This chapter marks the third major writing I have done for Elsevier over the past decade on facelift surgery. Although there is some overlap with previous writings (especially the inclusion of excellent drawings or images), I have continually enriched the content of the chapters with new discussion, pictures, and innovations to remain contemporary.
My own journey with facelift surgery has changed over the past decade as I continually research different techniques, approaches, and treatments for safe surgery with predictable outcomes. Because of this, there is always new content. For instance, in previous chapters I did not advocate the use of post-facelift drains, but having done almost a hundred cases using them, I feel they definitely expedited healing and reduced complications. My point is that dogma should be avoided and progress reported.
At the time of writing, I have performed 1000+ facelifts, with the following statistics:
29% had simultaneous full-face CO 2 laser skin resurfacing
I am proud of this number and I have charts, operation reports, and before-and-after pictures for every single patient to back up this statement. Of these 1000+ facelifts, 98% were traditional comprehensive facelifts with midline platysmaplasty and preauricular and postauricular flaps averaging 7 to 8 cm of circumferential dissection. In other words, large facelifts; 2% were short scar lifts. I have done every inch and every stich by myself. I have attempted to analyze and reanalyze every step. In a single chapter, it is impossible to cover all areas of facelift surgery, and that single topic could easily fill this entire text. My goal with this chapter is to convey the techniques that have proven to be safe and effective in the 1000+ facelifts. This does not mean that “my way” is the only way to do it or that it cannot be done better. My goal with this chapter lies in my slogan: Always be a teacher, always be a student .
Facelift surgery and anatomy are inseparable and great surgeons are great anatomists. Facial anatomic expertise is imperative to performing competent facelift surgery and avoiding complications. The best way to discuss anatomy is to consider the progressive layers encountered during the procedure from skin to bone ( Fig. 5.1 ).
Layers of the face:
Layer 1: Skin
Layer 2: Subcutaneous
Layer 3: Musculoaponeurotic
Layer 4: Areolar plane
Layer 5: Deep fascia and periosteum
The first layer concerned in facelift anatomy is the skin. Facial skin varies in thickness, being thinnest in the eyelids and thickest on the nasal tip and forehead. The dermal plexus of blood vessels nourishes the skin (and facelift flap) and must at all times be respected. The handling of lipocutaneous flaps in cosmetic facial surgery should be as gentle as other procedures in which the vascularity of the flap is essential to its survival. During facelift dissection, several millimeters of fat is left adherent to the dermal undersurface to protect this area and enhance flap viability. A general rule is that there should be fat on both sides of the facelift flap.
The next layer is the subcutaneous layer. This is the layer between the dermis and the superficial muscular aponeurotic system (SMAS). The subcutaneous layer is basically a safe layer in the face and can be undermined in the subcutaneous plane without damage to significant anatomic structures. This layer is of varying thickness depending upon the location and patient. The subcutaneous layer is plentiful in the cheeks and anterior neck but is extremely thin in the postauricular mastoid region. Very mobile structures such as the lips and eyelids have very little subcutaneous fat. Connective tissue fibers known as “retinacular cutis” originate at the periosteum and travel through the deep layers to terminate in the dermis. The subcutaneous layer becomes thickened over the malar region, where dissection can be tenuous. This tissue is attached to the malar periosteum by retaining ligaments that run from the underlying periosteum through the malar pad and insert into the dermis. This area is very tenacious, and because of its fibrous nature provides resistance when dissecting; it is referred to as McGregor’s patch . Brisk bleeding is also frequently seen in the area because of accompanying vasculature. The thickest layer of subcutaneous fat underlies the nasolabial folds.
The third layer is the superficial muscular aponeurotic system (SMAS) layer. This layer separates the overlying subcutaneous fat from the underlying parotidomasseteric fascia, facial nerve branches, and envelopes the facial mimetic muscles ( Fig. 5.2 ).
The superficial fascia is formed (from scalp to neck) by:
The galea aponeurotica (which splits to envelope the frontalis and occipitalis).
The superficial temporal fascia (also called “temporoparietal fascia”).
The superficial facial fascia in the cheek region (which splits to envelope the midface mimetic muscles).
The superficial cervical fascia (which splits to envelope the platysma).
This is a less defined layer containing facial spaces, retaining ligaments, and the facial nerve branches.
This consists of the deep fascia of the face and neck, and the periosteum over bone.
The deep layer of fascia is formed by:
The deep temporal fascia and the periosteum. Below this layer lie the muscles of mastication, the salivary glands and principal neurovascular structures. Over bony structures such as zygoma and cranium, this layer is indistinguishable from periosteum.
The deep facial fascia (parotidomasseteric fascia).
The deep cervical fascia.
The deep layer of the temporalis fascia is intimate to the temporalis muscle and is often referred to as the “superficial layer of deep temporal fascia.” This layer splits at the zygomatic arch, and the second layer is referred to as the “deep layer of the deep temporal fascia.” Some surgeons mistakenly call the fascia on the inferior side of the temporalis muscle the “deep layer of deep temporalis fascia.” This is not the case, and as stated in the previous sentence, the “deep layer of the deep temporalis fascia” occurs after the split on the arch.
The Superficial Muscular Aponeurotic System
Knowing about all of the above layers is essential to understand and safely perform facelift surgery. Although each layer is complex in its own right, the SMAS is the most controversial layer and its nomenclature is used correctly and incorrectly by surgeons and authors alike. The SMAS layer in the cheek, as described by many leading authors, is said to be continuous with the galea in the scalp, the temporoparietal fascia in the temples, and the superior cervical fascia in the neck. This structure was initially described by Mitz and Peyronie (1976) as muscular and fibrous tissue and termed the “superficial musculoaponeurotic system.” They stated the SMAS exists in the parotid and cheek regions and invests the muscles of facial expression. In their original article, the authors state, “To us, the SMAS appears to be a fibromuscular network located between the facial muscles and the dermis, one which covers the facial motor nerves.” They note that the SMAS separates two layers of fat in the face into superficial and deep layers. Their work also implied that the SMAS was continuous with the platysma.
Various authors contest Mitz and Peyronie’s finite description of the SMAS and related layers, and some surgeons do not agree that there is any such thing as the SMAS at all. Jost and Levet (1984) refuted the work of Mitz and Peyronie and disputed their findings. In their study, the authors combine embryology and comparative anatomy of other mammals as well as cadaver dissections and summarize that the SMAS as described previously was incorrect. These authors describe the SMAS as a double-layered system. The first layer is the superficial system, which is consistent with primitive platysma and includes parotid fascia and has no direct bone insertion. In addition, they state that a deep system exists, which includes the sphincter coli profundus. This group of muscles in the perioral region does possess bony attachments. These authors also contradict Mitz and Peyronie and state that the SMAS is not continuous with the platysma, but rather it is the parotid fascia that is continuous with the platysma. In addition, they comment that the parotid fascia is the uppermost part of the primitive platysma, which is a muscle that has undergone fibrous degeneration. Applying this to facelift surgery, these authors suggest dissection deep to the parotid fascia.
In an additional article denying that the SMAS exists as originally described, Gardetto et al. (2002) state that according to the work of Mitz and Peyronie, “no SMAS exists in any of the described regions that agrees with the basic criteria of Mitz and Peyronie.” This article corroborates through comparative anatomy and fresh cadaver dissection studies that the “SMAS does exist in the parotid region, where it is thick but becomes very thin and discontinuous in the cheek where it is impossible to identify or dissect it, even with microsurgical technique.” They further state that “there is no evidence of continuity of the SMAS and the temporal fascia but in contrast, in the lower eyelid, there is continuity with the lateral portion or the orbicularis oculi muscle.”
Most surgeons will agree it separates the subcutaneous fat from the underlying parotidomasseteric fascia. When a surgeon states that they pick up the SMAS, in reality they are picking up the subcutaneous adipose tissue and connective (aponeurotic) tissue above the parotidomasseteric fascia. This is what is frequently plicated, excised, imbricated, and otherwise managed in facelift surgery. Whether you agree or disagree with concepts about the embryology and histology, the remainder of this text will refer to the “SMAS” as the tissue between the dermis and parotidomasseteric fascia. The subcutaneous tissue and SMAS may be histologically and microscopically separate layers, but in actual surgery they are picked up, cut, pulled, and sewn as a single layer. Again, this text will consider the SMAS to be closely associated with the deep portion of the subcutaneous fat and superficial to the parotidomasseteric fascia. Fig. 5.3 shows the successive layers encountered in facelift surgery.