30.8Facelift Procedure with Release and Suspension of the Retaining Ligaments and SMAS

30.8.1 Design of Skin Incision

Short scar technique is currently used. An interiorly mild, curved incision is made for about 4 cm in the hair-bearing skin in the temporal region (Figs. 30.9 and 30.10). The incision continues in the preauricular area, corners around the ear lobe and is terminated in the retroauricular groove. The author used to place the incision along the

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posterior margin of the tragus (retrotragal incision). It was found that the retrotragal incision hides the scar but produces deformity of tragus, in spite of careful tailor of the skin to cover the tragus cartilage (Fig. 30.11). At present, an incision is used along the groove in front of the tragus. This pretragal incision causes no deformity of tragus and the resultant scar is well accepted by patients, although it is visible. A short horizontal incision is placed along the sideburn. Trimming of a triangular skin below this horizontal incision helps to reduce superior displacement of the sideburn and temporal hairline.

This design of incision line is not used for all cases. For those who have a remarkable skin redundancy, for

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Fig. 30.9 The lateral margin of muscle portion of SMAS and platysma is present at approximately 3 cm from the ear lobe. Through a short scar incision, the subcutaneous dissection is performed for 4 cm from the ear lobe. An incision is made in the SMAS and platysma at 3 cm from the ear. The subSMAS and subplatysma dissection continues beyond the anterior margin of the masseteric muscle in order to release all the masseteric ligaments

skin excision

skin incision

subcutaneous dissection

parotid cutaneous ligaments

zygomatic ligaments

sub-SMAS dissection

4 cm

masseteric ligaments

3 cm

mandibular ligament

SMAS incision

example, elderly patients or those who undergo the secondary facelift, the author chooses a hairline incision in the temporal area instead of an incision inside the hair-bearing skin (Fig. 30.10). For those who have vertical wrinkles in the neck or excess skin in the neck or those who request particularly for tightening of neck, the retroauricular incision is extended into the posterior hairline. An incision is made in the postauricular non- hair-bearing skin to bridge between the postauricular groove and occipital hairline. Care has to be taken so as to hide this scar by the ear when viewed from side. In pushing the ear down to the head, the outline of the helical margin is drawn on the postauricular skin. An incision

in the postauricular non-hair-bearing skin has to be made within this outline of the ear. Afterward, the incision continues along the occipital hairline.

30.8.2 Dissection

The lateral margin of platysma and muscular portion of SMAS is located at, approximately, 3 cm from the ear lobe (Figs. 30.9, 30.10, and 30.12). The subcutaneous dissection is made up to 4 cm from the ear lobe. An incision is made in the SMAS and platysma at 3 cm from the ear lobe. Deep cut has a risk of facial nerve injury. After

Fig. 30.11 Retrotragal incision. Postoperative scar along the posterior border of tragus is not visible but the tragus has lost the projection and the contour of the tragus has become dull

zygomatic ligament

SMAS

suction canula

sub–SMAS pocket

Fig. 30.12 Small arrows indicate the lateral margin of SMAS flap that is 3 cm from the ear lobe. *Mark indicates the subSMAS pocket. A suture ligation was placed on the cut end of the zygomatic ligament of the skin side. A 16 gauge liposuction cannula is inserted in the subcutaneous layer superficial to the SMAS

the muscular layer of SMAS and platysma is cut with care, blunt tip scissors are used to open the incision. Once the tip of the scissors enters the subSMAS and subplatysma space, the deep dissection continues forward with the spreading maneuver. The dissection is relatively easy because the attachment of SMAS and platysma on the underlying tissue is loose. When the deep dissection approaches to the anterior margin of masseteric muscle, the spreading procedure encounters resistance due to the presence of the masseteric ligaments. After identifying the masseteric ligaments, the ligaments are cut. This dissection continues from the mandibular border inferiorly to the neck and also superiorly. When extending the deep dissection superiorly, the distinctive fibrous band of zygomatic ligament is encountered. The ligament is cut after ligating the ligament in the skin side with 4–0 nylon suture. The further dissection in the superomedial area exposes the zygomatic major muscle. The dissection continues in the inferomedial direction following the lateral margin of the muscle up to the cross point of the lateral margin of the zygomatic major muscle and anterior margin of the masseteric muscle. At this point, a strong ligament band is found. The deep dissection is completed when this thick ligament is cut. At this point, the subSMAS dissection releases all the masseteric ligaments and lateral row of the zygomatic ligaments, which allow us to pull the medial portion of the skin and SMAS with traction of the SMAS flap.

30.8.3 Liposuction

Subcutaneous liposuction before surgical dissection of facelift may make the following subcutaneous dissection easy (Figs. 30.12 and 30.13). This method has a risk to injure the SMAS tissue and make the SMAS flap too weak to be used for suspension. Therefore, liposuction is performed after the subSMAS dissection is completed. A 16 gauge cannula is inserted into the subcutaneous fat layer above the SMAS under direction vision. The liposuction is performed in the bulging area according to the presurgical marking.

30.8.4Treatment of Crow’s Feet and Sagging Lower Eyelid

The subcutaneous dissection from the temporal incision toward the lateral canthal region reveals the lateral

Fig. 30.13 Liposuction is performed in the subcutaneous layer within the area marked at the presurgical plan

Fig. 30.14 The subcutaneous dissection exposes the orbicularis oculi muscle. To treat crow’s feet, the lateral portion of the orbicularis oculi muscle marked in blue is excised

margin of orbicularis oculi muscle (Fig. 30.14). In order to reduce the wrinkles in the lateral canthal area (crow’s feet), the orbicularis oculi muscle is excised in a fan shape in the lateral quadrant from 45° angle superiorly to 45° angle inferiorly.

The bulge of lower eyelid can be treated in this approach. Horizontal tightening of orbicularis oculi muscle on the lower eyelid can be performed with facelift dissection. After making an incision in the orbicularis oculi muscle, the dissection is carried out under the muscle. The orbicularis oculi muscle is elevated off from the periosteum of the zygomatic body and inferior orbital rim. This dissection is in the supraperiosteal (sub-muscular) plane. After completing the