Facial aging is consistently reported in the literature to be influenced by the four major facial tissue types—skin, fat, muscle, and bone. Surgery to correct facial aging was first reported over 100 years ago as excisions of discontinuous skin ellipses and subcutaneous facial muscle sectioning to smooth cheek wrinkles. ^, Yet, before World War II, the results of facial cosmetic surgery were transient and of minimal significance. Until Sam Fomon founded the organization that would eventually become the American Academy of Facial Plastic and Reconstructive Surgery, aesthetic surgeons were largely ill-regarded among the surgical community, fostering an environment of shame, secrecy, and scandal. ^,

Popular culture in the 1960s ultimately facilitated the reformation of the aesthetic surgery social paradigm. Advancements in facelift surgery techniques soon followed as surgeons recognized the limitations of the traditional subcutaneous dissection. In the mid-1970s Mitz and Peyronnie documented an expanded rhytidectomy technique by defining a sub-fascial dissection method—originally characterized by Skoog—and coined the term superficial musculoaponeurotic system (SMAS). ^, This sub-SMAS technique would pave the way to a more natural, non–operated-appearing facelift and become the basis for techniques that are still performed today.

In the 1990s, Sam Hamra drove innovations in midface aesthetic improvement with the deep plane and composite rhytidectomy, describing techniques to dissect in a plane below the SMAS of the midface. Despite taking three decades for the deep plane rhytidectomy to gain substantial popularity again, the intervening years were considered a renaissance in facelift surgery. This period saw the integration of the SMAS approach, which significantly enhanced outcomes and maintained acceptable rates of complications.

In conjunction with or independent of rhytidectomy, periorbital rejuvenation has also continued its ascent in popularity. The eyes and eyebrows convey highly nuanced emotional cues and speak the universal language of nonverbal communication.

More recently, literature emphasizing minimally invasive techniques has gained increasing popularity. Nonsurgical techniques such as botulinum toxin, fillers, and energy-based devices have dominated the media as an easy and cost-effective approach to facial rejuvenation. Choosing the correct upper face, midface, and neck procedure, whether surgical or noninvasive, is the key to ensuring the highest quality outcome for the patient. The task of the astute surgeon is to understand the patient’s priorities in the correction of facial aging while also evaluating them physically and emotionally to determine the correct treatment technique.

Rhytidectomy is most commonly indicated to correct the sagging appearance of the cheeks, deep skin creases, and excess jowling along the mandibular border. Additionally, rhytidectomy can be a powerful tool to reshape a more youthful facial appearance and address the deeper aging process associated with the neck.

It is a topic of contentious debate whether facial aging is primarily a product of gravity’s effects on the superficial soft tissues as described by Gordon, fat and soft tissue volume loss through progressive slowing of tissue regeneration, or skeletal remodeling and bone loss. In reality, a combination of each scenario presents itself in the typical candidate for upper, midface, and neck rhytidectomy and allows for the opportunity to use a multimodal treatment approach.

Perkins describes three types of rhytidectomy patients based on a patient’s degree of skin elasticity loss, jowling, lipoptosis, and platysmal laxity. This categorization isolates and grades discrete anatomic deficiencies to be addressed with rhytidectomy and functions as a basis to identify the procedures that would best achieve satisfactory, long-lasting results.

Bone volume loss is much more difficult to treat. Inward bony retrusion of the midface, resulting in loss of maxillary projection, accounts for deeper nasolabial folds and tear trough deformity. Buccal fat pseudoherniation contributing to jowl formation is worsened by the deteriorating ligamentous connections. Superior-medial bone loss of the orbital rim contributes to the deepening of glabellar lines as well as loss of fascial support, leading to upper eyelid medial fat pseudoherniation. Similarly, inferior-lateral bone retrusion of the orbital rim can cause fat pseudoherniation of the lower eyelid as well as the development of malar mounds and festoons due to limited bony support for the orbicularis oculi muscle. These issues often require autologous fat grafting, injectable fillers, alloplastic implant (chin augmentation), and/or buccal fat pad modification.

Understanding the goals of neck rejuvenation then follows the selection of appropriate surgical candidates. Ellenbogen and Karlin describe the common objective features of a youthful and attractive neck as (1) well-defined inferior mandibular border, (2) subhyoid depression, (3) visible thyroid cartilage, (4) visible anterior border of the sternocleidomastoid muscle, and (5) cervicomental angle of 105 to 120 degrees, or submental-sternocleidomastoid angle of 90 degrees. These features can similarly be thought of as the aesthetic targets for neck rejuvenation.

Although the various modifications of SMAS rhytidectomy offer excellent outcomes, our preferred approach to surgical facial rejuvenation is the sub-SMAS and sub-platysmal deep plane rhytidectomy. We often combine this technique with autologous fat grafting and deep neck platysmaplasty and subplatysmal fat modification with or without submandibular gland suspension or partial resection. This approach has provided very natural and long-lasting results in our patient population. Ultimately, the facelift technique chosen by the surgeon should be based on their comfort level with the technique and a careful balance between the patient’s present facial deformities and their individual aesthetic concerns.

Finally, a thorough assessment of the patient’s psychological status is imperative to ensuring a successful surgical outcome. A thoughtful discussion of the patient’s motivation and objectives for surgery should provide important insight into the patient’s expectations of the surgical outcome. Clear explanations of the benefits and aesthetic limitations of a face rejuvenation surgery should be given, and any unrealistic expectations such as surgery making the patient look to be in their 20s, surgery without scarring, or guaranteed results given poor tissue protoplasm should be addressed during initial consultation.

Appreciation of the nuances of a patient’s anatomy is essential when planning for successful facial rejuvenation surgery. Skin thickness, relative bone and muscle position, prior use of fillers and energy-based devices, anticipated tension vectors, and history of previous facial surgery will all have a varying, yet substantial effect on the surgical outcome. A surgeon must understand the myofascial planes and the relative position of the facial nerve as a foremost consideration in any facial surgery. Following its exit from the middle cranial fossa through the stylomastoid foramen of the temporal bone, the facial nerve traverses the parenchyma of the posterior aspect of the parotid gland. The nerve then divides into the pes anserinus, the dual branch of the facial nerve trunk. In general, the distal branches of the facial nerve (temporal, zygomatic, buccal, marginal, cervical) run deep to the SMAS and innervate the muscles of facial expression on their deep surface, except for the buccinator, levator anguli oris and mentalis muscles, which are innervated on their lateral edge or superficial surface. With these factors in mind, several surgical landmarks and danger zones have been established to allow the surgeon to proceed with facial rejuvenation safely.

Many of the described surgical landmarks allow for consistent recognition of the location of the facial nerve. Pitanguy’s line illustrates an imaginary point originating 0.5 cm below the tragus to 1.5 cm superior and lateral to the eyebrow. This line is used to identify the course of the frontal branch of the facial nerve as it travels between the temporalis muscle fascia deeply and the temporoparietal fascia superficially. Zuker’s point lies at the midpoint of a line drawn between the root of the helix and the oral commissure, approximating the location of the zygomatic-buccal nerve complex as it innervates the zygomaticus major muscle. The marginal mandibular nerve can be found posterior to the gonial notch of the mandible just above the inferior border of the mandible in close association with the facial vein in approximately 80% of patients; the marginal nerve can be found below the inferior border of the mandible in the remaining 20% of patients. Chowdhry et al. described a point 1 cm below the midpoint of a line between the mentum and mastoid tip at the level of the posterior tip of the gonion that is used to localize the cervical branch of the facial nerve.

The depressor labii inferioris (DLI) muscle is crucial for lowering the lower lip, contributing significantly to the creation of a full denture smile and various facial expressions during speech. Traditionally, the marginal mandibular nerve has been recognized as the primary controller of DLI movement. However, recent evidence indicates dual innervation of the DLI. The first is a branch of the marginal mandibular nerve, responsible for downward movement of the lower lip at the lower jaw’s edge. The second, more dominant, nerve stems from the cervical branch, often found in close association with the platysma muscle, particularly where the nerve emerges laterally from the parotid gland. This nerve branch ascends to connect with the DLI at the jawbone’s midpoint. Importantly, to protect the facial nerve, this nerve is located anteriorly and medially relative to the submandibular gland.

The great auricular nerve can generally be located at McKinney’s point along the posterior border of the SCM, approximately 1 cm posterior to the external jugular vein and one-third the distance from the mastoid tip to the SCM’s clavicular head.

Similarly, the landmarks for the major vascular supply of the facial skin flap must be appreciated. Injury to the transverse facial artery during both surgical and nonsurgical aesthetic procedures has been demonstrated as a potential rare complication resulting in blindness. This artery can be found as a branch of the superficial temporal or external carotid artery as it traverses the space between the zygomatic arch and parotid duct. The major perforator of the transverse facial artery can be consistently found 3.1 cm lateral and 3.8 cm inferior to the lateral canthus. ^, Toure et al. describe a space that runs from the tragus to the outer quarter of the upper lip as the risk area. Delayed wound healing and skin flap necrosis can also result following injury to this vessel. Additionally, it is vital to comprehend the anatomical positioning of the facial artery. This artery is situated 16 mm from the oral commissure along a line drawn from the earlobe to this corner. Further, a line drawn from the tragus to the nasal base reveals the artery’s location at 12 mm from the nasal ala.

The rhytidectomy is designed to rejuvenate the face by repositioning sagging tissue and restoring a more youthful and refreshed appearance. Several in-office facelift techniques have been developed over the years, each with its own set of advantages and disadvantages. The choice of technique depends on factors such as the patient’s anatomical characteristics, the extent of aging changes, and the surgeon’s experience and preferences. Office-based rhytidectomy can also be accompanied by ancillary facial rejuvenation procedures. The senior author uses facial anatomic subunit analysis when determining appropriate facial rejuvenation treatment plans.

Facelifts can be done under local anesthesia, conscious sedation, or general anesthesia. The term conscious sedation has also been called monitored anesthesia care, twilight sleep, and intravenous sedation. Sedation is now divided into the minimal, moderate, deep, and procedural sedation types. Anything beyond deep sedation is considered general anesthesia ( Table 25.1 ). Typically one drug is used for the hypnotic effect (propofol, ketamine, dexmedetomidine, midazolam) and another drug for analgesia and antinociception (remifentanil, other opioids, ketamine). We will discuss deep sedation for facelifts using propofol and supplemental opioids.

Deep sedation is defined as a controlled, pharmacologically induced state of depressed consciousness from which the patient is not easily aroused, and which may be accompanied by a partial loss of protective reflexes, including the ability to maintain a patent airway independently and/or respond purposefully to physical stimulation or verbal command. Supplemental oxygen should always be administered. The airway may need to be assisted with an oropharyngeal, nasopharyngeal, or laryngeal mask airway. If a controlled airway is indicated, such as for patients with obstructive sleep apnea or airway deformities, endotracheal intubation is warranted. In addition, all standard American Society of Anesthesiologists guidelines for monitoring should be followed, including end tidal CO ₂ monitoring.

In comparison to inhaled volatile agents, deep sedation with propofol has many advantages. There is significantly less postoperative nausea and vomiting with the use of propofol. There is a reduction of cognitive impairment and delirium in older patients. Avoiding intubation allows for reduced airway irritation in all ages, including postextubation cough. Deep sedation is suitable for use in patients with a potential or confirmed risk of malignant hyperthermia. Additionally, avoiding inhaled anesthetics allows for no pollution of environmental air.

Since propofol has no analgesic properties, deep sedation is commonly achieved by combining propofol infusion with local anesthetic infiltration by the surgeon, as well as supplemental opioids. The supplemental short-acting opioid of choice is remifentanil due to its favorable properties. Remifentanil has an elimination half-time of 3 to 10 minutes. In addition, it does not accumulate in hepatic or renal failure. Remifentanil is context insensitive. This means the time required for the drug concentration to fall by 50% is always the same (∼3 minutes), regardless of age, weight, sex, or hepatic or renal function. These properties allow for easy titration based on patient age, sex, weight, and height. It is important to remember to ensure adequate analgesia after remifentanil has worn off. If remifentanil infusion is not available, other methods of analgesia, such as fentanyl boluses, can be used.

The traditional facelift, also known as the SMAS facelift, is a commonly performed technique that targets the SMAS layer, a fibromuscular connective tissue sheet connecting the skin with the underlying facial muscles. The SMAS facelift provides significant improvement in the lower two-thirds of the face and upper neck, making it an excellent option for patients with mild to moderate skin laxity without significant mid-facial creasing or mid-face volume loss. The “imbrication” method is often the preferred SMAS facelift technique. The SMAS facelift can be performed under local anesthesia with sedation or general anesthesia, depending on the patient’s preference and the extent of the procedure.

Incision Placement: Incisions are typically made in the modified facelift incision pattern. The incision starts in the temporal hairline at the superior root of the helix, the incision curves anteriorly into a crescent shape along the root to the superior tragal incisura, progressing along the pretragal or retrotragal ear, continuing around the earlobe, then approximately 1 mm posterior to the postauricular crease, ending in the hairline at the posterior scalp. Factors such as the patient’s hairline, presence of facial scars, and sideburn position should be considered when planning incision placement. For instance, the surgeon may consider a pretragal incision for men with prominent sideburns to avoid hair-bearing regions overlying the tragus as a result of skin excision.

Skin Flap Elevation: The skin flap is carefully dissected from the underlying SMAS layer using sharp and blunt dissection techniques. Metzenbaum scissors are most commonly used in a spreading and snipping fashion. Dissection is performed in the subcutaneous plane, within the subcutaneous fat, taking care to preserve the facial nerve branches and maintain adequate skin perfusion. A short flap of 4 to 5 cm is preferred to preserve the structural integrity of the SMAS-skin complex.

SMAS Manipulation: The SMAS is raised following elevation of the skin flap. This fibrovascular layer can be identified superficial to the glint of the parotidomasseteric fascia and deep to the subdermal fat. The thick, durable SMAS near the ear thins as it spreads anteriorly along toward the midface. SMAS plication involves lifting and folding, or “plicating,” the SMAS, and then suturing the fascia into a new, elevated position. SMAS imbrication involves the resection of a segment of SMAS, overlapping the cut edges along an elevated vector, and suturing to resuspend the free fascial edges.

Redraping and Closure: The skin is redraped over the repositioned SMAS and platysma layers, taking care to avoid excessive tension on the skin. Any excess skin is trimmed, and the incisions are meticulously closed in multiple layers using sutures, staples, or tissue adhesives, depending on the surgeon’s preference. Surgical drains are almost always utilized.

The deep plane facelift (DPFL) is our preferred method of rhytidectomy as it offers comprehensive rejuvenation of the midface, lower face, and neck. This technique does require the surgeon to be more adept with anatomy, especially that of the facial nerve and the deeper muscle components.

Incision Placement: Incisions can be made in a trichophytic fashion or within the hairline at the temples, extending down in front of the ear, continuing around the earlobe, and then behind the ear, ending in the hairline at the posterior scalp. Modifications may be made to accommodate individual patient factors, such as hairline position and extent of skin that will be ultimately removed. Additionally, if a more vertical vector is required during the rhytidectomy, trichophytic temporal incision is prudent to avoid a significant change in the temporal hair tuft. More posterior vectors will require the same consideration in the occipital hair line to avoid stepoff. Finally, we routinely use a submental incision to perform deep fat and submandibular gland modification in addition to platysma myotomy/corset platysmaplasty.

Skin Flap Elevation: If the patient requires any neck work, a 3- to 6-cm submental incision in a curved fashion under the shadow of the mandible is utilized to access the region. In patients with thin skin or revision rhytidectomy cases, we perform our submental skin dissection using blunt dissection and raise the skin soft-tissue envelope off the platysma in a precise manner. This allows a much more consistent redraping and contouring. In some patients, the subcutaneous dissection is carried above the mandible to release some of the mandibulocutaneous ligaments from the submental incision (see later for further description of retaining ligaments). The inferior extent of the submental dissection is typically determined based on the lowest deep horizontal rhytid.

In the facial and cervical region, the subcutaneous skin flaps are sharply dissected for 4 to 5 cm anteriorly. Extensive subcutaneous skin dissection is avoided to maintain a robust skin-SMAS complex for the DPFL as well as maintaining a robust vascular supply to the skin flap. Elevation of the cutaneous flap will terminate 1 cm medial to the preoperatively marked sub-SMAS entry line along a diagonal line from the angle of the mandible to the lateral canthus. Greater mechanical advantage can be achieved with more medial access ( Fig. 25.1 ). Since we perform subplatysmal dissection in the cervical region, the subcutaneous elevation in this area can also be limited unless there is extensive skin laxity.

Elevation of the cutaneous flap during the deep plane facelift procedure. (A) The sub-SMAS entry line marked in purple is drawn along a diagonal from the angle of the mandible to the lateral canthus and signifies the boundary for the deep plane entry point; note the sub-cutaneous flap terminates 1 cm medial to this line. (B) The moment of entry into the deep plane, following the pre-marked margin.

With permission from the Center for Advanced Facial Plastic Surgery. SMAS: superficial musculoaponeurotic system. )

Neck Contouring: Our use of submental liposuction has decreased significantly over the past decade, as our experience has shown that the majority of neck-related aging changes are related to skin laxity, as well as the deep sub-platysmal fat compartment, platysma, and submandibular gland ptosis. Preoperatively, with the patient in an upright position, we will determine which of these issues are prevalent and develop a patient-specific plan before the initial facial incision. After the submental skin elevation is performed, the central edges of the platysma are identified and dissection beneath this muscle is cautiously carried out, extending 4 to 5 cm below the jawline toward the submandibular gland. The deep subplatysmal fat can be cautiously reduced with hot cautery or blunt dissection superficial to the anterior belly of the digastric, extending inferiorly to the hyoid bone, and laterally toward the submandibular gland. The facial nerve is safeguarded by staying anterior to the submandibular gland.

Modification to the submandibular gland can be performed with limited risk to the facial nerve through an intracapsular approach, particularly in cases of significant gland ptosis. Modifications to the digastric muscles are done with discretion and are often unnecessary in most patients. After addressing the deep neck fat and submandibular gland, a 3-cm wedge-shaped cut in the platysma is made and sutured at the level of the desired neck-chin angle.

Next, the platysma hammock sling technique involves reapproximating the central platysma, forming a strong midline tightening, then suspending and anchoring the lateral platysma to the mastoid periosteum, significantly enhancing the neck-jawline angle, and providing support to the submandibular gland. This method also addresses mild submandibular gland ptosis without requiring partial resection.

Deep Plane Entry, Facial Nerve, and Release of Retaining Ligaments: Retaining ligaments are key anatomical structures that surgeons must consider during rhytidectomy to achieve natural and lasting results. The five pivotal facial retaining ligaments that require strategic management are the orbito-malar, zygomatic-cutaneous (McGregor patch), mandibular-cutaneous, masseteric-cutaneous, and platysma-auricular ligaments, which support facial contours. The cervical retaining ligaments underpin the neck’s structural integrity. These ligaments are strong adhesions that could otherwise prevent the access of sufficient tension in the fascial layer during tissue resuspension. They are present in predictable anatomic locations and the lysis of these tissues are essential for achieving the ideal aesthetic outcome. The zygomatic-cutaneous ligament can be found originating along the inferior border of the zygomatic arch as it extends anteriorly toward the body of zygoma. The mandibular-cutaneous ligament is generally found along the anterior third of the mandible.

The SMAS layer is entered with a No. 10 blade, and initial blunt undermining is performed at the masseteric fascia level, with detachment of the masseteric-cutaneous ligaments. This fascia presents the most straightforward and secure entry point into the deep plane, as the facial nerve branches are located beneath this easily distinguishable fascia. The sub-SMAS dissection continues medially up to the facial artery. Superiorly, the deep plane advancement can be made deep or superficial to the orbicularis oculi muscle, extending toward the nasal facial crease. Here, the zygomatic nerve, which supplies the lower eyelid, extensively branches beneath the surface of the orbicularis oculi muscle. Dissection under this muscle is sometimes required to free the orbitomalar ligaments, yet it carries a risk of affecting the orbicularis muscle function, which may lead to malposition of the lower eyelid, particularly when combined with transcutaneous lower eyelid surgery. Our preference is to dissect above the orbicularis oculi muscle.

The zygomatic ligaments are safely released by remaining superficial to the zygomaticus major muscle during the midface dissection, ensuring the facial nerve is unharmed. This dissection can be carried to the nasolabial fold if desired. The zygomatic and masseteric dissections are then connected from superior to inferior dissection. In the neck, the SMAS/platysma incision extends down to 5 cm above the anterior edge of the SCM. The dissection under the platysma, then, begins with freeing the cervical retaining ligaments along the anterior border of the SCM, which allows for optimal repositioning of the platysma layer. The dissection is carried out medially, potentially joining the area elevated through the submental incision. In this region, blunt dissection is preferred due to the proximity of the facial nerve branches to the platysma’s undersurface, and cautery is deliberately avoided to prevent nerve injury.

SMAS, Platysma, and Buccal Fat Repositioning: Once the deep plane dissection is complete, the buccal fat pad can easily be seen and modified as needed ( Fig. 25.2 ). Hypertrophic or ptotic buccal fat pads need to be addressed in patients with significant fullness in the buccal space. Ptotic buccal fat pads can exaggerate jowling and impact the shape of the face. Yet, the buccal branch of the facial nerve travels on top of the buccal fat pad and it must be carefully avoided. Once the buccal fat pad fascia is entered, it can be easily teased out and resected. We always secure the remnant buccal fat pad with a Vicryl or PDS suture to prevent the descent of the remnant tissues.

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