Facelift

People sometimes also mistakenly think that if we pull the skin tight enough in facelift surgery, all of the wrinkles will be gone. For many reasons, this is not true. First of all, if one puts too much tension on the skin in facelift surgery, the scars are more unfavorable, the results of the lifted tissues are short-lived, and the wrinkles remain. Wrinkles are a natural process that occurs in aging skin. As we age, we lose important components in the skin, like collagen and elastin, which results in sagging skin that has more pronounced lines and crevices. Essentially we have two separate problems, which are treated differently. The sagging tissues of the cheek, jawline, and neck that occur from things like volume loss and gravity are treated with a facelift. The wrinkles within the skin itself are better addressed with resurfacing techniques like lasers, chemical peels, or dermabrasion. An analogy I use with my patients is that the skin of the face and neck are like a bed sheet. The facelift tucks in the sheets, and the laser irons out the wrinkles.

The superficial musculoaponeurotic system (SMAS) is a layer of tissue underlying the skin of the face. It is inferior to the zygomatic arch and superior to the platysma muscle. The temporoparietal fascia (aka superficial temporal fascia) is continuous with the SMAS superiorly, and this continues as the galea aponeurotic in the scalp. Inferiorly the SMAS is continuous with the platysma muscle. When one draws a line from the angle of the mandible to the lateral canthus (outer corner of the eye), the mobility of the SMAS is different on each side. The SMAS lateral to this line is more “Fixed” and less mobile because of its attachments to the parotid gland. The SMAS medial to this line is more mobile, and this is an important concept to understand when talking about the differences between lateral SMAS techniques and "deep plane" techniques.

Regardless of the technique, the SMAS plays a role in successful facelifts today. Once the SMAS is identified, there are many different ways to create the appropriate lift. Some surgeons will fold it upon itself (plication), which some argue is safer because, classically, there isn’t any sub-SMAS dissection where one worries about the possibility of injuring the facial nerve. Advocates also feel that it cuts down on surgical time. Disadvantages may include limitations of possible lift, the bulkiness of the tissues where it is folded (some say this could also be an advantage as a volumizing effect), or still a risk to facial nerve injury by inadvertently including it in the stitch that folds the SMAS.

Lateral SMAS techniques classically make an incision in the more “fixed” or lateral SMAS and usually include some degree of subSMAS dissection. It is thought to be safer since the initial dissection sub-SMAS begins over the parotid gland. The facial nerve here is embedded within the parotid gland, thus, protected. Of course, once dissection proceeds more anterior, the facial nerve branches exit the parotid gland and are more exposed. It is important to note that dissection immediately subSMAS is an appropriate and safe plane. Some surgeons perform a lateral SMASectmy, essentially removing a strip of lateral SMAS and then suturing the cut ends together in order to create the desired lift. SMAS imbrication (imbricate means to layer, similar to the way shingles on a roof overlap each other in layers) is when an incision is made, and the SMAS is then mobilized and layered upon itself to create the desired lift. The advantages are long-lasting and safe results. Some feel that improvement of the medial face is limited with these techniques since the more medial soft tissues are not classically released. Also, the initial dissection more laterally is more difficult to perform, given the more fixed SMAS to the parotid gland.

The term “deep plane” for the deep plane technique described by Sam Hamra is a bit of a confusing term. The main difference from the lateral SMAS techniques is that in the deep plane technique, the initial incision made in the SMAS is made at the line drawn from the angle of the mandible to the lateral canthus instead of being behind this line as in the Lateral SMAS techniques. Essentially, the subSMAS dissection begins immediately at the more mobile medial SMAS. The original deep plane facelift is actually superficial to the SMAS in the neck, below the SMAS in the lower face, and superficial to the SMAS higher in the face as one transitions the dissection from below the orbicularis oculi muscle to then be superficial to the zygomaticus major and minor muscles. This essentially becomes a deep subcutaneous dissection here to incorporate releases of the zygomatic cutaneous ligaments and mobilization of the malar fat pads while avoiding potential injury to the facial nerve.

The most recent "extended deep plane” facelift Jacono describes is a modification of the original Hamra technique. Hamra remained superficial to the platysma muscle and employed plication of the platysma at the neck. Jacono’s technique includes an extensive subplatysmal dissection connected to the subSMAS dissection. Also, the dissection in the midface begins above (instead of under) the orbicularis oculi muscle and continues in this plane on the surface of the zygomatic muscles in a safe plane protecting the facial nerve. The addition of a myotomy just inferior to the mandible creates a myoplastic flap that acts as a hammock of soft tissue that can help further tighten a neck with a nice natural jawline contour.

Often a facelift includes improvements to the lower two-thirds of the face and also the neck region. A lot of the neck work can be improved with the typical lateral incisions hidden around the ears and hairlines that we make to gain access to the SMAS. Issues with the anterior neck may require an additional incision under the chin to treat a variety of conditions. Platysma bands, preplatysmal fat excess, subplatysmal fat excess, large submandibular glands, and large digastric muscles are common problems here that we need to address in order to have the best results possible. Not every patient requires attention to all of these problems, so a very careful physical exam and sound communication with the patient to fully understand their goals is imperative when precisely planning their individualized treatment plan.