can be chosen at the patient’s request. The fat is harvested with liposuction maneuver and centrifuged for 3 min at 3,000 rpm. The fluid in the lower layer is discarded. The remaining fat layer is collected and used for injection. An 18 gauge cannula with blunt tip is used for injection. It is considered that only 30% of injected fat remains and the rest is absorbed; therefore, it is reasonable to inject the fat three times as much as the volume required to correct the depression. The necessary volume is determined at the beginning of operation in simulation with injection of local anesthetic solution. For the correction of nasolabial fold, marionette line and mid-cheek groove, subcision (subcutaneous dissection with 18 gauge sharp tip needle) is employed. The pocket space created with subcision is filled with fat. Additional volume is injected under the subcision pocket. For other area, such as lips, lateral cheek, upper midface, temple and chin, the fat is injected in the subcutaneous layer without dissection.

30.9 Clinical Cases

In the past, the author used the small SMAS flap with minimal subSMAS release, which is limited over the parotid. This procedure released the parotid cutaneous ligaments under the SMAS, but it left the masseteric ligaments and zygomatic ligaments intact. The author

also had experience with the lateral SMASectomy and the lateral SMAS plication. Neither of these techniques released the masseteric ligaments off the SMAS. The review of the patients who underwent those three types of procedures showed that the early result was excellent. The facial contour line along the mandible was straight, with no evidence of jowl. However, the jowl recurred in 1–3 months. Although the relapsed deformity was not more than the preoperative situation in some cases, it looked almost the same as the preoperative one in others (Figs. 30.18 and 30.19).

Review of the patients who underwent the current operation with release of the retaining ligaments and suspension of the short SMAS and platysma flap showed less or no recurrence of jowl deformity (Figs. 30.20 and 30.21).

It was found that suspension of the orbicularis oculi muscle in the lateral canthus area was useful to improve the bulging of the preseptal portion of lower eyelid without removal of orbital fat (Fig. 30.15). It is important to choose a proper portion of the muscle and right fixation point to achieve good improvement in the lower eyelid.

For Caucasian patients, the midface lift via the temporal approach, which mobilizes the midface soft tissue toward the zygomatic body, is useful. This results in enhancement of the malar protuberance. Most of Oriental patients do not like this change. In addition, traction of the tissue in the temple into the superolateral direction tends to exaggerate the appearance of

Mongoloid slant of Oriental eye. Although a few patients requests for this change in the lateral canthal area, it is a rare demand. Thus the facelift procedure using an approach from the temporal and preauricular incision is not effective to correct the nasolabial fold, although the release of retaining ligaments and suspension of deep tissue are involved. Lipofilling combined, particularly, with subcision is very useful to improve the nasolabial fold. The vertical direction is considered appropriate for the midface lift in Orientals. This should be performed via the lower eyelid incision. Volume augmentation of the upper midface is valuable in selective cases.

30.9.1 Case 1

A 42-year-old female presented with mild jowl deformity and heavy appearance in the upper eyelid (Fig. 30.8). Her facial contour appeared to be square rather than triangular. In the preoperative planning, traction of the preauricular skin with fingers demonstrated a possible result from the short scar facelift, changing the square facial contour into a triangular one. The simulation showed budging in the lateral cheek in spite of the strong pull. In order to trim down the bulge, which would remain after facelift alone, it was decided to use liposuction combined with facelift. The simulation of facelift with temporal lift made the lateral canthus look sharper. The patient did not wish

to have a temporal lift. The simulation of the brow lift, in which the vector of traction was applied mainly in the lateral portion of the eyebrow, showed improvement of heavy impression in the upper eyelid.

The patient underwent the short scar facelift. The incision was made in the hair-bearing skin in the temporal region and terminated in the postauricular groove. After release of the retaining ligaments with subSMS dissection, the subcutaneous fat was liposuctioned with a 16 gauge cannula in the lower lateral cheek in accordance with the presurgical marking. Additional liposuction was carried out in the submental area. Since her forehead was narrow, the endoscpic brow lift was performed, retracting the lateral part of eyebrow. A 1 cm cuff of SMAS and zygomatic ligaments were used for suspension.

Six months after surgery, the patient showed improvement of heavy upper eyelid with mild elevation of eyebrow. Her face obtained a triangular contour and her face line showed reduction of bulge better than the one shown in the presurgical simulation. The improvement of neck contour was also evident.

30.9.2 Case 2

A 59-year-old female presented with a history of having had skin excision along the temporal hairline and incisional upper blepharoplasty (Fig. 30.15). A hollow in the lower cheek anterior to the masseteric muscle, jowl

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