This document discusses different surgical approaches for facelifts, including determining which procedure is best based on a patient's needs and characteristics. It describes S-lifts, minitucks, and three-layer facelifts, indicating which options are suitable for mild, moderate, or severe laxity. The document also provides details on anatomical structures like the SMAS layer and platysma muscle, and the appropriate surgical planes for different areas of the face and neck to achieve optimal lifting results.

1. A Systematic ApproachA Systematic Approach
to Faceliftsto Facelifts
When to do a facelift, minituckWhen to do a facelift, minituck
or a S-liftor a S-lift

2. M. Sean Freeman, MDM. Sean Freeman, MD
The Center For FacialThe Center For Facial
Plastic andPlastic and
Laser SurgeryLaser Surgery
Fall Meeting, AAFPRSFall Meeting, AAFPRS

3. RhytidectomyRhytidectomy
How to determine approach offered to patientHow to determine approach offered to patient
– OptionsOptions
S-lift (thread lift), minituck (with deep plane lift of jowlS-lift (thread lift), minituck (with deep plane lift of jowl
area), three layer facelift (also called composite lift –area), three layer facelift (also called composite lift –
deep plane lift), three layer facelift with SMG shavedeep plane lift), three layer facelift with SMG shave

5. RhytidectomyRhytidectomy
Three layer facelift (with or without SMGThree layer facelift (with or without SMG
shave)shave)
– Patient with one or more of these findings in thePatient with one or more of these findings in the
neckneck
Excess fatExcess fat
Significant skin excessSignificant skin excess
Platysmal banding or inferior laxityPlatysmal banding or inferior laxity
Ptosis of SMGPtosis of SMG

8. RhytidectomyRhytidectomy
Minituck (with deep plane lift of jowl area)Minituck (with deep plane lift of jowl area)
– Applicable to a patient with one or more of theApplicable to a patient with one or more of the
followingfollowing
Minimal to moderate neck laxity involving mainly skinMinimal to moderate neck laxity involving mainly skin
Moderate to severe laxity of the jowlModerate to severe laxity of the jowl
Mid-face ptosisMid-face ptosis
Extended melolabial foldsExtended melolabial folds

11. RhytidectomyRhytidectomy
S-liftS-lift
– Useful in a patient with one or more of theUseful in a patient with one or more of the
following findingsfollowing findings
Mild jowlingMild jowling
Mild neck laxityMild neck laxity
– Does not help mid-face laxityDoes not help mid-face laxity
Consider a thread liftConsider a thread lift

13. RhytidectomyRhytidectomy
Now that we have an appreciation for theNow that we have an appreciation for the
why of these approaches let’s look into thewhy of these approaches let’s look into the
howhow
– Three layer facelift (with or without SMG shave)Three layer facelift (with or without SMG shave)
– MinituckMinituck
– S-liftS-lift

14. RhytidectomyRhytidectomy
What is the correct plane for the midface andWhat is the correct plane for the midface and
jowl?jowl?
– Wide subcutaneous with SMAS plicationWide subcutaneous with SMAS plication
– Wide subcutaneous followed by SMAS dissectionWide subcutaneous followed by SMAS dissection
– Limited subcutaneous dissection along with sub-Limited subcutaneous dissection along with sub-
SMAS dissection into the midface, jowl andSMAS dissection into the midface, jowl and
connected to sub-platysmal flapconnected to sub-platysmal flap
– SubperiostealSubperiosteal

15. RhytidectomyRhytidectomy
Wide subcutaneous undermining for midfaceWide subcutaneous undermining for midface
and jowland jowl
– Useful in patients whose primary concern isUseful in patients whose primary concern is
improvement in their acne scarringimprovement in their acne scarring
Breaks the fibrous connection between the base of theBreaks the fibrous connection between the base of the
acne scar and the SMASacne scar and the SMAS
– Depressed scars are improvedDepressed scars are improved
This procedure should be followed by skin resurfacingThis procedure should be followed by skin resurfacing
two to three months latertwo to three months later

16. RhytidectomyRhytidectomy
SMAS for midface and jowlsSMAS for midface and jowls
– System connects to the superficial temporal fascia,System connects to the superficial temporal fascia,
galea, frontalis muscle, superficial cervical fasciagalea, frontalis muscle, superficial cervical fascia
and the platysmaand the platysma
– System invests the superficial muscles of facialSystem invests the superficial muscles of facial
expressionexpression
platysma, orbicularis oculi, zygomaticus major andplatysma, orbicularis oculi, zygomaticus major and
minor and risoriusminor and risorius

18. RhytidectomyRhytidectomy
SMAS for midface and jowlsSMAS for midface and jowls
– System connects to the superficial temporal fascia,System connects to the superficial temporal fascia,
galea, frontalis muscle, superficial cervical fasciagalea, frontalis muscle, superficial cervical fascia
and the platysmaand the platysma
– System invests the superficial muscles of facialSystem invests the superficial muscles of facial
expressionexpression
platysma, orbicularis oculi, zygomaticus major andplatysma, orbicularis oculi, zygomaticus major and
minor and risoriusminor and risorius

20. RhytidectomyRhytidectomy
SMAS connections pertinent to rhytidectomySMAS connections pertinent to rhytidectomy
– Fascial fiber connections between the superficial muscles ofFascial fiber connections between the superficial muscles of
facial expression and the nasolabial foldfacial expression and the nasolabial fold
– Retaining ligaments: anchoring points from the underlyingRetaining ligaments: anchoring points from the underlying
bone to the dermisbone to the dermis
Zygomatic ligamentsZygomatic ligaments
mandibular ligamentsmandibular ligaments
– Fibrous septa connecting the parotid-masseteric fascia,Fibrous septa connecting the parotid-masseteric fascia,
SMAS and the dermis in the parotid and the anteriorSMAS and the dermis in the parotid and the anterior
border of the masseterborder of the masseter

21. RhytidectomyRhytidectomy
SMAS connections pertinent to rhytidectomySMAS connections pertinent to rhytidectomy
– Fascial fiber connections between the superficialFascial fiber connections between the superficial
muscles of facial expression and the nasolabial foldmuscles of facial expression and the nasolabial fold
– Retaining ligaments: anchoring points from theRetaining ligaments: anchoring points from the
underlying bone to the dermisunderlying bone to the dermis
zygomatic ligamentszygomatic ligaments
mandibular ligamentsmandibular ligaments
– Fibrous septa connecting the parotid-massetericFibrous septa connecting the parotid-masseteric
fascia, SMAS and the dermis in the parotid and thefascia, SMAS and the dermis in the parotid and the
anterior border of the masseteranterior border of the masseter

22. RhytidectomyRhytidectomy
SMAS connections pertinent to rhytidectomySMAS connections pertinent to rhytidectomy
– Fascial fiber connections between the superficialFascial fiber connections between the superficial
muscles of facial expression and the nasolabial foldmuscles of facial expression and the nasolabial fold
– Retaining ligaments: anchoring points from theRetaining ligaments: anchoring points from the
underlying bone to the dermisunderlying bone to the dermis
– Fibrous septa connecting the parotid-massetericFibrous septa connecting the parotid-masseteric
fascia, SMAS and the dermis in the parotidfascia, SMAS and the dermis in the parotid
(parotid cutaneous ligament) and the anterior(parotid cutaneous ligament) and the anterior
border of the masseter (masseteric cutaneousborder of the masseter (masseteric cutaneous
ligament)ligament)

24. RhytidectomyRhytidectomy
Importance of SMAS in relation to agingImportance of SMAS in relation to aging
– Fascial fiber connections between the superficialFascial fiber connections between the superficial
muscles of facial expression, the SMAS and themuscles of facial expression, the SMAS and the
dermis at the level of the nasolabial fold trap thedermis at the level of the nasolabial fold trap the
migration of the malar fat pad over time thusmigration of the malar fat pad over time thus
deepening this folddeepening this fold
– Over time, midface fibro-fatty tissue is displacedOver time, midface fibro-fatty tissue is displaced
above the level of the SMAS and then trapped byabove the level of the SMAS and then trapped by
the SMAS connections at the nasolabial foldthe SMAS connections at the nasolabial fold

26. RhytidectomyRhytidectomy
Importance of SMAS in relation to agingImportance of SMAS in relation to aging
– Jowling is caused by relaxation of the parotid-Jowling is caused by relaxation of the parotid-
masseteric fascia with prolapse of the fat pad ofmasseteric fascia with prolapse of the fat pad of
BichatBichat
SMAS is relatively thin over this areaSMAS is relatively thin over this area
– Jowling is caused by redundant skin which isJowling is caused by redundant skin which is
bounded by the mandibular ligament at its medialbounded by the mandibular ligament at its medial
borderborder

28. RhytidectomyRhytidectomy
Importance of SMAS in relation to agingImportance of SMAS in relation to aging
– Jowling is caused by relaxation of the parotid-Jowling is caused by relaxation of the parotid-
masseteric fascia with prolapse of the fat pad ofmasseteric fascia with prolapse of the fat pad of
BichatBichat
SMAS is relatively thin over this areaSMAS is relatively thin over this area
– Jowling is caused by redundant skin which isJowling is caused by redundant skin which is
bounded by the mandibular ligament at its medialbounded by the mandibular ligament at its medial
borderborder

30. RhytidectomyRhytidectomy
Subperiosteal approach for the midfaceSubperiosteal approach for the midface
– The periosteum does not relax with timeThe periosteum does not relax with time
– Pulling up on the periosteum in the midface liftsPulling up on the periosteum in the midface lifts
the superficial muscles of facial expression whichthe superficial muscles of facial expression which
will result in pulling in the fascial fiber connectionswill result in pulling in the fascial fiber connections
between these muscles and the nasolabial foldbetween these muscles and the nasolabial fold
Net effect on the depth of the fold is negligibleNet effect on the depth of the fold is negligible

31. RhytidectomyRhytidectomy
Subperiosteal approach for the jowl and neckSubperiosteal approach for the jowl and neck
laxitylaxity
– Jowl area can be improved if the fat pad of BichatJowl area can be improved if the fat pad of Bichat
is elevated by suture suspending the pad to theis elevated by suture suspending the pad to the
intermediate fascia over the deep temporal fasciaintermediate fascia over the deep temporal fascia
– Minimal to no improvement in the neck area unlessMinimal to no improvement in the neck area unless
a posterior neck lift is added to the procedurea posterior neck lift is added to the procedure

32. RhytidectomyRhytidectomy
What is the best plane in the midface?What is the best plane in the midface?
– Between the investing SMAS of the superficialBetween the investing SMAS of the superficial
muscles of facial expression and the overlyingmuscles of facial expression and the overlying
malar fat padmalar fat pad
Allows repositioning of the malar fat padAllows repositioning of the malar fat pad
– Zygomatic-cutaneous ligaments must be released to get a goodZygomatic-cutaneous ligaments must be released to get a good
liftlift
Allows lifting of the zygomaticus major muscle toAllows lifting of the zygomaticus major muscle to
improve a down turned corner of the mouthimprove a down turned corner of the mouth
– Care must be taken to avoid injury to the underlying buccalCare must be taken to avoid injury to the underlying buccal
nerve branchesnerve branches

33. Endoscopic view of head of
zygomaticus major
Endoscopic view showing division
of zygomatic-cutaneous ligament

38. RhytidectomyRhytidectomy
What is the best plane for improving the jowl area?What is the best plane for improving the jowl area?
– Splitting the parotid-masseteric fascia with division of theSplitting the parotid-masseteric fascia with division of the
masseteric cutaneous ligamentsmasseteric cutaneous ligaments
Allows tightening of this area without pulling on the corner of theAllows tightening of this area without pulling on the corner of the
mouth while putting tension on the parotid-masseteric fascia ofmouth while putting tension on the parotid-masseteric fascia of
sufficient amount to reduce the prolapsed fat pad of Bichatsufficient amount to reduce the prolapsed fat pad of Bichat
– At times fat must be removed via an intraoral approachAt times fat must be removed via an intraoral approach
Care must be taken to avoid injury to the facial nerve branchesCare must be taken to avoid injury to the facial nerve branches
over the masseter muscleover the masseter muscle

47. RhytidectomyRhytidectomy
What is the correct plane for the neck?What is the correct plane for the neck?
– SubcutaneousSubcutaneous
– Subcutaneous then beneath the platysmaSubcutaneous then beneath the platysma
– Subcutaneous and beneath the platysmaSubcutaneous and beneath the platysma

48. RhytidectomyRhytidectomy
What should be done with the platysma?What should be done with the platysma?
– Divide horizontally along its inferior borderDivide horizontally along its inferior border
– Pull the lateral borderPull the lateral border
– Suture the medial borderSuture the medial border
– A combination of aboveA combination of above

49. RhytidectomyRhytidectomy
Approach to the neckApproach to the neck
– Wide subcutaneous underminingWide subcutaneous undermining
Sharp lipectomy performed when indicatedSharp lipectomy performed when indicated
– Limited dissection of medial and lateral borders ofLimited dissection of medial and lateral borders of
platysmaplatysma
– Suture suspension of lateral border toSuture suspension of lateral border to
occipitomastoid fascia along break point of neckoccipitomastoid fascia along break point of neck

50. RhytidectomyRhytidectomy
Approach to the neckApproach to the neck
– Wide subcutaneous underminingWide subcutaneous undermining
Sharp lipectomy performed when indicatedSharp lipectomy performed when indicated
– Limited dissection of medial and lateral borders ofLimited dissection of medial and lateral borders of
platysmaplatysma
– Suture suspension of lateral border toSuture suspension of lateral border to
occipitomastoid fascia along break point of neckoccipitomastoid fascia along break point of neck

52. RhytidectomyRhytidectomy
Approach to the neckApproach to the neck
– Wide subcutaneous underminingWide subcutaneous undermining
Sharp lipectomy performed when indicatedSharp lipectomy performed when indicated
– Limited dissection of medial and lateral borders ofLimited dissection of medial and lateral borders of
platysmaplatysma
– Suture suspension of lateral border toSuture suspension of lateral border to
occipitomastoid fascia along break point of neckoccipitomastoid fascia along break point of neck
Mark break point at beginning of the case with patientMark break point at beginning of the case with patient
in the sitting positionin the sitting position

60. RhytidectomyRhytidectomy
Approach to the neckApproach to the neck
– Following sharp fat lipectomy, the medial borderFollowing sharp fat lipectomy, the medial border
of the platysma is drawn togetherof the platysma is drawn together
For patients with a short neck and small chin who agreeFor patients with a short neck and small chin who agree
to a chin implant the platysma is released from the hyoidto a chin implant the platysma is released from the hyoid
and the medial edges are plicatedand the medial edges are plicated
Patients who have banding of the platysma, their bandsPatients who have banding of the platysma, their bands
are excised and then the platysma is released from theare excised and then the platysma is released from the
hyoid and the medial edges are plicatedhyoid and the medial edges are plicated

61. RhytidectomyRhytidectomy
Approach to the neckApproach to the neck
– Following sharp fat lipectomy, the medial borderFollowing sharp fat lipectomy, the medial border
of the platysma is drawn togetherof the platysma is drawn together
For patients with a short neck and small chin who agreeFor patients with a short neck and small chin who agree
to a chin implant the platysma is released from the hyoidto a chin implant the platysma is released from the hyoid
and the medial edges are plicatedand the medial edges are plicated
Patients who have banding of the platysma, their bandsPatients who have banding of the platysma, their bands
are excised and then the platysma is released from theare excised and then the platysma is released from the
hyoid and the medial edges are plicatedhyoid and the medial edges are plicated

62. RhytidectomyRhytidectomy
Approach to the neckApproach to the neck
– Following sharp fat lipectomy, the medial borderFollowing sharp fat lipectomy, the medial border
of the platysma is drawn togetherof the platysma is drawn together
For patients with a short neck and small chin who agreeFor patients with a short neck and small chin who agree
to a chin implant the platysma is released from the hyoidto a chin implant the platysma is released from the hyoid
and the medial edges are plicatedand the medial edges are plicated
Patients who have banding of the platysma, their bandsPatients who have banding of the platysma, their bands
are excised and then the platysma is released from theare excised and then the platysma is released from the
hyoid and the medial edges are plicatedhyoid and the medial edges are plicated

63. RhytidectomyRhytidectomy
There isThere is notnot one correct plane for all three areas ofone correct plane for all three areas of
the facethe face
– On top of SMAS investing the superficial muscles of facialOn top of SMAS investing the superficial muscles of facial
expression for the midfaceexpression for the midface
– Deep to the SMAS, elevating and splitting the parotid-Deep to the SMAS, elevating and splitting the parotid-
masseteric fascia so as to elevate the fat pad of Bichatmasseteric fascia so as to elevate the fat pad of Bichat
– Both on top and deep to the platysma to independentlyBoth on top and deep to the platysma to independently
tighten the platysma, like a hammock for the neck, andtighten the platysma, like a hammock for the neck, and
then the skin on topthen the skin on top

64. RhytidectomyRhytidectomy
There isThere is notnot one correct plane for all three areas ofone correct plane for all three areas of
the facethe face
– On top of SMAS investing the superficial muscles of facialOn top of SMAS investing the superficial muscles of facial
expression for the midfaceexpression for the midface
– Deep to the SMAS, elevating and splitting the parotid-Deep to the SMAS, elevating and splitting the parotid-
masseteric fascia so as to elevate the fat pad of Bichatmasseteric fascia so as to elevate the fat pad of Bichat
– Both on top and deep to the platysma to independentlyBoth on top and deep to the platysma to independently
tighten the platysma, like a hammock for the neck, andtighten the platysma, like a hammock for the neck, and
then the skin on topthen the skin on top

65. RhytidectomyRhytidectomy
There isThere is notnot one correct plane for all three areas ofone correct plane for all three areas of
the facethe face
– On top of SMAS investing the superficial muscles of facialOn top of SMAS investing the superficial muscles of facial
expression for the midfaceexpression for the midface
– Deep to the SMAS, elevating and splitting the parotid-Deep to the SMAS, elevating and splitting the parotid-
masseteric fascia so as to elevate the fat pad of Bichatmasseteric fascia so as to elevate the fat pad of Bichat
– Both on top and deep to the platysma to independentlyBoth on top and deep to the platysma to independently
tighten the platysma, like a hammock for the neck, andtighten the platysma, like a hammock for the neck, and
then the skin on topthen the skin on top

66. RhytidectomyRhytidectomy
There isThere is notnot one correct plane for all three areas ofone correct plane for all three areas of
the facethe face
– On top of SMAS investing the superficial muscles of facialOn top of SMAS investing the superficial muscles of facial
expression for the midfaceexpression for the midface
– Deep to the SMAS, elevating and splitting the parotid-Deep to the SMAS, elevating and splitting the parotid-
masseteric fascia so as to elevate the fat pad of Bichatmasseteric fascia so as to elevate the fat pad of Bichat
– Both on top and deep to the platysma to independentlyBoth on top and deep to the platysma to independently
tighten the platysma, like a hammock for the neck, andtighten the platysma, like a hammock for the neck, and
then the skin on topthen the skin on top

67. Management of SMG PtosisManagement of SMG Ptosis
ProblemProblem
– Patient wishes improvement in neck line butPatient wishes improvement in neck line but
facial cosmetic surgeon notes soft tissue fullnessfacial cosmetic surgeon notes soft tissue fullness
in the digastric triangle of neck due to SMGin the digastric triangle of neck due to SMG
ptosisptosis

68. Management of SMG PtosisManagement of SMG Ptosis
In the past standard procedures have failedIn the past standard procedures have failed
to address this problem adequatelyto address this problem adequately

69. Management of SMG PtosisManagement of SMG Ptosis
SolutionSolution
– Caudal resection a portion of the SMG via aCaudal resection a portion of the SMG via a
submental incisionsubmental incision
Important considerationsImportant considerations
– RisksRisks
Knowledge of pertinent anatomyKnowledge of pertinent anatomy
SeromaSeroma
– Patient selectionPatient selection
Commonly seen in patients with a small chinCommonly seen in patients with a small chin

70. Management of SMG PtosisManagement of SMG Ptosis
Pertinent anatomy of digastric trianglePertinent anatomy of digastric triangle
– Boundaries: the two bellies of digastric, the lowerBoundaries: the two bellies of digastric, the lower
border of the mandibleborder of the mandible
– Floor: mylohyoid, hypoglossal, middle constrictorFloor: mylohyoid, hypoglossal, middle constrictor
– Ceiling: platysma, marginal mandibular nerveCeiling: platysma, marginal mandibular nerve
– Contents: SMG gland, facial artery and vein andContents: SMG gland, facial artery and vein and
hypoglossal nervehypoglossal nerve

71. 4
Parotid gland
External jugular vein
SMG
Anterior jugular vein
View with platysma removed
Facial artery
Facial vein
Marginal mandibular nerveSMG

72. Anatomy with SMG removed
Mandible
Anterior and posterior digastric
Hyoid
Digastric,
anterior
belly
Facial artery
Facial vein
Marginal mandibular nerve
SMG

74. MinituckMinituck
MinituckMinituck
– Same steps as regular facelift in mid-face andSame steps as regular facelift in mid-face and
jowl areajowl area
– Lift lateral Platysma onlyLift lateral Platysma only

79. S-liftS-lift
Limited incision around earLimited incision around ear
Estimation of amount of excess skin that canEstimation of amount of excess skin that can
be removedbe removed
Corresponding SMAS excision and lifting ofCorresponding SMAS excision and lifting of
SMASSMAS
Two layer closureTwo layer closure