Section 3: Facelift
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Facelift anatomy, SMAS,
retaining ligaments and
facial spaces
Bryan Mendelson
Anatomically correct facial rejuvenation surgery is the basis
for obtaining natural appearing and lasting results. The com-
plexity of the anatomy of the face, and especially that of the
midcheek, accounts for the formidable reputation of facial
surgery. This is to the extent that many surgeons design their
rejuvenation procedures around an avoidance of anatomical
structures, and thereby limit the intent to camouflaging of the
aging changes.
The purpose of this chapter is to establish a foundation for
the advancement of facial rejuvenation surgery by defining
clear general principles as the basis for a sound conceptualiza-
tion of the facial structure.
A proper anatomical understanding is fundamental to
mastery in facial rejuvenation for several reasons. The patho-
genesis of facial aging is explained on an anatomical basis,
and particularly the variations in individual patients. This is
the basis of preoperative assessment from which follows a
rational plan for the correction of the changes. The anatomy
explains the differences between the many procedures avail-
able and the apparent similarities in their results. An accurate
intraoperative map of the anatomy is essential for the surgeon
for efficient and safe operating with minimal morbidity, and
specifically addressing appropriate concern for the facial
nerve.
Functional evolution of the face
The anatomy of the face is more readily understood when
considered from the perspective of its evolution and the func-
tion of its components (Fig. 6.1). Located at the front of the
head, the face provides the mouth and masticatory apparatus
at the entrance to the embryonic foregut, as well as being the
location for the receptor organs of the special senses: eyes,
nose and ears. The skeleton of the face incorporates a bony
cavity for each of these four structures. Those for the special
senses have a well-defined bony rim, in contrast to the articu-
lated broad opening of the jaws covered by the oral cavity.
The soft tissues of the face, integral to facial beauty and attrac-
tion, are in reality, dedicated entirely to their functions.
CHAPTER 6
The soft tissue overlying each cavity undergoes modifica-
tions to form the cheeks, including the lips, the eyelids, the
nose, and the ears. For each there is a full thickness penetra-
tion through the soft tissue, around which superficial facial
muscles are located for control of the aperture of the function-
ing shutter. This is most evident for the lids and lips in the
human. While the primary function of the sphincteric shut-
ters is to protect the contents of the cavities, they are further
adapted to a higher level of functioning for the additional
roles of expression and communication. The degree of preci-
sion required for this important secondary function requires
the muscles to be more finely tuned and the soft tissue fixa-
tion modified, to allow mobility. The balance between these
two opposing functions, movement and stability, is integral
to the facial structure. Aging brings with it a change of the
youthful balance, leading to an altered expression on activity
and at rest. It is a major surgical challenge to restore the
youthful balance following rejuvenation surgery and to have
normal dynamic appearance.
Principle
The combination of continued movement and delicate fixation
of the tissues is the basis for the ligamentous laxity that
predisposes to the characteristic sagging changes of the aging
face.
Regions of the face
The traditional approach to the face in thirds (upper, middle
and lower) while useful, limits conceptualization, as it is not
based on the evolving structure. The significant muscles of
facial expression are all located on the front of the face (ante-
rior aspect) predominantly around the eyes and mouth,
where their effect is seen in communication. For these func-
tional reasons the anterior aspect of the face contains the
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Fig. 6.1 Functional evolution of the facial skeleton, from the primordial vertebrate, fish through to the primate chimpanzee (center) and to the human. The
facial skeleton supports four bony cavities whose size and location relate to their specific function. The eyes move to the front for stereoscopic binocular vision,
while the nasal aperture is reduced, due to the lesser importance of olfaction. The ear remains in its original location, at the back of the face. The location of
the orbits alters subsequent to cranial growth, which creates a new upper third of the face.

more delicate expressive areas, which are prone to developing
aging changes (Fig. 6.2).
In contrast, the lateral face is relatively immobile as it pas-
sively overlies the structures to do with mastication, which
are all deep to the investing deep fascia. These are the tem-
poralis and masseter on either side of the zygomatic arch,
along with the parotid and its duct. The only superficial
muscle in the lateral face is the platysma in the lower third,
which reaches no higher than the oral commissure. Inter-
nally, a distinct boundary separates the mobile anterior face
from the lateral face. The vertically oriented line of retaining
ligaments attached to the facial skeleton forms this boundary
(Fig. 6.2).
Principle
while the perioral part overlies the maxilla, a bone of dental
origin. The functional parts are inherently mobile and meet
at the relatively immobile boundary that extends in an oblique
line across the midcheek. This is the midcheek groove formed
by the dermal extensions of the zygomatic ligaments (Fig.
6.3).1
The soft tissue of the anterior face is further subdivided
according to: where it overlies the skeleton and: where it
overlies a bony cavity. The soft tissue is modified where it
forms the lid and the mobile cheek because there is no under-
lying deep fascia. The transitions that define the part of the
cheek overlying bone (the malar segment), and the mobile
extensions (lower lid and the mobile cheek, nasolabial
segment) are not visible in youth due to the shape of the
youthful midcheek, which has a compacted rounded fullness.
Subsequently, these transitions do become visible due to
aging laxity in the midcheek.

The anterior aspect is the region of the face requiring
rejuvenation.
From the perspective of priorities in rejuvenation surgery, the
midcheek is the most important area of the face, because of
its prominent central location between the two facial expres-
sion centers, the eyes and the mouth. The periorbital and the
perioral parts overlap in the midcheek (Fig. 6.2). The perior-
bital part overlies the body and orbital process of the zygoma,
The facial nerve in relation to regions of the face
The level in which the facial nerve branches travel relates to
the region of the face (Fig. 6.4). In the lateral face below the
zygomatic arch the branches remain deep to the investing
deep fascia. In the anterior face (and above the lower border
of the zygoma) the branches are more superficial in relation
to their muscles. The transition in levels occurs at the retain-
ing ligament boundary, which is the last position of stability
before the mobile anterior face. The nerves are protected here
as they course outward to their final destination

54

Layers of the face
The principles of facial structure can be summarized quite
simply:
1. The scalp is the basic prototype for understanding facial
anatomy, as it is the least differentiated part of the face
(Fig. 6.4).
2. The face is constructed of concentric soft tissue layers
over the bony skeleton.
3. The five layers of the scalp are: (i) skin; (ii) subcutaneous;
(iii) musculo-aponeurotic; (iv) areola tissue; (v) deep
fascia.
4. The layers are not homogenous over the face proper, as
they are modified in areas of function.
5. The key areas of function overlie the bony cavities, espe-
cially the eyelids and the cheeks and mouth.
6. A multilinked fibrous support system supports the
dermis to the skeleton (Fig. 6.5). The components of the
system pass through all layers.2
Chapter 6 Facelift anatomy, SMAS, retaining ligaments and facial spaces
Fig. 6.2 Regions of the face. The fixed lateral
face (shaded) overlies the masticatory structures
and is separated from the mobile anterior face by
the vertical line of facial ligaments (red). These
ligaments are, from above: temporal, lateral orbital,
zygomatic, masseteric and mandibular. The muscles
of facial expression are within the anterior face.
The midcheek is split obliquely into two separate
functional parts in relation to the two adjacent
cavities. The periorbital part above, (blue) and the
perioral part below (yellow), share the midcheek and
meet at the midcheek groove (oblique dotted line).
7. At the transition between that over the skeleton to that
overlying the cavities (eyelids and mouth) there is a mod-
ification of the anatomy.
8. The complexity of the facial structure results from the
balance required between mobility and stability (liga-
mentous support).
It should be remembered that the complexity of the facial
structure is entirely due to the bony cavities and their func-
tional requirements. Transitional anatomy occurs at the
boundary of the cavities, as in the scalp where the complexity
of the glabella occurs where the forehead adjoins the orbital
and nasal cavities. Here, the deeper facial muscles and related
retaining ligaments attach to the skeleton.
Details of the layers
Layer one – skin
The structural collagen of the dermis is the outermost part of
the fibrous support system and is intrinsically linked, both
embryologically and structurally, with the collagenous tissue
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of the deeper layers. The thickness of the dermal collagen
relates to its function, and tends to be in inverse proportion to
its mobility. The dermis is thinnest on the eyelids and thickest
on the forehead and nasal tip. The thinner, more mobile dermis
is susceptible to an increased tendency for aging changes.
Layer two – subcutaneous
The subcutaneous layer has two components: (i) the subcu-
taneous fat, which provides volume and mobility, is sup-
ported by (ii) the fibrous retinacular cutis that connects the
dermis with the underlying SMAS. Both components vary in
amount, proportion and arrangement according to the spe-
cific region of the face.
In the scalp, the subcutaneous layer has a uniform thick-
ness and consistency of fixation to the overlying dermis,
whereas, over the face proper, the subcutaneous layer has
considerable variation in thickness and attachment. In the
high function mobile areas bordering an aperture such as the
pretarsal part of the eyelid and the lips, this layer is com-
pacted and subcutaneous fat is not present, so that the layer
appears to be non-existent.
Each of the three midcheek segments has a distinctly dif-
ferent thickness of subcutaneous fat. The subcutaneous layer
is thinnest in the lid–cheek segment adjacent to the lid proper.
In the malar segment the layer is moderately thick and
uniform, whereas it is markedly thicker in the nasolabial
segment, which has the thickest layer of subcutaneous fat of
the face. Where the subcutaneous fat is thicker, the retinacu-
lum fibers are lengthened and more prone to weakness and
56
Fig. 6.3 The internal structure of the midcheek
is revealed by its surface anatomy when aging
changes are present. The two functional parts of
the midcheek relate to the underlying cavities
and are separated by the oblique line of the
midcheek groove (3) which overlies the skeleton.
The midcheek has three segments. The lid–cheek
segment (blue) and the malar segment (green) are
within the periorbital part and are adjacent to the
nasolabial segment (yellow) in the perioral part,
which overlies the vestibule of the oral cavity. The
three grooves defining the boundaries of the three
segments interconnect like the italic letter Y. The
palpebromalar groove (1) overlies the inferolateral
orbital rim and the nasojugal groove (2) overlies the
inferomedial orbital rim, then continues into the
midcheek groove (3). Mendelson BC, Jacobson SR.
Surgical anatomy of the midcheek: facial layers,
spaces, and the midcheek segments Clin Plast Surg
2008;35:395–404.
distension. The thick subcutaneous fat in the nasolabial
segment is named the malar fat pad, which is confusing ter-
minology given that its position is predominately medial to
the prominence of the zygoma in the perioral part of the
midcheek3,4 (Fig. 6.2).
Within the subcutaneous layer, the attachment to the over-
lying dermis is stronger than on its deep surface, due to the
tree-like arrangement of the retinacular cutis fibers (Fig. 6.5).
In superficial, i.e. subdermal, dissection of the subcutaneous
layer, many fine retinacula cutis fibers are encountered. At the
interface with the underlying layer 3, there are fewer, though
larger fibers and less subcutaneous fat, which appears not to
descend fully to the interface where it overlies the superficial
muscles, orbicularis oculi and platysma.
This explains why surgically the subcutaneous layer can be
more easily dissected off the outer surface of the underlying
muscle layer (orbicularis oculi and platysma) than over other
parts of layer 3.
The retinacular fibers are not uniform across the face, but
vary in their orientation and arrangement according to the
region. This variation mirrors the anatomy of the underlying
4th layer. As will be more apparent when the 4th layer is
discussed, the line of retaining ligaments continue vertically
through the subcutaneous layer to form septae, that form
boundaries which compartmentalize between more mobile
areas.5 Accordingly, where the subcutaneous layer overlies
spaces (in the 4th layer) there are no vertically oriented
subcutaneous ligaments extending through. In contrast, the
retinacular fibers overlying the spaces have a predominantly
 Chapter 6 Facelift anatomy, SMAS, retaining ligaments and facial spaces

Fig. 6.4 The layers of the face. The five layers of the scalp are a prototype of facial anatomy and the simpler basis for the more complex structure elsewhere
on the face. Layer 4 is the most changed layer, consisting of alternating spaces and ligaments. The course of the facial nerve changes level at the ligamentous
boundary transition from the lateral to the anterior face. Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek: facial layers, spaces, and the midcheek
segments; Clin in Plast Surg 2008;35:395–404.

Fig. 6.5 The ligaments of the multi-link fibrous support system of the face can be likened to a tree. This system attaches the soft tissues to the facial skeleton;
it links all layers of the face. The retaining ligaments are attached to the periosteum and deep muscle fascia and fan out via a series of branches into and
through the SMAS. In the outer part of the subcutaneous layer, the increased number of progressively finer retinacular cutis fibers securely grasp the dermis.

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horizontal orientation, being in strata-like layers that are less
restrictive to underlying movement.
Clinical correlation The variation in the arrangement of the
retinacular cutis fibers accounts for the variability in ease of
subcutaneous dissection between different parts of the face.
Where the subcutaneous dissection overlies a space and the
retinacular cutis fibers are more horizontal, the subcutaneous
layer tends to separate relatively easily, often with simple
blunt dissection. Where the subcutaneous dissection directly
overlies a facial ligament, the vertical septae are responsible
for a firmer adhesion between the SMAS and the dermis.
Sharp dissection is usually required for release here.
Layer three – musculo-aponeurotic
To fulfill its functional role, the face contains skeletal muscle
within its soft tissue structure. These ‘intrinsic’ muscles of
facial expression are fundamentally different to skeletal
muscles beneath the deep fascia, which move bones, because
they move the soft tissues of which they are a part. All the
muscles of the face are within this layer, enclosed to a varying
degree within a fascial covering and lining. The muscles are
all derived from the embryonic second branchial arch. The
muscle precursors migrated into the facial soft tissues in a
series of laminae, each lamina being innervated by its own
branch of the facial nerve. While the definitive muscles have
subsequently lost continuity with their origin, the facial nerve
branches remain, like the vapor trail of an airplane, as an
indicator of the migratory path.
In the anterior face, the migrated muscle masses are mainly
located over and around the orbital and oral cavities. The
double innervation of corrugator supercilii demonstrates the
dual origins of the muscle from the supraorbital as well as
the infraorbital migrating muscle mass.

Occipital
lamina

Cervical Infraorbital
lamina lamina

9 weeks

10 weeks

11 weeks

Fig. 6.6 Evolution of the facial muscles. The migratory path of the evolving muscles, including their connections and the multiple levels of the muscles,
explain the definitive location of the facial nerve branches. The mandibular lamina splits into two trunks around the oral cavity. The upper trunk, the infraorbital
lamina separates early for the developing midcheek while the mandibular lamina continues into the lower third. The two laminae later reconnect at the
modiolus, which explains the two buccal trunks of the facial nerve. The infraorbital lamina in turn splits around the orbital cavity as well as branching to
different depth levels.

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In the prototype scalp, the third layer demonstrates key
principles about the facial muscles. The superficial muscle,
occipito-frontalis, moves the overlying soft tissues including
the skin of the scalp and forehead. While the muscles have a
minimal area of bony origin, which is remote (on the supe-
rior nuchal line), they have an extensive area of insertion into
the overlying soft tissues.
The fibrous sheath enclosing the frontalis and occipitalis
is continuous across the entire scalp, whereas the enclosed
muscles are discontinuous. Where the fascia is present without
intervening muscle, the superficial and deep layers of the
sheath are apposed and fused to form the galea aponeuro-
tica. This is the basis for the aponeurotic part of the 3rd layer.
The superficial fascial layer is thin where it overlies the muscle,
and in areas such as over the forehead, muscle fibers extend
into the subcutaneous layer. In contrast, the deep layer of the
fascia is thicker, more supporting and provides a gliding
surface at the interface with the underlying 4th layer. The
original description of the SMAS (superficial muscloaponeu-
rotic system) in 1976 was essentially a description of this 3rd
layer, as is applies to the mid and lower thirds of the face.6
The flat superficial muscle component predominates in some
areas of layer 3, while in areas without muscle the aponeu-
rotic element predominates.
When a scalp flap is elevated, the flap naturally separates
from the periosteum following release of minimal attach-
ments in layer 4. A scalp flap, being a natural fusion of the
outer three layers, is a composite unit, both anatomically and
functionally. The fibrous component of the outer three layers
is the superficial fascia of the face. The SMAS is the deepest
of the three layers of the composite unit. In the mid and lower
face the composite structure is also present, although less
obviously apparent.
Principle
A composite flap is a naturally integrated anatomical structure.
Layer 3 is a continuous generic layer of the face, which for
descriptive purposes has different names to locate the particu-
lar part of the superficial fascia. Galea is the name of the scalp
part and temporoparietal fascia where this layer extends over
the temple, whereas over the orbital rim and upper cheek it
is the orbicularis muscle and its fascia.
The definitive muscles in level 3 have a layered arrange-
ment. The broad flat muscles form the superficial layer that
covers the anterior aspect of the face: frontalis overlies the
upper third and orbicularis oculi the middle third. The pla-
tysma, over the lower third extends onto the lateral face,
presumably related to jaw movement, which functionally
dominates the lower third. The superficial muscles are more
closely related to the overlying subcutaneous layer than they
are to the deeper structures. The superficial flat muscles have
a minimal direct attachment to the bone. They are indirectly
stabilized to the skeleton by a ligament, located at the lateral
border of the muscles. The frontalis is fixed by the superior
Chapter 6 Facelift anatomy, SMAS, retaining ligaments and facial spaces
temporal ligament along the superior temporal line, the
orbicularis oculi is stabilized by the main zygomatic liga-
ment at its inferolateral border and the platysma is stabilized
at its upper border by the upper key masseteric ligament
(Fig. 6.15).
The composite three-layer structure of the face suggests it
would be no less logical to use the SMAS as a ‘surgical carrier’
for the overlying soft tissue layers, than it is with a scalp
flap.
The deeper muscles within layer 3 are concentrated only in
areas of greater function, which is to do with the bony cavities.
For the upper third they are corrugator supercilii and procerus.
Around the oral cavity, the deeper muscles are the elevators
(zygomaticus major and minor, levator labii superioris, levator
anguli oris) and depressors (depressor anguli oris, depressor
labii inferioris) of the oral sphincter. Compared to the super-
ficial muscles, the deep muscles arise from a relatively larger
origin on the skeleton close to the target soft tissue and have
a short course through layer 4 to a more focused area of inser-
tion. Interestingly, the deeper intrinsic muscles of the eyelids,
the levator and capsulopalpebral fascia arise not from these
facial muscles, but have an orbital origin.
Layer four
In the scalp, layer 4 is a gliding plane, without structure, other
than the loose areolar tissue that allows movement of the
overlying composite superficial fascia secondary to contrac-
tion of occipito-frontalis. There are no structures traversing
the layer and impeding movement. However, where the scalp
is attached at its boundary with the temple along the superior
temporal line and across the superior orbital rim there is a
form of ligamentous attachment. This anatomical arrange-
ment illustrates the basic pattern of layer 4.
In the scalp the anatomy of the fourth layer is so inherently
simple and safe for surgery that a subgaleal scalp flap is the
easiest and most natural layer in which to dissect. In contrast,
layer 4 over the face proper, is the most complex and most
dangerous level to dissect. This complexity results from the
compaction of the midcheek components during vertebrate
evolution, such that the cavities and the structures to do with
their dynamic activity are in such close approximation that
they overlap. In addition, layer 4 is the battleground in which
the fight between mobility and stability is played out.
The following structures are contained within layer 4, but
each is distributed in different areas:
1. Retaining ligaments of the face.
2. The deep layer of the intrinsic muscles.
3. Soft tissue spaces.
4. Non-mobile areas of important anatomy.
5. Facial nerve branches.
The complexity of the anatomy within layer 4 becomes
simplified when it is understood how these structures are
arranged. The following principles assist with this
understanding:
• Overlying the skeleton, layer 4 is essentially composed of
a series of ‘spaces’ and non-mobile areas of important
anatomy.
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• The spaces are mobile functional areas. Each space has a

definite boundary and minimal fixation.
• The boundaries tend to be the least mobile part of the soft
tissue.
• The retaining ligaments are located within and reinforce
the boundaries that separate the different functional
areas.
• The intrinsic muscles of the deeper layer attach to the
bone within the boundaries.
• Superficially, the muscles insert into the mobile soft tissues
in layer 3, in the area of maximum mobility.
• All the deep muscles of clinical significance attach to the
bony border of the oral cavity.
• The retaining ligaments and muscle origins share a bony
origin at the boundary.
• A line of ligamentous attachment continues around the
perimeter of the bony cavities.
Principle
The five-layered soft tissue anatomy should be considered in
its two variants:
1. that overlying the skeleton, and
2. that overlying the bony cavities.
To allow physical movement of the soft tissue over the rigid
skeleton subsequent to contraction of the superficial muscles,
the soft tissue of the face incorporates a unique anatomical
arrangement in the form of a series of spaces. Movement is
possible only because of the presence of spaces beneath the
muscles. The spaces are located between places of fixation.
The facial spaces are in two forms:

Fig. 6.7 Relationship between muscles and underlying spaces. Movement occurs where there is muscle in layer 3 and a related space in layer 4. The spaces
are, from above: the preseptal space of the lower lid, the prezygomatic space, the masticator space for the buccal fat pad and the premasseter space.

60

1. Spaces provided by the bony cavities; the preseptal and
conjunctival spaces of the eyelids within the orbit and the
vestibule of the oral cavity beneath the lips and the naso-
labial segment of the cheeks.
2. Soft tissue spaces overlying the facial skeleton between
the bony cavities. The series of tissue spaces between level
3 and level 5 are voids in the attachment of the mobile
soft tissues to the underlying skeleton.
Principle
Where there is a muscle in the face there is always a related
space.
Chapter 6 Facelift anatomy, SMAS, retaining ligaments and facial spaces
The significance of the spaces is only now becoming appreci-
ated. The spaces are not only essential for function; their
presence explains much about the changes that occur with
facial aging. The appearance with aging of malar mounds,
jowls and labiomandibular folds is due entirely to changes of
previously unrecognized facial soft tissue spaces.7
Retaining ligaments of the face The retaining ligaments of
the face are located in specific locations.8,9 These are in
between areas of movement (spaces). The trunks of the liga-
ments pass out through layer 4 as part of the multilinked
fibrous support system.2,10 These structures were not origi-
nally thought of as being ligaments as they are not part of the
musculoskeletal system and do not have the typical appear-
ance of ligaments, such as the cruciate ligament. However, a
ligament is, by definition, a fibrous structure that binds or ties
adjacent structures. The soft tissue ligaments take varied forms
consistent with the functions of the face.
Fig. 6.8 The three morphologic forms of facial
ligaments. Moss CJ, Mendelson BC, and Taylor GI.
Surgical anatomy of the ligamentous attachments
in the temple and periorbital regions. Plast Reconstr
Surg 2000;105:1475.
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 Section 3: Facelift
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The lateral face immediately in front of the ear is not a
mobile area. This zone of no movement extends forward of
the ear cartilage for 25 to 30 millimeters due to an important,
but little appreciated, area of ligamentous attachment the
platysma auricular fascia (PAF).11 The PAF is unique because
it is two layers formed into one structure. It consists of a
diffuse area of layer 4 ligament that binds the SMAS with the
underlying parotid masseteric fascia and parotid capsule. It
includes the part of the SMAS (layer 3) between the ear carti-
lage and posterior border of the platysma. It is both part of
the SMAS (layer 3) as well as ligament (layer 4). The retinacu-
lar cutis overlying the PAF is ‘dense’ because it does not
overlie a space. Forward of the anterior border of the PAF
where the platysma is present, the soft tissue layers are
mobile.
Clinical correlation The unique qualities of the PAF are
important for facelifting. When a traditional SMAS facelift is
performed it is not easy to elevate the preauricular SMAS (as
it involves splitting the fused components of the PAF). This
dissection is difficult because it is not a natural plane of sepa-
ration as it is, for example, when elevating the SMAS where
it overlies a space. The fused PAF gives strength to the tissues,
which is an advantage for holding sutures used to fix the
advanced mobile SMAS and posterior platysma.
If tightening laxity of the anterior face is to be achieved,
when operating through the lateral face, the surgeon must
bypass the vertical line of retaining ligaments if they remain
sufficiently strong to be providing resistance to any traction
effect (Fig. 6.10).
In the anterior face the ligaments are arranged around the
entrance of each bony cavity. As there are not any retaining
62
Fig. 6.9 Topographical anatomy of level 4 over the
lateral face. Ligaments (red), spaces (blue) and the
areas of important anatomy (stippled). The largest
area of ligament, the PAF, dominates the posterior
part of level 4 at the least mobile part of the face. The
lateral face transitions into the anterior face at the
vertical line of retaining ligaments. Immediately above
and below the arch of the zygoma are the triangular-
shaped areas that contain the important anatomy
proceeding from the lateral face into the anterior face.
ligaments from within the bony cavities to provide support
for the mobile shutters of the lids and lips, there is a com-
pensatory gathering of the ligaments at the last place available
for skeletal support.
Sub-SMAS facial spaces The sub-SMAS layer 4 is largely
composed of ‘spaces’.7 These intervals have defined boundar-
ies and in the boundaries are located the retaining ligaments.
The spaces are by definition safe spaces, because there are no
structures within and no structures cross through the spaces.
This is important for the surgeon, as all facial nerve branches
are outside the spaces. Because spaces allow movement, laxity
develops more of the space than occurs in the ligamentous
boundaries. This differential laxity accounts for much of the
characteristic changes of aging.
Principle
The soft tissue spaces offer the surgeon ‘predissected’ areas,
which avoids the need for dissection. This means reduced
bleeding, bruising and risk of facial nerve trauma.
When operating in the upper temporal space, in the interval
between the superficial temporal (temporoparietal) fascia
and the surface of the underlying deep temporal (temporalis
muscle) fascia, simple blunt dissection only is sufficient to
separate the loose areolar tissue and convert a potential space
into a real space. A different surgical approach is required
when the ligamentous boundaries are released as the tempo-
ral branches of the facial nerve branches are in proximity.

The ligamentous boundary that separates the forehead
space from the upper temporal space is the superior tempo-
ral septum, which originates along the superior temporal line
(the zone of fusion).8 Within the temple a second fibromem-
branous ligamentous structure, the inferior temporal septum,
crosses the outer surface of the deep temporal fascia and sepa-
rates the upper temporal space from a lower triangular-shaped
zone containing detailed temporal anatomy. The superior
temporal septum and the inferior temporal septum meet at
the respective corners of the triangular-shaped temporal liga-
ment (also called orbital),12 an area of ligamentous adhesion
to the underlying periosteum and adjacent deep temporal
fascia (Fig. 6.11).13
As seen in the prototype forehead and temple, the fourth
layer is composed of a series of spaces that are separated by
boundaries containing the facial ligaments, the deeper facial
muscles and facial nerve branches. Because of the greater
movement of the middle and lower thirds of the face, soft
tissue spaces are more required.
The prezygomatic space overlies the prominence of the
body of the zygoma and allows displacement of the orbicu-
laris oculi, pars orbitale, in its roof (Fig. 6.12).14
The triangular-shaped space correlates with the shape of
the bony platform and is bounded above by the orbicularis
retaining ligament and inferomedially by the line of zygo-
matic ligaments. Contraction of the overlying muscle results
in visible zygomatic smile lines inferior to the horizontal
crows feet lines. With aging laxity of the roof these zygomatic
Chapter 6 Facelift anatomy, SMAS, retaining ligaments and facial spaces
Fig. 6.10 Concept of level 4 of the anterior
face. Note the ligamentous boundaries around
the entrance to both bony cavities and areas of
reinforced ligament.
lines become increasingly prominent and may eventually be
present at rest. Further laxity may result in a bulge of the roof
of the space at rest, the so-called malar mounds, or malar bags
(also called malar crescent). The presence of these changes
indicates laxity of the orbicularis for which tightening is the
treatment. When operating in the prezygomatic space it is
logical and inherently safer to use blunt dissection with an
appropriate surgical instrument, or finger.15
The premasseter space in the lower third of the lateral face
is analogous with the temporal space in overlying the deep
fascia of a muscle of mastication.10 Opening of the jaw
without restriction from the overlying soft tissue requires that
movement of the soft tissues be provided by the premasseter
space. Eventually, laxity develops in the platysma roof of the
space and its attachment along the inferior and anterior
boundaries leading to the bulging that forms the jowl and the
labiomandibular fold (Fig. 6.13).
The masticator space (also called the buccal space because
of its content, the buccal fat pad) is different in character
being on the anterior face (Figs 6.7, 6.13). It underlies
the midcheek medial to the masseter. Similar to the oral
cavity, the masticator space facilitates movement of the over-
lying nasolabial segment of the midcheek. Aging results in
weakness of support of the boundaries and roof especially
from attrition of the masseteric ligaments. As a result, the
platysma becomes less closely bound to the masseter, allow-
ing the masticator space to bulge inferiorly below the level of
the oral commissure and into the lower face (Fig 6.15). With
63
 Section 3: Facelift
Aesthetic Plastic Surgery

Fig. 6.11 Ligamentous anatomy of the temple and the upper temporal space. The boundaries of the space are the superior temporal septum (STS) and
inferior temporal septum (ITS), which are extensions of the temporal ligament adhesion (TLA). No structures cross the temporal space. The TLA continues
medially as the supraorbital ligamentous adhesion (SLA). Inferior to the temporal space is the triangular-shaped area of detailed temporal anatomy (stippled).
Crossing level 4 in this area are the medial and lateral branches of the zygomatico-temporal nerve (ZTN) and the sentinel vein. The temporal branches of the
facial nerve (TFN) course on the underside of the temporoparietal fascia over the area immediately inferior to the inferior temporal septum. The periorbital
septum (PS; green) is on the orbital rim at the boundary of the orbital cavity. The lateral orbital thickening (LOT) and the lateral row thickening (LBT) are parts of
the periorbital septum. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast
Reconstr Surg 2000;105:1475.

major descent, the buccal fat comes to overlie the anterior
border of the lower masseter, such that the fullness of the
displaced fat increases the prominence of the labiomandibu-
lar fold.
Surgical access to the masticator space is through the weak-
ened borders with the adjacent spaces, either the premasseter
space or oral cavity or the periosteum over the lower
zygoma.
Areas of important anatomy Over the lateral face, on either
side of the zygomatic arch, are two similar areas containing
important anatomy (Fig. 6.9). These have not been specifi-
cally mentioned in the surgical literature, so for purposes of
description they are named here as the lower temporal
and upper masseteric areas of important anatomy, as they
are neither spaces nor ligaments. By definition they are not
spaces, as they contain anatomical structures and are not
lined by membrane. They both have soft fat protecting their
contents, and can be gently opened, like a space using precise
dissection.
The lower temporal area of important anatomy between
the upper temporal space and the arch is the passageway from
the lateral face into the upper third (Fig. 6.11). The temporal
branches of the facial nerve are suspended from the roof in a
wafer-like strata of protective fat, immediately inferior to the
inferior temporal septum. The contents, which cross the
area from deep to superficial, include both zygomatico-
temporal nerve branches and the sentinel vein.
The upper masseteric area of important anatomy, between
the inferior border of the arch and the premasseter space is
the route from the lateral face through to the midcheek and
upper jaw. Here, structures course along, but do not cross
from deep to superficial. These include the anterior extension
of the parotid gland, its accessory lobe and the parotid duct.
The zygomatic branch is above and the upper buccal trunk of
the facial nerve is inferior to the duct.

64

Fig. 6.12 A&B, The prezygomatic space overlies the body of the zygoma. The origins of the zygomatic muscles extends under the floor. The roof is formed
by the orbicularis oculi lined by the SOOF (suborbicularis oculi fat). The upper ligamentous border formed by the orbicularis retaining ligament is not as strong
as the zygomatic ligament reinforced lower border. Mendelson BC, Muzaffar AR, and Adams WP, Jr. Surgical anatomy of the midcheek and malar mounds. Plast
Reconstr Surg 2002;110:885.
Careful dissection in this area may be required to access
the lateral zygomatic and upper masseteric ligaments.
Facial nerve branches Confidence in the performance of
facial surgery comes from understanding the course of
the facial nerve branches, and this is based on the anatomy
of the facial layers as previously described. The nerve branches
remain deep to layer 5 in the lower two thirds of the lateral
face. The final pathway of the nerves to the anterior face is on
the underside of the muscles in layer 3.
Clinical correlation The facial nerve branches are ‘at greatest
risk’ where they transverse layer 4 to access layer 3. The nerves
cross this level in predictable locations, in relation to the
vertical ligamentous line defining the lateral face/anterior face
transition where they are under the protection of the retaining
ligaments (Figs 6.4, 6.7).
The temporal and mandibular branches are the most
important facial nerve branches in terms of surgical risk. The
temporal branches gain the underside of layer 3 immedi-
ately on leaving the parotid, inferior to the zygomatic arch.
These branches course within a wafer-like layer of fat con-
tained in a fibrous envelope suspended from the underside
of the temporal SMAS, as they course over the arch and the
lower temporal triangle, where they are immediately inferior
to the inferior temporal septum (Fig. 6.11). The temporal
branches can be safely avoided by maintaining the plane of
dissection directly on the outer surface of the deep temporal
fascia and avoiding compression neurapraxia from retractor
pressure.
Chapter 6 Facelift anatomy, SMAS, retaining ligaments and facial spaces
The mandibular branches are at risk where they are fixed
by having a close relationship to ligament. Initially, this is
within the PAF, and then well anteriorly by the mandibular
ligament (Fig. 6.13). Over most of its course, where it is in
relation to the premasseter space, the nerve is mobile. The
absence of retaining ligaments along the mandible between
the PAF and the mandibular ligament allows an inherent
mobility of the tissue. For this reason, it is not necessary to
dissect in the immediate vicinity of the mandibular branch
in order to correct laxity of the platysma overlying the jaw
and submandibular triangle.
Layer five
The deepest soft tissue layer of the face is the deep fascia. This
is in the form of periosteum overlying the bony skeleton,
which has, for the most part, a mobile covering of preperios-
teal fat through which pass the attachments for the deep facial
muscles and the facial ligaments. In the mobile soft tissue
shutters covering the bony cavities, there is no periosteum and
the fifth layer is not a structural layer but a mobile lining layer
derived from the cavity. That is conjunctiva or oral mucosa.
Over the lateral face the muscles of mastication largely
conceal the skeleton and here the deep fascia equivalent is
the deep temporal and masseteric fascia, which also provide
attachment for retaining ligaments. The investing layer of
deep cervical fascia is the corresponding layer in the neck. The
deep fascia is traditionally taken to be the deep boundary of
the territory for aesthetic surgery. However, in recent times
this boundary is transgressed for subperiosteal ‘lifting’ and for
65
 Section 3: Facelift
Aesthetic Plastic Surgery

Fig. 6.13 The rhomboidal-shaped premasseter space overlies the lower half of the masseter. The roof of the space is formed by platysma in the SMAS. The
posterior border is defined by the anterior edge of the strong PAF and the anterior border is reinforced by the masseteric ligaments near the anterior edge of
the masseter. The inferior boundary is mesenteric-like and does not contain any ligament. Weakness of attachment of the platysma roof at the inferior
boundary leads to the formation of the jowl directly behind the strong mandibular ligament. The masticator space containing the buccal fat is anterior to the
upper masseteric ligaments. All facial nerve branches course around and outside the space. The surgically important mandibular branch, after leaving the fixed
PAF, courses under the inferior boundary of the space then rises onto the highly mobile outer surface of the mesenteric inferior border before reaching the
mandibular ligament. With kind permission from Springer Science+Business Media: Surgical anatomy of the lower face; the premasseter space, the jowl, and
the labiomandibular fold. Aesth Plast Surg 2008; 32(2), 185–195, Mendelson, Freeman et al., Figure 3.10

bone contouring procedures. In the neck it is incised for Layer six

access to the deeper located submandibular gland.
The periosteum is the carrier for all the overlying structures
when a subperiosteal upper third or mid-facelift is performed.
The effect of its displacement is transmitted through all levels
of the multi-ligamentous support system
Inherently the anatomy of the periosteum imposes limita-
tions, which require special surgical considerations:
1. An overcorrection is required to compensate for the ‘lift
lag’ phenomenon. This is to compensate for the accumu-
lated aging changes throughout the entire ligamentous
support system to the dermis, in order to transmit suffi-
cient effect to obtain the desired changes of shape and
tone to the skin.
2. There is inherently more benefit from subperiosteal lifting
where the overlying soft tissue layers are more tightly
attached. This occurs overlying the skeleton, but is less so
over the bony cavities as there is no periosteum in the
eyelid or the mobile part of the cheek.
3. Because of the unyielding nature of periosteum, an exten-
sive undermining is needed beyond the immediate area
for intended correction. The alternative is to perform a
‘periosteal release’, that is to incise the periosteum at the
boundary. This boundary release is commonly performed
along the superior orbital rim and less consistently along
the boundary with the lateral face.
Layer six is a natural plane entered by a subperiosteal dissec-
tion to create a space. In the scalp, the periosteum separates
so readily from the frontal bone that the surgeon must be
cautious not to unintentionally ‘strip’ the periosteum. Yet
the periosteum is firmly attached where there is ligament at
the periphery, along the superior temporal line and across the
superior orbital rim.
On the face proper, the periosteum follows the same
pattern of attachment, being similar to the other layers in
not having a uniform attachment. It mirrors the anatomy of
the 4th layer. Where the muscles and ligaments at the bound-
aries of the overlying 4th layer pass through into bone, the
periosteum is tightly adherent, as it is at suture lines
and foraminae. Elsewhere, the periosteum is not strongly
attached.
Anatomy over the cavities in the skeleton
The layered anatomy, as described over the lateral aspect of
the face, is modified where the orbital and oral cavities are
present over the anterior face (Fig. 6.1). The gaps in the bone
surface, due to the presence of the cavities, make up about
half of the surface area of the skeleton and necessitate modi-
fications to the layered structure.

66

Most of the movement of the face results from the muscular
activity in the soft tissues overlying the spaces, and the sur-
rounding periorbital tissues for the orbits. The movement
occurring on the lateral face is essentially passive, secondary to
active movement of the muscles on the anterior aspect of the
face around the eye and the mouth, and to jaw movement.
Retaining ligaments are a feature of the skeletal anatomy
and are not present in the spaces. Because layer 5 deep fascia
is not present over the bony cavities, there is no base for liga-
ment attachment. As ligaments do not exist over the cavities,
there is not the same vertical reinforcement through to the
retinacular cutis.
Chapter 6 Facelift anatomy, SMAS, retaining ligaments and facial spaces
Around the bony rims there are anatomical and functional
transitions between the relative stability over the fixed area of
skeletal attachment and the high mobility of the soft tissue
shutters over the bony cavities. This is mainly in layer 4,
where there is a concentration of ligaments around the bony
rims, at the last available place for soft tissue ligament fixation
before the void of the bony cavity (Fig. 6.14).
The generic 5 layer concept also explains the soft tissue
anatomy where it overlies the bony cavities. The submuscular
space of the lower lids, between the septum orbitale and the
overlying preseptal orbicularis, allows mobility of the lids.
This space contributes to the pattern of aging changes,
Fig. 6.14 The anatomy over the midcheek skeleton and adjacent
bony cavities, showing the relationship of soft tissue spaces to bone
cavity spaces. Soft tissue transitions are located along the rim of the
bony, orbital and oral cavities. The prezygomatic space is separated
from the preseptal space of the lower lid by the orbicularis retaining
ligament, and from the vestibule of the oral cavity by the line of
zygomatic ligaments. The ligaments continue through the soft tissue
layers to provide dermal attachments, which are manifest on the skin
surface as cutaneous grooves. The prezygomatic space allows mobility
of the outer cheek where it overlies the zygoma, but it does not
extend medially over the maxilla. Movement of the medial cheek is
enabled by the soft preperiosteal, (level 4) fat.
67
 Section 3: Facelift
Aesthetic Plastic Surgery

particularly the development of lower lid bags. The oral cavity
is the largest of the facial spaces and allows movement of
most of the midcheek as well as of the lips.
The layers undergo significant adaptations as they leave
the bone surface and continue over the orifices. Only the
outer three-layer composite superficial fascia forms these soft
tissue extensions that are in the form of a composite flap.
The SMAS layer within the flap extension has the sphincteric
orbicularis muscle around the free edge of the soft tissue
aperture of the lids and lips. The facial ligaments in (layer 4)
that normally support the composite soft tissue shutters do
not exist over the cavities. They are remote where they are
condensed along the rim of the bone. This is the basis for
the periorbital ligament around the orbital rim, of which the
lower lid part is the orbicularis retaining ligament, which
stabilizes the overlying orbicularis to the orbital rim perios-
teum (Fig. 6.11). The orbicularis does not have any attach-
ment to the septum orbitale, (deep fascia) directly beneath,
other than the attachments of the orbicularis to the medial
and lateral canthal tendons and the nearby orbital rim
periosteum.
The lining layer beneath the composite shutters is derived
from the underlying cavity (conjunctiva, oral mucosa).
The extent of the oral cavity has a major impact on the
facial structure and on aging of the face. The vestibule of the
oral cavity covers a large area of the surface of the maxilla
and of the mandible (Fig. 6.14). The part of the skeleton
underlying a space is unavailable for ligamentous attachment
for support of the soft tissue cover over this large area.
Accordingly, the non-attached cheek overlying the oral cavity
is the least supported and most mobile part of the face. The
indication for a facelift is largely to correct the changes that
occur in this poorly supported part of the cheek around the
lips.
Anatomy and aging of the face
The youthful face has the appearance of rounded fullness.
Laxity gradually develops in the boundaries of the spaces
consequent on the repetitive movement that occurs with
expression and jaw function. The laxity develops most in
the roof of the spaces (level 3). The membranous lining of
the spaces undergoes distension in proportion to the degree
of laxity developing in the adjacent retaining ligaments,
although these are not uniformly affected by laxity. For
example, in the lower face the lower masseter ligaments at
the anterior boundary of the premasseter space undergo attri-
tion, yet the nearby mandibular ligament remain strong and
resist laxity (Fig. 6.15).
As aging changes progress, the bulging over the spaces
contrasts with the restriction imposed by the ligaments at the
boundaries. These do not bulge as much and form the cutane-
ous grooves (Fig. 6.3).

Fig. 6.15 The facial spaces and their role in aging of the face. Youthful (left), aged face (right). Distension of the facial spaces occurs secondary to laxity of
their ligamentous boundaries. This process is most pronounced in the roof of the spaces: lower lid bags (preseptal space of lower lid), malar mounds
(prezygomatic space), nasolabial folds (vestibule of oral cavity), jowls (premasseter space) and labiomandibular folds (masticator space). Greater laxity occurs in
the lower facial spaces due to movement of the jaw. The masseteric ligaments, illustrated, along the anterior border of the masseter, undergo attrition with
distension on aging, so that the overlying platysma loses its close relation with the masseter and mandible, leading to the development of jowls and
labiomandibular folds.

68
 Chapter 6 Facelift anatomy, SMAS, retaining ligaments and facial spaces

SMAS does not need to be dissected where it overlies a space).

Principle The SMAS here is inherently mobile and the laxity can be
tightened by plication or imbrication.
The pattern of laxity in the roof and walls of the spaces largely The more superficial the carrier layer for the overlying lax
determine the characteristic appearance of the changes of soft tissues, the more direct and the effective is the benefit
aging. of the redraping on layers 1 and 2. Accordingly, periosteal
redraping has the least benefit for major laxity of the skin and
subcutaneous layer.

Application of anatomy to surgical technique Application to facelift, levels of dissection

Many facelift techniques deliver comparable results. However,
the difference on closer analysis is in the extent of harmoni-
ous facial shape achieved and the balance between skin
tension and shape. Excessive tension flattens natural shape.
This is anatomical, and specifically determined by the level
in which the dissection has been performed and the layer
used for redraping (Fig. 6.16).16
The dissection is performed to gain access to the lax tissues
of the anterior face. The advancement is applied directly to
the layer that has been mobilized on the upper surface of the
dissection plane. There are three possible layers on which to
apply the traction force: skin (layer 1); SMAS (layer 3); and
periosteum (layer 5), this layer being the carrier for the overly-
ing (undissected) tissue. When a subcutaneous dissection is
performed, there is also the option to tighten the exposed
surface of the deeper layer (SMAS because the underlying
When a facelift is initiated over the lateral face, the level of
dissection can be changed at the transition to the anterior
face, e.g. subcutaneous for lateral face extended to sub-SMAS
for the anterior face, or vice versa. Because the objective of
the surgery is correction of the laxity of the mobile anterior
face, the level of dissection used for the lateral face is of sec-
ondary importance.
Level 4: sub-SMAS
Understanding the anatomy of layer 4 allows sub-SMAS dis-
section to be utilized in a proactive manner. This provides
many advantages based on the fact that the spaces are natu-
rally predissected areas, so the surgical dissection is quick,
easy and atraumatic. The surgical approach is commenced
with a subcutaneous dissection, which is extended forward

Fig. 6.16 The alternative levels for dissection and redraping in facelifts. Dissection can be performed through any one of three alternate layers, namely:
subcutaneous (layer 2), sub-SMAS (layer 4) and subperiosteal (layer 6) (for the upper two thirds of the face). Redraping is performed on the mobilised layer
according to the dissection plane. These are: skin (Layer 1), SMAS (Layer 3), and periosteum (Layer 5) A subcutaneous dissection (2) allows not only redraping of
the mobilised layer 1, but also tightening of the surface of the revealed deeper layer, SMAS where it overlies a space.

69
 Section 3: Facelift
Aesthetic Plastic Surgery
until over the posterior part of the roof of the appropriate
space. The space is then entered, using traction on the layer
3 roof. Once inside the space, blunt dissection only is used
to define the boundaries.
If dissection anterior to the space is required, the position
of the ligaments and nerves is indicated by the knowledge
that they are located within the boundaries. Precise dissection
is now used to locate the residual retaining ligaments by their
tethering effect and then to release the ligaments as is neces-
sary. In younger patients this step is more difficult, as more
ligament is present and it is tighter because of less aging
attrition.
The anatomy of the relationship of the nerves to the liga-
ments here provides a guide to the technique. Because the
facial nerve branches are immediately adjacent to the liga-
ments, precise dissection is now necessary. Blunt scissors are
used in a gentle spreading motion oriented in a vertical, i.e.
outward direction. This provides maximum effect on the
ligament while, at the same time, having a nerve-sparing
effect. The surrounding areolar and fatty tissues separate
to clearly reveal the ligament and any related nerves. Now,
under visual control, the ligament yields to the tissue
stretching force while the nerve, being more mobile and
obliquely oriented, is not tightened and can be dislodged
out of the way, being unaffected by the controlled stretching
force.
The spaces can be used, like stepping stones, to safely
navigate across the face. In fact, the spaces have long been
used in facial surgery, without considering them in these
conceptual terms. Some examples include:
• The transconjunctival (space) approach to access the pre-
septal space of the lower lid.
• The deep temporal lift dissection from the upper temporal
space, around the lateral orbital rim, into the prezygo-
matic space.
• The premasseter approach to the masticator space, used
to reduce displaced buccal fat and to tighten laxity of
the overlying superficial fascia lateral to the oral
commissure.
Principle
It is inherently easier and safer to enter the SMAS where it over-
lies a space, rather than where it is fixed by ligament.
When the ‘deep plane facelift’ was introduced, the term
‘deep’ referred to dissection in level 4, deep to the SMAS.17
Although not clear at that time, the deep dissection was only
over the lateral face18 as the level of dissection changed to
more superficial (deep subcutaneous level 2) at the transition
to the anterior face and over the level 3 muscles, orbicularis
and zygomaticus major.3,4 The deep plane procedure evolved
into the ‘composite facelift’,18 the difference being that the
sub-SMAS plane of dissection was also used in the anterior
face. Sub-SMAS dissection over the midcheek can be
approached either through the lateral approach (extended
70
SMAS)19 or directly the through anterior face via the lower lid
(zygorbicular dissection).18,20
Level 2: subcutaneous
The subcutaneous layer is unique in having a thickness. This
provides options regarding the level within the layer to
perform the dissection
Principle
The ease of dissection varies at different levels within the subcu-
taneous layer.
When performing a subcutaneous dissection, knowledge of
the spaces in level 4 is beneficial in explaining the easier dis-
section where the subcutaneous layer overlies superficial
muscle, especially over orbicularis oculi and platysma. Move-
ment of the muscle is associated with a lesser attachment of
the subcutaneous layer at this interface, while the orientation
of the retinacular fibers is more horizontal overlying the surgi-
cal spaces (beneath the muscle).
Principle
At any point in the subcutaneous layer the orientation of the reti-
nacular cutis fibers reflects the underlying anatomy of level 4.
The intended role for the fibrous retinacular cutis in the reju-
venation determines which level within the subcutaneous
layer to perform the dissection. If the skin flap is to be used
for the redraping, the fibrous retinacular component should
be left on the flap by performing a ‘deep’ level of subcutane-
ous dissection. If external plication of the anterior SMAS is
the objective, a deep subcutaneous level of dissection is
required to visualize the outer surface of the SMAS.21,22 This
level of deep subcutaneous dissection at the interface with
level 3 has been given several names: the superficial muscu-
loaponeurotic plane (SMAP)11 and the extended suprapla-
tysma plane (ESP).23
Alternatively, when a ‘separate’ SMAS flap is to be used,
it is advantageous to keep most of the retinacular cutis
mass attached to the SMAS, as this optimizes the strength of
the thin SMAS flap. This is achieved with a superficial level
of subcutaneous undermining, the so-called, ‘thin skin
flap’.24,25
Principle
The shape of the face is the product of the shape of the facial
skeleton and of the quality of attachment of the overlying soft
tissues.

Summary
This chapter has been structured to assist the reader to develop a
conceptual understanding of facial anatomy. It is the missing
framework on which to attach the detailed anatomical informa-
tion now available in the literature. Once understood, this ana-
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3. Owsley JQ. Lifting the malar pad for correction of prominent
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8. Furnas DW. The retaining ligaments of the cheek. Plast
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11. Furnas D. The superficial musculoaponeurotic plane and the
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13. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of
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15. Aston SJ. The FAME Procedure. Presented at the Annual
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17. Hamra ST. Deep-plane rhytidectomy. Plast Reconstr Surg
1990;86:53.
18. Hamra ST. Composite Rhytidectomy. Plast Reconstr Surg
1992;90:1.
19. Stuzin JM, Baker TJ, Gordan HL, Baker TM. Extended SMAS
dissection as an approach to midface rejuvenation. Clin Plast
Surg 1995;22(2):295–311.
20. Hamra ST. The zygorbicular dissection in composite
rhytidectomy: An ideal midface plane. Plast Reconstr Surg
1998;102:1646.
21. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS
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restoration of normal cheek contour. Plast Reconstr Surg
1995;96:1279.
22. Trepsat F, Cornette de Saint-Cyr B, Delmar H, Goin J.-L, Thion
A. Les nouveaux liftings. Ann Chir Plast Esthet 1994;39:597.
23. Hoefflin S. The extended supraplatysmal plane (ESP) facelift.
Plast Reconstr Surg 1998;101:494.
24. Connell BF, Gaon A. Surgical correction of aesthetic contour
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71
 Section 3: Facelift
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Facelift with SMAS technique
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History
Surgery of the deep layer tissues of the face and neck is now
established as a permanent part of facelift operations. There
is no clear consensus as to how to treat the midface and its
related nasolabial fold. Skoog introduced tightening of the
midface superficial fascia and platysma muscle in the late
1960s, and Mitz and Peyronie verified the anatomy of the
superficial musculoaponeurotic system (SMAS) in 1976.
Surgery of the midface developed subsequent to descriptions
of the retaining ligaments of the cheek, as the focus of facial
rejuvenation extended to correction of the nasolabial fold.
Masseteric-cutaneous and lateral zygomatic-cutaneous liga-
ment release allowed lifting of the SMAS to correct the lower
face below the zygoma. However, approaches to the prezygo-
matic SMAS developed in an effort to gain harmony of the
upper and lower parts of the face. In this effort two different
approaches are in use:
1. Wide skin undermining and separate dissection of a
SMAS platysma flap.
2. Very limited skin undermining in the cheek and the dis-
section beneath the SMAS layer in continuity with the
skin.
In the deep plane facelift the plane of the dissection for
the lateral segment of the face is in the sub-SMAS plane, but
more anterior the plane changes to become more superficial
overlying the zygomatic muscles, therefore the cheek fat
remains adherent to the skin flap. The composite facelift tech-
nique (this technique later modified by Hamra with the
zygoorbicular dissection) continues the sub-SMAS dissection
beneath the central part of the malar fat including the prezy-
gomatic SMAS and the orbicularis oculi muscle and its fascia.
Mendelson has noted that this prezygomatic space is a surgi-
cally safe space that can be entered through the lower eyelid
or laterally through a space between the temporal and the
zygomatic branches of the seventh nerve as is performed in
the FAME (finger assisted malar elevation) technique.
CHAPTER 7
Physical evaluation
• Evaluate the face in general for the bone structure of the
entire face including the forehead, orbits, zygomas, zygo-
matic arches, maxilla, mandible, mentum, as well as the
lips, nose and teeth.
• Evaluate skin quality and laxity, fat deposits and/or bulges
in the face and neck.
• Evaluate midface thickness, laxity, and mobility to finger
tip manipulation.
• Evaluate nasolabial folds, and labiomandibular folds if
present.
• Evaluate neck including fat deposits, platysma muscle
anatomy, hyoid position, thyroid cartilage contour and
submandibular gland position.
• Evaluate the malar area for bony contour and the thick-
ness of the soft tissue lying medial to the zygomaticus
major muscle.
• Evaluate the lower eyelids for the integrity and function
of the orbicularis oculi muscle.
• Evaluate the lower eyelids for prominence of herniated
fat, prominence of the bony orbital rim, palpebromalar
grove and nasojugal grove.
• Determine patient’s main concerns.
• Make detailed photographs.
Anatomy
The midcheek can be understood as part of the midface and
refers to a part of the cheek medial to a line extending from
the frontal process of the zygoma to the oral commissure
and from the lower lid above to the nasolabial fold below.
It is composed of two functionally distinct parts including
the prezygomatic part over the body of the zygoma and
maxilla and infrazygomatic part below, as described by
Mendelson (Ch. 6). A major determinant of the shape of the
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 Section 3: Facelift
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midface is the underlying skeleton as it connects the orbital

and oral cavities and provides a bony platform for their skel-
etal attachments and retaining ligaments of each muscle. The
aging changes that appear in the midcheek largely reflect the
effect of laxity and ptosis of the soft tissues relative to the
underlying skeleton. This affects the upper face by revealing
the anatomy of the orbit, with exposure of the bony orbital
rim inferiorly, palpebromalar groove laterally, and nasojugal
groove medially. The displaced soft tissue accentuates the
nasolabial fold and reveals lower lid fat bulges. With soft
tissue descent, laxity of the structures of the prezygomatic
space including the orbital retaining ligament at its upper-
most aspect and its roof (pars orbitale of the orbicularis oculi)
are resisted by the zygomatic-cutaneous ligaments below.
When visibly enlarged this area forms the clinical entity
known as the malar mounds, also termed malar bags and
malar crescent. It should be noted that the presence of the
malar septum was described by Pessa and Garza and Pessa
et al. to explain the clinical appearance of a black eye, and
explain the anatomic basis of malar mounds and malar
edema. Malar mounds should be distinguished from the
malar fat pad. The anatomical terminology regarding this area
can be somewhat confusing, as the malar fat pad is also
simply known as malar fat.
Specifically, the malar fat pad is a term used to describe
the subcutaneous fat of the medial cheek that exaggerates the
nasolabial fold. The malar fat pad is a localized thickness of
the subcutaneous panniculus adiposus (Fig. 7.1). The malar
fat pad is of maximum thickness centrally in youth with a
well-defined border at the nasolabial crease and less discrete Malar fat pad
border in the upper face as it blends imperceptibly into the
lower lid with a gradual decrease in thickness over the promi- Fig. 7.1 Malar fat pad is a localized increase thickness of the panniculus
nence of the orbital rim and zygoma. The malar fat has upper, adiposis.
middle and lower components. The fullness of the nasolabial
fold is in large part caused by the medial and inferior migra-
tion of the soft tissue medial to the zygomaticus major muscle
(primarily the malar fat pad). It is triangular in shape with its brane and the most cephalad of the zygomatic-cutaneous
base along the nasolabial crease, and its apex overlies the ligaments as they extend between the origins of the lip eleva-
body of the zygoma. The malar fat pad firmly attaches to skin. tor muscles through the subcutaneous fat to the dermis. With
It is easily separated from underlying fascia, and the malar fat blunt dissection in this space, as in the FAME procedure, the
pad moves forward and down perpendicular to the nasolabial smooth surface of this membrane remains intact and preperi-
crease during the aging process. osteal fat remains attached to the underlying facial bones.
The prezygomatic space overlies the body of the zygoma Mendelson has noted that the prezygomatic space can be
and the origins of the lip elevator muscles. It extends to the entered from (1) the lower eyelid; (2) the temporal area; (3)
posterior border of the body of the zygoma and can be laterally passing between the seventh nerve branches as per-
accessed from the lower temporal region and lower lid. The formed with the FAME procedure to enter the prezygomatic
floor is a thick layer of preperiosteal fat with an overlying thin space (Fig. 7.2).
membrane which covers the origins of the muscle bellies of
the lip elevators. The upper border of the space is formed by
the orbicularis retaining ligament, which separates the prese- Technical steps
ptal from the prezygomatic space and becomes confluent at
the inferolateral orbital rim with the broad lateral orbital The senior author (SJA) began using the FAME technique in
thickening that overlies the frontal process of the zygoma. The the early 1990s as a procedure in conjunction with a standard
zygomatic-cutaneous neurovascular pedicle is the only struc- SMAS/platysma facelift to improve the midface and nasola-
ture crossing this space as Mendelson has previously eluci- bial fold. The FAME technique (finger assisted malar eleva-
dated. The roof of the space is the orbicularis oculi and its tion) is a composite technique designed to elevate skin, lateral
investing fascia, which is contiguous with the temporopari- orbicularis oculi muscle, and reposition the malar fat pad.
etal fascia laterally. The inferior wall of the prezygomatic This technique is used in combination with skin undermining
space is lined by a continuation of the preperiosteal mem- and a SMAS/platysma flap to correct the remainder of the

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 Chapter 7 Facelift with SMAS technique and FAME

laxity in facial and cervical areas. The description given here In the temporal area the skin is undermined sharply
is as performed for approximately 14 years. Recent modifica- for approximately half the distance between the ear and
tions since February 2006 will be described below. lateral canthus. The right index finger is rotated medially and
inferiorly so as to separate the orbicularis oculi muscle
from the temporal fascia; the lateral canthus is easily reached
Orbicularis retaining Suborbicularis (Fig. 7.3).
ligament oculi fat
Next, the facial and cervical skin flap undermining, as
indicated for the individual, is completed. In the midface skin
undermining is carried medially to approximate the course of
the zygomaticus major muscle. In the lower face, when indi-
cated by skin redundancy, undermining may be carried medi-
ally to the labiomandibular fold. The mandibular ligament is
divided in most patients. Any anterior platysma procedures
are completed. Complete submandibular and submental skin
undermining and anterior platysma procedures are frequently
indicated. Necessary anterior platysma procedures are per-
formed prior to lateral platysma and cheek work.
Attention is now returned to the lateral canthus. With the
index finger pulp surface down under the orbicularis oculi
muscle pressure is exerted downward, inferiorly, and medi-
ally across the malar prominence (Fig. 7.4A&B). The orbicu-
laris oculi muscle and the malar fat pad separate rather easily
from the underlying fascia overlying the preperiosteal fat thus
entering the prezygomatic space (Fig. 7.4C). The entire malar
fat pad in undermined with the index finger going to near the
nasal alar attachment (Fig. 7.4D). The index finger is turned
over with the pulp surface up in order to permit leverage for
complete mobilization of the malar fat pad. Bimanual palpa-
tion with one index finger in the “deep plane” helps evaluate
Preperiosteal Zygomatic Prezygomatic malar fat pad thickness and mobility (Fig. 7.5).
fat ligament space At this point the levels of dissection have been established
Fig. 7.2 Mendelson’s description of the prezygomatic space and the three
(1) subcutaneously and (2) underneath the malar fat pad and
access routes, lower lid, temporal and lateral. Reproduced with permission orbicularis oculi (in the deep plane and a composite flap).
from Mendelson BC, Muzaffar AR, Adams WP, Jr. Surgical anatomy of the The subcutaneous soft tissue bridge separates the two planes
midcheek and malar mounds. Plast Reconstr Surg 2002;110:885–896. at the lower quarter of the malar prominence. Redraping of

Lateral canthus

A B

Fig. 7.3 The right index finger is advanced across the temporal area separating the orbicularis oculi muscle from the temporal fascia.

75
 Section 3: Facelift
Aesthetic Plastic Surgery

Orbicularis oculi Malar fat pad

Malar fat pad

Zygomaticus
A B major muscle

Malar fat pad

C D

Fig. 7.4 A, The index finger is passed under the lateral orbicularis oculi muscle. B, The index finger is turned to pass under the orbicularis oculi muscle and to
enter the prezygomatic space. C, The index finger is advanced into the prezygomatic space under the orbicularis muscle and the malar fat pad. D, The index
finger is advanced to the base of the prezygomatic space.

the composite flap in a cephaloposterior direction with the
emphasis on the vertical vector will demonstrate reposition-
ing of the malar fat pad to its earlier location over the malar
prominence. If more mobility is needed for repositioning of
the malar fat pad, the subcutaneous bridge is dissected until
the desired mobility of the composite flap is achieved.
Next, attention is directed to developing a SMAS/platysma
flap. The lateral border of the platysma muscle is incised at
the anterior border of the sternocleidomastiod muscle and
carried from the angle of the mandible inferiorly 7–8 cm
below the angle of the mandible. Subplatysmal dissection is
carried medially for 4–7 cm, depending on the amount of
platysma mobility needed for the individual patient. The
zygomatic arch is palpated with fingertips to determine its
exact location, and an incision is made through the SMAS
along the lower border of the zygomatic arch extending from
approximately 5 mm anterior to the base of the tragus to
approximately 1 cm from the subcutaneous bridge separating
the deep plane and subcutaneous plane.
A SMAS flap is developed going inferiorly to join the sub-
platysmal dissection and going medially anterior to the
parotid gland until the desired flap mobility is obtained. The

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 Chapter 7 Facelift with SMAS technique and FAME

SMAS platysma flap and, when indicated, anterior platysma
procedures give independent control for lower facial and cer-
vical contouring. The SMAS/platysma flap is elevated and
rotated in the cephaloposterior direction with the vectors of
lifting and repositioning according to the anatomy of the
patient and the desired facial contouring.
Fig. 7.5 Bimanual palpation determines the thickness of the malar fat pad
and mobility.
Orbicularis oculi
Zygomaticus
major
Excess SMAS is then resected along the horizontal SMAS
incision line and sutured to the incised SMAS edge. In the pre-
auricular area the SMAS is then cut vertically creating a small
SMAS flap, which is positioned behind the ear and sutured to
the sternocleidomastoidmastoid fascia to help with jawline
contouring. The lateral platysma is sutured to the sternocleido-
mastoid muscle fascia. Final jawline fat contouring is carried
out by open suction lipectomy or sharp dissection.
The description of the technique above is as performed by
the senior author for approximately 15 years. Most cases were
performed without malar fat pad fixation to the zygoma.
However, in some patients the malar fat was sutured to the
periosteum of the zygoma to help maintain the vertical vector.
In February 2006 the senior author modified the technique
by extending the SMAS flap through the subcutaneous bridge
between the deep plane and the subcutaneous plane. It is now
an extended SMAS flap joining the FAME composite deep
plane flap, thereby giving more mobility to the malar soft
tissue (Fig. 7.6A&B). The SMAS flap is not excised but sutured
to the temporal fascia (high lamella fixation) in order to
maximize the vertical vector of the midface repositioning
(Fig. 7.7A). The elevated malar fat pad is sutured to the peri-
osteum of the zygoma in a vertical vector (Fig. 7.7B). In
patients with a thin or poor quality SMAS, the FAME tech-
nique can be performed with plication of the SMAS. Likewise,
a smasectomy can be performed with the FAME in patients
where it is desirable to excise facial fat.
Redraping of the skin flap in the cephaloposterior direc-
tion repositions the malar fat pad and orbicularis oculi
muscle. In general, the maximum vertical vector possible is
desired in order to return the malar soft tissue onto the

SMAS flap

A B
Facial nerve Parotid
branches gland

Fig. 7.6 A, Extended SMAS flap showing dissection medial to the zygomaticus major and joining the FAME dissection. B, Intraoperative photograph showing
zygomaticus major muscle and gauze in the prezygomatic space.

77
 Section 3: Facelift
Aesthetic Plastic Surgery
A B
Fig. 7.7 A, Vertical vector elevation of extended SMAS flap and malar fat pad. B, Flap sutured to temporal fascia and zygoma at lateral canthus. Excess
preauricular SMAS flap transposed and sutured to sternocleidomastoid fascia.
malar prominence. An incision is made beneath the tempo-
ral hairline so as not to narrow or elevate the sideburn. A
Burrow’s triangle is excised so as to place only minimal
tension on the elevated and rotated skin flap. Excess tension
will only result in scar migration and add nothing to the lift.
In the vast majority of patients, an incision along the ante-
rior hairline is avoided entirely. When a small “dog ear” is
present at the end of the transverse incision under the hair-
line, a small anterior hairline incision (5 to 7 mm) will
eliminate the “dog ear” and permit restoration of the side-
burn shape and position. The remainder of the skin flap is
trimmed and sutured in a routine fashion. The FAME proce-
dure can be performed with a short scar facelift technique
or conventional scar technique, where the posterior scar is
curved in the mastoid hair so as to be as almost impercep-
tible. Pre- and postoperative views of patients who have
undergone a facelift with the FAME technique are shown
(Figures 7.C1–C5).
Postoperative care
Standard postoperative facelift care is used. A facelift dressing
is placed in the operating room and removed the first day
after surgery. Treatment of hypertension and maintenance of
blood pressure is stressed especially in the perioperative
period, and drains are usually removed on the first postopera-
tive day. The following information is typical of that given to
our facelift patients.
78
Sample instructions for the facelift patient
General
• Take pain medication as prescribed.
• Do not take aspirin, ibuprofen or any products containing
these drugs, as they can cause bleeding problems after
surgery. Tylenol is permissible. Also avoid vitamin E and
multivitamins containing vitamin E. Stop herbal and
homeopathic medications, as some may cause bleeding
after surgery.
• Abstain from alcohol for a minimum of 7 days post-op.
Do not drink alcohol when taking pain medications.
• Do not smoke, as smoking delays healing and increases
the risk of complications.
• Following surgery, sleep on your back for 2 weeks. Keep
head elevated on two pillows while sleeping.
• You may shampoo 24 hours after removal of the drainage
tubes. Hair is generally shampooed on the 2nd postopera-
tive day. Wash hair daily for two weeks following surgery.
Use a cool setting on the hair dryer. Do not use rollers for
1 week after surgery. Do not color hair or use harsh chemi-
cals prior to 2 weeks post-op.
• Soft foods are easier to consume post-op.
• Always use a strong sunblock, if sun exposure is unavoid-
able (SPF 30 or greater).
• You may use cold compresses for comfort and to help
decrease the swelling.
 Chapter 7 Facelift with SMAS technique and FAME

Fig. 7.C1 A 58-year-old-patient following facialplasty with FAME technique, extended SMAS/platysma flap, endoscopic browlift and lower lid blepharoplasty.
Postoperative photographs show lower and midface repositioning and lateral orbicularis tightening.

79
 Section 3: Facelift
Aesthetic Plastic Surgery

Fig. 7.C2 A 59-year-old patient 10 months postoperative facialplasty with FAME technique, extended SMAS, laternal platysma dissection, high lamella fixation,
chin implant, 4-lid blepharoplasty, erbium laser resurfacing lower lids and rhinoplasty. Postoperative photographs show repositioning of mid and lower facial
soft tissue and lateral orbicularis tightening.

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 Chapter 7 Facelift with SMAS technique and FAME

Fig. 7.C3 A 58-year-old patient 1 year postoperative facialplasty with FAME technique, SMAS/platysma flap procedure and 4-lid blepharoplasty. Postoperative
photographs show repositioning of thick, heavy midface and lateral orbicularis tightening.

81
 Section 3: Facelift
Aesthetic Plastic Surgery

Fig. 7.C4 A 55-year-old patient 2 years postoperative facialplasty with FAME technique, SMAS/platysma flap procedure, 4-lid blepharoplasty and chin implant.
Postoperative photographs show mid and lower face correction and lateral orbicularis oculi tightening.

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 Chapter 7 Facelift with SMAS technique and FAME

Fig. 7.C4, cont’d

83
 Section 3: Facelift
Aesthetic Plastic Surgery
Activities
• Start walking as soon as possible. This helps to reduce
swelling and lowers the chance of blood clots in the
legs.
• Do not drive until you are no longer taking any pain
medications (narcotics), and can turn your neck easily.
• No strenuous activities, including sex and heavy house-
work, for at least 2 weeks. (Walking and mild stretching
are permissible).
Incision care
• The area of sutures must be washed gently and
thoroughly.
• Keep incisions clean and inspect daily for redness or signs
of inflammation.
• You may use makeup after the sutures are removed; new
facial makeup can be used to cover up bruising, but not
on the incisions until 48 hours after suture removal. It is
important to gently remove all makeup.
What to expect
• Swelling, bruising and numbness is normal and to be
expected.
• Expect to feel tightness and a pulling sensation in your
face and neck, especially when turning your head.
• Face may look and feel strange and distorted from the
swelling.
• Men need to shave behind their ears, where beard-growing
skin is repositioned.
Pearls & pitfalls
Pearls
• Apply firm downward fingertip pressure when dissecting
across the temporal area to go under the orbicularis oculi
muscle. This establishes the plane you want to be in.
• Inject anesthetic hemostatic agent perpendicular to the face
of zygoma so as to infiltrate prezygomatic space.
• Apply fingertip pressure downward on malar bone to go
under malar fat pad.
• Dissect prezygomatic space completely to mobilize entire
malar fat pad.
• Use absorbable sutures (PDS, Vicryl, and Monacryl) to secure
malar fat pad to periosteum.
84
• Expect a bruised and puffy face for 7–14 days, although
some patients do not bruise at all. Wearing scarves, turtle-
necks and high-collared blouses masks the swelling and
discoloration.
• By the third week, you will look and feel much better.
• Final result is not fully realized for approximately 3
months.
Follow-up care
• Sutures are usually removed from in front of the ear in
3–5 days.
• Remaining sutures and metal clips, if used, are usually
removed in 8 days.
• If a drainage tube is inserted, it will be removed in 1–2
days.
Complications
Possible complications are those of a standard facelift. Serious
complications from facelift surgery are extremely rare. As with
any surgical procedure, complications and risks can often be
minimized if the operation is performed by an experienced
surgeon who has performed many facelifts. Complications of
any facelift include bleeding (hematoma), infection, promi-
nent or widened scars, alopecia, or nerve damage. Sequelae
specific to the FAME facelift that patients should be advised
of is the possibility of midface edema that resolves usually
over the first 2 to 3 months. However, all facelift techniques
have some edema that resolves over this amount of time.
Pitfalls
• Failure to dissect under the orbicularis oculi muscle laterally,
therefore injuring the muscle and delaying the return of
lower lid function.
• Failure to dissect under malar fat pad at its apex; therefore
dissection will probably not be in the prezygomatic space
but tear the malar fat pad.
• Injury to the small motor branch that crosses the upper
zygomaticus major muscle to innervate the lateral orbicularis
oculi muscle.
• Subcutaneous dissection medial to zygomaticus major
muscle.
• Performing the procedure on a patient with thin malar fat
pads.

Summary of steps
1. Infiltrate face and neck with anesthetic hemostatic
solution.
2. Infiltrate prezygomatic space.
3. If indicated undermine anterior neck skin through a
submental incision and perform anterior platysma
procedure through submental incision.
4. Dissect sharply in the subcutaneous plane in the
preauricular area and temporal area half distance to lateral
canthus.
5. Rotate index finger downward and medially going under
the lateral orbicularis oculi muscle.
6. Complete skin undermining as needed in cervical area.
7. Complete midcheek undermining in subcutaneous plane
up to the lateral border of the zygomaticus major muscle.
8. Place index finger under lateral orbicularis oculi and push
downward against malar bone so as to go under the apex
of the malar fat pad.
Further reading
Aston SJ. The FAME technique, presented at the Aging Face
Symposium. Waldorf Astoria Hotel, New York, NY, 1993.
Aston SJ. Platysma-SMAS cervicofacial rhytidoplasty. Clin Plast
Surg 1983;10(3):507.
Barton FE, Jr. The aging face: rhytidectomy and adjunctive
procedures. Select Read Plast Surg 2001;9(19)22.
Barton FE, Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr
Surg 1992;90:601.
Hamra ST. The zygorbicular dissection in composite rhytidectomy:
an ideal midface plane. Plast Reconstr Surg 1998;102:1646.
Mendelson BC. Discussion; A study of long-term effect of malar fat
repositioning in face lift surgery: short term success but long-
Chapter 7 Facelift with SMAS technique and FAME
9. Push index finger into the prezygomatic space and release
the entire malar fat pad.
10. Bimanual palpation of malar fat pad to determine malar
fat pad thickness.
11. Test mobility of this composite flap.
12. Perform lateral platysma and SMAS procedure (SMAS,
extended SMAS, plication or smasectomy) as indicated for
the individual patient.
13. Rotate and elevate the extended SMAS flap (most often
used technique) and secure to temporalis fascia (high
lamella fixation).
14. Redrape composite skin flap and determine position of the
elevated malar fat pad with vertical vector.
15. Secure malar fat pat with 4-0 PDS to zygoma
approximately 1 cm lateral to lateral canthus.
16. Redrape and trim skin flap, suture skin and place drains.
17. Apply dressing.
term failure, by Sam T. Hamra, MD. Plast Reconstr Surg
2002;110(3):952.
Mendelson BC. Surgical anatomy of the midcheek and malar
mounds. Plast Reconstr Surg 2002;110(3)885.
Owsley JQ. Lifting the malar fat pad for correction of prominent
nasolabial folds. Plast Reconstr Surg 1993;91:463.
Skoog T. Rhytidectomy – A personal experience and technique,
presented at the Seventh Annual Symposium of Cosmetic
Surgery. Cedars of Lebanon Hospital, Miami, FL. 1973.
Stuzin JM, Baker TJ, Baker TM. Extended SMAS dissection as an
approach to midface rejuvenation. Clin Plast Surg
1995;22:295.
85
 Section 3: Facelift
Go to www.expertconsult.com
to see updates to this chapter
The SMAS facelift – restoring
See DVD
facial shape in facelifting
James M. Stuzin
Introduction
The works of Skoog, Mitz and Peyronie enlightened plastic
surgeons to the possibility of repositioning descended facial
fat to the anatomic position of youth, providing an alterna-
tive to skin envelope tightening to enhance contour in the
aging face. The recognition that sub-SMAS dissection offered
a technical solution for facial rejuvenation spawned multiple
anatomic studies to delineate an accurate understanding of
facial soft tissue anatomy. This led to further investigations
which more clearly defined both the anatomic and morpho-
logic changes which occur in the aging face, leading to a
plethora of technical approaches for facial rejuvenation. In
reviewing the literature, good results can be seen utilizing
what appears to be very different technical approaches. In
reality, most of these seemingly different technical procedures
share a common theme that contour restoration is predomi-
nantly through the re-elevation of facial fat as opposed to skin
envelope tightening. While good results are possible through
a variety of techniques, in my opinion, all methods have
advantages, disadvantages and limitations, with the ultimate
result often dependent upon underlying skeletal support and
the quality of facial soft tissues for a particular patient. From
my perspective, the key to consistent results in facelifting is
not the particular technique utilized, but rather the preopera-
tive aesthetic analysis and how the operative plan is individu-
alized according to the aesthetic needs of the patient.
To consistently improve facial shape in facelifting requires
the surgeon to accurately understand both facial anatomy and
the anatomic changes which have occurred in aging for a
particular patient, appreciate the importance of underlying
skeletal support in formulating the treatment plan, and incor-
porating one’s aesthetic vision into a surgical destination
which is appropriate for a specific patient.
History
All early facialplasty procedures were limited to skin excision
and wound closure without subcutaneous undermining.
Bames described subcutaneous face and neck undermining,
skin redraping, and excision of excess skin. The continuous
incision described by Bettman and subcutaneous undermin-
CHAPTER 8
ing recommended by Bames essentially established the basic
facelift procedure for the next 40 years.
Skoog described a technique of dissection of the superficial
fascial layer in the face in continuity with the platysma muscle
in the neck and advancement of the myofascial unit in a
cephaloposterior direction. This was the beginning of the
modern era in facelifting. Mitz and Peyronie used cadaver
dissections to define the limits of the superficial musculoapo-
neurotic system (SMAS) in the face and noted that tightening
of this layer would be beneficial in facialplasty. SMAS-
platysma facelifting, wide skin undermining, and extensive
fat removal soon gained worldwide popularity. Surgery of
the tissue layers deep to the skin of the face and neck is
now established as an essential part of cervical and facial-
plasty operations. Many surgeons have described different
SMAS-platysma techniques to improve the cervicofacial
area and to remedy problems not corrected by conventional
facialplasty.
Furnas, in 1989, described the retaining ligaments of the
midface, which led to a better understanding of anatomic
areas where facial soft tissue is supported and the involve-
ment of these ligaments in leading to the anatomic changes
that occur with aging. These ligaments were further defined
by others who felt that loss of the support from the retaining
ligament system allowed facial fat to descend inferiorly in the
face, deepening the nasolabial fold and forming facial jowls
with aging. The importance and location of the retaining liga-
ments led to modifications in procedures involving retaining
ligament release in sub-SMAS dissection, the primary goal of
these procedures being to reposition descended facial fat back
to the anatomic location of youth. Other surgeons, preferring
subperiosteal rather than sub-SMAS dissection to reposition
fat, developed procedures whose similar goal is to resuspend
descended malar fat to the malar eminences using the sub-
periosteal plane. A combination of subperiosteal and subcu-
taneous lifting has also been described.
Physical evaluation – patient planning
• Skin quality and elasticity.
• Age.
• Subcutaneous fat accumulation.
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 Section 3: Facelift
Aesthetic Plastic Surgery
• Contour change developing from attenuation of deep
layer support, i.e. jowling, deep nasolabial fold; and pla-
tysma banding with cervical obliquity.
• Degree of facial deflation.
• Degree of skeletal support – malar prominence, mandibu-
lar ramus height and length of mandibular body.
• The relationship between malar convexity and submalar
concavity.
Anatomic considerations
The anatomic basis that allows rhytidectomy to be performed
safely is that the facial soft tissue is arranged as a series of
concentric layers. This concentric arrangement allows dissec-
tion within one anatomic plane to proceed completely sepa-
rate from structures lying within another anatomic plane. The
layers of the face are the (1) skin; (2) subcutaneous fat; (3)
SMAS (superficial facial fascia); (4) mimetic muscles; (5)
parotidomasseteric fascia (deep facial fascia); and (6) plane
of the facial nerve, parotid duct, buccal fat pad, and facial
artery and vein.
The anatomic components of facial soft tissue anatomy,
which are essential for the surgeon attempting to master sub-
SMAS dissection to understand include the following:
1. Although there is variation in the thickness of the various
layers from patient to patient, structures within each layer
are anatomically constant. On a two-dimensional basis,
the facial nerve exhibits a variety of branching patterns,
but on a three-dimensional basis, the facial nerve always
lies within a specific anatomic plane. This anatomic
arrangement allows the surgeon to perform extensive sub-
SMAS dissection safely, as long as the dissection proceeds
at a level superficial to the plane of the facial nerve.
2. There is significant variability in terms of the thickness of
the superficial fascial layer (SMAS). This variability of
SMAS thickness is obvious from patient to patient. Also,
the thickness of the SMAS will vary from one region of the
face to another. Overlying the parotid gland, within the
temporal region (temporoparietal fascia) and within
the scalp (galea), the superficial fascia (SMAS) represents
a substantial, discrete layer. As the superficial fascia is
traced anteriorly in the face, overlying the masseter, buccal
fat pad, and into the malar region, the SMAS tends to
become thinner and less substantial. To elevate the super-
ficial fascia in these areas requires precise dissection, so that
the flap is thick enough to be useful in facial contouring.
3. The muscles of facial expression are arranged in four
anatomic layers which overlap one another. The muscles
that are encountered in facelifting, including the pla-
tysma, orbicularis oculi, zygomaticus major and minor,
and risorius muscle, are all superficially situated mimetic
muscles. This is in contrast to deeply situated mimetic
muscles such as the buccinator and mentalis muscle.
Most of the muscles of facial expression lie superficial to
the plane of the facial nerve. Because these muscles are
superficial to the plane of the facial nerve, they receive
their innervation along their deep surfaces. The only
88
muscles within the facial soft tissue architecture that lie
deep to the plane of the facial nerve are the mentalis,
buccinator, and levator anguli oris muscles. Because these
muscles lie deep to the plane of facial nerve, they receive
their innervation along their superficial surfaces.
4. The muscles of facial expression, which are situated
superficially within the facial soft tissue architecture and
are involved with the movement of facial skin, are invested
by the superficial fascia, which lines both the superficial
and deep surfaces of these muscles. Because these muscles
are invested by superficial fascia, this SMAS-mimetic
muscle complex forms a single anatomic and functional
unit whose components work together to move facial
skin during animation.
5. Deep to the SMAS-mimetic muscle complex lies the deep
facial fascia. The deep facial fascia represents a continua-
tion of the superficial layer of the deep cervical fascia
cephalad into the face. Where this fascial layer is identi-
fied, it is given specific nomenclature. Overlying the
parotid gland, the deep fascia is termed “parotid fascia”
or “parotid capsule”; overlying the masseter muscle, it is
termed “masseteric fascia”; and in the temporal region, it
has been termed “deep temporal fascia.” The significance
of the deep facial fascia is that all the facial nerve branches
within the cheek lie deep to the deep facial fascia. Typically,
these nerve branches course deep to the deep fascia until
they reach the muscles of facial expression that they
innervate, at which point they penetrate the deep fascia
to innervate these mimetic muscles along their deep sur-
faces (Fig. 8.1).
In an overview of the architectural arrangement of the
facial soft tissue, the essential point to grasp is that there is a
superficial component of the facial soft tissue that is defined
by the superficial facial fascia and includes the SMAS and
those anatomic components that move facial skin (including
superficially situated mimetic muscle invested by SMAS, the
subcutaneous fat, and skin). This is in contrast to the deeper
component of the facial soft tissue, which is defined by the
deep facial fascia and those structures related to the deep
fascia (including the relatively fixed structures of the face,
such as the parotid gland, masseter muscle, periosteum of the
facial bones, and facial nerve branches) (Fig. 8.2). As the
human face ages, many of the stigmata that are typically seen
in aging relate to a change in the anatomic relationship that
occurs between the superficial and deep facial fascia.
Extended SMAS technique
Except perhaps in the younger facelift patient, most individu-
als undergoing rhytidectomy will benefit from tightening of
the superficial fascial layer. Restoration of support to the
underlying deeper facial soft tissues has become an integral
part of the rejuvenation of the aging face. If the SMAS is thin
and tenuous, plication of this layer is a useful alternative to
formal SMAS elevation. Nonetheless, in my opinion, better
contouring and longer lasting results are obtained following
a formal dissection of the superficial fascia.
 Chapter 8 The SMAS facelift – restoring facial shape in facelifting

A B

Fig. 8.1 A, Cadaver dissection after SMAS-platysma elevation within the cheek exposing the underlying parotid gland, the anterior border of parotid (marked
in ink), and the parotid-masseteric fascia (held in forceps). The surgical significance of the parotid-masseteric fascia is that the facial nerve branches within the
cheek are always deep to this anatomic layer. B, Cadaver dissection after elevation of the parotid-masseteric fascia exposing the underlying masseter muscle
and the marginal mandibular nerve as it crosses the facial artery and vein. From Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep
facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89:441.

In skin flap dissection, it is important to develop uniform
skin flaps during the subcutaneous undermining, with care to
leave some fat intact along the superficial surface of the SMAS.
If the skin flaps are dissected such that no fat is left along the
superficial surface of the SMAS, then the SMAS becomes more
difficult to raise, appearing thin, tenuous and prone to tearing.
Much of the contouring that I obtain in my facelift has to do
with elevation and fixation of the SMAS layer. The more sub-
stantial the SMAS flap, often the better long-term results that
can be obtained in terms of facial contouring. Transillumina-
tion when performing subcutaneous dissection is a useful
technique in allowing precise skin flap elevation.
I usually carry the subcutaneous skin flap dissection well
into the malar region and usually the skin overlying the
lateral two-thirds of the zygomatic eminence is undermined.
I prefer to stop the skin undermining several centimeters
lateral to the nasolabial fold rather than undermining the
skin to this facial landmark. This is to limit the dissection of
the skin flap in the medial aspect of the cheek, subsequently
preserving the attachments from the SMAS to facial skin. The
preservation of these attachments, followed by adequate
undermining of the superficial facial fascia (SMAS), will allow
the surgeon to re-elevate facial skin through SMAS rotation
rather than to redrape the superficial fascia completely inde-
pendent of skin flap redraping. The ability to re-elevate and
resuspend facial skin through SMAS rotation, in my opinion,
produces a more pleasing aesthetic result in most patients,
and preserves some of the peripheral vascularity to the facial
skin flap.
SMAS elevation
The dissection of the superficial fascia allows the surgeon to
re-elevate jowl and descended malar fat back upward into the
face toward their previous normal anatomic location. In
patients with prominent nasolabial folds, and significant
malar pad descent, it has been my feeling that the SMAS dis-

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 Section 3: Facelift
Aesthetic Plastic Surgery

Zygomatic ligaments

Zygomaticus minor muscle

Zygomaticus major muscle

Masseteric cutaneous
Parotid cutaneous
ligaments
ligaments
Risorus muscle

Mandibular ligaments

Fig. 8.2 Facial soft tissue is maintained in a normal anatomic location by a series of supporting ligaments. The zygomatic and mandibular ligaments are
examples of osteocutaneous ligaments that originate from the periosteum and insert directly into the dermis. The masseteric cutaneous and parotid cutaneous
ligaments are formed as a coalescence between the superficial and deep facial fascias. Rather than originating from periosteum, these ligaments originate from
relatively fixed facial structures such as the parotid gland and the anterior border of the masseter muscle. Attenuation of support from the retaining ligaments
is responsible for many of the stigmata seen in the aging face. From Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias:
relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89:441.

section should extend into the malar region in an effort to
re-elevate the malar fat pad back upward overlying the zygo-
matic eminence. An added benefit of performing a more
extensive anterior dissection of the SMAS is that it frees this
layer from the restraint of both the zygomatic and masseteric
ligaments, and this anterior release provides for a more com-
plete elevation of the facial fat below the oral commissure
and along the anterior portion of the jowl.
The incisions for extended SMAS dissection begin approxi-
mately 1 cm inferior to the zygomatic arch to ensure frontal
branch preservation (Fig. 8.3). This horizontal incision is con-
tinued several centimeters forward to the region where the
zygomatic arch joins the body of the zygoma. At this point,
the malar extension of the SMAS dissection begins with the
incision angling superiorly over the malar eminence toward
the lateral canthus for a distance of 3 to 4 cm. On reaching
the edge of the subcutaneous skin flap in the region of the
lateral orbit, the incision is carried inferiorly at a 90 degree
angle toward the superior aspect of the nasolabial fold. A
vertical incision is designed along the preauricular region,
extending along the posterior border of the platysma to a
point 5 to 6 cm below the mandibular border. In essence, the
malar extension of the SMAS dissection simply represents an
extension of a standard SMAS dissection into the malar region
in an attempt to obtain a more complete form of deep layer
support.
The SMAS in the malar region is then elevated in continu-
ity with the SMAS of the cheek. When elevating this flap, the
fibers of the orbicularis oculi, as well as the zygomaticus
major and minor, are usually evident and the flap is elevated

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 Chapter 8 The SMAS facelift – restoring facial shape in facelifting

Fig. 8.3 In patients with prominent nasolabial folds, I perform what I term an extended SMAS dissection. By this, I mean I extend the SMAS dissection into the
malar region in an attempt to re-elevate ptotic malar fat back upward over the zygomatic prominence. The incisions begin at the junction where the
zygomatic arch joins the body of the zygoma. From this point, the incision in the SMAS is angled superiorly toward the lateral canthus and along the lateral
orbital rim. The incision in the SMAS is then carried medially and inferiorly toward the peripheral extent of skin flap undermining, angling toward the
uppermost portion of the nasolabial fold (the amount of subcutaneous undermining is shaded in pink, whereas the amount of SMAS undermining is shaded in
yellow). From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, pp. 254–255.

directly along the superficial surface of these muscles. It is
important to carry the dissection directly external to these
muscle fibers, where a natural plane exists, remembering that
the facial nerve branches lie deep to these muscular bellies.
The malar SMAS is then elevated until the flap is freed from
the underlying zygomatic prominence. Freeing of the SMAS
completely from the zygomatic attachments is an important
technical point in obtaining the mobility necessary to reposi-
tion the malar soft tissue superiorly. To obtain this mobility
usually also requires a division of the upper fibers of the
masseteric cutaneous ligaments, which will expose the
underlying body of the buccal fat pad. The cheek portion of
the SMAS dissection is performed beginning directly overly-
ing the parotid gland and then extending this dissection
anterior to the parotid utilizing a combination of sharp and
blunt dissection toward the anterior border of the masseter
(Fig. 8.4).
In most patients, following extended SMAS dissection of
the cheek and malar regions, mobility of the soft tissues lying
lateral to the nasolabial fold remains restricted unless the
dissection is carried more medially. This restriction in move-
ment results from the undivided retaining ligaments which
originate medial to the zygomaticus minor. To improve
mobility, I commonly continue malar pad elevation medially
in an area where we have not subcutaneously undermined
the skin. This dissection is carried directly in the plane between
the malar fat and the superficial surface of the elevators of the
upper lip. It is usually quite easy to delineate this level of
dissection after the malar SMAS elevation is complete, and
the superficial surface of the elevators of the upper lip is visu-
alized. The scissors are then inserted directly superficial to the
elevators of the upper lip, and blunt dissection is quickly
performed by pushing the scissors in a series of passes bluntly
toward the nasolabial fold. We find that when we insert the
scissors in the proper plane, the dissection quickly glides
through the malar soft tissues and we usually will feel a
“snap” as we dissect through the remaining retaining liga-
ments. Once these structures are divided, one notes greater
mobility when traction is applied to the malar portion of the
SMAS flap, translating into greater movement along the
uppermost portion of the nasolabial fold (Fig. 8.5).
Repositioning and closure of the SMAS is then performed.
The malar SMAS flap is advanced superiolaterally over the
zygomatic prominence in a direction perpendicular to the

91
 Section 3: Facelift
Aesthetic Plastic Surgery

A B

Fig. 8.4 A&B, The malar-SMAS dissection is then performed in continuity with the cheek-SMAS dissection. Dissecting in the malar region carries the dissection
directly along the superficial surface of the zygomaticus major and usually exposes the lateral aspects of the zygomaticus minor as well. To obtain adequate
mobility in terms of SMAS dissection, it is necessary to elevate the malar portion of the dissection completely from the zygomatic eminence and free it from
the zygomatic ligaments. To obtain mobility in terms of SMAS movement affecting the jowl contour, the uppermost portions of the masseteric cutaneous
ligament commonly are divided, especially where they merge with the zygomatic ligaments of the malar area. If these fibers are not divided, they will restrict
the upward redraping of jowl fat. This diagram and intraoperative photograph illustrate the typical degree of mobilization performed in the extended SMAS
dissection. From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, pp. 254–255.

nasolabial fold, and usually paralleling the zygomaticus major
muscle. After superior and lateral advancement, if a malar
augmentation is not planned, the excess tissue can be excised
and the flap securely fixated to the zygomatic periosteum with
interrupted sutures. In many patients, I incorporate Vicryl
mesh (an absorbable mesh) into the SMAS fixation to improve
the tensile strength of SMAS closure (Figs 8.6, 8.7).
If significant platysma banding is present, a platysma-
plasty is performed through a submental incision. I typically
approximate the medial edges of the platysma extending
from the mentum caudally toward the base of the neck, fol-
lowed by a transverse platysma myotomy performed low in
the neck to alleviate tension along the platysma closure
(Figs 8.8–8.12).
Postoperative care
The patient is provided with specific instructions about post-
operative care. Some surgeons provide the patient with a
printed list, whereas others prefer to give the instructions
verbally.
If the patient is healing well at the end of a week or 10
days, return is advised in 2 to 3 weeks for a routine postopera-
tive visit and again in 6 weeks. The patient is instructed to
return or call at any time if there are any questions about the
postoperative course.
During the first week the patient is allowed to walk and is
encouraged to be up and about as much as is reasonably pos-
sible. Strenuous physical activities such as tennis, water-skiing,
and golf are not permitted for 5 or 6 weeks. A good basic rule
is: “If it hurts, don’t do it.”
The following postoperative recommendations have
proven helpful for most patients:
• Pressure dressings are not used. A light facelift dressing is
placed for the first 24 hours.
• The head of the bed is elevated at all times, but flexion of
the patient’s neck is avoided because this may compro-
mise circulation to the cervical flap.
• Appropriate pain and sleep medications are given; strong
narcotics are rarely required.
• The patient may go to the bathroom with assistance on
the first postoperative day and as desired thereafter.

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 Chapter 8 The SMAS facelift – restoring facial shape in facelifting

Fig. 8.5 It is commonly necessary to extend the malar SMAS dissection

more peripherally than the subcutaneous dissection to obtain adequate
flap mobility of the soft tissues lateral to the nasolabial fold. This portion
of the dissection is easily performed by simply inserting the scissors in
the plane between the superficial surface of the elevators of the upper
lip and the overlying subcutaneous fat. Once the scissors are inserted in
the proper plane, the surgeon bluntly dissects in a series of passes past
the nasolabial fold (area marked in green). As long as the scissors remain
superficial to the elevators of the upper lip, motor nerve injury will be
prevented. Two or three passes are usually required to obtain adequate
flap mobility. From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation
of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, p. 257.

Fig. 8.6 The vectors of redraping of the extended SMAS flap are
determined according to the preoperative evaluation of the patient and
are generally more cephalad than skin flap redraping. From Baker TJ,
Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St.
Louis: Mosby-Year Book, 1996, p. 259.

93
 Section 3: Facelift
Aesthetic Plastic Surgery

Fig. 8.7 Diagram illustrating how the excess SMAS, rather than being
excised, is rolled onto itself (forming a double layer of SMAS
thickness). Once the roll has been formed, it is fixated to the
periosteum of the zygomatic buttress using permanent sutures. It is
important to obtain a secure intraoperative fixation, and emphasize
that fixation is as important as adequate SMAS mobilization. A small
piece of Vicryl mesh is typically incorporated into the roll of the SMAS
to improve its tensile strength. From Baker TJ, Gordon HL, Stuzin JM.
Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book,
1996, p. 263.

Fig. 8.8 After edge-to-edge approximation of the platysma from the mentum to the cricoid
cartilage, some form of muscle release is performed. This usually consists of a horizontal cut
extending from the midline to the anterior border of the sternocleidomastoid muscle. The
key to platysma transection is to perform it low in the neck.

94
 A

Fig. 8.9 A, Preoperative appearance of a 59-year-old male following a 90 pound weight loss from a gastric bypass procedure. Notice the significant areas of
facial deflation along the infraorbital rim, lateral orbital rim and malar region. Also notice the radial expansion of skin and fat lateral to the nasolabial fold, most
marked on the right side. Not only does malar fat descend, but attenuation of the retinacular connections among skin, fat and deep facial fascia lateral to the
nasolabial line allows prolapse of soft tissue, which accentuates nasolabial prominence. B, Postoperatively, the areas of deflation along the infraorbital rim,
lateral orbital rim, and malar region are improved as facial fat has been repositioned into these regions. The nasolabial folds are somewhat improved after malar
pad repositioning, but correction is incomplete, especially on the right. Malar pad elevation helps to flatten the prominent nasolabial fold, but does little to
correct radial expansion, with the skin lateral to the nasolabial line remaining prolapsed from its attachments to the facial skeleton. From Stuzin JM. Restoring
facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362–376.
 Section 3: Facelift
Aesthetic Plastic Surgery

A B

Fig. 8.10 A&B, Long, thin faces often benefit from an enhancement of malar volume. SMAS dissection and facial fat repositioning carried anteriorly over the
zygomatic eminence allows the surgeon to restore malar volume, thereby increasing bizygomatic diameter. When malar volume is enhanced, the face appears
wider, detracting from the relatively excessive facial length. From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis
and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362–376.

A B

Fig. 8.11 A, Preoperative appearance. Note that facial shape is oval, secondary to malar deflation, associated with an increase in submalar fullness.
B, Postoperatively, following malar pad elevation, malar volume is enhanced in association with a restoration of submalar concavity, producing a more
angular appearance to facial shape.

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 Chapter 8 The SMAS facelift – restoring facial shape in facelifting

A B

Fig. 8.12 A, Preoperatively, this patient shows a similar blunting of the relationship between the malar and submalar regions. B, Postoperative appearance.
Enhancing malar volume (and bizygomatic diameter) and restoring the concavity within the submalar region make the face appear more angular, as well as
vertically shorter.

• The first dressing is changed after 24 hours. At this time, lems. The most common complications after rhytidectomy
the wounds are inspected and no further dressing is are:
utilized.
• Hematoma (70% of all rhytidectomy complications).
• Preauricular sutures are removed on the fifth or sixth post-
• Postoperative edema.
operative day.
• Ecchymosis.
• All sutures are removed by the tenth postoperative day.
• Nerve injury.
• Antibiotics are routinely used preoperatively and for 5
days postoperatively. My current preference is Levaquin, • Unacceptable scarring (hypertrophic).
500 mg once daily, begun the night prior to surgery. • Skin slough.
• If crusty or oozing, wounds are cleaned with hydrogen • Seromas.
peroxide and coated with a topical antibiotic ointment. • Contour irregularities.
• Infection.
• Patient dissatisfaction.
Complications

No surgical procedure exists without complications. The

surgeon must be able to recognize and deal with these prob-

97
 Section 3: Facelift
Aesthetic Plastic Surgery
Pearls & pitfalls
Pearls
• Improving technical control through contouring the
superficial facial fascia and platysma provides for a more
consistent, aesthetically pleasing result which is natural in
appearance.
• Patient selection is probably the most critical factor when
determining the success of a proposed aesthetic procedure.
• Although aging represents a complex process, many of the
stigmata developing in the aging face involve a change in
the relationship between the superficial and deep facial
fascia, with the superficial unit of the facial soft tissue
descending inferiorly in relation to the fixed deeper struc-
tures of the face.
• The prime advantage of performing skin undermining
separately from SMAS dissection is that it allows these two
layers to be redraped along vectors which are independent
of one another.
• The importance of incision quality cannot be overempha-
sized in diminishing the stigmata that the patient has
undergone a surgical procedure.
Summary of steps for extended SMAS procedure
1. Tragal margin incision design which respects the aesthetic
units of the tragus and preserves the tragal insisura.
2. The use of transillumination to allow precise skin flap
undermining which preserves the fat along the superficial
surface of the SMAS provides greater consistency in SMAS
flap elevation.
3. Limiting subcutaneous undermining over the buccal
recess and buccinator allows this region of the cheek to be
repositioned through SMAS rotation producing greater
control in terms of submalar contour and jowl correction.
4. The incision of the extended SMAS dissection parallels the
zygomatic arch and then extends superiorly over the malar
eminence in the area where the arch joins the body of the
zygoma.
5. Releasing the SMAS from the restraints of the retaining
ligaments until the SMAS moves freely requires the
surgeon to carry the dissection into the mobile region of
the SMAS which lies anterior to the retaining ligaments
over the malar eminence and parotid.
98
Pitfalls
• Imprecise subcutaneous undermining of the skin flap can
lead to a paucity of fat being left along the superficial surface
of the SMAS, making it difficult or impossible to raise the
SMAS as a discrete anatomic layer, limiting its usefulness in
facial contouring.
• Not extending the release of the SMAS anterior to the
adherence of the retaining ligaments limits the movement of
this layer, thereby limiting surgical control in terms of
restoring facial shape.
• Vertical skin tension to tighten the face often produces an
unnatural surgical appearance to the postoperative result
and can be avoided by utilizing the superficial fascia to
vertically reposition facial fat.
• Imprecise incision design and skin flap inset can lead to
noticeable scars, hairline shifts, tragal and earlobe distortion.
Limiting skin tension by utilizing the SMAS to restore facial
shape provides the surgeon with greater control in terms of
scar perceptibility.
• Attempting to improve cervical contour through lateral
platysma tension and closed suction lipoplasty of the neck
provides less consistent results than approaching platysma-
plasty anteriorly through a submental incision.
6. Vectoring the SMAS should be patient-specific and should
be determined preoperatively with the patient in an
upright position. Variation in vectors between the right
and left side of the face are common.
7. Secure fixation of the SMAS, often incorporating Vicryl
mesh into the closure improves consistency in shaping
and postoperative results.
8. Approaching platysmaplasty through a submental incision
and suturing the platysma from the mentum to the base
of the neck provides greater control in cervical contouring.
9. Meticulous hemostasis leads to a low hematoma rate and
more rapid postoperative recovery.
10. Placement of drains along the base of the neck prior to
closure promotes rapid postoperative recovery.
11. Precise skin flap inset and closure with minimal tension,
especially along the tragus and earlobe leads to control of
scar perceptibility.

Further reading
Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face,
2nd edn. St. Louis: Mosby, 1996.
Bames H. Truth and fallacies of face peeling and facelifting. Plast
Reconstr Surg 1927;126:86.
Barton FE, Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr
Surg 1992;90:601.
Connell BF. Neck contour deformities: The art, engineering,
anatomic diagnosis, architectural planning, and aesthetics of
surgical correction. Clin Plast Surg 1987;14:683.
Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg
1990;85:333.
Furnas D. The retaining ligaments of the cheek. Plast Reconstr Surg
1989;83:11.
Mitz V, Peyronie M. The superficial musculoaponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg
1976;58:80.
Chapter 8 The SMAS facelift – restoring facial shape in facelifting
Owsley JQ, Jr. Lifting the malar fat pad for correction of prominent
nasolabial folds. Plast Reconstr Surg 1993;91:463.
Skoog T. Plastic surgery – New methods and refinements.
Philadelphia: W.B. Saunders, 1974.
Stuzin JM. Restoring facial shape in facelifting: The role of skeletal
support in facial analysis and midface soft-tissue
repositioning. Plast Reconstr Surg 2007;119:362.
Stuzin JM, Baker TJ, Baker TM. Refinements in facelifting:
Enhanced facial contour using Vicryl mesh incorporated into
SMAS fixation. Plast Reconstr Surg 2000;105:290.
Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS
dissection as an approach to midface rejuvenation. Clin Plast
Surg 1995;22:295–311.
Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial
and deep facial fascias: Relevance to rhytidectomy and aging.
Plast Reconstr Surg 1992;89:441.
99