5.4.1.3 Fatty SMAFS

In case of Fatty SMAFS (Fig. 5.2), debulking of SMAFS via closed liposuction, using suction machine and either a keel cobra tip (3 mm diameter) or a flat spatula cannula should be carried out. However, if the SMAFS is mild to moderately fatty, an open vacuum cleaner technique of open liposuction should be followed using suction machine and a flat spatula cannula. Since, there will be a change in facial features if considerable debulking of SMAFS is done, this possibility should be discussed with the patient prior to surgery in order to prevent patient dissatisfaction. If the patient agrees to the thinning of face, surgery should be planned. After debulking of the SMAFS, plication and/or lift should be carried out as in a Classical/Delta or S-lift.

5.4.1.4 Flaccid SMAFS

When flaccidity of SMAFS is considerable, smaller SMAFS bites should be taken, and lifting and attaching it to the periosteum of zygoma using vertical U and horizontal O sutures, or tensing and plicating it below the zygoma using 2/3 Prolene sutures, should be considered.

result of repeated fat injections into the face, especially when sharp needles have been used for transfer and injections have been deeper. In these cases, SMAFS suturing should be considered primarily, and SMAFS repair should be carried out using 2/0 or 3/0 Prolene. Mild to moderate lift can be provided simultaneously if one or two discontinuous/patches exist. However, if the gaps in SMAFS are wide or discontinuity is more, only SMAFS repair should be carried out, and lifting should be deferred for several months to a year later.

5.4.1.7 Fleshy SMAFS

In case of fleshy SMAFS (Fig. 5.3), relatively deeper bites of SMAFS should be taken, three SMAFS sutures

should be applied, and either plication as in a Delta/ Classical lift or attachment to the periosteum of zygomatic bone as in an S-lift, should be done.

5.4.1.8 Fibrous SMAFS

In case of fibrous SMAFS, whether plication as in a Classical/Delta lift or attaching the SMAFS to the periosteum of the zygoma is carried out, results of facelifts are not so good.

5.4.1.9 SMAFS Sleep Lines Correction

SMAFS sleep lines can be corrected easily using either silk or Gore-Tex threads, using either a KH needle, or a conveniently sized Keith needle. Silk threads are suitable for persons of Asian descent or Hispanics, as in fair complexioned people, the black color of silk threads, reflects through the skin, especially, if these threads are inserted very superficially. The drawbacks of Gore-Tex threads are extrusion and infection. Other options are fat, collagen, Polymethol-Methacrylate, and Botox for these lines.

5.4.2Clinical Significance of Attachment and Regional Variations of SMAFS in Facelift Surgery

Attachment and regional variations of SMAFS are in Tables 5.3 and 5.4.

Facelift results (Classical/Delta/S-lift) are excellent, when a clear cut supraand infrazygomatic SMAFS exists [11, 12]. In open facelift surgery, Delta/S-lift/

Table 5.3 Attachment variations of SMAFS

Suprazygomatic and infrazygomatic SMAFS (usual)

Single unit (Unipolar) SMAFS

Discontinuous facial/neck SMAFS

Continuous/discontinuous suprazygomatic SMAFS

Continuous/discontinuous parotid/masseteric SMAFS

Thin and discontinuous central facial SMAFS (usual)

Thick and continuous central facial SMAFS (rare)

Table 5.4 Regional variations of SMAFS

Classical lift and others, consideration should be paid to the entire SMAFS not only the fibro-aponeurotic part. It is important to take bites, plicate, lift, and attach not only the fibro-aponeurotic part but also the superficial muscular part of SMAFS [11, 12]. Only in this way, longer lasting and durable results of facelift will be achieved. If only superficial fibro-aponeurotic part is dissected and plicated/lifted, tissue sagging will reappear months after the procedure as the superficial fibrous part that is attached to the skin via fibrous septa will keep the skin lifted and the fibro-aponeurotic part, which ensheaths and encircles the superficial mimetic muscles will keep the muscles lifted. Over several months fascia lengthening takes place and muscles of facial expression that have not been plicated, droop. At the same time, it is also important, not to go deep into the muscles, otherwise, motor nerve injury will take place.

In the subperiosteal space, attachments are 1 cm above the orbital rim. Superomedial osteoperiosteal ligament is 13 mm from the midline and superolateral osteoperiosteal ligament is 23 mm from the midline [13]. Supraorbital nerve is lateral to the ligaments. At the orbital rim, inferomedial osteoperiosteal ligament is 12.6 mm from the midline. Supraorbital nerve is lateral to it. Release of the medially based ligaments results in easier lifting of the medial aspect of the eyebrow. The three subperiosteal ligaments extend into the subgaleal level. There is a broad ligament that extends across the lateral aspect of the supraorbital rim. Release of the lateral segment of the broad ligament results in easy elevation of the lateral portion of the eyebrow. Dissection between the medial retaining ligaments in the central tunnel provides exposure for treating the medial corrugator and procerus muscles in the glabellar area. The zygomatic ligament (McGregor’s Patch) originates at or near the inferior border of the anterior zygomatic arch, and inserts into the skin [13]. The mandibular ligaments (Furnas Ligaments)

originate from bone of mandible about 1 cm above the mandibular border [13]. It restrains anterior skin, preventing gravitational sagging. The platysma-auricular ligament is a condensation of the posterior border of platysma, often attached to the overlying skin [13]. Anterior-Platysma cutaneous ligaments are attachments of the anterior platysma to skin of the middle and anterior cheek [13]. These ligaments are closely associated with nearby vessels and facial nerve branches.

Results are better in case of single unit SMAFS, where no division exists. However, in these cases, if entire upper and lower SMAFS is not lifted, and only lower SMAFS is lifted like in Delta or S-lift, the upper sagging of SMAFS will become considerable, resulting in patient dissatisfaction. Plication of the condensed superficial parotid fascia and parotid fascia or attaching these fascias to the periosteum of zygomatic arch along with section of the platysma-auricular ligaments should be the aim in the lateral cheek area while performing facelift surgery. The authors do not recommend the subparotid fascia (masseteric fascia) plane for facelifting, going under the platysma muscle. The parotid gland is covered on its superior surface by the parotid fascia, which is a fibrotic degeneration of the primitive platysma muscle and is in direct continuity with platysma, risorius, and depressor anguli oris muscles. In the space between the parotid and masseteric fascia planes lie not only the parotid gland, but also Stenson’s duct and emerging branches of the facial nerve; therefore, facial nerve injury can take place and parotid fistula can form if the surgeon works close to the masseteric fascia. When the SMAFS is thin and discontinuous, as in the central face, results of facelift are limiting here, for example, for the nasolabial folds, silk or Gore-Tex threads or other fillers like PMMA have to be used like in a Delta-lift to provide good results. However, rarely, when the SMAFS is continuous and thick in the central face, SMAFS plication results in obvious obliteration of nasolabial folds and fillers are not required in these cases. When the SMAFS is discontinuous or broken (Island SMAS) suprazygomatically, infrazygomatically, or in the neck, restoring continuity of SMAFS, rather than lifting should be the primary aim. When continuity of SMAFS has been restored, lifting should be planned at a subsequent stage, especially if gaps in SMAFS are more. The only exception to this rule is the central face, where discontinuous SMAFS is usual, and obliteration of nasolabial folds should be done with fillers, rather than achieving

SMAFS continuity, otherwise, dissection will become very extensive, and branches of the facial nerve can get damaged, as the SMAFS is extremely thin here. Regional variations of SMAFS have an impact on the results of facelift surgery. However, generally, the surgeon should follow the general guidelines while dealing with regional SMAFS variations. The very fatty SMAFS assessed preoperatively should be defatted using suction machine and closed liposuction, using either a keel-cobra tip or a flat spatula cannula, in those regions. In cases of mild to moderately fatty SMAFS, defatting should be done using suction machine and a flat spatula cannula with an open vacuum cleaner technique. Deeper bites of SMAFS should be taken in case of fleshy SMAFS, more bites of SMAFS should be taken in case of membranous SMAFS, and continuity should be restored in case of Island (broken) SMAFS, in the SMAFS regions, where these variations are encountered; in all cases, including also thick, fibrous, flaccid and mixed.

Varieties, lifting and attaching either to the periosteum of zygomatic arch or plication should be considered, according to the skill and experience of the surgeon, and according to the type of SMAFS.

5.4.3Importance of SMAFS Variations in Transcutaneous Facelifts, MiniInvasive Lifts, and Thread Lifts

Transcutaneous facelift and thread lifts are blind procedures, where SMAFS assessment has to be done preoperatively and externally. Pinch test (lifting the SMAFS with the thumb and index finger) should be carried out over the face, neck, and temporal regions. Thickness, thinness, tone, density, elasticity, flaccidity, continuity, and other gross parameters should be assessed. In transcutaneous facelifting, where the SMAFS is thin and membranous, superficial SMAFS bites using the KH needle or a Keith needle, and two to three sutures for lifting and attaching the SMAFS to the thick temporal fascia or periosteum of the temporal bone provide a stable lift [14]. Where the SMAFS is thick, fatty, or fleshy, relatively deeper and more SMAFS bites should be taken, more lift should be provided and attachment should be to the periosteum of the temporal bone. Since there is discontinuity between the supraand infrazygomatic SMAFS mostly, lifting