339

is more effective if traction is applied to the tissue in the

the vertical direction, but also in the horizontal direction.

more medial region away from the ear. The lateral edge

In sum, the stretching takes place in two dimensions.

of the SMAS flap is closer to the central face zone than

The expansion does not appear uniformly over the whole

the lateral edge of the skin flap. The use of SMAS

face. The skin over the insertion of the retaining liga-

allows for traction of more anterior tissue than the

ments develops minimal expansion. The skin surrounded

preauricular skin incision line. Since the SMAS is

by the retaining ligaments expands to a certain degree in

strongly anchored to the underlying tissue by the retain-

two dimensions, which causes bulging out. As a result

ing ligaments, the ligaments restrain the traction power

of aging process, multiple protrusions develop over the

when the lateral margin of the SMAS is pulled, unless

facial skin just like a buttoned-up sofa. In addition, sub-

the retaining ligaments are released [4, 5]. It is, there-

cutaneous fat lose the volume with aging. As the volume

fore, essential to release the zygomatic ligaments and

reduction occurs unevenly over the facial surface, greater

masseteric ligaments in order to transmit the lifting

diminution of fat causes depression evidently in certain

power to the medial tissue [4, 6, 7].

areas. Thus, aging change of surface contour of the face

In order to provide stronger lift effect to the central

takes place not in one dimension but in three dimen-

facial zone, traction should be applied to the medial

sions; expansion of skin surface area and change in fat

tissue. Therefore, the lateral edge of SMAS flap should

thickness. Although release of restraining effect of the

be made medially apart from the ear. The use of a short

retaining ligaments and use of short SMAS flap provide

SMAS flap elevated over the masseteric muscle is

greater stretch to the skin in the medial face, this lift

more effective when compared with the long SMAS

is limited in one direction only and is not sufficient

flap elevated in the preauricular area [6].

to correct the three-dimensional deformity. To achieve

The retaining ligaments are distinctive fibrous band

improvement in three-dimensional deformity, liposuc-

which has strong adhesion to SMAS and skin. Suspen-

sion of masseteric ligaments and zygomatic ligaments

is a theoretically appropriate technique to provide

strong lift in the medial face [8]. The author has found

that practically this procedure is not worth adapting

because it is complicated and time consuming. First,

this treatment requires the ligation of each ligament

It is helpful to pull the skin in front of the ear with hands

before it is cut to secure the ends. Second, suspension

to see a possible result from facelift operation (Fig. 30.8).

of each end might produce a dimple if excess traction

This simple simulation helps a surgeon to determine the

is applied. In case dimples occur, loosening of suspen-

direction of lift, whether it should be in superoposterior

sion or release of subcutaneous fibrous tissue is neces-

direction or should be in more vertical direction. It is

sary. The author has no longer used direct suspension

also useful to examine the facial contour while pulling

of masseteric ligaments. Currently, the zygomatic liga-

the preauricular skin, and evaluate whether there is a

ments are used for suspension.

need for volume reduction or volume filling. If volume

reduction is found to be necessary, liposuction should

be employed at the same time of facelift. In the consul-

30.6 Correction of Bulges and Grooves

tation while lifting the preauricular skin, the area where

bulge remains is marked for liposuction procedure.

Caused by Aging

In addition, while pulling the preauricular skin, depres-

sed areas are determined and marked for lipofilling.

It is said that facial skin sags with aging. What is sag-

Fat injection is commonly applied to the nasolabial

ging? With aging, skin and subcutaneous fat lose the

fold, marionette line, cheek depression anterior to the

firmness and they become vulnerable to gravity. The

masseteric muscle, upper midface, temple, lips, and

skin is stretched and expands its surface are. Although

chin. To determine adequate fat volume needed for

the cheek skin shows downward ptosis in the upright

lipo-injection, it is useful to fill the area planned for

position, the skin surface area does not expand only in