteal dissection here is critical to avoid injuring the frontal
branch of the facial nerve. The midface dissection extends under the masseteric
fascia for 2–3 cm.

MS with
suspension
suture

SOOF with
suspension
suture

271

the so-called buccal space (Fig. 11.8.8). To enter here, you need
to open the periosteum/buccinator that forms its anteromedial wall. This is just medial to the masseter tendon. This
is best done with a blunt and long scissor. The blades of the
scissors are opened and the fat pad will extrude from its
encased buccal space. The fat pad is then gently pulled with
two blunt scissors. Simultaneously, the surgical assistant will
push with his ﬁnger from the external lower cheek/jowl area
encouraging the most inferior portion of the fat pad to migrate
toward the oral cavity. During this process, the fascia that
forms the wall of the buccal space is gently teased. The buccal
fat pad has a very thin fascial layer that protects the fat pad
and carries the nourishing vessels. This has to be maintained
to maintain the integrity of the pad. Separating the buccal wall
fascia from the fat pad itself is similar to the maneuver used
to reduce an inguinal hernia. Once the fat pad has been delivered, it is still attached to buccal fat remaining inside the
buccal space and to the deeper structures of the modiolus. A
4-0 PDS suture with an RB1 needle is weaved into the fat pad
utilizing two or three passes. The next step is to anchor these
sutures. The ﬁrst one to be anchored is the Bichat’s fat pad
suture, which is done to the loop of SOOF suture applied
beforehand. We call this technique “piggy backing” the SOOF

Fig. 11.8.7 An endoscopic browlift is shown in conjunction with an endoscopic
midfacelift. For the midfacelift, four sutures are used to obtain the maximal
remodeling and beneﬁcial effect of the subperiosteal dissection. The anterior SOOF
(suborbicularis oculi fat) effaces the infraorbital V deformity. The lateral SOOF lifts
the midface. The MS (modiolus suspension) lifts the corner of the mouth. These
three sutures also produce imbrication, thus increasing the anterior projection of the
cheek. The last suture suspension is the buccal (Bichat’s) fat pad (BF). This is the
structure that helps more than any other to create the Ogee line of the midface.

BF with
suspension suture

Technique

Facial artery

Facial vein

Buccal branch

Zygomatic branch

Masseter

SECTION I •11.8• Facelift: Subperiosteal facelift

suture. The objective is to limit the upward mobilization of
the buccal fat pad and its potential accidental tearing off of
this structure. The next maneuver is to anchor the modiolus
stitch to the anterior part of the temporal fascia proper just
behind the anchor point of the anterior SOOF. Last is the ﬁxation of the lateral SOOF to the most posterior portion of the
temporal fascia proper. All the sutures anchored to the temporal area are done using the endoscopic sliding Peruvian
ﬁsherman’s knot.8 This suture technique allows control of the
tension applied to each structure. It is also reversible up to
some point, therefore it can be made a bit looser if needed. A
2 mm “butterﬂy” drain is introduced via a mini stab incision.
The last suspension suture is applied to the superﬁcial temporal fascia at the inferior lip of the temporal entrance port
and anchored to the temporal fascia proper above and anterior to it. During this process, the temporal scalp is pulled in
a superomedial direction. This prevents posterior shifting of
the sideburn and encourages a more vertical lift of the upper
cheek temple areas. The scalp is closed with staples.
One effect of this multiple and independent suture suspension is that the lower eyelid will be elevated in relation to the
orbital rim, and the V deformity of the lower orbit will be
totally or partially effaced (Fig. 11.8.9). The degree of this
effacement will depend on the amount of soft tissue in the

Fig. 11.8.8 The Bichat’s (buccal) fat pad has its own facial covering and its own
blood supply. It is located inside the buccal space. This space has a gliding surface
that allows the buccal fat pad to work as a syssarcosis but also makes it prone to
pseudo-herniation towards the para commissural/jowl area. This fat pad can be
mobilized towards the malar area after opening the periosteum/buccinator layer.

Buccinator

272

• The midface cavity is irrigated with antibiotic solution
and closure of the intraoral incision is done with
interrupted 4-0 chromic catgut sutures.
• After the blepharoplasty is done, the forehead and
midface are tapped with brown colored micropore tape
for additional support and temporary splinting effect.
• The lower blepharoplasty is then done in a totally
different fashion to the traditional technique.
There are two fundamental differences here, compared
with traditional methods. First, I usually do not remove any
fat from the lower eyelids/orbits. In the few cases that I have
done, it was done in an extremely conservative manner and
using muscular or transconjunctival tunnels. Second, I do not
detach the pretarsal muscle from the preseptal portion. The
continuity of the orbicularis oculi is maintained. The preservation of fat prevents the sunken eye appearance with postsurgical enophthalmos that eventually leads to small beady
eye look, seen in many post-blepharoplasty patients. The
preservation of muscle integrity will maintain its innervation
and its function. The eye after this type of blepharoplasty will
look healthy, vibrant, and fuller, with a slight pretarsal roll
typical of a youthful eye. The ciliary margin will be in an
excellent position, facilitating good lacrimal tear ﬁlm distribution and normal pumping of tears by the good muscle
function.
Lower eyelid blepharoplasty is done after the midfacelift
is completed. A skin incision 2 mm below the ciliary border
is extended directly into the crow’s foot area without making
any sharp curves as traditionally we were taught. The full
thickness lower eyelid skin is “peeled” off the orbicularis
muscle layer for an average of 1.5–2 cm inferiorly, creating a
pure skin ﬂap. The exposed lateral extension of the preseptal
portion is anchored to the most anterior portion of the temporal fascia proper with a 5-0 or 6-0 Prolene suture. For this
maneuver, a window in the lateral orbital portion of the

anterior SOOF area and the localization of this deformity. If
the deformity is mostly in the area medial to the location of
the infraorbital nerve then the improvement will be minimal.
This technique improves mostly the laterally and centrally
located defect. A different procedure such as fat grafting or
orbital rim implant will be required to obtain a signiﬁcant
improvement of the centrally located defect. Another effect is
the volumetric augmentation of the midface. This is created
by the combination of the lateral SOOF lift and Bichat’s fat
pad repositioning. During aging or in chubby faces, Bichat’s
fat pad will usually migrate towards the lower anterior cheek
area just above the area of the jowl. In the oblique view, this
contributes to the ﬂat, linear conﬁguration of the upper cheek
and convex shape in the lower cheek. Changing the anatomical position of the buccal fat pad will simultaneously, with one
maneuver, augment the upper cheek and change the lower
cheek from a convexity to either a ﬂat surface or to a concavity.
This helps create the “Ogee line”, which is a feature of beauty
and youth. Bichat’s fat pad, the imbrication by the lateral
SOOF suspension and the direction of traction of the modiolus suture all will converge at the so-called “zygomaxillary
point”.9 This is the point that will get the maximal augmentation. This is also the point that has the maximal convexity in
the outline of the Ogee in the young and beautiful individual.
Therefore, this technique allows creating or recovering this
line of beauty.

SOOF

B

C

The methods described above will work in the majority of
patients, particularly in the younger group (up to age 50),
However those patients with thin faces, those with poor skeletal support and the much older individuals will require other
ancillary procedures to improve the results of the midface
rejuvenation and provide three-dimensional rejuvenation. As
indicated in one of my previous articles, there are several
methods to enhance the tri-dimensional or volumetric rejuvenation of the entire face.10 In relation to the midface these
include implants (cheek, periorbital, paranasal) and fat
grafting.
Fat grafting techniques can be easily incorporated into
the operation because fat can be injected anywhere from the
dermis down to the periosteum. Fat is usually obtained from
the periumbilical area and after it is spun in a centrifuge the
ﬂuid elements are separated. Using a 1 cc Luer Lock type of
syringe with mini-cannulas the fat is injected to correct any
residual asymmetries, to improve the nasolabial folds and
into the brow and glabellar areas as needed. I use an average
of 30 cc of fat for the entire face as an adjunctive technique.

Methods to enhance midface rejuvenation

orbicularis muscle is created with a blunt dissection. This
maneuver will lift the entire lower orbicularis and apply
tension on the post-septal fat pushing the fat inside the eye
orbit. The skin will also be brought up by the orbicularis
elevation and thick soft tissue will be positioned over the
inferior orbital rim giving additional support to the intraorbital fat and improving the infraorbital V deformity. The
upward lifting of the orbicularis will also roll up muscle ﬁbers
from preseptal to pretarsal areas, providing to this area the
natural fullness seen in younger individuals.

273

The lower face and neck is another facial aesthetic unit that
traditionally has been treated with various methods of cervicofacial lift that are covered elsewhere in this text. I rarely do
isolated cervicofacial lifts because that will create a disharmony with rest of the face. Furthermore, the horizontal/
oblique pull that is done with these techniques will create
tension bands in a horizontal or oblique direction. These
tension bands may not be visible on photographs taken in
neutral expression but are much more evident during facial
animation. These are, in my observation, more prevalent in
those patients who have had SMAS facelifts because the
SMAS is attached to the facial mimetic muscles and is pulled

Lower face and neck

However, I do not rely on fat grafting for the volumetric augmentation of the cheek unless the patient is too thin and
emaciated and does not have enough soft tissues to create
volume with the imbrications techniques and advancement of
Bichat’s fat pad.
Facial implants to the paranasal areas, to the lower
periorbita and to the cheek are used as a way to enhance
the aesthetic results but in cases of atrophy of those areas by
the aging process as a way to restore the facial skeleton
volume and provide long term support to the tissues that
has been lifted. Since the dissection has been done at the
subperiosteal plane, the ﬁeld is ready for the use of this
implant. Those implants are customized to the facial contour
with the use of physical facial skeletal model obtained from
a reformatted facial CT scan. This is an advanced methodology to obtain the most precise ﬁtting of those implants to the
facial skeleton. Implants are ﬁxed in place with titanium
miniscrews.

Fig. 11.8.9 The medial suborbicularis oculi fat (SOOF) located below the inferior orbital rim can be elevated to efface the V deformity. This can be sutured to the arcus
marginalis or to the post-septal fat pads which are advanced over the infraorbital rim. OOM, orbicularis oculi muscle.

A

Orbicularis oculi

Intraorbital fat

Orbital septum

Technique

BF

Intraoral
incision

SOOF

SECTION I •11.8• Facelift: Subperiosteal facelift

B

C

D

laterally, affecting those muscles. Consequently, on muscle
contraction during facial animation tension bands become
evident.
I include the cervicofacial lift during facial rejuvenation of
patients with signiﬁcant laxity or excessive fat accumulation
of those areas. This is usually in patients above the age of 50
years (Fig. 11.8.10). After the midface rejuvenation has been
done, the lower face is approached at the same surgical stage
or as a second stage through a periauricular incision extending posteriorly into the occipital scalp. The anterior auricular
incision extends up to the sideburn. No temporal scalp incision is done. I prefer the marginal tragal incision as opposed
to the pretragal one in both female and male patients. In
males, I trim the root of the hair follicles on the periauricular
ﬂaps.
My retroauricular incision in done at the crease itself and
not against the conchae, as is sometimes taught. I make the
incision high in the anterior mastoid area at the level of the
superior insertion of the ear. From here, the incision angles
sharply (about 45° angle), initially for 1–2 cm at the hairline
and gradually into the occipital scalp in an oblique direction.
That way, I avoid a visible scar and a sharp contrast of skin
color and texture in the mastoid area. It also avoids distortion
of the ear due to pull in the conchae. The dissection is done
at the subcutaneous plane. I make a thick subcutaneous dissection initially with the scissors and after the very adherent
areas are separated using a sharp periosteal elevator. This
separates the subcutaneous plane from the SMAS in an anatomical plane and does not make perforations of the subcutaneous plane that often occur with the scissors. Dissection is
usually extended as far as an oblique line from the sideburn
to the jowl area. The neck dissection is through-and-through
across the midline. If needed, a submental incision is done to
defat the area, do a platysmaplasty or do a subplatysmal dissection. After the appropriate amount of skin is removed, the
ﬂaps are inset and closed in two layers using 5-0 and 4-0
Prolene. To create a natural parotid area-ear interface, a

Fig. 11.8.11 (A) Preoperative front view of a 55-year-old woman without history of previous facial surgery requesting total facial rejuvenation. Observe the heavy face and
neck and the poor chin bone support. (B) Postoperative front view 2 years after. She underwent endo-forehead, endo-midface, functional lower blepharoplasty, cervicofacial
component with short preauricular incision, deep neck defatting, 5 mm Medpor RZ geniomandibular custom carved chin implant and liplift, with the bull’s horn incision. No
upper blepharoplasty was done. (C) Preoperative three-quarters view. More evident is the heaviness of her face, particularly around the jaw line and neck. Also, observe the
“witch’s chin”. (D) Postoperative three-quarters view. Observe the brow elevation, improvement of the lower orbital V deformity, and the creation of the “double Ogee line”
on the oblique outline. Also, observe the improvement of the perioral aesthetics and dynamics due to the combined effect of the midfacelift, liplift and chin implant. Make
particular note of the reversal of the suprajowl convexity to a slight concavity and the increase of the zygomaxillary point.

A

Fig. 11.8.10 An endoscopic browlift is shown in conjunction with a midfacelift
and a subcutaneous facelift. This creates a biplanar facelift in which the central oval
of the face (forehead, midface, and chin) is addressed at the subperiosteal level and
the peripheral hemicircle is dissected at the subcutaneous plane. The vectors of
traction are different in both regions. There is some overlap between both planes of
dissection but the intermediate lamella of the face is preserved.

Subcutaneous
dissection

274

B

C

D

275

B

C

D

Subperiosteal dissection of the chin and anterior mandible
is done to insert the different shapes of implant designed to
enhance the rejuvenation of the lower face. Subperiosteal
mentopexy is another procedure used to lift the ptotic chin.
Dissection of the gonial area and lateral mandible is done to
insert mandibular ramus or gonial angle implants. These
implants give support and enhance the lower face. The
upward lifting of the midface also helps to lift the detached

The role of subperiosteal dissection

pretragal depression is created with the technique previously
published.11

Well over 800 patients have had subperiosteal facial rejuvenation of the midface. The complication rate has been minimal
and of no long-term duration or signiﬁcance. It is a safe operation and the surgical results speak for themselves, as is shown
in the random sample of patients included in this chapter
(Figs 11.8.11–11.8.13).

Results

soft tissues of the jaw line area. Also, once subperiosteal
detachment of the soft tissues is done, the ﬂaps of the cervicofacial lift helps to remodel these areas.

Fig. 11.8.13 (A) Preoperative front view. Observe the depressed and tired look typical of the aging face. Notice the hooding of the upper eyelids and the V deformity of the
lower orbit. The woman’s corrugator hyperactivity gives her a tense and angry look. Her cheeks are sagging and the lower face presents jowls and jaw line laxity. Her neck is
loose and presents platysma bands and horizontal creases. She had previous neck surgery via a submental incision, performed somewhere else. (B) Postoperative front view
at 36 month’s follow-up. She underwent endo-forehead, endo-midface, lower blepharoplasty, cervicofacial lift and small amount of fat grafting. (C) Preoperative threequarters view. Hyperactivity of the frontalis is more evident in this view. (D) Postoperative three-quarters view. Observe the more sophisticated outline of the Ogee line and a
natural and beautiful look. There is no windswept appearance.

A

Fig. 11.8.12 (A) Preoperative front view of a 48-year-old woman with generalized aging of the face. Observe the periocular aging with a lower orbital V deformity, brow
ptosis, nasolabial fold, jowls. (B) Postoperative front view 18 months after. She had the author’s biplanar version of facial rejuvenation: endo-forehead, endo-midface, lower
blepharoplasty, cervicofacial lift and a small amount of fat grafting. There was no upper blepharoplasty done. Observe the generalized rejuvenation without the typical
stigmata of a “facelift”. (C) Preoperative three-quarters view. Observe corrugator hyperactivity, sagging of brows, V deformity on the lower orbits, sagging cheeks, jowls and
laxity of neck. (D) Postoperative three-quarters view. Patient has not changed her features but looks signiﬁcantly younger and more beautiful. Observe the double Ogee line of
the oblique outline, her beautiful cheeks and excellent jawline. There is no windswept appearance.

A

Results

SECTION I •11.8• Facelift: Subperiosteal facelift

1. Ramirez OM, Maillard GF, Musolas A. The extended
subperiosteal facelift: a deﬁnitive soft tissue remodeling
for facial rejuvenation. Plast Reconstr Surg. 1991;88:
237–238.
The authors report favorable results with their technique
for deep plane rhytidectomy. Salient operative details are
discussed.
2. Ramirez OM. Endoscopic full facelift. Aesthetic Plast
Surg. 1994;18:363–371.
3. Ramirez OM, Volpe CR. Double ogee facial
rejuvenation. In: Panﬁlov DE, ed. Aesthetic surgery of the
facial mosaic. New York: Springer Verlag; 2007:288–299.
4. Ramirez OM. Transblepharoplasty forehead and upper
face rejuvenation. Ann Plast Surg. 1996;37:577–584.
A technique for facelifting through blepharoplasty incisions
is detailed. Indications, procedural details, and outcomes are
reviewed.
5. Ramirez OM. Spastic frontalis: a description of a new
syndrome. Presented at the Annual Meeting of the
American Society of Aesthetic Plastic Surgery, Dallas,
Texas; 1994:April.
6. Ramirez OM, Santamarina R. Spatial orientation of
motor innervation to the lower orbicularis oculi muscle.
Aesthetic Surg J. 2000;20:107–113.

References

276

11.

10.

9.

8.

7.

Cadaveric dissections were performed to detail the course of
the facial nerve as it supplies the lower portion of orbicularis
oculi. Implications for blepharoplasty and midface access are
addressed.
Ramirez OM. Three-dimensional endoscopic midface
enhancement. A personal quest for the ideal cheek
rejuvenation. Plast Reconstr Surg. 2002;109:329–340.
Midface rejuvenation is achieved by a combined open/
endoscopic approach through a temporal slit and upper oral
sulcus incisions. Complications were minimized and results
compared favorably with those achieved by the author with
other midface rejuvenation techniques.
Ramirez OM, Tezel E, Ersoy B. The Peruvian
ﬁsherman’s knot: a new, simple, and versatile selflocking sliding knot. Ann Plast Surg. 2009;62:114–117.
Nahai F. The art of aesthetic surgery: principles and
techniques. St Louis: Quality Medical; 2005.
Ramirez OM, Heller L. The anchor tragal ﬂap: A
method of preserving the natural pretragal depression
during rhytidectomy. Plast Reconstr Surg. 2005;116:
1115–1121.
The tragus and pre-tragus depression are facial landmarks
often sacriﬁced during rhytidectomy. A technique to preserve
these structures is described.
Ramirez OM. Full face rejuvenation in three dimensions:
a “face-lifting” for the new millennium. Aesthetic Plast
Surg. 2001;25:152–164.

Ramirez OM. The central oval of the face: three-dimensional
endoscopic rejuvenation. Facial Plast Surg. 2000;16:
283–298.
Ramirez OM. Aesthetic craniofacial surgery. Clin Plast Surg.
1994;21:649–659.
Ramirez OM, Heller L. Facial rejuvenation. In: Peled IJ,
Manders EK, eds. Aesthetic surgery of the face. London:
Taylor & Francis; 2004:73–90.
Ramirez OM, Volpe CR. Three-dimensional endoscopic
facelift. In: Azizzadeh B, Murphy MR, Johnson CM, eds.
Master techniques in facial rejuvenation. Philadelphia:
Saunders Elsevier; 2007:173–196.
Ramirez OM. Advanced considerations determining
procedure selection in cervicoplasty: Part one:
anatomy and aesthetics. Clin Plast Surg. 2008;35(4):
679–690.
Ramirez OM. Cervicoplasty: Non excisional anterior
approach. Plast Reconstr Surg. 1997;99:1576.
Ramirez OM. Cervicoplasty non-excisional anterior
approach: ten year follow up. Plast Reconstr Surg.
2003;111:1342.
Fuente del Campo A. Facelift without preauricular scars.
Plast Reconstr Surg. 1993;92:642.
Ramirez OM, Roberston KM. Comprehensive approach
to rejuvenation of the neck. Facial Plast Surg. 2001;
17:129.

Bibliography

276.e1

Vasconez LO, Core GB, Gamboa-Bobadilla M, et al.
Endoscopic techniques in coronal brow lifting. Plast
Reconstr Surg. 1994;94:788–793.
Isse NG. Endoscopic facial rejuvenation: endoforehead,
the functional lift. Aesthetic Plast Surg. 1994;18:21–29.
Ramirez OM. Endoscopic techniques and facial
rejuvenation: I. An overview. Aesthetic Plast Surg.
1994;18:141–147.
Hamas RS. Endoscopic management of glabellar frown
lines. Clin Plast Surg. 1995;22:675–681.
Ramirez OM. Fourth generation subperiosteal approach to
the midface: The tridimensional functional cheek lift.
Aesthetic Surg J. 1998;8:133–135.
Ramirez OM. The central oval of the face: Tridimensional
endoscopic rejuvenation. Facial Plast Surg. 2000;16:
280–298.
Little JW. Three-dimensional rejuvenation of the midface:
volumetric resculpture by malar imbrication. Plast
Reconstr Surg. 2000;105:267–285.
Ramirez OM. Buccal fat pad pedicle ﬂap for midface
augmentation. Ann Plast Surg. 1999;43:109–118.
Ramirez OM. Endoscopically assisted biplanar forehead-lift.
Plast Reconstr Surg. 1995;96:323–333.
Ramirez OM, Pozner JN. Subperiosteal endoscopic
techniques in secondary rhytidectomy. Aesthetic Surg J.
1997;17:22–26.
Aiche AE, Ramirez OM. The suborbicularis oculi fat (SOOF):
An anatomical and clinical study. Plast Reconstr Surg.
1995;95:37–42.

Bibliography

©

Although many aspects of planning and performing secondary
facelift surgery are similar to those of the primary procedure, one
must identify and treat not only new problems that are the product
of age, but those that have resulted from any prior procedure as
well. Often it is these secondary deformities that present the
biggest challenge in terms of creativity, planning, preparation,
and technique.
Recognizing the problems in the secondary facelift patient and
appreciating their underlying anatomical abnormalities is
fundamental to planning and performance of any repair. Although
not all problems can always be completely corrected, any surgeon
able to recognize their anatomic basis can, through the application
of logic and careful planning, select techniques that are safe,
effective, and rational.
Secondary deformities are worth every surgeon’s consideration,
even if he or she performs only the occasional secondary
procedure, as they exist as compelling reminders of mistakes to
avoid in the planning and performance of any primary procedure.
Hairline displacement and disruption remain predictable outcomes
of many currently used facelift plans and are a source of
disappointment and frustration for patients and surgeons alike.
These problems are the result of poor analysis and planning and
failure to use an incision along the hairline when indicated.
The placement of an incision and thus of the resultant scar along
a hairline at secondary surgery represents a choice between two
imperfect alternatives but the best overall artistic and aesthetic
compromise in many patients.
Using the SMAS to lift sagging facial tissues and restore facial
contour circumvents the problems associated with skin-only
facelifts, as it is an inelastic structural layer capable of providing
meaningful and sustained support. Although skin must be excised
in SMAS procedures, only redundant tissue is sacriﬁced and
closure can be made under normal skin tension.
“Lamellar” dissections, in which the skin and SMAS are dissected
as two separate layers, offer the important advantage that skin and
SMAS can be advanced different amounts, along separate vectors,

SYNOPSIS

䊏

䊏

䊏

䊏

䊏

䊏

䊏

and suspended under differential tension. This allows each layer
to be addressed individually as indicated and, in turn, results in a
more comprehensive and natural appearing improvement.
It is not enough in most secondary facelift procedures to limit
treatment of the neck to pre-platysmal lipectomy and post-auricular
skin excision in secondary facelift patients. For many patients,
subplatysmal fat accumulation, submandibular salivary gland
“ptosis”, and digastric muscle hypertrophy will contribute
signiﬁcantly to their neck deformity and necessitate additional
treatment.
As experience is gained in evaluation of patients presenting
for secondary surgery, prominent submandibular glands will
increasingly be recognized as a frequent part of the secondary
neck deformity and the underlying cause of objectionable residual
bulges in the lateral triangle of the lateral submental region. In most
instances, the secondary facelift will provide an opportunity for
proper diagnosis and appropriate treatment, when present.
The secondary facelift will generally require a comparatively small
resection of skin and an increased focus on correcting deep layer
problems and secondary deformities, depending upon the skill of
the surgeon performing the primary procedure and the type of
technique used.
Secondary facelifts are often time consuming and technically
demanding when compared to primary procedures and are likely
to test the patience and composure of most surgeons.
Many patients requesting secondary facelifts are chronologically
elderly, but deceptively young in appearance. A careful medical
history must be taken because they often have medical problems
consistent for their age group.
The opportunity to perform a facelift is a unique artistic privilege
granted to us by our patients that carries a signiﬁcant
responsibility. It deserves nothing less than our best effort, and a
few extra hours of our time in the operating room beneﬁts them for
the rest of their lives.
Performing a secondary facelift if frequently a considerable
undertaking and its difﬁculty should not be underestimated.

Timothy J. Marten and Dino Elyassnia

Secondary deformities and the secondary facelift

2013, Elsevier Inc. All rights reserved.

䊏

䊏

䊏

䊏

䊏

䊏

䊏

Aesthetic Surgery of the Face

12

SECTION I

The procedure must be carefully planned, meticulously carried out,
and the patient’s safety and wellbeing unfailingly insured.
Performance of the procedure itself only fulﬁlls part of our
obligation to the patient and the care they receive perioperatively is
arguably as important as the surgery itself. Diligent perioperative
care will ensure the best result and reduce the likelihood that
problems and complications will occur.

Surgery does not halt the aging process and patients requesting secondary or tertiary facelifts usually present with many
of the same problems seen when they presented for their
primary procedures. This is particularly true if the primary
facelift was limited and consisted of skin excision and skin
tightening only. In such instances, a tight or pulled appearance will typically be present, but problems of deep layer
origin will still be evident and will likely have worsened over
time. These include nasolabial folds, labiomental folds, cheek
ptosis, infraorbital hollowing, malar ﬂattening, jowl laxity,

Identiﬁcation and analysis of
secondary aging deformity

The increased number of patients seeking facelifts at a younger
age, coupled with the continued good health of an older
group of patients who have already undergone one or more
procedures, has resulted in a signiﬁcant increase in requests
for secondary and tertiary procedures. Although many aspects
of planning and performing secondary surgery are similar to
those of the primary procedure, additional considerations
must be taken into account in the evaluation and treatment of
the patient presenting for secondary facelift, as one must identify and treat not only new problems that are the product of
age, but those that have resulted from any prior procedure as
well. Often, it is these secondary deformities that present the
biggest challenge to the surgeon in terms of creativity, planning, preparation, and technique.
Consideration must also be given to possible underlying
anatomical damage that may have resulted from previous
procedures but is not evident as a visible deformity. This
includes possible damage to skin, fat, SMAS and deeper layer
structures. Injury to these tissues at the time of the primary
procedure can preclude certain maneuvers and limit the
overall amount of improvement possible at the time secondary surgery is performed. “Red ﬂag” procedures in this regard
include radiofrequency and ultrasonic “skin tightening” treatments, prior “suture lifts”, and prolonged large volume use
of facial ﬁllers (“ﬁller ﬁbrosis”).
As in primary procedures, recognizing the problems in the
secondary facelift patient and appreciating their underlying
anatomical abnormalities is fundamental to planning and performance of any repair. Although not all problems can always
be completely corrected, any surgeon able to recognize their
anatomic basis can, through the application of logic and
careful planning, select techniques that are safe, effective and
rational.

The number and degree of secondary deformities present will
determine the difﬁculty of any additional surgery and the
overall potential for improvement possible. Typical problems
seen in the patient presenting for secondary facelift include
hairline displacement, hair loss, poorly situated scars, thick
scars, wide scars, scleral show, eyelid dysfunction, tragal distortion, earlobe distortion, over-excision of cervicofacial fat,
distortion and abnormal appearances due to inappropriate
tissue shifts, and abnormal appearance when emoting. Less
commonly, problems related to nerve injury, skin slough, or
other surgical complications may be present. These problems
are worth every surgeon’s consideration, even if he or she

Identiﬁcation and analysis of
secondary surgical deformities

subplatysmal fat accumulation, submandibular gland hypertrophy, and cervical band formation (Fig. 12.1).
Regrettably, many surgeons have been traditionally taught
to perform a limited “tuck” or “touch-up” in secondary procedures consisting of additional skin excision and skin tightening. This does not address the true underlying problems
however, and compounds the secondary deformities present
in many patients.

Fig. 12.1 Identiﬁcation of secondary aging deformities. Surgery does not arrest the
aging process, and patients requesting secondary facelifts usually present with
many of the same problems seen when they presented for their primary procedures.
This is particularly true if the primary facelift was limited and consisted of skin
excision and skin tightening only, as with this patient. Problems typically seen
include nasolabial folds, labiomental folds, cheek ptosis, infraorbital hollowing,
malar ﬂattening, jowl laxity, submental fat accumulation, and platysma band
formation. Note that although some wrinkling and atrophy are present, the patient’s
predominant problem is deep layer tissue ptosis. Additional skin excision and
tightening under these circumstances will be of little beneﬁt to the patient.
(Previous procedure performed by an unknown surgeon.)

SECTION I • 12 • Secondary deformities and the secondary facelift

Introduction

䊏

278

A

B

279

Hairline displacement and disruption remain predictable outcomes of many currently used facelift plans and are a source
of disappointment and frustration for patients and surgeons
alike. These problems are the result of poor analysis and planning at the time of the primary procedure and failure to use
an incision along the hairline when indicated. Although hairline displacement may be acceptable after some primary
facelifts in which incisions were made in the traditional location within hair bearing scalp, it will almost always be intolerable after a secondary facelift if such an incision plan is used
again. For this reason, thoughtful planning of secondary and
tertiary facelifts frequently requires the use of incisions placed
along hairlines, rather than behind them.
The placement of an incision and thus of resultant scar
along a hairline at secondary surgery represents a choice
between two imperfect alternatives but the best overall artistic
and aesthetic compromise in many patients. Although incisions upon the scalp produce concealed scars within the hair,
they will result in tell-tale and objectionable hairline displacement in many patients that is usually readily apparent upon
casual glance and at some distance. These deformities are
often not subtle and frequently result in an unnatural or even
grotesque appearance (Fig. 12.2). In addition, they are uniformly difﬁcult for the patient to disguise and a challenge for
the surgeon to correct.

Hairline displacement and disruption

performs only the occasional secondary procedure, as they
exist as compelling reminders of mistakes to avoid in the
planning and performance of any primary procedure.

Placing the incision along a hairline, however, usually
results in a ﬁne scar only visible on close inspection when
correctly planned and proper technique is used. And unlike
displaced hair, a scar along the hairline can usually be easily
concealed with make-up or tattooed if necessary, but generally go unnoticed in most social situations and casual encounters. Often, they are difﬁcult to detect even on close inspection
(see Fig. 12.5). Attempts to disguise displaced hair by combing
adjacent hair over these areas is no more effective than the
“comb-over” hairstyles worn by many balding men. Although
this is perhaps preferable to the patient to having bald spots
and missing hair showing, it is immediately evident that the
problem is still present in most cases.
The temporal portion of the facelift incision traditionally
placed within the temporal scalp will frequently result in a
tell-tale and unnatural-appearing superior elevation and posterior displacement of the temporal hairline. Secondary or
tertiary facelifts using the same incision plan will compound
this problem and often result in a bizarre appearing and objectionable absence of temple hair (Fig. 12.3).
This can best be minimized or avoided at secondary facelift
by the use of an incision along the hairline (Fig. 12.4).
If it is appropriately planned and carefully executed, an
acceptable scar will result that is artistically and aesthetically
superior to additional hairline displacement (Fig. 12.5).
In choosing the location of the temporal portion of the
facelift incision, it is important to note the degree of existing
temple “skin show” (Fig. 12.6) and consider it in conjunction
with skin redundancy present over the cheek (Fig. 12.7).
This allows an estimate to be made of the degree of elevation and/or displacement of the sideburn and temporal hair

Fig. 12.2 (A,B) Displacement of the sideburn and temple hair due to poor incision planning. The temporal portion of the facelift incision was made in the temporal scalp in
a well-intended effort to hide the resulting scar. Because cheek ﬂap redundancy was large and skin elasticity poor, advancement of the cheek skin ﬂap has resulted in
objectionable hairline displacement. An incision along the hairline would have prevented this deformity. (Procedures performed by an unknown surgeon.)

Identiﬁcation and analysis of secondary surgical deformities

B

that will occur when facelift ﬂaps are shifted, and thus facilitates rational planning of incision placement. In certain
instances, a sub-sideburn incision used in conjunction with a
traditional incision on the temporal scalp will be adequate in
preventing objectionable sideburn elevation and/or hairline
displacement. In other situations, however, the incision must
extend more superiorly along the temple hairline. Such an
incision will accommodate large posterior-superior skin shifts
and prevents tell-tale hairline displacement.

The occipital portion of the facelift incision is traditionally
placed high upon the occipital scalp, in a well intended, but
almost always counter-productive effort to hide the resulting
scar. Unfortunately, any such a plan embodies an inherent
defect in design that will preclude optimal improvement in
the neck and frequently result in a tell-tale and unnatural
appearing displacement of the occipital hairline (Fig. 12.8).
A high transverse post-auricular incision plan presumes
that the resultant vector of skin redundancy is directed mostly

Fig. 12.5 (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 in these patients, it is not evident upon casual inspection. Note the preservation of lush temple hair and
a full, youthful appearing sideburn (compare with Figs 12.2 and 12.3). (Procedures performed by Timothy J Marten, MD, FACS.)

A

Fig. 12.4 Plan for incision along the temporal hairline. An incision along the
temporal hairline should be considered whenever objectionable displacement of the
sideburn and temple hair is predicted. Although a ﬁne scar is present in these
patients, it is not evident upon casual inspection. Note the preservation of lush
temple hair and a full, youthful appearing sideburn.

SECTION I • 12 • Secondary deformities and the secondary facelift

Fig. 12.3 Sideburn elevation and displacement of the temporal scalp after multiple
facelifts. A secondary facelift using the same incision plan as at the primary
procedure has resulted in the telltale displacement of temple hair and elevation of
the sideburn (procedure performed by an unknown surgeon).

280

281

B

superiorly over the upper lateral neck and sometimes onto
the pre-lobular and post auricular area. It must also be kept
in mind that neck contour should be the result of deep layer
repair, and not skin tightening. Thus, neck skin should be
shifted and excised along a vector that allows maximum elimination of redundancy, and not one that appears to produce
the most neck tightness.
Although occipital hairline displacement may sometimes
be acceptable to patients after their primary procedure, secondary or tertiary facelifts using the same incision will compound this problem and usually result in an unnatural and
intolerable absence of occipital hair and notching of the occipital hairline (Fig. 12.9).
If an attempt is made to reconstitute the hairline by superior shifting of the post- auricular ﬂap, a wide scar will usually
result as the tissue discarded in any such maneuver is necessary for side-to-side head tilt and shoulder drop when the
patient is in an upright position. These problems can best be
minimized at the time of secondary facelift by the use of an
incision along the occipital hairline (Fig. 12.10).
If the incision is appropriately planned and carefully executed, an acceptable scar will result that is artistically and
aesthetically superior to additional hairline displacement. In
addition, this plan will sometimes allow scalp displaced at the
primary procedure to be partially advanced back towards its
proper position (Fig. 12.11).
When and incision is used along the occipital hairline it
should be planned in such a way that the inferior portion of
the incision and thus the resulting scar is turned back into the
scalp and at the junction of thick and ﬁne hair on the nape of
the neck (see Figs 12.10, 12.11). It should not be carried more
inferiorly because it will be incompletely concealed and is
likely to be visible to others (Fig. 12.12).
Fundamental to obtaining an inconspicuous, well-healed
scar when incisions are placed along the temporal or occipital
hairline is the diversion of tension to deeper tissue layers and
precise ﬂap trimming so that wound edges abut each another
under little if any tension before sutures are placed. The incision is then closed using a combination of half buried vertical

Fig. 12.7 (A,B) Estimating skin redundancy over the upper cheek. Gauging the skin redundancy over the cheek assists in predicting the degree of temporal hairline
displacement that will occur when the facelift ﬂap is shifted.

A

Fig. 12.6 Temporal skin show. The distance between the lateral orbit and the
temple hairline and how it will change with ﬂap shift must be considered when
planning the temple portion of the facelift incision.

superiorly and that the majority of skin redundancy is present
over the lateral neck. Both careful consideration and direct
observation will reveal the proper direction of post auricular
ﬂap shift to be in a mostly posterior, slightly superior direction
that roughly parallels the mandibular border if an optimal
result is to be achieved in the cervicosubmental area. This is
because it is along this vector that the majority of neck skin
redundancy is present. As the ﬂap is shifted along a more
superiorly directed vector, as it must be with any high transverse occipital incision plan, tension will rise across the cervicomental angle, but a diminished effect will be seen over
the anterior neck and submental regions. In addition, transverse cervical rhytides, if present, will be unnaturally shifted

Identiﬁcation and analysis of secondary surgical deformities

mattress sutures of 4-0 nylon with the knots tied on the scalp
side and multiple simple interrupted sutures of 6-0 nylon. The
6-0 sutures provide precise wound alignment and are removed
in 5 days. The half buried vertical mattress sutures of 4-0
nylon provide wound support, while simultaneously avoiding cross-hatched marks. These sutures are removed 7–10
days after surgery.
Although incisions placed along the frontal, temporal,
and occipital hairlines will prevent additional hairline

Fig. 12.10 Plan for incision along the occipital hairline. An incision along the
occipital hairline should be considered whenever objectionable displacement of the
occipital hairline is predicted. This incision plan protects the hairline and prevents
hairline displacement.

Hair loss is an all too common and avoidable stigmata of
facelift surgery seen in many patients presenting for secondary procedures. Hair loss is generally the result of technical
errors, including improperly made incisions that damage hair
follicles, placement of overly tight sutures, or the closure of
inadequately mobilized scalp ﬂaps under too much tension.
It may occur, however, in smokers, certain individuals with
scalp disease (alopecia areata), eating disorders, or patients
with a variety of systemic illness in the absence of any wrong
doing on the part of the surgeon. Consideration should be
given to an origin of this sort before hair loss experienced by
the patient at the primary procedure is attributed to technical
error. Hair loss is also frequently the result of the ill-conceived
shifting of scalp ﬂaps along the wrong vector. This is commonly seen on the temporal scalp after erroneous attempts to
smooth the forehead and glabella by applying lateral traction
on the forehead ﬂap (Fig. 12.13).
The use of cautery near or within the plane of hair follicles
can also result in hair loss, as can rough ﬂap handling
and pinching or prolonged folding of scalp ﬂaps beneath
retractors.
Small areas of hair loss resulting from tight suture placement or attempts at spot suspension of the scalp can often be
corrected at the time of secondary facelift by direct excision
after adequate mobilization of surrounding tissue or by incor-

Hair loss

displacement at a secondary procedure, they do not provide
for correction of large and severe problems sometime seen
(see Figs 12.2, 12.3, 12.8, 12.9). In these situations, consideration must be given to the use of hair ﬂaps, hair transplantation, and scalp expansion.

Fig. 12.9 Elevation and displacement of the occipital scalp after multiple facelifts.
A secondary facelift using the same incision plan as at the primary procedure has
resulted in the objectionable displacement of the hairline (procedure performed by
an unknown surgeon).

SECTION I • 12 • Secondary deformities and the secondary facelift

Fig. 12.8 Displacement of occipital scalp due to poor incision planning. The
occipital portion of the facelift incision was made high within the occipital scalp in
a well-intended effort to hide the resulting scar. Because cervical redundancy was
large and skin elasticity poor, advancement of the neck skin ﬂap has resulted in
objectionable hairline displacement. An incision along the hairline would have
prevented this deformity (procedure performed by an unknown surgeon).

282

B

283

Fig. 12.12 Improper design of an incision along the occipital hairline. The incision
has been made too low and carried too far inferiorly in front of the ﬁne hair on the
nape of the neck. It would have been better concealed if it had been made more
superiorly and turned posteriorly into scalp hair more superiorly. (Procedure
performed by an unknown surgeon.)

Fig. 12.13 Temporal hair loss. Hair loss is frequently the result of improper
shifting of scalp ﬂaps along the wrong vector. This is commonly seen on the
temporal scalp after well intended but misguided attempts to smooth the forehead
and glabella by excising temporal scalp and applying lateral traction on the
forehead ﬂap (procedure performed by an unknown surgeon).

Fig. 12.11 Healed incision along the occipital hairline. The use of an incision along the occipital hairline will prevent hairline displacement without compromising the end
result. Although a ﬁne scar is present in these patients, it is not evident upon casual inspection and they are free to wear their hair up off their neck in any manner they
choose. (Procedures performed by Timothy J Marten, MD, FACS.)

A

Identiﬁcation and analysis of secondary surgical deformities

Poorly situated scars are a common problem after primary
facelift and the result of artistic insensitivity, poor planning,
and tension-based surgical techniques. In many patients, secondary facelift will provide the opportunity to relocate these
to a more appropriate, less conspicuous location, but in others
it must be recognized and accepted that complete correction
is not possible if additional problems are to be avoided.
Poorly situated scars are typically seen in the pre-auricular,
peri-lobular, and post-auricular areas. They can also be found
in the submental region in many patients. Proper placement
of incisions is important, particularly in the pre-auricular area,
because even a thin, well-healed scar will ultimately be visible
and noticed by others in most cases as a result of the gradient
of skin color and texture typically present on each side of it.
Although differences in skin color can sometimes be concealed with make-up, differences in texture usually cannot.
Scars placed along natural anatomic interfaces tend to be
overlooked by the eye however, where a gradient of color
and texture is expected to be seen and where the scar appears
to be a natural crease on the face. Make-up becomes less necessary as the scar is lost in shadow, appears to be a natural

Poorly situated scars

poration of the hairless area into a more comprehensive incision plan (Fig. 12.14).
Larger areas of hair loss resulting from excessive ﬂap
tension, an overly tight closure or ill-conceived scalp ﬂap
shifting are usually much more difﬁcult to correct, especially
if scalp excision was aggressive at the primary procedure and
little residual redundancy is present (Fig. 12.15). In such
instances, the patient and surgeon must accept that complete
correction may not be possible at the time of secondary facelift
and that hair transplantation, scalp ﬂaps and even scalp
expansion may be necessary at a later date. The goal at any
secondary procedures in these patients is to select a surgical
plan that does not further compound the problem.
part of the face, or is mistaken to be a reﬂected highlight
(Fig. 12.16).
The pre-auricular region is a common point of reference for
those seeking to identify the facelift patient, and, as such, it is
of concern to patients and worthy of careful consideration by
the surgeon. The pre-helical portion of the pre-auricular scar
is often situated too far anteriorly in the patient presenting for
secondary surgery and the illusion of the scar as an anatomical feature is lost. Moving this scar so that it rests in the
helical-facial sulcus will result in a less conspicuous scar and
a more natural appearance. This is generally possible in most
secondary and tertiary cases if skin resection has not been
overly excessive at prior procedures (Fig. 12.17).
Although it is not possible to move a pre-tragal scar to a
“retro-tragal” position along the margin of the tragus in every
patient presenting for secondary surgery, this is preferred
when possible, for the reasons outlined above (Fig. 12.18). The
feasibility of relocating a pre-tragal scar to a retrotragal position will depend on the amount of cheek skin redundancy that
remains after the primary procedure. Because preoperative
assessment of residual cheek skin redundancy can be difﬁcult
and exceedingly deceptive at the tragus, it is sometimes best
to make the initial incision along the existing pre-tragal scar,
when present. The decision to sacriﬁce the remaining skin
over the tragus and move the scar to the tragal margin can
then be delayed until after cheek ﬂaps have been mobilized,
SMAS advanced, and the actual amount of cheek skin recruited
through these maneuvers, if any, determined. Often, skin
recruited is needed to recreate an absent pre-tragal sulcus and
to correct a “buried tragus” deformity. In such instances, relocation of a pre-tragal scar to the margin of the tragus will not
be possible and the existing pre-tragal location of the scar

Fig. 12.15 Large areas of hair loss. Large areas of hair loss are usually difﬁcult to
correct, especially if scalp excision was aggressive at the primary procedure and
little residual redundancy is present. In such cases, complete correction may not be
possible at the time of secondary facelift and that hair transplantation, scalp ﬂaps
and scalp expansion may be required (procedure performed by an unknown
surgeon).

SECTION I • 12 • Secondary deformities and the secondary facelift

Fig. 12.14 Hair loss resulting from tight suture placement or attempts at spot
suspension of the scalp. These problems can often be corrected at the time of
secondary facelift by direct excision after adequate mobilization of surrounding
tissue or by incorporation of the hairless area into a more comprehensive incision
plan (procedure performed by an unknown surgeon).

284

B

C

285

B

C

must be accepted. If the secondary facelift incision is initially
made along the margin of the tragus when a pre-tragal scar
is present but before intraoperative assessment of skin redundancy can be made, needed skin may be erroneously excised.
This will force an inappropriately tight closure and result in
tragal distortion, tragal retraction, and obliteration of the pretragal sulcus.

The peri-lobular area is a common location for poorly situated facelift scar in secondary and tertiary facelift patients.
Typically, it is low lying due to poor planning and the skin
settling that occurs after “skin only”, non-SMAS facelift techniques (Fig. 12.19).
Unlike the pre-helical and post-auricular portions of the
facelift scar, however, which should be placed directly in their

Fig. 12.17 Improper and proper placement of pre-helical scar. The pre-helical portion of the pre-auricular scar is often poorly situated (A,B) and the illusion of it as an
anatomical feature is lost. (A) The pre-helical incision has been made too far anteriorly and the illusion of the scar as an anatomical feature is lost. (Procedure performed by
unknown surgeon.) (B) The pre-helical incision has been made too far posteriorly and has obliterated the helical facial sulcus and part of the helix itself. The illusion of the
scar as an anatomical feature is lost. (Procedure performed by unknown surgeon.) (C) A patient with a properly placed pre-helical incision. The scar has been placed directly
in the helical facial sulcus. In this location a transition of color and texture is expected and the scar appears to be a natural anatomical feature. (Procedure performed by
Timothy J. Marten, MD, FACS.)

A

Fig. 12.16 Retrotragal scar. (A) The scar resulting from a properly situated retrotragal incision will usually be inconspicuous, even if it is suboptimally healed, as the eye
will mistake it for a reﬂected highlight. Note the well-concealed scar on this darkly complexioned patient. A scar of the same type would be more obvious if the incision had
been placed in a pretragal position. (B) A healed retrotragal face lift incision in another patient with fair skin. Transitions of color and texture are hidden along natural
interfaces. (C) A healed retrotragal incision in another patient. If the incision is closed carefully, a natural appearance without anatomic distortion should result.

A

Identiﬁcation and analysis of secondary surgical deformities

B

SECTION I • 12 • Secondary deformities and the secondary facelift

B

respective anatomic creases the peri-lobular scar should not
lie directly in the lobular-facial crease because the crease itself
constitutes a delicate, aesthetically signiﬁcant anatomical
subunit that cannot be reconstructed and should not be disrupted. Other factors being equal, a superior result will be

obtained if the scar is situated a few millimeters inferior to
this junction and an attempt is not made to join thin, soft
earlobe skin directly with course, thick cheek skin. As is the
situation with the relocation of other scars about the ear, relocation of the peri-lobular portion of the facelift scar at the time

Fig. 12.19 Improper and proper placement of the peri-lobular incision. (A) The peri-lobular incision has been made too far inferiorly and is evident even on casual
inspection. (Procedure performed by an unknown surgeon.) (B) A different patient seen after facelift. The peri-lobular scar has been placed more superiorly and in such a
manner that it is hidden by the lobule itself. In this location it cannot be seen. (Procedure performed by Timothy J. Marten, MD, FACS.)

A

Fig. 12.18 Pre-tragal and retrotragal incisions compared. (A) Pre-tragal incision in a patient presenting for secondary facelift. The scar has healed satisfactorily but attention
is drawn to it due to differences in color and texture on each side of it. (Procedure performed by an unknown surgeon.) (B) Same patient after secondary facelift in which
incision was moved to a retrotragal position. Color and texture differences, and the scar itself, are hidden along natural anatomic interfaces. (Procedure performed by Timothy
J. Marten, MD, FACS.)

A

286

B

of secondary or tertiary facelift will depend on the amount of
cheek skin that remains after the primary procedure. If cheek
skin excision has been excessive at the primary procedure, or
if a “pixy” earlobe is present, relocation may not be possible.
For these patients, it must be accepted that only partial correction can be accomplished.
A poorly situated post-auricular scar, although not as
readily apparent and easier to disguise in most social situations than a poorly situated scar in the pre-auricular region,
is nonetheless an objectionable deformity that should be corrected when possible. Typically, the poorly situated postauricular scar will be seen to lie outside the auriculo-mastoid
sulcus, and too low over the mastoid to be concealed by the
pinna. Such a deformity is the result of poor planning and
inferior–posterior migration of the post-auricular ﬂap due to
excessive tension placed upon it at the primary procedure
(Fig. 12.20).
Moving the post-auricular scar so that it rests directly in
the auriculo-mastoid sulcus is sometimes possible in secondary and tertiary patients, if tissue sacriﬁce has not been excessive or along an improper vector at the primary procedure.
Moving the scar more superiorly, although seemingly straight
forward, is often not possible because of the common practice
of inappropriately excising tissue from the superior tip of the
post-auricular ﬂap at the primary procedure. Attempts to do
so will often result in a forced closure under excessive tension
and eventual inferior migration and widening of the scar due
to inferior traction on the post-auricular ﬂap. Although an
apparent redundancy will be present in the supine patient on
the operating table due to a high lying position of the shoulders, this will be seen to vanish in the upright position when
the shoulders fall to a normal position. As a result, little if any

287

redundant skin is available along the needed superior vector
of shift.
The submental incision will frequently be seen to have been
erroneously placed directly along the submental crease in a
well-intended effort to hide the resulting scar (Fig. 12.21).
Regrettably, this serves only to reinforce the submental retaining ligaments and accentuate a “double chin” or “witch’s
chin” appearance. In such situations, consideration should be
given to moving the submental incision 1–2 cm posterior to
the crease so that the existing scar car be undermined and
released. Although this results in a new scar, it will be inconspicuously hidden in the shadow of the mandible in all but
the unusual case (Fig. 12.22). This is preferable and a worthwhile trade-off for correction of the more obvious and objectionable contour deformity that would result if the incision
were made again in the same place upon the existing scar. If
limited work in the neck only is needed and minimal or no
double chin deformity is present, it may be possible and
appropriate to use an existing scar in the submental crease as
the site for secondary incision. If more extensive maneuvers
are required and a marked double chin deformity is present
however, a new more posteriorly situated submental incision
is indicated (Fig. 12.23).
If skin excision has been aggressive and excessive at the
primary procedure, relocation of poorly situated scars may
not be possible at the time of request for secondary facelift,
regardless of how much the patient and surgeon would wish
otherwise. These patients have typically undergone aggressive skin-only, non-SMAS procedures and have overly tight
faces with wide and/or hypertrophic scars (Fig. 12.24). Often
earlobes have been pulled or placed too far inferiorly into the
cheek as well, compounding the problem. In such cases, it is

Fig. 12.20 Improper and proper placement of the post-auricular incision. (A) The post-auricular incision has been made too far posteriorly. The scar lies outside the
auriculomastoid sulcus and is evident if hair is worn short or up off the neck (Procedure performed by an unknown surgeon.) (B) A different patient seen after facelift.
The post-auricular scar has been placed in the auriculomastoid sulcus. In this location it mimics a natural anatomic feature and is overlooked on even close inspection.
(Procedure performed by Timothy J Marten, MD, FACS.)

A

Identiﬁcation and analysis of secondary surgical deformities

B

SECTION I • 12 • Secondary deformities and the secondary facelift

usually best to defer surgery until scars are mature, skin has
relaxed, and adequate tissue is available to make proper
repair. In most cases, this will mean waiting until 2–3 cm or
more of skin can be pinched up along each jaw line along a
line extending from the chin to the lobule. Re-operation in the
absence of adequate skin to make proper repair will be a
frustrating act of futility in which little if any beneﬁt will be
gained.

Fig. 12.22 Placement of the submental incision. Close-up view of the submental
region of a patient after secondary face lift. A previous incision had been made
directly in the submental crease (small arrow). The incision used at the secondary
procedure was made posterior to the prior incision (large arrow), and the scar and
crease were released. Smooth submental contours are present, and both scars are
inconspicuous.

Cross-hatched scars are a completely avoidable deformity
commonly seen in patients presenting for secondary facelift.
Like most secondary facelift deformities, they are the product
of errors in both planning and technique. The underlying
cause of most cross-hatched scars can be traced directly to
skin tension and tension-based facelift techniques. When incisions are closed under tension, larger sutures must be used,
and these must be tied tighter and left in longer. Inevitably,
varying degrees of necrosis occur beneath each, and these

Cross-hatched scars

Wide, thick, hypertrophic, and keloid scars, often attributed
to be the result of the patient’s own poor healing, are more
often due to the over excision of skin along improper vectors
in procedures in which the surgeon has employed skin tension
as a vehicle to lift sagging deeper layer tissue, rather than the
SMAS and platysma. In fact, it is noteworthy that scar widening and hypertrophic healing have rarely seen after a primary
facelift in patients of all skin types, providing a technique of
no skin tension has been employed.
Because the factors underlying suboptimal healing leading
to wide or hypertrophic scars are still present to some extent
in the patient requesting secondary surgery, each must
be approached with caution. Like the patient with a skin
shortage and poorly situated scars, the patient with wide or
hypertrophic scars may be impossible to effectively treat if
skin excision has been excessive at the primary procedure
(Fig. 12.25). This is true, regardless of how much the patient
and surgeon wish otherwise. Re-operation in the absence of
adequate skin to make proper repair will be a frustrating act
of futility in which little, if any, beneﬁt will be gained.

Wide scars

Fig. 12.21 Incorrect and correct plan for the submental incision. (A) Incorrect position for the submental incision. The incision should not be placed directly along the
submental crease because this will accentuate it and reinforce the double chin appearance. Note that the traditional plan of skin undermining (shaded area) also promotes a
double chin. (B) Correct position for the submental incision. Placement of the submental incision posterior to the submental crease prevents accentuation of the double chin
and witch’s chin deformities and provides for easier dissection and suturing in the anterior neck. Note that this incision plan allows the submental crease to be undermined
(shaded area) and released and the fat of the chin pad and neck to be blended.

A

288

A

B

289

spots go on to heal as scars. As skin relaxation occurs
over time the hatch marks and suture hole scars stretch and
migrate away from the incision scar, giving the appearance
that the wound was closed in a crude fashion with large,
widely placed sutures. Almost always cross-hatched scars are
accompanied by other signs of over reliance on skin tension

Fig. 12.24 Poorly situated, hypertrophic scars. If skin excision has been aggressive
at the primary procedure, relocation of poorly situated incisions may not be
possible at the time of request for secondary facelift. In these situations, it is
usually best to defer surgery until scars have matured, skin has relaxed, and
adequate tissue is available to make proper repair. This may mean waiting until
2 cm or more of skin can be pinched up along each jaw line. (Procedure performed
by unknown surgeon.)

including hairline displacement, hypertrophy, and wide scars
(Fig. 12.26).
Cross-hatched scars can simply and easily be avoided by
employing a facelift technique that does not rely on skin
tension. Diverting tension to the SMAS allows skin incisions
to be closed under little if any tension with loosely tied, ﬁne
sutures that can safely be removed in 4–5 days after surgery.
Diverting tension to the SMAS and platysma will not, in
and of itself, prevent cross-hatched scars. If skin is closed
under tension, or shifted along an improper vector after
SMAS and platysma ﬁxation, the opportunity to avoid
tension-based secondary deformities will be lost and one of
the major beneﬁts of the utilization of the SMAS and other
deep layer tissue will be subverted.

Fig. 12.25 Wide scars. Wide, thick, hypertrophic and keloid scars, often attributed
to be the result of the patient’s own poor healing, are usually due to the over
excision of skin along improper superiorly directed vector in procedures in which
the surgeon has employed skin tension as a vehicle to lift sagging deeper layer
tissue. As is the case in the patient with poorly situated scars, the patient with wide
or hypertrophic scars may be impossible to effectively treat if skin excision has
been excessive at the primary procedure. (Procedure performed by unknown
surgeon.)

Fig. 12.23 Correction of the double chin and witch’s chin deformities. If the submental incision is placed posterior to the submental crease, the submental retaining
ligaments can be released and the fat of the chin and the neck blended. (A) Patient with double chin before secondary facelift. (Procedure performed by an unknown
surgeon.) (B) Patient after secondary facelift. The submental incision was made 1 cm posterior to the submental crease, the submental restraining ligaments released, and
the subcutaneous fat of the chin and the submental areas sculpted and blended to achieve optimal contour. Platysmaplasty, transverse platysma myotomy, and
submandibular gland reduction were also performed. (Procedure performed by Timothy J Marten, MD, FACS.)

Identiﬁcation and analysis of secondary surgical deformities

Distortion of tragal anatomy is a common problem in patients
presenting for secondary facelifts. Like many other problems
associated with secondary surgery, it is the result of artistic
insensitivity, poor planning, and errors in technique. In many
patients, the secondary facelift will provide an opportunity to
improve or correct tragal distortion, but in others complete

Distortion of tragal anatomy

Accepting that skin need not be tight is difﬁcult for most
surgeons trained in classical facelift technique. For many, it
seems not only counter-intuitive, but also at cross-purposes
with traditional goals and objectives. Dismissing this idea,
and failing to accept related concepts, however, are major
stumbling blocks to achieving high quality scars and a “nonsurgical” and natural postoperative appearance.
The correction of cross-hatched scars is often difﬁcult
because the factors leading to the problem are still present to
some extent in the patient requesting secondary surgery, and
each must be approached with caution. As is the situation in
the patient with hairline displacement and wide or poorly
situated scars, for the patient with cross-hatched scars, it
may be impossible to effectively treat the patient with
cross-hatched scars if skin excision has been excessive at the
primary procedure or if enough residual skin redundancy is
not present to allow simultaneous excision of scars, skin
ﬂap advancement along an appropriate vector, and closure
without tension.
It is a common error to think that scars can simply be
excised and the skin needed for closure can be recruited by
wide undermining of overly tight adjacent areas. Experience
will show that re-operation in the absence of adequate skin to
allow excision along a proper vector along with a tension free
closure will result in a recurrence of the problem and other
associated tension-based deformities. In most patients, it is
best to accept partial correction of the problem, rather than
create new or worse problems by attempting complete elimination. Make-up, tattooing or restyling of hair may be necessary to conceal the residual scars.

There is perhaps nothing as tell-tale and objectionable in the
patient who has undergone a prior facelift as distortion or

Distortion of earlobe anatomy

correction may not be possible if additional problems are to
be avoided.
Common types of tragal distortion seen after primary
facelift include changes in tragal shape, changes in tragal
contour, tragal retraction, and obliteration of the pre-tragal
sulcus. Less commonly, more severe degrees of distortion can
also be present. In rare cases, the tragal cartilage has been
excised and the tragus is absent.
The most commonly observed forms of tragal distortion
seen in patients presenting for secondary facelift are loss of
tragal contour and obliteration of the pre-tragal sulcus. These
are frequently seen concurrently, although they have somewhat different underlying causes. Loss of tragal contour is
usually the result of improper incision planning, superior
overshifting of cheek skin, and imprecise trimming of the
tragal skin ﬂap. The tragus is seen to have no distinct beginning or end and no posterior projection. A tell-tale “choppedoff” appearance results (Fig. 12.27A). This is generally
correctable if tension is diverted to the SMAS, skin can
recruited from secondary advancement of the cheek skin ﬂap,
and the skin ﬂap is properly trimmed and ﬁt over the tragal
cartilage.
Loss of the pre-tragal sulcus results from failure to leave
enough skin to ﬁll the pre-tragal depression when the tragal
ﬂap is trimmed and is almost unavoidable in any technique
in which tension is placed on the cheek skin ﬂap. The overtrimmed skin ﬂap bridges the pre-tragal sulcus which in turn
is gradually ﬁlled with ﬁbrotic tissue and scar over time. The
tragus appears “buried” and indistinct from the cheek anterior to it. It can also be seen to have a ﬂat, two-dimensional
contour (Fig. 12.27B).
Correction of the buried tragus deformity requires recruitment of sufﬁcient skin from the cheek at the secondary procedure to ﬁll the three dimensional contours of the pre-tragal
area. Pre-tragal subcutaneous scar ﬁlling the pre-tragal sulcus
must also be excised, and the tragal skin ﬂap must be redraped
under no tension. Skin must then be trimmed to a precise ﬁt
while the ﬂap is depressed and held in the pre-tragal sulcus.
No deep suture is necessary to hold the skin ﬂap in the pretragal hollow if the above steps are properly carried out.
The “retracted tragus” represents an extreme case of the
“buried tragus” deformity. It too, is the result of technical
error and has its origin in an overly tight and excessively
trimmed cheek skin ﬂap. The retracted tragus deformity
differs from the buried tragus deformity, however, in that not
only is the pre-tragal sulcus obliterated by subcutaneous scar,
but the tragal cartilage itself is pulled anteriorly by the overtrimmed skin ﬂap. This results in an open auditory canal and
a tell-tale and unnatural appearance (Fig. 12.27C). Simple
recruitment of skin from the cheek and excision of pre-tragal
subcutaneous scar is not sufﬁcient to correct the retracted
tragus deformity because the retracted tragal cartilage is
usually stiff, ﬁbrotic, and unable to return to its natural position and conﬁguration on its own. Correction usually requires
that the cartilage be scored on its anterior surface and then
secured with a mattress suture once in its proper anatomic
position (Fig. 12.28).

SECTION I • 12 • Secondary deformities and the secondary facelift

Fig. 12.26 Cross-hatched scars. The underlying cause of most cross-hatched
scars can be traced directly to skin tension and tension based facelift techniques.
When incisions are closed under tension, necrosis occurs beneath sutures and
these spots go on to heal as scars. As skin relaxation occurs over time the hatch
marks and suture hole scars stretch and migrate away from the incision scar, giving
the appearance that the wound was closed with large, widely placed sutures.
(Procedure performed by unknown surgeon.)

290

B

C

291

mal-position of the earlobe. Like most other problems associated with secondary surgery, it is the result of artistic insensitivity, poor planning and errors in technique. Common
types of earlobe distortion seen after primary facelift include
the “pixy ear” and the “loving cup” ear.

Fig. 12.28 Correction of the “retracted tragus” deformity. To correct the retracted
tragus deformity cheek skin is undermined and subcutaneous scar in the pretragal
sulcus be excised. The anterior surface of the tragal cartilage then incised to allow
it to bend posteriorly to its proper anatomical position. The cartilage is secured in
this conﬁguration with a mattress suture of 4-0 nylon. Skin is then recruited by
facelift ﬂap advancement and the tragal ﬂap is carefully trimmed to ensure that
adequate skin is preserved to ﬁll the pre-tragal sulcus. (Procedure performed by
Timothy J. Marten, MD, FACS.)

“Pixy ear” is a pejorative term used by some to describe
the unnatural, impish, or elf-like appearance the ear assumes
when the lobule is attached directly to the cheek and pulled
anteriorly and inferiorly (Fig. 12.29A).
It is often the result of inartistic, improper, or careless
resetting of the earlobe into the cheek after the cheek ﬂap has
been suspended. It can also result as a delayed effect after
artistically appropriate resetting of the lobule at the time of
surgery in a skin only – non-SMAS facelift. The lack of deep
layer support in such cases will inevitably lead to some
inferior migration and settling of the cheek skin ﬂap and
eventual traction on the lobule. “Loving cup” ear is used
to describe the situation in which the ear resembles the
handles commonly seen on vase-like trophy cups. In this
deformity, the earlobes are joined to the cheek in a less extreme
fashion, but also have been inset or pulled too far inferiorly
(Fig. 12.29B).
This problem is often made worse by inferior migration of
the cheek skin ﬂap over time when a skin-only, traction-based
facelift technique is used.
A full understanding of the origin of lobular deformity
requires that the surgeon understands and appreciates normal
lobular anatomy. This sets the stage for appropriate and
natural resetting of the lobule into the cheek at the time of the
primary procedure and the avoidance of unnatural secondary
deformities. Young patients presenting for other procedures
and friends and family members who have not undergone
plastic surgery serve as useful subjects for study in this regard.
Photographs of actors, models, and celebrities are less valuable however, as many have secondary lobular deformities
that may not be immediately recognized due to concealment
of scars by photo-retouching or make-up.

Fig. 12.27 “Chopped-off”, “buried” and “retracted” tragal deformities. (A) In the “chopped-off” tragus deformity the tragus is seen to have no distinct beginning or end
and no posterior projection. It is usually the result of improper incision planning, superiorly overshifting of the cheek skin and imprecise trimming of the tragal ﬂap. (B) In
the “buried” tragus deformity the tragus appears indistinct from the cheek anterior to it and the pre-tragal depression is absent. This deformity results from failure to leave
enough skin to ﬁll the pre-tragal sulcus and is commonly seen when tension is placed on the cheek skin ﬂap. (C) The “retracted tragus” represents an extreme case of the
“buried tragus” deformity and is the result of an over trimmed cheek skin ﬂap. The retracted tragus deformity differs from the buried tragus deformity, however, in that not
only is the pre-tragal sulcus obliterated, but the tragal cartilage itself is pulled anteriorly. This results in an open auditory canal and a tell-tale and unnatural appearance. (All
procedures performed by unknown surgeons.)

A

Identiﬁcation and analysis of secondary surgical deformities

B

SECTION I • 12 • Secondary deformities and the secondary facelift

B

C

A careful examination of the youthful lobule will show that
it is distinct from the cheek and that its long axis lies approximately 15° posterior to the long axis of the pinna (Fig. 12.30A).
As the axis of the lobule is moved anteriorly to rest anterior
to the long axis of the pinna, a tell-tale “surgical” appearance
is produced (Fig. 12.30B). If the long axis of the lobule is
shifted well anterior to the long axis of the pinna and/or is
drawn inferiorly, an objectionable and grotesque appearance
can result (Fig. 12.30C).
On occasion a patient presenting for primary facelift will
be encountered, in whom the lobule naturally sits in an
anterior–inferior position. In these patients, it is best to reset
the lobule in an attractive, artistically appropriate, more posterior position, rather than where it was originally found. If
the lobule is reset in its original position, a “surgical” appearance is likely to result. This will not only raise suspicion that

A

the patient has had a facelift, but also will make appropriate
positioning of the lobular difﬁcult at a secondary procedure.
Correction of the pixy and loving cup ear deformities
requires that sufﬁcient skin can be recruited along the jaw line
at the secondary procedure to allow the lobule and cheek ﬂap
to be elevated to a natural position under no tension. As is the
case in the patient with a skin shortage and poorly situated,
cross-hatched, or wide scars, the patient with a pixy or loving
cup earlobe may be impossible to effectively treat if skin excision has been aggressive and excessive at the primary procedure or if the ear lobe has been reset too far inferiorly into the
cheek. In addition, if deep layer support is not provided, it is
likely that skin elevated at a secondary procedure will migrate
inferiorly over time and the deformity will recur. This is true,
regardless of how much the patient and surgeon wish otherwise, and re-operation in the absence of adequate skin to

Fig. 12.30 Earlobe aesthetics. (A) In the youthful
appearing attractive ear, the long axis of the lobule (dotted
line) will be seen to rest 15° posterior to the long axis of
the pinna (solid line). (B) As the long axis of the lobule is
shifted anterior to the long axis of the pinna a less natural
“surgical” appearance is produced. (C) If the long axis of
the lobule is shifted further anteriorly and/or inferiorly an
objectionable deformity will result.

Fig. 12.29 The “pixy ear” and “loving cup ear” deformities. (A) “Pixy ear” describes the unnatural, impish or elf-like appearance the ear assumes when the lobule is
attached directly to the cheek. It is the result of inartistic resetting of the earlobe into the cheek after the cheek ﬂap has been suspended. It can also result as a delayed effect
after artistically appropriate resetting of the lobule at the time of surgery in a “skin only” facelift. (B) “Loving cup ear” describes the state in which the ear resembles the
handles commonly seen on vase like trophy cups. In this deformity, the earlobes are not only attached to the cheek, but have been inset or pulled too far inferiorly.
(Procedures performed by unknown surgeons.)

A

292

B

make proper repair will be a frustrating act of futility in which
little, if any, beneﬁt will be gained.
Redundant skin available over the jaw line and in the
upper neck can be assessed by pinching it up and measuring
it. In general, if <2–3 cm is present, it is best to advise the
patient that complete correction will most likely not be possible. The extent to which correction can be made will depend,
of course, on the degree of deformity present. Although commonly practiced, anchoring the lobule to auricular cartilage
or adjacent deep tissue with buried sutures will not be effective if enough skin is not present to allow closure to be made
under minimal skin tension. Over time, the lobule will migrate
inferiorly.
In all but the unusual case, there will not be enough skin
present to correct loving cup earlobes by undermining and
elevating the cheek skin. It will also be an artistic error to
simply place the lobule back in an inappropriate position. In
such instances, it may be best to move the lobule into a normal
position and carefully close the defect into which it was originally inset using meticulous technique. The resulting scar will
go unnoticed because the eye will not be drawn to the area as
it once was by the abnormal appearing lobule. In addition,
the scar itself will often heal well following this maneuver, as
the incision can be closed under minimal tension under these
circumstances. A small amount of make-up or a cosmetic
tattoo is often usually sufﬁcient to conceal it. If the healed scar
is raised or irregular and is incompletely concealed with
make-up dermabrasion can be performed as a subsequent
step. For most patients, a scar on the cheek will be less noticeable than a displaced lobule, and an acceptable trade-off for
obtaining proper lobular position.

293

The introduction of liposuction, along with ill-conceived
procedures in which subcutaneous fat of the face and neck
is aggressively curetted, excised or even subjected to laser
and ultrasound treatment, has resulted in a group of patients
with excessively defatted necks and concomitant deformities
(Fig. 12.31).
These patients with “cadaver necks” have little fat between
their cervical skin and the underlying platysma and present
a difﬁcult problem when they request secondary procedures.
Often, they require platysma surgery, although they have little
superﬁcial fat to disguise any irregularities that may arise
from these procedures. In addition, if isolated surgery on the
neck was performed as the primary procedure, pseudoptotic
jowl fat and fat lying along the mandibular border has usually
been erroneously excised. This can result in harsh or irregular
contours when the SMAS is subsequently elevated and defatted areas are unavoidably advanced superiorly onto the face
(Fig. 12.32).
In these situations, care must be taken in any secondary
procedure to preserve as much fat as possible and to carefully
contour fat at the interface between face and neck.
It should be the aim of every surgeon who endeavors to
rejuvenate the face to create an attractive neck and not one
simply devoid of fat. Excessive fat excision does not produce
attractive or youthful contours, and often exposes and accentuates other neck problems. These problems include platysma
bands, prominent submandibular glands and large digastric
muscles. Each of these neck problems generally requires that
wide cervical skin undermining be performed if appropriate

Over-excision of subcutaneous fat

Fig. 12.31 Over-excision of subcutaneous fat. (A) The patient has undergone a “weekend” facelift in which aggressive liposuction was performed and too much fat was
removed. The neck and submental region are irregular and unattractive. (B) A different patient who has had a previous facelift. Submental “microliposculpture” was
performed as part of the procedure. Inappropriate over-resection of fat has resulted in harsh and unnatural contours. Note the contrast with the soft contours of the cheek
and neck. (Procedures performed by unknown surgeons.)

A

Identiﬁcation and analysis of secondary surgical deformities

Although not all surgeons routinely explore the subplatysmal
space and excise subplatysmal fat, patients with an unappealing “dug out neck” deformity are increasingly presenting for
secondary procedures. The dug out neck deformity is a term
used by some to describe situations in which subplatysmal
and/or deep cervical fat has been erroneously over-excised
resulting in an objectionable depression in the submental
region (Fig. 12.33). Typically, this depression is more evident
when the neck is ﬂexed somewhat or when the patient
swallows.
Correction of the dug out neck deformity is best made
using fat injections if it is the only problem present. If large
digastric muscles and/or large submandibular glands are

Over-excision of subplatysmal fat

Fig. 12.32 Erroneous excision of submental and
pseudoptotic jowl fat. Aggressive liposuction is
performed as a primary procedure over the neck and
jowl (shaded area) in a misguided attempt to
rejuvenate the face. When the patient returns for formal
facelift and ptotic deep layer tissues are properly
repositioned, denuded areas are advanced up onto
visible areas of the face. This can result in harsh and
irregular contours.

As experience is gained in evaluation of patients presenting
for secondary surgery, prominent submandibular glands will
increasingly be recognized as a frequent part of the secondary
neck deformity and the underlying cause of objectionable

Prominent submandibular glands

Although the judicious excision of buccal fat will occasionally
beneﬁt certain patients seeking primary or secondary facelift,
it will usually result in an ill or haggard look inconsistent
with the intended goal of producing an improved appearance
(Fig. 12.34A). This is evident in many patients presenting for
secondary surgery who have undergone “minilifts”, “weekend facelifts”, and limited incision procedures in which buccal
fat excision is often performed. In these patients, SMAS
advancement or midfacelifts can exacerbate this situation by
elevating the over-reduced buccal pad. These patients will
often beneﬁt from less aggressive SMAS surgery and avoidance of midfacelifting.
Correction of the over-resection of buccal fat is most easily
made using fat injections and these can generally be performed as part of the secondary facelift procedure (Fig.
12.34B). Injections should be made meticulously in small
amounts and in multiple passes in multiple planes with a
small blunt inﬁltration cannula. In general, 3–7 cc of centrifuged fat is needed for each cheek. Alternatively, free fat
grafts, or dermis fat grafts can be used. Facial fat injections
can also be performed as a separate procedure after secondary
facelift is performed. This allows the patient and surgeon to
examine what was accomplished during the secondary procedure, and adjust the fat injection procedure accordingly.

Over-excision of buccal fat

present, reducing these as part of the procedure may be sufﬁcient to hide the deformity. If secondary surgery is planned
and adequate platysma is present, an anterior invagination
(rather than excision) of the redundant portion of the medial
platysma borders can also produce some improvement.

SECTION I • 12 • Secondary deformities and the secondary facelift

correction is to be made. This is often difﬁcult when little
fat is present. Any such dissection must be carried out with
great care to avoid any injury to residual subdermal fat, the
platysma, and regional motor nerves. Excessive fat excision
can also result in troublesome dermomuscular adhesions.
These frequently result in tethering and abnormal appearances in animation and generally require careful division if
an open dissection of the neck is planned. If no modiﬁcation
of the platysma or other deep layer structures is needed,
dermomuscular adhesions can be treated transcutaneously
with a “V” tipped needle dissector and carefully placed fat
injections.
Although judicious excision of cervical fat is often necessary as part of rejuvenation of the aging neck, the excision of
facial fat will usually produce an aged and haggard look,
inconsistent with the intended goal of producing an improved
appearance. This haggard appearance is evident in many
patients presenting for secondary surgery who have undergone “minilifts”, “weekend” facelifts, “microliposculpture”,
and other procedures in which facial liposuction is often
performed. In these cases, remaining fat must be carefully
tailored to produce the best contours possible. These patients
will also often beneﬁt from facial fat injections.

294

B

B

C

residual bulges in the lateral triangle of the lateral submental
region (Fig. 12.35). Often, these bulges go unnoticed at the
time of the primary procedure owing to the fact that they are
obscured by neck fat and lax platysma muscle. In most
instances, the secondary facelift will provide an opportunity
for proper diagnosis and appropriate treatment, when present.
If a large or ptotic sub-mandibular gland is present, it can
usually be seen and/or palpated lateral to the ipsilateral anterior belly of the digastric muscle within its respective submandibular triangle.
Large glands can be incrementally resected through the
sub-mental incision after raising the ipsilateral platysma but
before submental platysmaplasty is performed, if indicated.
Submandibular glands are usually ﬁrm and have a distinctive
lobulated appearance. Reduction is begun by incising the
glandular capsule inferomedially and grasping the inferior
most portion of the gland. The gland can then easily

be separated from its capsule and adjacent tissue using a
combination of gentle blunt and sharp scissors technique.
Care should be taken when mobilizing the superior-lateral
portion of the gland as both the retromandibular vein and the
marginal mandibular branch of the facial nerve are in proximity in this area.
An examination of the dissected submandibular gland will
show it to be large, and not “ptotic”, and careful consideration
of this fact will reveal that attempts to reposition it more
superiorly with sutures or by tightening the platysma are
misguided and will ultimately be fruitless. This observation
forms the basis of the recommendation that partial resection
be performed in these patients.
After the protruding portion of the gland has been exposed
and freed from adjacent tissue, the redundant portion of the
submandibular gland is excised using a long tipped cautery
and a long pair of shielded forceps. Adequate exposure is

Fig. 12.34 (A) Inappropriate excision of buccal fat. Excision of buccal fat as part of a “mini” face lift has resulted in an ill or haggard look. This problem is most easily
corrected by fat injections, and these can generally be performed as part of the secondary face lift procedure. (Procedure performed by unknown surgeon.) (B,C) Correction
of the overresected buccal fat pad. (B) Secondary face lift patient who had buccal fat removed as part of her primary procedure. An unattractive, ill appearance has resulted.
(Procedure performed by unknown surgeon.) (C) Same patient after secondary face lift that included fat injections. The lower face has been ﬁlled and lost buccal volume
restored. A healthy, youthful, and attractive appearance results. (Procedure performed by Timothy J. Marten, MD, FACS.)

A

A

295

Fig. 12.33 (A,B) The “dug out neck”
deformity. The “dug out neck” deformity is
a term used to describe situations in which
subplatysmal and/or deep cervical fat has
been erroneously over excised resulting in
an objectionable depression in the
submental region. (Procedures performed by
unknown surgeons.)

Identiﬁcation and analysis of secondary surgical deformities

B

SECTION I • 12 • Secondary deformities and the secondary facelift

necessary, as is good light, an attentive assistant, and a good
source of suction. It should be noted that all vital structures
are situated lateral to the dissection and lie outside the glandular capsule. Excision is begun by grasping the inferior
portion of the gland and gently pulling it inferiorly and medially out of its fossa and away from adjacent structures. The
redundant portion is subsequently incised incrementally
along the planned line of resection (Fig. 12.36).

Fig. 12.36 Overview of the technique for reduction of prominent submandibular
gland. A submental incision has been made approximately 1 cm posterior to the
submental crease and the neck subcutaneously undermined. The right platysma
muscle has been elevated and is retracted with a double pronged skin hook and a
malleable retractor. The gland will be seen as a distinct bulge just lateral to the
ipsilateral anterior belly of the digastric (scissors tips rest on digastric). The
capsule has been incised inferiorly and medially and the submandibular gland
isolated using blunt dissection. The gland, once isolated, is gently pulled inferiorly
(forceps). The protruding portion is then excised incrementally with electrocautery.
(Courtesy of Timothy J. Marten, MD, FACS.)

As experience is gained in evaluation of patients presenting
for secondary surgery, large, low lying anterior bellies of the
digastric muscles will increasingly be recognized as a frequent
part of the secondary neck deformity and the underlying
cause of objectionable linear paramedian fullness in the submental region. These bulges often go unnoticed at the primary
procedure because they are often obscured by neck fat and lax
platysma muscle. In most cases, the secondary facelift will
provide an opportunity for proper diagnosis and appropriate
treatment (Fig. 12.37).
Prominent anterior bellies of the digastric muscles can
be treated by superﬁcial subtotal myectomy. Superﬁcial,
subtotal anterior digastric myectomy is performed under
direct vision, working through the submental incision after
the subplatysmal space has been opened and the medial

Large digastric muscles

This corresponds to a plane tangent with the ipsilateral
inferior mandibular border and anterior belly of the digastric
muscle. Intraglandular vessels are often encountered and
these must be carefully divided and immediately cauterized
in a controlled fashion. Any bleeding points on the raw surface
of the gland are then further cauterized once the redundant
portion has been excised. Platysmaplasty (suturing the medial
borders of the right and left platysma muscles together in the
midline) and platysmamyotomy (transverse division of the
platysma at the level of the cricoid cartilage) are then performed as indicated. A 10F closed suction drain is placed in
both the pre-platysmal and subplatysmal spaces when submandibular gland reduction is performed. It is not necessary
to remove the entire gland to create an attractive cervical
contour. Complete submandibular gland excision risks injury
to the marginal mandibular branch of the facial nerve and is
likely result in a depression or other contour abnormality.
Subtotal submandibular gland excision to date has resulted in
no cases of nerve injury, hematoma, seroma formation, salivary ﬁstula, or gustatory sweating.

Fig. 12.35 (A,B) Prominent submandibular glands. Prominent submandibular glands are commonly seen in patients presenting for secondary facelifts. They are typically
evident as objectionable residual bulges in the lateral triangle of the lateral submental region. Prominent glands often go unnoticed at the primary procedure because they are
obscured by neck fat and lax platysma muscle. (Procedures performed by unknown surgeons.)

A

296

The introduction of liposuction has resulted in many surgeons
adopting a closed plan of treatment for the neck, consisting

Residual platysma bands

platysma muscle borders mobilized. Partial digastric myectomy is usually best performed after subplatysmal fat excision
and submandibular gland reduction have been performed, if
indicated, as it is easiest to assess the muscles at that time.
Two basic techniques can be used: incremental tangential
shave excision and muscle splitting myectomy. In the former
the protruding portion of the muscle is shaved tangentially in
an incremental fashion using a DeBakey forceps and medium
Metzenbaum scissors until appropriate contour is obtained.
The neck is re-examined and the maneuver repeated until an
improved contour is obtained. Usually this entails the excision of 25–50% of the superﬁcial most part of the anterior
muscle belly, but occasionally 50–90% of the muscle must be
removed. In the muscle-splitting partial myectomy technique
the protruding portion of the muscle is isolated on a tonsil
forceps, or similar instrument, by pushing the instruments
tips transversely through the muscle belly (Fig. 12.38). The
isolated segment is then excised with scissors or electrocautery by dividing the muscle near the mandible and the hyoid
(Fig. 12.39). Contours are checked and the maneuver repeated
as indicated. Platysmaplasty (suturing the medial borders of
the right and left platysma muscles together in the midline)
and platysmamyotomy (transverse division of the platysma
at the level of the cricoid cartilage) are then performed as
indicated.
A 10F closed suction drain is usually placed in the
subplatysmal space when digastric myectomy is performed,
and almost always if subplatysmal fat excision or submandibular gland reduction is concomitantly carried out.
Digastric myotomy has not resulted in dysphagia, dysphonia,
or other functional problem.

Fig. 12.37 Prominent anterior belly of the digastric muscle. The patient has had
prior face and necklift. The anterior belly of the digastric muscle can be seen as
objectionable linear paramedian fullness in the submental region that spoils and
otherwise good result. Prominent digastric muscles often go unnoticed at the time
of the primary procedure due to the fact that they are frequently hidden by cervical
fat and lax platysma muscle. (Procedure performed by unknown surgeon.)

297

of suction excision of preplatysmal fat with and without postauricular skin excision. Although this occasionally yields a
good result in a younger patient with modest deep layer problems, more often it accomplishes little more than exposing
underlying platysma bands, resulting in an objectionable and
elderly appearance.
Primary and secondary platysma bands are best treated
by transverse platysma myotomy (transverse division of the
platysma at the level of the cricoid cartilage), as the underlying problem is one of platysma hyperfunction, not horizontal
platysmal laxity. Dividing the muscle defunctionalizes the
muscle similar to the way in which the gastrocnemius muscle
is defunctionalized when the Achilles tendon is ruptured.
Platysmaplasty alone (suturing the right and left platysma

Fig. 12.39 Excision of protruding portion of anterior digastric muscle. The muscle
has been isolated on a hemostat. The isolated muscle segment is then divided near
the hyoid and mandible using electrocautery. (Courtesy of Timothy J Marten, MD,
FACS.)

Fig. 12.38 Isolation of the protruding portion of the anterior digastric muscle. The
tips of curved hemostatic forceps are bluntly pushed through the midbody of the
muscle belly. (View from patient’s right of right digastric muscle through submental
incision. Patient’s chin is on the left and neck on right.)

Identiﬁcation and analysis of secondary surgical deformities

Fig. 12.41 Treatment of residual anterior and lateral
platysma bands. Schematic showing anterior and
lateral bands and plan for platysma myotomy. After
myotomy and SMAS ﬂap advancement.

Fig. 12.40 Treatment of residual anterior platysma
bands. Schematic showing anterior band and plan for
platysma myotomy. After myotomy and SMAS ﬂap
advancement.

taught, muscle and low lip dysfunction is common and
an unattractive overly sharp cervicomental angle is likely
to result.
Anterior bands require transection of the platysma to
a point lateral to the band to the midpoint of the muscle
(Fig. 12.40). If lateral bands are present, transection is extended
further laterally to a more lateral point in the muscle to include
them as well (Fig. 12.41).
Platysma bands are the result of platysma muscle hyperfunction they are not logically or effectively treated in most
cases by suspension sutures or direct excision. Suspension
sutures and straps, especially those extending from mastoid
to mastoid, often result in an overly rigid noose that is disturbing and uncomfortable to patients, especially when they
look down. Sutures extending partially across the neck are

SECTION I • 12 • Secondary deformities and the secondary facelift

muscles together in the midline) is usually insufﬁcient as it
does not address the underlying cause of the problem.
Transverse platysma myotomy generally requires complete
subcutaneous undermining of the neck because myotomy
must be preformed at or near the level of the cricoid cartilage
where the platysma muscle is thin if visible irregularities are
to be avoided. Bleeding will also be minimal when myotomy
is performed at this location, and there is minimal chance that
lower lip dysfunction will be produced. If platysma transection is performed higher where the muscle is thicker, bleeding
from cut muscle edges is more common, and contour irregularities are likely to be evident once swelling is gone and
healing is complete. A high division of the platysma can also
precipitate lower lip dysfunction. If wedge resection of the
platysma is made near the hyoid as is often traditionally

298

A careful examination of the typical patient presenting for
secondary surgery is commonly remarkable for an uncorrected or under corrected midface evident as infraorbital hollowing, malar ﬂattening, and nasolabial fold formation. These
changes often appear more obvious and more objectionable
after the patient’s primary procedure as they typically stand
in contrast to an overly tight jaw line and against a background of aggressive rejuvenation of other adjacent areas.
Treatment of midface problems remains controversial and
a consensus of opinion as to the best way to correct them has
yet to arise. A major short-coming of “skin lifts” and the
typical “low” SMAS ﬂap elevated below the zygomatic arch,
is that neither is able to produce signiﬁcant improvement in
the midface area. Skin lifts fail because skin provides little in
the way of support of the malar fat pad. “Low” SMAS ﬂaps
are ineffective, as they are unable by design to exert a signiﬁcant vector of pull over the midface and infraorbital region.
Incising and elevating the SMAS ﬂap “higher”, along the midbody of the zygomatic arch, and extending the dissection
medially to release and mobilize midface tissue, however,
enables problems in these areas to be addressed (Figs 12.42,
12.43). This high SMAS plan, as such, provides a means for
both elevating ptotic infraorbital and malar tissue, and increasing lower lid support.

Uncorrected and under-corrected
midface deformities

better tolerated and may be helpful for minor muscular irregularities. Neither, however, addresses directly the anatomical
basis of the problem.
Excision of platysma bands, although recommended and
practiced for some time, can result in nerve injury and muscle
dysfunction, and typically results in visible irregularity, and
recurrent deformity. Excision does not address the anatomic
basis of the problem and often results in new bands on each
side of the excised muscle.

299

Fig. 12.42 “Low” SMAS ﬂap. The traditional “low”
plan for the cheek SMAS ﬂap is by design only able to
apply a vector to the lower cheek and jowl, but not the
midface. Plan for low SMAS ﬂap. Low SMAS ﬂap after
advancement and ﬁxation. Arrow indicates that ﬂap
elevation results in improvement in the lower cheek
and jowl only.

It is common at the time of secondary facelift surgery to
ﬁnd that the SMAS has been dissected timidly at the primary
procedure and that the high, extended dissection described
above can easily be performed in a virgin plane. Fortunately,
a secondary SMAS dissection is also still possible after a more
extensive primary SMAS procedure, and the subSMAS plane
usually offers little in terms of scar, adhesions, or other
encumbrances.
Advancing the cheek SMAS ﬂap superiorly and suspending it without excising its superior margin or folding it superior edge upon itself at the primary procedure, provides the
ideal setting for secondary SMAS surgery. The overlapping
tissue segments are easily dissected at some future date and
minimal subSMAS cicatrix is produced. A high SMAS plan
also precludes dimpling and irregular contours over the
upper cheek when the patient smiles (“smile block”) due to
impingement of the cheek pad at suture sites and tethering of
tissue there. This can occur, however, if attempts are made to
suspend midface or malar pad over the superior aspect of the
zygoma or to the periosteum along the infraorbital rim.
It should be recognized that the nasolabial fold and crease
are a product of the patient’s individual anatomical make-up
and in many cases a speciﬁc familial trait. In such cases, elevation of the midface as described should not be expected to
eliminate or obliterate these features. Indeed, in such cases
there is little artistic imperative to do so.
Most midfacelifts are generally conceptually ﬂawed and
of limited utility in the secondary facelift patient in that they
erroneously assume the problem seen in the anterior upper
cheek to be solely one of tissue sagging. Failure to acknowledge the fact that atrophy 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 “midfacelift” procedures. It is questionable and remains to be answered however, whether these
procedures can produce a restoration of lost volume as simply,
naturally, and effectively as can be obtained with fat

Identiﬁcation and analysis of secondary surgical deformities

Incomplete elevation of the jowl, or recurrent jowl ptosis, is a
common problem seen in patients presenting for secondary
facelifts that in all but the unusual case, represents incomplete
mobilization, improper shift, inadequate ﬁxation or other
improper or under utilization of the cheek SMAS (Fig. 12.44).

Residual jowl

injections. The current trend seems to strongly favor a “ﬁlling”
rather than a “lifting” approach.

Fig. 12.43 “High” SMAS ﬂap. The “high” plan for the
cheek SMAS ﬂap allows a vector to be applied to not
only the lower cheek and jowl, but not the midface
and infraorbital region as well. Plan for High SMAS
ﬂap. High SMAS ﬂap after advancement and ﬁxation.
Arrow indicates that ﬂap elevation results in not only
improvement in the lower cheek and jowl, but in the
midface and infraorbital region as well (compare with
Fig. 12.42A,B).

Many patients presenting for secondary facelift will have
abnormal appearances due to inappropriate shifts of skin
ﬂaps. This problem is particularly common in the older patient
with deep rhytides and poor skin elasticity and will typically
be evident as superiorly over-shifted cervicofacial rhytides in
the lower lateral cheek, perilobular area, and upper lateral
neck sometimes referred to as a “wrinkle shift deformity”
(Fig. 12.45).
Superior over-shifting of cervicofacial rhytides is commonly seen in skin-only facelifts and “composite” type procedures, and in MACS (minimal access cranial suspension)
lifts, and other “short-scar” procedures in which a short postauricular incision is used and skin is obligatorily shifted along

Distortion and abnormal appearances
due to inappropriate skin shifts

In most patients, the secondary facelift will provide an opportunity to reposition sagging jowl tissues and to restore attractive mandibular contour. Although liposuction and direct
excision of jowl fat can be used to improve mandibular contours in some instances, this fat more appropriately belongs
higher on the face and should not be arbitrarily sacriﬁced (see
Fig. 12.33). In addition, in most instances liposuction and/or
direct jowl fat excision was performed aggressively at the
primary procedure, and little residual superﬁcial fat is typically present in secondary cases. Almost all patients with
residual jowls presenting for secondary surgery will be better
served by formal SMAS dissection and suspension, than by
fat excision. Occasionally, patients with very heavy jowls will
require the combination of repositioning of jowl fat via SMAS
elevation and conservative jowl fat removal via direct excision
or liposuction. In a minority of instances however, residual
large jowls present after a primary facelift represent a combination of residual excess fat, jowl tissue ptosis, and atrophy
at the geniomandibular groove, and a combination of SMAS
elevation, judicious fat excision, and geniomandibular groove
fat grafting may be indicated.

SECTION I • 12 • Secondary deformities and the secondary facelift

Fig. 12.44 Residual jowl and jaw line laxity. Incomplete elevation of the jowl is
commonly seen in patients presenting for secondary facelifts and represents
incomplete or under utilization of the cheek SMAS. Although liposuction and direct
excision of jowl fat may straighten mandibular contours, this fat more appropriately
belongs higher on the face and should not be arbitrarily sacriﬁced. (Procedure
performed by unknown surgeon.)

300

superiorly directed vector. This deformity is commonly
accompanied by temporal hairline displacement, unless an
incision along the temporal hairline has been used. The fundamental problem with these procedures is that they fail to
address the fact that skin and SMAS age at different rates and
along different vectors. In general, skin needs to be advanced
along a vector perpendicular to the nasolabial fold whereas the
SMAS and deep layer tissue needs to be advanced along a more
superiorly directed vector roughly parallel to the long axis of the
zygomaticus major muscle. In skin-only lifts, skin is typically
over-shifted along a superiorly directed vector in a misguided
attempt to correct problems of deep layer origin seen in the
lower face and along the jowl. In deep plane and composite
procedures, skin is obligatorily advanced as a composite with
underlying SMAS and skin must be over-shifted superiorly to
obtain the best SMAS effect. The “wrinkle shift deformity” is
most problematic in MACS lifts and short scar procedures,
and any similar procedure in which an attempt is made to
shorten or eliminate the post-auricular scar. These procedures,
by design, require that cervicofacial skin ﬂaps be shifted
along a purely vertical vector, and do not provide a means for
wrinkled cervical skin to be partially excised, shifted more
posteriorly, and kept on the cervical area.
Separating the skin and SMAS from one another into separate lamella and advancing each along independent vectors
allows each layer to be treated most appropriately and as
indicated. When this is done, wrinkled cervical skin can be

Fig. 12.45 Abnormal appearance due to inappropriate skin shifts. Wrinkles
originally present on the neck have been moved up over the jaw line and in front of
the lobule. This occurs in “skin lift” procedures when the skin is advanced along a
superiorly directed vector in a mistaken attempt to improve neck contour. It can
also occur in Skoog and “composite” procedures as skin and SMAS must
obligatorily be advanced in the same direction. (Procedure performed by unknown
surgeon.)

301

Whenever prospective patients and the lay public discuss
facelift surgery they inevitably express the most concern and
dismay over the tight faces of various celebrities and their
friends and acquaintances who have undergone the procedure. Many unhesitatingly demonstrate what they see to be
the problem by pulling forcefully on their cheeks, eyes, and
eyebrows asking either not to look that way after their surgery,
or stating they will never undergo surgery for fear of ending
up with a similar appearance. This concern is reinforced by
the numerous jokes and references in the popular press to
“masks”, “wind tunnels”, and “faces so tight they will crack”
if their wearer smiles. Despite these expressed concerns and
the frequent popular ridicule of the typical outcome of multiple skin-only facelifts, procedures based predominantly on
skin excision that produce a tight look continue to be widely
performed.
The fundamental problem with a “skin-only” facelift, especially if multiple such procedures are performed, is that skin
is meant to serve a covering function and not a supporting
one. Most of the changes seen in the aging face, however, are
the result of an attenuation of support and subsequent descent
of deep layer facial tissues, and not sagging of skin. Any
attempt to lift signiﬁcant sagging of deep facial tissue with

Skin deﬁciencies and “tight look”

Although advancement of the SMAS along a mostly superiorly directed vector will produce the most comprehensive
improvement in the midface, cheek, jowl, and infraorbital
areas, it will also inevitably produce compression of the
temporal face and lateral orbital region if tissue shifts have
been meaningful and temple lift or foreheadplasty is not performed. This compression and wrinkling not only contribute
to a “young face–old forehead” deformity, but also will be
worse after a secondary facelift if temple and lateral upper
facial tissue are not correspondingly repositioned.
Patients are often aware that a problem exists in the temple
area after their primary facelift but often mistakenly assume
it to be a problem of skin wrinkling and residual “crow’s feet”.
Many rightly observe that tissue compression is worse upon
smiling. These patients will beneﬁt from repositioning of temporal tissues or formal foreheadplasty if not performed as part
of the primary procedure.

Compression of the temporal face

shifted posteriorly and partially excised, and kept off the face.
This minimizes cervical wrinkle shift onto the face and other
secondary irregularities resulting from improper skin shifts.
This treatment of the skin and SMAS as separate layers is
referred to as a “lamellar” or “bi-directional” facelift.
Neck to face wrinkle shift is difﬁcult to correct, especially
in the patient with little residual skin redundancy. Although
skin ﬂap elevation and re-advancement along a more posteriorly directed vector can produce some improvement, the
degree to which the ﬂap can be shifted back into a normal
position will be limited by the severity of the previous skin
over-shifting, the previous cut-out made for the lobule at the
primary procedure, and the amount of recurrent redundant
skin present at the time that secondary surgery is requested
(Fig. 12.46).

Identiﬁcation and analysis of secondary surgical deformities

B

SECTION I • 12 • Secondary deformities and the secondary facelift

skin will be short-lived, destined to produce an overly tight
appearance, and doomed to result in secondary deformities.
As the elastic limits of skin are exceeded in a skin-only
facelift, a tight or pulled appearance develops and facial
contour is ﬂattened. Tightness and ﬂattening will be most
pronounced in the pre-auricular region where tension is
highest and the threshold of elasticity exceeded the most.
More inferiorly, in the jowl and peri-oral region, skin will be
under less tension and below its threshold of inelasticity. Less
tightness will thus be present in these areas, where it is needed
most. Further tightening of the skin usually results in more
pre-auricular ﬂattening but little improvement in jowl and
peri-oral contour. Over time, “tight lines” (Fig. 12.47) will
appear across the lower cheek and upper lateral neck upon
neck ﬂexion and “drapery lines” (Fig. 12.48), or “lateral
sweep” will develop over the lower cheek and jowl. Drapery
lines and lateral sweep develop because skin is ﬁxed and
tethered in the pre-auricular and peri-stomal regions, but has
no support in between where deep layer tissue sagging is
greatest. Wrinkling and tightness extending from the lobule
to the jowl and submental area when the patient looks down
(“tight lines”) also occurs after well-intended attempts to
contour the face by skin excision because the elastic limits
of cheek skin is exceeded when the neck is ﬂexed and its
normal covering function is corrupted (Fig. 12.47). This telltale deformity is typically evident when the patient is looking
down and the neck is markedly ﬂexed (e.g., when looking at
a menu, book, or theater program).
The patient presenting for secondary facelift who had skin
excision only at their primary procedure is the quintessential
patient in need of deep layer support. Additional skin
Fig. 12.47 “Tight lines”. Wrinkling and tightness extending from the lobule to the
jowl and submental area when the patient looks down (“tight lines”) occurs after
well-intended attempts to contour the face by skin excision because the elastic
limits of cheek skin is exceeded and its normal covering function is corrupted.
(Note other tension artifacts including retracted lobule and wide, cross-hatched
peri-lobular scar.) (Procedure performed by unknown surgeon.)

Fig. 12.46 Improvement of inappropriate skin shifts. (A) Wrinkles originally present on the neck have been moved up over the jaw line and in front of the lobule at the
patient’s primary procedure. (Procedure performed by unknown surgeon.) (B) After secondary facelift. Contour has been created using the SMAS and platysma and cheek
skin has been shifted inferiorly to the extent possible. (Procedure performed by Timothy J. Marten, MD, FACS.)

A

302

The continued popularity of procedures in which the skin
of the face and neck is extensively undermined and then
suspended under abnormal tension in an attempt to create
youthful contour has resulted in the continued occurrence of
potentially avoidable secondary deformities resulting from
skin slough. Skin slough is also frequently the result of inappropriately aggressive surgery on smokers and arguably risky
procedures in which a facelift is performed concomitantly
with aggressive laser resurfacing of undermined skin.
Small areas of scarring resulting from skin slough in
patients presenting for secondary surgery can sometimes be
corrected at the time of the secondary procedure by direct
excision after adequate mobilization of surrounding tissue
or by incorporation of the scarred area into a more comprehensive incision plan. Larger areas of skin loss resulting from
excessive ﬂap undermining, excessive ﬂap tension, rough
tissue handling, or overly tight facial bandages are usually
much more difﬁcult to correct, especially if skin excision
was aggressive at the primary procedure and little residual
redundancy is present. Regrettably, this is all too frequently
the case. In such situations, the patient and surgeon must
accept that complete correction is not possible at the time of
the secondary procedure no matter how much they wish it
were so.
It is a common error to assume that scarred areas can
simply be excised and that the skin needed for closure can be

Skin slough

excision will result in an accentuation of their deformities, and
little improvement in facial contour.

Fig. 12.48 “Drapery lines” and “lateral sweep”. “Drapery lines” and “lateral
sweep” are common problems following a “skin-only” facelift. In these procedures
skin tightness is most pronounced in the pre-auricular region where it is least
needed. More inferiorly, in the jowl and peri-oral region, skin will be under less
tension where it is needed most. “Drapery lines” develop because skin is ﬁxed and
tethered in the pre-auricular and peri-stomal regions, but has little no support in
between where deep layer tissue sagging is greatest. (Procedure performed by
unknown surgeon.)

303

recruited by wide undermining of adjacent cheek or neck
tissue. Even the surgeon who knows better will often set good
judgment aside when subjected to the persistent pleading of
a patient desperate for some kind of improvement. Experience
has shown however, that simple scar excision and adjacent
tissue undermining in these patients will result in inadequate
skin for a tension free repair and a forced, excessively tight
closure. This tight closure, in turn, will inevitably result in
wound dehiscence, scar widening, and associated tensionrelated deformities including scar hypertrophy, cross hatched
suture marks, facial distortion, tragal irregularities, and
lobular malposition. In these patients it is best to accept partial
correction of the problem, rather than creating a new one, or
injuring remaining normal tissue. Make-up, camouﬂage tattooing, or restyling of hair are better alternatives to conceal
the residual scars in these circumstances.
If make-up is ineffective in concealing scars due to ridges
and step-offs where they abut normal tissue, dermabrasion
may be helpful in reducing the discrepancy in tissue height
and smoothing the transition between the two areas. Even if
discrepancies in tissue height can be reduced in this manner,
there is usually a marked difference in tissue texture that
prevents the scar from being completely concealed. Patients
wishing further improvement may beneﬁt from scar excision
and full thickness skin grafting as this technique can provide
cover with more natural appearing skin texture. Several
follow-up dermabrasion procedures may be necessary to
smooth the interface between the skin and skin grafts and
these patients are likely to beneﬁt from the use of a silastic gel
sheet and/or facial compression garments during the healing
process. In some circumstances, it may be better to excise
some normal skin along with scarred areas and graft a large
anatomical sub-unit, rather than creating a patch quilt of
smaller grafts. In extreme situations, consideration may have
to be given to cheek or neck skin expansion.
Skin slough can be minimized or avoided by exercising
caution, using common sense, and adhering to basic plastic
surgery principles. All patients who smoke or have a history
of smoking should be identiﬁed and their surgery planned in
a way that recognizes their increased risk for compromised
healing skin necrosis. Consideration should be given to not
performing a facelift on heavy smokers with a long history of
tobacco use, or employing a facelift technique that does not
involve wide skin ﬂap undermining and skin ﬂap tension.
Many of these patients will be satisﬁed with a combination of
limited lower risk procedures including closed foreheadplasty, eyelid surgery, conservative submental liposuction, fat
injections, and laser resurfacing. Smokers should always be
approached with caution however, and every surgeon should
recognize these patients have a higher risk of experiencing
healing problems after surgery.
Flap necrosis is dependent upon a variety of factors under
the surgeon’s control and can be minimized by procedure
design. These factors include tissue trauma, the extent of skin
undermining, and skin tension. Because deep layer techniques
limit skin undermining, preserve important cheek perforators, and avoid excessive tension on cervicofacial skin ﬂaps,
a careful surgeon employing a gentle, atraumatic, technique
in carefully selected patients should infrequently encounter
skin slough. And when the procedure is performed in this
manner, skin slough, should it occur, should be limited and
easily managed.

Identiﬁcation and analysis of secondary surgical deformities

Many patients presenting for secondary facelift will have had
skin only, non-SMAS procedures and as such, will be potentially free from deformities related to inappropriate SMAS
maneuvers. SMAS injury during non-SMAS surgery can,
however, result in distortion and irregularities of SMAS
origin, even though no actual SMAS surgery was performed.
The typical SMAS injury resulting in secondary deformity
occurs when the SMAS is knowingly or unknowingly “buttonholed”. This will result in asymmetries and contour irregularities, especially when the patient is in animation or clenches
their teeth (Fig. 12.49). Identiﬁcation and repair of these SMAS
defects at secondary surgery will eliminate many of these
types of problems. Larger rents or defects in the SMAS, resulting from larger areas of SMAS injury, SMAS excisions, and
failed plications present a bigger challenge and can be difﬁcult to fully correct.
Patients who have had prior SMAS lifts may have other
secondary SMAS deformities that must be recognized and
addressed as well. These deformities include ridges from
SMAS plication or SMAS excision, irregularities from an
uneven or overly tight SMAS suspension, and distortion and
unnatural appearances from advancement of the SMAS along
an improper vector.
Ridges and irregularities from prior plication or SMAS
excision may limit the potential for improvement in secondary procedures, and secondary correction techniques must be

Distortion and abnormal appearances due to
inappropriate SMAS shifts or SMAS injury

Attempts to directly suspend the midface or malar fat pad
with sutures, or low rigid suspension of the SMAS to the facial
skeleton, will prevent natural gliding of cheek and midface
tissue during animation. This will be clinically apparent postoperatively, when the patient emotes as dimpling and contour
irregularities often referred to as “smile block” (Fig. 12.50).
Smile block can usually be improved at a secondary procedure by a thorough release of the tethered area and
re-suspension of ptotic tissues using a technique that allows
unrestrained and natural gliding of malar pad and midface.

“Smile block”

individualized according to the speciﬁc problems present.
Some correction is usually possible if tissues are carefully
examined and the origins of the problem can be ascertained.
SMAS advancement along an improper vector can result in
distortions in animation and at rest. These typically occur
when the cheek SMAS ﬂap has been erroneously advanced
and suspended under tension along a predominantly posterior, rather than mostly superior vector and are typically
evident as a “clown mouth” or “pulled mouth” appearance
and bizarre and unusual facial movements in animation.
The proper vector of advancement of the SMAS is along a vector
parallel to the long axis of the zygomaticus major muscle. If the
SMAS is advanced along another vector, the zygomaticus
major muscle will be bowed off its axis of normal function
and its action corrupted. Posterior traction also exaggerates
risorius action and results in an objectionable change in the
resting posture of peri-oral tissues. Secondary deformities
related to an improper advancement of the SMAS ﬂap are
often markedly improved during secondary surgery when the
SMAS is re-elevated and re-advanced along a proper vector.

Fig. 12.50 “Smile block”. If the SMAS is suspended too low, too far medially over
the zygoma, or too rigidly directly to the periosteum, tissue tethering can result in
dimpling and other irregularities when the patient smiles (arrow). This problem can
also be seen when attempts are made to directly suspend the malar pad or when
the malar midface or other mobile area of the face is suspended to the infraorbital
rim or other part of the bony skeleton. (Procedure performed by unknown surgeon.)

SECTION I • 12 • Secondary deformities and the secondary facelift

Fig. 12.49 Contour irregularity (arrow) due to prior SMAS injury. A common
type of SMAS injury resulting in secondary deformity occurs when the SMAS is
knowingly or unknowingly “button-holed” at the primary procedure. This can result
in bulges or contour irregularities when the patient animates or clenches her teeth.
(Note the bulge in the lower cheek in this patient when clenching her teeth.)
(Procedure performed by unknown surgeon.)

304

It is not uncommon to ﬁnd patients presenting for secondary
facelift who have inappropriate or unaesthetic facial implants
that detract from their appearance and limit the potential for
improvement at any secondary procedure. Frequently, these
implants were placed in an attempt to offset the deﬁciencies
and shortcomings of a “minilift”, “laser facelift”, “infomercial
lift”, “franchise facelift”, or “weekend” procedure, or placed
in an isolated procedure in a patient who would have arguably been better served by formal facelift surgery. These
can include under and over-sized malar implants, submalar
implants, chin implants, and mandibular angle implants.
Often even more troublesome are PTFE (Gore-Tex®) strips and
similar implants placed in the lips and nasolabial folds. These
can be seen to result in visible surface irregularities and buckle
and fold upon facial animation.
Although facial implants collectively comprise a signiﬁcant
advance in aesthetic surgery and have helped many patients,
they were devised primarily to be used in individuals with
skeletal deﬁciencies. Patients troubled by age-associated soft
tissue ptosis are more logically, appropriately, and effectively
treated by procedures that reposition and redistribute ptotic
tissue, rather than those designed to augment the facial skeleton. Patients troubled predominantly by soft tissue atrophy
are likewise more appropriately treated by fat injections than
with facial implants.
Many patients with unaesthetic facial implants are aware
that all is not right with their appearance and are more than
willing to consent to implant exchange or removal. These
patients are typically seen to have small button-like chin
or cheek implants, oversized malar implants, or submalar
implants placed in a failed attempt to improve their nasolabial
folds.
A more difﬁcult situation exists when the patient does not
see the problem and is unwilling to consider implant exchange
or removal. In these patients, one must decide whether it is
possible to work around this, or if it is preferable to let the
patient enlist the services of another surgeon.
In general, the removal or exchange of facial implants at
the time of secondary facelift is not difﬁcult and results in a
few untoward occurrences. If implants were originally placed
subcutaneously, a more natural appearance can usually be
obtained when they are moved to a subperiosteal position.
Submalar implants often can be removed at secondary procedures, as cheek and midface repositioning will often result in
abnormal appearances if these are left in place. Alternatively,
they can be left in place and removed in a subsequent procedure, if necessary, if the patient desires.
PTFE (“Gore-Tex”) implants placed in the lips and nasolabial folds present a particular problem in that they can be
exceedingly difﬁcult to remove. In addition, removal can

Unaesthetic facial implants

This is usually best accomplished by high suspension of
the cheek and midface using a high SMAS ﬂap (Fig. 12.43),
or by employing a subperiosteal midfacelift technique.
Techniques that require suture ﬁxation of more superﬁcially
situated tissue, or “low” ﬁxation on the face, should be
avoided. Smile block can also often be corrected percutaneously by release of tethered areas with a small “V” tipped
lipo-inﬁltration needle and concomitant fat injection.

305

Rarely does isolated aging occur in the cheek and neck.
Nonetheless, most attempts to rejuvenate the face are targeted at these areas and many patients presenting for
secondary facelift will have a distinct and tell-tale “young
face–old forehead” deformity. This results from a failure to
recognize and treat forehead aging at the primary procedure
(Fig. 12.51).
A careful consideration of the typical patient presenting for
secondary facelift frequently reveals that isolated tightening
of the neck and cheeks is often an artistically inappropriate
undertaking. This is due, at least in part, to the fact that
changes in the forehead are more likely to be mistakenly
assigned emotional signiﬁcance than those in the lower face
and neck, and as such, play a greater role in how we interact
with and are regarded by others. In addition, rejuvenating
the lower face and neck only will typically result in facial
disharmony and an unnatural, unbalanced, and “surgical”
appearance.
Recognizing the “young face–old forehead” deformity is
necessary for it to be corrected and a pre-requisite to communicating the need for forehead surgery to the patient. To
appreciate the “problem”, the surgeon must examine the
patient’s face in its entirety and consider the way in which his
or her appearance might make others feel. This is often best
accomplished by viewing the patient’s face at a distance and
momentarily deferring to one’s intuition.
Because a patient’s hairstyle can conceal important signs of
forehead aging, and compensatory frontalis spasm can give
the false impression that the eyebrows are in an appropriate
position, it is imperative that the face of the patient presenting for
secondary facelift be examined with the patient’s hair pushed well
back off their forehead. In addition, because patients who wear
forehead concealing hairstyles often do not see the full extent
of these problems, it is helpful, as it is during the rest of their
evaluation, for the patient to hold a hand mirror during this
part of the examination. They can then be shown these important ﬁndings and counseled as to how they are actually the
product of forehead ptosis.
The erroneous assumption that forehead ptosis is not present
because the eyebrow appears to be in a normal position is the single
biggest stumbling block in evaluating the forehead for patients and
surgeons alike. Patients are accustomed to optimizing the
appearance of their face when looking at their reﬂection by
unconsciously raising their eyebrows. This is often further
compounded by the fact that many women aggressively
pluck the inferior-lateral portion of their eyebrow to give the
allusion that it is higher and more arched. In many cases, the
entire outer third of the eyebrow will be seen to be missing
and has been drawn on in a higher position with an eyebrow

The un-rejuvenated forehead

often result in troublesome and difﬁcult to correct secondary
deformities. It is often best to encourage the patient to return
to the surgeon who originally placed these implants before
secondary surgery is performed if he or she wishes them to
be removed. This allows problems associated with implant
removal to be clearly deﬁned prior to the secondary surgery,
and an appropriate plan for correction to be made. If implant
removal is made as part of the secondary facelift, problems
may be erroneously attributed to that procedure or the technique used.

Identiﬁcation and analysis of secondary surgical deformities

B

SECTION I • 12 • Secondary deformities and the secondary facelift

Although advanced peri-oral aging is usually appreciated at
the time of primary facelift, more subtle deformities often go
unnoticed, especially when viewed against a background of
advanced aging elsewhere on the face. As a result, peri-oral
deformities often go untreated at the primary procedure and
usually appear more apparent after rejuvenation of adjacent
areas is done. This can result in a tell-tale “young face–old
mouth” deformity.
Recognizing the “young face–old mouth” deformity is necessary if improvement is to be made and a pre-requisite to
communicating the need for the procedure to the patient.
Because many patients presenting for secondary facelift will
have an un-rejuvenated peri-oral area, peri-oral rejuvenation
will often be an important component of the planned secondary “facelift” procedure. This will usually require some form
of skin resurfacing to improve skin quality and reduce skin
wrinkling, and fat or ﬁller injections to counteract peri-oral
atrophy. Other treatments such as upper liplifts and corner
lifts of the mouth are also very useful in secondary facelift
patients.

Un-rejuvenated peri-oral region

pencil. The all too commonly observed circumstance is one in
which the patient with a marked frontalis spasm and marked
transverse forehead wrinkling holds a hand mirror during his
or her consultation and sees only that his or her eyebrows
appear in a normal position.
Because many patients presenting for secondary facelift
will have un-rejuvenated foreheads, foreheadplasty will usually be an important component of the planned facelift procedure. (Forehead rejuvenation is discussed in Chapter 7.)
Traditionally, the aging face has been thought of and deﬁned
in terms of tissue relaxation and surface wrinkling, but
more recently surgeons have come to appreciate atrophy
and lipodystrophy as integral parts of the aging process.
A careful examination of patients presenting for secondary
facelift will reinforce this assertion and reveal that simply
smoothing wrinkles and lifting sagging tissues will fall short of
truly rejuvenating the face in most cases. This is particularly
true if the patient is thin, buccal fat was removed as part
of the primary procedure, or facial liposuction was performed (Fig. 12.52).
Atrophy is usually most profound and most easily observed
around the orbits, upper midface, and infraorbital and perioral areas but can be seen on close inspection of many patients
in the forehead, brow, temple, cheek, jaw line, chin and neck.
Atrophy is not corrected by traditional “facelift” procedures,
and is usually incompletely or poorly corrected by traditionally used facial implants. These procedures may even exacerbate the problem, and result in an arguably more unnatural,
hard and objectionable appearance.
Correction of facial atrophy requires the addition of volume to the
face, not a subtraction, lifting, or tightening, and a rethinking of the
traditionally taught approach to rejuvenation of the face. Unlike
problems corrected by a “lift” of the face, correction of atrophy
requires the surgeon to employ techniques that “ﬁll” and
“sculpt” the face, and to think in three, instead of just two,
dimensions (Fig. 12.52).
Currently, the most effective and natural correction of facial
atrophy is best achieved through the use of fat injections. Fat
injections, when properly performed produce soft and natural

Facial atrophy

Fig. 12.51 The “young face–old forehead” deformity. (A) Patient seen after face lift, neck lift, genioplasty, and eyelid surgery performed elsewhere. Her forehead appears
older than the rest of her face, and her overall appearance is disharmonious and unnatural. (Procedure performed by unknown surgeon.) (B) Same patient seen after hairline
lowering foreheadplasty. No eyelid surgery or other procedures have been performed. Her face appears more natural, harmonious, and balanced, and all areas appear to be
the same age. (Procedure performed by Timothy J. Marten, MD, FACS.)

A

306

E

B

F

C

307

Fig. 12.52 Facelift and fat injection example. (A–C) Before surgery view of a woman, aged 75, who has had multiple prior facelifts and related procedures, including laser
resurfacing, performed by unknown plastic surgeons. Note marked, uncorrected panfacial atrophy and, despite her multiple traditional lifts, a frail, ill, and elderly appearance.
(D–F) Same patient, 1 year 4 months after secondary facelift, necklift, foreheadlift, upper and lower blepharoplasties, canthopexy, and aggressive fat transfer to the forehead,
temples, cheeks, upper and lower orbits, lips, peri-oral area, buccal recess, chin, and jaw line. A total of 90 cc of fat was injected. No skin resurfacing, facial implants, or
ancillary procedures were performed. Note that the patient has soft, natural facial contours and absence of a tight or pulled appearance. Atrophy in all treated areas has been
markedly improved with fat injections to create a softer, more youthful, ﬁt, healthy, athletic, and energetic appearance. Such an improvement cannot be obtained with
traditional lifting and tightening. It can only be achieved by volume replacement. As was the case in this patient, for many secondary facelift patients, volume replacement is
more important than the facelift itself.

D

A

Identiﬁcation and analysis of secondary surgical deformities

Motivated by largely unscientiﬁc claims of laser manufacturers and enticing, but deceptive, early postoperative photographs of patients shown at meetings and included in
commercial advertisements, many plastic surgeons and physicians in other specialties embraced laser resurfacing as a
substitute for traditional surgical maneuvers in which ptotic
deep layer tissue was repositioned and redundant tissue
excised. Indeed, laser resurfacing was often referred to as a
“laser facelift” and numerous claims were made regarding the
lasers ability to incite skin contraction and “tighten” the facial
skin. Although laser resurfacing has proven to have clinical
utility, experience has shown that it does not produce the skin
tightening once hoped for. In addition, “wrinkle relapse” is
common once patients are fully healed and all traces of swelling are gone.
Many patients who have undergone laser resurfacing are
now presenting for formal facelifts, disappointed in the lack
of “lift” gained from their “laser facelift” and concerned over
associated secondary deformities including hypopigmentation, skin sensitivity, abnormal skin texture, lower lid
malposition, and an unnatural “smooth face-wrinkled neck”
appearance. Radiofrequency and ultrasound-based technologies suffer the additional drawback that they often result in a
loss of subcutaneous facial fat.
Artistically, the fundamental problem with laser resurfacing is that its primary effect is to smooth skin, and that it does
little, if anything, to reposition ptotic tissue, to reduce skin
redundancy, or to correct facial atrophy. Its misapplication to
the patient with ptotic deep layer tissue and redundant skin
typically produces an unnatural, incongruent and “smooth
skin-sagging face” appearance. Because this combination
appears rarely in nature, the patient is left with a tell-tale

Over reliance on laser resurfacing

Many patients presenting for secondary facelift have undergone aggressive excision of eyelid skin at their primary
procedure and are secondarily troubled functionally by nocturnal lagophthalmos, lid retraction, canthal laxity, scleral
show, and dry eye problems, and aesthetically by orbital hollowing, change in eye shape, and unnatural ocular appearance. (These problems and deformities and their treatment are
discussed in Chapter 9.)

Eyelid skin deﬁciencies and
eyelid malposition

As a practical matter, fat injections are most effectively
performed in areas where tissue planes have not been opened.
As a result, they are less applicable and less commonly performed concurrently with a facelift in some areas. These areas
include the pre-auricular cheek and the neck. Other areas,
however, including the temples, forehead, brows, glabella,
radix, orbits, cheeks, midface, “tear troughs”, buccal recess,
lips, nasolabial folds, nasal base, stomal angles, geniomandibular grooves, chin, and jaw line lend themselves to concurrent treatment, when indicated.

ONLY

Many patients requesting secondary or tertiary facelifts are
chronologically elderly, but deceptively young in appearance.
A careful medical history must be taken because they often

Patient considerations

“surgical” appearance, often easily recognized by even the
untrained eye at a considerable distance.
In all but the unusual instance, facial contour takes artistic
precedent over smooth skin. Indeed, a few surface wrinkles
will be overlooked by the eye if youthful facial contour is
successfully re-established. A more balanced, harmonious and
natural appearance will result, and a less “surgical look” will
be present.
If the patient presenting for secondary facelift has had
good repositioning of ptotic tissue at the primary procedure,
and little recurrent ptosis is present, skin resurfacing may be
worthwhile and appropriate if residual surface textural wrinkling is present. It must be kept in mind, however, that
skin resurfacing will do little to permanently reduce wrinkles
that are the product of muscle hyperactivity. These include glabellar frown lines, transverse forehead wrinkles, and lateral
periorbital lines. Correction of these “expression lines” will
require reduction or resection of hyperactive muscles, repositioning of ptotic tissue, or removal of excess tissue stimulating
muscle contraction. Although skin resurfacing will temporarily disguise forehead wrinkles by inciting swelling, it is no
substitute for formal foreheadplasty.
Patients who have undergone prior skin resurfacing can
present a number of technical problems at the time of secondary facelift as well. The most vexing of these is the inevitable
shift of the line of demarcation between resurfaced and
un-resurfaced areas below the jaw line onto the lower face.
This “demarcation line shift” usually requires that a second
resurfacing procedure be performed to lower this line back
into the shadow of the submental area.
Although many surgeons now assert concomitant facelift
and laser skin resurfacing to be safe (and cheek skin has arguably been “delayed” at the primary procedure) this combination of procedures still carries signiﬁcant risk in any case in
which skin has been undermined. For this reason it is preferable to defer resurfacing until three months or more after the
facelift procedure, at which time the face can be safely, comprehensively, and aggressively treated, if necessary.
The patient who has had a previous combined facelift and
skin resurfacing procedure is often an excellent candidate for
secondary facelift. This is because the previous surgeon,
fearing complications might result from aggressive surgical
undermining or relying heavily on resurfacing to make up for
shortcomings of the chosen surgical procedure, has been conservative in his or her surgical approach and timid during
dissection. Indeed, examination usually shows that these
patients have residual uncorrected or under corrected deep
layer ptosis and residual forehead deformities.
A new generation of “skin shrinking” technologies has now
been introduced that have been widely embraced and said by
some to eventually supplant the traditional facelift. In its
current form this certainly is not the case, and for the time
being at least, facelifts and secondary facelifts offer improvements unobtainable by other means.

SECTION I • 12 • Secondary deformities and the secondary facelift

contours and afford one the opportunity to correct problems
FIG 12.53 APPEARS ONLINE
traditional surgery cannot (Fig. 12.53).

308

D

B

308.e1

Fig. 12.53 Case study 1. Multiple views of a 57-year-old woman before and 12 months after secondary cervicofacial rejuvenation. The primary facelift was performed by an
unknown surgeon using conventional techniques and included aggressive upper and lower blepharoplasty but no forehead surgery. The secondary procedure consisted of a
high cheek SMAS advancement with post-auricular transposition ﬂaps, preplatysmal and subplatysmal cervical lipectomy, anterior platysmaplasty, and platysma myotomy.
Incisions along the hairline were used in the temporal and occipital areas and the preauricular incision was moved from a pretragal position to the margin of the tragus.
Foreheadplasty, lower blepharocanthoplasty, bilateral ptosis correction, and perioral dermabrasion were also performed. Full thickness skin grafts taken from the postauricular
areas were applied to the upper lids to allow foreheadplasty to be performed and the eyebrows elevated to an appropriate position. No resurfacing or other ancillary
procedures were performed. (A) Patient, aged 57, several years after primary conventional facelift, necklift and upper and lower blepharoplasty were performed elsewhere.
Note residual and secondary deformities including unrejuvenated forehead, bilateral senile ptosis, midface ptosis, and residual jowl laxity. (B) Same patient, 12 months
after secondary facial rejuvenation. Note improvement in forehead, cheeks, periorbital area, and along jaw line that has been achieved without a tight or pulled appearance.
(C) Aged 57, several years after conventional facelift was performed elsewhere. Note residual and secondary deformities including obvious preauricular scar. (D) Same
patient, 12 months after a secondary facial rejuvenation. (Secondary facelift and related procedures performed by Timothy J. Marten, MD, FACS.)

C

A

References

H

J

G

I

Fig. 12.53, cont’d (E) Aged 57, several years after conventional facelift was performed by an unknown surgeon. Note residual and secondary deformities midface ptosis,
malar ﬂattening, residual jowl, residual cervical obliquity and “witch’s chin” deformity. (F) Same patient, 12 months after a secondary facial rejuvenation. Cheek and midface
tissue has been elevated, the pretragal scar has been moved to the margin of the tragus, and cervical contour improved. The witch’s chin deformity has also been corrected.
(G) Aged 57, several years after conventional facelift and upper and lower blepharoplasty was performed elsewhere. Note severe, untreated residual brow ptosis. When the
patient’s eyebrows were held up in an appropriate position, she was unable to close her eyelids. (H) Same patient, 12 months after a secondary facial rejuvenation. Full
thickness postauricular skin grafts were applied to the upper eyelids so that foreheadplasty could be performed without compromising lid function. Canthopexy and bilateral
ptosis correction was also performed. (I,J) Improved periorbital appearance is evident.

F

E

The secondary or tertiary facelift will present technical problems and certain risks not seen in primary procedures. In
addition, the general approach to secondary procedures is
somewhat different depending upon the type of secondary
deformities present.
The secondary or tertiary facelift will generally require a comparatively small resection of skin and an increased focus on correcting deep layer problems and secondary deformities, depending
upon the skill of the surgeon performing the primary procedure and the type of technique used. This is because the focus
of most primary procedures is usually on skin resection and
this is more easily and quickly performed than deep layer
maneuvers. In addition, skin resection and skin tightening are
the underlying cause of many secondary problems. Very
often, the skin elevated and recruited by deep layer maneuvers at the secondary or tertiary procedure is needed to correct
these problems and will not be excised.
It should also be recognized that secondary facelifts are
often time consuming and technically demanding when compared with primary procedures and are likely to test the
patience and composure of most surgeons. It is highly recommended that additional operating room time be allotted for
the procedure and that the services of an anesthesiologist or
competent nurse anesthetist be enlisted. This is particularly
true if the procedure is being performed on a patient who is
overly apprehensive or has a history of anesthetic difﬁculties,
hypertension or other medical problems.
Although less bleeding is often encountered in elevation of
the skin ﬂap in secondary surgery, skin ﬂap undermining is
often more taxing because of subcutaneous scar and adhesions resulting from the previous dissection. Scissors pushing
techniques should not be used and it is wise that dissection
be made carefully, under direct vision, in good light, with an
experienced assistant.
Patients undergoing secondary procedures have at least
some areas of their face or neck that have been aggressively

Technical considerations in
secondary facelift

have concomitant medical problems consistent for their age
group that were not present at the time of their primary procedure. It is also wise to obtain independent medical clearance
prior to surgery as this group of patients will commonly minimize existing problems and deny important symptoms of age
related illness.
A careful documentation of all existing secondary problems and deformities must also be made in patients undergoing secondary facelift procedures, including, but not limited
to, facial muscle weakness, dyskinesias, numbness, paresthesias, eye dryness, visual disturbances, and chronic pain. These
problems do not show up in a photograph and are not always
recognized or volunteered by the patient. If not documented
preoperatively, they will inevitably be attributed to be the
result of the secondary procedure.

309

ONLINE ONLY

stripped of fat and these areas must be carefully dissected
when skin ﬂaps are elevated. Not uncommonly, dermomuscular adhesions are present in the upper lateral neck over the
superﬁcial most portion of the great auricular nerve. Similar
caution must be taken when subcutaneous dissection is made
secondarily in the temple. It is also very common for the
anterior neck and submental regions to have been aggressively defatted at the primary procedure by aggressive small
cannula liposuction, ultrasonic lipectomy, excessive direct
excision, or by other means. In such patients, it is very easy
to perforate, get under the platysma or damage it while
attempting to re-elevate the cervicosubmental skin. Entry
under the platysma can result in nerve injury and platysma
dysfunction, and can render the SMAS or platysma useless in
the planned repair. For these reasons, all skin ﬂap dissection
must be made with great care in secondary procedures and it
is not advisable to use aggressively patterned “super-sharp”
or serrated scissors for ﬂap elevation. These scissors tend to
pick up and cut delicate structures and are more likely to
result in the inadvertent fenestration of the platysma, or unintended excision of subdermal fat.
Subcutaneous fat is generally precious in the secondary
facelift patient and as much of it as possible should be preserved until the surgeon is certain that its sacriﬁce is artistically appropriate and of beneﬁt to the patient. Care must be
taken however, not to injure the SMAS and platysma, while
elevating skin ﬂaps as these will serve as the workhorse
tissue layers in restoring more youthful facial contours.
The margin for error is thus very small, and often critically
so. The careful inﬁltration of dilute local anesthetic solutions
is often helpful in these situations in pre-establishing
the proper plane by hydrodissection. This beneﬁcial effect
will be lost if inﬁltration is made carelessly or in the
wrong plane.
A satisfactory and uncomplicated SMAS dissection can
usually be performed in most secondary procedures particularly if the primary surgeon previously elevated the SMAS in
a skilled manner. Occasionally, the SMAS will be found to
have been damaged or thinned however, or compromised by
previous plication or suture lifts, making elevation difﬁcult
and putting facial nerve branches at risk. Use of a nerve stimulator or raising the ﬂap with cautery on a low setting can be
helpful in such instances to differentiate retaining ligaments
from nerve branches. Ultimately, however, no amount of
aesthetic improvement is worth a facial nerve injury and dissection should not be continued if overly difﬁcult and motor
nerve branches are put at unacceptable risk. In such cases, a
formal SMAS elevation may have to be abandoned and
replaced by an arguably safer alternative treatment such as
SMAS plication.
Not all deformities resulting from the primary procedure
can necessarily be corrected and the patient needs to have
their expectations set in this regard. In addition, the secondary
facelift patient will often need ancillary procedures in addition to secondary facelift surgery if maximum improvement is to be obtained (Figs 12.53–12.55). FIGS 12.54, 12.55 APPEAR

Technical considerations in secondary facelift

D

C

309.e1

Fig. 12.54 Case study 2. Multiple views of a 64-year-old woman before and 13 months after tertiary cervicofacial rejuvenation. The primary facelift and secondary necklift
were performed by an unknown surgeon using conventional techniques. The secondary procedure consisted of trifurcated cheek SMAS advancement with temporal and
postauricular transposition ﬂaps, preplatysmal and subplatysmal cervical lipectomy, anterior platysmaplasty, platysma myotomy and correction of “loving cup” ear.
Incisions along the hairline were used in the temporal and occipital areas and the preauricular incision was moved from a pretragal position to the margin of the tragus.
Foreheadplasty, lower blepharoplasty, bilateral ptosis correction and crow’s feet reduction were also performed. No resurfacing or other ancillary procedures were performed.
(A) Patient, aged 64, 8 years after primary conventional facelift was performed by an unknown surgeon. A secondary necklift had also been performed by the same surgeon
at a later date. Note residual and secondary deformities including unrejuvenated forehead, bilateral senile ptosis, midface ptosis, and residual jowl laxity. (B) Same patient
aged 65, 13 months after tertiary facial rejuvenation. Note improvement in forehead, cheeks, periorbital area, and along jaw line that has been achieved without a tight or
pulled appearance. Note also residual aging in perioral area (“young face–old mouth” deformity). Regrettably, the patient declined recommended perioral rejuvenation.
(C) Patient age 64, 8 years after primary conventional facelift was performed elsewhere. A secondary necklift had been performed by the same surgeon at a later date
as well. (D) 13 months after tertiary facial rejuvenation. Note that SMAS and platysma surgery has not resulted in abnormalities during expression.

B

A

References

H

F

SECTION I • 12 • Secondary deformities and the secondary facelift

Fig. 12.54, cont’d (E) Patient aged 64, 8 years after conventional facelift was performed by an unknown surgeon. Note residual and secondary deformities. (F) 13 months
after a secondary facial rejuvenation. Note improvement in jowl contour has achieved made without the creation of skin tightness or ﬂattening of facial contour. (G) Patient
aged 64, 8 years after conventional facelift was performed elsewhere. Note residual and secondary deformities midface ptosis, malar ﬂattening, shift of cervical wrinkles onto
lower face, loving-cup ear, residual jowl and residual cervical obliquity. (H) 13 months after a secondary facial rejuvenation. Cheek and midface tissue has been elevated, the
pretragal scar has been moved to the margin of the tragus, the lobular-facial junction has been improved, overshifted wrinkles have been partially moved back onto neck, and
cervical contour improved.

G

E

309.e2

J

309.e3

Fig. 12.54, cont’d (I) Patient aged 64, 8 years after conventional facelift was performed by an unknown surgeon. Note shift of cervical wrinkles onto lower face, loving-cup
ear, and residual cervical obliquity. (J) 13 months after a secondary facial rejuvenation. The pretragal scar has been moved to the margin of the tragus, the lobular-facial
junction has been improved, overshifted wrinkles have been partially moved back onto neck, and cervical contour improved. (K) An incision along the temporal hairline was
used to prevent objectionable hairline displacement. Although the scar can be seen on close inspection, it is not evident on casual glance and in social situations.

K

I

References

D

B

Fig. 12.55 Case study 3. Secondary cervicofacial rejuvenation. Multiple views of a 68-year-old woman seen before, and 1 year and 8 months after secondary facelift and
related procedures. The primary procedure was performed by an unknown surgeon. The secondary procedure consisted of a high SMAS facelift, neck lift, small incision
closed forehead lift, upper and lower blepharoplasties with reinsertion of the levator aponeurosis and canthopexy, facial fat injections, peri-oral dermabrasion, scalp scar
revisions, and nevus excision. The neck procedures included excision of residual subplatysmal fat, submandibular gland reduction, superﬁcial digastric myectomy, anterior
platysmaplasty with post-auricular transposition ﬂaps, and full width platysmamyotomy. No subcutaneous cervical fat was removed. Fat injections were performed in the
temples, upper and lower orbits, the upper nasal dorsum, the cheeks, midface, piriform, nasolabial, stomal angle, peri-oral, lips, chin, GMG (geniomandibular groove),
and jaw line areas. No resurfacing or other ancillary procedures were performed. (A) Preoperative AP view. The patient can be seen to have suboptimal eyebrow position
and conﬁguration with over-elevation of the medial brow, residual cheek and jowl ptosis, and poor posture of the peri-oral tissues. The peri-ocular appearance suggests
aggressive upper and lower blepharoplasty had been previously performed. Marked atrophy can be seen in the temples, orbits, cheeks, oral and peri-oral, and peri-mental
areas. Marked facial asymmetry, mild peri-oral wrinkling, and bilateral senile ptosis, worse on the left, are also present. Overall, the face has an ill, tired, and aged
appearance. (B) Postoperative AP view. The patient has a soft, natural nonsurgical appearance. The lateral portion of each eyebrow has been raised and eyebrow position and
conﬁguration have been improved creating a more alert and engaged appearance. The cheek mass and jowls have been raised and the posture of tissues around the mouth
improved. The temples and the upper and lower orbits have been ﬁlled using fat injections. A slight under correction of upper orbital atrophy on the left can be seen. Atrophy
present in the oral, peri-oral, chin, geniomandibular groove and upper nasal dorsum areas has been nicely improved using fat injections as well. The lips have been subtly
ﬁlled with fat and the lip border enhanced without a “stung by a bee” or “ﬁller lip” appearance. The combination of fat injections and peri-oral dermabrasion has produced
natural appearing correction of peri-oral wrinkling. Overall improved facial symmetry can also be seen. The patient’s ptosis has been improved. (C) Preoperative smiling
view. Smiling reveals mandibular asymmetry and a poor transition from the lower eyelid to the cheek. (D) Postoperative smiling view. The patient appears natural when
smiling. The transition from the lower eyelid to the cheek is improved. The chin is integrated with the jaw line and the two together form one continuous and desirable
aesthetic line. The lips are fuller but the shape of the mouth is unchanged.

C

A

H

G

Fig. 12.55, cont’d (E) Preoperative oblique view. The patient has a sad, forlorn appearance and the orbital area looks sunken and hollow. The lower face lacks strength and
aesthetic appeal and appears elderly. Suboptimal eyebrow position and conﬁguration is evident and residual cheek and jowl ptosis can be seen. Atrophy can be seen in the
temples, orbits, upper cheek, oral and peri-oral, and peri-mental areas. The chin is frail and narrow appearing and is poorly integrated with the jaw line. The posterior jaw
line is weak and the mandible has a diminutive appearance. The lips are thin and have an elderly retruded appearance. (F) Postoperative oblique view. Overall, the patient
has a soft, natural, nonsurgical look and a youthful, athletic, aesthetic, and healthy appearance. The lateral eyebrow has been raised and the eyebrow position and
conﬁguration have been improved. The cheek mass and jowls have been re-positioned and the temples and the upper and lower orbits have been ﬁlled. An improved
transition from the lower eyelids to the cheeks is present. Atrophy present in the oral, peri-oral, chin, and geniomandibular groove areas has been nicely improved and the
posterior jaw line has been strengthened with fat injections. This has resulted in a broader more aesthetic and youthful appearing chin that is integrated with a stronger, more
photogenic jaw line. The lips have been subtly ﬁlled and the lip border enhanced, and the entire peri-oral area can be seen to have been ﬁlled and strengthened. Fat
injections to the upper nasal dorsum have also resulted in a more aesthetic and attractive nasal line. A better overall aesthetic balance between facial features is present and
the patient has a more attractive and feminine appearance. (G) Preoperative lateral view. The patient can be seen to have a poor transition from the lower eyelid to the cheek,
cheek and jowl ptosis, residual cervicosubmental fullness and platysmal bands, a large submandibular gland, suboptimal jaw line contour, a retracted tragus, and a mild
“loving-cup” earlobe. Marked atrophy can also be seen in the upper and lower orbits, cheeks, oral and peri-oral, and peri-mental (geniomandibular) areas. (H) Postoperative
lateral view. Overall, the patient has a soft, natural, nonsurgical look. Improved balance between facial features can be seen and the patient has an attractive, photogenic
appearance. Scars are well concealed and the retracted tragus and loving cup earlobe have been corrected. The cheek mass and jowl have been raised resulting in
improvement in “drool lines” and nasolabial folds. Atrophy present in the oral and peri-oral areas has been improved with fat injections and the lips have been subtly ﬁlled
and the lip border enhanced creating a more youthful and attractive mouth. The geniomandibular groove (“pre-jowl sulcus”) has been ﬁlled integrating the chin and the jowl
into a strong, aesthetically desirable, continuous line. The posterior jaw line has also been strengthened with fat injections adding to the effect. The protruding portion of the
enlarged submandibular gland has been reduced, the cervicomental angle improved, and platysma bands corrected. The improved cervicosubmental conﬁguration provides a
youthful, ﬁt, decisive, and attractive appearance.

F

E

J

SECTION I • 12 • Secondary deformities and the secondary facelift

Fig. 12.55, cont’d (I) Preoperative lateral ﬂexed view. The patient can be seen to have a poor transition from the lower eyelid to the cheek, cheek and jowl ptosis, residual
cervicosubmental fullness, an indistinct jaw line, and a “double chin”. Residual poor neck contour results an overweight, indecisive, and unattractive appearance. The lips
are ﬂat and the peri-oral area is retruded resulting in an elderly appearance. (J) Postoperative lateral ﬂexed view. The patient now has a ﬁt, athletic look and an attractive,
photogenic appearance. A strong mandibular contour is present with the chin and the jowl integrated into a distinct, aesthetically desirable, continuous line. Residual
subplatysmal fat and protruding portions of the submandibular glands have been removed, and platysma laxity corrected. The posterior jaw line has also been strengthened
with fat injections adding to the effect. The double chin deformity has been eliminated by dissecting subcutaneously in a retrograde fashion onto the chin to release the
submental retaining ligaments, and blending the fat of the chin and submental regions. The orbits have been ﬁlled using fat injections, and the lips and peri-oral are project
to produce a more aesthetic and youthful appearance.

I

309.e6

Fig. 12.54 Case study 2. Multiple views of a
64-year-old woman before and 13 months
after tertiary cervicofacial rejuvenation. The
primary facelift and secondary necklift were
performed by an unknown surgeon using
conventional techniques. The secondary
procedure consisted of trifurcated cheek
SMAS advancement with temporal and
postauricular transposition ﬂaps, preplatysmal
and subplatysmal cervical lipectomy, anterior
platysmaplasty, platysma myotomy and
correction of “loving cup” ear. Incisions along
the hairline were used in the temporal and
occipital areas and the preauricular incision
was moved from a pretragal position to the
margin of the tragus. Foreheadplasty, lower
blepharoplasty, bilateral ptosis correction and
crow’s feet reduction were also performed. No
resurfacing or other ancillary procedures were
performed. (A) Patient, aged 64, 8 years after
primary conventional facelift was performed
by an unknown surgeon. A secondary necklift
had also been performed by the same
surgeon at a later date. Note residual and
secondary deformities including unrejuvenated
forehead, bilateral senile ptosis, midface
ptosis, and residual jowl laxity. (B) Same
patient aged 65, 13 months after tertiary facial
rejuvenation. Note improvement in forehead,
cheeks, periorbital area, and along jaw line
that has been achieved without a tight or
pulled appearance. Note also residual aging
in perioral area (“young face–old mouth”
deformity). Regrettably, the patient declined
recommended perioral rejuvenation. (C)
Patient age 64, 8 years after primary
conventional facelift was performed
elsewhere. A secondary necklift had been
performed by the same surgeon at a later
date as well. (D) 13 months after tertiary facial
rejuvenation. Note that SMAS and platysma
surgery has not resulted in abnormalities
during expression. (E) Patient aged 64, 8
years after conventional facelift was performed
by an unknown surgeon. Note residual and
secondary deformities. (F) 13 months after a
secondary facial rejuvenation. Note
improvement in jowl contour has achieved
made without the creation of skin tightness or
ﬂattening of facial contour. (G) Patient aged
64, 8 years after conventional facelift was
performed elsewhere. Note residual and
secondary deformities midface ptosis, malar
ﬂattening, shift of cervical wrinkles onto lower
face, loving-cup ear, residual jowl and residual
cervical obliquity. (H) 13 months after a
secondary facial rejuvenation. Cheek and
midface tissue has been elevated, the
pretragal scar has been moved to the margin
of the tragus, the lobular-facial junction has
been improved, overshifted wrinkles have
been partially moved back onto neck, and
cervical contour improved. (I) Patient aged 64,
8 years after conventional facelift was
performed by an unknown surgeon. Note shift
of cervical wrinkles onto lower face, loving-cup
ear, and residual cervical obliquity. (J) 13
months after a secondary facial rejuvenation.
The pretragal scar has been moved to the
margin of the tragus, the lobular-facial junction
has been improved, overshifted wrinkles have
been partially moved back onto neck, and
cervical contour improved. (K) An incision
along the temporal hairline was used to
prevent objectionable hairline displacement.
Although the scar can be seen on close
inspection, it is not evident on casual glance
and in social situations.
Fig. 12.55 Case study 3. Secondary cervicofacial
rejuvenation. Multiple views of a 68-year-old
woman seen before, and 1 year and 8 months
after secondary facelift and related
procedures. The primary procedure was
performed by an unknown surgeon. The
secondary procedure consisted of a high
SMAS facelift, neck lift, small incision closed
forehead lift, upper and lower blepharoplasties
with reinsertion of the levator aponeurosis and
canthopexy, facial fat injections, peri-oral
dermabrasion, scalp scar revisions, and nevus
excision. The neck procedures included
excision of residual subplatysmal fat,
submandibular gland reduction, superﬁcial
digastric myectomy, anterior platysmaplasty
with post-auricular transposition ﬂaps, and full
width platysmamyotomy. No subcutaneous
cervical fat was removed. Fat injections were
performed in the temples, upper and lower
orbits, the upper nasal dorsum, the cheeks,
midface, piriform, nasolabial, stomal angle,
peri-oral, lips, chin, GMG (geniomandibular
groove), and jaw line areas. No resurfacing or
other ancillary procedures were performed. (A)
Preoperative AP view. The patient can be seen
to have suboptimal eyebrow position and
conﬁguration with over-elevation of the medial
brow, residual cheek and jowl ptosis, and
poor posture of the peri-oral tissues. The
peri-ocular appearance suggests aggressive
upper and lower blepharoplasty had been
previously performed. Marked atrophy can be
seen in the temples, orbits, cheeks, oral and
peri-oral, and peri-mental areas. Marked facial
asymmetry, mild peri-oral wrinkling, and
bilateral senile ptosis, worse on the left, are
also present. Overall, the face has an ill, tired,
and aged appearance. (B) Postoperative AP
view. The patient has a soft, natural
nonsurgical appearance. The lateral portion of
each eyebrow has been raised and eyebrow
position and conﬁguration have been
improved creating a more alert and engaged
appearance. The cheek mass and jowls have
been raised and the posture of tissues around
the mouth improved. The temples and the
upper and lower orbits have been ﬁlled using
fat injections. A slight under correction of
upper orbital atrophy on the left can be seen.
Atrophy present in the oral, peri-oral, chin,
geniomandibular groove and upper nasal
dorsum areas has been nicely improved using
fat injections as well. The lips have been
subtly ﬁlled with fat and the lip border
enhanced without a “stung by a bee” or “ﬁller
lip” appearance. The combination of fat
injections and peri-oral dermabrasion has
produced natural appearing correction of

Bonus images for this chapter can be found online at http://www.expertconsult.com

SECTION I • 12 • Secondary deformities and the secondary facelift

Fig. 12.53 Case study 1. Multiple views of a
57-year-old woman before and 12 months
after secondary cervicofacial rejuvenation. The
primary facelift was performed by an unknown
surgeon using conventional techniques and
included aggressive upper and lower
blepharoplasty but no forehead surgery. The
secondary procedure consisted of a high
cheek SMAS advancement with post-auricular
transposition ﬂaps, preplatysmal and
subplatysmal cervical lipectomy, anterior
platysmaplasty, and platysma myotomy.
Incisions along the hairline were used in the
temporal and occipital areas and the
preauricular incision was moved from a
pretragal position to the margin of the tragus.
Foreheadplasty, lower blepharocanthoplasty,
bilateral ptosis correction, and perioral
dermabrasion were also performed. Full
thickness skin grafts taken from the
postauricular areas were applied to the upper
lids to allow foreheadplasty to be performed
and the eyebrows elevated to an appropriate
position. No resurfacing or other ancillary
procedures were performed. (A) Patient, aged
57, several years after primary conventional
facelift, necklift and upper and lower
blepharoplasty were performed elsewhere.
Note residual and secondary deformities
including unrejuvenated forehead, bilateral
senile ptosis, midface ptosis, and residual
jowl laxity. (B) Same patient, 12 months
after secondary facial rejuvenation. Note
improvement in forehead, cheeks, periorbital
area, and along jaw line that has been
achieved without a tight or pulled appearance.
(C) Aged 57, several years after conventional
facelift was performed elsewhere. Note
residual and secondary deformities including
obvious preauricular scar. (D) Same patient,
12 months after a secondary facial
rejuvenation. (Secondary facelift and related
procedures performed by Timothy J. Marten,
MD, FACS.) (E) Aged 57, several years after
conventional facelift was performed by an
unknown surgeon. Note residual and
secondary deformities midface ptosis, malar
ﬂattening, residual jowl, residual cervical
obliquity and “witch’s chin” deformity. (F)
Same patient, 12 months after a secondary
facial rejuvenation. Cheek and midface tissue
has been elevated, the pretragal scar has
been moved to the margin of the tragus, and
cervical contour improved. The witch’s chin
deformity has also been corrected. (G) Aged
57, several years after conventional facelift
and upper and lower blepharoplasty was
performed elsewhere. Note severe, untreated
residual brow ptosis. When the patient’s
eyebrows were held up in an appropriate
position, she was unable to close her eyelids.
(H) Same patient, 12 months after a
secondary facial rejuvenation. Full thickness
postauricular skin grafts were applied to the
upper eyelids so that foreheadplasty could be
performed without compromising lid function.
Canthopexy and bilateral ptosis correction
was also performed. (I,J) Improved periorbital
appearance is evident..

310

integrating the chin and the jowl into a strong,
aesthetically desirable, continuous line. The
posterior jaw line has also been strengthened
with fat injections adding to the effect. The
protruding portion of the enlarged
submandibular gland has been reduced, the
cervicomental angle improved, and platysma
bands corrected. The improved
cervicosubmental conﬁguration provides a
youthful, ﬁt, decisive, and attractive
appearance. (I) Preoperative lateral ﬂexed
view. The patient can be seen to have a poor
transition from the lower eyelid to the cheek,
cheek and jowl ptosis, residual
cervicosubmental fullness, an indistinct jaw
line, and a “double chin”. Residual poor neck
contour results an overweight, indecisive, and
unattractive appearance. The lips are ﬂat and
the peri-oral area is retruded resulting in an
elderly appearance. (J) Postoperative lateral
ﬂexed view. The patient now has a ﬁt, athletic
look and an attractive, photogenic
appearance. A strong mandibular contour is
present with the chin and the jowl integrated
into a distinct, aesthetically desirable,
continuous line. Residual subplatysmal fat and
protruding portions of the submandibular
glands have been removed, and platysma
laxity corrected. The posterior jaw line has
also been strengthened with fat injections
adding to the effect. The double chin
deformity has been eliminated by dissecting
subcutaneously in a retrograde fashion onto
the chin to release the submental retaining
ligaments, and blending the fat of the chin
and submental regions. The orbits have been
ﬁlled using fat injections, and the lips and
peri-oral are project to produce a more
aesthetic and youthful appearance.

311

1. Guyuron B, Eriksson E, Persing JA, et al., eds. Facelift
in plastic surgery: indications and practice. Philadelphia:
Saunders; 2009.
2. Marten TJ. High SMAS facelift: combined single ﬂap
lifting of the jaw line, cheek, and midface. Clin Plast Surg.
2008;35(4):569–603.
3. Marten TJ. Lamellar high SMAS face and midfacelift:
a comprehensive technique for natural-appearing
rejuvenation of the face. In: Nahai F, ed. The art of
aesthetic surgery: principles and techniques. 2nd ed.
St Louis: Quality Medical; 2010:1525.
4. Marten TJ, ed. Facelift – state of the art. Seminars in
plastic surgery. New York: Thieme Medical; 2002.

References

patient are worth careful consideration, even for the surgeon
who performs only the occasional secondary procedure, as
they exist as compelling reminders of mistakes to avoid in the
planning and performance of any primary procedure.

nicely improved and the posterior jaw line has
been strengthened with fat injections. This has
resulted in a broader more aesthetic and
youthful appearing chin that is integrated with
a stronger, more photogenic jaw line. The lips
have been subtly ﬁlled and the lip border
enhanced, and the entire peri-oral area can
be seen to have been ﬁlled and strengthened.
Fat injections to the upper nasal dorsum have
also resulted in a more aesthetic and
attractive nasal line. A better overall aesthetic
balance between facial features is present
and the patient has a more attractive and
feminine appearance. (G) Preoperative lateral
view. The patient can be seen to have a poor
transition from the lower eyelid to the cheek,
cheek and jowl ptosis, residual
cervicosubmental fullness and platysmal
bands, a large submandibular gland,
suboptimal jaw line contour, a retracted
tragus, and a mild “loving-cup” earlobe.
Marked atrophy can also be seen in the upper
and lower orbits, cheeks, oral and peri-oral,
and peri-mental (geniomandibular) areas. (H)
Postoperative lateral view. Overall, the patient
has a soft, natural, nonsurgical look. Improved
balance between facial features can be seen
and the patient has an attractive, photogenic
appearance. Scars are well concealed and
the retracted tragus and loving cup earlobe
have been corrected. The cheek mass and
jowl have been raised resulting in
improvement in “drool lines” and nasolabial
folds. Atrophy present in the oral and peri-oral
areas has been improved with fat injections
and the lips have been subtly ﬁlled and the lip
border enhanced creating a more youthful
and attractive mouth. The geniomandibular
groove (“pre-jowl sulcus”) has been ﬁlled

The increased number of patients seeking early facelifts at a
younger age, coupled with the continued good health of an
older group of patients who have already undergone one or
more procedures, has resulted in an increase in requests for
secondary facelift procedures. Although many aspects of
planning and performing secondary surgery are similar to
those of the primary procedure, additional considerations
must be taken into account in the evaluation and treatment
of the patient presenting for secondary facelift as one must
identify and treat not only new problems that are the product
of age, but those that have resulted from the prior procedure
as well. Often, it is these secondary deformities that present
the biggest challenge to the surgeon in terms of creativity,
planning, preparation and technique. The secondary facelift
patient is also usually short on skin and will typically present
with problems of deep layer origin. Additional excision of
large amounts of skin is likely to be counterproductive, result
in unnatural appearances and compound existing deformities. Many of the problems seen in the secondary facelift

Conclusion

peri-oral wrinkling. Overall improved facial
symmetry can also be seen. The patient’s
ptosis has been improved. (C) Preoperative
smiling view. Smiling reveals mandibular
asymmetry and a poor transition from the
lower eyelid to the cheek. (D) Postoperative
smiling view. The patient appears natural
when smiling. The transition from the lower
eyelid to the cheek is improved. The chin is
integrated with the jaw line and the two
together form one continuous and desirable
aesthetic line. The lips are fuller but the shape
of the mouth is unchanged. (E) Preoperative
oblique view. The patient has a sad, forlorn
appearance and the orbital area looks sunken
and hollow. The lower face lacks strength and
aesthetic appeal and appears elderly.
Suboptimal eyebrow position and
conﬁguration is evident and residual cheek
and jowl ptosis can be seen. Atrophy can be
seen in the temples, orbits, upper cheek, oral
and peri-oral, and peri-mental areas. The chin
is frail and narrow appearing and is poorly
integrated with the jaw line. The posterior jaw
line is weak and the mandible has a
diminutive appearance. The lips are thin and
have an elderly retruded appearance. (F)
Postoperative oblique view. Overall, the patient
has a soft, natural, nonsurgical look and a
youthful, athletic, aesthetic, and healthy
appearance. The lateral eyebrow has been
raised and the eyebrow position and
conﬁguration have been improved. The cheek
mass and jowls have been re-positioned and
the temples and the upper and lower orbits
have been ﬁlled. An improved transition from
the lower eyelids to the cheeks is present.
Atrophy present in the oral, peri-oral, chin, and
geniomandibular groove areas has been

References

8. Connell BF, Marten TJ. Facelift. In: Cohen M, ed. Mastery
of plastic and reconstructive surgery. Boston: Little Brown;
1994:1873–1902.
9. Connell BF, Marten TJ. Orbicularis oculi myoplasty:
surgical treatment of the crow’s feet deformity. In:
Jurkiewicz MJ, Culbertson JH, eds. Operative techniques
in plastic and reconstructive surgery. Philadelphia: WB
Saunders; 1995.

SECTION I • 12 • Secondary deformities and the secondary facelift

5. Marten TJ, ed. Maintenance facelift: early facelift for
younger patients. In: Facelift: state of the art. Seminars in
plastic surgery. New York: Thieme Medical; 2002.
6. Marten TJ. Facelift: planning and technique. Clin Plast
Surg. 1997;24:269.
7. Connell BF, Marten TJ. Deep layer techniques in cervicofacial rejuvenation. In: Psillakis J, ed. Deep face-lifting
techniques. New York: Thieme Medical; 1994.

312

Plastic Surgery -

Comments

Content

Sponsor Documents

Recommended