Refinements in Tailoring the Lift-and-fill Facelift.

Abstract

Individualizing facelift techniques through proper preoperative analysis is an important technique that can successfully enhance the patient’s overall result.1–5 Accurate preoperative analysis is key in the decision-making process for how the superficial musculoaponeurotic system (SMAS) is shaped and lifted. Techniques that center on SMASectomy and SMAS stacking with wide skin undermining allow for exceptional results without the need for an extended sub-SMAS dissection.5–13 The area to be undermined is first injected with 120 mL per side of dilute lidocaine (1:400,000) solution with epinephrine. Skin incisions and flap undermining are identical in both approaches. The procedure is started by creating a curvilinear skin incision parallel to the root of the helix followed by a separate intertragal incision. The incision continues following the lobule facial sulcus, leaving approximately 1 mm of facial skin on the lobule. Next, the incision is completed staying 2–3 mm onto the postauricular skin, then curving at the auricularis posterior down along then into the hairline. The skin flap is sharply dissected off the underlying SMAS as outlined below. These zones are not based on anatomical landmarks but are instead used to help simplify the flap undermining process. (See Video [online], which demonstrates the authors’ lift-and-fill facelift.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"SMAS Stacking. Video 1 from “Refinements in Tailoring the Lift and Fill Facelift”","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_7nq17ych"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} There are 3 zones of dissection: The first zone is composed of 2 lines: the first from the alar base to the tragus and the second from the tragus down to the anterior border of the sternocleidomastoid. The second zone is from posterior to the sternocleidomastoid to the post auricular neck area. The third zone is everything cephalic from a line drawn from the alar base to the lobule. Differences in facial length must be recognized because altering the direction of SMAS movement can help balance final facial shape.5,14 Facial analysis can identify variations in facial structure: long versus short and narrow versus wide. The most common combinations of these being long/narrow and short/wide.15 Identification of the long side of the face will dictate the direction of SMAS pull, with long faces requiring a horizontal pull and short faces necessitating a more oblique vector. Facial fullness is also an important factor to consider when deciding between SMAS plication (SMAS stacking) and SMASectomy. Faces with excess facial fullness need to have volume removed, which is accomplished with SMASectomy to create a more balanced facial structure. For the SMASectomy, only a superficial portion of the SMAS is excised, preserving the facial nerve branches below.16,17 If the face is overly thin, then this may be corrected through SMAS stacking, which creates more fullness in the malar region. Therefore, for the esthetic management of a long/narrow face, SMAS stacking with a horizontal vector of pull allows for malar fullness while correcting for excess facial length. Similarly, a short/wide face is best treated with SMASectomy and plication in a more oblique vector to maintain facial length while correcting for excess malar fullness, creating a more youthful look. Filling of deflated facial fat compartments using autologous fat is an essential supplement to any rhytidectomy. The “lift-and-fill” technique has modernized facial rejuvenation, with precise volume augmentation as a compulsory component of complete facial rejuvenation.15,18 We are able to accurately and precisely augment deflated facial fat compartments while the SMAS and its involved structures are selectively repositioned. The superficial and deep fat compartments as well as the lift-and-fill technique have been extensively researched with excellent long-term results.15 A complete understanding of preoperative facial structure allows for the surgeon to customize the lift-and-fill facelift technique to produce increased balance and correction of preoperative asymmetries. By altering the direction of SMAS pull and through the manipulation of SMAS volume, a complete restoration of malar fullness and facial width is accomplished.