High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

Why use the SMAS?

The fundamental flaw in “skin-only” facelifts, “mini-lifts”, and similar non-SMAS procedures is the fact that skin was intended to perform a covering function and not a structural or supporting one. Skin is inherently elastic and was intended to stretch and move as we emote and express ourselves. It was not intended to support sagging muscle, fat, and other structures lying underneath it that descend with age. Attempts to lift sagging deep layer tissue by tightening and removing skin corrupts its covering function and results in abnormal skin tension and related secondary problems, including poor scars, tragal retraction, earlobe malposition, and a tight and unnatural appearance. Skin tension also flattens contour, rather than restoring it, and because skin stretches as tension is applied, objectionable temple, sideburn and occipital hairline displacement is common when “skin-only” techniques are used. In addition, because skin is inherently elastic and not capable of providing a sustained support of deep facial tissues, the results of most “skin-only” facelifts, “mini-lifts” and other non-SMAS procedures are usually short-lived.

Using the SMAS to restore facial contour overcomes many of the problems associated with skin-only lifts as it is an in elastic structural layer that is attached to and envelopes facial tissues sagging with age, and it is capable of providing meaningful and sustained support. Although skin must be excised in SMAS procedures, and proper excision will produce an improved result, only truly redundant tissue is removed and closure is properly made under normal skin tension. Facial skin so treated will distribute itself naturally over new contours created by SMAS modification and is capable of some self-repair and contraction. This averts a tight or “lifted” appearance, provides for optimal wound healing and well healed scars, and further enhances the overall end result.

SMAS and the midface

The midface is generally defined as an inverted triangular area situated over the anterior upper cheek that is bounded by the zygomaticus major muscle laterally, the nasolabial fold medially and the orbitomalar ligament superiorly. In healthy, youthful-appearing individuals this area is full and makes a smooth transition into the adjacent cheek and lower eyelid. As a person enters their early mid-life and beyond, there is generally atrophy and a loss of volume from this area. Over time this results in a loss of confluence with the fat of the lower eyelid and cheek and, eventually, an elderly, or even ill and haggard appearance. Midface atrophy is felt by some surgeons to also be accompanied by descent of midface tissues, and the aging change seen in the upper cheek area is, as a result, often (although perhaps imprecisely) thought of and referred to as midface “ptosis”.

The recognition of midface “ptosis” as a component of the changes occurring in the aging face, combined with the realization that the traditional SMAS facelift produced little or no improvement in the midface region, has led to a variety of procedures designed to specifically target the midface area. Many of these “midface lifts” have been designed to be performed as isolated procedures or have been performed in conjunction with lower eyelid surgery.

Although there is merit in the idea of rejuvenating the midface, routine isolated midface lift procedures have been largely abandoned, and a consensus of opinion as to how and when they should best be performed has never been reached. Most midface lift procedures have a steep learning curve and have been fraught with complications, especially those performed through a blepharoplasty incision. These complications include lid retraction, ectropion, canthal displacement, and related corneal exposure and dry eye problems. As a result, many midface lift techniques have necessarily come to incorporate potentially problematic aggressive adjunctive surgical maneuvers including canthotomies, canthoplasties and orbicularis oculi muscle suspensions to reduce the likelihood of these problems occurring. These maneuvers often result in a “changed look” that is disturbing to many patients, however, and carry a high risk of significant and troublesome complications of their own.

Careful evaluation of patients who need or request a midface lift will show that most also need a facelift. It is rare to encounter a patient with midface aging who does not also have sagging in the cheek and jowl, and midface lifts are, as a result, arguably more logically performed in conjunction with a formal facelift procedure. When performed together improvement is more balanced and comprehensive, and a more harmonious and natural-appearing result is usually obtained.

Experience has also shown that healing is faster and complications are less likely if midface improvement can be obtained through the facelift incision, rather than through a blepharoplasty or intra-oral approach.

Analysis of the aging face will also show that midface lifts are generally conceptually flawed in that they erroneously assume the problem seen in the anterior upper cheek to be solely one of tissue ptosis. Failure to acknowledge the fact that atrophy is present to a significant degree in most cases has led to general long-term disappointment for both patients and surgeons following many procedures, and has resulted in the addition of dermis fat grafts, orbital fat transposition, “septal resets” and similar maneuvers to midface “lift” techniques. It has proven questionable whether midface procedures can provide a restoration of lost volume as simply, naturally, and effectively as can be obtained with autologous “micro” fat grafting.

The “high SMAS” concept

The traditional “low” cheek SMAS flap elevated below the zygomatic arch suffers the drawback that it cannot, by design, have an effect on tissues of the midface and infra-orbital region. Low designs target the lower cheek and jowl only and produce little if any improvement in the upper anterior cheek area. Planning the flap “higher”, along the border of the zygomatic arch, and extending the dissection medially in an extended SMAS fashion (see Fig. 9.8.2B ) to mobilize midface tissue, overcomes this problem and produces an improved result ( Fig. 9.8.1 ).

Benefits of the high SMAS technique include a combined, balanced, and harmonious elevation of sagging tissues of the midface, cheek and jawline, without the need to perform a separate or distinct midface lift procedure. High SMAS procedures are also readily combined with midface fat grafting since midface and infra-orbital tissue planes are not opened or dissected. This averts the need to perform complex and potentially problematic procedures in which orbital fat is transposed, the orbital septum “reset”, or free grafts are placed.

At least part of the popularity of “low” SMAS designs can be attributed to concerns regarding anatomical constraints about the zygomatic arch and laudable efforts to design flaps that could be dissected safely without jeopardizing the frontal branch of the facial nerve. Published studies and a careful appraisal of frontal branch anatomy, however, show that a “high” dissection is anatomically sound and, clinically safe. For most patients, the repositioning of midface tissue obtained with a “high” SMAS flap will be satisfactory, and no additional or separate midface lift procedure will be required.

“Lateral sweep” and the SMAS

Traditional “skin-only” facelifts and “low SMAS” procedures typically result in over-tightening of the lateral cheek skin and provide little support of the midface, lateral perioral, and jowl areas. In time, these unsupported tissues continued to descend in a disproportionate fashion while the lateral face remained tight, resulting in a characteristic and objectionable “swept up” appearance over the jawline and lateral face, often referred to as “lateral sweep” ( Fig. 9.8.4 ). This is particularly true of techniques that use a “vertical vector” for skin flap advancement.

Lateral sweep is generally most apparent in the lateral view when the patient looks down. In this position lateral facial tightness is increased due to better tissue fixation and exaggerated SMAS support in the pre-auricular area, and the “sweep” appearance accentuated due to the comparatively poor or non-existent support of the more anterior-medial midface and lateral perioral areas.

Lateral sweep is an unavoidable eventual consequence of all traditional skin-lift, “mini-lift”, “low” SMAS, and deep plane and composite procedures that are not designed and carried out in a way that supports the midface and lateral perioral area. These skin-only and low deep layer procedures, are incapable of providing uniform support to both the anterior and lateral cheek, and are biogeometrically inclined to produce an unbalanced and unnatural appearance. A “high SMAS” flap in contrast, provides simultaneous and uniform one-flap support of the lateral facial, midface, and lateral perioral areas, and this results in a more balanced, comprehensive and natural rejuvenation, and minimizes the chance the lateral sweep will occur.

Lateral sweep can result when a high SMAS technique is used if the lateral perioral region is over-dissected subcutaneously and ligamentous attachments between the SMAS and the skin are inappropriately divided (see Fig. 9.8.25B,C ). These ligaments are the means by which the high SMAS flap supports the lateral perioral area, and over-dissection of this sort is a common error made by surgeons who erroneously assume that extended skin undermining will help improve the nasolabial fold. This is not a flaw in the technique, it is merely a failure to perform it correctly.

Planning the temple incision

The temporal portion of the facelift incision has traditionally been placed within the temporal scalp in a well-intended, but all too frequently counterproductive, attempt to hide the resulting scar. When cheek skin redundancy is small and abundant temple and sideburn hair is present, such a plan can sometimes be used without producing objectionable sideburn elevation and temporal hairline displacement. Patients best suited for this incision plan are usually younger and troubled by mild to moderate cheek laxity only. In many other situations, however, larger skin shifts and the presence of sparse temple hair can result in unnatural and tell-tale sideburn elevation and displacement of the temporal hairline if such a plan is used ( Fig. 9.8.6A,B ).

Proper analysis, careful planning, and the use of an incision along the hairline, when indicated, can avert this problem without compromising the overall outcome of the procedure ( Fig. 9.8.7A,B,C ).

In appropriately choosing the location of the temporal portion of the facelift incision it is important to consider each patient’s particular circumstances including the amount of excess skin present over the upper lateral face and the skin shift that will occur when the facelift flap is lifted. This can be assessed by pinching up redundant skin and measuring it. The surgeon’s estimate of skin redundancy over the cheek, when considered in conjunction with an assessment of the amount of temple/sideburn hair present, allows rational selection of the best site for temporal incision placement ( Fig. 9.8.8 ).

In patients in whom minimal or modest skin shift is predicted to occur and for whom abundant temporal scalp hair is present the temporal portion of the facelift incision can be placed in the traditional location 4–5 cm within the temporal scalp, extending superiorly up from the anterior-superior aspect of the ear ( Fig. 9.8.9 ). While individual circumstances will vary and the decision as to where the incision be placed should be based on the circumstances present and not arbitrarily based on age, typically patients in whom this incision plan is indicated are under 45 years old.

In patients in whom significant skin shift is predicted to occur and in whom the inferior margin of the temporal tuft of hair (“sideburn”) is predicted to be shifted above the junction of the ear with the scalp, and for whom more sparse temporal scalp hair is present, the temporal portion of the facelift incision should be placed along the hairline ( Fig. 9.8.10 ; see also Fig. 9.8.7 ) rather than within the temporal scalp. This incision plan will accommodate large posterior-superior skin flap shifts and allows maximum improvement in the upper lateral face to be made. If the incision is made with care and closed under no tension, the resulting scar is usually inconspicuous and will be far less troublesome for the patient than a displaced hairline (see Fig. 9.8.6 ). While individual circumstances will vary and the decision as to where the incision be placed should be based on the circumstances present and not arbitrarily based on age, patients in whom this incision plan is indicated are typically 45 years old, or older.

Options for the placement of the temporal portion of the facelift incision should be discussed with any patient in whom significant displacement of the temporal hairline or elevation of the sideburn might occur. Incision placement is best presented as a choice between two imperfect alternatives and it is wise that the final decision as to where the incision will be located be left to patient after appropriate discussion has been made. In all, it has been our experience that most patients are disturbed by the prospect of temporal hairline/sideburn displacement and recognize it as a tell-tale sign that a facelift has been performed. When properly counseled and given the choice, most will readily consent to an incision along the hairline.

Planning the pre-auricular incision

Open to inspection, the pre-auricular region exists as a frequent point of reference for those seeking to identify a facelift patient and in essence arguably comprises the surgeon’s “signature” (or lack thereof) of their work. Traditionally, incisions in this area are made well anterior to the anterior border of the helix and continued inferiorly, anterior to the tragus ( Fig. 9.8.11A ).

This plan, however, works well only for the unusual patient with cheek and tragal skin of similar characteristics who, in addition, exhibits favorable healing. Unfortunately, most patients have a marked gradient of color, texture, and surface irregularities over these areas and a tell-tale mismatch will be evident, even in the presence of an inconspicuous scar. For these reasons, and in all but the unusual case (secondary and tertiary procedures in patients with minimal or no skin excess), the pre-auricular portion of the facelift incision should be precisely placed along the posterior margin of the tragus, rather than in the pretragal sulcus ( Fig. 9.8.11B ). In this location a mismatch of color, texture, or surface irregularities will not be noticed and the scar, if visible, will appear to be a tragal highlight ( Fig. 9.8.12 ; see also Fig. 9.8.17 ).

In addition, a properly planned and executed incision along the margin of the tragus will not produce tragal retraction or other anatomical irregularity ( Figs. 9.8.13 & 9.8.14 ).

In the male patient a similar incision plan is used. In many cases skin flap shifts will be such that beard hair will not be retro-posteriorly displaced enough to be advanced onto the tragus itself. In cases where larger skin flap shifts occur, the tragus can be kept free of beard hair when a retrotragal incision is used by intra-operative destruction of beard follicles from the underside of the tragal flap when indicated ( Fig. 9.8.14 ; see Chapter 9.11 , Fig. 9.11.35 Male facelift).

The pre-auricular incision consists of three component incisions: (1) a prehelical incision; (2) the tragal incision; and (3) a prelobular incision. Careful attention to the planning of each must be undertaken if a well-concealed scar and natural appearance is to be obtained.

The superior, prehelical portion of the pre-auricular incision should be planned as a soft curve paralleling the curve of the anterior border of the helix. This will result in a natural-appearing “width” to the helix in keeping with the rest of the ear and the resultant scar, if visible, will appear to be a helical highlight and/or the natural anatomic transition from smooth pinker skin of the helix to the paler, coarser skin of the cheek ( Fig. 9.8.15 ).

If the prehelical portion of the pre-auricular incision is placed too far anteriorly or is situated so that it encroaches on the helix itself, the illusion of the scar as an anatomic interface and/or reflected highlight is lost ( Fig. 9.8.16 ).

As the tragus is approached, the mark for incision is carried into the depression superior to it and then continued along its posterior margin . In this location the scar, if visible, will appear to be a natural highlight ( Fig. 9.8.17 ).

At the inferior portion of the tragus the incision must turn anteriorly and then again inferiorly and a right angle, into the crease between anterior lobule and cheek. If a more relaxed plan is made, or if a straight line or “lazy S” incision plan is used, skin settling and scar contraction will result in crowding of the incisura, obliteration of the inferior tragal border, and a tell-tale elongated and “chopped-off” tragal appearance ( Fig. 9.8.18A,B ).

To obtain a natural perilobular appearance, it is essential in cases where a naturally shaped earlobe is present to preserve the natural sulcus between the earlobe and the cheek and to avoid destruction of or excision of this and aesthetically important anatomic subunit. This is accomplished by marking the incision 1–2 mm inferior to this junction in women and 2–3 mm inferior to it in men. Placing the incision slightly more inferiorly in men facilitates shaving postoperatively should bearded skin be shifted superiorly against the incision as it commonly will be. In both cases, when a naturally shaped lobule is present, all other factors being equal, a superior result will be obtained when such a plan is used, in comparison to any plan in which the incision is placed directly in the sulcus and an attempt is subsequently made to directly join thin, soft earlobe with coarse, thick cheek.

Planning the postauricular incision

The “postauricular” portion of the facelift incision is actually composed of three component incisions: (1) a postauricular incision extending in and along the concho-mastoid sulcus (see Fig. 9.8.20D , gray dotted line); (2) a transmastoid component incision traversing horizontally across the mastoid to the occipital scalp (see Fig. 9.8.20D red line); and (3) an occipital incision extending into the occipital scalp or along the occipital hairline (see Fig. 9.8.20D , white dotted line). A careful consideration of the design of each is important if an overall well-concealed and inconspicuous scar is to be obtained.

Planning the transmastoid portion of the postauricular incision

Considerable confusion exists among surgeons performing facelift procedures as to what level the transmastoid part of the postauricular facelift incision should cross over to the occipital scalp and, as a result, this part of the incision is often not placed strategically and in a manner that best conceals it, or in a way that allows optimal excision of skin from the anterior neck to be performed. If it is placed too low it will be visible when the patient’s hair is worn up or if they wear a short hairstyle. If it is placed too high the defect created will force and overly vertical shift of the postauricular skin flap and compromise improvement in the anterior neck and submental region ( Fig. 9.8.19 ). Fortunately, if one assesses the goals sought and employs simple logic in meeting them, rational and effective transmastoid incision placement becomes possible.

A useful guide in siting the transmastoid part of the postauricular incision is to envision a horizontal line through the point at which the anterior and superior crus of the anti-helix diverge. Typically at that level the outer rim of the helix extends posteriorly back to the occipital hairline to the so-called “helix-hairline touch point” and a transmastoid incision placed at that level will be hidden behind the ear in the lateral view ( Fig. 9.8.20 ).

Planning the occipital portion of the postauricular incision

Planning the location for the occipital portion of the postauricular incision is conceptually similar to that of the temple region and the incision plan must take into account and address similar concerns of hairline displacement and scar visibility. Traditionally this incision is arbitrarily placed low transversely, into the occipital scalp, in a well-intended but almost always counterproductive attempt to hide the resultant scar ( Fig. 9.8.21A ).

Regrettably, many other conceptually flawed, similar incision plans, which do not recognize the tissue biogeometry of the postauricular area or provide for skin excision along a useful vector, have been advocated. A thoughtful consideration of what one is trying to accomplish, however, allows one to employ incision plans that are logical and effective.

For patients in whom neck skin redundancy is small and shifting and excision of postauricular skin is unnecessary, a traditional postauricular incision plan (as shown in Fig. 9.8.21A ) is appropriate if its transmastoid portion is situated superiorly enough to be concealed behind the ear (see preceding discussion) and will result in a well-concealed scar. Patients in this category are usually young and troubled by mild neck deformity only, and in these situations the incision is used for access to the lateral neck only, and not as a means to remove postauricular skin . Mistakenly using this incision to excise skin along a posteriorly directed vector will predictably result in the advancement of neck skin into the occipital scalp and “notching” of the occipital hairline ( Figs. 9.8.21 and 9.8.22A,B ). Similarly, using this incision to excise skin along a superiorly directed vector will predictably result a wide transmastoid scar ( Fig. 9.8.23 ). Skin excision along either vector using this incision is conceptually flawed and the source of all-to-common secondary facelift irregularities.

Although not all patients and their surgeons will recognize these irregularities for what they are, most are nonetheless aware an unnatural appearance is present, especially those patients who wear short hairstyles, wear their hair up or back, or who lead active lives and engage in activities that may displace camouflaging wisps of remaining hair. Proper analysis, careful planning, and the use of an incision along the hairline ( Figs. 9.8.24 & 9.8.25 ), when indicated and carried out in a technically correct manner, will prevent this problem, and allow skin to be excised along a correct posterior-superior vector, while simultaneously producing a well-concealed scar ( Fig. 9.8.25 ; and see also Fig. 9.8.20A ).

In logically designing and deciding upon the position of the occipital portion of the postauricular incision one must gauge the skin redundancy along the predicted posterior-superior direction of flap shift. This can be accomplished by pinching up tissue over the upper lateral neck and estimating the amount present. If 2 cm or less of excess neck skin is present, a “traditional” incision over the mastoid extending posteriorly into the scalp at the level of the mid-ear (see Fig. 9.8.21A ) will, in most cases, not result in objectionable disruption of the occipital hairline. Typically this incision plan will be used in patients under 40 years old. If more than 2 cm of neck skin redundancy is present, however, the incision should be placed along the occipital hairline but designed in such a manner that a tell-tale scar will not be visible in front of the fine hair on the nape of the neck (see Figs. 9.8.24 & 9.8.25 ). This incision plan is typically needed in patients over 40 years old if hairline displacement is to be avoided and neck skin is to be excised along a proper and useful vector.

The length of the occipital portion of the postauricular incision will necessary vary depending on the quality of the patient’s tissues and the amount of redundant skin present in the anterior neck and submental area (size of “wattle”), and “ small,” “medium,” and “long” (length of incision along the occipital hairline) incision plans are used as indicated (see Fig. 9.8.26 ). In patients with good tissue quality and minimal anterior neck and submental skin excess (“small wattle”), a “short” incision along the hairline will be indicated ( Fig. 9.8.26A ). In patients with modest loss of skin quality and modest anterior neck and submental skin excess (“medium wattle”), a “medium”-length incision is made along the occipital hairline ( Fig. 9.8.26B ). In elderly patients with poor skin elasticity and a large anterior neck and submental skin excess (“large wattle”), a “long” incision along the occipital hairline will be needed ( Fig. 9.8.26C ).

As is the case with temporal incision placement, options for the placement of the occipital portion of the postauricular incision should be discussed with the patient preoperatively and presented as a choice between two imperfect alternatives: a scar “hidden” in the occipital scalp but with hairline notching and displacement; or a scar along the hairline but with hairline preservation. It is wise that the final decision as to where the incision will be located is ultimately left to the patient, after the advantages and disadvantages of each have been thoroughly discussed. In all, it has been our experience that most patients are disturbed by the prospect of occipital hairline displacement and recognize it as a tell-tale sign that a facelift has been performed. When properly counseled and given the choice, most will readily consent to an incision along the hairline.

General

All patients undergo a preoperative physical evaluation and any patients with significant medical problems must be cleared by their internist or personal physician before their procedure is performed. Each patient is required to avoid agents known to cause platelet dysfunction for 2 weeks prior to surgery.

Smoking

All patients who smoke are asked to quit 4 weeks before their procedure and are required to avoid smoking and all second-hand smoke for 2 weeks after surgery. Patients who smoke, or have a significant past history of smoking but have quit, are advised in writing that their risk of serious complications, including poor healing, flap necrosis, skin slough and thromboembolic phenomena is significantly higher than in non-smokers. Smokers should be approached with caution, however, and it should be recognized that these patients are suboptimal candidates for surgery and at higher risk for serious local and systemic complications .

Radiofrequency and ultrasonic “skin-shrinking” treatments

Patients should be questioned carefully about previous non-invasive radiofrequency (RF) and ultrasonic “skin-shrinking” procedures, as these treatments appear to damage skin subdermal microcirculation and compromise superficial micro-lymphatic vessels, and patients who have undergone these treatments seem to be compromised candidates for facelift procedures. Similarly, patients who are long-standing filler users, especially if they have used more inflammatory fillers such as poly-L-lactic acid (PLLA), are likely to have internal facial fibrosis and inflammatory changes, rendering them more challenging candidates as well.

The patient who has undergone facial RF and/or ultrasonic “skin-shrinking” treatments is part of a growing body of patients who seem to sustain clinically significant compromise of their skin microcirculation as a result of these and similar treatments that puts them at greater risk of slough and healing-related problems following facelift procedures and suboptimal take when fat grafting is performed. Unlike when laser resurfacing is performed, in “skin-shrinking” procedures energy is directed and dispersed under the skin rather than on its surface, and energy meant to “tighten” the face appears to damage the subdermal microcirculation, superficial micro-lymphatic vessels, and adjacent subcutaneous fat. The incidence of problems seems to parallel the number and intensity of treatments the patient has undergone, which one would expect to parallel the degree of compromise to their tissues. These patients also seem to experience prolonged edema and a longer period of recovery following facelift surgery.

Consideration should be given to advising patients who have undergone previous RF and ultrasonic “skin-shrinking” treatments in writing that their risk of serious complications, including poor healing, flap necrosis, and skin slough, is significantly higher than in patients who have not undergone these procedures, especially if they have undergone multiple previous treatments. From the surgeon’s standpoint, these patients should be regarded, approached, and treated as similar to smokers.