a systematic approach to facelifts

A Systematic A Systematic Approach to FaceliftsApproach to Facelifts

When to do a facelift, When to do a facelift, minituck or a S-liftminituck or a S-lift

M. Sean Freeman, MDM. Sean Freeman, MD

The Center For FacialThe Center For FacialPlastic andPlastic and

Laser SurgeryLaser Surgery

Fall Meeting, AAFPRSFall Meeting, AAFPRS

RhytidectomyRhytidectomy How to determine approach offered to How to determine approach offered to

patientpatient– Options Options

S-lift (thread lift), minituck (with deep plane lift S-lift (thread lift), minituck (with deep plane lift of jowl area), three layer facelift (also called of jowl area), three layer facelift (also called composite lift – deep plane lift), three layer composite lift – deep plane lift), three layer facelift with SMG shavefacelift with SMG shave

RhytidectomyRhytidectomy Three layer facelift (with or without Three layer facelift (with or without

SMG shave)SMG shave)– Patient with one or more of these findings Patient with one or more of these findings

in the neckin the neck Excess fatExcess fat Significant skin excess Significant skin excess Platysmal banding or inferior laxityPlatysmal banding or inferior laxity Ptosis of SMGPtosis of SMG

RhytidectomyRhytidectomy Minituck (with deep plane lift of jowl Minituck (with deep plane lift of jowl

area)area)– Applicable to a patient with one or more of Applicable to a patient with one or more of

the followingthe following Minimal to moderate neck laxity involving Minimal to moderate neck laxity involving

mainly skinmainly skin Moderate to severe laxity of the jowlModerate to severe laxity of the jowl Mid-face ptosisMid-face ptosis Extended melolabial foldsExtended melolabial folds

RhytidectomyRhytidectomy S-liftS-lift

– Useful in a patient with one or more of the Useful in a patient with one or more of the following findingsfollowing findings

Mild jowlingMild jowling Mild neck laxityMild neck laxity

– Does not help mid-face laxity Does not help mid-face laxity Consider a thread liftConsider a thread lift

RhytidectomyRhytidectomy Now that we have an appreciation for Now that we have an appreciation for

the why of these approaches let’s look the why of these approaches let’s look into the howinto the how– Three layer facelift (with or without SMG Three layer facelift (with or without SMG

shave)shave)– MinituckMinituck– S-liftS-lift

RhytidectomyRhytidectomy What is the correct plane for the midface and What is the correct plane for the midface and

jowl?jowl?– Wide subcutaneous with SMAS plicationWide subcutaneous with SMAS plication– Wide subcutaneous followed by SMAS dissectionWide subcutaneous followed by SMAS dissection– Limited subcutaneous dissection along with sub-Limited subcutaneous dissection along with sub-

SMAS dissection into the midface, jowl and SMAS dissection into the midface, jowl and connected to sub-platysmal flapconnected to sub-platysmal flap

– SubperiostealSubperiosteal

RhytidectomyRhytidectomy Wide subcutaneous undermining for midface Wide subcutaneous undermining for midface

and jowland jowl– Useful in patients whose primary concern is Useful in patients whose primary concern is

improvement in their acne scarringimprovement in their acne scarring Breaks the fibrous connection between the base of the Breaks the fibrous connection between the base of the

acne scar and the SMASacne scar and the SMAS– Depressed scars are improvedDepressed scars are improved

This procedure should be followed by skin resurfacing This procedure should be followed by skin resurfacing two to three months latertwo to three months later

RhytidectomyRhytidectomy SMAS for midface and jowlsSMAS for midface and jowls

– System connects to the superficial temporal fascia, System connects to the superficial temporal fascia, galea, frontalis muscle, superficial cervical fascia galea, frontalis muscle, superficial cervical fascia and the platysmaand the platysma

– System invests the superficial muscles of facial System invests the superficial muscles of facial expressionexpression

platysma, orbicularis oculi, zygomaticus major and platysma, orbicularis oculi, zygomaticus major and minor and risoriusminor and risorius

RhytidectomyRhytidectomy

SMAS for midface and jowlsSMAS for midface and jowls– System connects to the superficial temporal fascia, System connects to the superficial temporal fascia,

galea, frontalis muscle, superficial cervical fascia galea, frontalis muscle, superficial cervical fascia and the platysmaand the platysma

– System invests the superficial muscles of facial System invests the superficial muscles of facial expressionexpression

platysma, orbicularis oculi, zygomaticus major and platysma, orbicularis oculi, zygomaticus major and minor and risoriusminor and risorius

RhytidectomyRhytidectomy SMAS connections pertinent to rhytidectomySMAS connections pertinent to rhytidectomy

– Fascial fiber connections between the superficial muscles of Fascial fiber connections between the superficial muscles of facial expression and the nasolabial foldfacial expression and the nasolabial fold

– Retaining ligaments: anchoring points from the underlying Retaining ligaments: anchoring points from the underlying bone to the dermisbone to the dermis

Zygomatic ligamentsZygomatic ligaments mandibular ligamentsmandibular ligaments

– Fibrous septa connecting the parotid-masseteric fascia, Fibrous septa connecting the parotid-masseteric fascia, SMAS and the dermis in the parotid and the anterior SMAS and the dermis in the parotid and the anterior border of the masseterborder of the masseter


SMAS connections pertinent to rhytidectomySMAS connections pertinent to rhytidectomy– Fascial fiber connections between the superficial Fascial fiber connections between the superficial

muscles of facial expression and the nasolabial foldmuscles of facial expression and the nasolabial fold– Retaining ligaments: anchoring points from the Retaining ligaments: anchoring points from the

underlying bone to the dermisunderlying bone to the dermis zygomatic ligamentszygomatic ligaments mandibular ligamentsmandibular ligaments

– Fibrous septa connecting the parotid-masseteric Fibrous septa connecting the parotid-masseteric fascia, SMAS and the dermis in the parotid and the fascia, SMAS and the dermis in the parotid and the anterior border of the masseteranterior border of the masseter


SMAS connections pertinent to rhytidectomySMAS connections pertinent to rhytidectomy– Fascial fiber connections between the superficial Fascial fiber connections between the superficial

muscles of facial expression and the nasolabial foldmuscles of facial expression and the nasolabial fold– Retaining ligaments: anchoring points from the Retaining ligaments: anchoring points from the

underlying bone to the dermisunderlying bone to the dermis– Fibrous septa connecting the parotid-masseteric Fibrous septa connecting the parotid-masseteric

fascia, SMAS and the dermis in the parotid fascia, SMAS and the dermis in the parotid (parotid cutaneous ligament) and the anterior (parotid cutaneous ligament) and the anterior border of the masseter (masseteric cutaneous border of the masseter (masseteric cutaneous ligament)ligament)

RhytidectomyRhytidectomy Importance of SMAS in relation to agingImportance of SMAS in relation to aging

– Fascial fiber connections between the superficial Fascial fiber connections between the superficial muscles of facial expression, the SMAS and the muscles of facial expression, the SMAS and the dermis at the level of the nasolabial fold trap the dermis at the level of the nasolabial fold trap the migration of the malar fat pad over time thus migration of the malar fat pad over time thus deepening this folddeepening this fold

– Over time, midface fibro-fatty tissue is displaced Over time, midface fibro-fatty tissue is displaced above the level of the SMAS and then trapped by the above the level of the SMAS and then trapped by the SMAS connections at the nasolabial foldSMAS connections at the nasolabial fold

RhytidectomyRhytidectomy Importance of SMAS in relation to agingImportance of SMAS in relation to aging

– Jowling is caused by relaxation of the parotid-Jowling is caused by relaxation of the parotid-masseteric fascia with prolapse of the fat pad of masseteric fascia with prolapse of the fat pad of BichatBichat

SMAS is relatively thin over this areaSMAS is relatively thin over this area– Jowling is caused by redundant skin which is Jowling is caused by redundant skin which is

bounded by the mandibular ligament at its medial bounded by the mandibular ligament at its medial borderborder

RhytidectomyRhytidectomy Subperiosteal approach for the midfaceSubperiosteal approach for the midface

– The periosteum does not relax with timeThe periosteum does not relax with time– Pulling up on the periosteum in the midface lifts Pulling up on the periosteum in the midface lifts

the superficial muscles of facial expression which the superficial muscles of facial expression which will result in pulling in the fascial fiber connections will result in pulling in the fascial fiber connections between these muscles and the nasolabial foldbetween these muscles and the nasolabial fold

Net effect on the depth of the fold is negligibleNet effect on the depth of the fold is negligible

RhytidectomyRhytidectomy Subperiosteal approach for the jowl and Subperiosteal approach for the jowl and

neck laxityneck laxity– Jowl area can be improved if the fat pad of Bichat Jowl area can be improved if the fat pad of Bichat

is elevated by suture suspending the pad to the is elevated by suture suspending the pad to the intermediate fascia over the deep temporal fasciaintermediate fascia over the deep temporal fascia

– Minimal to no improvement in the neck area unless Minimal to no improvement in the neck area unless a posterior neck lift is added to the procedurea posterior neck lift is added to the procedure

RhytidectomyRhytidectomy What is the best plane in the midface?What is the best plane in the midface?

– Between the investing SMAS of the superficial Between the investing SMAS of the superficial muscles of facial expression and the overlying muscles of facial expression and the overlying malar fat padmalar fat pad

Allows repositioning of the malar fat padAllows repositioning of the malar fat pad– Zygomatic-cutaneous ligaments must be released to get a good Zygomatic-cutaneous ligaments must be released to get a good

liftlift Allows lifting of the zygomaticus major muscle to Allows lifting of the zygomaticus major muscle to

improve a down turned corner of the mouthimprove a down turned corner of the mouth– Care must be taken to avoid injury to the underlying buccal Care must be taken to avoid injury to the underlying buccal

nerve branchesnerve branches

Endoscopic view of head ofzygomaticus major

Endoscopic view showing divisionof zygomatic-cutaneous ligament

RhytidectomyRhytidectomy What is the best plane for improving the jowl What is the best plane for improving the jowl

area?area?– Splitting the parotid-masseteric fascia with division of the Splitting the parotid-masseteric fascia with division of the

masseteric cutaneous ligamentsmasseteric cutaneous ligaments Allows tightening of this area without pulling on the corner of the Allows tightening of this area without pulling on the corner of the

mouth while putting tension on the parotid-masseteric fascia of mouth while putting tension on the parotid-masseteric fascia of sufficient amount to reduce the prolapsed fat pad of Bichatsufficient amount to reduce the prolapsed fat pad of Bichat

– At times fat must be removed via an intraoral approach At times fat must be removed via an intraoral approach Care must be taken to avoid injury to the facial nerve branches Care must be taken to avoid injury to the facial nerve branches

over the masseter muscleover the masseter muscle

RhytidectomyRhytidectomy What is the correct plane for the neck?What is the correct plane for the neck?

– SubcutaneousSubcutaneous– Subcutaneous then beneath the platysmaSubcutaneous then beneath the platysma– Subcutaneous and beneath the platysmaSubcutaneous and beneath the platysma

RhytidectomyRhytidectomy What should be done with the What should be done with the

platysma?platysma?– Divide horizontally along its inferior borderDivide horizontally along its inferior border– Pull the lateral borderPull the lateral border– Suture the medial borderSuture the medial border– A combination of aboveA combination of above

RhytidectomyRhytidectomy Approach to the neckApproach to the neck

– Wide subcutaneous underminingWide subcutaneous undermining Sharp lipectomy performed when indicatedSharp lipectomy performed when indicated

– Limited dissection of medial and lateral borders of Limited dissection of medial and lateral borders of platysmaplatysma

– Suture suspension of lateral border to Suture suspension of lateral border to occipitomastoid fascia along break point of neckoccipitomastoid fascia along break point of neck


– Wide subcutaneous underminingWide subcutaneous undermining Sharp lipectomy performed when indicatedSharp lipectomy performed when indicated

– Limited dissection of medial and lateral borders of Limited dissection of medial and lateral borders of platysmaplatysma

– Suture suspension of lateral border to Suture suspension of lateral border to occipitomastoid fascia along break point of neckoccipitomastoid fascia along break point of neck

Mark break point at beginning of the case with patient Mark break point at beginning of the case with patient in the sitting positionin the sitting position


– Following sharp fat lipectomy, the medial border Following sharp fat lipectomy, the medial border of the platysma is drawn together of the platysma is drawn together

For patients with a short neck and small chin who agree For patients with a short neck and small chin who agree to a chin implant the platysma is released from the hyoid to a chin implant the platysma is released from the hyoid and the medial edges are plicatedand the medial edges are plicated

Patients who have banding of the platysma, their bands Patients who have banding of the platysma, their bands are excised and then the platysma is released from the are excised and then the platysma is released from the hyoid and the medial edges are plicatedhyoid and the medial edges are plicated

RhytidectomyRhytidectomy There is There is notnot one correct plane for all three one correct plane for all three

areas of the faceareas of the face– On top of SMAS investing the superficial muscles of facial On top of SMAS investing the superficial muscles of facial

expression for the midfaceexpression for the midface– Deep to the SMAS, elevating and splitting the parotid-Deep to the SMAS, elevating and splitting the parotid-

masseteric fascia so as to elevate the fat pad of Bichatmasseteric fascia so as to elevate the fat pad of Bichat– Both on top and deep to the platysma to independently Both on top and deep to the platysma to independently

tighten the platysma, like a hammock for the neck, and tighten the platysma, like a hammock for the neck, and then the skin on topthen the skin on top

Management of SMG PtosisManagement of SMG Ptosis ProblemProblem

– Patient wishes improvement in neck line Patient wishes improvement in neck line but facial cosmetic surgeon notes soft but facial cosmetic surgeon notes soft tissue fullness in the digastric triangle of tissue fullness in the digastric triangle of neck due to SMG ptosisneck due to SMG ptosis

Management of SMG PtosisManagement of SMG Ptosis In the past standard procedures have failed In the past standard procedures have failed

to address this problem adequatelyto address this problem adequately

Management of SMG PtosisManagement of SMG Ptosis SolutionSolution

– Caudal resection a portion of the SMG via a Caudal resection a portion of the SMG via a submental incisionsubmental incision

Important considerationsImportant considerations– RisksRisks

Knowledge of pertinent anatomyKnowledge of pertinent anatomy SeromaSeroma

– Patient selectionPatient selection Commonly seen in patients with a small chinCommonly seen in patients with a small chin

Management of SMG PtosisManagement of SMG Ptosis Pertinent anatomy of digastric trianglePertinent anatomy of digastric triangle

– Boundaries: the two bellies of digastric, the Boundaries: the two bellies of digastric, the lower border of the mandiblelower border of the mandible

– Floor: mylohyoid, hypoglossal, middle Floor: mylohyoid, hypoglossal, middle constrictorconstrictor

– Ceiling: platysma, marginal mandibular nerveCeiling: platysma, marginal mandibular nerve– Contents: SMG gland, facial artery and vein Contents: SMG gland, facial artery and vein

and hypoglossal nerveand hypoglossal nerve

4

Parotid gland

External jugular veinSMG

Anterior jugular vein

View with platysma removed

Facial arteryFacial vein

Marginal mandibular nerveSMG

Anatomy with SMG removed

Mandible

Anterior and posterior digastric

Hyoid

Digastric,anteriorbelly

Facial arteryFacial veinMarginal mandibular nerve

SMG

MinituckMinituck Minituck Minituck

– Same steps as regular facelift in mid-face Same steps as regular facelift in mid-face and jowl areaand jowl area

– Lift lateral Platysma onlyLift lateral Platysma only

S-liftS-lift Limited incision around earLimited incision around ear Estimation of amount of excess skin Estimation of amount of excess skin

that can be removedthat can be removed Corresponding SMAS excision and lifting Corresponding SMAS excision and lifting

of SMASof SMAS Two layer closureTwo layer closure

a systematic approach to facelifts

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