Composite Facelift Research Articles

The Evolution of My Extended SMAS-Biplanar Deep Plane Facelift to a Composite Tissue Deep Plane Face and Neck Lift: Similarities and Differences.

In this article, Dr. Stephen Perkins, a seasoned facial plastic surgeon, presents his refined techniques in facelift surgery developed over four decades of practice. His evolution from traditional methods to the current composite tissue deep plane facelift is elucidated. His composite tissue deep plane facelift involves meticulous dissection and repositioning of the superficial musculoaponeurotic system (SMAS) and platysma in the deep plane, as well as incorporating his innovative "Perkins' Kelly clamp anterior platysmaplasty." This technique, refined through years of experience, aims for natural, enduring results, crucially addressing patient concerns such as jowling and neck laxity. Long-term analysis reveals the advantages of Dr. Perkins' technique, particularly in achieving sustained cervicomental angle improvement for over a decade postoperatively. This article underscores the importance of understanding deep plane facelift techniques, distinguishing between different approaches, and tailoring surgical interventions to individual patient characteristics. Dr. Perkins' comprehensive approach, incorporating advancements in surgical technique and meticulous patient care protocols, exemplifies the goal of achieving natural, long-lasting facial rejuvenation.

Lifting the Anterior Midcheek and Nasolabial Fold: Introduction to the Melo Fat Pad Anatomy and Its Role in Longevity and Recurrence.

A limitation of current facelift techniques is the early postoperative reappearance of anterior midcheek laxity associated with recurrence of the nasolabial fold (NLF). This study was undertaken to examine the regional anatomy of the anterior midcheek and NLF with a focus on explaining the early recurrence phenomenon and to explore the possibility of alternative surgical methods that prolong NLF correction. Fifty cadaver heads were studied (16 embalmed, 34 fresh; mean age, 75 years). Following preliminary dissections and macrosectioning, a series of standardized layered dissections were performed, complemented by histology, sheet plastination, and microcomputed tomography. Mechanical testing of the melo fat pad (MFP) and skin was performed to gain insight on which structure is responsible for transmission of the lifting tension in a composite facelift procedure. Anatomic dissections, sheet plastination, and microcomputed tomography demonstrated the 3-dimensional architecture and borders of the MFP. Histology of a lifted midcheek demonstrated that a composite MFP lift causes a change in connective tissue organization from a hanging-down pattern into a pulled-upward pattern, suggesting traction on the skin. Mechanical testing confirmed that, in a composite lift, despite the sutures being placed directly into the deep aspect of the MFP, the lifting tension distal to the suture is transmitted through the skin and not through the MFP. The usual method of performing a composite midcheek lift results in the skin, and not the MFP itself, bearing the load of the nondissected tissues distal to the lifting suture. For this reason, early recurrence of the NLF occurs following skin relaxation in the postoperative period. Accordingly, specific surgical procedures for remodeling the MFP should be explored, possibly in combination with volume restoration of the fat and bone, for more lasting improvement of the NLF.

Asian Face Lift with the Composite Face Lift Technique.

The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors' technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure. Composite face lifts were performed on 128 Asian patients between January of 2010 and June of 2020. Ninety-four were primary face lifts, and 34 were secondary or tertiary face lifts. The authors' surgical technique and adaptations for the specific requirements of Asian patients are described in detail. The mean follow-up was 26 months (range, 6 to 108 months). Fat grafting was an integral part of our procedure, with 95 percent having concomitant facial fat grafting with their face lift. Patients were followed up in accordance with a standardized schedule. The majority of patients reported high satisfaction with the aesthetic outcome of the technique, with natural, long-lasting results. The face lift plane of dissection is through the facial soft-tissue spaces, which provide atraumatic sub-SMAS access with precise release of the intervening retaining ligaments for effective flap mobilization. By emphasizing tension on the composite flap with no tension on the skin closure, the scars were discrete in the great majority of patients. Complications were few, with no hematomas or skin flap necrosis. The temporary nerve injury rate was 1.5 percent, with no patient having a permanent nerve injury. The composite face lift is an ideal technique for Asian patients, as it delivers natural, long-lasting results; a quick recovery; and high patient satisfaction. Therapeutic, IV.

Building the Composite Face Lift: A Personal Odyssey.

This article is a 42-year history of the development of a comprehensive face-lift technique by the author. It describes how the composite rhytidectomy has been constructed, anatomical area by anatomical area, over the author's lifetime career as a plastic surgeon. Over the course of these years, beginning with Skoog's 1973 description of using the platysma muscle of the lower face, it describes how progressively the other significant structures of anatomy necessary to be used in achieving significant rejuvenation have been analyzed by the author and in turn surgically repositioned. The theory was based on creating a composite flap of the face, keeping the orbicularis oculi muscle, facial platysma muscle, and cheek fat in their normal anatomical and intimate relationship with each other by using the skin as the carriage. In addition, differences of vectors between the composite rhytidectomy and traditional techniques are demonstrated. The gradual and persistent pursuit of periorbital rejuvenation using the lower eyelid fat and the septal orbitale is described. Each of the anatomical structures involved and the description of their importance and surgical execution have been published over the surgical career of the author, including use of the same principles for reversing suboptimal face-lift results.

Commentary on: Total Composite Flap Facelift and the Deep-Plane Transition Zone: A Critical Consideration in SMAS-Release Midface Lifting.

I must say I was pleased when asked by the editor of this journal to write a commentary when I received the title,1 since I developed (and named) the composite facelift. Every surgeon who publishes original work wants to see his contribution accepted by his peers. However, I was baffled when reading this article. The technique the author describes is not a composite facelift, as he has entitled his publication. Perhaps the history of the development of the composite facelift2 will clarify and justify my criticism of this article. I was fortunate to start with the Skoog rhytidectomy in 1973,3 and together with Dr. Mark Lemmon we published the only extensive series on Skoog rhytidectomy4 since Prof. Skoog died in 1974. In 1985, after performing the tri-plane rhytidectomy, which I had published in 1983,5 I continued to be unhappy with the results. This was essentially an extension of the Skoog rhytidectomy, but with a subcutaneous elevation of cervical skin, since we concluded that the subplatysma cervical Skoog rhytidectomy could not create optimal neck contouring. While the jawline was satisfactory, I felt that the nasolabial fold could be better, and then began working on the technique that I wanted to give an original designation. I called it the deep plane rhytidectomy6 since it was an extension of the tri-plane rhytidectomy. The concept was relatively simple, as the cheek fat that was between the zygomaticus major and minor was lifted with the skin and kept in continuity with the platysma of the lower face (SMAS). Thus the skin was the vehicle for moving the cheek fat and the SMAS in the traditional lateral direction toward the ear. This original dissection was published, and met with enthusiasm among aesthetic surgeons everywhere. The result of the deep plane …

Esthetic Outcome After Soft Tissue Reconstruction of the Face Using Deep Dissection and Composite Facelift Technique

Large defects in the face resulting from the excision of malignant tumors, trauma, and congenital malformation pose a significant challenge to reconstructive surgeons. Achieving good esthetic and functional outcomes is often very demanding. A facelift technique was used in 47 patients (25 female, 22 male; age range, 17.5 to 82.3 years; mean age, 49.3 years) to replace lost tissue of the face from 2009 through 2012. The minimum defect size was 2 cm in diameter and the maximum was 8 cm. To achieve tension-free coverage with a reliable blood supply, a deep-plane dissection, including the skin and superficial musculoaponeurotic system (SMAS), was performed. The deep sub-SMAS dissection was extended into the neck and the contralateral part, as needed. A thick flap was created and composite lifting was performed. No significant deformity concerning the lower eyelids, nose, and lip was registered. Most scars could be placed in hidden regions and became undetectable after a year. The facial nerve function remained intact in all patients. Using these facelift techniques, including the incision, sub-SMAS dissection for volumetric positioning of the skin, and the SMAS flap, the closure of extensive facial defects with excellent functional and esthetic results is conceivable.

Facelift and Patterns of Lymphatic Drainage

It has commonly been assumed that deeper facelift dissection causes greater and more prolonged swelling. In this preliminary report, the authors compare the lymphatic reconstitution after multiple techniques of rhytidectomy by means of dynamic lymphoscintigraphy. Three patients were enrolled in this study. All three were female, were similar in age, and exhibited similar signs and degrees of facial aging. Each woman underwent a facelift with a different technique: (1) subcutaneous dissection with superficial musculoaponeurotic system (SMAS) plication, (2) subcutaneous dissection with SMASectomy, and (3) a "high SMAS" composite facelift. Postoperatively, (99m)Tc-sulfur colloid was injected into a standardized infraorbital location in each patient to compare patterns of lymphatic drainage using lymphoscintigraphy. Postoperative scans at two weeks, six weeks, three months, six months, and one year were compared to the preoperative scans taken seven days prior to surgery. All rhytidectomy techniques appeared to temporarily create a significant and similar degree of interruption in lymphatic drainage. There was a subtotal recovery of lymphatic pathways within three months and complete return to baseline drainage pattern after six months, regardless of surgical technique. Based on the results of this study, it appears that the extent of facial dissection, rather than the depth, is the most significant factor in postoperative edema.

Nuances of the Composite Face-lift Technique

The composite face-lift is a well-described, comprehensive facial rejuvenation technique that results in harmonious repositioning of all components of the aging face. It is distinguished by the superior-medial movement of the cheek and the septal reset maneuver. The composite rhytidectomy reverses the unbalanced vectors of the traditional face-lift in patients with the lateral sweep and may reestablish the youthful convexity in patients with hollow eyes.

The Composite Facelift

Harmonious long-term facial rejuvenation can be achieved with the technique of composite facelifting. The composite facelift elevates not only the skin but also the platysma, the malar fat, and the orbicularis muscle. The development of a zygorbicular flap, along with an arcus marginalis release, allows for a strong superior medial pull, which results in a more youthful face and eyes.

Prevention and correction of the "face-lifted" appearance.

In spite of the increasing demand and popularity of facial rejuvenation procedures, there has been little real change of traditional techniques over the past few decades. Face lifts continue to be lateral vector techniques, whether skin lifts, superficial musculoaponeurotic system (SMAS) lifts, or deep plane malar fat maneuvers are done. Lower eyelid procedures continue to include removal of orbital fat in most cases. Laser blepharoplasties combine transconjunctival fat removal with laser skin abrasion. Forehead lifts continue to be optional in most cases, in spite of clear indications. The unfortunate results of these traditional procedures that may occur are becoming easy to recognize. The unopposed tension of lateral vector face lifts allows the cheek tissues to descend eventually over the tightened jawline, creating a "lateral sweep" or pulled appearance of the face. A crescent-shaped mound over the malar area is the inferior orbicularis oculi muscle, not repositioned with conventional procedures. Following conventional blepharoplasty, the lower eyelid contour becomes deeper, and often an hollow appearance develops. A composite face lift combined with an arcus marginalis release can correct these typical problems. The primary vector of the face is superiomedial, which will reverse the unopposed tension of lateral vector techniques and reposition the cheek tissues to their original position. The arcus marginalis release combined with repositioning of the complete orbicularis muscle in a zygorbicular midface flap can be used to correct the most severe hollow lower eyelid. Unwanted and unattractive results are not the fault of the surgeon or the patient but are caused by the surgical technique. As a primary rejuvenative procedure, a composite rhytidectomy will deliver an impressive result that will disallow the ultimate lateral sweep and hollow eyes. In patients that have the unhappy signs of surgery this procedure can effectively correct the face-lifted appearance.

The zygorbicular dissection in composite rhytidectomy: an ideal midface plane.

Composite rhytidectomy added the repositioning of the orbicularis oculi muscle to the deep plane face lift to achieve a more harmonious appearance of the face by adding periorbital rejuvenation. By not separating the orbicularis oculi from the zygomaticus minor and by extending the dissection under medial portions of the zygomaticus major and minor muscles, a more significant improvement in composite rhytidectomy can now be achieved. A thin nonrestrictive mesentery between the deep plane face lift dissection and the zygorbicular dissection still allows vertical movement of the composite face lift flap without interrupting the intimate relationship between the platysma, cheek fat, and orbicularis oculi muscle. This modification eliminates the occasional prolonged edema and occasional temporary dystonia previously observed. It allows the continuation of the use of the arcus marginalis release, which has also been modified by resetting the septum orbitale over the orbital rim. These two modifications allow a more predictable and impressive result. They reinforce the concept of periorbital rejuvenation as an integral part of facial rejuvenation, which not only produces a more harmonious immediate result but prevents the possible unfavorable sequelae of conventional rhytidectomy and lower blepharoplasty.

Deep-Plane Cervicofacial Rotation-Advancement Flap for Reconstruction of Large Cheek Defects

The blood supply and reliability of cervicofacial rotation-advancement flaps for cheek reconstruction can be improved significantly by dissecting the flap in the deep plane (i.e., below the superficial musculoaponeurotic system and the platysma). This modification, similar in technique to that used in composite or deep-plane face lift, was used successfully in seven patients, including several heavy cigarette smokers who were unlikely to have achieved a successful outcome with a conventional cervicofacial flap. No facial nerve weaknesses were observed. We now believe that the deep plane is the level of choice for dissection of cervicofacial flaps when used for reconstruction of cheek or other facial defects.

Repositioning the Orbicularis Oculi Muscle in the Composite Rhytidectomy

While blepharoplasties are routinely done with face lift procedures, the improvement is accomplished by removing excess orbital fat with eyelid skin and muscle along the incisional line. The orbicularis oculi muscle remains intact as its inferior border, which has become ptotic and redundant with aging, and actually remains in the same position following a conventional lower lid blepharoplasty and rhytidectomy. However, by elevating the orbicularis oculi with the cheek fat and platysma in a composite face lift flap, and by excising the redundant inferior border of the orbicularis muscle, a total rejuvenation of the malar area is accomplished. The descent of the orbicularis oculi muscle is in an inferolateral vector, whereas the vector of facial aging is inferomedial. Thus, repositioning the orbicularis oculi is in a superomedial vector and is obligatory in a composite rhytidectomy.

Repositioning the orbicularis oculi muscle in the composite rhytidectomy.

While blepharoplasties are routinely done with face lift procedures, the improvement is accomplished by removing excess orbital fat with eyelid skin and muscle along the incisional line. The orbicularis oculi muscle remains intact as its inferior border, which has become ptotic and redundant with aging, and actually remains in the same position following a conventional lower lid blepharoplasty and rhytidectomy. However, by elevating the orbicularis oculi with the cheek fat and platysma in a composite face lift flap, and by excising the redundant inferior border of the orbicularis muscle, a total rejuvenation of the malar area is accomplished. The descent of the orbicularis oculi muscle is in an inferolateral vector, whereas the vector of facial aging is inferomedial. Thus, repositioning the orbicularis oculi is in a superomedial vector and is obligatory in a composite rhytidectomy.