sub-SMAS Dissection Research Articles

FACELIFT TECHNIQUES: AN OVERVIEW.

Facelift techniques can be classified according to the depth and extent of the dissection applied. Imbrication and plication of the SMAS referred to as "SMAS lifts" or "classical facelifts" are the most commonly used techniques. Plication techniques involve in-folding of the SMAS and suture suspension without any SMAS incision whereas imbrication techniques involve a SMAS incision with a portion of the SMAS either removed or transposed with or without limited subSMAS dissection. Ageing changes in the lower face and neck can be successfully treated with SMAS lift techniques. However, there is no lifting effect at midface level or improvement of the nasolabial folds since the retaining (zygomatic cutaneous and masseteric cutaneous) ligaments that prevent the transmission of traction to the malar portion of the facelift dissection are not released. Extended facelift techniques involve surgical release of these ligaments, and produce combined, balanced and harmonious rejuvenation of the midface, cheek, and lower face without requiring a separate midface lift procedure. There are different techniques having similar extended midface dissections with some variations: The extended SMAS technique involves a long skin flap and a distinct SMAS flap dissected and pulled separately. The high SMAS technique has a similar dissection but involves a higher SMAS flap along the superior border of the zygomatic arch. The deep plane facelift involves undermining of skin-SMAS flap as a single unit following a more limited subcutaneous dissection. In the composite plane facelift, in addition to deep plane facelift dissection, the lower part of the orbicularis oculi muscle is also dissected and included in the flap. As they have a single unit, deep and composite flap facelifts allow excellent blood supply to the overlying skin. In this article, various facelift techniques are discussed in detail in line with the relevant surgical anatomy.

Analysis of the Outcome of Reoperative Face Lifts Using Sub-SMAS Techniques

Reoperative face lift can be technically more demanding than primary face lift because of altered anatomy and scarred tissue plane. This study was carried out to analyze the outcome of reoperative face lift using sub-superficial musculoaponeurotic system (SMAS) techniques, including facial nerve injury. Seventy reoperative face lifts using sub-SMAS techniques were studied. Data analysis includes the patients' demographic information, the interval between the previous face lift and the reoperative face lift, intraoperative findings of the SMAS-platysma anatomy, complications, and rate of revision. A separate group of 180 primary face lifts using sub-SMAS techniques during the same period was analyzed for the incidence of facial nerve injury only. Intraoperative findings in the reoperative group consist of anatomical changes in the SMAS-platysma in 82.9 percent of the cases, including increased fibrosis, changes in thickness, limited movement, and increased adhesion on the undersurface. Sub-SMAS dissection was completed in 137 hemifaces. Complication consists of seroma (1.4 percent), delayed healing (1.4 percent), and temporary facial nerve injury (7.1 percent), which was not correlated with increased fibrosis or adhesion under the SMAS-platysma. The rate of revision within 18 months was 11.4 percent. There was a 2.2 percent incidence of temporary facial nerve injury in the primary face-lift group. Sub-SMAS techniques, with few exceptions, were successfully used in a series of reoperative face lifts. Temporary facial nerve injury was the most frequent complication. Satisfactory outcome was obtained in all the cases. The incidence of facial nerve injury was higher than in primary face lift using sub-SMAS techniques. Therapeutic, IV.

The Art and Science of Extended Deep Plane Facelifting and Complementary Facial Rejuvenation Procedures

Dr Jacono and the team at Quality Medical Publishing (St. Louis, MO) have produced a handsome volume dedicated to his personal surgical approach to the treatment of facial aging. The book, at 500 pages, closely follows the size, format, and high standard established by previous QMP hardcover books in aesthetic surgery, with plenty of beautiful illustrations and clinical color photos, and easy-to-read text. The first portion of the book focuses on Dr Jacono’s approach to facelifting. Dr Jacono, a respected facial plastic surgeon from New York, has been developing and refining this technique for over a decade. The first 4 chapters add up to nearly one-half of the book and thoroughly discuss the rationale, safety, and effectiveness of the technique; the relevant surgical anatomy; anatomic changes associated with aging; and the facelift technique itself, which is the longest chapter and very comprehensive. For those unfamiliar with the author’s facelift approach, I will try to summarize. First, the “deep plane” portion of the title is a reference to the work of Dr Sam Hamra, who in 1990 published a paper with a then-new technique utilizing that particular title. Like Dr Hamra’s method, Dr Jacono’s dissection into the deep plane starts on a line between lateral canthus and the angle of the mandible, dissecting deep to the malar fat pad and superficial musculo-aponeurotic system (SMAS), and over the mimetic muscles forward to the naso-facial crease. This develops a composite flap, which is not delaminated or separated from the skin, as in most lateral SMAS-based techniques. Jacono’s procedure differs from that discussed in Hamra’s 1990 paper in several key aspects: he performs a sub-platysmal dissection in the neck, beginning laterally and extending 5 cm below the angle of the mandible, and then makes a 4-cm superior platysmal myotomy, approximately 1 cm below the mandibular border, which is employed to contour the neck. Jacono also stresses the need to release the facial retaining ligaments—the zygomatic cutaneous, masseteric cutaneous, mandibular cutaneous, and cervical retaining ligaments—to obtain appropriate tissue mobility. He describes his anatomic approach to do so in detail, because these ligaments are so often in proximity to facial nerve branches. Numerous intra-operative photos are shown, detailing each step of the procedure, with pearls on incision placement, flap elevation, sub-SMAS dissection, fat contouring, and suspension of the flap and skin closure, and multiple cases are shown with long-term follow-up photos. Interested readers can get a flavor for the book by looking at the author’s recent publications in Facial Plastics Clinics of North America and ASJ.

Superficial Fascia of the Cheek Shown in P45 Sheet Plastination.

In this paper, the authors attempted to determine the extent of the superficial fascia of the cheek using P45 sheet plastination.Three head and neck specimens were sliced in horizontal (46 slices), coronal (30 slices), and sagittal (29 slices) sections using P45 sheet plastination (special polyester resin corrosion-resistant method designed to preserve biological sectional specimens in situ). Through slicing, bleaching, dehydration, casting, forced impregnation, curing, cutting, and sanding the molds, P45 plastination sheets provided good light transmission, allowing the internal structures within the sheet to reveal clearly in their intact form.P45 sheet plastination revealed that the superficial fascia in the cheek area is generally composed of 3 layers: a superficial fatty layer, a membranous layer, and a deep fatty layer. Anteriorly, the membranous layer of superficial fascia (MSF) extended to the posterior border of the zygomaticus major muscle, enveloping this muscle, and then to the lateral border of the orbicularis oculi muscle. Posteriorly, the MSF extended to the anterior border of the parotid gland, and then was continuous with the parotid fascia. Superiorly, the MSF extended to the line from the tragus to the alar base. Inferiorly, the MSF extended to the line from the mandibular angle to the mouth corner. Below this line, the SMAS continued to the upper border of the platysma muscle.Our results using P45 plastination concorded well with Mitz's original drawing. We suggest that the results of the present study may be helpful for practicing surgeons to apply in subcutaneous dissection or sub-SMAS dissection in facelift procedures.

Refinements in Tailoring the Lift-and-fill Facelift.

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.

Triple-S Lift for Facial Rejuvenation.

Since the beginning of the last century, when the aesthetic rejuvenating surgery was first described, there have been great changes in tactics and methods for solving the problems of age-related facial changes. Since the first description of the superficial muscular aponeurotic system (SMAS), there have been two main approaches to influencing this structure. These are various types of SMAS plications and different in-depth and technique sub-SMAS liftings. Each of these approaches has its advantages and disadvantages. We have developed and applied a face-lift technique that combines the advantages of both approaches. We call it the triple-S lift, which is based on three basic principles: 1. A short scar technique; 2. The safety SMAS (limited sub-SMAS dissection to anterior border of the masseter muscle); 3. The support system (a complex of ligatures in the sub-SMAS layer, which allows lifting and plication of the medial part of the SMAS simultaneously) According to this method, there were 93 operations performed on 8 men and 85 women aged 38 to 72years. The first clinical applications produced good results. The patients noted a high degree of satisfaction, and the level of complications was quite low. Since the technique has been performed for a short period of time, we demonstrate results of the 2-year period. The described technique requires further study, but the first results suggest that this type of a surgical intervention is safe, easy to execute, and may be an option to choose for surgical correction of facial aging changes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Superficial Fascia (SF) in the Cheek and Parotid Area: Histology and Magnetic Resonance Image (MRI)

The aim of this study is to compare the superficial fascia (SF) in the cheek and parotid areas histologically and through MRI. An in vitro study included a histological report and an MRI of the cheek of two Korean adult cadavers. The in vivo study included 100 MRI images and three axial image cuts (mandibular condyle, notch, and half the distance between the top of the condyle and the angle). Four angles, one length, and four thicknesses were measured and compared. The MRI results were in concord with the gross specimen or histology. The SF consisted of multilayered horizontal and vertical fibrous connective tissues at all three levels in both the histology and MRI. In the cheek, both histology and MRI showed horizontal fibrous connective tissues which were connected with the zygomaticus major, visualized as a continuous membrane (membranous layer, MSF). MSF divided the SF into the superficial fatty layer (SFS) and the deep fatty layer. The thickness of the SF depended upon the thickness of the SFS since the thickness of the MSF was very similar irrespective of the three levels. The thickness of the SFS was thicker in females than in males. At the condyle level, the AS-PS angle (AP line-the most posterior superficial fascia angle) and AS-PS length increased significantly (p=0.001, y=0.15x+16.19, and p<0.001, y=0.33x+14.68, respectively). We hope the information we have gathered could be useful to provide subcutaneous dissection or sub-SMAS dissection in facelift surgeries. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical Anatomy of the Middle Premasseter Space and Its Application in Sub–SMAS Face Lift Surgery

The premasseter space is a recognized, sub-superficial musculoaponeurotic system (SMAS) soft-tissue space overlying the lower masseter immediately anterior to the parotid. The performance, safety, and effectiveness of composite face lifts are enhanced when the space is used. This has drawn attention to the need for better understanding of the premasseter anatomy above the space. The anatomy of the upper premasseter region was investigated in 20 fresh cadaver dissections as well as intraoperatively in hundreds of composite face lifts. A small, transverse, rectangular soft-tissue space overlies the upper masseter and was named the middle premasseter space. The space (transverse width, 25 to 28 mm; vertical width, 10 mm) is separated from the originally described (lower) premasseter space by a double membrane. It is a safe space between the upper and lower buccal trunks of the facial nerve, which are immediately outside the space and separated from it by the respective upper and lower boundary membranes. The parotid duct immediately beneath the floor of the space usually underlies the upper boundary membrane. The middle premasseter space is significant, as it is the center of the key anatomy immediately cephalad to the lower premasseter space. When used in composite face lifts, the space provides predictable sub-SMAS dissection between the buccal trunks of the facial nerve to the mobile area beyond the anterior border of the masseter where the SMAS overlies the buccal fat pad.

Facial Rejuvenation With Fine-Barbed Threads: The Simple Miz Lift

Since the invention of the first barbed (short) suture by Sulamanidze in the late 1990s, different techniques have been described including Woffles (long) thread lifting, Waptos suture lifting, Isse unidirectional barbed-threads lifting, and silhouette lifting. The authors have implemented a newly developed type of thread integrating more small cogs and a soft and fragile feeling of the material (medical grade polypropylene: 16.5cm long, 15cm of length covered with cogs, and 0.40mm in diameter). This study aimed to describe the authors' thread and the surgical techniques they have adopted to counteract the descent and laxity of facial soft tissues. A retrospective chart review was performed during a period of 2years, from March 2010 to February 2012. The procedure was performed with the patient under local anesthesia and intravenous sedation. The face was marked preoperatively to determine the appropriate vector of the thread and its five end fixation points. The superior border of the incision was approximately at the level of the lateral brow, and the lower border was about 2cm above the superior margin of the helical root. After the temporal incision was made, the dissection was carried all the way down to the deep temporal fascia to create a plane between the superficial and deep temporal fascias. Using blunt cannulas, the dissection was continued in an inferomedial direction from the temporal incision to the lower face through the sub-submucosal aponeurotic system (sub-SMAS) plane, which was marked preoperatively. This sub-SMAS dissection could easily proceed to the premasseteric space (PMS). The face-lift sutures (Gusan Inc., Seoul, Republic of Korea) then were inserted through the cannula from the lower face to the temporal incision line. The sutures were trimmed, and the proximal ends were secured on the deep temporal fascia reinforced with Vicryl interrupted sutures. The results were assessed objectively using serial photography and subjectively according to patient assessment. Complications also were recorded. All but two patients (100/102, 98.1%) were satisfied with the outcomes after surgery. Consensus ratings by two independent plastic surgeons found that objective outcomes were divided among "excellent," "good," and "fair." The postoperative course was uneventful except for one patient (1/102, 1%) who presented with minor skin dimpling and another patient (1/102, 1%) who had a temporary facial weakness. These two complicated cases were resolved spontaneously without any surgical interventions. The reported technique has several advantages over current approaches. First, the use of nonabsorbable sutures with sufficient maintenance potential can produce long-lasting, satisfying results. Second, use of the authors' fine thread can avoid complications such as extruded or visible thread, which often have been complaints with thread lifting. Third, use of a loose areolar plane, including sub-SMAS and PMS free of vital structures, which is deeper than the traditional lift procedure, can avoid any traction line during rest or animation without any significant complications. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Anatomic study of full facial and scalp allografts without cutaneous facial scars

Conventional reconstructive procedures for face and scalp reconstruction fall short of aesthetic and functional goals because of the unique quality and quantity of facial and scalp soft tissue. The purpose of this cadaver study was to demonstrate the feasibility of a flap design for full face and scalp composite tissue allotransplantation, without cutaneous facial scars. Six fresh human cadavers were dissected with sagittal scalp and mucosal incisions for full face and scalp harvest without cutaneous facial incisions. Sub-galeal and sub-SMAS dissection allowed for inclusion of the external carotid and internal jugular systems. Time of facial-scalp flap harvesting, length of the arterial and venous pedicles, length of sensory nerves (that were included in the facial flaps) and approximate surface area of the flaps were measured. Three of six flaps were transferred to recipient cadavers and the time of transfer was recorded. As a proof of concept, the external carotid arteries of one of six cadavers was flushed to remove clots and perfused with a radio-opaque latex polymer, Microfil (Flow Tech Inc.), to study flap perfusion by X-ray imaging. In the donor cadaver, the mean harvesting time of the total facial-scalp flap was 105 ± 19 minutes. The mean length of the supraorbital, infraorbital, mental and great auricular nerves were 1.3 ± 0.2, 1.3 ± 0.1, 1.3 ± 0.1, and 4.8 ± 0.6 cm, respectively. The mean length of the external carotid artery and external jugular vein were 8.7 ± 0.3 and 9.2 ± 0.4 cm, respectively. The approximate area of the harvested flap was 1063 ± 60 cm2. In preparation for full face and scalp allotransplantation in humans, this study has demonstrated the feasibility of a full face and scalp flap without visible facial incisions.

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.

Deep-Plane Technique

Deep-Plane Technique

The extended SMAS facelift: identifying the lateral zygomaticus major muscle border using bony anatomic landmarks.

Extended superficial musculoaponeurotic system (SMAS) rhytidectomy has been advocated for improving nasolabial fold prominence. Extended subSMAS dissection requires release of the SMAS typically from the upper lateral border of the zygomaticus major muscle and continued dissection medial to this muscle. This maneuver releases the zygomatic retaining ligaments and achieves more effective mobilization and elevation of the ptotic malar soft tissues, resulting in more dramatic effacement of the nasolabial crease. Despite its presumed advantages, few reports have suggested greater risk of nerve injury with this technique compared with other limited sub-SMAS dissection techniques. Although the caudal extent of the zygomaticus muscle insertion to the modiolus of the mouth has been well delineated, the more cephalad origin has been vaguely defined. We attempted to define anatomic landmarks which could serve to more reliably identify the upper extent of the lateral zygomaticus major muscle border and more safely guide extended sub-SMAS dissections. Bilateral zygomaticus major muscles were identified in 13 cadaver heads with 4.0-power loupe magnification. Bony anatomic landmarks were identified that would predict the location of the lateral border of the zygomaticus major muscle. The upper extent of the lateral border of the zygomaticus major muscle was defined in relation to an oblique line extending from the mental protuberance to the notch defined at the most anterior-inferior aspect of the temporal fossa at the junction of the frontal process and temporal process of the zygomatic bone. The lateral border of the zygomaticus major muscle was observed 4.4 +/- 2.2 mm lateral and parallel to this line. More accurate prediction of the location of the upper extent of the lateral border of the zygomaticus major muscle using the above bony anatomic landmarks may limit nerve injury during SMAS dissections in extended SMAS rhytidectomy.

The High???Superficial Musculoaponeurotic System Technique in Facial Rejuvenation:

The medical charts of 267 patients who had primary high-superficial musculoaponeurotic system (SMAS) rhytidectomies were reviewed. The depth of the nasolabial fold was used as an indicator of the degree of descent of the subcutaneous cheek mass, as a guide in procedure selection, and as a method of judging the operative results. Fold depth was assigned a score of 0 to 3, with 3 being most severe. According to their preoperative fold depth, patients were operated on using one of three variants of the high-SMAS technique: sub-SMAS dissection up to the nasolabial fold, sub-SMAS dissection up to the nasolabial fold plus transnasal SMAS graft, or sub-SMAS dissection across the nasolabial fold. An independent trained observer rated the postoperative fold depth in each case from photographs taken at the 6-month follow-up visit. Of patients with fold scores of 2 or 3, 97 percent (183 of 189 patients) showed visible improvement in nasolabial crease depth after the operation.

Face-Lifts and Their Long-Term Results

Introduction: The literature on face-lifting over its history varies from simple to complex. It can be difficult to determine which technique is best for each individual patient. We collected a series sufficiently large to show valid conclusions up to 6 years postoperatively. Materials and Methods: Between January 1987 and January 1997, 348 female and 26 male patients underwent face-lifting. Based on complexity of the procedure, the cases were stratified into 5 groups. Group A had limited skin undermining out to 5 cm, with submuscular aponeurotic system (SMAS) plication (21 patients). Group B had longer skin flaps with undermining out to 10 cm, with SMAS plication (27 patients). Group C had skin undermining out to 7–8 cm and sub-SMAS dissection to the anterior border of the parotid, with myofascial imbrication (136 patients). Group D had skin undermining and sub-SMAS dissection to the caudal limit of the melolabial groove and mandibular ligament and for 7–8 cm below the platysma, with myofascial imbrication (153 patients). Group E had composite lifts according to Hamra (37 patients). At 2 and 6 years' follow-up, patients were evaluated in a blinded fashion with direct observation by 2 nurses and with photographic comparisons made by 3 independent surgeons. Results: Two-year follow-up evaluations were performed for 189 patients. Six-year follow-up evaluations were performed for 128 patients. At 2 years, the degree of improvement tended to favor the more complex techniques, and at 6 years, it definitely favored the more complex techniques. Complications were: 10 hematomas, evenly distributed among the groups; 13 cases of temporary facial nerve weakness, with a higher percentage in groups D and E; 4 skin sloughs, 1 for group B and 3 for group D; and no infections. Discussion: While some patients can obtain satisfactory results with skin undermining and SMAS plication, the majority of our patients enjoyed longer-lasting results with more complex face-lifts, encompassing SMAS dissection and imbrication.

Superficial/Skin Level Rhytidectomy Provides Safe, Superior Facial Contouring

The superficial/skin level rhytidectomy is a safe procedure, with a reasonably short recovery time and predictably excellent results. My dissection is above the superficial musculoaponeurotic system (SMAS) plane over the checks, the mandibular border, the chin, and the neck. I dissect through the nasolabial crease on to the upper lip, and all the way across the neck, through a submental incision. This allows direct removal of fat from the labial mandibular fold and the jowls to improve the contour in those areas. Obviously a sub-SMAS dissection technique prohibits the surgeon from individualizing the fat contouring. Differential vectors are used for tension on the skin and tension on the SMAS. This is very important. Across the cheeks, the SMAS vector is superolateral, whereas …

Triplane rhytidectomy. Combining the best of all worlds.

To combine certain aspects of the sub-superficial musculoaponeurotic system (sub-SMAS) and subperiosteal rhytidectomies to maximize the advantages while minimizing the disadvantages of each. The subperiosteal rhytidectomy is used to reposition the ptotic malar fat pad concomitantly with the elevation of the corner of the mouth by means of shifting upward the origin of the zygomatic major muscle. The sub-SMAS rhytidectomy is used to maximize elevation of the jowl. Ambulatory surgical facility. Preauricular and temporal dissection is subcutaneous to the malar eminence above and angle of mandible below. A subperiosteal dissection of the middle part of the face is then accomplished through a sublabial approach combined with an incision over the malar eminence. An incision is made through the SMAS from the malar eminence to the mandibular angle and sub-SMAS dissection is accomplished under the jowl. The subperiosteal dissection is suspended to the temporal fascia and the SMAS dissection is imbricated with 2 suspension suture lines. Follow-up in patients who are 1-year postoperative demonstrates a continued youthful elevation and flattening of the melolabial fold and complete correction of the jowl. No facial nerve injury or hematomas were observed.

Extended sub-SMAS dissection and cheek elevation: Mendelson BC. Clin Plast Surg 22:325, 1995

Extended sub-SMAS dissection and cheek elevation: Mendelson BC. Clin Plast Surg 22:325, 1995

Rhytidectomy: The multiplane approach

This paper addresses the technique and experience of the multiplane face-lift. It discusses the multiplane approach as a modification of the deep-plane face-lift, combining the subSMAS dissection with wide subcutaneous undermining. This technique allows for the development of separate SMAS and skin flaps that can be treated individually as opposed to advancement as a single unit. A discussion of the anatomy with regard to the SMAS and retaining ligaments of the cheek describes how the underlying muscles affect the appearance of the nasolabial fold and why the multiplane face-lift results in superior treatment in this area. A step by step description outlines treatment of the neck, face and forehead, and use of wide MicroFoam for the final dressing.

Extended Sub-Smas Dissection and Cheek Elevation

The extended SMAS facelift techniques gave plastic surgeons the ability to correct the nasolabial fold and medial cheek. Retensioning the SMAS transmits the benefit through the multilinked fibrous support system of the facial soft tissues. The effect is to provide a recontouring of the ptotic soft tissues, which fills out the cheeks as it reduces nasolabial fullness. Indirectly, dermal tightening occurs to a lesser but more natural degree than with traditional facelift surgery. Although details of current techniques may be superseded, the emerging surgical principles are becoming more clearly defined. This article presents these principles and describes the author's current surgical technique.