34.4 Discussion

The present strategies for midface rejuvenation include skin quality refinement, skin tightening, soft tissue repositioning, and volume restoration. In soft tissue repositioning, various patterns have emerged for SMAS release, elevation, and anchoring. This review considered only two of these patterns, comparing a high SMAS elevation, two layer dissection, multivector suspension to the same with an additional back cut in the SMAS flap over the zygomaticus major muscle.

The release of these structures tethering ptotic midfacial tissue may improve the vertical movement of soft tissue and allow for better repositioning. This study quantifies the measurement of the SMAS vertical advancement flap before and after release from the zygomaticus major muscle. The large improvement in the medial movement of an additional 14 mm under the same tension resulting from the release of the zygomaticus major muscle validate this small surgical maneuver and has not been associated with any particular negative effect. SMAS excess at the zygomatic arch may be overlapped for additional augmentation of the arch. Resecting the excess SMAS in the zygomatic area provides restoration without the appearance of skeletal change if desired. In special cases of extreme malar deficiency, the SMAS excess can be folded and tucked into a pocket over the ZMM and malar eminence. There are many other patterns to be investigated and quantified. These maneuvers are important in improving midface soft tissue repositioning without relying on excessive skin tension and can be utilized to provide additional contour shaping when necessary.

34.5 Conclusions

The aim of today’s facial aesthetic surgery is to rejuvenate the aging face in an anatomic and physiologic way. Special attention must be given to obtain consistency and to improve longevity of results. For correction of the aging process, various techniques have evolved that have been used with both advantages and disadvantages [2–6].

The evolution of midface soft tissue contouring in rhytidectomy has progressed significantly [7–18]

(Figs. 34.7–34.14). Cheek skin was initially used as a supportive structure and tightened sufficiently to unfurl wrinkles and to flatten sagging soft tissues [10]. Since skin stretched and aging contours reappeared, cheek fat was then contoured through excision and later through tightening with SMAS plication [11, 12].The composite lift incorporated elevation of the SMAS attached to the skin flap and repositioned skin and soft tissue for restoration. After detailed description of the SMAS retaining ligaments, release of tethering ligaments allowed for improved repositioning [13–18]. Next, separation of the SMAS and skin allowed for more vertical SMAS lift with less temporal hairline shift and splitting the SMAS created bidirectional SMAS movement for better midface vertical elevation and improved platysma suspension.

Multiple strategies have evolved to maximize midface soft tissue repositioning. In order to maximize SMAS lifting, various authors have advocated more aggressive elevation and release of the retaining ligaments. A back cut over the zygomaticus major muscle substantially improves the vertical elevation and repositioning of the medial SMAS. Midface restoration may be best utilized by an advancement rotation flap because of improved vertical advancement, especially medially, for longer lasting results and better shelving of the medial cheek portion of the SMAS flap. Since there is more even mobilization of the flap and the cheek is elevated to a similar distance as the preparotid fat, the tension appears to be more even throughout the flap and may have less distortion with time. Without the ZMM release the axis of rotation is near the ZMM origin and sometimes the SMAS can appear very tight over the parotid and still loose in the midface. Release of the zygomaticus major muscle allows for more significant movement of the medial SMAS, by providing more midface soft tissue elevation. This single maneuver aids in cheek and jowl elevation and preserves midface soft tissue. The surgeon should have an adequate comfort level with the described anatomy and fit the procedure to the patient’s needs and recovery time.

Restoration of the midface has become one of the great challenges of facial rejuvenation, in part because of the success of improved brow and neck lifting techniques, leaving the midface sometimes with less than anticipated results. Also, adjacent structures like the lower lid and ear create limitations in midface lifting,

since overzealous elevation can create deformity and distortion of these structures, like ectropion, scleral show, and a pixie ear. Undue tension on the skin can create increased postoperative morbidity, a tight or wind-blown appearance, and with time the possibility of lateral lines of relaxation. There are other limitations. Lifting the ptotic cheek fat with repositioning

and suspension is limited by medial flap movement and failure results in recurrent nasal labial folds, jowling and tear troughs. Challenges still lie in the selection of the most advantageous flap design for a specific set of contour abnormalities. The utilization of multiple flap patterns and strategies may provide a more tailored and elegant result.

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Fig. 34.8 Facelift with SMAS pattern of high SMAS, excised excess, no platysma or ZMM SMAS release, and neck lift with moderate cervical scissor lipectomy and platysmaplasty. (a) Preoperative. (b) Postoperative

H.A. Mentz III

388

H.A. Mentz III

Fig. 34.9 (continued)

Fig. 34.10 Endoscopic browlift, upper and lower blepharoplasty with right suture canthopexy, facelift with SMAS pattern of high SMAS, excised excess, with ZMM SMAS backcut and no platysma backcut, neck lift with minimal cervical scissor lipectomy and platysmaplasty and fat graft to the cheek.

(a) Preoperative.

(b) Postoperative

a

a

b

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Fig. 34.11 Upper and lower blepharoplasty with bilateral suture canthopexy, facelift with SMAS pattern of high SMAS, excised excess, with ZMM SMAS backcut and lateral platysma backcut, neck lift with minimal cervical scissor lipectomy and platysmaplasty and fat graft to the cheek, nasolabial fold, and prejowl.

(a) Preoperative.

(b) Postoperative

H.A. Mentz III

a

Fig. 34.12 Upper and lower blepharoplasty with bilateral suture canthopexy, facelift with SMAS pattern of high SMAS, arch excess tucked over ZMM into malar area, with ZMM SMAS backcut and lateral platysma backcut, neck lift with minimal cervical scissor lipectomy and platysmaplasty, fat graft to the cheek, nasolabial fold, and prejowl, and chin augmentation.

(a) Preoperative.

(b) Postoperative

b

b

a

b

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Fig. 34.14 Endoscopic browlift, lower blepharoplasty with bilateral suture canthopexy, facelift with SMAS pattern of high SMAS, excess excised, with ZMM SMAS backcut, neck lift with no lipectomy, platysmaplasty, fat graft to the cheek, nasolabial fold, prejowl, and corner of the mouth lift. (a) Preoperative. (b) Postoperative

H.A. Mentz III