dissection to the medial corner of inferior orbital rim, the lateral edge of the orbicularis oculi muscle flap is pulled laterally and sutured to the periosteum of the lateral orbital rim and deep temporal fascia. It is important to suspend the muscle fibers closer to the lateral canthal tendon, related to the preseptal portion of the orbicularis oculi muscle in order to restore tight tension band in the lower eyelid (Fig. 30.15).

a

c

Fig. 30.15 (a) Preoperative patient. (b) The areas to be treated by lipofilling are shown in green. (c) Presurgical simulation. Traction of the preauricular skin. (d) Presurgical simulation. Traction of the preauricular and temporal regions demonstrates the lateral pull of the lateral canthus and tightening of lower eyelid. (e) One year after facelift with release of retaining ligaments and lipofilling. The patient shows correction of hollow cheek and jowl deformity. The lower eyelid shows tightening and reduction of bulge

30.8.5 Suspension

The vector of the lift is determined in the presurgical planning as described (Figs. 30.16 and 30.17). The lateral margin of the SMAS is pulled in the direction according to the vector decided preoperatively, commonly in the superolateral direction. The 1 cm long SMAS cuff that is attached to the medial skin flap is

b

d

Fig. 30.15 (continued)

Fig. 30.16 Before suspension of 1 cm long cuff of SMAS (small arrows) and zygomatic ligament (a large arrow). **Marks show the subSMAS pocket

sutured to the SMAS over the parotid in the preauricular region. The SMAS over the parotid is relatively immobile and provides a good platform to suspension. The most medial zygomatic ligament is suspended to the periosteum of the zygomatic body using the ligation suture if it has been tied with suture before cutting. The zygomatic ligaments in more lateral position are then suspended to the zygomatic arch or temporal fascia. The lateral margin of the platysma is anchored

to the mastoid fascia. At this point, the skin of the medial face has been lifted and fixed; therefore, further traction of the margin of the skin flap in front of the ear has no more effect to lift the medial face. At the completion of SMAS suspension, dents or grooves may be evident on the skin surface along the attachment of the cuff of the SMAS and platysma to the skin. The excess skin is then trimmed along the incision and the skin is approximated under the tension which is just enough to smooth out the dents or grooves. At first, the wound is closed in the preauricular region. A triangular piece of skin is trimmed below the horizontal incision at the sideburn, minimizing upward displacement of the sideburn. In case of short scar facelift, where the postauricular incision is terminated in the postauricular groove, excess skin is produced and appears behind the ear lobe. Wound closure in the postauricular groove may develop a dog ear or gathers, although it was tailored with meticulous care. The deformity may fade away in 3 months; otherwise it needs to be corrected with skin trimming 3 months after the facelift procedure.

30.8.6 Lipofilling

Lipofilling is performed after completing the skin closure. Although a common donor site for fat harvest is the lower abdomen, the flank or medial thigh