facelift

1. Facelift

2. Surgical anatomy of the face
5 layers of the face are
◦ (1) skin
◦ (2) subcutaneous tissue
◦ (3) musculo-aponeurotic layer (SMAS)
◦ (4) loose areola tissue
◦ (5) deep fascia

6. Lateral and anterior component based on
function (lateral face is relatively immobile)

7. To secure these five layers to
the facial skeleton, an
elaborate system of retaining
ligaments bind the dermis to
the skeleton (or deep fascia
where the facial skeleton is
covered by skeletal muscles
for mastication); the
components of this system
pass through all layers.

9. Layer 3 – musculo-aponeurotic layer
All muscles of facial expression have either all or the majority of their course within layer 3
Layer 3 is continuous over the entire face
◦ galea over the scalp
◦ temporoparietal (superficial temporal) fascia over the temple
◦ orbicularis fascia in the periorbital region
◦ SMAS over the mid- and lower face
◦ platysma in the neck.

10. Layer 4
Contains the following structures:
◦ (1) soft-tissue spaces
◦ (2) retaining ligaments
◦ (3) deep part of the intrinsic muscles where passing from their bone attachment to their more superficial
soft-tissue origin
◦ (4) facial nerve branches, passing from deep to superficial
Functionally, a series of soft-tissue spaces exist in layer 4 to allow independent movement of the
periorbital and perioral muscle of facial expressions over the deep fascia on the major muscles for
mastication directly beneath.

11. Platysma auricular fascia (PAF).
As no facial expression occurs here, the
dermis, subcutaneous tissue, SMAS, and the
underlying parotid capsule (layers 1–5) are
bound together as an area of diffuse retaining
ligament.
Layer 4 here is reduced to a layer of fusion
without a soft-tissue space, as mobility of the
superficial fascia is not required here.

12. The system of retaining ligaments situated
around the bony cavities

13. Facial spaces
SubSMAS layer 4 consists of soft-tissue “spaces”.
Defined boundaries by retaining ligamnts.
As the roof of each space is the least supported part, they are more prone to developing laxity here
with aging, compared to their ligament-reinforced boundaries.
This differential laxity accounts for much of the characteristic changes that occur with aging.

15. Prezygomatic space
Triangular-shaped space over the body of the zygoma
Allows the independent displacement of the orbicularis oculi (pars orbitale) in its roof from the
zygomatic muscles under the floor.
Contraction of the overlying orbicularis elevates the prezygomatic soft tissues, which results in
zygomatic smile lines (below the crows feet) (Fig. 6.1.10).
With aging laxity, the roof of the space rests at a lower level. As a result, there is a now a greater
amplitude of movement on orbicularis contraction, which exaggerates the zygomatic lines with
aging.
This aging of the prezygomatic space, with bulging over its roof accentuated by its wellsupported
boundaries, is the anatomical basis for the clinical entity variously described as malar mounds,
bags, or malar crescent.

16. Premaxillary space
This quadrangular space overlies the maxilla.
Its floor is formed by the levator labii superioris.
The space allows the independent displacement of the
obicularis oculi in its roof from the lip elevators under
the floor. Fig. 6.1.11
This space is clinically significant in that laxity over its
roof contributes to the deepening of the nasolabial fold
with aging.

17. Lower premasseter space
Overlies the lower half of the masseter .
Roof is formed by the platysma.
Anatomical basis for the development of jowls with aging.
Laxity in the roof of the space, particularly where it has a weakened attachment to the anterior
masseter by the masseteric ligaments and its inferior boundary where there is no ligament,
manifests as the labiomandibular fold and jowl, respectively.
Fixation by the mandibular ligament - dimple that is commonly seen separating the labimandibular
fold above and the jowl below.

18. Middle premasseter space
Rectangular space.
Its floor is formed by the masseteric fascia and its roof by the SMAS
It is an important facial soft-tissue space in subSMAS facelift as it is an anatomical safe area to
dissect, with the facial nerve branches located immediately outside the space within its superior
and inferior boundaries.
The parotid gland and the duct are closely associated with the upper boundary of the middle
premasseter space.

19. Buccal space
Deep to the deep fascia (layer 5).
Medial to the anterior border of the masseter
Aging and attrition of the boundaries, particularly of the masseteric ligaments inferiorly, result in
the platysma being less firmly bound to the masseter.
This allows the space to enlarge, as a consequence of which the buccal fat prolapses inferiorly,
below the level of the oral commissure into the lower face.
As the buccal fat comes to overlie the anterior border of the lower masseter, it results in increased
prominence of the labiomandibular fold and jowl.

20. Facial nerve branches
Important to
(1) Have an understanding of the three-dimensional course of the nerve relative to the layered
anatomy as described above
(2) by visually identifying the nerves in relation to defined landmarks.
The facial nerve branches exit the parotid gland and remain deep to layer 5 in the lateral face.

21. As they approach the anterior face, the branches traverse layer 4, ascending to reach the underside
of the mimetic muscles of the face.
It is at these transition points across layer 4 that the nerves are at greatest risk of injury.
The transitions occur at predictable locations, in close association with retaining ligaments that
provide stability and protection for the nerves.
The surgical release of these ligaments to gain the needed mobility should be performed with
extreme care on account of the proximity of the nerves.

22. Aging changes of the face
Youthful face has the general appearance of high, rounded fullness
Aging process is characterized by a look of depletion and sagging, suggestive of tiredness.
Changes of the skin are readily observable
Changes in the skeleton affecting layer 5 can be observed radiologically.
Bulging occurs over the roof of soft-tissue spaces
Absence of bulging of the adjacent cutaneous grooves - reflect the restriction imposed by the
dermal insertions of the retaining ligaments

25. Facial spaces and retaining ligaments
Attenuates with aging, decreasing strength of the ligaments, and increasing laxity.
Spaces expand with aging in proportion to the amount of movement.
Greatest with the lower premasseter space and the related mandibular movement
Least over the zygoma.

27. Bone changes
Changes dramatically with aging.
Profound impact on the appearance.
Areas with strong predisposition to resorption include
◦ midface skeleton, particularly that part contributed by the maxilla including the pyriform area of
the nose
◦ the superomedial and inferolateral aspects of the orbital rim
◦ the prejowl area of the mandible.
Retrusion of the maxilla causes increased prominence of the tear trough and the nasolabial folds.

29. Facelift
With age the soft tissues of the face descent down.
The technique of lifting up of the soft tissues of the face with repositioning of fat to give a
younger look and a more functional face is called as facelift.
First done by Dr.Erich Lexer in 1906
Popularised by Dr.Eugen Hollander in 1912
Same technique was continued for more than half a century
This technique consisted of only skin lift with excision of sagging skin around the face

30. The technique of skin pull was not long lasting and also had poor appearance.
Dr.Tord Skoog in 1973 showed the importance of muscle pull and not the skin.
Dr.Valdimir Mitz and Dr.Martine Peyronie described the Superficial Musculo-aponeurotic
system(SMAS)
Various techniques developed by manipulating,pulling, excising SMAS but still lacking
was the correction of nasolalbial fold due to the zygomatic and masseteric retaining
ligaments.
Then developed the technique of sub-SMAS and sub-periosteal dissection.

31. Dissection planes
The subcutaneous plane of dissection (level 2) is the most commonly used plane in facelifts, either
in isolation or more commonly with some form of SMAS management from the superficial aspect.
Safe - remains superficial to the facial nerve branches at all times (main appeal).
The subcutaneous dissection can be performed either in the superficial subcutaneous or deep
subcutaneous level.

33. SubSMAS dissection (level 4)
Potentially the most risky plane to dissect because of the facial nerve branches that transition
through this level from level 5 to supply the facial muscles in level 3.
Raising the flap at level 4 gives a robust and structurally integrated composite flap that can be
effectively tightened
Dissection can be performed safely in level 4 by applying the understanding of the three-
dimensional anatomy, the key being the facial spaces

34. Various incisions

36. Various techniques
Subcutaneous Face Lift
◦ the lift may vary from a skin pinch to wide undermining that permits flap elevation and
repositioning in a single vector.
◦ due to skin tension during closure the face appears tightly pulled

37. Subcutaneous Face Lift with SMAS
Manipulation
The S-lift and minimal access cranial suspension rely on purse-string suture lifting of the
neck, jowl, and/or midface.
Variety of SMAS plication techniques
Nerve ligature can lead to neuropraxia.

38. Lateral SMASectomy
The removal of a strip of SMAS, 2 to 4 cm in width , parallel to nasolabial fold, along a
trajectory toward the lateral canthus and overlying the anterior portion of parotid gland.

39. SMAS Flap: Extended and High
Dual plane approaches incorporating both a subcutaneous and a SMAS flap
Malar fat pad elevation after detachment of the malar fat pad from upper lip elevators.

40. Deep plane, composite and Subperiosteal
Face Lifting
Deep plane lifting of the skin, subcutaneous tissue, and SMAS as a single flap was
established by Tord Skoog in 1974.
Advantage of mobilising nasolabial fold, more natural looking and longer lasting
rejuvenation
More chances of facial nerve injury
Subperiosteal approaches are enhanced through the use of endoscopic instrumentation.
The technique offers avoidance of facial nerve branches , but offers little improvement in
neck contour and has little to no effect on facial skin.

43. Complications
1. Hematoma- can be prevented by BP control, Fibrin glue, Quilting sutures, Tumescent
infiltration.
2. Facial nerve injury, m/c Buccal branch
3. Facial edema and ecchymosis
4. Pixie Ear deformity
5. Skin flap necrosis
6. Parotid fistula

44. Thank you