Chapter-44-Lamellar High SMAS Face-Lift

T E C H N I Q U E S 222 Part 1 Facial Aesthetic ■■

to aid in the dissection. If confusion is encountered or the anatomy is unclear, it is better to limit dissection in this area until additional experience is gained as no amount of improvement in SMAS release is worth a facial nerve injury. ■■ The endpoint to the SMAS dissection is ultimately clini- cal and not anatomic. Gentle traction on the superior margin of the flap should produce motion at the nasal ala, philtrum and stomal angle, and elevation of infra- orbital and lower eyelid tissue. If there is limited move- ment with this traction test, then residual tethering fibers are identified and released and the traction test repeated. in this manner is greatly facilitated if the mesotempora- lis is gently pushed inferiorly as sutures are placed. No suturing is needed more medially over the zygoma or along the infraorbital rim as this can result in unnatural tissue tethering and dimpling. ■■ When an incision along the temporal hairline is used, the deep temporal fascia will not be exposed. In these cases, the galea can be incised just inferior to the sideburn to expose the deep temporal fascia. The SMAS can then be anchored as described above ( TECH FIG 4B–E ). ■■ In patients with a wide midface (ie, Asian or Slavic ancestry) or in many men, overlapping the SMAS may not be artisti- cally appropriate. In such cases, the redundant tissue along the superior edge of the flap can be excised, and the flap margin sutured edge to edge to the superior margin of the initial incision made in the SMAS over the zygomatic arch.

Directly inferomedial to the origin of the zygomaticus major muscle, and superomedial to the accessory lobe of the parotid, lies the zone of transition between the zygo- matic and masseteric-cutaneous ligaments and the most dangerous part of the SMAS dissection. Proper liberation of the SMAS flap usually requires at least partial division of restraining ligaments in this area but moves the dissec- tion into very close proximity to the zygomatic branches of the facial nerve ( TECH FIG 3C ). ■■ In this area, it can be difficult to distinguish between nerve branches and ligamentous attachments. The inex- perienced surgeon should consider using loupe magni- fication and the use of a disposable nerve stimulator ■■ Once the SMAS flap has been properly released, it should be shifted in a posterior-superior vector parallel to the long axis of the zygomaticus major muscle. If a more vertical or posterior vector is used, the function of the zygomatic major muscle will be corrupted, and abnor- mal appearances during animation may result. ■■ The technique of flap suspension will vary depending on overall facial morphology. In most cases, no trimming of the superior margin of the flap is performed as the overlapping tissue segments of SMAS add volume to the zygomatic arch. In cases where a temporal scalp incision is used, the superior edge of the flap is anchored well over the zygomatic arch directly to the deep temporal fascia using 3-0 Vicryl or Mersilene ( TECH FIG 4A ). Suspension ■■ SMAS Suspension

TECH FIG 4  • High SMAS flap suspension with a temporal scalp incision. A. The SMAS flap has been advanced superiorly, the mesotemporalis pushed inferiorly, and the flap secured to the temporalis muscle fascia. B–E. High SMAS flap suspension with temporal hairline incision. To gain access to the temporalis muscle fascia to suspend the SMAS, the sideburn is retracted and the galea incised (B) . Completed incision of the galea under the sideburn exposing the temporalis muscle fascia. Once incised, a “mesotemporalis” (transition from subcutaneous plane of cheek to subgaleal plane in temple) is created (C) . The suture has been placed through the corner of the SMAS flap. Note that the mesotemporalis is being pushed inferiorly as the suture is placed (D) . Additional sutures have been placed between the superior margin of the SMAS flap and the temporalis muscle fascia, securely anchoring the flap. Once suspension of the SMAS is complete, the sideburn is placed back in a proper anatomic place and anchored down (E) .