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Areas of undermining for the author's technique. Limits of skin (in blue) and SMAS (in red) undermining for the author's technique, with the DTZ entirely within the red area of composite-flap undermining. The area of undermining medial to the zygomaticus major muscle is subcutaneous by definition, since there is no SMAS layer in this zone. (The premasseteric dissection joins an extended subplatysmal dissection into the neck. Platysma, but not skin, is undermined towards the midline of the neck, preserving cervical facial nerve branches. This continuation of the facial composite flap into the neck generates a very smooth, youthful jaw and neckline, while elevating ptotic submandibular glands and avoiding irregularities characteristic of subcutaneous neck dissection.)
Source publication
Background
Recent anatomic studies suggest the superficial musculoaponeurotic system (SMAS) layer attenuates in the midface. This led the author to switch from a bilamellar high SMAS dissection to a “total composite flap” technique, preserving skin and SMAS/platysma as one layer in a critical “deep-plane transition zone” (DTZ) lateral to the zygoma...
Contexts in source publication
Context 1
... borders of the trapezoidal-shaped DTZ are: laterally, an oblique line start- ing 4.5 cm anterior to the tragus and ending 2.5 cm antero-inferior to the ear lobule, even with the oral commis- sure; superiorly, the midpoint of the zygomatic arch; medially, the zygomaticus major muscle with an anterior bend over the prezygomatic space; and inferiorly, the transverse line even with the oral commissure. As shown in Figure 5, the deep- plane dissection continues inferior to this line, across the jawline and into the neck, but the area above it is the portion relevant to midface elevation. facial halves and intraoperative observations during 150 deep-plane facelifts by Gassner et al concluded that "(s) uperolateral to the modiolus, a soft tissue gap separates the zygomaticus major muscle and the SMAS … . ...
Context 2
... author's composite flap (including suborbicularis oculi) midface dis- section begins more anteriorly in its uppermost section than the high-SMAS techniques previously described, which initi- ate the dissection more laterally with a right angle just anteri- or to the helical root. [1][2][3]11 The purpose of the author's more anterior entry into the SMAS is to move the point of flap fixa- tion closer to the midface while still maintaining SMAS at- tachments to skin in the DTZ ( Figure 5). This orientation also incidentally places the dissection anterior to the course of the temporal branch of the facial nerve. ...
Context 3
... is a concept the author presented at the 2008 American Society for Aesthetic Plastic Surgery annual meeting, and which has been argued by Marten, Mendelson, and others. 1-3,5,11-13 This pattern of release is shown in Figure 5 with areas of skin (in blue) and SMAS (in red) undermining for the author's tech- nique, with the DTZ entirely within the red area of composite- flap dissection. The lower, middle, then upper premasseteric spaces are opened, followed by the prezygomatic space which, as noted above, is entered from a SMAS incision more anteriorly than the conventional high-SMAS technique. ...
Context 4
... of the malar fat pad, since this plane is free of facial nerve branches (and, as shown in Figure 5, is deep to malar fat but not sub-SMAS since the SMAS layer does not exist here). Retaining ligaments between the prezygomatic and premasseteric spaces are carefully separated. ...
Context 5
... criticism of this technique has been that the neck skin often ages faster than platysma, so it should be undermined separately. 3 However, several points support using a composite flap in the neck: (1) even in cases of accelerated neck aging, the neck skin remains attached to platysma muscle, and extensive subplatysmal undermining and advancement carries a significant amount -often 3 to 5 cm -of skin to be removed; (2) al- though cervical facial nerve branches will be encountered and should be preserved, the subplatysmal plane in the neck opens up even more readily than that in the face with no specific ligaments to be released (both of which may explain why the neck sometimes ages faster than the face); (3) as in the face -and even moreso -irregularities result- ing from separate skin dissection are avoided; (4) elevation of a face-neck composite flap as one unit means that the neck portion supports the face portion rather than exerting downward traction on it; (5) ptotic submandibular glands, which are subplatysmal, are elevated and supported; and (6) restoration of platysma to its original position over the mandibular border creates a smoother, fuller jawline ( Figure 10D and Supplemental Figure S5D). ...
Similar publications
Patients with thick skin typically present with a redundant, baggy, lax skin envelope together with prominent nasolabial folds, jowls, and a heavy neck. Durable and natural-appearing rejuvenation is not possible unless the deformities are addressed adequately and harmoniously in these patients. Traditional superficial musculoaponeurotic system tech...
Citations
... Knowing the extent of SMAS distribution and tissue thickness is important in determining the extent of resection and the traction vector for best results from face-lift surgeries. 9,28 In this study, the SMAS was clearly visualized. Because this evaluation method by detailed cadaveric studies and advanced CT studies is highly objective, these findings supplemented previously established cosmetic surgical knowledge about the SMAS as well as adding new findings of the SMAS in the mandibular region. ...
Background
The superficial musucloaponeurotic system (SMAS) is an important structure to understand for face-lift surgeries. However, the detailed distribution and imaging findings of the SMAS have not been established yet.
Objectives
The aim of this study is to establish the accurate distribution and CT imaging findings of the SMAS based on cadaveric studies.
Methods
This study was designed in a three-step procedure. First: Seven cadaver faces were used to understand the distribution and histology of the SMAS. Second: The SMAS’s findings from the cadaveric studies were compared to the CT images. Third: CT images were enrolled for the SMAS interpretation.
Results
In seven cadaveric studies, the SMAS was observed as a subcutaneous fibro-membranous structure extending from the galea aponeurotica to the platysma muscle, and laterally connected to the parotid fascia. On the medial side, it also connects with major and minor zygomatic muscles. The SMAS consisted of muscular fibers, collagen fibers and elastic fibers, histologically. Eighteen CT images (all females; age range, 21-82 years) showed the thin linear structures corresponding to the fibro-membranous structures in the cadaveric studies. CT density of the SMAS was similar with the muscle’s, and the SMAS was able to be recognized in all 18 subjects.
Conclusions
The SMAS is a definite anatomical structure that can be demonstrated as a thin membranous structure on CT. This clinical application could be applicable to the development the cosmetic surgical procedures.
... • SMAS plication: 58 studies, 9267 patients 16 8,14,[187][188][189][190] ...
Background
Sub-SMAS rhytidectomy techniques are considered to have a higher complication profile, especially for facial nerve injury, when compared to less invasive SMAS techniques. This results in surgeons avoiding sub-SMAS dissection.
Objective
Aggregate and summarize data on complications among different SMAS facelift techniques.
Methods
A broad systematic search was performed. All included studies: (1) described a SMAS facelifting technique categorized as SMAS plication, SMASectomy/imbrication, SMAS flap, high lateral SMAS flap, deep plane, and composite; and (2) reported the number of postoperative complications in participants. Meta-analysis was performed in accordance with PRISMA guidelines.
Results
183 studies were included. High lateral SMAS (1.85%) and composite rhytidectomy (1.52%) had the highest rate of temporary nerve injury and were the only techniques to show a statistically significant difference when compared to SMAS plication (OR = 2.71 and 2.22, respectively, p < 0.05). There was no difference in the risk of permanent injury amongst techniques. An increase in major hematoma was found for the deep plane (1.22%, OR 1.67, p < 0.05) and SMAS imbrication (1.92%, OR 2.65, p < 0.01). Skin necrosis was higher with the SMAS flap (1.57%, OR 2.29, p < 0.01).
Conclusions
There are statistically significant differences in complication rates between SMAS facelifting techniques for temporary facial nerve injury, hematoma, seroma, necrosis, and infection. Only high lateral SMAS and composite rhytidectomy techniques showed a statistically significant increase in the odds ratio of temporary neuropraxia. Because these complications occur at such a low rate, they are of limited clinical significance. Technique should be selected based on quality of results and not the complication profile.
... I must say I was pleased when asked by the editor of this journal to write a commentary when I received the title, 1 since I developed (and named) the composite facelift. Every surgeon who publishes original work wants to see his contribution accepted by his peers. ...
I must say I was pleased when asked by the editor of this journal to write a commentary when I received the title,1 since I developed (and named) the composite facelift. Every surgeon who publishes original work wants to see his contribution accepted by his peers. However, I was baffled when reading this article. The technique the author describes is not a composite facelift, as he has entitled his publication. Perhaps the history of the development of the composite facelift2 will clarify and justify my criticism of this article.
I was fortunate to start with the Skoog rhytidectomy in 1973,3 and together with Dr. Mark Lemmon we published the only extensive series on Skoog rhytidectomy4 since Prof. Skoog died in 1974. In 1985, after performing the tri-plane rhytidectomy, which I had published in 1983,5 I continued to be unhappy with the results. This was essentially an extension of the Skoog rhytidectomy, but with a subcutaneous elevation of cervical skin, since we concluded that the subplatysma cervical Skoog rhytidectomy could not create optimal neck contouring. While the jawline was satisfactory, I felt that the nasolabial fold could be better, and then began working on the technique that I wanted to give an original designation. I called it the deep plane rhytidectomy6 since it was an extension of the tri-plane rhytidectomy. The concept was relatively simple, as the cheek fat that was between the zygomaticus major and minor was lifted with the skin and kept in continuity with the platysma of the lower face (SMAS). Thus the skin was the vehicle for moving the cheek fat and the SMAS in the traditional lateral direction toward the ear. This original dissection was published, and met with enthusiasm among aesthetic surgeons everywhere.
The result of the deep plane …
Objectives
Public's interest in noninvasive skin rejuvenation treatments continues to grow. The advantage of combination therapy lies in that it can target different aspects of skin rejuvenation. This study aimed to assess the efficacy and safety of microfocused ultrasound (MFU) combined with delicate pulsed light (DPL) for facial rejuvenation.
Methods
Twenty‐one patients with facial relaxation were enrolled. All patients received whole‐face MFU treatment, and one side of the face was randomly assigned to receive DPL. MFU treatment was performed at Months 0 and 3, while DPL treatment was performed at Months 1, 2, 4, and 5. The length and angle of the nasolabial fold and perioral wrinkles, melanin index (MI), erythema index (EI), transepidermal water loss (TEWL), and follow‐up time were recorded at Months 0, 3, and 6. Side effects were recorded during treatment and each follow‐up visit.
Results
Twenty patients successfully completed the study. At the sixth month, the average length of perioral wrinkles and nasolabial folds on the combined side decreased by 11.5% ( p within < 0.001) and 6.5% ( p within = 0.011), while 8.3% ( p within = 0.012) and 3.8% ( p within = 0.02) on the MFU side. Compared with MFU treatment alone, the combined treatment also showed significant improvements in nasolabial fold angle (from 28.8 ± 3.4° to 32.7 ± 5.0°) and perioral wrinkle angle (from 39.3 ± 5.0° to 43.7 ± 5.1°). In addition, the combined side had greater benefits than the MFU side in improving MI, EI, TEWL, and skin elasticity ( p between < 0.05). Except for one patient who withdrew due to increased skin sensitivity after MFU treatment, other subjects did not experience permanent or serious side effects.
Conclusions
The combination of MFU and DPL for facial rejuvenation treatment is safe and effective. The combined treatment has better efficacy in skin firmness, and improving skin tone.
The extended deep plane facelift is a powerful technique to correct aging of the midface and neck. After many years of superficial muscular aponeurotic system lift techniques, the senior author transitioned to an extended deep plane facelift for all patients. The primary catalyst for this shift in practice was the pursuit of superior rejuvenation of the midface. Consistent uniform elevation of the deep plane with complete ligament release and management of the soft tissue flap were the most significant challenges in the early adoption period. Navigating the transition was facilitated by consultation with experienced colleagues and frequent cadaver dissections. This manuscript details the authors' current technique. Complications and recovery from this technique are similar to those reported with historical techniques and are minimized with proper preparation, precision, and perioperative management. In our experience the results from this procedure are extremely reproducible, durable, and natural, and patients are overwhelmingly extremely satisfied.
Deep-plane or composite flap facelift techniques allow deep structural rejuvenation of the face by release of retaining ligaments in the sub-SMAS plane with elevation and fixation of the SMAS/platysma/skin flap as a single, “en-bloc” unit. This means that in cases with mild to moderate skin laxity, the preauricular incision serves the purpose of access only. The author therefore developed an endoscopic-assisted, en-bloc composite flap face and necklift without a preauricular incision. The technique uses the prezygomatic and premasseteric (facial) and subplatysmal (neck) spaces as ideal optical cavities for endoscopic dissection and ligament release. Verticalization of fixation vectors and modified concho-mastoid traction sutures are used to minimize preauricular skin reduncancy. The surgical procedure is described in detail. Clinical experience in 41 consecutive cases and comparison to other techniques with respect to relevant anatomy are also presented. This endoscopic en-bloc composite flap facelift technique consistently and safely produced results comparable to conventional, “open” composite flap facelifts done by the same surgeon on similar candidates during a prior period.
It is crucial for a facelift surgeon to have a comprehensive understanding of ageing-related changes on the volume, elasticity, and relative position of various facial tissues and layers. These changes lead to an alteration in the surface topography, contour, and ultimately shape of the face. The depressions and sagging of tissues created as a result of ageing then has a bearing on one's perceived age. This article describes the various layers of the face and neck affected by ageing. The fat compartments, superficial musculoaponeurotic system (SMAS), potential facial spaces, facial ligaments, and facial nerve are discussed in detail. Safe and effective execution of facelift requires a thorough understanding of the intricate relationship between the various layers of face and neck, in particular the path of facial nerve, as it negotiates between these layers. The emphasis of this article is on integrating this knowledge to generate practical tips for safe dissection, effective tissue movement, and repositioning during various type of facelift procedures.
Background:
Early relapse is an adverse outcome of facelift surgery. The rate of early relapse is an indirect measure of the longevity and efficacy of facelift techniques. However, early relapse after facelift is ill-defined, under-evaluated, and under-reported, and literature data on the subject are dispersed. In this systematic review, we aimed to analyze facelift studies using relapse-related outcomes (RROs). Our secondary aim was to highlight the importance of early relapse as an essential outcome measure.
Methods:
The study design was a systematic review of the English literature and meta-analysis of RROs after facelift surgery. RROs that occurred within the first 2 years after surgery were considered "early". Performance, analysis, and reporting were performed in accordance with the PRISMA guidelines. The systematic search was conducted using the PubMed database as of February 2020. Initial screening was performed using the keywords "facelift", "rhytidectomy", "surgical rejuvenation", "face lift", "rhytidoplasty", and "facial rejuvenation". Articles were excluded by using a set of inclusion and exclusion criteria.
Results:
RROs were reported only in 4.4% (19/433) of the papers that underwent full-text review. The frequency of RROs ranged between 0.2 and 50% among facelift papers. The weighted median rate of RROs after facelift surgery was found to be 2.4% in the meta-analysis.
Conclusions:
Future research on preventive measures will be successful upon acknowledgment of the actual prevalence of this problem. Consensus on its definition and objective criteria for its diagnosis are required for further progress.
Level of evidence iii:
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Objective:
This study aims to investigate the clinical effects of the combination of rhytidectomy and temporomandibular joint (TMJ) disc repositioning surgery in internal derangement (ID) stage IV-V and facial aging patients.
Methods:
Eighteen facial aging with bilateral ID IV-V patients were enrolled in this study. All of them had undergone temporomandibular disc repositioning surgery and rhytidectomy by the same surgeon (Yao Min Zhu). Pre-/post-surgical clinical manifestations, facial photography, radiographic data were recorded and analyzed, as well as doctor, patient, third-party evaluation of postsurgical facial appearance satisfaction.
Results:
The average age of 18 female patients was 52.9. The average of presurgical visual analog pain scale score was 5.94, ranged from 4 to 8. After 6 months, the average of postsurgical visual analog pain scale score was 0.28, ranged from 0 to 1 (P > 0.05). The average maximal mouth opening of presurgical and postsurgical was 2.19 and 3.29 cm, ranged from 1.2 to 2.8 cm and 3.0 to 3.5 cm, respectively (P < 0.05). Postoperative magnetic resonance imaging showed the location of the bilateral TMJ discs directly above the mandibular condyle. The satisfaction rate of doctors, patients and third-party with facial appearance was 95% to 98%, 96% to 99% and 96% to 99%, respectively, with an average of 95.72%, 98.11%, and 97.50%.
Conclusions:
For patients with bilateral ID IV-V and facial aging, the combination of disc repositioning surgery and rhytidectomy is a very feasible procedure to treat TMJ disorders and improve patients' facial appearance and satisfaction.
Background:
Important differences in facial anatomy and how faces age must be considered when performing facelifts in Asian populations. Few facelift methods are specifically designed for Asian patients.
Objective:
This study evaluated the efficacy of lateral superficial muscular aponeurotic system (SMAS)-stacking/SMAS-ectomy with orbicularis-malar fat repositioning.
Materials and methods:
Between February 2013 and December 2016, 62 women underwent the evaluated technique and completed the follow-up (15 months, ranging from 3 to 38.5 months). Three blinded, independent observers graded wrinkles, laxity, nasolabial fold depth, malar prominence, and tear trough deformity using quantitative comprehensive grading scales. FACE-Q scale items were assessed, and complications were recorded.
Results:
The mean postoperative scores for wrinkles, laxity, nasolabial fold depth, malar prominence, and tear trough deformity decreased from 2.64, 2.62, 2.01, 2.06, and 2.40 to 1.48, 1.34, 0.93, 1.21, and 1.27, respectively. The preoperative and postoperative scores differed significantly for all parameters (p < .05). The FACE-Q results showed that the patients were highly satisfied with their appearance, quality of life, adverse effects, and care.
Conclusion:
The authors' technique allows midfacial and periorbital rejuvenation and offers dual benefits by correcting individual facial asymmetries and reshaping the jowls and neck contour in Asian patients.
