Chapter-44-Lamellar High SMAS Face-Lift

C H A P T E R 44

Lamellar High SMAS Face-Lift

Dino Elyassnia and Timothy Marten

DEFINITION

and at the same depth as the parotid duct and facial vessels. The nerve branches then proceed to innervate the mimetic muscles on their deep surface (except for the deep layer of muscles, mentalis, levator anguli oris, and buccinator). ■■ The retaining ligaments of the face ( FIG 4 ) are vertically ori- ented fibers that penetrate the concentric horizontal layers of the face and function in a supportive role. 2,3 There seems to be two types of retaining ligaments: ■■ The first type is true osteocutaneous ligaments that run from the periosteum to the dermis and are made up of the zygomatic and mandibular ligaments. ■■ The second type of retaining ligaments is formed by a coalescence of superficial and deep facial fascia that form fibrous connections vertically spanning from deep struc- tures such as the parotid gland and masseter muscle to the overlying dermis. Examples of these include parotid and masseteric cutaneous ligaments. ■■ The parotid cutaneous ligaments span over the entire sur- face of the parotid gland. ■■ The masseteric cutaneous ligaments are a series of fibrous bands that are found along the entire anterior border of the masseter muscle starting in the malar region down to the mandibular border. PATIENT HISTORY AND PHYSICAL FINDINGS ■■ A focused history should include all previous cosmetic sur- gery or treatments including previous face-lifts, injectables, or laser treatments. ■■ To determine the proper location for the temporal portion of the face-lift incision, each patient’s cheek skin redundancy must be examined, and location of temple and sideburn hair noted. Assessing cheek skin redundancy requires pinching up redundant skin over the upper cheek and measuring it. Also, the distance between the lateral orbit and anterior aspect of the temporal hairline must be measured. In youth- ful individuals, the distance should measure no more than 4 to 5 cm ( FIG 5 ). ■■ If cheek skin redundancy is small and ample temple and sideburn hair is present, a temple incision can be placed within the temple scalp ( FIG 6A ). ■■ When the temporal hairline is predicted to shift more than 5 cm away from the lateral orbit or sideburn shifted above the junction of the ear with the scalp, a temple hairline inci- sion should be used ( FIG 6B ). Failure to follow this plan can result in unnatural shifting or displacement of the temporal hair.

■■ As face-lift techniques have evolved, it has become clear that an attractive and natural appearance is not possible without diverting tension away from the skin to the superficial mus- culoaponeurotic system (SMAS) and platysma. ■■ Using the skin as the vehicle to support sagging tissue will always result in poor scars, tragal retraction, earlobe malpo- sition, and a tight unnatural look. ■■ The SMAS, however, is capable of providing sustained sup- port to facial tissues while allowing only redundant skin to be excised and wound closure under no tension. This averts a tight, “pulled” appearance and produces high-quality scars. ■■ A SMAS flap is a reliable and time-tested method of treating the SMAS and has been shown to provide excellent long- term outcomes. A flap is likely less destructive to the SMAS compared to various plication techniques and can be easily raised in secondary and tertiary procedures when carried out skillfully. ■■ The conventional “low” cheek SMAS flap elevated below the zygomatic arch suffers from the drawback that it can- not, by design, have an impact on tissues of the midface and infraorbital region. Planning the flap “higher” along the superior border of the zygomatic arch provides the biome- chanical means by which a combined and simultaneous lift of the midface, lower cheek, and jowl can be obtained and avoids the need to perform a separate mid–face-lift ( FIG 1 ). ANATOMY ■■ The great auricular nerve is a sensory nerve derived from the cervical plexus and provides sensation to the earlobe and lateral cheek ( FIG 2 ). It runs obliquely from the posterior belly of the sternocleidomastoid muscle to the earlobe. The classic external landmark to locate the nerve is at the mid- belly of the sternocleidomastoid muscle 6.5 cm inferior to bony external auditory canal. 1 The most common area of injury is where the nerve emerges from around the posterior border of sternocleidomastoid muscle. ■■ The facial nerve emerges through the stylomastoid foramen and is immediately protected by the parotid gland. Within the parotid, it divides into an upper and lower trunk and then into its five major branches: the frontal, zygomatic, buc- cal, marginal mandibular, and cervical ( FIG 3 ). The branches leave the parotid gland lying on the surface of the masseter immediately deep to the parotidomasseteric fascia. Medial to the masseter, the nerve branches lie on the buccal fat pad

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