consideration in the mobilization of the flaps. For this relief, dissection underlies the expanded SMAS and composite techniques. While identifying the fixation method of mobilized SMAS, the functions and original localizations of these retaining ligaments should be considered. The localizations of retaining ligaments increase more in the middle cheek region rather than in preauricular region for fixation. In medial cheek region and lateral cheek region the attachments of retaining ligaments are more than the neighboring SMAS fixation [10, 11].

Whetzel and Mathes observed that the transverse facial perforating artery provides the major direct blood supply to the lateral cheek and preauricular area following rhytidectomy, if preserved. This perforator was reported to occupy a constant anatomic location 3.1 cm lateral and 3.7 cm inferior to the lateral canthus. The greater variability in localizing the submental perforating artery was depicted. This perforator also contributed significantly to lateral facial blood supply. Both perforator locations were noted to be within the area of standard undermining for rhytidectomy; during this procedure, especially in the clinical setting of a patient with vascular compromise or who is a smoker, the lateral facial perforators were proposed to be preserved [30, 41, 42].

36.6Retaining Ligament Correction and SMAS Plication in Facelift

The fixation of the face-lift flap rose from the original skin flap technique. A wide area which needs to stick under flap rose through wide decollation. In 1950, Aufricht sutured the subcutaneous layer to the parotidomasseteric fascia [10].

The SMAS or deep plane face-lift surgery described by Skoog included the fixation of the superficial fascial flap to the masseteric muscular fascia. The developments in SMAS surgery provide the attachment of the mobilized SMAS flap to the preauricular region instead of the middle cheek region. Preauricular fixation is attached to the periost of posterior zygomatic arch or to neighboring deep fascia or to undecessed SMAS of that region [43]. Recently the fixation at the middle cheek level has been advocated by Stuzin and Mendelson [8–11].

During the sub-SMAS surgery over the masseteric region, care should be taken to avoid injuring the branches of the facial nerve. The contouring of the facial soft tissue remains a difficult challenge because

of the variations in the quality of facial skin and in fascial content of the SMAS from patient to patient. Fixation of the thin superficial layer results in early descent, and the excess SMAS is preferably plicated over instead of being excised [8, 9].

The retaining ligaments of the cheek are stout, firm, and flexible, attaching the facial skin to the facial skeleton and to the deep fascia through subcutaneous tissue. Their efficiency depends on the width of the attachments to the skin and, if small, the ligament stretches in time, but the ripples are not away from the fixation points.

The ptosis of the cheek anterior to the zygomatic ligament and the jowling posterior to the mandibular ligament are evidence.

It provides a more youthful view, to loosen all tissues that prevent the vertical movement of the ptotic facial tissue for the elevation of the nasolobial fold, to lift up the ptotic facial skin with vertical movements, and to fix it so that the ripples disappear and to form a new insertion of the zygomatic ligament. In every four patients facial nerve neuropraxia is reported. The most effective lift can be made if these ligaments separate in the location where the cheek skin severely drapes. Mandibular ligament blocks the skin for a lifting power which has a relation to the cheek flap, which cannot transmit its surgical importance to the submandibular region or cheek region. The surgical release of this ligament provides more effective submental lift and this creates space for lipectomy without doing a submental incision. Platysma auricular ligament is important in terms of making it possible for the surgeon to move to the wrong layer during dicession [31, 33].

The attachments of the facial mimetic muscles, especially the zygomatic muscles, to the SMAS cause difficulties with the sub-SMAS dissection, which ought to be held attentively. These attachments account for the minimal change in the nasolabial crease after a sub-SMAS face-lift dissection [13].

Stuzin et al. mentioned the variability of fat tissue composition from patient to patient and the necessity of the various vectors in lifting. Materials such as Vicryl mesh could be used where the SMAS is weak and in regions where fixation is difficult, such as the inferior SMAS region [8, 9].

Mendelson proposed fixation of the mobilized region to the immobilized region, and claimed that the more suturing was performed to the small area, the better were the results that were encountered.

Sub-SMAS dissection in the middle cheek region and buccal region is difficult. During the dissection and

fixation at the middle cheek and buccal region, there’s a risk of facial nerve injury. When the laxity and bagginess in the face are lifted up, the resistance of the tissues resumes. The plicated SMAS descends with stress. The lifting vectors should be parallel to the mimetic muscles of the face and should be in at least three vectors, considering the plane in three dimensions, which would not flatten the face, forming the natural view. The plications decrease the tension and also the incision scar [10, 11, 44].

For correction of the aging face, various techniques have evolved and have been used and have both advantages and disadvantages. The understanding of the mechanism of the aging face and the correction depending on this is the basic principle. Anatomic repositioning of the anatomic layers, muscles, fat pads, ligaments, and skin structure seems to be possible [21, 45–47].

36.6.1Preparations for Surgery and Skin Marking

In the operation room, the face-lift incision plane and probable branch localizations are fixed by drawing after the proper region is cleaned, under general anesthesia, the proper region is diluted 2% lidocaine and half face is diluted HCL + 0.025 adrenalin of 6 ml. local anesthetic and 6 ml. saline solution. It starts after the face-lift region is given subcutan. After waiting for 5–10 min, skin incision is planned in oblique posterovertical localization and in preauricular region, and it is planned according to the preauricular skin line from in front of tragus from the line between ear lobe and skin, in postauricular region from postauricular line and in occipital region into the scalp.

36.6.2 Surgical Technique

The skin flap is elevated superior to the superficial temporal fascia and hair follicles in the temporal region according to the supra-SMAS face-lift technique. Under 4x loupe magnification, the zygomatic ligament is dissected in the zygomatic region. If the artery and the nerve are identified, these are preserved to avoid disturbing the nourishment and sensation of the skin, and the attachment of the ligament to the subcutaneous tissue is dissected sharply. The dissection is continued toward the preauricular region, marking the ligament

with a suture. In the preauricular region under loupe magnification, the parotid cutaneous ligament is dissected and separated sharply from the skin; meanwhile, the identified cutaneous nerve is preserved and the ligament marked with a suture. The dissection is held anteriorly and inferiorly, reaching the parotidomasseteric and anterior platysma cutaneous ligaments; the attachments are separated and the ligaments are marked. The anterior masseteric border is attained with careful dissection, with the disadvantage of the negative effect on skin flap circulation. A better visualization can be obtained with a headlamp directed toward the mandibular ligament. It is proper to continue with the dissection using a loop coming to the probable part of the ligament which is marked. When the cutaneous nerve and the artery are identified the ligament is separated from the skin and marked with a suture leaving more subcutaneous tissue on the skin flap to avoid dimpling during the anatomic correction of the ligaments (Fig. 36.16). After hemostasis, SMAS plications of

Skin flap

Retaining ligament

SMAS flap

Figure of 8 continous suture

Fig. 36.16 Dissection and suturing design in the anteroinferior portion of the ligament to prevent dimpling [32]

0–1 cm in anterosuperior and anteroposterosuperior vectors with 3–6 cm 5/0 nonabsorbable, colorless propylene sutures are accomplished in the cheek region and with 2–3 cm sutures in the parotid region, the knots localized inferiorly (Fig. 36.17) [32].

The branches of the facial nerve should be cared for, especially in the middle cheek region.

Plication

zone

Dissection

zone

Fig. 36.17 Plication design in the middle and posterior cheek region

SMAS tension and resistance is increased with SMAS plication. The gravitationally descended facial fat is replaced to the anatomic position. While the skin flap is dispersed over the SMAS, avoiding excessive stretching, the new localizations of the mandibular, parotidomasseteric, zygomatic, anterior platysmal, and preauricular parotid ligaments are pointed out on the skin flap (Fig. 36.18). Suturing of the ligaments to the new localizations is accomplished with colorless 5/0 nonabsorbable propylene using either continuous or figure-of eight sutures every 5–10 mm, depending on the size of the ligament, avoiding stretching and dimpling. With the impact of the edema from postoperative period, dense suturation or tension results in a dimple. After correction of the ligaments, the excess skin flap is excised, preventing the sideburn line displacement and avoiding tension between the incision lines. During excision the ear lobule and the skin flap should be sutured so that the distinct shape of the ear lobule is preserved. An Axiom silicone drain could help to prevent hematoma and control the hemostasis. The incision line is sutured anatomically as two layers of subcutaneous tissue and skin. The operation is finished with a dressing that doesn’t cause excessive pressure [32, 48].

Investigation of the cutaneous arterial supply of the face-lift flap is useful during dissection and preservation of sufficient structures, especially in patients with vascular compromise or who are smokers. Although the subperiosteal face-lift, central suspension, deep plane, and multiplane face-lift techniques have been used in face-lift surgery today with the disadvantages determined and explained by the authors, the properties of being physiologic and less traumatic, and having decreased complications and fast healing are