Sub-superficial Musculoaponeurotic System Research Articles

Safe Zones for Facial Fillers: Anatomical Study of SubSMAS Spaces in Asians.

The study "Spaces of the Face for Filler Procedures: Identification of subSMAS Spaces Based on Anatomical Study" explores the anatomy of facial spaces crucial for safe and effective filler injections. By delineating the subSMAS (sub-superficial musculoaponeurotic system) spaces, this research highlights how these virtual compartments, bordered by fat, muscles, fascia, and ligaments, facilitate independent muscle movement and reduce the risk of damaging critical structures. The thicker and more robust skin of East Asians necessitates deeper filler injections, emphasizing the significance of accurately identifying these spaces. A cadaver study with dyed gelatin validated the existence and characteristics of these subSMAS spaces, confirming their safety for filler procedures. Key spaces, such as the subgalea-frontalis, interfascial and temporalis, and prezygomatic spaces, were examined, illustrating safe zones for injections. The findings underscore the importance of anatomical knowledge for enhancing facial aesthetics while minimizing complications. This study serves as a guide for clinicians to perform precise and safe filler injections, providing a foundation for further research on the dynamic interactions of these spaces and long-term outcomes.

Ultrasonic Deep-Plane Neck Lift.

Ultrasonic deep-plane neck lift is a new approach for addressing both the subsuperficial musculoaponeurotic system and subplatysmal soft tissues during facial rejuvenation procedures. This innovative surgical approach utilizes 2.2, 2.9, and 3.7 stainless steel probes that are powered by high-frequency ultrasound. Using high-frequency ultrasound in the subcutaneous spaces has been accomplished for the past 20 years with a very suitable safety profile. In this technique, emulsification of the fat layer in both the superficial and deep planes is accomplished with tumescence of the soft tissues in the same fashion as subcutaneous liposuction. In ultrasonic deep-plane neck lift, the superficial and deep layers of fat are targeted for emulsification, and this creates a loosening of these spaces for lifting and repositioning. The procedure facilitates more accurate surgery, because the tissue effects include hemostasis and scalpel- and scissor-free undermining due to the emulsification of the fat layers of the face and neck. The other advantages of ultrasound-assisted facial contouring and rejuvenation include treatment of hard-to-treat areas like the perioral region and distal neck, which can be rapidly and safely undermined utilizing this technology. The third component of ultrasound- and energy-based facial rejuvenation surgery is the long-term remodeling and tightening that occurs beginning approximately 8 weeks after the procedure. When many conventional facelifts are beginning to fall at 3 to 4 months postoperatively, the energy-based facelifts are still tightening and this remodeling continues for up to a year after the procedure. Combining technology with conventional facelift procedures is a new approach to facial rejuvenation and is the result of 15 years of research and cooperation with the aesthetic device industry. The result of this merger of technology with conventional surgery is TESLA Facelifting, the facelift of the future.

Superior Vector Plication of the Mobile Anterior Midface: The Delta Facelift.

Traditional plication techniques have been ineffective in addressing the anterior midface when compared to the sub-superficial musculoaponeurotic system (SMAS) "deep plane" approaches. However, by moving the plication much closer to the mobile medial fat tissues, a more effective and long-lasting plication can be accomplished without releasing the SMAS layer. The authors' "Delta facelift" approach combines a rotation vertical advancement of the midface fat with a dual-vector platysmaplasty and deep cervicoplasty as indicated for a harmoniously youthful neck. A retrospective chart review was performed on all patients who underwent facial rejuvenation with the Delta facelift technique between January 1, 2012, and May 30, 2021, for patient demographics, procedure details, outcomes, and complications. A total of 283 patients underwent Delta facelift (273 females, 10 males). The average age was 60.8 years old. Primary facelift was performed in 229 patients, whereas 54 facelifts were secondary or further procedures. Adjunctive procedures included autologous fat grafting (93%), blepharoplasty (52%), and skin rejuvenating procedures (35%). There were 11 self-resolving neuropraxias, 6 minor hematomas, and 6 infections. Nine patients underwent repeat Delta facelift at an average of 9.3 years. The Delta rotation vertical advancement of the anterior facial fat counters the descent and deflation associated with facial aging. Dual-vector platysmaplasty, with or without myotomy, effectively manages the jowl and delineates the jawline. Addition of deep cervicoplasty is recommended for patients with oblique necks or those with subplatysmal volume excess.

Temporal Facelift: A New Method for Temporal and Mid-face Lifting.

Lifting the temporal and mid-face areas creates a very dynamic change in the facial appearance and different planes of dissection were described before. In this article, a new plane of dissection is described which allows the surgeon to perform a very quick and safe dissection in both the temporal and mid-face regions. Patients were operated on using the presented technique and brow lift, cantopexy, and mid-facelift were performed. The outcome of the surgery was analyzed by the authors from standardized photos before and 6 months after the surgery with measurements of the brow and lateral canthus. The plane of dissection is just over the subgaleal fascia which is actually the sub-superficial musculoaponeurotic system layer in the mid-face. This plane of dissection is easy and quick and creates a very mobile mid-face and temporal flap. Forty female patients were operated using the presented technique with a mean follow-up period of 15 months, the longest follow-up was 26 months. No major complication was encountered in these patients. In 5 patients, transient unilateral frontal branch palsy was encountered. In 1 patient, bilateral temporal area depression was observed 8 months after the surgery and treated with a fat injection under local anesthesia. One patient had alopecia in the temporal suture line which can be covered with hair. Temporal facelift is a versatile method with long-lasting results due to its important features; creating a very mobile flap for suspension dissection area, a large surface for adherence, and numerous sutures sharing the tension on the key sutures. Despite its slightly difficult early healing period, the technique should be kept in mind for the rejuvenation of the periorbital area and mid-face. Level of Evidence: Level I.

The Effect of Rhinoplasty Dissection Planes (Sub-SMAS, Subperichondrial, and Subperiosteal) on the Viability of Diced Cartilage Grafts in a Rabbit Model.

Dorsal preservation surgeries in which the subperichondral and subperiosteal planes are used to elevate the soft tissue envelope of the nose have become increasingly widespread because they can reduce postoperative edema and promote faster healing. However, the effects of surgical dissection planes on the viability of cartilage grafts are not known. The aim of this study was to determine, in a rabbit model, the viability of diced cartilage grafts in different rhinoplasty dissection planes (sub-superficial musculoaponeurotic system [SMAS], subperichondral, subperiosteal). Diced cartilage samples were placed in the sub-SMAS, subperichondrial, and subperiosteal planes, and after 90 days, histopathologic analysis was performed. Cartilage graft viability was evaluated based on the loss of chondrocyte nuclei in the lacuna, the presence of peripheral chondrocyte proliferation, and the loss of matrix metachromasia in the chondroid matrix. The median [interquartile range] percentages of live chondrocyte nucleus viability in the sub-SMAS, subperichondrial, and subperiosteal groups were 67.5% [18.75%] (range, 60%-80%), 35% [17.5%] (range, 20%-45%), and 20% [30.0%] (range, 10%-45%), respectively; and the percentages of peripheral chondrocyte proliferation were 80.0% [22.5%] (range, 60%-90%), 30% [28.75%] (range, 15%-60%), and 20% [28.75%] (range, 5%-60%), respectively. There was strong statistical significance in both parameters (P = .001). Intergroup examination revealed a difference between the sub-SMAS and the other surgical planes (P = .001 for both parameters). A smaller loss of chondrocyte matrix was observed in the sub-SMAS group compared with the other 2 groups, which supports the findings of cartilage viability (P = .006). Elevating the soft tissue envelope of the nose in the sub-SMAS surgical plane preserves the viability of cartilage grafts better than subperichondrial and subperiosteal elevation.

Histological effects of a combined collagen stimulation procedure consisting of microfocused ultrasound, soft tissue filler, and Ca‐HA injections

An increasing demand for in-office aesthetic procedures aiming to improve collagen stimulation has been reported. To analyze the effects of combinations of different aesthetic collagen stimulation procedures using histological analysis. Histological analysis was performed on skin samples of the excess skin of a 60-year-old patient after sub-superficial musculo-aponeurotic system facelift surgery. The excess skin before facelift surgery was divided into three areas per hemiface. Each area-with exception of area A as a control-received an isolated or combined treatment of microfocused ultrasound (MFU), injections of calcium-hydroxylapatite/hyaluronic-acid-based soft tissue filler, and microneedling. The effect of the treatments was analyzed using histological analysis with H&E coloration and PAS staining. A threefold increase of epidermal and dermal thickness was achieved by treating the skin with the proposed combined treatment comprising MFU and injections of calcium-hydroxylapatite- and hyaluronic-acid-based soft tissue fillers. The investigated treatments act synergistically in the production of collagen and combining these treatments allows for an increase in collagen production.

Defining the Cervical Line in Face Lift Surgery: A Three-Dimensional Study of the Cervical and Marginal Mandibular Branches of the Facial Nerve.

Continuous subSMAS dissection in the cheek with subplatysmal dissection in the neck is an important feature of many face lift techniques, yet the neural anatomy in this area remains unclear, and recommendations regarding continuous dissection of these adjacent areas vary widely. The purpose of this study is to define the vulnerability of the facial nerve branches in this transitional area from the face lift surgeon's perspective and to specifically identify the location of the cervical branch penetration through the deep cervical fascia. Ten fresh and 5 preserved cadaveric facial halves were dissected under 4X loupe magnification. The skin was reflected followed by elevation of a SMAS-platysma flap with identification of the location of cervical branch penetration through the deep cervical fascia. The cervical and marginal mandibular branches were then dissected retrograde through the deep cervical fascia to the cervicofacial trunk to confirm identifications. The anatomy of the cervical and marginal mandibular branches were found to be similar to the other facial nerve branches, all of which initially course deep to the deep fascia in their post-parotid course. The location of emergence of the terminal branch or branches of the cervical branch through the deep cervical fascia was consistently at or distal to a line from a point 5 cm below the mandibular angle on the anterior border of the sternocleidomastoid muscle to the point where the facial vessels course over the mandibular border (Cervical Line). Continuous dissection of the SMAS in the cheek with subplatysmal dissection in the neck crossing over the mandibular border is possible without jeopardizing the marginal mandibular or the cervical branches if done proximal to the Cervical Line. This study serves as the anatomic justification of continuous SMAS-platysma dissection and has implications for all types of SMAS flap manipulations.

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.

Sub-SMAS Reconstruction of Retaining Ligaments.

Retaining ligaments must be fully released for effective soft-tissue mobilization during sub-superficial musculoaponeurotic system (SMAS) facelifts. Standard deep temporal fascia and lateral SMAS fixation techniques may fail earlier than anticipated, which may cause a relapse of facial aging signs. Reconstruction of retaining ligaments was previously proposed to enhance facelift fixation. The author sought to assess the effect of their ligament reconstruction technique on early relapse rates and complication rates. This study was a comparative analysis of 188 consecutive facelift cases where retaining ligaments were reconstructed employing the described techniques. A total 104 patients with standard fixation were analyzed in the control group. A novel set of criteria was established for the diagnosis of early relapse after facelift surgery based on the validated Merz scale. Early relapse rate was significantly lower (0.53% vs 5.76%) in the ligament reconstruction group compared with the control group. Ligament reconstruction was associated with an increased rate of temporary nerve paralysis (8.5%). Sub-SMAS reconstruction of retaining ligaments enhances facelift fixation and reduces the rate of early relapse. Increased risk of temporary neuropraxia is a reasonable trade-off.

Three-Dimensional Arterial Distribution Over the Midline of the Nasal Bone.

A comprehensive understanding of arterial variations around the midline of the nose is of great importance for the safety of filler injection. The aim of the study was to clearly define the 3-dimensional location of the arteries along the midline of the nasal bone. The arterial structures overlapping the nasal bone along the midline were observed in 79 cadavers. The present study found that 0 to 3 named arteries per nose segment could be identified. All the arterial structures were located in or above the superficial musculoaponeurotic system layer overlapping the nasal bone. The probability of encountering named arteries at 5 defined points, P1 to P5, was 5/79 (6.3%), 4/79 (5.1%), 1/79 (1.3%), 6/79 (7.6%), and 9/79 (11.4%), respectively. The depth of the main arterial trunk was 1.2 ± 0.4 mm, 1.6 ± 0.6 mm, 1.8 ± 0 mm, 1.0 ± 0.4 mm, and 0.9 ± 0.5 mm below the skin at P1 to P5, respectively. The authors confirmed that sub-superficial musculoaponeurotic system injection along the midline through a needle is anatomically reliable and that a technique with 1 entry point through the rhinion via a cannula can easily keep the needle sufficiently deep for safe nasal filler injection.

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.

The Selection of Facelift Approach on the Basis of Midfacial Ptosis.

Facial aging in the midface has been described to encompass both soft tissue descent and volumetric change. Currently, there is no established and widely accepted grading system for midfacial ptosis. We propose a simplified grading system for midfacial ptosis ranging from mild to severe in terms of Grades I through III. Using this classification system, we describe an algorithm to help select the facelift approach most appropriate for each patient. The sub-superficial musculoaponeurotic system rhytidectomy, deep plane rhytidectomy, and subperiosteal midface lift techniques are described in detail. The nuances of the selection process also include a discussion on the various approaches to the orbital fat, namely a transconjunctival lower lid blepharoplasty with skin pinch versus a lower lid blepharoplasty with fat transposition, as well as the aging neck. Furthermore, we integrate the addition of postoperative adjunctive procedures which include injectables, chemical peels, and dermabrasion to address facial rejuvenation from not only a gravitational aspect but also the volumetric and textural components.

Rhinoplasty Dissection Planes (Subcutaneous, Sub-SMAS, Supra-perichondral, and Sub-perichondral) and Soft Tissues Management.

Rhinoplasty as an operation is akin to a game of chess, where every maneuver will influence the eventual outcome. Undoubtedly, more than one approach to the nasal soft tissues envelop can produce beautiful and safe results as will be described in the paper namely, the subcutaneous, sub-superficial musculoaponeurotic system, supra- and sub-perichondral planes. For different justifiable reasons surgeons have their preferences, regarding dissection planes on the tip, middle and upper thirds, and regarding the manipulation of the soft tissue layers and nasal ligaments. The concept of the nasal layers and the presence of relevant ligamentous structures and how to restore them in an anatomical fashion, will help to understand the logic behind various approaches.

Anatomical Continuation Between the Sub-Superficial Musculoaponeurotic System Fat and Retro-Orbicularis Oculi Fat: The True Nature of the Retro-Orbicularis Oculi Fat.

Objective: This study aims to analyze the anatomical location and continuation between the retro-orbicularis oculi fat (ROOF) and sub-superficial musculoaponeurotic system fat (subSMAS fat; named "innominate fascia") by comparing their layered structures, thereby letting us suggest a safe minimally invasive procedure guideline for the forehead and temple. Methods: Ultrasonographic scanning was performed from the upper medial eyebrow to the lateral side of the superior temporal line in 109 volunteers. Hematoxylin and eosin staining was performed on five specimens at the same area as ultrasonographic scanning. Then, four embalmed cadavers were dissected from the orbicularis oculi, frontalis muscle, superficial temporal fascia, and SMAS to confirm the location and continuation pattern of the ROOF and subSMAS fat. Results: On ultrasonography and histological images, there was a continuous fatty layer from the ROOF to the subSMAS fat. When dissecting, the ROOF, which was located deep below the frontalis muscle, also continued to the subSMAS fat, passing through the superior temporal line in the upper temporal region. Conclusions: This study confirmed that the subSMAS fat is an anatomical fat structure that is continuous with the ROOF. Since the subSMAS fat layer is known as a less vascular area, it is considered a safer layer to avoid serious complications, and injecting accurately into the subSMAS fat layer has been a goal of clinicians. Based on this study, a cannula will safely approach the subSMAS fat through the ROOF injection that named "forehead-downward approach."

Photographic Comparison of Malar Projection in 100 Facelift Patients Treated with and without Fat Injection.

Background:Facelifts are frequently combined with fat injection to restore volume. However, the efficacy of simultaneous fat grafting has not been objectively evaluated in a large number of patients that includes a control group. This study was undertaken to fill this gap in our knowledge base.Methods:A retrospective comparative cohort study was undertaken among 100 patients who underwent a subsuperficial musculoaponeurotic system facelift with (n = 61) or without (n = 39) simultaneous malar fat injection. Rigorously standardized photographs were obtained 1, 3, and 6 months after surgery, including oblique photographs with the nasion aligned with the far inner canthus. Malar projection and area were measured with the assistance of a computer imaging software.Results:Fat injection produced a significant (P < 0.001) increase in right and left malar projection. The mean increase in projection was 3 mm, significantly greater than control patients, who also demonstrated a significant (P < 0.001) but more modest (<1 mm) increase. Malar projection was significantly correlated with the fat injection volume (P ≤ 0.001). The increase was sustained at follow-up times up to 6 months, and 1 year in a smaller patient cohort (n = 44), with no evidence of a decline or rebound. The calculated fat retention was 34%.Conclusions:Fat injection at the time of a facelift effectively adds malar volume, and this increase is sustained at time points up to 1 year after surgery, consistent with the cell survival theory.

Ten Tips Based on Anatomy and Design to Refine Face and Neck Lift Surgery.

Background:Any face/neck lift operation has a natural flow of slower and speedier portions; slower when dissecting under the superficial musculoaponeurotic system and around nerves while faster during opening, undermining, defatting, and closing. Surgeons can maximize efficiency with these simple maneuvers.Methods:We introduce and demonstrate ten reproducible surgical techniques based on anatomy, which span aspects of the entire face and neck lift procedure including markings, skin flap elevation, sub-superficial musculoaponeurotic system manipulation, preplatysmal fat management, skin re-draping, and post-operative dressings.Results:As examples, altered scissors facilitate “push” undermining, scoops reduce time for fat removal in the neck, a non-inset method for lobule creation, and digital measurements for certain technical maneuvers are discussed. Moreover, a block and tackle method of facial nerve blocks is reviewed which permits local-only face and neck lifting as well as hematoma drainage without patient intolerance.Conclusions:Implementation of these surgical techniques in face and neck lift procedures allows the surgeon to potentially decrease operative time and work towards minimizing post-operative edema while attaining aesthetic and natural results.

Clinical Evaluation of 225 Sub-SMAS Facelifts with No Temporal Incision.

Background:Despite their name, “short scar” procedures leave scars in the temples and the postauricular scar often requires extension. Redraping the orbicularis muscle for periorbital rejuvenation increases the risk of facial nerve injury. This retrospective cohort study was undertaken to clinically evaluate a surgical approach that eliminates the temporal incision.Methods:A sub-superficial musculoaponeurotic system (SMAS) facelift was used, incorporating a triple-vector platysmaplasty and fat injection for periorbital rejuvenation. From 2009 to 2019, 225 consecutive outpatients underwent a sub-SMAS facelift with a triple-vector (superior, lateral, medial) platysmaplasty, either alone or in combination with fat injection, laser resurfacing, blepharoplasties, endoscopic forehead lift, and other cosmetic procedures. Release of the retaining ligaments optimized SMAS mobilization. A temporal incision was not used. Fat (mean volume 32 ml) was injected into the undissected subcutaneous tissue plane. The mean follow-up time was 28 months.Results:The most frequent complication was a neuropraxia (7.6%), usually affecting a frontal nerve branch, and always temporary. Two deep venous thromboses were detected by ultrasound surveillance. No significant correlation was detected between complications and age, sex, body mass index, smoking history, or a previous facelift. Sixteen patients (7%) returned for a secondary facelift (mean interval, 3.5 years).Conclusions:A sub-SMAS facelift and triple-vector platysmaplasty with fat injection combine effective neckline rejuvenation with facial volume restoration. Avoiding a temporal incision eliminates a telltale scar. Orbicularis preservation avoids additional dissection, possibly reducing the risk of neuropraxia. Fat injection provides a net increase in facial volume. Long-term measurement studies are recommended.

Anatomic Study of Ophthalmic Artery Embolism Following Cosmetic Injection

Cosmetic injections of dermal fillers or fat could cause ophthalmic artery embolism and even blindness, the high-risk regions of which are considered glabellar, nasal dorsum, and nasolabial fold. Understanding anatomy of the related arteries is important for a physician to safely perform filler injections. To investigate the mechanisms of ophthalmic artery embolism following the injections, cadaver anatomy was studied. Ophthalmic artery, facial artery, their branches, and anastomoses among them were anatomized in 12 fresh cadavers. Mimetic injections of hyaluronic acid were performed in glabellar region, nasal dorsum, and nasolabial fold, the relationships between injected filler and related arteries were then investigated. It was clearly found that 4 arteries were located in common injection regions and connected to ophthalmic artery: supratrochlear artery, supraorbital artery, dorsal nasal artery, and angular artery. In the glabellar region, the deep injection on the periosteum will be risky to injure supratrochlear artery and supraorbital artery, whereas in nasal dorsum and nasolabial fold, the sub- superficial musculo aponeurotic system layer injection has the possibility to injure dorsal nasal artery, angular artery, and facial artery. The anatomic mechanism of ophthalmic artery embolism is the anastomoses among the related arteries and ophthalmic artery. Based on the findings of the study, injections in periosteum layer at glabellar region or sub-superficial musculo aponeurotic system layer of nasal dorsum and nasolabial fold are not advised.

The Staged Face Lift

Although early secondary face lift is a highly scrutinized procedure, it is beneficial for a select group of patients. Justification for performing the early secondary face lift or staged face lift is more apparent when considering the biomechanical limitations of the primary face lift. All patients undergoing primary face-lift procedures performed by the senior author (T.A.M.) between 1998 and 2008 were followed for 2 years to determine which patients would benefit from an early secondary rhytidectomy. Early secondary face lifts were performed in the same sub-superficial musculoaponeurotic system plane as the primary procedure and entailed full undermining. Forty-seven of 742 patients (6.3 percent) undergoing a primary face-lift procedure underwent an early secondary rhytidectomy. Identified limiting factors of the primary face lift included suture-tearing force, viscoelastic properties (tissue creep and stress relaxation), blood supply, and an attempt to avoid an overly pulled appearance. Indications for early secondary rhytidectomy included early symptoms of recurrence or residual age-related changes in patients with severe preoperative laxity or poor soft-tissue elasticity and mainly involved the perioral region. There were no significant complications and there was high patient satisfaction in all cases. With thorough understanding of the viscoelastic properties of facial tissues and proper consultation with patients, the early secondary face lift can be used as a safe and effective option with which to address the limitations of a primary face lift. Therapeutic, IV.

A Complete Subperichondrial Dissection Technique for Rhinoplasty With Management of the Nasal Ligaments

A complete subperichondrial and subperiosteal dissection technique during rhinoplasty may minimize soft tissue disruption, resulting in less scar tissue formation and preservation of ligamentous structures. The authors describe their results with subperichondrial dissection of the nasal framework and manipulation of the preserved nasal ligaments. The charts of 228 consecutive patients who underwent rhinoplasty with complete subperichondrial dissection via an open or closed approach between May 2008 and April 2011 with the senior author (BÇ) were retrospectively reviewed. Intraoperatively, the scroll ligament and Pitanguy's midline ligament were repaired to stabilize the internal valve and tip position, respectively. Patients in this series (182 women, 46 men) ranged in age from 18 to 54 years (mean, 24.3 years). A total of 203 procedures were primary rhinoplasties; 14 were secondary, and 11 were revisions. The open approach was used in 92 patients, whereas a closed dome delivery was used in the remaining 136 patients. Follow-up ranged from 9 months to 3 years. A complete subperichondrial dissection technique resulted in relatively limited edema and more rapid patient recovery compared with the authors' previous experience with the sub-superficial musculoaponeurotic system (SMAS) approach. Repeat elevation in the subperichondrial plane was easier and less traumatic in revision cases compared with secondary rhinoplasty cases. Subperichondrial dissection of the nasal framework allows reshaping and redraping of the nasal tip and controlled manipulation and repair of ligaments without disturbing the overlying soft tissue.