Building the Composite Face Lift: A Personal Odyssey

An Approach to Selection of Face-Lift Techniques for Different Types of Faces: An Analysis of 1000 Asian Patients Over 9 Years

BACKGROUND

A face-lift or rhytidectomy is the procedure most directly associated with rejuvenation. There are several surgical techniques for face-lifts, but criteria for the selection of techniques, based on the patient's face shape, are lacking. In this study, we report on our experience with specific indication criteria for each technique and the consequent achievement of good outcomes.

METHODS

From 2015 to 2023, 1 surgeon performed face-lifts on 1000 patients. Three different superficial musculoaponeurotic system (SMAS) techniques (SMAS dissection, SMASectomy, and SMAS plication) were applied depending on the degree of sagging of the patient's lower face, lateral facial profile, and SMAS mobility and condition. Superficial musculoaponeurotic system dissection was considered for the improvement of a square face, sagging jowls, and marionette lines. Superficial musculoaponeurotic system plication was applied with patients with less sagging jowls and prominent zygoma with concave lateral facial profile. SMASectomy was applied with patients with convex lateral facial profiles or when the SMAS was too thin or damaged. Patient postoperative satisfaction was surveyed using the FACE-Q score 1 year post surgery.

RESULTS

Most of the patients attained natural-looking and long-lasting aesthetic outcomes and exhibited high satisfaction. The patients indicated that they looked about 11.2 ± 5.2 years younger than their actual age after the surgery. The mean satisfaction scores for each facial feature were as follows: cheeks (91.1 ± 7.8), marionette lines (88.5 ± 13.6), lower face and jawline (92.5 ± 14.2), under chin (87.8 ± 15.1), and neck (86.2 ± 18.5). Complications such as facial nerve injury, infection, hematoma, and flap necrosis were very rare.

CONCLUSIONS

Establishing criteria for the selection of face-lift surgical techniques based on the degree of lower face sagging, lateral facial profile, and SMAS mobility and condition led to good outcomes. These criteria can be used by physicians to determine the most effective face-lift surgery technique based on a patient's individual features, which may improve surgical outcomes.

Trials, Tribulations, and Techniques for Transitioning to an Extended Deep Plane Facelift for All Patients: Insight from a Very Experienced Surgeon's Perspective

The extended deep plane facelift is a powerful technique to correct aging of the midface and neck. After many years of superficial muscular aponeurotic system lift techniques, the senior author transitioned to an extended deep plane facelift for all patients. The primary catalyst for this shift in practice was the pursuit of superior rejuvenation of the midface. Consistent uniform elevation of the deep plane with complete ligament release and management of the soft tissue flap were the most significant challenges in the early adoption period. Navigating the transition was facilitated by consultation with experienced colleagues and frequent cadaver dissections. This manuscript details the authors' current technique. Complications and recovery from this technique are similar to those reported with historical techniques and are minimized with proper preparation, precision, and perioperative management. In our experience the results from this procedure are extremely reproducible, durable, and natural, and patients are overwhelmingly extremely satisfied.

Mini-Incision Direct Festoon Access, Cauterization, and Excision (MIDFACE): A 12-Year Analysis of a Novel Festoon Surgery

BACKGROUND

Surgical festoon management often entails aggressive dissection, flaps, unsightly scars, prolonged recovery, and high recurrence rates. The authors present outcomes with subjective and objective evaluation of an office-based, novel, minimally invasive (1-cm incision) festoon repair: mini-incision direct festoon access, cauterization, and excision (MIDFACE).

METHODS

Charts of 75 consecutive patients from 2007 to 2019 were evaluated. Photographs of 39 patients who met inclusionary criteria were evaluated by three expert physician graders for festoon and incision visibility (339 randomly scrambled preoperative and postoperative photographs taken with and without flash and from four different views: close-up, profile, full-frontal, and worm's eye) using paired t tests and Kruskal-Wallis tests for statistical evaluation. Surveys returned by 37 of 75 patients were evaluated for patient satisfaction and possible contributing factors to festoon formation or exacerbation.

RESULTS

There were no major complications in the 75 patients who underwent MIDFACE. Physician grading of photographs of 39 patients (78 eyes, 35 women; four men; mean age, 58 ± 7.7 years) demonstrated statistically significant sustained improvement in festoon score postoperatively up to 12 years regardless of view or flash. Incision scores were the same preoperatively and postoperatively, indicating incisions could not be detected by photography. Average patient satisfaction score was 9.5 on a Likert scale of 0 to 10. Possible factors for festoon formation or exacerbation included genetics (51%), pets (51%), prior hyaluronic acid fillers (54%), neurotoxin (62%), facial surgery (40%), alcohol (49%), allergies (46%), and sun exposure (59%).

CONCLUSION

MIDFACE repair results in sustained improvement of festoons with an office-based, minimally invasive procedure with high patient satisfaction, rapid recovery, and low recurrence.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

U-type soft tissue lifting: A new composited technique for reversing lower eyelid and midfacial aging

BACKGROUND

Facial rejuvenation is becoming more and more popular, particularly among middle-aged persons. There are currently many techniques for improving the aforementioned situations, but each has its drawbacks. Our study aimed to discuss the treatment effect of a composited technique for reversing both lower eyelid and midface aging.

METHODS

The patient's face was designed and measured before surgery. During surgery, a traditional lower blepharoplasty incision was made. The layer between the orbital septum and the orbicularis oculi muscle was separated to approximately 4-5 mm below the infraorbital, then the orbital septum and orbicularis retaining ligament were found to be released. A self-made suspension curving needle subconsciously passed through the brim of the superficial cheek fat pad via the "U-type" path and raised them to the proper location. Then sutured them to the infraorbital rim periosteum, as well as the suborbicularis oculi fat (SOOF) and the orbital septum fat. Secured the outside canthus to keep the lower lid position stable.

RESULTS

From February 2020 to November 2022, 106 patients underwent the new surgical procedure and were successfully followed up for 20 ± 6.5 months postoperatively. The mean GAIS score was 2.42 ± 0.78, patient satisfaction rate was 95%. All of the Barton grades were decreased. The nasal base level suspension points were elevated to a level of 5 ± 2 mm. 3D measurement data revealed significant improvements.

CONCLUSIONS

The composited technique is a safe and effective way to reverse the aging of the lower eyelid and midface.

Facelift Techniques: An Overview

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

High SMAS Facelift: Combined Single Flap Lifting of the Midface, Cheek, and Jawline

The traditional deep plane and "low" cheek superficial musculoaponeurotic system (SMAS) flaps elevated below the zygomatic arch suffer the drawback that they cannot, by design, exert an effect on tissues of the midface and infra-orbital region. Traditional deep plane and low designs target the lower cheek and jowl only and produce no improvement in the upper anterior cheek and "midface" area. Planning the flap "higher," along the zygomatic arch, and extending the dissection medially in an "extended SMAS" fashion to release and mobilize midface tissue, overcomes this problem and allows a combined, simultaneous, single flap lifting of the jawline, cheek, and midface. An improved outcome is obtained in many patients and no separate midface lift procedure is needed.

Modified Composite Plane Facelift with Extended Neck Dissection

The attenuation of retaining ligaments with aging leads to downward displacement of facial fat compartments and is responsible for many of the stigmata that occur with aging. The zygomatic cutaneous and masseteric cutaneous ligaments prevent the transmission of adequate traction to the malar portion of the dissection during traditional low superficial muscular aponeurotic system (SMAS) facelift techniques which involve plication or imbrication of the exposed surface of the SMAS because they do not include surgical release of these ligaments. Inadequate release of these ligaments, especially the zygomatic cutaneous ligament may lead to an unbalanced, unnatural appearance with unopposed nasolabial folds. In contrast, extended facelift techniques (extended SMAS, high SMAS, deep plane facelift, and composite plane facelift) involving the release of these ligaments and can reposition the ptotic malar fat and diminish the nasolabial folds. Additionally, the composite and modified composite plane facelifts include orbicularis oculi muscle elevation and can achieve a more harmonious rejuvenation. However, due to facial nerve injury risk, many facelift surgeons either inadequately release these ligamentous attachments or prefer less-invasive techniques. Modified composite plane facelift allows safe release of the zygomatic cutaneous ligament, and safe entry into the right plane leaving all malar fat pad attached to the skin. Modified composite plane facelift technique also produces combined, balanced, and harmonious rejuvenation of the midface, cheek, lower face, and neck without requiring a separate midface lift procedure or a transblepharoplasty approach. Extending the sub-SMAS/subplatysmal dissection inferior to the angle of mandible, releasing of the cervical retaining ligaments, and adding a horizontal platysma myotomy below the angle of the mandible significantly improve the cervical contouring and enhances the jawline rejuvenation. This study explains modified composite-flap facelift with extended neck dissection in a step-by-step manner and highlights anatomical details to perform a safe, effective, and successful extended face and neck lift surgery.

Facelift Patients Receiving Intraoperative Administration of a Self-assembling Hemostat Agent Experienced Minimal Bruising and No Acute Hematomas: A Pilot Study

Background

Hematomas are consistently cited as the most common complication of facelift surgery, with reported incidence rates ranging from 1% to 9% despite preventative measures. A self-assembling RADA16 peptide solution (PuraSinus, 3-D Matrix, Newton, MA) designed to aid in wound healing, adhesion prevention, and bleeding control has demonstrated hemostatic control of intra- and postoperative bleeding associated with various surgical procedures, including nasal and sinus surgery.

Objectives

To report surgical experience using novel application of RADA16 hemostatic agent in facelift procedures.

Methods

Through exploring incorporation of RADA16 hemostatic agent into standard of care, 15 higher-risk facelift patients were treated intraoperatively between December 2020 and July 2021. Postoperative follow-up was on post-procedure day 1 and 3 and at approximately one week. During follow-up, potential complications were assessed subjectively, including hematoma, swelling, and bruising; postoperative observations recorded; and photographs taken.

Results

Among facelift patients receiving intraoperative RADA16 hemostatic agent there were no hematomas or protracted ecchymosis events. The only significant complication was one patient admitted for intravenous hydration due to post-operative nausea and vomiting. All patients had minimal bruising or a dramatic absence of bruising and experienced no hemorrhage or hematoma. Through surgical experience, technique for RADA16 hemostatic agent placement was optimized and procedural details are provided.

Conclusions

Intraoperative administration of topical RADA16 hemostatic agent appears to deter acute hematoma and hemorrhage formation and early experience suggests that RADA16 hemostatic agent may also attenuate post-operative bruising in facelift patients. These observations warrant further investigation in a larger randomized controlled study.

Level of Evidence: 4

Asian Face Lift with the Composite Face Lift Technique

BACKGROUND

The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors' technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure.

METHODS

Composite face lifts were performed on 128 Asian patients between January of 2010 and June of 2020. Ninety-four were primary face lifts, and 34 were secondary or tertiary face lifts. The authors' surgical technique and adaptations for the specific requirements of Asian patients are described in detail. The mean follow-up was 26 months (range, 6 to 108 months). Fat grafting was an integral part of our procedure, with 95 percent having concomitant facial fat grafting with their face lift.

RESULTS

Patients were followed up in accordance with a standardized schedule. The majority of patients reported high satisfaction with the aesthetic outcome of the technique, with natural, long-lasting results. The face lift plane of dissection is through the facial soft-tissue spaces, which provide atraumatic sub-SMAS access with precise release of the intervening retaining ligaments for effective flap mobilization. By emphasizing tension on the composite flap with no tension on the skin closure, the scars were discrete in the great majority of patients. Complications were few, with no hematomas or skin flap necrosis. The temporary nerve injury rate was 1.5 percent, with no patient having a permanent nerve injury.

CONCLUSION

The composite face lift is an ideal technique for Asian patients, as it delivers natural, long-lasting results; a quick recovery; and high patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Facelift Part II: Surgical Techniques and Complications

Although previous publications have reviewed face and necklift anatomy and technique from different perspectives, seldom were the most relevant anatomical details and widely practiced techniques comprehensively summarized in a single work. As a result, the beginner is left with a plethora of varied publications that require sorting, rearrangement, and critical reading. A recent survey of US plastic surgery residents and program directors disclosed less facility with facelift surgery compared with aesthetic surgery of the breast and trunk. To this end, 4 of the widely practiced facelift techniques (ie, minimal access cranial suspension-lift, lateral-SMASectomy, extended-SMAS, and composite rhytidectomy) are described in an easy review format. The highlights of each are formatted followed by a summary of complications. Finally, the merits and limitations of these individual techniques are thoroughly compared and discussed.

LEVEL OF EVIDENCE: 4

Trinity Lift: A Unique Technique for Endoscopic Midface and Lower Periorbital Unit Lift

INTRODUCTION

A harmonious face is defined in terms of a balanced relationship among all facial tissues. This balance among skin, fat, muscle, and bone is lost with aging as progressive changes occur in their volume, shape, position, and consistency. Aging of the human face generally starts in the third decade of life, mainly in the midface and periorbital areas. Traditional face-lifting surgeries result in minimal improvements in the midface area. Various techniques have been developed using different dissection planes and vectors with different forms of incision, including endoscopic techniques.

METHODS

We attempted to combine endoscopic subperiosteal dissection techniques with the percutaneous needle technique, especially in young- to middle-aged patients. We aim to share technical details of our preferred suspension and fixation method for an endoscopic midface lift with the aid of a percutaneous needle and to present the outcomes of this particular technique in 75 patients.

RESULTS

Significant rejuvenation of the nasojugal groove was achieved, and patient satisfaction was high. All cases exhibited satisfactory, symmetrical, and stable elevation of the midface. None of the patients required a second surgery.

CONCLUSION

Trinity lift allowed for stronger, easier, and faster application of sutures during endoscopic facial surgery without any other mucosal or transcutaneous incisions.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Guided suturing technique for midface lift through minimal temporal incision

BACKGROUND

The midface has been a difficult zone to manage in rejuvenating surgeries. The major challenge for midface lift is to achieve extensive dissection and elevate the composite tissues en bloc through minimal incisions.

METHODS

In a total of 22 composite midface lift cases, a titanium cable wire was used. The wire was made into an elastic loop that guided three SMAS-suspending sutures out of the subcutaneous plane through a short incision at the temporal region. Then, each suture was fixated to the deep temporal fascia. Postoperative complications and the subjective assessment of the patients were evaluated.

RESULTS

Surgeries were successfully commenced in all cases. Midface sagging, eye bags, and nasolabial folds all exhibited considerable improvements. Major complications such as nerve injury and alopecia were not observed. The patients were followed up for an average of 16.9 months. In general, 90% of the patients were satisfied with their outcome.

CONCLUSION

This guided suspension suturing technique effectuates a more convenient and efficient way to conduct multi-points anchorage of the composite malar flap. When properly executed, this technique allows the anchorage sutures to bite into the deeper layer of the SMAS that ensures firm suspensions in midface rejuvenation surgery.

Face Lift Using Dual Deep Tissue Support

BACKGROUND

Utilizing the concept of Barton's high superficial musculo-aponeurotic system (SMAS) technique, the authors performed the more extensive skin-attached SMAS/platysma flap elevation and the 'dual deep tissue support' technique involving multiple plications of the parotid-masseteric fascia, repositioning of the SMAS, and platysma muscle. Our aim was to demonstrate a specific surgical procedure for face and neck lift and offer its pitfalls and outcomes.

METHODS

This study included 83 patients aged between 54 and 73 years. The pre- and 10-month postoperative photographs of all patients were used to assess the extent of the nasolabial folds, the labiomental fold, and the cervical band (platysma band). Each patient's subjective aesthetic satisfaction was also evaluated.

RESULTS

At 3 and 6 months postoperatively, 94% (n = 3) of patients achieved "minimal" and "mild" nasolabial folds. Most patients (89.1%, n = 74) were satisfied with their outcomes. Two minor hematomas (2.4%) occurred locally over the temporal or retro-auricular area. No incidence of skin flap necrosis or permanent facial nerve injury was observed.

CONCLUSIONS

Our extensive skin-attached SMAS/platysma flap elevation with dual deep tissue support, both by multiple parotic masseteric plication and SMAS/platysma repositioning, provided not only the definite lifting effect in the immediate postoperative period, but also resulted in long-lasting lifting outcomes without remission.

LEVEL OF EVIDENCE

IV.

Facelift Part I: History, Anatomy, and Clinical Assessment

In this article, the authors aim to thoroughly describe the critical surgical anatomy of the facial layers, the retaining ligamentous attachments of the face, and the complex three-dimensional course of the pertinent nerves. This is supplemented with clarifying anatomic dissections and artwork figures whenever possible to enable easy, sound, and safe navigation during surgery. The historic milestones that led the evolution of cervicofacial rejuvenation to the art we know today are summarized at the beginning, and the pearls of the relevant facial analysis that permit accurate clinical judgment and hence individualized treatment strategies are highlighted at the end. The facelift operation remains the cornerstone of face and neck rejuvenation. Despite the emergence of numerous less invasive modalities, surgery continues to be the most powerful and more durable technique to modify facial appearance. All other procedures designed to ameliorate facial aging are either built around or serve as adjuncts to this formidable craft.

Modified Composite-Flap Facelift Combined With Finger-Assisted Malar Elevation (FAME): A Cadaver Study

BACKGROUND

Inadequate release of retaining ligaments during facelift surgery may lead to an unnatural appearance. However, most facelift surgeons are hesitant in transecting these ligaments to avoid possible injury to facial subbranches.

OBJECTIVES

In the authors' surgical practice for modified composite flap rhytidectomy, the authors employed the finger-assisted malar elevation (FAME) technique in order to enable safe release of the zygomatic cutaneous ligaments through the prezygomatic space under direct vision. The aim was to evaluate the anatomical basis and safety measures of this technique through a cadaveric dissection study.

METHODS

Modified composite-flap facelift with the FAME technique was carried out in 22 fresh cadaver hemi-faces. All facial nerve subbranches were dissected thoroughly to assess for any evidence of injury during facelift, and to evaluate the safety of the operation. The relations among the facial nerve, zygomatic cutaneous and masseteric ligaments, orbicularis oculi muscle, and malar fat pad were investigated.

RESULTS

Finger dissection of the prezygomatic space allows safe release of the zygomatic cutaneous ligaments as well as adequate entry to a proper surgical plane above the zygomatici muscles under direct vision, while leaving the malar fat pad and overlying structures attached to the skin without the need of a transblepharoplasty approach.

CONCLUSIONS

This study by the authors shows that a modified composite-flap facelift with FAME technique is a safe procedure that allows adequate and effective repositioning of an en-bloc composite flap that produces balanced and harmonious rejuvenation of the midface and lower face without the need of a separate midface lift.

Review of the Nomenclature of the Retaining Ligaments of the Cheek: Frequently Confused Terminology

Since the time of its inception within facial anatomy, wide variability in the terminology as well as the location and extent of retaining ligaments has resulted in confusion over nomenclature. Confusion over nomenclature also arises with regard to the subcutaneous ligamentous attachments, and in the anatomic location and extent described, particularly for zygomatic and masseteric ligaments. Certain historical terms—McGregor’s patch, the platysma auricular ligament, parotid cutaneous ligament, platysma auricular fascia, temporoparotid fasica (Lore’s fascia), anterior platysma-cutaneous ligament, and platysma cutaneous ligament—delineate retaining ligaments of related anatomic structures that have been conceptualized in various ways. Confusion around the masseteric cutaneous ligaments arises from inconsistencies in their reported locations in the literature because the size and location of the parotid gland varies so much, and this affects the relationship between the parotid gland and the fascia of the masseter muscle. For the zygomatic ligaments, there is disagreement over how far they extend, with descriptions varying over whether they extend medially beyond the zygomaticus minor muscle. Even the ‘main’ zygomatic ligament’s denotation may vary depending on which subcutaneous plane is used as a reference for naming it. Recent popularity in procedures using threads or injectables has required not only an accurate understanding of the nomenclature of retaining ligaments, but also of their location and extent. The authors have here summarized each retaining ligament with a survey of the different nomenclature that has been introduced by different authors within the most commonly cited published papers.