the SMAFS infrazygomatically, and making Prolene 2/0 knots in the suprazygomatic SMAFS (thick temporal fascia) provides a stable lift in most of the cases. However, in cases of unipolar SMAFS (continuous supraand infrazygomatic SMAFS), this attachment will result in certain sagging after a while, and the results of facelift will become poor. In these cases, attachment should be deep to the periosteum of temporal bone. If you are suspecting Island SMAFS on preoperative examination, TCFL can result in asymmetry of face. In these cases, restoring continuity of SMAFS, and mild/moderate lifting should be carried out via open technique and subsequent lift should be planned if considerable lift is required. The SMAS-Platysma facelift also aims at attaching the SMAS to the periosteum of mastoid bone, providing a stable lift [15].

A variety of thread lift procedures have also been advised to provide stability to the SMAFS; some use a feathering technique like the Sulamanidze threads for providing micro-stability and lift [16]; others aim at placing threads in the SMAFS providing a sort of micro-volume augmentation. Fournier [17] has developed a technique of cementing the threads with fat in the cheek areas, providing volume augmentation to SMAFS in the cheek areas. In any case, threads provide a very mild lift/stability to the SMAFS. The subperiosteal facelift of Hamra [18] was an intense procedure where undermining was carried deep to the SMAFS to the periosteum. It has been abandoned by most of the surgeons as a result of increased morbidity/ complications. The argument was that in going deep to the bone and lifting the results were longer lasting. Some physicians are still using a somewhat modified technique for lifting the SMAFS, for example, for eyebrow lift, cheek lift, chin lift using blunt needles, going deep to the periosteum of bone and then coming back to the same point superficially taking SMAFS and dermis, using absorbable sutures. However, we believe that while performing these blind procedures, anatomical landmarks like the motor branches of facial nerve, should be taken into consideration to prevent motor nerve injury [19]. These procedures should only be performed by experienced surgeons and anatomical landmarks should be marked beforehand prior to needle insertion. In case of TCFL, and other suspension lifts, needle bites should be taken from the superficial muscular component of SMAFS, in order to provide a stable lift. In case of thread lifts, threads should be

inserted into the superficial muscular component. The spikes of threads will go into the muscle fibers, thereby providing micro-lift. If the threads without spikes are used, whether they are inserted into the superficial muscular component, or into the fibro-aponeurotic component, threads will only provide a sort of volume augmentation in these cases.

5.5 Conclusions

The type, nature, and variations of SMAFS have an impact on the outcome of facelift surgery. Therefore, it is important for all surgeons performing facelift surgery to understand in detail the various types of SMAFS and their variations. They should be able to assess gross parameters of SMAFS by external manipulation and SMAFS examination and should be able to analyze various types of SMAFS preoperatively. They should be able to plan the correct operative technique of debulking, plicating, lifting, and attaching the SMAFS to the bony periosteum according to the nature and type of SMAFS present in order to achieve good results. Surgeons must undergo training programs from experienced rhytidectomists, before performing facelift surgery independently.

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