Face-Lifting Techniques

Abstract

Facial rhytidectomy is a rejuvenative surgical procedure designed to improve the aging changes in the lower third of the face and neck. It can significantly improve jowling, the jaw line, and the portion of the neck from the hyoid bone to the jaw line (the cervicomental angle). It is less successful at improving the midface or nasolabial folds. Rhytidectomy optimizes the age-appropriate aesthetic but does not stop the normal aging progression after surgery. While a wellperformed rhytidectomy is extremely gratifying for both patient and surgeon, it is elective and invasive, with prolonged rehabilitation and potential morbidity. Complications are poorly tolerated, and therefore pitfalls should be meticulously avoided. Fundamental steps in facial rhytidectomy include incision planning, skin flap dissection, addressing the superficial musculo-aponeurotic system (SMAS) and platysma, liposuction or direct lipectomy, skin redraping, and wound closure. These are standard in lower-third facial and neck rejuvenation. Face lifting is an imperfect procedure: the surgeon takes advantage of camouflaged incisions and healing patterns to obtain optimal rejuvenation. The facial anatomy of the lower third of the face and neck is complex but may be best viewed in a layered approach. Facial skin varies in thickness, with eyelid skin being the thinnest and cheek skin the thickest. The skin of the face is nourished via a dermal plexus, which must be maintained in rhytidectomy surgery. Beneath the skin lies facial subcutaneous fat. This fat is lobulated and enclosed by fibrous septa, which connect the superficial fascia to the dermis. The thickest portion of subcutaneous fat is the malar fat pad, bounded by the infraorbital rim above, the nasolabial fold medially, and the zygomaticus major muscle laterally. Minimal subcutaneous fat is located in the lower eyelid region and in the perioral region. Below the level of the subcutaneous fat is the SMAS. This fibromuscular sheet is continuous with the superficial temporalis fascia and galea cranially and the platysma muscle caudally. The SMAS envelops and connects the superficial mimetic muscles to the dermis, expanding the range of facial expression to the skin via distribution of force.