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This 40-year-old woman underwent a high-SMAS facelift and fi nger-assisted facial spaces dissection, as well as fat grafting of the central forehead, upper medial malar area, nasolabial fold, and anterior chin. Preoperative anteroposterior (A) and oblique (C) views and 12-month postoperative anteroposterior (B) and oblique (D) views are shown.
Source publication
Few facelift methods are designed specifically for Asian patients. Because of their characteristic thick skin and flat, wide facial geometry, satisfactory facelift results can be difficult to achieve in these patients.
The authors evaluated outcomes achieved with a high superficial musculoaponeurotic system (high-SMAS) facelift with finger-assisted...
Context in source publication
Context 1
... for surgical rejuvenation of the face is rapidly increasing in Asia as a result of continued economic develop- ment and growth of the aged population. Few facelift methods have been described or developed speci fi cally for older Asian patients, whose distinct facial characteristics make achievement of satisfactory results relatively dif fi cult. 1,2 Nevertheless, facelift procedures have continued to evolve as understanding of surgical facial anatomy has improved. 3-7 We present our experience and results with a facelift technique incorporating a high super fi cial musculoaponeurotic system (high-SMAS) facelift and fi nger-assisted facial spaces dissection to rejuvenate the aging Asian face. From April 2011 to April 2013, 53 consecutive patients underwent a facelift procedure that incorporated a high-SMAS technique and fi nger-assisted facial spaces dissection. The indication for surgery was typical sagging of the face associated with aging, and the relative contraindications were previous facelift and severe facial atrophy. Additional procedures performed as necessary to improve facial aging included fat grafting (40 patients), brow lift (11 patients), upper blepharoplasty (7 patients), lower blepharoplasty (13 patients), and submentoplasty with medial platysmar- rhaphy and subplatysmal fat debulking (18 patients). After the patient was given general anesthesia or intravenous sedation, 1% lidocaine with 1:200,000 epinephrine was in fi ltrated along the incision. Tumescent solution con- sisting of 0.1% lidocaine with epinephrine (1:1,000,000) was in fi ltrated to both sides of the face, with approximately 120 mL to 150 mL administered per side. An incision was made along the temporal hairline, the tragal margin, and the occipital hairline, and a skin fl ap was elevated. A transverse incision was made on the SMAS following the superior border of the zygomatic arch and continued obliquely (anteriorly) to prevent a dog-ear. A vertical incision was made 1 cm anterior to the preauricular skin incision and followed inferiorly and posteriorly up to the anterior border of the sternocleidomastoid (Figure 1). To avoid injury to the temporal nerve branches at the zygomatic arch, the dissection was carefully made with the SMAS fl ap placed under cephalad traction. Anterior and in- ferior to the SMAS, the orbicularis oculi and platysma were connected and included in the SMAS fl ap dissection. The main zygomatic and upper masseteric retaining ligaments were released carefully, without injury to the facial nerve branches (Figure 2). Finger elevation of the malar fat pad was performed through the prezygomatic space between the orbicularis oculi and the zygomaticus (Figure 3). In a similar fashion, fi nger dissection was performed to the mandibular ligament through the premasseter space, between the platysma and the masseteric fascia (Figure 4). Release of the retaining ligaments was con fi rmed with a traction test, and the SMAS fl ap was redraped in the cheek (Figure 5). The SMAS fl ap was pulled parallel to the vector of the long axis of the zygomaticus major and brought to the edge of the original SMAS incision. Redundant tissue was then excised. The preauricular SMAS fl ap was trans- posed postauricularly and fi xed to the mastoid fascia. The cheek skin fl ap was redraped in a vector perpendicular to the nasolabial fold, and the postauricular skin fl ap was redraped parallel to the mandibular border. After redundant skin was excised, skin closure was performed with minimal to no tension (Figure 6). After closed suction and placement of Silastic drains (Dow Corning, Midland, MI), a gentle-compression dressing was applied. Among the 53 Asian patients (47 women), mean age was 50.7 years (range, 35-66 years).Patients received either general anesthesia (48 patients) or intravenous sedation with local anesthesia (5 patients). Mean postoperative follow-up was 19 months (range, 10-34 months). In all cases, improvement in soft-tissue sagging was seen in the midface and lower face (Figure 7 and Supplemental Figure 1, available online at www.aestheticsurgeryjournal.com). One patient (1.9%) had unilateral temporal nerve injury, which partially resolved with obser- vation only. Three patients (5.7%) had a hematoma, which was surgically evacuated. Two patients (3.8%) had wound dehiscence that required resuturing. Although scarring is often a problem in Asian patients who undergo facelift procedures, none of the patients in this study had scarring issues. We attribute this result to the fact that the SMAS fl ap, not the skin, did the lifting; therefore, the skin could be closed with minimal to no tension. Asians have thick skin — fi brous and rich in collagen — and a fl at, wide facial geometry. 1,2 These features complicate achievement of satisfactory results in facial rejuvenation, especially rejuvenation of the sagging midface. Facelift techniques such as the extended-SMAS facelift, the high-SMAS facelift, and the facelift with fi nger-assisted malar elevation (FAME) improve not only the lower face, but also the midface. 3-7 We combined these techniques in a high-SMAS facelift with fi nger-assisted facial spaces dissection to address the aging Asian face speci fi cally. Extended-SMAS dissection includes the release of all retaining deep attachments of the SMAS. The zygomatic ligaments suspend the soft tissue over the zygomatic emi- nence. Without release of these ligaments, repositioning of the malar soft tissue and improvement of the nasolabial fold is not possible. In addition, the masseteric ligaments are responsible for supporting the soft tissue of the cheek. To improve the lower face, these ligaments must also be released. 3,4 In many Asian patients, there is extra protrusion of the zygomatic prominence, lengthening the distance from the preauricular incision to the anterior face. Because this makes improvement of the anterior portions of the midface and lower face more dif fi cult, the retaining ligaments must be released via the sub-SMAS plane to achieve a satisfactory result in these patients. Vital structures such as the facial nerve, mimetic muscles, and parotid duct are adjacent to the zygomatic and masseteric ligaments. Therefore, particular care must be taken when dissection is performed near these structures. The main zygomatic ligaments are located at the junction of the body of the zygoma and the arch. The upper masseteric ligaments are located about 1 cm to 2 cm below this junction. This junction is a reliable landmark for release of the ligaments. 8 Tumescent solution can be used to perform hydrodissection and provide a bloodless surgical fi eld. This step is important, because release depends heavily on a clear fi eld of vision to differentiate retaining ligaments from facial nerve branches. Blunt Metzenbaum scissors are used in a “ push-down technique ” for release of the ligaments, eliminating the need for sharp dissection. In cases where the retaining ligaments are confused with the facial nerve branches, blunt dissection minimizes damage, whereas sharp dissection can injure nerve branches. At this point in the procedure, vertical traction must be carefully applied to the SMAS fl ap to stretch the ligaments that will be released and to identify nearby structures. Facial nerve branches run obliquely, whereas retaining ligaments are oriented vertically; therefore, it is less risky to release in the upper portion of the retaining ligaments (ie, retaining ligaments can be reliably released and facial nerve injury can be avoided). When ligaments and facial nerve branches are dif fi cult to differentiate, a nerve stimu- lator can help to distinguish them. Intraoperatively, the release of the zygomatic and masseteric ligaments can be quanti fi ably con fi rmed by visualization of the zygomaticus and facial nerve branches (Figure 8). Because the ligaments are located laterally and attach around the origin of the muscle, the muscle and nerve cannot be seen without their release. Clinical con fi r- mation of the SMAS fl ap dissection occurs when the nasal alar base and corner of the mouth can be pulled without re- sistance after the fl ap has been placed in traction. The traditional high-SMAS technique elevates the SMAS from above the zygomatic arch to achieve a lift of not only the lower face, but also the sagging tissues of the midface. This method consists of a limited skin dissection and then the elevation of a composite skin and SMAS fl ap up to the lateral border of the zygomaticus major, with subcutaneous dissection medially. Depending on the depth of the nasolabial fold, subcutaneous dissection can be extended medially. 5 Conversely, Marten 6 prefers lamellar dissection of the skin and SMAS fl aps, which allows the fl aps to be pulled with different amounts of tension and vector. Our technique follows a lamellar dissection, which can create a more natural result without causing a lateral sweep deform- ity. If dissection is continued to the nasolabial fold, it ...
Citations
... However, for patients willing to accept visible scars and desiring a long-lasting result from a more extensive face lift procedure, the high SMAS technique described by others can be offered. 5,7 With good communication with patients, the extensive procedures described by the authors for facial rejuvenation in Asians may still have value with acceptable outcomes in the hands of experienced surgeons. ...
I read the article entitled “Subcutaneous Face and Neck Lift: A Traditional Method With Definite Effects Among Asians” with great interest. In this article, the authors introduce their preferred technique of skin-only face and neck lift for facial rejuvenation in Asians. The authors state that their technique can achieve noticeable improvements in terms of increasing volume in the zygomatic region of the face but decreasing volume in the nasolabial fold and lateral cheek regions. Their clinical experience was based on 119 patients with median age of 46 years (range, 40-53 years) over a 24-month period. They not only report clinical outcomes based on the surgeon’s evaluation but also provide objective measurements of facial volume changes based on 3-dimensional (3D) imaging analysis. Patient-reported outcomes based on FACE-Q scales were also recorded. The face lift technique described by the authors was clearly able to provide their patients with good to excellent results.
... Ryu reported that it is important to keep the area raised during a face lift. 13,14 The purpose of this study was to determine any differences in the structures of the subcutaneous tissue containing SMAS among different facial parts such as the nasolabial fold, the infra orbital region and the lateral angle of the eye where wrinkling, slack and other skin changes due to aging are most obvious. In order to make this determination, specimens were stained with Hematoxylin and eosin (HE) for histological observation of the subcutaneous structure. ...
Fascia of the facial area is contiguous between fat tissues of the subcutaneous and connective tissue layers and does not envelope the muscle surface like other parts of the human body. This structure is called the superficial musculoaponeurotic system (SMAS), which is accepted as an international anatomical terminology. This special structure is commonly used to pull facial muscles during plastic surgeries such as a face lift. Most reports regarding the facial subcutaneous tissue structure including SMAS are in the field of plastic surgery, and only a few studies from a morphological perspective has been reported. Since the facial fascia does not envelope the muscular surface layer which is different from the deep fascia found on the general skeletal muscle surface, a clear definition of this structure has not been established yet. The purpose of this study was to clearly identify the basic morphological structure of the subcutaneous tissue layer containing the SMAS three-dimensionally through a scanning electron microscope using dissected specimen rather than living subjects. Moreover, this study explores structural differences among seven aging facial areas; thereby further clarifying the properties of the structure and add clinical significance and considerations.
... A 54-year-old lady with no known medical illness underwent a high SMAS facelift with finger-assisted facial spaces dissection. 1,2 Although the zygomatic and upper masseteric retaining ligaments were released in the sub-SMAS plane, the orbicularis branches of the zygomatic nerve were identified about 1.5 cm lateral to the origin of the zygomaticus major muscle on the right side (Fig. 1). An OOM flap incorporating the orbicularis branches of the zygomatic nerve was made after excising the redundant SMAS and OOM (Fig. 2). ...
The orbicularis oculi muscle (OOM) is sometimes incorporated with the superficial musculoaponeurotic system (SMAS) flap to provide a stronger flap. While elevating the OOM flap, it is important to avoid injury to the orbicularis branches of the zygomatic nerve. When the orbicularis branches of the zygomatic nerve are identified during the OOM-SMAS flap elevation, a transverse OOM flap was created to preserve the nerve. Postoperative follow-up was 12 months. There was no functional impairment of the OOM in the follow-up period. There are anatomical variations of the orbicularis branches of the zygomatic nerve. When it is identified, a transverse OOM flap incorporating it can be raised to avoid inadvertent injury. Using this method, good results were achieved with virtually no complications.
... This is especially true for children presenting with HM in an eye clinic, even after follow-up examinations with reference to the diagnostic criteria of STL and after the identification of the causative mutations in COL2A1 or COL11A1. Some of the previously described signs, such as flat or broad and round facial features, are commonly seen in the general population living in Southeast Asia [47,92,93]. Therefore, certain characteristic facial features, such as malar hypoplasia, a broad or flat nasal bridge, and micrognathia or retrognathia, might be not considered diagnostic signs of STL in such a population [47]. ...
Purpose
Our previous study reported that 5.5% of probands with early-onset high myopia (eoHM) had mutations in COL2A1 or COL11A1. Why were the probands initially considered to have eoHM but not Stickler syndrome (STL)?
Methods
Probands and family members with eoHM and mutations in COL2A1 or COL11A1 were followed up and reexamined based on the criteria for STL. Further comprehensive examinations were conducted for patients with eoHM and mutations in COL2A1 or COL11A1 and controls with eoHM without mutations in COL2A1 or COL11A1. We performed comparisons between probands, affected family members with mutations in COL2A1 or COL11A1, and controls with eoHM without mutations in COL2A1 or COL11A1.
Results
Twelve probands (8.91±4.03 years) and 14 affected family members (37.00±11.18 years) with eoHM and mutations in COL2A1 or COL11A1, as well as 30 controls with eoHM but without mutations in COL2A1 or COL11A1, were recruited. Among them, 25.0% of probands and 50.0% of affected family members met the diagnostic criteria for STL after reexamination. Posterior vitreous detachment/foveal hypoplasia (PVD/FH), hypermobility of the elbow joint (HJ), and vitreous opacity were more frequent in patients with eoHM with mutations in COL2A1 or COL11A1 than in the controls (p = 1.40 × 10⁻⁵, 3.72 × 10⁻⁴, 2.30× 10⁻³, respectively). HJ was more common in the probands than in the affected family members (11/12 versus 3/14; p = 3.42 × 10⁻⁴), suggesting age-dependent manifestation. EoHM presented in all the probands and in 11/14 affected family members, suggesting that it is a more common indicator of STL than the previously described vitreoretinal abnormalities, especially in children. The rate of STL diagnosis could increase from 25.0% to 66.7% for probands and from 50.0% to 92.9% for affected family members if eoHM, PVD/FH, and HJ are added to the diagnostic criteria.
Conclusions
In summary, it is not easy to differentiate STL from eoHM with routine ocular examination in outpatient clinics. Awareness of atypical phenotypes and newly recognized signs may be of help in identifying atypical STL, especially in children at eye clinics.
... Indeed, Ryu and Moon, whose patients were Asian and 50.7 years average in age, reported that their single case of (temporary) temporal branch injury was due to "grabbing periosteum at the mid-zygomatic arch" during a fixation attempt. 6 As long as this is recognized and avoided during fixation, the more inferomedial flap origin (with a diagonal incision in the SMAS, as opposed to a vertical one closer to the ear; Figure 1) has the advantage of proximity to the nasolabial fold and hence more power in elevating the cheek. This is the reason I converted from the lateral, right-angled SMAS incision to the diagonal and more medial one about six years ago. ...
... Indeed, Ryu and Moon noted prolonged postoperative edema with their blunt finger dissection in the facial spaces. 6 Obviously, though, the finger dissection technique if done gently is a safe and time-honored one that perhaps makes this procedure more reproducible. The authors' supplementary operative video shows the dissection crossing the mandible as far anterior as the facial artery, where the marginal mandibular branch becomes superficial. ...
... Asian faces are generally wide and flat in shape, with skin and retaining ligaments that are generally thicker and tougher. So, achieving a good result in a facelift is a challenge [1][2][3]. Particularly, improvement of the midface is not only difficult, but anatomically complex. Techniques such as high-SMAS, extended-SMAS, and the FAME technique have been proposed to improve the midface and lower face [4][5][6][7][8]. ...
... From April 2011 to March 2015, 121 consecutive Asian patients underwent a facelift procedure that incorporated a high-SMAS technique and finger-assisted facial spaces dissection [2]. The indication for surgery was typical sagging of the middle and lower face. ...
... The SMAS flap The SMAS flap, including the orbicularis oculi and platysma, was elevated. Release of the zygomatic and upper masseteric retaining ligaments in the sub-SMAS plane was important to identify the branches of the facial nerve and the origin of the zygomaticus major [2] was pulled parallel to the vector of the long axis of the zygomaticus major and brought to the edge of the original SMAS incision. Redundant tissue was then excised. ...
Background:
In the malar region, the SMAS flap can be thin and tear easily, making it difficult to securely fix it. And the surgical anatomy of the region may be unclear and confusing. The authors performed an anatomical study on the location of the lateral margin of the orbicularis oculi muscle (OOM) and the origin of the zygomaticus major muscle (ZMM) when using a high-SMAS facelift with finger-assisted spaces dissection technique, which included elevation of the SMAS flap with OOM.
Methods:
One hundred twenty-one Asian patients underwent this facelift procedure. Of those, the distances between the posterior margin of tragus and the lateral margin of the OOM and the center of the origin of the ZMM were measured in 20 patients.
Results:
The mean age of the initial 121 patients was 50.9 years. In all cases, improvement was seen in soft tissue sagging of the midface and lower face. There was no functional impairment of the OOM. In 20 patients of them, the lateral margin of the OOM and the center of the origin of the ZMM were located at mean distances of 50.6 (range 48-53 mm) and 61.0 mm (range 60-65 mm) from the posterior margin of the tragus.
Conclusions:
The SMAS flap with the OOM is sufficiently strong enough so that it can maintain the pulling force and also helps to securely fix it. The authors hope that these anatomical findings would be useful when performing it and aid in the understanding of the relationship between the muscles in the malar area.
Level of evidence iv:
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 .
... A c c e p t e d M a n u s c r i p t without functional assessment, above mentioned studies and our clinical experience show that, dissection of the OOM does not cause noteworthy impairment of its function due to its having a plexiform innervation. 5,15,21,23,24 Moreover, the malposition or deformities of the lower eyelid mentioned in the literature would be more likely occur due to the combined lower blepharoplasty operation which leads to denervation of the pretarsal OOM during subciliary incision, with or without combination of excessive skin excision, septal (middle lamella) scar contraction and requires lower-lid reinforcing maneuvers such as orbicularis muscle suspension, lateral canthopexy or canthoplasty. 21 As an important notice, the term 'modified' composite flap facelift in our manuscript refers to incorporation of the suborbicularis dissection along with the SMAS, MFP, and skin and does not mandatorily entail adjunctive maneuvers (transcutaneous lower blepharoplasty, arcus marginalis release, lateral cantopexy, zygoorbicular dissection, septal reset, orbicularis muscle suspension, orbicularis muscle repositioning, forehead lift) suggested by Hamra. ...
Background
Inadequate release of retaining ligaments during facelift surgery may lead to an unnatural appearance. However, most facelift surgeons are hesitant in transecting these ligaments to avoid possible injury to facial subbranches.
Objectives
In our surgical practice for modified composite flap rhytidectomy we use the finger-assisted malar elevation (FAME) technique in order to enable safe release of the zygomatic cutaneous ligaments through the prezygomatic space under direct vision. Our aim is to evaluate the anatomical basis and safety measures of this technique through a cadaveric dissection study.
Methods
Modified composite-flap facelift with FAME technique was carried out in 22 fresh cadaver hemi-faces. All facial nerve subbranches were dissected thoroughly to assess for any evidence of injury during facelift, and to evaluate the safety of the operation. The relations among the facial nerve, zygomatic cutaneous and masseteric ligaments, orbicularis oculi muscle, and malar fat pad were investigated.
Results
Finger dissection of the prezygomatic space allows safe release of the zygomatic cutaneous ligaments as well as adequate entry to a proper surgical plane above the zygomatici muscles under direct vision, while leaving the malar fat pad and overlying structures attached to the skin without the need of a transblepharoplasty approach.
Conclusions
Our study shows that a modified composite-flap facelift with FAME technique is a safe procedure that allows adequate and effective repositioning of an en-bloc composite flap that produces balanced and harmonious rejuvenation of the midface and lower face without the need of a separate midface lift.
... However, in this patient, the risk of the zygomatic branch injury is higher, so blunt dissection, adequate vertical traction of the SMAS flap, and the use of tumescent solution are needed to visually differentiate between the retaining ligaments and the nerve branches to avoid any injury. 3 ...
... Liposakşının teknik olarak standardize edilmesinden sonra yağ enjeksiyonu birçok doku defektinin onarımında kullanılmıştır (10). Yağ greftlerinin rezorbsiyonunu azaltıcı birçok çalışma yapılmıştır (2). ...
... Most plastic surgeons use lidocaine for local anesthesia, usually in a concentration of 0.5% (range, 0.25-1%). 14,[20][21][22][23][24]26,27,30,31,33,36,[38][39][40]60 Other investigators use bupivacaine either on its own 29,35,63,64 or with lidocaine. 14,20,25,28,31,62 Bupivacaine has a greater potency and duration of action than lidocaine. ...
Unlabelled:
Face lift dissections are believed to compromise skin flap circulation, possibly leading to wound healing complications. To reduce blood loss, plastic surgeons commonly inject a solution of local anesthetic that contains epinephrine. However, the effect of surgery on skin perfusion and the degree of vasoconstriction caused by the epinephrine have not been quantitated. Little information is available to guide the selection of epinephrine concentration.
Methods:
Nine consecutive patients undergoing a deep-plane face lift were asked to participate in this prospective study. All patients consented (inclusion rate, 100%). The SPY Elite Intraoperative Perfusion System was used to quantitate perfusion. Measurements were made at 5 sites on both sides of the face and the neck. A nondissected temple site served as a reference. Three patients received no epinephrine in their local anesthetic solution, 3 patients received 1:800,000 epinephrine, and 3 patients were injected with 1:300,000 epinephrine.
Results:
All 9 patients were female nonsmokers. There was no reduction in skin perfusion measurements after surgery. In patients treated with 1:800,000 and 1:300,000 epinephrine, 4 sites showed significantly (P < 0.05) decreased perfusion compared with the no-epinephrine group. Combined perfusion data were almost 50% reduced, but the difference was nonsignificant, likely because of the small sample sizes. One patient developed a hematoma. Two of the 3 patients who received no epinephrine developed extensive bruising.
Conclusions:
A deep-plane face lift dissection does not impair skin flap perfusion. Both 1:300,000 epinephrine and 1:800,000 epinephrine concentrations are effective in producing intraoperative vasoconstriction.
