Are There Differences Between the Upper and Lower Parts of the Superficial Musculoaponeurotic System? A Preliminary Biomechanical Study

Modified Deep-Plane Face Lift and Lower Midface Lifting Using Deep Fat Compartment Mobilization and Zygomaticus Major Muscle Plication

BACKGROUND

Most face-lift techniques greatly improve the lower face; however, techniques for lifting the midface are limited and difficult. Original deep-plane face lift is a way to lift the superficial musculoaponeurotic system and skin as a compound unit. Although it minimizes tear of the superficial musculoaponeurotic system during dissection, damage to the vascular system, and the incidence of skin necrosis, and can be easily used in secondary cases, the deep-plane face lift does not adequately improve nasolabial fold. The authors perform a modified and enhanced deep-plane face lift to improve the midface. In this article, the authors explain the effects and procedures of the method.

METHODS

This retrospective study included patients ( n = 632) on whom deep-plane face lift (DPF group; n = 299) and modified deep-plane face lift (M-DPF group; n = 333) was performed by a single surgeon from January of 2014 to January of 2017, and from February of 2017 to December of 2020, respectively, at a local clinic. The degree of improvement in wrinkles in the patients' nasolabial fold was assessed using the five-grade Wrinkle Severity Rating Scale (WSRS).

RESULTS

The preoperative WSRS score was 2.95 ± 0.89 in the DPF group and 2.89 ± 0.92 in the M-DPF group. There was no significant difference in the preoperative WSRS score between the two groups ( P = 0.058). The postoperative WSRS score was 1.81 ± 0.68 in the DPF group, which was significantly greater than the 1.65 ± 0.66 found in the M-DPF group.

CONCLUSION

This method developed by the authors that combines deep-plane face lift with deep fat compartment mobilization and zygomaticus major muscle plication is safe and directly improves the nasolabial fold and promotes a smiling expression for rejuvenation effects.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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

BACKGROUND

Traditional plication techniques have been ineffective in addressing the anterior midface when compared to the sub-superficial musculoaponeurotic system (SMAS) "deep plane" approaches. However, by moving the plication much closer to the mobile medial fat tissues, a more effective and long-lasting plication can be accomplished without releasing the SMAS layer.

OBJECTIVES

The authors' "Delta facelift" approach combines a rotation vertical advancement of the midface fat with a dual-vector platysmaplasty and deep cervicoplasty as indicated for a harmoniously youthful neck.

METHODS

A retrospective chart review was performed on all patients who underwent facial rejuvenation with the Delta facelift technique between January 1, 2012, and May 30, 2021, for patient demographics, procedure details, outcomes, and complications.

RESULTS

A total of 283 patients underwent Delta facelift (273 females, 10 males). The average age was 60.8 years old. Primary facelift was performed in 229 patients, whereas 54 facelifts were secondary or further procedures. Adjunctive procedures included autologous fat grafting (93%), blepharoplasty (52%), and skin rejuvenating procedures (35%). There were 11 self-resolving neuropraxias, 6 minor hematomas, and 6 infections. Nine patients underwent repeat Delta facelift at an average of 9.3 years.

CONCLUSIONS

The Delta rotation vertical advancement of the anterior facial fat counters the descent and deflation associated with facial aging. Dual-vector platysmaplasty, with or without myotomy, effectively manages the jowl and delineates the jawline. Addition of deep cervicoplasty is recommended for patients with oblique necks or those with subplatysmal volume excess.

LEVEL OF EVIDENCE: 3

Essential Surgical Anatomy for Facelift

It is crucial for a facelift surgeon to have a comprehensive understanding of ageing-related changes on the volume, elasticity, and relative position of various facial tissues and layers. These changes lead to an alteration in the surface topography, contour, and ultimately shape of the face. The depressions and sagging of tissues created as a result of ageing then has a bearing on one's perceived age. This article describes the various layers of the face and neck affected by ageing. The fat compartments, superficial musculoaponeurotic system (SMAS), potential facial spaces, facial ligaments, and facial nerve are discussed in detail. Safe and effective execution of facelift requires a thorough understanding of the intricate relationship between the various layers of face and neck, in particular the path of facial nerve, as it negotiates between these layers. The emphasis of this article is on integrating this knowledge to generate practical tips for safe dissection, effective tissue movement, and repositioning during various type of facelift procedures.

Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System

BACKGROUND

Suspension of the superficial muscular aponeurotic system (SMAS) is generally believed to be necessary in facelift surgery. Although many techniques have been suggested, all rely on the viscoelastic properties of the SMAS.

OBJECTIVES

The aim of this study was to determine the viscoelastic properties of bursting strength, stress relaxation, and creep in the lateral, mid-cheek, and medial regions of the SMAS.

METHODS

The viscoelastic properties of the SMAS were determined in 12 cadaveric hemifaces. Lateral SMAS was classified as the SMAS overlying the parotid gland; mid-cheek SMAS as anterior to the parotid and overlying the masseter muscle; and medial SMAS as including tissue extending medial from the lateral canthus and ending at the nasolabial fold.

RESULTS

The 3 SMAS regions showed significantly different bursting strengths: 38.9 N for the lateral SMAS, 26.7 N for the mid-cheek SMAS, and 11.9 N for the medial SMAS (P < 0.0001). Stress relaxation was similar in all vertical regions with measurements of 54% in the lateral, 48% in the mid-cheek, and 59% in the medial SMAS. Creep was found to be similar in the lateral and mid-cheek SMAS with values of 18% and 19%, respectively. The medial SMAS was noted to have a higher creep at 22%.

CONCLUSIONS

The lateral SMAS has a stronger bursting strength than the mid-cheek and medial SMAS. Creep appears to be lower in the lateral and mid-cheek SMAS. Stress relaxation appears to be similar in all 3 vertical regions.

Total Composite Flap Facelift and the Deep-Plane Transition Zone: A Critical Consideration in SMAS-Release Midface Lifting

BACKGROUND

Recent anatomic studies suggest the superficial musculoaponeurotic system (SMAS) layer attenuates in the midface. This led the author to switch from a bilamellar high SMAS dissection to a "total composite flap" technique, preserving skin and SMAS/platysma as one layer in a critical "deep-plane transition zone" (DTZ) lateral to the zygomaticus major muscle. This allows traction on the SMAS to translate to the malar fat pad via a "cantilever bridge" effect, which is lost when skin is undermined in the DTZ.

OBJECTIVES

This paper attempts to answer the question of whether the composite flap or bilamellar technique better lifts the midface, comparing groups where the DTZ was undermined: (1) only at a sub-SMAS level; or (2) at both subcutaneous and sub-SMAS levels.

METHODS

Thirty-five patients underwent bilamellar facelifts with skin and SMAS separated in the DTZ. Midfacial elevation was measured using size-matched preoperative and 18-month (average) postoperative photographs for the 70 hemi-midfaces. The same analysis was done for 35 patients undergoing total composite flap facelift, maintaining skin and SMAS as one layer in the DTZ. The two groups were compared.

RESULTS

In the bilamellar group, the mean percentage of midfacial elevation at 18 months postoperative was 5.5% (range, 0.0%-17.8%). In the composite flap group, the percentage was 11.7% (range, 0.1%-32.3%). The difference was statistically significant.

CONCLUSIONS

Maintaining skin-SMAS attachments in the DTZ improves midface elevation during SMAS facelifting, exploiting a "cantilever bridge" effect of the skin transferring traction on the SMAS to the malar fat pad.