Chapter-44-Lamellar High SMAS Face-Lift

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Part 1 Facial Aesthetic

Low SMAS

No mid-face or peri-oral improvement

Upper border of SMAS flap “low”

A

B

High SMAS

Mid-face and peri-oral improvement

Upper border of SMAS flap “high”

FIG 1  • “High” and “low” SMAS tech- niques compared. A. Plan for low SMAS procedure. Note that upper border of the flap lies below the zygomatic arch. B. Low SMAS flap after dissection and suspension. Area of flap effect ( green solid circle ) is limited to the lower cheek and jowl, and no improvement is obtained in the midface, infraorbital, or perioral regions ( black dashed circle ). C. Plan for high SMAS procedure. Note that upper border of the flap lies over the zygomatic arch. D. High SMAS flap after dissection and suspension. Area of flap effect ( green solid circle ) includes not only both the cheek and jowl but the midface, infraorbital, and perioral regions ( black dashed circle ) as well.

D

C

■■ Like the temple, planning the appropriate location for the occipital incision requires examining each patient’s neck skin redundancy. This is done like the cheek and entails pinching up tissue over the upper lateral neck and measur- ing it. ■■ If 2 cm or less of excess neck skin is present, the incision can be placed transversely, high on the occipital scalp into the hair. ■■ If more than 2 cm of neck skin redundancy is present, the incision should be placed along the occipital hairline but then turned into the scalp at the junction of the thick and thin hair at the nape of the neck ( FIG 7 ). Failure to follow this plan can result in a visible notching of the occipital hairline. IMAGING ■■ Typically, radiographs are not necessary in facial rejuvena- tion surgery. ■■ All patients should have standardized photographs taken preoperatively, and any markings made preoperatively on patients should be photographed as well.

■■ These photos should be used intraoperatively to help guide treatment. SURGICAL MANAGEMENT ■■ A lamellar dissection for a high SMAS face-lift involves elevating the skin and SMAS as separate layers so that they can be advanced “bidirectionally” along different vectors and suspended under differential tension. Because skin and SMAS age at different rates and along somewhat different vectors, a lamellar strategy is needed to address each layer individually and to create a natural improvement. 4,5 ■■ On the other hand, if a composite dissection is performed, the skin and SMAS must be advanced with the same amount in the same direction under more or less similar tension, which can result in skin overshifting, skin overtightening, and other unnatural appearances. Preoperative Planning ■■ All patients undergo a preoperative physical evaluation, and patients with significant medical problems must be cleared by their internist.