Face and Neck Lift (Cervicofacial Rhytidectomy)

Facelift History

The scientific literature is replete with descriptions of early facelift techniques from the early 20th century that primarily detailed skin tightening via excision ( Fig. 3.3 ).

Lexer described subcutaneous rhytidectomy in 1916. In 1973, Skoog presented a technique of elevating the platysma muscle without detaching the skin. In 1976, Mitz and Peyronie described the SMAS, and later other authors described techniques of SMAS plication and imbrication. By the late 1970s and mid-1980s, a combination of complete platysma muscle transection, plication of medial borders, and pulling laterally was presented as the way to get the “best result.” Patient complaints, complications, and overoperated necks occurred, and many of these techniques were abandoned. Deep-plane and subperiosteal techniques have been described by multiple authors, as have endoscopic approaches.

Facelift Anatomy

Facial anatomic expertise is imperative to performing competent facelift surgery and avoiding complications. Facelift surgery and anatomy are inseparable and great surgeons are great anatomists. An organized way to discuss facial anatomy is to consider the progressive layers encountered during the procedure from skin to bone ( Fig. 3.4 ). The layers of the face are as follows:

• Layer 1: Skin

• Layer 2: Subcutaneous layer

• Layer 3: Superficial fascia (musculoaponeurotic)

• Layer 4: Areolar plane

• Layer 5: Deep fascia

The Superficial Musculoaponeurotic System

Understanding all of the aforementioned layers is essential to understand and safely perform facelift surgery. Although each layer is complex in its own right, the SMAS is the most controversial layer, and its nomenclature is used correctly and incorrectly by surgeons and authors alike. The SMAS layer is a fibrofatty muscular layer in the cheek. It has been described by many leading authors and said to be continuous with the galea in the scalp, the temporoparietal fascia in the temporal region, and the superior cervical fascia in the neck. This structure was initially described by Dr. Paul Tessier Fellows Dr. Vladimir Mitz and Dr. Martine Peyronie as muscular and fibrous tissue and termed the superficial musculoaponeurotic system . They stated that the SMAS exists in the parotid and cheek regions and invests the muscles of facial expression. In their original 1970 article, the authors state, “To us, the SMAS appears to be a fibromuscular network located between the facial muscles and the dermis, one which covers the facial motor nerves.” They note that the SMAS separates two layers of fat in the face into superficial and deep layers. Their work also implied that the SMAS was continuous with the platysma.

Various authors contest Mitz and Peyronie’s finite description of the SMAS and related layers, and some surgeons do not agree that the SMAS exists. Reviewing the historic literature on the SMAS is to say the least confusing and frequently contradictory.

I think most contemporary surgeons will agree that the SMAS separates the subcutaneous fat from the underlying PMF. When a surgeon states that they pick up the SMAS, in reality they are picking up the subcutaneous adipose tissue and connective (aponeurotic) tissue above the PMF. This fibro-fatty-muscular tissue is what is frequently plicated, excised, imbricated, and otherwise managed in facelift surgery. Whether you agree or disagree with concepts about the embryology and histology, the remainder of this text will refer to the SMAS as the tissue between the dermis and PMF. The subcutaneous tissue and SMAS may be histologically and microscopically separate layers, but in actual surgery they are picked up, cut, pulled, and sewn as a single layer. Teleologically, this makes sense, as the physiologic function of the SMAS is to more effectively transfer mimetic muscle movement to the facial skin by septae that extend from the SMAS to the dermis. In theory, this would allow kinetic amplification, allowing the face to move more as a unit (as opposed to each individual muscle), thus making expression more efficient. When traction is placed on this layer, it moves all of the superficial layers of tissue, including the mimetic muscles, and basically repositions the deep ptotic facial tissues in the desired vector to reset the facial “mask” ( Fig. 3.5 ). All motor nerves providing movement of the facial muscles are deep to the SMAS plane (under the deep fascial layer).

Layer 5: Deep Fascia and the Periosteum

This layer consists of the periosteum over bone and the deep fascia of the face and neck. The deep layer of fascia is formed by the following:

• The periosteum in the skull

• Temporalis fascia in the temple region (over bony structures such as the zygoma and cranium); this layer is indistinguishable from periosteum

• The PMF (deep facial fascia)

• The investing layer of the deep cervical fascia

Staying superficial to the PMF (deep fascia) provides a safe level of protection during facelift surgery as the facial nerve branches lie inferior to this plane.

These fascial layer descriptions can be very confusing as they have multiple names and are frequently mischaracterized in various texts and diagrams. I believe the easiest way to understand them is to appreciate the two layers of fascia in the head and neck; superficial and deep. The first layer is the superficial facia, which includes the galea, temporoparietal fascia, SMAS, and superior cervical fascia ( Table 3.1 ; Figs. 3.4 and 3.6 ). The second layer is the deep fascia which includes the periosteum of the skull, the temporalis fascia, the PMF and the deep cervical fascia ( Table 3.2 ; Fig. 3.4 ; Figs. 3.6–3.10 ).

Table 3.2

Deep Fascia Layers Listed from Cephalad to Caudad

Layer 5 Deep Fascia
The periosteum in skull The superficial layer of the deep temporal fascia in the temple region. (Over bony structures such as zygoma and cranium, this layer is indistinguishable from periosteum) The parotidomasseteric fascia (deep facial fascia) The investing layer of the deep cervical fascia

The loose areolar plane lies between these two fascial layers, which accounts for the gliding mobility of the tissues in these areas.

Author’s note: What can become confusing is the deep temporal fascia. The outer temporalis fascia is intimate to the temporalis muscle and is often referred to as the superficial layer of deep temporal fascia . This layer splits at the zygomatic arch and is separated by a fat pad (see Fig. 3.4 ). The lateral split of tissue is referred to as the superficial layer of the deep temporal fascia , and the medial layer of the split is referred to as the deep layer of the deep temporal fascia . Some surgeons mistakenly call the fascia on the cranial side of the temporalis muscle the deep layer of the deep temporalis fascia . This is not the case, and as stated earlier, the “deep layer of the deep temporalis fascia” occurs after the split on the arch. Many surgeons simplify this nomenclature by simply referring to these layers as temporalis fascia .

Surgically speaking, this plane is “tiger territory”! Although this plane can be violated and navigated by experienced surgeons, many complications can be encountered by inadvertent entry by novice surgeons. Figs. 3.11 and 3.12 show the facial nerve branches crossing the masseter muscle under the masseteric fascia.

The parotid gland is also very important in facelift surgery as the facial nerve branches are deeper in the parotid gland until they emerge at the anterior border of the gland and cross the masseter muscle. Novice surgeons frequently limit their SMAS treatment to an area over the actual parotid gland. More experienced surgeons or those performing deep-plane dissections can dissect more distally. Keeping any SMAS-tightening procedure over the confines of the parotid gland is the safest route for novice surgeons. It is this subSMAS junction of the parotid gland and masseter muscle that constitutes one of the major danger zones in facelift surgery. The PMF is very thin over this region, and the underlying facial nerve branches are vulnerable (see Fig. 3.12 ). There is a subSMAS loose areolar tissue plane that extends from the anterior border of the parotid gland to the anterior border of the masseter. In proper deep-plane technique, blunt dissection in this plane can proceed safely even though it is almost intimate with the underlying facial nerve branches. Another reason the facial nerves are protected in deep-plane dissection is that most nerves innervate the mimetic muscles on their inferior surface (under the muscle). The only muscles of facial expression that have superficial (on top of the muscle) innervation are the deepest lying muscles: the levator anguli oris, the buccinator, and the mentalis, which are all innervated on their anterior surface ( Fig. 3.13 ). These muscles are also the deepest of the facial mimetic muscles. Again, this level of dissection should be limited to experienced surgeons only to prevent motor nerve damage. Staying over the parotid gland and above the parotid fascia is the safest anatomic area for novice facelift surgeons.

Several other structures are frequently encountered in facelift surgery and are particularly vulnerable to injury. The sternocleidomastoid (SCM) muscle is a significant landmark because the external jugular vein (EJV) ( Figs. 3.14 and 3.15 ) and greater auricular nerve (GAN) are intimate and traverse this muscle in the midlateral neck at a region known as Erb’s point (also called McKinney’s point ) ( Figs. 3.16 and 3.17 ).

The GAN originates from the cervical plexus and is composed of branches of spinal nerves C2 and C3. It provides sensory innervation for the skin over the parotid gland and mastoid process and both surfaces of the outer ear. The EJV and GAN lie deep to the SMAS and are protected as long as the dissection remains in the subcutaneous plane. The subcutaneous tissue becomes very thin in this part of the neck, and the dermis is sometimes intimate to the fascia of the SCM muscle, which can put the nerve and vein in jeopardy ( Figs. 3.16–3.18 ). The GAN is the most commonly injured nerve in facelift surgery.

Also of note is that the spinal accessory nerve (cranial nerve XI) exits the posterior border of the SCM muscle also at the level of Erb’s point ( Fig. 3.19 ). Technically, Erb’s point was classically described as a point where the cervical plexus exits from behind the posterior border of the SCM muscle. The four cutaneous nerves of the cervical plexus are the lesser occipital nerve, great auricular nerve, transverse cervical nerve, and supraclavicular nerve. The scientific literature has many different descriptions of Erb’s point, and many articles describe the spinal accessory and GAN emerging from Erb’s point. This description will be used in this text.

This nerve enters the posterior triangle to innervate the trapezius muscle and can be exposed between the posterior border of the SCM and the anterior border of the trapezius muscle. The platysma muscle stops at the mid-SCM muscle and only skin, a variable amount of fat, and fascia overlie the spinal accessory nerve, making it prone to injury. Surgeons must remain extremely vigilant to avoid sensory and motor nerve damage in this region.

Much has been discussed about neuroanatomy during the facelift procedure; however, the face and neck are some of the most vascular portions on the body, and blood supply knowledge of vascular anatomy and hemostasis are critical factors in cervical facial rhytidectomy ( Fig. 3.20 ).

The facial artery and vein (branches of the external carotid and jugular veins, respectively) provide profusion and drainage to the facial structures. The vascular pattern closely parallels the course of the facial nerves. Competent surgeons always have a mental image of the underlying anatomy in all steps of an operation. Like all surgical procedures that involve vascular flaps, facelift surgery flap viability relies on nourishment of the flap from intact vessels. ( Fig. 3.21 ). A decrease in blood flow can cause flap necrosis and significant scar and hemorrhage under the flap can cause other complications including hematoma.

The deepest layer in the face is the periosteum and underlying bone. During a facelift, some surgeons perform subperiosteal dissection over the maxilla and mandible in an effort to mobilize the deepest tissue planes to better free the ptotic facial tissues and to allow this plane to scar down during healing in hopes of maintaining the lifted position. Cheek and chin implants are frequently performed in conjunction with facelift surgery, and this related subperiosteal dissection may provide additional deep tissue mobilization.

The youthful face is in part suspended by retaining ligaments that support the skin over the facial bones. These ligaments become lax with age and are responsible in part for the sagging of facial tissues. These connective tissue ligaments can course from bone to dermis (osteocutaneous ligaments) or from soft tissue to dermis (cutaneous ligaments). The exact name and location of these ligaments is described differently (and sometimes conflictingly) by various authors and texts. Regardless of the various names and anatomic descriptions, these liga­ments can be appreciated when performing facelift dissection. The mandibular and zygomatic ligaments present noticeable adhesions that hamper tissue mobilization unless they are released. When the mandibular and/or zygomatic ligaments are separated from the dermis, the previously bound tissue becomes noticeably mobile. Release of the masseteric and platysmal retaining ligaments are also performed in most facelift procedures. Fig. 3.22 shows a rendition of the approximate position of these retaining ligaments.

Patient Selection

It is often difficult for patients to truly understand what a face and neck lift does and does not do. In the most basic explanation, the facelift addresses the jawline and neck. A facelift is mostly for the lower face and neck and does very little in the central oval of the face ( Fig. 3.23 ). For this reason, is is very common for most patients to have concomitatant procedures with their lift, such as eyelid, brow, cheek, chin, or skin enancement.

Proper patient selection is paramount for successful and safe surgery with happy patients. Patients must have sufficient aging for a lift. Novice surgeons must be wary of young patients who want a facelift but really do not need it. On the other hand, just because a patient has face and neck aging does not mean they are a suitable candidate. They must understand the procedure, the recovery, the complications, the financial constraints, and what the lift will and will not do.

It is not uncommon for patients to be very nervous when it comes to discussing their aging problems. One of the most important things to do is to relax the patient with casual conversation so they can focus on candid conversation about what bothers them without being nervous or embarrassed. This is one of the prime goals for the surgeon and the staff.

Most patients do not have a true understanding of the anatomy and physiology of their aging; they just know that they do not like what they see when they look in a mirror. It is important to explain during the consultation what aging changes they have, what processes contribute to this aging, and what options are available for rejuvenation.

I like to have the patient look in a mirror and discuss with me what bothers them. This is a controversial situation for some surgeons, and they say that many aging patients do not like looking at themselves in a mirror. I understand that and occasionally have a patient who refuses to look in the mirror. I feel that this is really the most accurate way for them to express what bothers them because this is the face that they see day in and day out in their mirrors at home. Much of this is already discussed in the chapter on patient consultation.

When I examine patients and then discuss options, I like to present a menu to them. Basically, this is a description of what aging changes they have and what procedures are available for improvement. I further explain that although I am discussing various aging changes, this does not mean that these problems bother the patient or that the patient is interested in addressing any or all of them. I always reinforce that cosmetic surgery is 100% elective, and patients should only pursue improvement of the things that really bother them.

From experience over three decades, I would say the most common situation people present with is to place their fingers on their cheeks and pull it back and say, “I do not need a facelift. I just need a little tuck like this” ( Fig. 3.24 ). Their next point of discussion is frequently the desire for some magic or extremely minimal procedure instead of a traditional facelift, which must be dispelled.

Many surgeons and patients like digital imaging to show facelift surgical predictions. Although I developed and marketed one of the original imaging systems over 25 years ago, I am really not a fan of this technology for numerous reasons. First and foremost, I tell patients it is really just a digital cartoon, and I can make them look any way I want on the computer, but I cannot necessarily duplicate that result surgically. I am too familiar from personal experience with patients from other offices who were shown a prediction and resulted in their being unhappy because it overstated what the facelift actually did.

My preferred technique for surgical prediction is to place the patient in the supine position and have them extend their chin upward while looking in a hand mirror ( Fig. 3.25 ). This resets the gravitational forces and shows the patient a pretty accurate rendition of what their jawline and neck would look like with a facelift. I personally think this is the most accurate way to show somebody a surgical result. This also works well for brow lift or cheek implants as the mid and upper face ptosis is also reset.

Secondary to this positional prediction, I feel that showing the patient hundreds of before and after photos is truly the best way for them to appreciate anticipated changes. Experienced surgeons should have a plethora of cases for patients to review. I believe that viewing various small, medium, and large facelift before and after photos can portray a realistic idea of what exactly a facelift and concomitant procedure will and will not do. Obviously, any supplemental information such as videos, social media, patient testimonials, speaking with previous surgical patients, and staff reinforcement all help educate patients on their expectations.

A facelift is not a one-size-fits-all operation, and I believe facelifts come in three sizes: small, medium, and large ( Fig. 3.26 ). Younger patients may benefit from a very conservative short scar lift, but most patients who are in their mid to late fourth decade are not great candidates for a conservative procedure. As stated throughout this text, performing a small lift on somebody who needs a large lift will result in disappointment, lack of result, and lack of longevity.

In addition to letting a patient know what to expect from a procedure, it is equally and sometimes more important to let them know what not to expect. I always reflect back to Fig. 3.23 to explain to patients which areas of their face and neck will be improved and which areas will not. I think it is paramount for them to see this photo numerous times and understand this concept ( Fig. 3.24 ).

Also, specific patient differences can affect results. The following situations may require a special explanation to the patient so they understand potential problems or limitations of the procedure:

• Medical compromise (the at-risk surgical patient who may only be cleared for a small procedure)

• Extreme neck skin excess

• Heavy jowling

• Obesity

• Severe facial and neck wrinkling (extreme actinic damage)

• Unfavorable anatomic neck and hyoid and laryngeal anatomy ( Fig. 3.27 )

  

• Patients who would benefit from chin or cheek implants but refuse

• Previously operated patients with earlobe, incision, and hairline changes.

What the surgeon begins with may influence what the surgeon ends with. It is impossible for a patient to have too much preoperative information. The surgeon and staff must remember that the patient will only remember a small amount of the information given to them. It is something that surgeons and staff discuss numerous times a day, but the patient may only hear it once in their life, and it is our job to make sure they hear enough of it.

In my practice, we generally have the patient present 2 weeks before surgery. At this time, we review their history and physical examination, discuss all preoperative and postoperative instructions, and discuss caregiving. Before this appointment, we communicate with the patient on numerous events. If they still fail to understand the finite details of their surgery and what is required of them and their caregivers, it may be prudent to delay the procedure or perhaps not operate on the patient. Obviously, a big part of this procedure is the verbal and written informed consent of what the procedure will do and what can happen. Equally, if not more important, is my alternate informed consent entitled “What Your Facelift Won’t Do.” This consent addresses areas that will not be affected by the facelift. Again, this relates back to Fig. 3.23 but includes the perioral region, marionette lines and nasolabial folds, lip rhytids, and periorbital and brown regions. In my novice days, I actually had patients come back after a facelift and complain that they still had excess skin on their eyelids. Although this is almost comical, I really had to blame myself and not the patient as it is my job to tell them what the lift will and will not do; Hence I started using the alternate consents. I also have a special consent for smokers.

Another means of evaluating submental anatomy is to use a tongue blade to retract the excess submental skin and/or fat and document it with a photo. This can provide an idea for the surgeon and patient of the degree of submental improvement ( Fig. 3.28 ).

In concert with this discussion are patients who have small chins or a deflated midface. I have many patients who would benefit from cheek augmentation (i.e., cheek implants, filler, or fat) and/or a chin implant, and they resist because they are conservative or for financial reasons. Unfortunately, forgoing these augmentive procedures can have a huge negative impact on the surgical result. A chin implant can dramatically improve a retrognathic profile and tremendously enhance a facelift. Performing a facelift on a patient who needs midface augmentation but refuses will make them look tighter, but not younger. In such a case, deflated cheeks make the jowls look larger. This can disable the ability to make the face tapered. In a youthful situation, the face is tapered because the cheek region is fuller than the jawline. Foregoing cheek augmentation in a patient who needs it will always produce a facial imbalance. It is so important to put something back during facelift surgery, and patients must realize this ( Fig. 3.29 ). In some cases the patient declines, but I do it free of charge because I feel that it is so important for my final result, reputation, and brand. To me, this is a marketing decision and not a financial one.

Health

There is no doubt that patient health and safety and the health of the patient are the most important factors to determine the success or failure of face and neck lift surgery. This procedure lasts several hours and can last 4 to 5 hours when performed with simultaneous procedures; therefore anesthetic and medical implications are more significant than many other cosmetic facial procedures commonly performed. Because the age group for face and neck lift is primarily the fifth decade through the eighth decade, these patients are obviously older and may have more comorbidities then patients who present for other cosmetic facial procedures.

Systemic problems such as hypertension, cardiovascular disease, diabetes, hyperlipidemia, arthritis, osteoporosis, and depression are common in the age group for facelift patients. Another confounding situation is a patient who is in good general health but is taking anticoagulants to manage such disease states as atrial fibrillation. These may be as simple as aspirin or as complex as more potent anticoagulants. Because a facelift is a bloody operation and hematoma can be a devastating consequence, these patients are a particular challenge. Advances in medicine have enabled patients to live longer and with multiple co-morbidities. It is not uncommon for patients in their seventh and eighth decade to undergo procedures with general anesthesia such as total joint replacement. Age, in an of itself, is not necessarily a contraindication to surgery and general anesthesia. Because cosmetic surgery is totally elective, there are medical, societal, and ethical differences among older patients with comorbidities who present for purely cosmetic procedures. Even in the 20 plus years that I have been performing facelift surgery, I currently feel more comfortable with medically managed patients than I did in the early part of my career. We simply have better medications and anesthetic agents and a higher safety index. One of the most intense tasks in my practice and common for most practitioners is navigating the hurdles of medical clearance. Although my anesthesiologist and I are credentialed to perform preoperative history in physicals, I always have the patient see their private physician. No one knows the patient better than their primary care physician, and patient safety is simply something that cannot be taken to chance. If patients have more significant medical problems and are seeing specialists such as cardiologists, neurologists, or endocrinologists, then I require separate medical clearance from these practitioners as well. As one of my instructors told me in residency, “You can never have too many names on a patient’s chart when it comes to safety and medical clearance.”

I refuse to operate on a patient who does not have written medical clearance from their physician and/or specialists. If they do not present with the proper paperwork and clearance at least 2 weeks before surgery, they are automatically cancelled. The elective nature of cosmetic surgery makes the situation of serious injury or office death a career-ending possibility along with the other obvious stresses. I have provided expert review in defense cases for numerous plastic or cosmetic surgeons with serious complications. In any case I have ever reviewed, one of the first things plaintiff attorneys looked for is lack of proper medical clearance as a breach of the standard of care. It can be difficult for younger practitioners to turn away a patient who has adequate funds and a sagging face. Sometimes it is a matter of inexperience and risk taking, and other times it is simply a matter of the surgeon not knowing how to say “no” to a patient. This will be discussed in the patient management portion of this textbook, but I strongly feel that you will never be sorry for the patients you turn away, only those you do not.

I have observed two other significant changes in several decades of performing face and neck lift surgery. First is the change in obtaining preoperative laboratory testing as a routine for all patients. When I first started practice, it was pretty much the standard of care for every patient scheduled for a complex procedure such as a facelift to have an ECG, chest x-ray, complete blood count, blood chemistry, coagulation studies, hepatitis C testing, and HIV testing. In today’s evidence-based medical and surgical environment, we obtain much less routine testing, and any testing that we do obtain is based on the patient history and physical examination. This has been a great change to streamline the process, which was a burden on the health care system anyway. The second change that I have seen is the dramatic decrease in cigarette smoking over the past 25 years. I trained and practice in Richmond, Virginia, which is the headquarters for Altria (formerly Phillip Morris). Smoking is ingrained in this local culture to the extent that potatoes are in Idaho. It was the biggest local economy and promoted for decades. Anyone reading this text understands that smoking compromises surgery and healing for numerous reasons and that smokers are a greater anesthetic and surgical risk. I do have to say from my unpublished evidence of over 1500 facelifts, which I intend to publish at some point in time, that almost 8% were smokers. Most of my patients who were smokers did not have a higher complication rate than nonsmokers, but I was judicious about operating on people that were truly excessive smokers. It was not uncommon for me in the past to encounter patients with yellow fingernails and nostrils who smoked anywhere from two to four packs a day. This is truly an unusual situation at this point in time, and I believe that this is a national trend.

The entire gamut of the cosmetic facial surgery patient is interesting. I have performed facelifts on patients well into their eighth decade who were healthier than some of my patients in their early fifth decade. Each patient and each case presented specific challenges and required solutions. One mantra I have tried to maintain throughout my practice life is to never do anything on a patient that I would not do on one of my family members.

I have always said that “the best surgeons are always a little bit scared.” This means that many of their surgical decisions are somewhat based on “what can go wrong.” This can be a good limiter and ensures a double-check to stay safe with surgery and anesthesia. It is not uncommon for sick patients to want to have surgery. It is also not uncommon to have them get angry if they are turned down because of health risks. As difficult as it is to turn down a surgical patient, smart surgeons know how and when to say no.

Psychological Stability

The psychology of cosmetic surgery patients is discussed at length in Chapter 1 . Psychological imbalance or body dysmorphic disorder may not be a huge problem in a patient seeking lip filler or neurotoxin treatment, but it can provide extreme challenges and malpractice actions with a facelift. All novice surgeons should read Chapter 1 and learn the warning signs of potentially problematic patients and how to deal with them. Changing the face of a well-balanced individual can be a slight challenge, but changing the face of someone who is not mentally or socially adjusted can be tragic and has resulted in the death of multiple surgeons from disgruntled patients.

Recovery

Patients must be able to take time away from work or play commensurate with the procedure(s) being performed. Everyone is busy, and with more women in the workplace, it is difficult to balance cosmetic surgery and work. One of the biggest mistakes a surgeon can make is to downplay a recovery. If you tell a patient they will recover in 1 week and it takes 2 weeks, they can be furious. If you tell them it takes 3 weeks and they recover in 2 weeks, you can be a hero. Many of the aspects of surgery, such as incisions, sutures, anesthesia, bandages, and so forth, can be objectively and accurately described. Recovery, on the other hand, is very subjective. On several occasions, I have performed the same procedure on identical twins, and one twin did great while the other twin had unusual swelling and bruising. It is impossible to guarantee precise recovery, and the surgeon must rely on the mean recovery of a procedure or procedures. I tell facelift and laser patients that the average patient can return to work or social situations at 2 weeks. I explain to them that on the bell curve, some patients may look great at 9 days, and others may still be bruised at 3 weeks. The surgeon should always err on the high side; if the patient is given a range of 6–14 days, 6 days is the only number they will remember. All of this must be covered in the consent and presurgical material issued to the patient. I give patients the option of a Thursday surgery, which gives them a weekend, a full workweek, and another weekend to recover. This is sufficient for selected surgeries, but I tell them that no surgeon can guarantee a specific recovery. If they are having a facelift before a big event, such as a child’s wedding, a reunion, or an important vacation, I suggest 4–6 weeks for recovery. I also explain that the recovery process in actuality takes about 90 days, and they will see positive changes throughout this period. Missing 2 weeks from work or play can be very difficult for the nonretired patient, and recovery serves as one of the biggest limiters of the ability for patients to have surgery. In today’s health culture, it is also common for patients to want to get back to the gym earlier than we would suggest. Most of my patients can begin light cardio at 2 weeks, and all of my patients can do anything they want at 4 weeks. It is amazing how many people will try to bend these parameters. In some respects, physical fitness is an addiction.

Budget

Patients must have adequate finances for the procedure(s). Cosmetic surgery is expensive, and I tell my patients it is a good long-term investment. Some patients desire cosmetic surgery but in reality, cannot afford it. In normal circumstances, there is significant stress for the patient when having cosmetic surgery. Add the stress of a poor financial situation, and this may put some patients over the edge. In addition, patients who cannot afford a procedure tend to skimp on details that are important, such as not purchasing expensive antivirals or antibiotics, or using private duty nurses. If the financial stress causes family problems, the experience can turn into a negative one. Also, in the rare instance that these patients would have to pay for revision surgeries or see other types of practitioners related to their surgery, their lack of funds can become the source of great discontent. Some patients should simply postpone surgery until they can afford it; otherwise they may ask the surgeon to compromise throughout the surgical experience. Offering alternate financing options to patients is helpful but occasionally can enable them to do something that at this point in their life is impractical. Although senior surgeons with excellent reputations often command extreme fees for facelifts, most parts of the country have similar fees for facelifts. Some surgeons will discount secondary procedures such as facial implants or laser skin resurfacing when performed simultaneously with a facelift. The average patient understands that cosmetic surgery is an upper-class luxury and are usually not shocked when they hear the fees. I post my fees on my website as a general range, and this has helped eliminate a number of casual consultations that did not turn into surgeries. I also think it is important that patients understand that they are getting value for their money. I explain to patients that I do not take shortcuts with any part of their procedure and that patient safety and predictable outcomes are the most important parts of my practice. I also back up my surgery and perform free revisions in the first 12 months after surgery. This puts many patients at ease because one of their main concerns is what happens if they need touch-ups or revisions?

Preoperative Consultation Workup

Most cosmetic facial surgeons perform a multitude of procedures. Face and neck lift surgery requires a greater level of communication, consent, medical clearance, and so on. This is covered in Chapter 2 .

At the preoperative consultation, patients are given prescriptions for their postoperative medications. This generally includes an antibiotic, and analgesic, and an antiviral if laser is performed. A prescription for a Scopolamine patch is given to decrease nausea and vomiting, and all surgical patients are prescribed prednisone. The prednisone is taken in a non-tapering dose. The patient is given fifteen (20 mg) tablets and take 3 tablets (60 mg) once a day until gone. This is started on the first post-operative day.

Facility

When I first entered practice, most cosmetic surgery was performed in hospital operating rooms. A second wave of facilities evolved as corporate-owned surgery centers, essentially small hospitals without overnight stays. Over the past 15 years, credited in-office ambulatory surgery centers have now become extremely popular and probably the preferred norm for cosmetic facial surgery. I have had a fully accredited office surgery center for almost 20 years, and it became a life-changing experience in a very positive way. First of all was convenience. I no longer had to worry about finding block time in the hospital or getting bumped by other cases. It was also extremely convenient for me as I did not have to leave my office, and it was convenient and private for my patients as they would not be exposed to other people and possible pathogens in the hospital environment, where privacy is also an issue. Many surgeons fear accreditation as they think they are going to have to tear out walls and rebuild, but in reality, it is much more about governance than it is physical plant. There are multiple changes to which one must comply, but they are not financially incapacitating. In reality, my nurse and staff do the lion’s share of the work required for accreditation.

I have admitting privileges and operating room privileges for all of my cosmetic facial procedures. Although it may not be necessary, I think it is important and probably the standard of care. The playing field is often unfair because of specialty politics, but most privileges are training- and proficiency-based in this day and age.

Some novice surgeons, in the beginning, may choose to operate with a procedure chair, dental chair, or procedure table. If a surgeon is serious about cosmetic surgery, there is no substitute for a formal operating table, and these can be purchased refurbished. Having the ability to position patients laterally (airplane) can be of great assistance, especially with older patients who have limited neck mobility, which makes intraoperative head positioning difficult ( Fig. 3.30 ). This prevents the surgeon from bending over and working upside down. Most hospital operating tables are square and meant for body procedures, hence when doing head and neck surgery the surgeon must bend over. This can be very taxing on one’s posture. A head-neck extension (neuro-extension) allows the head and neck to be extended from the table, allowing closer access for the surgeon. These extensions also allow the surgeon to operate in a seated position with their thighs under the patients’ head, similar to ergonomic dentistry. I perform the platysmaplasty in the standing position and sit for the remainder of the facelift procedure. The fully adjustable positions of a operating room table are important. In addition, you want your operating room to look like an operating room.

An additional item that has become personally indispensable is an operator stool that can be vertically repositioned ( Fig. 3.31 ). Cosmetic facial surgery, especially facelift surgery, requires much repositioning of the patient, hence the surgeon must change his or her positions throughout the procedure. I begin in an elevated position but frequently “drop down” to look under the pre-auricular flaps and other structures. Having an easily adjustable and comfortable stool can facilitate long procedures. As previously stated, surgery can produce a lot of wear and tear on the surgeon, and paying attention to these details early in one’s career can extend one’s longevity.

Instrumentation

Although many specialized instruments exist specifically for rhytidectomy, in reality the procedure can be performed with relatively basic surgical instruments most surgeons already have in their offices ( Fig. 3.32 ).

A basic list is as follows:

• 1.

  Operating table

• 2.

  Headlight and loupes, fiber-optic retractors

• 3.

  Marking pen, surgical ruler, measuring caliper

• 4.

  Surgical prep

• 5.

  Tissue dissector cannulas ( www.kolstermethods.com )

• 6.

  Liposuction cannulas (2 mm, 3 mm, and 5 mm)

• 7.

  Retractors

  • a.

    One pair of Senn retractors

  • b.

    One pair of Army/Navy retractors

  • c.

    One pair of 6-inch small skin hooks

  • d.

    One pair of double-ended skin hooks

  • e.

    One Aufricht nasal retractor for generalized soft-tissue retraction

• 8.

  Periosteal elevator

• 9.

  Round-handle scalpel

• 10.

  Padgett “Gorney” facelift scissors ( www.miltex.com )

• 11.

  Pickup forceps (two of each)

  • a.

    Medium

  • b.

    Small

  • c.

    Long bayonet

• 12.

  Radiofrequency or electrosurgery system for coagulation

• 13.

  Mosquito hemostats of various sizes, including a long, thin tonsil clamp for placing cheek implants

• 14.

  Needle holders in various sizes

• 15.

  Micro skin stapler and staple remover

• 16.

  Suture scissors

• 17.

  Sutures ( www.ethicon.com )

  • a.

    2-0 Vicryl

  • b.

    4-0 gut

  • c.

    5-0 gut

  • d.

    4-0 Vicryl

• 18.

  4 × 4 radiographically marked gauze

• 19.

  Hair comb

• 20.

  Suctions, various size Frazier-tipped and tonsil suction

• 21.

  Local anesthetic (2% lidocaine with 1:100,000 epinephrine) and syringes with 1.5-inch 25-gauge needles (or 32-gauge needles for eyelid injections)

• 22.

  1 L of tumescent local anesthesia mixture (0.1% lidocaine with 1:1 million epinephrine)

  • a.

    1 g lidocaine,

  • b.

    1 mg 1:1000 epinephrine

  • c.

    1 g tranexamic acid

  As only 500 mL is used on the average facelift patient, the formulation can be split in half with 500 mL normal saline

• 23.

  Tumescent pump or 60-mL syringe, and 18- or 22-gauge spinal needle or blunt infiltration cannula

• 24.

  Hair wash

  • a.

    Hydrogen peroxide (H ₂ O ₂ )

  • b.

    Sterile water

  • c.

    Large plastic trash bag to catch runoff when washing hair

• 25.

  Dressings (for traditional facelift dressing)

  • a.

    Triple antibiotic ointment

  • b.

    Xeroform gauze

  • c.

    3-inch Kling

  • d.

    3-inch Coban bandage

  • e.

    Gauze “fluffs”

• 26.

  “Niamtu Facelift Dressing”

  • a.

    4 × 4 gauze

  • b.

    Elastic head and neck compression bandage (jaw bra)

  • c.

    Jackson-Pratt drains for selected patients (#10 for females, #15 for males

Some surgeons use many other instruments, and others use less. It is important to have what you are comfortable with and the correct instruments for the procedure. Of all the instruments, good-quality, sharp facelift scissors are the most important single instrument. In my experience, the more facelifts one does, the fewer instruments one requires.

Lighting is an absolute necessity during any surgery: the better you can see, the better you can operate. Although many surgeons operate using overhead lights, these require continual adjustment, which is a distraction during surgery. They also frequently produce shadows and can emit extreme heat, making the team uncomfortable. Working with a headlight can eliminate all of the negatives of overhead surgical lights and improve vision of the surgical field.

Headlights are a superior option for this type of surgery, but there are several caveats. It is imperative that the surgeon maintains a normal posture when using a headlight. Oftentimes it is too easy to bend one’s head instead of adjusting the table or the patient. It is important that the staff point this out and encourage correct surgical posture for the entire team as I have seen many competent surgeons retire before their time because of severe neck problems. The surgeon should adjust the headlight and the patient, not his or her neck ( Fig. 3.33 ). I also know of surgeons who have their staff wear headlights and alternate with their staff to avoid the taxing posture situation.

Fiber-optic lighted retractors are also an extremely useful adjunct for facelift surgery ( Fig. 3.34 ). They are specifically useful for platysmaplasty, flap dissection, and SMAS work as they provide the ability to simultaneously retract and light the field. This is a great investment and also allows surgeon to see the bottom of deep flaps without placing their neck in extreme bent-over positions.

Incision Design

I personally feel that marking incisions are just as important as a blueprint for construction of a house. I also feel that it is paramount to mark the patient in the upright seated position before any anesthetic is injected. I have already discussed the importance of surgical markers. If your markings rub off before you are ready to make your incisions, it can be very confusing, especially if tumescent anesthesia has already been injected. There is absolutely no place for inaccuracy when it comes to incision design. I firmly believe that you can look at any given surgeon’s patients and determine his or her ability by looking at the incision scars, the earlobe position, and the evenness of the hairline. All surgeons must understand that although we perform aggressive and extreme procedures inside the flap and with the SMAS, the only thing the patient ever sees after the surgery is their incision. Becoming known for great postoperative incision scars can greatly increase referrals in a facelift practice. Although the patient may not be able to see most of their scars, they are certainly visible to hairdressers, friends, and medical practitioners. I have received many referrals over the years because of my commitment to excellent postoperative incisions. Facelift incision markings include the following:

• Pre-auricular and sideburn incision

• Post-auricular and hairline incision

• Submental incision for platysmaplasty

Markings are made around the jowls, the platysmal bands, and the region of anticipated submental liposuction. Additional markings are made for any concomitant procedures that may be performed, such as blepharoplasty. A facelift marking video accompanies this text.

One statement that I will continually repeat throughout this text is, “The best way to perform any procedure is the one that provides maximum patient safety and predictable outcomes in the hands of a given surgeon.” The same thing can be said about incision markings. There are numerous ways to make incisions, and the way that works best in the hands of a given surgeon is the preferable method. I would encourage novice surgeons to utilize several different pre-auricular and post-auricular incisions to see which ones work best for them and provide the most aesthetic scars.

It would be very easy to simply describe how to take a marker and make drawings on the face, but the subject is far more complex than that. For this reason, unlike many other sections in this book, this particular section will include reasons for doing a certain incision and reasons for not doing it as well as illustrations of complications associated with incision choices.

Pre-auricular Incision

Each time I write another edition of my text, I research the literature about the subjects on which I write. Incisions can be one of the most controversial topics from article to article and textbook to textbook. There are many types of surgical incisions, approaches, and modifications thereof. This dogma from author to author can really be confusing for the novice surgeon. When I read some of the descriptions for facelift incisions, it would lead me to think that I am operating incorrectly. My surgical results, however, are not consistent with this. I see authors who would lead one to think that a pretragal facelift incision is doomed for poor scarring and is simply an improper technique. I could not disagree more with this. I have performed over 1500 lifts at this writing with 3000 incisions (two sides for each patient). For the first decade, I used retrotragal incisions, which healed well but occasionally led to tragal blunting. For the past decade, I have used pretragal incisions and have experienced my absolute best results with the most aesthetic scars. So it is simply not right for someone to tell me that I am doing it wrong. Like anything else in life, there are numerous ways to perform a given task. Some people perform it one way and have excellent results, while the results may be suboptimal in the hands of others. The challenge for every surgeon is to experiment with various accepted techniques and find out which one works best for them in terms of patient safety and predictable outcomes. This choice may not always be consistent with the literature.

I begin my markings with the sideburn incision, which is a very critical part of aesthetic scarring. If you examine 100 facelift postoperative patients from different surgeons, it is amazing how much variance there is in the sideburn incision.

While discussing this incision, I must point out one of the major commandments of facelift surgery which is not to elevate the sideburn. Pre-auricular and sideburn incisions with aggressive temporal extension are well described in various textbooks and can result in major hair loss in the temporal region, which is one of the worst stigmata of facelift surgery ( Fig. 3.36 top image).

Some surgeons make their incision at the junction of the temporal tuft and the skin. This is a guaranteed way not to displace the temporal tuft but is problematic if the incision hypopigments, which is not uncommon in this area and can be extremely visible ( Fig. 3.36 bottom image).

My preferred temporal incision is inside the temporal tuft with a transfollicular (also called trichophytic ) design. This type of transfollicular incision is described in great length in the open brow and forehead lift section of this text. Basically, the incision is made in an extreme hyperbeveled manner with the scalpel almost horizontal to the skin. This produces a transection of some of the follicles, which remain viable and grow back through the incision to camouflage the scar ( Fig. 3.37 ).

In addition to the hyperbeveled incision, I prefer to keep my sideburn incision within the temporal tuft as it will be totally camouflaged by the patient’s hair. I also make my incisions irregular and undulating as these incidental geographic incisions heal superiorly to straight line, nonbeveled incisions ( Fig. 3.38 ).

The sideburn incision described earlier produces minimal elevation of the temporal tuft. The superior portion of the temporal tuft can also be undermined and released, which also helps manage closure ( Fig. 3.39 ). Sideburn management is more straightforward in bearded males as they can adjust better as a result of beard/hair junction.

The next step is to mark the remainder of the pre-auricular incision. There are basically two ways to make this anterior incision: pretragal and retrotragal ( Fig. 3.40 ). Pretragal incisions are almost always used on male patients as these prevent displacement of the hair-bearing skin on the tragus, which is difficult to shave and unsightly (although hair removal lasers have lessened this problem).

Whether a surgeon prefers pretragal or post-tragal incisions is a matter of personal preference. The supposition of using a pretragal incision is that it will hide the scar, but the problem with this incision is that cartilaginous remodeling can occur, even in the best surgical hands, which can produce a blunted tragus. When the delicate and naturally rounded tragus is blunted, it allows direct vision into the external auditory canal, which is unsightly and a recognized stigma of facelift surgery ( Fig. 3.41 ).

In my 1500 or so career facelifts, I probably performed post-tragal incisions in the first 600 lifts. My results were generally good, but I occasionally experienced tragal blunting. I switched to retrotragal incisions, which I currently use today. For me, in my hands, I get the best results I have ever had with postsurgical scars when I employ my triarcuate technique of pretragal incision.

The triarcuate incision, as the name states, consists of three arcs in the pre-auricular region. The superior arc is at the helical attachment between the cheek and ear, the middle arc is anterior to the tragus, and the inferior arc involves the earlobe attachment. I always avoid straight-line incisions as they are very visible after surgery.

When creating preoperative markings, it is imperative to place your marking at the precise junction of the cheek and ear skin. Placing the incision too far anteriorly or posteriorly creates a visible scar ( Fig. 3.42 ). The texture and color of these two anatomic units are different and will stand out if a precise incision junction is not utilized.

A predictable way to obey the cheek–helical junction is to put traction forward on the superior helical attachment and press down firmly with the marking pen, which automatically allows the pen to fall in the crease at the proper junction ( Fig. 3.43 ). Adapting this triarcuate incision pattern was a big step in refining my postoperative incision scars ( Figs. 3.44 and 3.45 ).

Figs. 3.46–3.48 show some of the author’s before and after facelift scars using the triarcuate incision technique.

Posterior Incision

Numerous texts recommend placing the posterior auricular incision several millimeters to the posterior auricular crease with the suggestion that the scar will contract into the crease and be hidden. This is something that is not consistent with my personal experience as I have found the scar to remain where it was placed. Therefore I place the incision in the center of the posterior auricular crease where it is most hidden ( Figs. 3.49 and 3.50 ).

Although the posterior regular incision is more hidden, it is still imperative to be attentive with incision planning. Most of the incision is hidden in the posterior auricular crease, but the area of the incision that extends in or about the hairline is critical (see Fig. 3.49 ).

The posterior hairline incision is also an extremely critical part of the facelift procedure. Failure to produce a contiguous hairline or a skewed hairline can prevent female patients from wearing their hair up. This it can be a significant disability for this population as it severely limits their tonsorial options. Low mastoid incisions as shown in Fig. 3.51 are an immediate problem, but failure to produce an even hairline can be a significant problem.

Over the past 20 plus years, I have had my best post-auricular hairline incisions with the high hairline incision as shown in Figs. 3.44 and 3.49 .

I always place my posterior incision superior, at the greatest width of the pinna, as shown in Fig. 3.49 . As the incision transitions from vertical to horizontal, some textbooks advocate a 90-degree angle ( Fig. 3.52 ). I personally make more of a gentle curve as the incision transitions from vertical to horizontal (see Fig. 3.52 and Fig. 3.100 ). I have performed this both ways and have not seen a distinct advantage with healing or scar. Being the terminal corner of a flap, it is a common area of flap breakdown, but using the right angle over a curve has not seemed to make a difference in my personal experience.

Many surgeons place their posterior hairline incision at the junction of the occipital skin and descending hairline. This low-placed incision does facilitate the posterior dissection as the flap is shorter, but I personally do not think the tradeoff is worth it. As similarly stated with sideburn incisions, the occipital region can hypopigment or form hypertrophic scars. Although most incisions placed in this area will heal well, it is problematic when they do not ( Fig. 3.53 ).

For the aforementioned reasons, I place my posterior incision within the hairline with a hyperbeveled, irregular incision. Over the years, I have had my best aesthetic results with this incision placement. Figs. 3.54 and 3.55 show examples of my postoperative high-hairline incisions. I cannot honestly say that every single incision I make is perfect, but in this stage of my career it is rare to have unsightly incisions. If they occur, I treat them with anti-inflammatory injections and CO ₂ laser resurfacing.

Of over 1500 facelifts, I have only personally operated on a handful of bald patients. In the case of female patients, they were post-chemotherapy or had alopecia totalis. I have performed facelifts on several bald male patients; one was a plastic surgeon requesting a lift. Being bald myself, I am pretty sympathetic about giving someone a permanent visible scar. I actually attempted to talk these men out of operating, but they were committed to improving their appearance ( Figs. 3.56 and 3.57 ).

After the periauricular incisions are marked, the jowl and submental structures are marked ( Fig. 3.58 ).

Finally, the submental incision is marked. A mirror is held under the patient to illuminate the area, and the incision is placed several millimeters below the crease ( Fig. 3.59 ).

The submental incision is not as noticeable as the other incisions, but it is still very important to make this incision in the correct area and to make it symmetric. Many patients have a deep submental crease, and making an incision in this crease as described in many textbooks can actually deepen the crease ( Fig. 3.60 ).

Although this crease is somewhat hidden, a crooked or depressed scar in this area is still extremely noticeable. It is important to keep the incision on equal sides of the midline and to keep the incision as small as possible when performing platysmaplasty.

As stated earlier, I like to make my submental incision about 5–10 mm below the crease. Also, the surgeon must keep in mind that with full submental regions, liposuction and skin tightening may move the incision in a more posterior or inferior position. On the contrary, if a chin implant is placed, the submental crease may be in a more anterior position, which must be considered as well.

Like so many other facets of surgery, some well-known surgeons advocate placing the incision in the crease and do not feel that it accentuates it. Always remember that different techniques work better for different surgeons. My advice to new surgeons is to figure out what gives you the best result, and stay with it.

In the Operating Suite

When the patient is taken into the operating room, some of the most vulnerable times are at the very beginning of the case and at the very end of the case because the staff is frequently preoccupied with their initial and last duties of the case. Especially in the beginning of the case, when everyone is trying to get their particular task started, medication, wrong procedure, and wrong surgery site errors can occur. The surgical staff undergoes a team time out at which point we review any pertinent medical or anesthetic information, medications, drug allergies, surgical sites, consents, and any other pertinent information. This is a critical time in our office, and everyone must stop and pay full attention during the time out ( Fig. 3.61 ). One of the main goals of facelift anesthesia is to prevent hypertension, which is one of the major contributors to postoperative hematoma. A bloody field also complicates and obscures the surgery. Tight preoperative control of any medication or preparation that affects platelet function and attention to blood pressure are imperative for successful surgery.

All offices have different setups and vary with the amount of time a surgeon has been in practice, their particular facility, and their method of anesthesia. In my office-based AAAHC-accredited surgery center, we operate in a sterile hospital environment ( Fig. 3.62 ).

I have friends who perform facelifts in a “clean” and not “sterile” environment and use local anesthesia. However, I believe that most recognized surgeons with high-volume facelift practices treat their patients in a similar manner as I do, with general anesthesia in a sterile operating room environment.

The surgeon and surgical staff are present during anesthetic induction and intubation. Once the endotracheal tube is placed and confirmed, the tube is sutured around the upper teeth to maintain stability throughout the case. As part of deep-vein thrombosis prevention, the patient wears compression hose. We also use sequential compression devices on the lower extremities ( Fig. 3.63 ).

After anesthesia is induced, the surgical staff begins prepping the patient for surgery. Using a surgical marker, I make a mark over the region of the carotid pulse and the cricothyroid ligament. I have never had to resort to a surgical airway, but in the event of emergency, it would be helpful to have landmarks in an otherwise tumesced neck. Having a similar mark for the carotid pulse has the same reasoning.

The hair is then washed with a surgical scrub, and the entire head, ears, nose, and upper shoulders are also prepped with an appropriate surgical scrub. The hair on either side of the hair-bearing incisions is braided with orthodontic rubber bands. This isolates the incisions and generally keeps the remainder of the hair controlled and out of the operative field ( Figs. 3.64–3.66 ).

After the surgical prep is completed, the patient is draped with cloth and paper drapes. The cloth headwrap is attached with staples to keep it in place during the procedure and to keep the hair out of the operative field ( Figs. 3.67 and 3.68 ).

One chore for the surgeon and the assistants in facelift surgery is continually picking up and putting down instruments to retract the ear during surgery. To facilitate this, I place a 3-0 silk suture through the lateral helical rim and attach it to hemostats. This allows us to have a retractor present during the entire case ( Fig. 3.69 ).

One prime job of the surgical team is to protect the patient during surgery. To keep debris and blood out of the external auditory canal, we pack the canal with a cotton ball and change it if needed during surgery. It is important to remember to remove this after surgery, otherwise it can become compacted and left in place ( Fig. 3.70 ).

The eyes must also be protected to prevent corneal abrasion. There is a lot of activity, and it is not uncommon for a surgical drape, gown cuff, or surgical tubing to inadvertently rub against the eye, causing injury. Protection can be implemented with corneal shields, tape, a barrier membrane, or a tarsorrhaphy suture. This is frequently managed at the beginning of the case by the anesthesia team. I prefer a simple strip of tape for cases without blepharoplasty. Because I usually laser the lower lids with my blepharoplasties, the tape does not stick on the lasered skin, so we use a 6-0 gut tarsorrhaphy suture ( Fig. 3.71 ).

Tumescent Anesthesia

One of the major innovations in the past 20 years has been the development of tumescent anesthesia. In the past, surgeons used local anesthetic injections or sometimes no local anesthetic at all. Having local anesthetic and epinephrine in the tumescent anesthesia produces a threefold advantage. First, it serves to hydrodissect the tissue planes to make the facelift dissection easier. Second, it serves as a local anesthetic, which reduces perceived pain and allows the anesthesia team to use less drugs and agents. Third, the epinephrine promotes hemostasis. I feel that tumescent anesthesia is a critical part of facelift surgery.

There are many recipes for tumescent anesthesia. I generally use 500 mL of tumescent solution for a typical face and neck lift. My mixture contains the following ( Fig. 3.72 ):

• 500 mL of normal saline solution

• 50 mL of 1% lidocaine (0.5 g)

• 0.5 mL of 1:1000 epinephrine (0.5 g)

• 1 g of tranexamic acid

This produces 500 mL of 0.1% lidocaine with 1:1 million epinephrine ( Fig. 3.73 ). The tranexamic acid has been a more recent addition, and many surgeons are now using it to promote hemostasis. Anecdotally, this appears to be a very useful addition, and I have not had a postoperative hematoma in the 2 years since I began using the tranexamic acid.

I generally inject the tumescent solution with a Klein pump before the patient is totally prepped and draped for surgery. The injection points are prepped with the surgical scrub. Using an 18-gauge spinal needle or blunt infiltration cannula (best choice for novice surgeons), the solution is infiltrated in the pre- and post-auricular regions on each side and the submental region. All areas that will be undermined or dissected are infiltrated with the tumescent anesthesia ( Fig. 3.74 ).

When tumescent anesthesia is used for body liposuction, it is frequently taught to inject the solution until the tissues are “rock hard.” I do not believe that this is necessary in facelift surgery, and I feel that overinjection of tumescent anesthesia can balloon the tissues to a point that it may affect skin tightening during the procedure if the solution has detumesced. Mild ballooning of the tissues is usually adequate for local anesthesia hemostasis and hydrodissection.

While discussing hemostasis, it is imperative for any surgeon attempting facelift surgery (or most cosmetic procedures) to have some type of coagulation modality. The most common devices are traditional electrosurgery units or radiofrequency machines ( Fig. 3.75 ). Although rare, significant and serious bleeding can occur during facelift surgery and it is important not only to have the skill to be able to control the bleeding but to have devices use for large and or small hemostatic applications. I have significant experience with the Ellman and Soniquence Radiowave System ( Fig. 3.75 )

Step-by-Step Facelift Technique

Before discussing the actual step-by-step facelift technique, is important to mention that most facelift patients have other procedures performed at the same time as their facelift. In my practice, the most popular simultaneous procedures are cosmetic blepharoplasty, cheek or chin implants, brow lift, and CO ₂ laser resurfacing.

It is personal preference as to which procedures are performed and in what order. Personally, I prefer to perform upper face procedures such as blepharoplasty and brow lift before the facelift. Cheek implants can be placed at the beginning or end of the procedure, and a chin implant is placed during the procedure. For years, I performed aggressive simultaneous full-face CO ₂ laser resurfacing with my facelifts, but I no longer do this because of the intensity of recovery for these combined procedures. I have found that is it better for the patient if I perform full-face laser resurfacing as a secondary procedure. I do commonly perform perioral and periorbital segmental laser resurfacing at the same time of the facelift procedure. I perform this at the beginning of the case. Because of the intensity of the laser treatment, increasing anesthesia toward the end of the case delays and extends anesthesia emergence.

The next part of this chapter will deal with a step-by-step description and photos (supplemented by accompanying videos) of various face and neck lift procedures and approaches. These will vary from the simplest short-scar facelifts to the more complex deep-plane lifts. For novice surgeons, the short-scar facelift is an important starting point, and the comprehensive face and neck lift is probably the most common procedure performed today for mid-level or experienced surgeons. Other descriptions of various types of lifts from expert practitioners will also be described for reference and for surgeons with significant expertise and experience. As stated in the introduction of this textbook, no doctor should ever attempt to perform procedures for which they are not trained or cannot manage the common complications associated with those procedures. Face and neck lift surgery takes years to master and my advice to novice surgeons is to “walk before you run”; start with smaller procedures, and progress to larger procedures when you have mastered the common techniques.

The intraoperative surgical discussion will begin with what I call the comprehensive face and neck lift . I use this nomenclature because I feel that this technique is probably the most commonly utilized on an international basis. It is what most people think about when they discuss a “facelift.” It consists of pre- and post-auricular incisions, platysmaplasty, flap elevation, liposuction, treatment of the SMAS, and removal of excess skin. In a nutshell, this is the basic facelift.

Skin incisions were described in the previous section. My preferred technique is the triarcuate incision pre-auricularly and keeping the posterior and sideburn incisions in the hair-bearing regions (see Fig. 3.44 ).

Every surgeon has a preference for the steps he or she performs first or last. My personal order of face and neck steps are as follows:

• 1.

  Tumescent anesthesia

• 2.

  Submental dissection, liposuction, platysmaplasty

• 3.

  First side pre-auricular and post-auricular incisions

• 4.

  Flap dissections

• 5.

  “Open” liposuction

• 6.

  SMAS treatment

• 7.

  Key sutures

• 8.

  Posterior auricular flap tailoring and closure

• 9.

  Anterior auricular flap tailoring and closure

• 10.

  Temporal tuft tailoring and closure

• 11.

  Earlobe tailoring, positioning, and closure

• 12.

  Repeat on second side

• 13.

  Submental incision closure

Submental and Anterior Cervical Treatment: Dissection, Liposuction, and Platysmaplasty

Treatment in the submental area for the average facelift surgery includes subcutaneous dissection, liposuction, platysmaplasty, and for advanced surgeons may include deep platysma fat reduction, digastric muscle reduction, and submandibular gland reduction.

I prefer round scalpel handles for all of my cosmetic procedures (see Fig. 3.32 ). I believe that they are simply more artistic, they have the feel of a pen or paintbrush, and they can be rolled with the fingers to change direction and just provide better control. Flat scalpel handles are fine for body incisions but are not as well suited for curvilinear facelift incisions. To make a level horizontal scar in the submental region, the surgeon can use their index and second finger to make an inverted “peace sign” and stretch the tissue laterally on each side ( Fig. 3.76 ). Once the incision is made, two bleeders are usually encountered (one on each lateral side) and must be coagulated (see Fig. 3.76 ), or they can bleed during the entire case. For aesthetic reasons, this incision should be kept to the smallest length to allow the surgeon to perform the surgery; this is usually 3–4 cm. A caveat for novice surgeons is not to make this incision too long laterally as closure will produce bilateral dog ears on each side of the incision that are difficult to deal with postoperatively ( Fig. 3.77 ). To prevent this, the incision should not extend past the inner table of the mandible on each side.

After the incision is made, the next step is to begin the subcutaneous dissection. It is important to leave an adequate layer of fat on the dermal side of this flap. Not leaving enough fat and having a thin flap with exposed dermis is problematic for several reasons. It can show underlying irregularities very easily because of the thinness, and the dermis may be traumatized during dissection when making a very thin flap. This can create telangiectasias and inflammation that are quite visible postoperatively and may need treatment with vascular lasers or intense pulsed light devices after surgery. A 5-mm-thick flap is probably adequate.

I feel that a large part of performing competent surgery is having great assistants who understand how to help the surgeon navigate these tissues. Placing the tissues on vertical and horizontal stretch help dissection in this area by making a curvilinear structure flatter during the dissection. This allows the scissors to advance more easily with less trauma or chance of perforation of the flap. The submental incision is retracted by the surgeon using a Cottle ring retractor and by the assistant using a forked skin hook ( Fig. 3.78 ).

Subcutaneous dissection of the anterior neck is also facilitated by superior/inferior and lateral retraction by the assistant. As stated, this stretches this curved anatomy into a straighter anatomic unit therefore facilitating dissection ( Fig. 3.79 )

Another means of facilitating dissection in this area is using curved Padgett facelift scissors. The angle on this instrument is perfect to ergonomically negotiate this area ( Fig. 3.80 ).

As the surgeon begins the dissection, there are several methods of performing this task. Many surgeons will use sharp scissors and simply advance the scissors with the tips open to cleave the tissue plane. Other surgeons will do more of an alternating snipping and spreading action where they are snipping the tissue, then advancing the scissors and spreading the tips. The cut/spread method works well because many facelift scissors have cutting edges on both sides of each blade. Whatever the surgeon’s preference, the important thing is to leave enough fat on the dermal side of the flap without traumatizing the dermis and to extend the dissection adequately for the specific patient. Smaller facelifts may only require inferior dissection to the hyoid region, medium facelifts may require dissection to the thyroid prominence, and large facelifts may require dissection to the sternal notch. The extension of any dissection should be commensurate with the amount of release needed for that particular patient. Overdissection creates more dead space and bleeding and can promote hematoma, seroma, or other complications.

Ptotic chin anatomy with a deep cervical mental crease was discussed previously. This “witch’s chin” deformity can be addressed by superior dissection from the submental incision ( Fig. 3.81 ). This superior dissection coupled with violating the mandibular ligaments will release much of the tethering on the chin seen in some patients. Placing a chin implant in these patients can also greatly improve chin and profile aesthetics and normalize chin ptosis ( Fig. 3.82 ).

Once the anterior cervical flap is elevated and any bleeding is controlled, the surgeon will then focus attention on the fat and muscle. The next step for most surgeons is liposuction, also referred to as lipocontouring or liposculpture . The idea with this nomenclature is that we are not blatantly removing all fat but rather sculpting or contouring the patient’s existing fat to support and cushion the skin flap. One of the biggest and most egregious mistakes made by novice surgeons is overresection or overliposuction of fat. When too much fat is removed under a flap, the dermis can bind to the exposed platysma muscle and create a significant webbed deformity that can be extremely difficult to improve ( Fig. 3.83 ). Many surgeons learn liposuction techniques before they learn facelift techniques, and sometimes fat is considered “the enemy.” It is important to keep in mind that fat is far from the enemy and can be your best friend in face and neck lift surgery. Even thin, patients usually have an adequate insulating layer of fat that provides contour, softness, and a natural appearance of the overlying skin flaps. Excess fat removal is always avoided.

A curved, lighted retractor is extremely useful in this region. It is difficult to aim overhead lights or headlights in this area, and the angled fiber-optic retractor not only retracts the issue but provides light directly on the surgical field to enhance precision ( Fig. 3.84 ).

The average facelift patient is at an age during which increased body mass index, obesity, and generalized aging are responsible for increased cervical facial fat deposits. It is rare, and only the thinnest patients who present for face and neck lift do not need any fat reduction.

Some surgeons prefer to perform the submental liposuction through a small stab incision. This allows more of a vacuum and is somewhat more efficient, but it also does not allow the operator to view the surgical field (closed liposuction). Because facelift surgery with platysmaplasty will involve an open incision, it is my personal preference to make the incision, perform the skin undermining, and then liposuction the fat under direct vision. I refer to this as open liposuction . If I were performing a submental procedure that did not require platysmaplasty and only required liposuction, obviously I would not make the wide incision but rather a puncture.

When operating in the submental region, the surgeon is potentially treating two different fat layers. The subcutaneous fat is the layer immediately beneath the dermis and above the platysma muscle. In the superior part of the neck and the jaw/hyoid region, the deeper subplatysmal fat pad lies between the two anterior bellies of the digastric muscle ( Fig. 3.85 ). I am judicious about reducing the deep fat pad because even people with significant fat can be left with a hollowed submental region (cobra deformity) if the surgeon is too aggressive with removal of the deeper fat ( Fig. 3.86 ).

Although many surgeons use dedicated liposuction aspirators as a suction source, these machines are large, expensive, noisy, and not necessary when limiting liposuction to the face and/or neck. For most of my career, I have used our standard wall-suction unit with a collection bucket (see Fig. 3.86 ). This provides plenty of suction to get the job done.

I generally begin with a 6-mm cannula to efficiently reduce the cervical, submental, and inframandibular fat ( Fig. 3.87 ).

Again, most of this is direct vision and allows me to gauge how much fat I am removing and leaving. Liposcultping is the word sometimes used to describe this type of fat reduction. Instead of thinking of the situation as a total removal of fat, it is a better concept to think of it as sculpting or terracing the fat to allow fullness where you want it and reduction where you need it. Again, I cannot mention too many times the importance of not overtreating fat in the neck. Over the years, I have become less aggressive with submental and anterior cervical fat reduction as this layer is necessary for a soft, smooth result. As stated, overtreatment can thin the tissues and show subdermal irregularities. The key is to remove excess fat and leave enough “good” fat.

The next step is addressing the platysma muscle. As I have stated, I perform platysmaplasty in about 98% of my patients. Exceptions are younger patients without platysma banding who are undergoing short-scar lifts or older adult patients who may have some level of medical compromise requiring a less-detailed and shorter procedure. With these two exceptions, I feel that some form of platysmaplasty is extremely important. The prime reason is that most patients despise platysma banding, and if a facelift is performed without some component of addressing the anterior platysma borders, then the banding may not be improved or may return in the early postoperative period. One of the most disconcerting factors for post-facelift patients is residual platysmal bands. In addition, I think platysmaplasty is important because it enables more undermining of skin. By mobilizing the skin from the subcutaneous structures, more free skin is available in the cervicomental region. I feel that this translates into an increased amount of freed skin that will be available to be trimmed from the auricular flaps ( Fig. 3.88 ). Finally, patients who have a midline and posterior “plication” will have an anatomic platysmal sling that tightens the entire neck, sometimes noticeably reducing the neck size in patients.

If a chin implant is slated, this is a good time to incise the soft tissues over the midline mandible to the bone of the inferior border. A periosteal elevator is used to dissect the subperiosteal pocket with care to preserve the mental nerves. Once the implant is symmetrically placed and the midline verified, one or two 12-mm titanium retention screws are placed. I generally place one screw in the midline and a second screw several centimeters laterally to prevent rotational displacement. Finally, the periosteum is closed, and attention is focused on the platysmaplasty. Fig. 3.89 shows silicone implant placement from a submental approach.

At this point, the platysma muscles are addressed. Many patients have an extreme mass of fibrofatty tissue overlying the submental region. Sometimes this is difficult to see in the supine position as gravity flattens it, but it is easy to see when it is picked up with forceps ( Fig. 3.90 ). When this tissue mass is lifted, it can be excised, and this excision can extend inferiorly to the desired position. Generally, I remove a wedge of this overlying tissue from the inferior border of the mandible to the level of the thyroid cartilage. Smaller lifts may only extend to the hyoid level. I elevate this tissue with bayonet forceps and use facelift scissors to reduce this elevated tissue. I continue inferior dissection in this plane to also incise the medial borders of both platysma muscles. Patients with significant platysmal banding generally have ptotic and atrophic medial platysmal borders. Excising several centimeters of this tissue in a lateral direction removes the ptotic tissue back to a level where the platysma is more substantial. After this excision, the surgeon can view the deep platysmal fat pad, the deeper muscles of the neck, and sometimes the pretracheal fascia. The paired anterior jugular veins can be encountered in this deeper plane and occasionally produce brisk bleeding that is controlled with cautery. Some surgeons prefer to elevate the central soft tissue mass and clamp it longitudinally with a long clamp ( Fig. 3.91 ). In patients with extreme submental fullness, the deep platysmal fat can be debulked and reduced. The average patient does not need deep fat recontouring, which can lead to a hollow depression on the submental region.

I would estimate the direct midline platysma plication is the most common procedure performed to address the bands and tighten the neck. Although this is frequently referred to as a plication , the Latin word plica means “fold,” and this generally is not an open-type repair. Technically, I feel platysorrhaphy is a more accurate term and is consistent with surgical procedures such as hernia repair. Orrhaphy is derived from Greek “to sew or join.” There are many different ways to treat this area. Some surgeons use criss-cross (Giampapa) sutures that attach to the mastoid fascia. Some surgeons resect a portion of platysma on each side instead of placating it (platysectomy). This prevents recurrent platysmal banding but can also expose the submandibular glands, which may protrude into the lateral submental area. In this case, a partial submandibular gland resection can be performed. This will also be discussed in the deep-plane facelift section and is a procedure for advanced surgeons.

Some surgeons do not treat the midline platysma at all. I personally have had my best results with a simple midline platysma repair, which I refer to as a shoestring repair ( Fig. 3.92 ).

This is also called a corset platysmaplasty as it resembles the stitching on a woman’s corset.

I always trim the medial platysmal borders before they are sutured together in the midline. This reduces some of the ptosis, allows for a tighter repair, and permits the raw borders to heal together. If the medial platysmal borders are extremely ptotic, it is important to excise the edges back to normal muscle. Performing a midline repair with ptotic platysmal borders detracts from the result and can produce visible bunching under the overlying neck skin. In some patients the platysma is a very visible thick red muscle, and in other patients it is very thin and wispy. It is easy to place midline sutures in patients with a thicker platysma structure as you are simply picking up the muscle and sewing it to the contralateral muscle. On the occasional patient with a less-defined platysma border, the surgeon may be securing other tissues associated with the platysma border and bringing those to the midline on each side. This has the same effect, and the point is that the platysma is well-defined in some patients and poorly defined in others.

I prefer a 2-0 Vicryl absorbable suture for the platysma repair. Some surgeons use bigger or smaller sutures, and others also use permanent sutures. Resorbable sutures are my choice because the sutures that hold tissues together are only important until the dissected tissue planes scar together. It is this scarification during healing that maintains the result. After this healing occurs (usually within 4–6 weeks), internal sutures are not necessary. Experienced surgeons are well aware that during revision facelift surgery, previously placed permanent sutures are frequently seen loose in the tissues serving no function. Secondary to that, although rare, they can become a source of foreign-body reaction and of infection. I choose the Vicryl suture because it ties easily, has adequate friction to keep the knot together, and is strong and resorbable.

The platysma repair is begun by using the lighted retractor to retract the anterior cervical skin and illuminate the deeper tissues. I place the first platysma suture at the cervicomental angle, which is the junction of the neck and submental region that corresponds to the hyoid region ( Figs. 3.93 and 3.94 ). By placing the first suture in this region, the loose tissues are tucked superiorly and posteriorly and “set” the platysmal position for the remaining sutures. I place approximately six or seven interrupted sutures above and below this first holding suture. These midline sutures run from the inferior border of the mandible to either the hyoid region or the thyroid region, depending on the aggressiveness of the cervical flap. Generally, smaller facelifts only require dissection to the hyoid region, and larger lifts may require dissection to the thyroid area or beyond.

As previously stated, sutures are placed from the mandibular border inferiorly to the hyoid or thyroid region, depending on the magnitude of the facelift. Fig. 3.95 shows a representation of the 2-0 Vicryl midline sutures.

Many surgeons advocate performing a releasing “cutback” at the hyoid region to prevent a “bowstring” effect of the sutured platysma border seen as a longitudinal ridge under the skin. For smaller lifts in which my platysmaplasty only extends to the hyoid region, I rarely perform a cutback. For larger lifts that extend to the thyroid region or beyond, I do make cutbacks at the cervicomental region to release repair. The contour of the neck and submental regions are curved, and a long midline platysma repair can tighten the borders to the point where the platysma becomes a straight line instead of negotiating the curvilinear contour of the neck and submental regions. Making the releasing cutback allows the tissues to relax at this junction, thus preventing a straight-line ridge that can show through the skin ( Fig. 3.96 ). The cutback allows a more normal skin drape. One of the chief complaints of platysmaplasty patients in the early postoperative period is neck tightness. Anecdotally, patients with a releasing cutback seem to complain less of immediate postoperative tightness.

It is notable that numerous texts describe various positions of the cutback on the platysma. Some texts recommend the platysma cutback to be as low as possible in the neck to allow better skin drape. When I utilize a cutback (and I do not always), I try to place it at the level where the neck and submental contours merge. This seems to be generally in the region between the hyoid bone and laryngeal promenince of the thyroid cartilage, but it can technically differ from patient to patient based on their specific anatomy. Generally, by extending the head, the surgeon can palpate the "cord or bowstring" and figure out the most efficient area to transect to release the deformity.

After the platysmaplasty is completed, attention is then focused to the first side of a facelift. In my experience, right-handed surgeons usually begin on the right side, and left-handed surgeons like myself begin on the left side. This makes no difference and is simply a matter of convention. Incision design has been discussed at length in the previous portion of this chapter. I begin using a round scalpel handle with a #15 blade. I start with a transfollicular sideburn incision and a triarcuate pre-auricular (and pretragal) incision, which continues around the base of the earlobe. The posterior auricular incision then is continued superiorly in the depth of the post auricular sulcus to the greatest width of the pinna. At this point, the incision is extended horizontally with an inferior taper into the posterior hairline. Small facelifts may only require 3–4 cm of horizontal extension into the hairline, and larger lifts may extend 8–10 cm into the posterior hairline ( Fig. 3.97 ).

One of the most challenging parts of facelift dissection for novice surgeons is staying in the correct plane. The initial plane for most face and neck lift surgery is the subcutaneous plane. Failure to dissect deep enough can thin the lipocutaneous flap and cause problems with perforation or viability. Dissecting too deeply can damage significant neurovascular structures. One of the first skills to be mastered in facelift surgery is finding and staying in the proper surgical plane. For novice surgeons, I recommend a pre-dissection technique (also referred to as pretunneling ). This is performed before any flap dissection. Small stab incisions are made in the sideburn at the earlobe and behind the ear. This can be performed before or after the pre-auricular incisions. Using blunt dissection cannulas specifically designed for this (or a spatulate liposuction cannula without a suction source, the cannula is rapidly passed back and forth in a reciprocal manner to undermine the subcutaneous plane from the deeper tissues ( Fig. 3.98 ). The pretunneling makes “Swiss cheese” tunnels in the subcutaneous plane. Performing this maneuver for several minutes makes hundreds of these perforations under the flaps ( Fig. 3.99 ).

If this procedure is performed, it is easier for novice surgeons to find and stay in the subcutaneous plane. It also greatly facilitates scissor dissection because of the pre-dissection ( Fig. 3.100 ). When the scissors are inserted, cutting is much easier as you are simply joining the “Swiss cheese” tunnels. In many cases, the scissors do not even need to be opened and closed (for snipping) and can just be held in an open position and advanced through the tissue to dissect.

The pretunneling is especially useful in the mastoid region. The posterior auricular flap is normally very thick, but as the mastoid region is approached, there is little or no subcutaneous tissue. In this region, the dermis is virtually bound down to the fascia of the SCM muscle. This is a trying area for both novice and experienced surgeons as it is easy to perforate the flap. Alternately, if the dissection is carried deeper and follows the SCM muscle inferiorly, the EJV and GAN are at risk. Fig. 3.101 shows how transparent this tissue can be in a cadaveric specimen with a blunt cannula inserted under the dermis.

Flap Dissection

The crux of facelift surgery is creating lipocutaneous flaps on the anterior neck and pre- and post-irregular areas. My dissections are contiguous, so all of the flaps and dissections are contiguous. Some surgeons do not connect the anterior cervical and submental flaps with the pre-auricular and post-auricular flaps. I believe that connecting all the flaps will mobilize more skin and result in a better drape with a more comprehensive result. A possible negative feature of connecting all of the flaps is that a hematoma in one region could involve all of the dissected regions.

After the initial incisions are made in front of him behind the ear the cutaneous flaps are developed. As previously stated, a sufficient layer of fat should be left on the dermal side of the flap as well as this mass side of the flap. As also previously stated, these flaps should be treated in a gentle manner as loss of viability can result in horrific circumstances.

Flap dissection can be performed with scissors, a scalpel, or cautery depending on surgeon preference ( Fig. 3.102 ). Cautery dissection should only be used in experience hands as excessive lateral thermal damage can be problematic. Scalpel dissection also takes experience as it is easy to dissect too thin or too deep during the dissection. I personally believe that scissor dissection is the easiest method to learn and control for novice surgeons.

Once the scissor dissection is started, the facelift scissors can be advanced by several methods. On patients with thicker and more tenacious tissues, opening and closing the tips in a snipping motion and spreading the tips are required to advance ( Fig. 3.103 ).

On patients with more fragile tissue, leaving the tips in a semi-open position and advancing the scissors without opening and closing is effective. This depends on surgeon preference and the resilience of the tissue being dissected. Some patients have extremely thick and fibrous tissues that require a cutting motion, and others have more fragile and less robust tissues that can be separated with a gliding motion of the open scissors. As stated many times in this chapter, controlling the level of dissection is paramount to avoid perforation or unintended tissue depth ( Fig. 3.104 ).

The extent of flap dissection is commensurate with the amount of aging and tissue excess. In general, a 45-year-old patient would have smaller flaps than a 65-year-old patient. I have previously mentioned that facelifts come in three sizes: small, medium, and large ( Fig. 3.105 ). The bottom line is that the extent of flap dissection must extend enough to free the excess tissues so they can be retracted and redraped in a passive manner without dimpling or puckering ( Fig. 3.106 ). The extent of the flap dissection is essentially what defines the size of a facelift. It is important to remember that this lipocutaneous flap is delicate (see Fig. 3.21 ). It should be protected at all times from excessive retraction, compression, heat, and other physical insults that occur during surgery.

Flap Dissection

Some surgeons begin with dissection of the pre-auricular flap, and others begin with the post-auricular flap; this is a matter of preference. The goal of flap dissection is to extend the subcutaneous undermining in the correct plane while protecting the underlying anatomy. The extent of undermining, as previously described, is commensurate with the amount of aging and skin excess. It is not uncommon for the preregular flap to extend to the orbicularis oculi muscle, the mid-cheek region, mid-jowl region, and mandibular border (see Fig. 3.106 ). The posterior flap dissection can extend to the mid-occipital region and, as stated, can vary from 4–10 cm in length. The inferior extent of the pre-auricular and post-auricular flaps are usually contiguous with the cervical dissection and become a single unit (see Fig. 3.107 ).

As the pre-auricular flap is developed anteriorly in the subcutaneous plain, various structures may be observed. First and foremost is the attachment of the zygomatic ligaments, also referred to as McGregor’s patch . This ligamentous structure anchors the skin of the cheek to the inferior border of the zygoma and is found just posterior to the origin of the zygomaticus minor muscle (see Fig. 3.22 ). In the average patient, the surgeon will recognize this as a tenacious connection between the dermis in the deeper tissues. It frequently presents as an obstacle to dissection and will result in a visible skin dimple intraoperatively and possibly postoperatively if it is not transected ( Fig. 3.107 ).

In many patients, the buccal fat pad is prominent or herniated and is identifiable under the anterior flap during dissection. Failure to address the buccal fat pad can detract from an otherwise great facelift because of residual jowl prominence. If this structure has significant bulging, then it should be treated at this point. In the case of minor prominence, the buccal fat pad can be reduced by placing horizontal mattress sutures over the fascia to flatten the area. In the case of significant herniation, I enter this space with blunt dissection to prevent damage to facial nerves, tease the buccal fat pad out of its capsule, and then reduce it intraoperatively ( Fig. 3.108 ). After this reduction is performed, the fascia is closed with 4-0 Vicryl sutures. The buccal fat can alternately be reduced via an intraoral incision at surgeon preference ( Fig. 3.109 ). Treating the buccal fat pad can slim the face, and ignoring a full buccal fat pad can detract from a result.

During the entire dissection of the anterior flap, close observation is required by the surgical assistants as well as the surgeon. For safety, the patient must be monitored for any facial muscular twitching or evidence of stimulation of facial nerve branches that may run superficial in this region.

After dissecting the anterior flap to the mandibular border, attention is turned to the posterior auricular flap. Again, some surgeons may begin with the posterior flap first; this makes no difference and is a matter of preference. This posterior flap is retracted and undermined with scissor dissection in the same manner as the pre-auricular flap. Dissection ergonomics are facilitated by keeping the flap under tension using a Cottle (or otherwise appropriate) retractor. As the flap is retracted posteriorly, the scissors are advanced anteriorly ( Fig. 3.110 ). Keeping the flap under slight tension facilitates dissection. The same dynamics hold true for the anterior flap. Considering the significant anatomy described earlier in this chapter, close attention and direct vision is necessary when proceeding inferiorly with this dissection. The first complexity encountered with this dissection is the thin tissue over the mastoid region. Careful dissection is required to stay in the correct plane. Dissecting too superficially can result in skin perforation, and too deep of a dissection can lead to injury of the GAN and or EJV as they cross the SCM muscle ( Fig. 3.111 ). As the posterior dissection advances around the earlobe, the lobe is mobilized ( Fig. 3.112 ). I prefer to make a releasing incision at the base of the lobe so it can be mobilized to a natural position when trimming the flap later in the operation. The anterior flap dissection is carried to the mandibular border. The combination of both dissected flaps leads to increased freedom of the flap and related visualization. As anterior or posterior flap dissection proceeds inferiorly, it is important to have optimum visualization. I prefer using a fiber-optic lighted retractor in this area.

When dissecting in the hair-bearing area of the posterior flap, the surgeon must be mindful of the hair follicles, which are sometimes visualized. There is an adage that “if you see the hair follicles, they are already damaged.” I think this is overstated as I have encountered hair follicles many times while dissecting the posterior flap without any damage to the overlying hair ( Fig. 3.113 ). Having said this, I do pay very close attention to protecting the follicles, and I am mindful when using cautery in this area as the lateral thermal damage could potentially damage the hair follicles.

The dissection is continued to the required extent in the pre-auricular and post-auricular regions working anteriorly, posteriorly, and inferiorly ( Fig. 3.114 ). The temporal dissection of my average facelift extends to the region of the lateral orbital rim ( Fig. 3.115 ).

My average facelift dissection in the temporal region extends to the area of the lateral orbital rim (see Fig. 3.115 )

Earlier discussion detailed the importance of transecting the zygomatic ligaments. It is equally important to transect the mandibular ligament on each side for full freedom of the dissection and flap mobilization ( Fig. 3.116 ).

Hemostasis is critical throughout the entire case, and bleeding must be controlled as the surgeon progresses, otherwise it may be impossible to “catch up” at the end of the case. Periodically packing the surgical site with 3% hydrogen peroxide or chilled saline gauze and waiting a few minutes is a good way to further control hemostasis and identify existing bleeders ( Fig. 3.117 ).

As the cervical dissection and platysmaplasty have already been addressed, the main goal in the operation up to this point has been to dissect the pre-auricular and post-auricular flaps. As stated numerous times in this text, the extent of dissection is related to the amount of aging, skin excess, and ptotic tissues present ( Fig. 3.118 ).

After all flaps are dissected, the platysmaplasty is completed, and hemostasis is achieved, further liposuction may be performed. Because this is done with direct vision, I refer to it as open liposuction . This may involve areas of the lateral neck but is especially focused on the jowl region. Fig. 3.58 shows the areas of jowling above and below the mandibular border, and Fig. 3.119 shows actual liposuction of these areas. Almost every patient, with the exception of thin or atrophic individuals, is a candidate for some component of jowl liposuction. As we will discuss later in this chapter, two of the most common complaints after face and neck lift surgery are residual jowling and submental skin excess. I have modified my facelift technique over the years to specifically address these deficiencies. One of the most important parts of addressing this situation is paying extra attention to the jowl region during liposuction and SMAS treatment. With all flaps open and optimum lighting and visualization, the surgeon may discover areas of fat that were overlooked during the liposuction at the beginning of the case. Liposuction may also be performed in the lateral neck at this point. This may be especially helpful for patients with extremely heavy necks. The surgeon must be careful to never over-liposuction any area that may allow the dermis to contact muscle because of the postoperative deformities that can occur.

Addressing the Superficial Musculoaponeurotic System

The more a student studies face and neck lift surgery, the more differences they see performed by various practitioners. One common denominator is that virtually every accomplished facelift surgeon addresses the SMAS layer in some manner. Experience over the past century has shown that only treating the skin and ignoring the deeper structures will have significant implications on result and longevity. There are many surgical descriptions of how to treat the SMAS and more than I list below. Some of the more common means of treating the SMAS layer include the following:

• SMAS plication

• SMAS flap

• SMASectomy

• Deep plane subSMAS

• Energy-based SMAS tightening

The SMAS is described in more detail earlier in this chapter but is a dynamic layer in the structure of the face. In this text I am defining the SMAS as the fibrofatty layer beneath the dermis and above the PMF in the cheek. This layer can also extend into the neck under the dermis and above the deep cervical fascia (see Fig. 3.6 ). As stated, it allows an entire group of facial muscles to be animated or surgically repositioned without addressing the individual structures. In short, the surgeon is repositioning the "sheet of SMAS," which will in turn reposition the much of the entire middle layer of the face.

Closed Treatment of the Superficial Musculoaponeurotic System (SMAS Plication)

The most basic techniques for management of this mass begin with suture plication. These may be in the form of purse-string sutures, which as the name implies, gather a circular portion of the SMAS and produce tightening. I have never been a fan of this type of suturing technique. Although it may be effective in tightening, if for any reason the suture breaks, the entire repair is jeopardized. When used, several purse-string sutures are placed at different angles and positions to achieve the desired SMAS repositioning ( Fig. 3.120 ).

The facelift literature not only is full of controversy about the actual structure and histology of the SMAS, but also about the nomenclature of SMAS treatment, namely SMAS plication and SMAS imbrication. The term plication is defined as “folded, crumpled, or corrugated” and is derived from the Latin “plica–tus folded, from plica–re to fold.” The term plica commonly describes a fold in the orthopedic, surgery, and ophthalmology literature. In this text, plication will describe a bunching or folding of the SMAS. It can be achieved by passing the needle and suture through the SMAS (distally), pulling it in a given direction, taking another bite (proximally), and then securing it with a knot (see Figs. 3.121–3.123 ).

There is no absolute universal position for plication sutures. It is, however, quite common to place the first suture at a distal position on an imaginary line from the corner of the mouth and then secure it in a proximal position to an area in front of the tragus (see Fig. 3.121 ). It is imperative when placing sutures through the SMAS to maintain a level above the PMF as not to ensnare branches of the facial nerve with the suture (see Fig. 3.11 ). Care of suture depth is also observed over the parotid gland as suturing through the gland could contribute to a sialocele.

SMAS plication is very effective, and I would suggest this technique of SMAS management for novice surgeons. Having said this, I know many accomplished surgeons who perform SMAS plication. One relative drawback of this technique is that the bunching or folding can create a thickening that may be visible under the skin. This is usually not significant, and if there is visible thickening it resolves with healing.

SMASectomy

This text describes the common SMASectomy techniques as well as my own progression of SMASectomy evolution to provide safety and predictable outcomes. My first experience in SMASectomy was a simple linear SMAS excision. Extending this into the neck was my next step. I then progressed to what I refer to as the "7 SMASectomy" and to better address the jowl, that gave way to the "C SMASectomy" which also extended into the neck. As described below, the jowl portion of the "C SMASectomy" is sometimes not sutured but serves as a jowl reduction. Finally, I also perform a "Deep Plane SMASectomy" in which the SMASectomy is performed followed by deep plane undermining. In a given patient, on a given day I may perform some modification of any of these techniques to best address the patients specific anatomy. In my experience, due to SMAS thickness and related anatomy the exact same SMASectomy technique cannot be performed on every single patient. Some patients have very thick SMAS that is amenable to deep plane undermining while other patients may have a very friable SMAS that is not optimal for deep plane technique. This SMASectomy section of my book details my personal evolution experience and common techniques. Please note that terms like "7 SMASectomy and "C SMASectomy" are my personal nomenclature and not universal in surgical reference. Every surgeon should understand these and other SMAS options and best apply them based on their experience of safety and natural outcomes. Over my 25-year experience with facelift surgery I would say that SMASectomy has been the most common SMAS treatment among all the specialties performed during cosmetic facial surgery. The technical definition of SMASectomy is to cut and remove a section of SMAS (ectomy) . As with other procedures in any other type of surgery, many variations exist. I believe that SMASectomy is an intermediate technique and that novice surgeons are best beginning with SMAS plication. Once a surgeon is comfortable navigating the various anatomic layers of the face, he or she can proceed to the SMASectomy procedure.

The most basic SMASectomy procedure involves the excision of a strip of SMAS that is parallel with the nasolabial fold. The confines of this excision are from the zygomatic area to the angle of the mandible ( Fig. 3.124 ). The width of the SMAS excision varies from 1.5–3 cm and is commensurate with the amount of ptosis in the SMAS layer and the desired amount of traction and tightening distal to excision ( Fig. 3.125 ). For novice surgeons, it is best to perform this excision over the substance of the parotid gland to remain posterior to the facial nerve branches as they become exposed when they exit the anterior border of the gland. It is important to keep the excision out of the glandular tissue, which can cause a postoperative sialocele. Regardless of where this excision is placed, it always remains superficial to the PMF.

This described technique is the most basic SMASectomy procedure, and the excision is not undermined or carried into the cervical tissues. In this case, the lateral platysma in the neck is treated as a secondary procedure. It is also important to state that some patients have a very wispy or friable SMS layer, and it may not be thick enough or strong enough to hold suture tension. In this case, the technique is reverted to SMAS plication. The situation is not unusual in revision facelift surgery in which the layers are scarred and there is no definitive SMAS to excise and suture.

In theory, the strip of SMAS is removed to the level of the PMF. In reality, not every bit of SMAS tissue must be excised nor does it need to be excised 100% to the level of the PMF. In reality, only enough SMAS must be removed to allow mobility of the distal tissues and have a thick enough SMAS border to hold sutures. Too thin of a SMAS resection may not be effective for elevating the distal tissues and may be friable, allowing sutures to pull through. The section of excised SMAS should be an ellipse with tapered ends to allow closure without bunching.

To close the SMASectomy, I prefer a 2-0 Vicryl suture. They are resorbable, strong enough to withstand tension, and small enough not to be visible through the skin. One of the main reasons for performing a SMASectomy is to allow the surgeon to control various vectors. The initial SMASectomy suture is placed lateral to the jowl on an imaginary horizontal line from the corner of the mouth. The suture is then secured to the proximal border of this SMAS in a superolateral vector ( Fig. 3.126 ).

Before placing the first SMASectomy suture, the surgeon should explore various positions on the inferior and distal portion of this SMASectomy. Bayonet forceps are used to elevate the ptotic tissue in a superolateral direction. This location is not the same in every patient, and it may take several attempts to pick up the most moveable tissue. When the surgeon finds a position that elevates the neck, the mandibular border, the jowl, and the corner, the suture is placed in this spot. I refer to this as the sweet spot , where elevation of this area will improve the neck, mandibular border, jowl, and corner of the mouth. This will be obvious in the video section that accompanies this textbook.

After this initial suture is in place, it pretty much controls the remaining vectors of the SMASectomy repair. Additional sutures are placed above and below the first suture to bolster the repair and further enhance the desired vectors to a more youthful position. Extending the inferior Portion of the SMASectomy below the inferior border of the mandible allows more ability to control the ptotic SMAS in the upper cervical and mandibular regions ( Fig. 3.127 ).

Fig. 3.128 shows the sutured SMASectomy site and the excised strip of SMAS overlying the skin in its approximate position. Some surgeons use the excised SMAS as grafting material in the lips, nasolabial folds, or other areas.

The basic SMASectomy technique is effective, and I have evolved using several personal modifications. As surgeons advance in their knowledge, experience, and ability, they will understand that modifying the SMASectomy procedure can provide more flexibility in controlling vectors and improving and stabilizing results. The second modification of the SMASectomy I have used is the “L” or “inverted 7” or right-angled SMASectomy. In addition to the described vertical member, a horizontal SMAS strip is removed at or above the zygomatic arch ( Fig. 3.129 ). Staying above the PMF layer protects the frontal branch of the facial nerve. The combination of this vertical and horizontal member allows for greater control of vectors, especially in the superior and lateral direction ( Fig. 3.130 ). If this right-angled flap were undermined in a subSMAS dissection, the procedure would be similar to that of a SMAS flap or a deep-plane facelift subSMAS dissection ( Fig. 3.131 )

The right-angled SMASectomy can be extended inferiorly on the neck on patients with SMAS tissue that is thick enough to cut and sew. On some patients, the SMAS dissipates and becomes too thin to cut and sew below the mandibular border. Many patients, however, do have the same thickness of SMAS in their neck that they do in their facial regions, and in these patients the SMASectomy can be continued down as far as the surgeon desires ( Figs. 3.132 and 3.133 ). In addition, the angle of the cervical SMASectomy can be manipulated for the most optimum lifting vectors. Having extended degrees of vector manipulation in the deep layers enables a more natural and less windswept look when the skin is redraped. The importance of SMAS treatment can never be overstated.

As stated earlier in this text, the best surgeons are continually trying to up their game. They are always curious and looking for ways to improve patient safety and predictable outcomes. I make before and after photos and analyze all of my postoperative results carefully. It is important for every patient to be happy. Sometimes the doctor is happy with the result and the patient is not, and other times the patient is happy with the result and the doctor is not. It is important to resolve these issues because the only thing we have is our brand. As I stated earlier, I always explain to my patients that for me to look good, they have to look good, and I further state that it is their face but my reputation.

Over the years, the two main things I have observed after facelift surgery are residual jowling and submental skin excess. Although revisions compose a small percentage of my facelifts, they are required by all surgeons. One of my quests has been to continually improve my facelift technique, especially to better control the jowl and the minor submental skin excess that can occur.

I have modified my SMASectomy technique to have better control of the jowl tissue. It is important for the surgeon to understand that when the patient is asleep and recumbent, it may be difficult to judge the actual amount of jowl tissue excess because the area collapses as a result of gravity ( Fig. 3.134 ).

This SMASectomy evolution combined with my quest to improve the jowl region led me to start using a technique that I refer to as the “C” SMASectomy.

The geometry is similar to the previously described “7” SMASectomy ( Fig. 3.135 ), but has two horizontal limbs: a superior and inferior. The superior horizontal limb is at or above the zygomatic arch, and the vertical limb is over the parotid region. The inferior horizontal limb is at or about the mandibular border ( Fig. 3.136 ). More precisely, it is over the most ptotic and full portion of the jowl. Lifting the jowl as shown in Fig. 3.137 . shows the true extent of jowl excess. This is frequently underestimated when the patient is in the supine position. It is important to determine the fullest part of the excess to be excised. Fig. 3.135–3.138 show the markings for the “C” SMASectomy.

The mechanics of this SMAS procedure involve the same type of dissection as other forms of SMASectomy. The SMAS is elevated off of the PMF and excised with scissors. One important caveat is that the marginal mandibular nerve runs very close to the inferior (mandibular) horizontal limb, therefore care must be taken to stay above the PMF and platysma to prevent damage to the marginal mandibular nerve. Fig. 3.136 shows the excision of the upper horizontal (zygomatic) and vertical limb, and Fig. 3.137 shows the lower horizontal SMAS excision over the jowl. Fig. 3.138 shows a representation of the completed “C” SMASectomy and the completed and sutured vertical and lower and upper limbs. The jowl SMAS can be closed, but in many cases, simple scissor reduction without closure is enough to treat the jowl excess. The “C” SMASectomy has proven to be a comprehensive treatment. I also perform a deep plane SMASectomy by undermining the cheek and neck SMAS as shown in Fig. 3.136 .

The procedure is completed by closing the SMASectomy with 2-0 Vicryl interrupted sutures ( Fig. 3.139 ).

It is important to remember that adjusting the suture placement on the proximal and distal SMASectomy margins can produce the desired vector. A SMASectomy is an adjustable procedure. Again, most of the rejuvenation vectors are superolateral, and the first suture I place is usually in the pattern shown in Fig. 3.121 . The remaining sutures contribute to the desired vectors and stabilize the SMASectomy repair.

I have discussed several popular SMASectomy procedures that I have personally used over the past several decades. At this point, I prefer using “C” SMASectomy; in addition, I frequently extend the vertical limb into the neck (see Figs. 3.132, 3.133, and 3.135 ). The lower horizontal limb can be excised and closed as part of the “C” SMASectomy but can also be done as a final step after the face and neck SMAS has been closed (see Figs. 3.137 and 3.138 ). In other words, I perform an “extended 7” SMASectomy. I use the pattern shown in Fig. 3.138 but extend it onto the cervical region. I then close the extended 7 SMASectomy. The final step here is to excise the SMAS and fibrofatty tissue over the jowl (which is the same as the lower horizontal limb of the “C” SMASectomy. This lower horizontal limb can be performed after the rest of the SMAS has been addressed.

Deep-plane and other methods of SMAS treatment are discussed later in this chapter.

After the SMASectomy is performed, it is important to recheck the skin surface for residual dimpling. It is not uncommon to have a smooth contour of the dissected facelift flap before the SMAS procedure but dimpling or contour irregularities after the SMAS sutures are placed. This may require further dissection to release any dimpling or contour irregularities (see Fig. 3.106 ).

Treating the Posterior (Lateral) Platysma

As stated previously, many surgeons perform some type of midline platysmaplasty procedure. I personally believe that it is important to also address the posterior platysma. This is frequently referred to as posterior platysmal plication . I would like to point out that I disagree with the nomenclature of anterior and posterior platysma, and believe it should be referred to as medial and lateral platysma. As stated earlier, I also disagree with the term plication as this is more complex than simply folding tissue over on itself. Regardless of the semantics, addressing the lateral or posterior platysma is important because I believe that when combined with the midline platysma treatment, it creates a sling that helps tighten, support, and elevate the submental and cervical regions ( Fig. 3.140 ).

I have heard some surgeons say that they do not perform a lateral platysmal suspension because they feel that it negates the effect of the medial repair. Again, I think it actually augments the effect of the medial platysmaplasty and creates a sling. I have also heard surgeons say that they do not perform lateral platysmal suspension because the sutures will compress the GAN. It is true that the sutures may run directly over the greater regular nerve; however, I believe that any permanent damage would be extremely rare. I have done this several thousand times (two sides on each patient), and it has never been problematic. If the combination of these sutures is placed with excessive tension, it can be very uncomfortable in the initial postoperative days. I believe these structures only need moderate tension in the same manner of SMASectomy closure. All sutures relax as edema resolves and so do most patients’ complaints of tightness.

I personally perform this step before skin closure on each side. The lateral platysma is addressed through the post-auricular flap. In many patients, the lateral platysmal border is very identifiable in patients with significant thickness of the muscle. In this case, it is simple to secure the lateral border and suspend it in the proper vector. Many patients do not have an extremely visible lateral platysmal border. If the lateral platysmal border is not visibly evident, the lateral platysmal suspension can still be performed by securing the associated tissues that overlie the lateral platysmal border. This usually involves fibrofatty tissue; the suture passes through the overlying tissue and platysma and is fixated posteriorly or posterolaterally ( Fig. 3.141 ).

Many textbooks describe the use of long sutures from the lateral platysmal border to the mastoid region or to the fascia of the SCM muscle. These long sutures are often referred to as cable sutures or spanning sutures . Although I used these long sutures on my initial cases, I realized that there was really no point in having all of this suture excess. The important thing is to secure the lateral platysmal border and suture it to tissues that are strong enough to retain the suture without pulling through. Also, the posterior suspension point must not overlie any significant neurovascular anatomy. Given these parameters, I do the same lateral platysmal suspension; however, I use a much shorter 2-0 Vicryl suture and secure it approximately 50% of the distance posteriorly than I did in the past ( Fig. 3.142 ). It just makes sense to me to have less foreign body, and I believe the longer sutures have a greater propensity to loosen. I generally place 2–3 mattress sutures from superior to inferior.

As the surgical team prepares for the skin management phase of the procedure, it is the last chance to monitor what is happening “under the flap.” Obviously, the main concern is any uncontrolled bleeding. Experienced surgeons are able to differentiate minor soft tissue oozing from significant bleeding that can accumulate and contribute to hematoma formation. The surgical field should be dry before proceeding to the skin-closing steps. Gently packing any undermined flaps with chilled saline solution or hydrogen peroxide and leaving them in place for several minutes greatly aids the ability to ascertain hemostasis. I routinely use undiluted 3% hydrogen peroxide, which will foam on contact with blood, to control bleeding and identify active bleeding (see Fig. 3.117 ).

Residual contour irregularities are also a concern and must be addressed before skin closure. These irregularities can include lumps and bumps of fat from the adipose layer, bulging tissues between sutures, and areas of muscle or tissue irregularities over tight suture lines. Smoothing the irregularities is important as they may otherwise be visible through the skin. Although many irregularities will dissipate with healing, some may remain and be visible and permanent. Figs. 3.143–3.145 demonstrate various deeper soft tissue contour irregularities that produced visible bulges or lumps through the skin.

Skin Redraping, Fixation, and Excision

The next part of the procedure is to redrape, fixate, and trim the excess skin. Facelift surgery is like many things in life where a small mistake at one point can be amplified in the final result. As previously stressed, it is important to have a smooth contour under the skin so there are no visible irregularities. Anyone who has ever seen or done upholstering understands that the bottom layers must be perfectly smooth before the top covering is placed or irregularities will be visible. Again, all bleeding must be controlled at this point. Before any closure is begun, it is beneficial for the staff to take a short time out to make sure that no previous steps have been omitted, all steps have been performed bilaterally, and no foreign bodies remain under the flaps. It is not impossible to leave a gauze pad within a facelift flap, and for this reason I only use surgical gauze with radiographic markers on them. My team always performs a gauze count before any skin closure is started.

The skin closure represents a turning point in the case as it is a transition to the end of the procedure. By this point, most of the “heavy lifting” is finished. Managing the skin is one of the most important parts of the case. Despite an aggressive surgical procedure, the incision scars are the only thing the patient really sees. A well-done facelift can be ruined by failure to effectively manage the skin, incisions, earlobe postition, and hairlines. In my several-decade experience with face and neck lift surgery, I can attest that the main fear of every single patient is the fear of the wind-blown or “done” look. Some of what happens at this point must be discussed well in advance of the actual surgical procedure. First and foremost, the patient must understand that a facelift is not a procedure for skin wrinkles. Some wrinkling will be improved by the mere fact that the skin will be stretched; however, however having the correct patient expectations is paramount. I have had patients who complained that the facelift did not correct their wrinkles even though this was addressed in numerous preoperative conversations and verbal and written consents as well as my videos, web page, and other literature that the patient reviews before surgery. Because a facelift is considered such a big procedure, patients expect a big outcome. As I stated numerous times at the beginning of this chapter, they must have a great understanding for not only what the procedure will do but what it will not do. I spend a significant amount of extra time with patients who have significant skin wrinkling. I must explain to these patients that if they do not address their skin wrinkling, the vectors of the facelift reposition the wrinkles into an unnatural pattern with the feared “upswept” appearance. For these patients, laser resurfacing is an important adjunct to the facelift procedure. Although I have performed over 400 facelifts with simultaneous CO ₂ laser resurfacing, I am moving away from this combined procedure for several reasons. First and foremost, it truly increases the amount of recovery and postoperative care for the patient and family. Second, I never laser the skin overlying the undermined flaps at the same fluence as I do on the central oval of the face. This can be problematic postoperatively because the undermine flaps can have a different texture and color from the more aggressively central oval of the face. Oftentimes this can be very noticeable and may require secondary laser over these areas. If the skin over the undermined flaps does have significant wrinkling, the lighter laser will not properly address it. For all of the aforementioned reasons, I now only perform more superficial simultaneous laser skin resurfacing or chemical peeling on facelift patients with minimal skin rhytids. I do, however, perform subunit resurfacing, mainly perioral and periorbital, on a majority of my facelift patients. With this rationale, patients who have skin excess and skin wrinkling will generally require two separate procedures in my office. Sometimes the patient wishes to opt for the facelift first in hopes that it will address their wrinkling. Performing the facelift first may reposition the skin wrinkles to an unnatural appearance, which can affect the result for the patient and the reputation of the surgeon. For the small subset of patients with both severe skin wrinkling and skin excess, I prefer to perform the laser resurfacing first and the facelift procedure at a later date. This decreases the chance of unnatural repositioning of skin wrinkles with skin pull vectors ( Fig. 3.146 ).

Additional caveats that can produce unnatural postoperative results are patients with significant volume loss or patients who have had numerous facelifts. The hypovolumized patient who refuses some type of volume enhancement such as facial implants, fat injection, or filler treatment must understand that their result may be compromised. Over the years, I have changed this from a verbal consent to part of my written consent because sometimes patients have very short memories when it comes to their refusing a treatment plan. The multiply operated patient can also be problematic as the surgeon may perform a perfect facelift, but the problems or limitations of previous surgeries can affect the final outcome. Preoperative communication is everything in elective cosmetic surgery procedures.

Setting the skin flaps begins with grasping the pre-auricular and post-auricular skin and elevating with careful assessment the natural anti-aging vectors. Any number of instruments can be used to grasp the flap edges. Simple hemostats or Allis clamps work well, but I prefer the Pitanguy flap-grasping forceps as they are fabricated to not damage the flap ( Fig. 3.147 ).

A review of various textbooks shows some surgeons advocating vertical skin traction and others advocating various other vectors. I personally believe that the correct anti-aging vector is a little bit different on each patient but grossly similar. For illustration purposes, I believe these vectors are largely approximately two o’clock on the left side and ten o’clock on the right side; you could also say the left side is northeast and the right side is northwest ( Fig. 3.148 ). This merely gives the novice surgeon some direction in which to pull the skin flaps. In reality, the surgeon must inspect the neck, submental region, jowl, corner of the mouth, midface, and temple regions to truly assess the proper direction of skin “pull” (tension). All of these areas must be improved and have a natural appearance as the final result equals the sum of the parts. An excessive transverse vector can distort and stretch the corner of the mouth and produce the “joker”-type appearance in the lower face and an unnatural slant of the eyelids and cheeks. These are some of the most feared stigmata for patients.

Distracting the skin in an incorrect vector will not only change the position of the patient’s wrinkles ( Fig. 3.156 ), but it can also produce a distortion of the face ( Fig. 3.149 ).

Although I do not remember seeing neutral head positioning in any textbook, I have come to employ this over the years, and feel it is important. Many surgeons have the head turned away from them during surgery for better visualization. If the head is turned away from the surgeon while adjusting the skin flaps, there will be a difference in accuracy compared with the patient in the neutral position with their face toward the ceiling ( Figs. 3.150 and 3.151 ). More skin is available when the head is in the neutral position.

The amount of available excess skin is largely dependent on age and the degree of aging; however, skin elasticity or lack thereof is also a major contributor. Fig. 3.152 shows varying degrees of skin excess, which can vary from millimeters to centimeters.

Before stabilizing the vectored skin, the surgeon must decide how much tension to place on the flaps. Various textbooks recommend varying degrees of tension from significant tension to approximation with no tension. Although some authors have attempted to quantify flap tension, I personally feel that there are too many variables to arrive at an accurate and repeatable number in grams of tension on a scale. Patient position, skin elasticity, and vector direction can all factor into how much tension to place on the flap. Placing excessive tension can affect blood supply and contribute to flap necrosis. Failure to place enough tension on the flap can lead to postoperative skin excess. My definition is “The flap should be tight enough reduce skin excess and to maintain the contours of the neck, jawline, jowls, and midface without excessive tension that could affect blood supply.” This is one of the many steps in a facelift procedure that require observation and hands-on experience. Blanching of the flap would be a sign of excessive tension. I can say that I do pull the skin “tight” when setting the flap to accept the key sutures.

An additional critical step in preserving the natural curvature of the posterior hairline requires a component of anterior rotation of the post-auricular facelift flap ( Fig. 3.153 ). This anterior rotation is necessary to be able to obtain post-auricular tissue approximation as a totally posterolateral vector would leave a gap (see Fig. 3.153 ). Also, more clinically relevant is that failure to provide a component of anterior rotation will cause a step-off on the posterior hairline (see Fig. 3.153 ). An unnatural step in the posterior hairline is a significant disability in female patients who wear their hair up or in male patients who cannot hide the deformity. A female patient who has worn her hair up for most of her life will be furious if she has to permanently change the hairstyle that has defined her.

As the reader can tell, a great deal of coverage has been afforded to the relatively simple task of suspending the skin flaps in a natural position.

The next step in the procedure is to suspend the flaps in their final position. Once the surgeon decides on the correct vector, a skin cutback is made in the pre-auricular and post-auricular regions and secured with a suture ( Figs. 3.154–3.156 ). This is frequently referred to as the key or cardinal suture because it sets the stage for the final flap position. These are the only sutures in the entire case that will be placed under tension. I would call this “moderate tension,” and the amount of pull is enough to maintain the flap in the correct position with the head in the neutral position. Close attention is required to not overcut the skin cutback as it cannot be reversed. As with any skin incision or excision, use the old adage, “measure twice, cut once.” Undercutting the skin cutback can build in laxity that will be apparent postoperatively. The angle of the skin cutback is also important and should follow the vector of the skin pull. I prefer 4-0 Vicryl for the key sutures. The first key suture is placed at the junction of the helical attachment and the sideburn incisions ( Fig. 3.154 ). A skin cutback is made, and a 4-0 Vicryl suture is placed. The post-auricular key suture is placed similarly at the vertical and horizontal incision junction ( Fig. 3.155 ).

In some cases, the post-auricular key suture can be placed without a skin cutback if the tissue is edge to edge ( Fig. 3.156 ).

Although most texts define only two key sutures, I personally place a third set of key sutures. I place several 4-0 Vicryl sutures at the posterior sulcus in a manner to gently pull the proximal skin flap in a superior direction ( Fig. 3.157 ). In my early experience, I noticed that some patients were left with residual submental skin after surgery. I started using the sulcus suture, which when performed in the correct vector will actually tighten the skin on the mandibular border to the midline (honest, try it). Because this suture “steals” some excess laxity, I refer to it as the steal stitch .

Turning the head to the neutral position (see Fig. 3.150 ), using 3–4 steal stitches on the posterior ear incision (see Fig. 3.157 ), redoing the key sutures after the earlobe is delivered, and performing submental skin excision in selected cases have improved the overall tightness of my submental regions to a point where residual postoperative skin excess has been dramatically reduced. As novice surgeons will eventually experience, a patient can present several months after a well-done lift saying, “I am pretty happy, but I still have some loose skin under my chin.” The reply of the surgeon is usually, “I am surprised because I pulled the skin as tight as I could to still have a natural result.” I personally feel that this is frequently from “built-in relapse” where various steps in the facelift procedure each contribute a small amount of laxity, which can reduce the amount of tension of original skin pull. Because these small changes are amplified on the contralateral side, the sum of these parts can lead to noticeable postoperative excess. I feel that these are important points and will be further discussed.

Earlobe delivery is a critical part of facelift surgery. When it is not effectively managed, it can cause some of the worse stigmata of facelift surgery: the dreaded pixie earlobe ( Fig. 3.158 ).

For smaller facelifts, the earlobe may be delivered without any skin-releasing incision. It is simply “untucked” from under the overlying skin and will lie in the perfect position without any further inferior release ( Fig. 3.159 ).

On larger facelifts, a releasing incision of the overlying skin flap is necessary to free the lobe. It is at this step where an otherwise perfect facelift can go awry. The mortal sin of earlobe delivery is overcutting the overlying skin. When this occurs, the lobe is sutured to the overcut skin and stretched inferiorly. The surgeon must always remember intraoperatively that the patient is lying down and gravity will pull tissue downward when they return to the upright position. If the earlobe release is overextended, it will stretch the lobe downward, and this will be amplified postoperatively when the patient is upright.

Facelifts with mild to moderate skin excess will frequently require some component of skin release to deliver the earlobe. To highlight the previous point, it frequently would appear that a larger releasing incision is needed to untuck the earlobe. Again, this is the exact point where many surgeons get into trouble. I personally recommend that novice surgeons release one-third to one-fourth of the length they originally think necessary ( Fig. 3.160 ). My advice is to first attempt to simply untuck the lobe (see Fig. 3.161 ), and if there is still skin excess preventing the lobe from a relaxed position, then cut one-third to one-fourth of that apparent distance and proceed in small intervals.

I prefer to make the releasing incision on an arc following the natural helical rim ( Fig. 3.161 ) In the end, the goal is to have the cheek flap lie superior to the earlobe ( Fig. 3.162 ).

There is one note of caution I would like to point out concerning this discussion. If significant skin is overlying the earlobe and a releasing incision is made, then there is some component of laxity commensurate with the amount of space the earlobe was occupying under the flap. In other words, once the earlobe is released, the skin will not be under the same amount of tension it was before the release. This could mean that a small amount of skin excess would be noticeable after surgery. This is amplified times two when considering this on the other side. When there is significant skin overlying the earlobe, I make a releasing incision, undo the key sutures, and with the head in the neutral position retract the skin flaps for a second time and replace the key sutures to compensate for the amount of laxity caused by the skin release. Making these small adjustments along the way can reduce the amount of postoperative skin excess that may go unnoticed during the procedure.

I have outlined two techniques of lobe delivery that should prevent even the novice surgeon from overcutting the flap. As mentioned earlier, some surgeons can “eye” the amount of skin removal in flap trimming. Experienced surgeons can also simplify lobe delivery by grasping the corners of each flap and retracting them while freehand cutting the proper amount of earlobe release, without suspending or suturing the flaps ( Fig. 3.163 ). This is more of an advanced method and can be unpredictable for novice surgeons.

After the key sutures are placed, the earlobe is released, and excess post-auricular skin is excised, the excess posterior skin flap and hair-bearing scalp are addressed. The horizontal post-auricular proximal flap skin incision must follow the bevel and irregularity of the original incision ( Fig. 3.164 ). This is of particular importance in the hair-bearing scalp for the follicles to regrow (see Fig. 3.37 ) and camouflage the scar.

The next step is to deal with the skin excess of the flaps. The gross excess is first approximated and reduced with a curved incision that mimics the geometry of the original incision ( Fig. 3.165 ).

Experienced surgeons can freehand or “eye” the degree of bevel, irregularity, and geometry of the original incision. This is a skill that takes some time to develop. For novice surgeons, it is not uncommon to use some type of flap-marking device such as an Allis clamp or dedicated Pitanguy flap markers ( Fig. 3.166 ).

At this point, the skin excision and matching geometry is grossly completed. The next step is extremely important and can save the patient and surgeon from another stigma of facelift surgery, the stepped hairline. If the flap is simply elevated in a vertical direction, the hairline may have a significant step, especially in cases with large skin excess ( Figs. 3.167 and 3.168 ). To prevent this step, the surgeon must advance the proximal flap border anteriorly during closure. This is usually done is small steps with several sutures. It may leave small puckers between the suture, but these resolve with wound contracture during healing.

Fig. 3.168 illustrates the same principal as Fig. 3.167 on a different patient.

It is not uncommon, especially on larger lifts, to end up with a “dog ear” at the most distal portion of the posterior regular incision. A Burrow’s triangle (also called Burow’s or Burow triangle ) is a technique in which a wedge of skin is removed at the end of a closed-wound incision created by flap advancement, so a smooth contiguous repair is achieved. I prefer a simple “hockey stick” release where an accessory releasing incision is made at approximately a 30-degree angle from the long axis of the posterior incision ( Fig. 3.169 ).

At this point, the continuity of the natural hair line is confirmed, and the surgeon verifies that no significant skin excess remains. The final incision can be closed with staples or 4-0 suture ( Fig. 3.170 ). I do not use any subcutaneous or nonresorbable sutures in my facelift cases.

For surgeons who use drains, the terminal ends of each posterior auricular and the submental incision are not closed so as to have an opening to place the surgical drain.

The order of skin trimming and closure is up to surgeon preference. I personally prefer to close and trim the post-auricular incision first, and then transition to the pre-auricular incision, the sideburn incision, and finish with the earlobe.

Trimming the pre-auricular incision is different for pretragal and retrotragal approaches. Using the triarcuate pattern simplifies tailoring of the tragal region because all incisions are anterior to the tragus. The first step in the anterior skin tailoring is making cutbacks above and below the tragus and securing the skin edges with 5-0 gut sutures ( Fig. 3.171 ).

With pretragal incisions, the next step is to trim the skin excess on the tragal arc. The basic technique of trimming the skin excess for this approach is to simply excise three arcs of skin at the lobe, the tragus, and the helical attachment ( Fig. 3.172 ). Facelift scissors are curved for a reason, and gently adjusting the angle of the cut as it progresses produces a very accurate curvilinear pattern. This will be highlighted in the accompanying videos.

With practice, this can be performed with great accuracy and almost perfectly abutted skin margins ( Fig. 3.173 ).

Surgeons with less experience may want to cut smaller patterns as they acquire the accuracy of freehand tissue trimming ( Fig. 3.174 ).

Many surgeons prefer the post-tragal incision for facelift surgery. I have stated earlier that it does hide 5 or 6 mm of the anterior scar; however, if for any reason the tragal cartilage encounters healing problems, it leaves a very difficult and noticeable problem for the patient and surgeon. I would say more of my colleagues use the retrotragal approach, but I have my best postoperative aesthetic scars with the triarcuate incision as described.

To address the post-tragal skin tailoring, the first step is to perform skin cutbacks superior and inferior tragal notches and secure them with sutures ( Fig. 3.175 ). I prefer 5-0 gut suture. This not only creates the cutback, but it also stabilizes the small peninsula of mobile skin. The sutures also facilitate tailoring this skin to a normal tragal contour.

The 5-0 gut sutures stabilize the otherwise mobile tragal skin to allow more precise contouring. I am personally more accurate using a radiofrequency fine wire microneedle ( www.cynosure.com/ellman ) then I am using scissors or a scalpel when performing this step ( Figs. 3.176 and 3.177 ).

Some surgeons also prefer to undermine the tragal skin for more passive closure with the pretragal approach ( Fig. 3.178 ). When using the retrotragal approach, the tragus is sometimes “defatted” to thin the otherwise cheek skin for a more homogenous result ( Fig. 3.180 ). Care must be taken to not damage the delicate flap.

After closing the posterior and anterior auricular incisions, I proceed to the temporal tuft. As with all hair-bearing incisions, the excess skin is removed in the same angle, bevel, and contour as the original incision ( Fig. 3.179 ). It is imperative that whatever method is used to trim this tissue that the temporal tuft is not elevated to an unnatural position. In some cases, especially larger ones, several millimeters of sideburn elevation may occur and still be acceptable and natural looking. Significant elevation in this area stands out like a sore thumb and again screams poor surgery, poor surgeon. As a side bar, hairdressers see many scars, and when you start getting referrals from salons, you know you are on the right track.

The next step involves trimming the extra skin at the base of the earlobe. As stated earlier, this is one of the most important facets of natural-appearing facelift surgery. It has been illustrated and discussed numerous times how lengthening the earlobe can grossly distort the anatomy and make a very unhappy patient. We must remember that we may take a patient’s face apart and put it back together and do a lot of work on the inside, but the only thing the patient and the people around them see is the incision, so it is so important to have all of the areas of incision appear natural.

Most patients have more pendulous lobes that are rounded and separate from the cheek, while others have “fixed” earlobes that blend into the cheek and are attached ( Fig. 3.180 ). On occasion, a patient may want fixed lobes converted to unattached lobes ( Fig. 3.181 ).

It is important to have documented and discussed the patient’s earlobe anatomy preoperatively. There are instances when somebody wants to change the way their lobe looks or is positioned, and this warrants preoperative discussion. I have had numerous patients who had fixed earlobes and were unhappy because they could never wear earrings and asked me to provide more of an actual rounded lobe at the time of surgery. Having the preoperative photos in the operating suite assists this part of the operation.

Any remaining skin excess on the flap is then trimmed to approximate the contour of the earlobe. I prefer to leave some skin excess until I address the actual final lobe position. The excess skin on the sulcular incision is trimmed to be flush with the skin of the ear when the pinna is lying passive ( Fig. 3.182 ).

When attempting to quantify a natural earlobe position, it is often discussed that the earlobe sits about 15 degrees from the long axis of the ear ( Fig. 3.183 ). I think that this measurement is difficult to quantify, especially when the patient is lying down, as the tissues are separated and distorted with tumescent anesthesia and edema. I think the easiest way to set the earlobe is to simply observe how it looks when the first positioning suture is placed. When I secure the earlobe with the first suture, close observation is made to examine for natural placement and contour. We do not use a protractor to measure angles. Experienced surgeons can make accurate observations concerning lobe position in the same manner that they treat the other tissues without measuring. Setting the lobe with the first suture is a very important step; if it is not natural, the stitches are removed and replaced until the earlobe is properly positioned. Understanding a measurement of 15 degrees from the long axis is fundamentally fine but difficult to actually reproduce surgically. Understanding such concepts is the “art of facelift surgery.”

Setting the lobe is the last major step on each side of the facelift and has significant impact on the success of the case. Therefore it warrants an in-depth discussion. When the skin flaps are sutured and the lobe is delivered, the cheek skin will be superior to the base of the lobe (see Fig. 3.162 ). This will usually require trimming some of the cheek skin so the lobe can be attached and sutured. Fig. 3.184 shows the skin excess that will require cutback. This is another stage in which removing excessive skin will pixie the lobe.

Overcutting the skin at this point may not be apparent ( Fig. 3.185 ). Fig. 3.186 shows the correct relationship of the base of the lobe to the suture line.

In some cases, placing the suture line superior to the lobe may pucker or “accordion” the lobe, but with return to the upright position and wound contraction, it will most commonly lie passive.

At this point, the entire first side of the lift is completed, and the same procedures are performed on the contralateral side. During this time, when the patient is repositioned, the team usually reorganizes the instruments and surgical tray and performs their preliminary sponge count. Physically turning the head on an intubated patient can be very stimulating, causing the patient to react with coughing and gagging. This is frequently accompanied by a spike in blood pressure, which may cause bleeding on the completed side of the facelift. I have seen this happen where the blood pressure spiked and stimulus from coughing caused an intraoperative hematoma that required stopping the case and reopening the completed side. To maintain a smooth anesthetic and to prevent unwanted changes in blood pressure, the operative team must inform the anesthesia provider 5 minutes in advance of turning the head or significantly repositioning the patient. This allows the anesthesia provider time to deepen the level of the anesthetic and have better control over the patient and the vital signs.

After the aforementioned procedures are performed on the contralateral side, attention is then focused to the submental incision, which is the last step in the facelift procedure. For many years, I performed a simple two-layered closure on this incision. As I have mentioned numerous times in this chapter, a small percentage of my post-facelift patients were left with residual submental skin that required revision. This led me to modify numerous steps in my procedure, including how I place my key sutures, the described posterior auricular “steal” stitch, and how I deal with submental incision closure. Before closing the incision, I grasp the distal skin margin and lift it superiorly ( Fig. 3.187 ). If there is no significant skin overlap of the proximal incision margin, then I perform a routine closure with subcutaneous sutures and skin sutures or subcutaneous sutures and a running intracuticular suture. If there is significant skin overlap, then I prefer to remove a triangle of skin excess, which will decrease the chance of laxity after surgery ( Fig. 3.188 ).

An alternate way to address the skin closure is to place several 5-0 gut subcutaneous sutures and use Steri-Strips ( www.3m.com ). Although I have used tincture of benzoin in the past, New Skin Liquid Bandage (over the counter) is an efficient and affordable adhesive (personal communication, Mark Berman, MD, Santa Monica, CA, 2019) ( Fig. 3.189 ).

As I have stated, I do not use subcutaneous sutures routinely on any part of my facelift. I prefer to close the hair-bearing incisions with 4-0 gut suture and the pre-auricular incision with a combination of 5-0 and 6-0 gut suture ( Fig. 3.190 ). The posterior auricular incision is closed with 4-0 suture. Suture material and size is surgeon preference. With the exception of the key sutures, it is imperative not to close any of the incisions with tension. After trimming and before suturing, the flaps should be passive (see Fig. 3.190 ).

I have performed almost 500 facelifts with simultaneous full-face CO ₂ laser resurfacing in my career ( Fig. 3.191 ). At one time, this was a very common combination of procedures in my practice. In the past several years, I have discouraged patients from having aggressive laser resurfacing at the same time as facelift surgery. This is because adding a full-face laser treatment to a facelift significantly increases the recovery and makes postoperative care significantly more complex. Another reason I perform fewer of these simultaneous procedures is the discontinuity results related to treatment depth. Although the central oval of the face can be aggressively lasered during facelift surgery, the undermined flaps are treated at a lower energy as not to compromise flap viability. Lasering the central oval of the face aggressively and the undermined flaps at a lower setting can produce texture and color changes between the two areas that sometimes require a revision laser procedure. It is now my preference to perform aggressive laser skin resurfacing several months before or after the facelift. This has simplified postoperative care for me, my patients, and my staff.

I do perform light laser treatment in which the entire face and flaps are treated at a lighter setting. This is much easier to care for and has fewer complications. I also perform medium-depth chemical peeling with facelift, but I treat the undermined flaps with less concentrated acid or fewer coats.

The subject of postoperative drains is controversial, and many surgeons use them on every case. I probably performed my first 800 facelifts without ever using a drain. I did experiment with placing two 14-gauge angiocath “vents” to allow drainage for several days ( Fig. 3.192 ). This is a simple solution for the surgeon desiring some component of passive drainage without cumbersome Jackson-Pratt drains. After watching many of my friends use Jackson-Pratt drains and swear that their postoperative course was better, I began using them for several years. I placed #10 Jackson-Pratt drains in female patients and #15 drains in male patients. My personal drainage technique consisted of a single drain that ran from the posterior auricular area on one side, at the most inferior part of the midline cervical, and exited the distal post auricular incision on the contralateral side. The drain was placed at the very end of the case and held in place with several 4-0 gut sutures that encircle the drain as it exits the incision ( Fig. 3.193 ). Drains were left in place anywhere from 24 hours to 5 days ( Fig. 3.194 ).

My experience was not overwhelming, and the main problems I had with drains were that the patients hated them. Also, if I left them in place longer than several days, a visible tunnel or drain tract was present and sometimes took weeks to resolve. Finally, and most important, I did not see any significant advantages of using the drains compared with my experience of not using them. I do not routinely use drains in any of my facelift procedures unless I have the unusual patient with significant intraoperative oozing, and this is almost always a male patient. Using drains probably does decrease seroma formation, but it does not prevent hematoma formation. Some advocates of drain placement say that it also decreases postoperative bruising, but again, this was not my observation. The use of drains is a personal operator preference.

When all procedures are finished, the hair is washed with sterile water and hydrogen peroxide ( Fig. 3.195 ). A curl detangler can be used on patients with extremely thick or curly hair.

At the end of the case, the anesthesia emergence is begun, and the patient is slowly awakened. As the patient returns to a normotensive state, it is important to closely monitor any oozing, bleeding, or hematoma formation on the operating room table. Intubated patients can become stimulated and “fight” the endotracheal tube with severe coughing and bucking. This can cause an increase in blood pressure and hematoma formation, which can make an otherwise successful case problematic. The art of anesthesia is integral for successful face and neck lift surgery. Accomplished and busy facelift surgeons have very capable anesthetic support and the continual communication with anesthesia and the surgical team is imperative. Besides the obvious skills of maintaining vital signs on an anesthetized patient, avoiding hypertension throughout and especially at the end of the case is critical. Hypertension is the most common cause of postoperative hematoma. There are few things more frustrating for a facelift surgeon than having to return to the operating room after a long surgical case to drain a hematoma.

After the hair is washed and the patient is cleaned up, a postoperative facelift dressing is applied. The type of dressing is operator preference, and facelift dressings vary from complex, football helmet–sized dressings to no postoperative dressing at all. Most facelift surgeons prefer light compression after surgery, but it is critical not to have a dressing so tight that it compromises vascularity. It is also important for the operator to understand that a pressure dressing in itself does not prevent hematoma formation. In my practice, I prefer a simple “jaw bra” type facial compression dressing (Facial Support, Medicointernational.com ) with Velcro closures on the top of the head and behind the neck. After this dressing is placed, several layers of gauze pads are inserted over all incision lines ( Fig. 3.196 ).

After all the aforementioned steps are complete, the patient is dressed in their postoperative clothing in the operating room and taken to the postanesthesia recovery room. I have used several systems over the years to move and recover patients. At one time, I had two hospital beds in my recovery room and moved the patients in and out of this suite with wheelchairs. I found the beds to be bulky, and they took up needed space. Also, when a patient is in a bed, they want to sleep in it, which can slow down the discharge process. I now use Stryker recovery chairs ( www.stryker.com ) ( Fig. 3.197 ). These have wheels that allow easy transfer from the operating suite to the recovery room, and the patient can be recovered in this chair until they are discharged. The chair has many different positions for comfort including the Trendelenburg position in case of emergency. There are also trays to place personal effects or postoperative beverages and medications. In the recovery suite, the patient is kept warm with a Bair Hugger system ( www.bairhugger.com ), and all vital signs are monitored until discharge ( Fig. 3.198 ).

The initial time in the recovery suite can be vulnerable. The staff is busy turning over the operating room, cleaning instruments, and preparing for other patients, while the anesthesia personnel are finishing their paperwork. In my office a dedicated person is assigned to recovery and sits with the patient, tending to their postoperative care, comforting them, and monitoring vital signs until discharge.

During this time, the patient’s caregiver is watching our postoperative videos and discussing postsurgical care with our staff. The caregiver is not brought back to the recovery suite until the patient is comfortable and lucid. Pain and nausea are common situations after facelift anesthesia. The conundrum with pain is not to administer narcotics in the recovery room as it will delay the patient’s discharge as well as possibly contribute to nausea. I prefer to give the patient 200 mg of Celebrex (celecoxib) ( www.pfizer.com ) as soon as they are able to swallow a pill. Patients are asked to bring their postoperative medications with them in the case their pain is significant. Postoperative nausea is treated with Zofran 4 mg ( www.gsk.com ) intravenously or by mouth. The intravenous line is left in place until the patient is discharged. It is very important to document as many things as possible at the time of discharge. This discharge criteria includes vital signs, level of consciousness, pain level, ambulation, ability to understand instructions, and having an effective caregiver and a safe place to recover. Premature or unsafe discharge can result in lawsuits, serious injury, and death. I personally explain to the caregiver any serious situations that may warrant an emergency call, such as respiratory distress, bleeding, or hematoma. All patients have my cell phone number and that of my nurse. One of the staff will check on the patient the night of the surgery, and this is recorded in the chart. The patient is scheduled to be seen in the office the next morning. Having written postoperative instructions as well as postoperative videos on my website prevents any confusion on what to do and not to do on the night of the surgery.

It is important to have a clean instrument setup as well as availability of anesthetic medications in the event that the patient must return to the office for hematoma drainage. It is also important to have a plan in place (i.e., assigned staff and anesthesia personnel to report to the office in case of emergency). Seeing a patient by oneself and not having access to instruments, drugs, and assistants can be a nightmare. All competent surgeons will plan ahead for a workable situation in case of an emergency or return to surgery.

I personally never have the patient apply ice or heat to undermined facelift flaps. Although some surgeons do, my goal is to not vasoconstrict the delicate flaps with ice. Because patients are numb over the flaps, they are easy to burn because of lack of pain response. I have seen numerous patients sustain severe full-thickness burns over flaps from various heat sources.

The patient is seen in the office the following morning. The dressings are removed, and the surgical sites are inspected for a hematoma, seroma, or compromise of tissue viability. Motor nerve function is also documented. All incisions are cleansed with peroxide and saline, and a triple antibiotic ointment is applied to all suture lines ( Fig. 3.199 ). Any fluid collections are aspirated at this time. The postoperative elastic dressing is then replaced, and the patient is asked to wear this as much as possible for the next 7 days on a 24/7 basis. In-town patients are asked to return at 1 week, 2 weeks, 1 month, and 3 months. At the 2-week appointment, any remaining staples or Vicryl sutures are removed. Obviously, any patients with problems are seen on an as-needed basis. Patients who have seromas are followed more closely as multiple aspirations may be necessary. Patients with induration or firmness (which is usually the submental or anterior neck regions) are seen several times a week for complimentary ultrasound treatments. Dilute steroid (triamcinolone 10 mg/mL) is also injected into indurated areas. Figs. 3.199–3.205 show patients at various postoperative stages. It is important to understand that the average surgeon can explain many things to patients with great predictability in detail, including incisions, operative procedures, prescriptions, and anesthesia. However, trying to attach predictability to swelling and bruising can be much more difficult as there are so many intrinsic variables (e.g., heredity and clotting) and extrinsic variables (e.g., age, health status, medications that affect coagulation) in play.

This must be explained to patients preoperatively. I have had older patients tell me they bruise at the slightest touch and have no postoperative bruising, and I have had young, healthy patients say they never bruise and have significant ecchymosis. The variability of healing is a significant factor

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Anesthesia

The patient is taken to the operating room and positioned supine. Pressure points are padded, pneumatic boots are placed, and anesthesia is induced. Deep sedation or general anesthesia without paralysis (to allow for monitoring of electrocautery facial nerve stimulation) are both acceptable options, in each case with a Foley catheter to monitor fluid status and prevent hypertension from bladder fullness. Because of the time-consuming nature of the procedure and the extreme sensitivity of the submandibular glands, local anesthesia alone or with light sedation is unlikely to be adequate for safe, comfortable surgery.

The senior author prefers a modified Friedberg PK-BIS deep-sedation technique. Because of the length of the surgery, in a deviation from Friedberg’s protocol, propofol infusion is complemented with 2 mg of midazolam at the case outset. Long infusions of propofol eventually fill muscle stores, prolonging the typically short time to emergence from propofol sedation. The addition of midazolam at the beginning of the case decreases the total propofol requirement, and midazolam may also be reversed in recovery if needed with flumazenil. In addition to routine intravenous antibiotics, additional routine premedications are administered before the ketamine bolus aiming to decrease the tendency for laryngeal hyperreactivity common in the first 20 minutes after a ketamine bolus. They include 50 mg of intravenous lidocaine to decrease laryngeal reactivity and 0.2 mg glycopyrrolate to help dry secretions.

Once the premedications have been given and the midazolam bolus with propofol infusion has achieved a steady-state BIS reading of 45–60, a Foley catheter is placed. The patient is then dissociated with a 50-mg ketamine bolus. Propofol is titrated to maintain the BIS in the 50 s. In the 3 minutes necessary for full N-methyl-D-aspartate (NMDA) blockade ketamine dissociation, the patient is sterilely prepped with betadine on the skin and Surgical Technology PREP by BAK in the hair, and sterilely draped. The operative field is then tumesced with 0.075% lidocaine, 1:500,000 epinephrine, and 0.1% tranexamic acid (TXA) solution (750 mg lidocaine, 1000 mg tranexamic acid (TXA), 2 cc 1:1000 epinephrine added to 1L of normal saline). Usually 350–500 cc of solution is required to adequately tumesce the face and neck, with additional solution being appropriate for tumescing the brow or fat donor sites if indicated. If local anesthesia infiltration requires more than about 20 minutes, it may be necessary to administer a second, 25-mg bolus of ketamine to complete infiltration.

The tumescent anesthetic is an important part of this procedure, as the infused volume makes planes more obvious, and the fluid serves as a heat sink to protect motor nerves from thermal injury. Cautery should be low during this portion of the case, on the order of 15–18 watts.

Incision design is largely surgeon preference. The SO-deep lift can be performed with any of the common periauricular facelift incision patterns. Because of the powerful midfacelifting effect, this lift can generate significant temporal skin excess. Temporal hairline trichophytic incision designs are generally preferred to prevent lifting of the sideburn (see Fig. 3.37 ). Similarly, a browlift may need to be considered to prevent “crowding” in the temple soft tissue that can occur when a ptotic brow tail is not addressed.

The deep-plane entry incision is planned from the lateral orbital rim (which is well anterior to the course of the temporal branch of the facial nerve over the zygoma) to the angle of the mandible (which is posterior to the eventual parotid exit of the marginal mandibular branch of the facial nerve) ( Fig. 3.264 ). The deep-plane incision then turns inferiorly along the anterior border of the SCM muscle at least 4–6 cm to release the platysma/auricular ligament to provide maximum passive facial lifting.

The SO-deep lift begins by elevating a skin flap raised to just beyond the deep-plane entry line. The skin is left attached to the SMAS from there forward and along the jawline so radial (outward) traction on the flap also pulls on the SMAS, which helps demonstrate and emphasize the subSMAS plane.

Deep-plane entry begins by incising the SMAS over the angle of the mandible, where platysma is most robust and easily identified. The surgical assistant uses two Army Navy retractors, toeing in and strongly lifting the skin flap away from parotid. Low current cautery is used to broadly incise the flap over the lower one-third of the face while the assistant and scrub watch for nerve stimulation. The tumescent lidocaine does not seem to inhibit twitching, though higher concentrations and systemic muscle relaxation may. As the incision is developed, one can usually identify the pink/gray/purple fibers of platysma as they are incised to enter the loose areolar plane between the SMAS/platysma and PMF floor of the dissection. Once this area has been opened broadly, gentle vertical spreading with scissors or a Trepsat dissector easily opens the potential space ( Fig. 3.265 ).

It is imperative that the PMF is not violated and left down covering (the often visible) buccal and marginal branches of the facial nerve. The spreading dissection end point is just anterior to the masseter, which completes disruption of the lower masseteric ligaments. There is no benefit to dissect further, and doing so puts the terminal branches of the facial nerve at risk.

Attention is then turned to creating the upper extent of the SMAS incision, over the malar eminence. As that incision is made, one can usually see the pink/purple fibers of lateral orbicularis muscle being incised and then the opening potential space between orbicularis and malar periosteum. Again, the surgical team aids the dissection with strong radial/outward tension and careful surveillance for nerve stimulation. Once the plane has been entered, blunt spreads of the Trepsat open it anteriorly to the lateral nose. The surgeon will feel the tight, restrictive zygomatic ligaments inferior to this tunnel, especially the main ligament at the origin of zygomaticus major.

To complete the subSMAS dissection and ligamentous release, one Army Navy retractor is placed into each of the two previously created subSMAS pockets, and the flap is retracted. The SMAS incision is continued to connect the upper and lower pockets, and dissection is carried forward in the subSMAS plane. A loose areolar tissue plane is definitely present and visible, though it is not as apparent as in the upper and lower pockets. The zygomaticus major can often be palpated and/or seen in the floor of the dissection. There is no need to skeletonize the muscle or carry the dissection more than 1.5 cm forward over the muscle. Doing either one will risk creating at least temporary smile dysfunction. The plane of dissection must remain superficial to zygomaticus major to protect the all-important zygomatic branch of the facial nerve. The surgeon should utilize the superior and inferior pocket planes as a guide and work from known to unknown. The final step of release is the zygomatic ligament itself, which should be performed immediately under the SMAS flap, rather than deep, near the zygomaticus major and the zygomatic branch of the facial nerve.

Next, the SMAS is undermined under the bare platysma along the anterior border of the SCM, which is both superficial to the deep cervical fascia and posterior to the marginal mandibular nerve’s exit from the parotid. The platysma is then released from the anterior border of the SCM for 4–6 cm with scissors or cautery, little by little, under direct vision, to protect the EJV. This step completely releases the platysma-auricular ligament ( Fig. 3.266 ).

Attention is turned back to the lateral face, and the skin is freed from the edge of the SMAS flap as needed just enough to create a 1-cm cuff (see Fig. 3.266 ). The skin for about 3 cm over the mandible border is also released from the SMAS flap to connect to the subcutaneous neck dissection. At this point, one may also ensure that the mandibular ligament has been completely released in the subcutaneous plane. If this skin and ligament are not free, it will be nearly impossible to access the submental neck at the end of the case, after both SMAS flaps have been secured.

The SMAS is now draped under moderate tension in a 60- to 75-degree superior/posterior vector ( Fig. 3.267 ). The redundant portion of SMAS overlapping the parotid anterior to the lobule and tragus may be designed into an inferiorly based SMAS transposition flap. Inset begins at the angle of the mandible, securing the SMAS flap edge to the SMAS overlying the parotid. SMAS repositioning and lifting is continued toward the malar eminence with a running 2-0 Vicryl progressive tension suture (see Fig. 3.368 ). As the superior end of the incision is reached, one may need to change the angle of SMAS tension to 45 or 30 degrees (more posteriorly) to prevent lower-lid bunching. The same suture is then used to run a second layer of strength back to the starting point at the angle of the mandible, where the suture is tied (see Fig. 3.267 ).

This second layer of closure does not create additional lifting but is useful in settling down any small bumps, and it creates a second layer of support to prevent the SMAS from being torn with mouth opening, facial expression, and similar stresses. The SMAS transposition flap, if created, is transposed behind the lobule and secured to the mastoid. No additional tension is placed on this flap as doing so will make closure of the infrahyoid platysma impossible. The purpose of the flap is not to create additional tension at rest. Instead, it creates dynamic tension in the chin-down head position. The mastoid rises relative to the hyoid as the head pivots on the atlantoaxial angle, and the SMAS flap autotensions the hyoid angle at that position only.

The procedure concludes by a final hemostasis check of both sides of the face and of the neck. If a deep neck lift has been performed (described later in this chapter), a drain is placed from a left post-auricular stab and run subcutaneously into the submental neck. There, it is transitioned to the subplatysmal plane by introducing hemostats at a right angle from under the anterior belly of the platysma and pushing the tips out through the plasma laterally to pull the drain tip into the submental subplatysmal space ( Fig. 3.268 ).

The platysma is closed with 2-0 Vicryl simple inverting sutures from symphysis down to at least the cricoid, taking care not to ensnare the deep drain. If low platysma cannot be approximated, the surgeon may stop at the hyoid angle, but the risk for dehiscence in the submental platysma increases because this closure is not “protected” by muscle closure of the vertical neck.

A second drain is introduced from the right side and kept entirely in the subcutaneous plane, traversing low in the neck all the way across to the left SCM region.

A final check for hemostasis and skin drape is performed, and the skin flaps are tailored and closed without tension (see Fig. 3.268 ). No dressings are used as they prevent early detection of hematomas and can cause pressure wounds or skin bunching.

Postoperatively, standard hematoma precautions are followed, including blood pressure management and strict avoidance of exercise and nonsteroidal anti-inflammatory drugs (NSAIDS) for 2 weeks. The patient is encouraged to rest supine rather than elevated to drive edema toward the undisturbed posterior column of lymphatics. Patients are instructed to ice through a cloth barrier for 20 minutes on, 20 minutes off cycles while awake. Diet is restricted to soft foods and small bites, and sialagogues are avoided for 5 days if submandibular gland surgery was performed.

Drains are removed when output has decreased sufficiently, usually on day 5. A patient is shown 1 week after the procedure ( Fig. 3.269 top). Her before pictures are shown in 3.270 bottom.

Although drain output may seem minimal on day 1 or 2, it is not uncommon for output to pick up on day 3 or 4 as the patient becomes more ambulatory and active. If output remains robust, the drains may be required for longer periods.

Walking is encouraged as soon as the patient feels well, usually on the evening of the surgery or the morning after. Mild to moderate aerobic exercise is acceptable at 2 weeks. Weightlifting and other endeavors that put muscular strain on the neck must be avoided for 6 weeks, when fraying of the SMAS and platysma closures is no longer a risk.

Figs. 3.270–3.272 show before and after results of deep-plane facelift patients.

The aforementioned description is specific for the deep-plane facelift. The cervical region can be managed in numerous ways, including the typical midline platysmaplasty (as previously described) or via the deep-plane neck lift technique described by the same author later in this chapter.

Complications are commensurate with the other types of lifts and described in the “Complications” section later in this chapter.