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Rhytidectomy Analysis – Twenty Years of Experience

Rhytidectomy Analysis – Twenty Years of Experience
Elbert T. Cheng, MD1

Stephen W. Perkins, MD FACS2

1Elbert T. Cheng, MD, Private Practice. 3375 Kenzo Court, Mountain View, CA 94040.

2Address for correspondence and reprint requests: Stephen W. Perkins, MD FACS. Private Practice. Meridian Plastic Surgery Center, 170th W 106th Street, Indianapolis, IN 46290. Dept of Otolaryngology-Head & Surgery, Indiana University School of Medicine, Indianapolis, IN.

Telephone number: (317) 575-0330

Email address: SWPerkins@AOL.com

Fax number: (317) 571-8667



Careful analysis of a patient for rhytidectomy is an important aspect of facial plastic surgery. Surgeons and physicians are successful when they diagnose patients correctly and then apply the correct treatment plan. The skilled facial plastic surgeon appropriately evaluates the patient, both physically and emotionally, and then performs the correct surgical maneuvers to achieve the desired results. This article focuses on the senior authors twenty years of experience in analyzing faces; the goal of this paper is to assist surgeons in achieving a patient post-operatively who is happy, as well as “natural looking”.

Historical Perspective

The acceptance of rhytidectomy in modern times has been a relatively recent phenomenon. Aesthetic surgery was shrouded in secrecy until the 20th century. Prominent physicians of the 20th century were often guarded in sharing their wisdom despite rumors of cosmetic surgery taking place in private clinics or offices. Following the Great War, the field of plastic and reconstructive surgery blossomed.

Prominent European surgeons were at the forefront of this field. In 1912, Hollander is credited with the first reported case in the literature of surgery to treat wrinkles.4 Shrouded in secrecy; prominent European physicians such as Passot (1919) and Joseph (1921) continued to advance techniques in facial rejuvenation. 4

After World War II, Sam Fomon came to prominence as one of the leaders and founding forefathers of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Up to that point, there still was limited exchange of ideas and knowledge gained in the field of cosmetic surgery. He willingly taught cosmetic surgery to those interested; one of his contributions was the recognition of the limits of subcutaneous rhytidectomy with his quote, “The average duration of the beneficial effects, even with the best technical skill, cannot be expected to exceed three or four years.”4

By the 1960’s and seventies, advances in anesthesia allowed elective surgery to be safely performed. Cosmetic surgery was literally coming out of the dark ages by embracing the free exchange of ideas between surgeons, critical analysis of short and long-term results by a peer-reviewed scientific community, and the growing need to accommodate a rapidly growing aging population in our society.

As the baby boom generation began, so did a new era in facial plastic and reconstructive surgery. A major advancement in the approach to rhytidectomy came in 1974 when Skoog published his thoughts on the subfascial rhytidectomy.11 In 1976, Mitz and Peyronie actually described this subfascial layer anatomically as the superficial muscular aponeurotic system (SMAS).8 Skoog and Lemmon demonstrated that by undermining and moving (SMAS), the entire skin and SMAS unit moved together - “the sliding tectonic plate.” This was the first approach advocating the effectiveness of imbricaion (advancement, shortening, suturing) as a technique in rhytidectomy.

The search for a “natural look” rhytidectomy with longer-lasting results continued into the 1980’s. Richard Webster demonstrated that just plicating (pulling back, folding over and suturing) the underlying fascia and muscular layer often gave a very nice, if not equal, improvement in the jaw and neckline, thereby achieving a natural appearance with few complications.4

Emphasis turned to improving the mid-face, traditionally the most difficult region of the face in which to affect change. The deep plane and composite rhytidectomy were the next step in the evolution of facelifting. These techniques were pioneered by Hamra and seemed to achieve improvement in the nasolabial fold region. Other surgeons have concurred with these improved results.5,6

Surgical techniques for facelifting continue to evolve. From conservative skin flap elevations, to the bi- and tri-plane rhytidectomy of Baker2, to the deep plane techniques of Kamer6, to subperiosteal dissections by Ramirez10, literature demonstrates significant differences of opinion in managing the aging face. A balance must be achieved between extended operative times, duration of postoperative healing, level of assumed risk and complications, and length of results for the patient. Over the past twenty years, the senior author’s analysis of patients and experience with the modified deep-plane facelift has consistently resulted in a happy and natural-appearing patient. This chapter will outline the analysis of the patient; preoperative preparation of the patient; algorithm for adjunctive procedures to achieve a balanced and harmonious youthful face; surgical technique, and possible postoperative complications.


Developing rapport with the patient is the most important initial step in any consultation. In order to build a patient-physician relationship, the patient needs to feel confident in the physician’s abilities and judgment. In the majority of patients, this can be accomplished by listening to the patient. This skill cannot be overemphasized – listen to the concerns of the patient.

The patient’s motivation behind wanting physical change is also vitally important. Patients who want to “look as young as they feel,” or are motivated to undergo surgery for their own self-esteem, often seem to benefit from surgery. Patients motivated to look younger in order to compete in the job market also seem to do well psychologically in the postoperative period. Ferreting out those individuals who do not have realistic expectations of surgery; may be pressured to have surgery from a relative or spouse; are unstable mentally or emotionally; or believe the surgery will solve their failing marriage, is necessary in order to avoid a postoperative patient who is either unhappy or will never be satisfied with the outcome no matter what the result. These “red flags” are important, and listening to one’s own intuition is as important as listening to the patient. When unsure, bring the patient back for a second consult.

The patient needs to complete a detailed report of his or her medical history, which is then to be thoroughly reviewed. The elective nature of cosmetic surgery is understood, and avoiding complications is of prime importance. The objective is to screen patients who have high-risk conditions for elective surgery, such as unstable cardiovascular disease, poor pulmonary reserve, acute/chronic hepatic or renal failure, as well as immunosuppressed patients or patients with chronic illnesses which may prevent adequate postoperative healing. Develop a low threshold for obtaining medical clearance on the patient and discuss the case with the anesthesiologist. The ideal patient for conscious sedation or general anesthesia is obviously a healthy, well-adjusted patient.

When obtaining the medical history, it is worthwhile to note diseases, which may prolong the postoperative healing phase in patients. These conditions include diabetes, peripheral vascular disease, collagen vascular diseases, and some autoimmune disorders. One must identify the actively smoking patient. For all these patients, one needs to either plan on performing a shorter skin flap elevation or not performing the facelift. Occasionally laser resurfacing is concomitantly performed on patients by the senior author, but smokers are not good candidates for the combined simultaneous resurfacing procedure.7 If the patient is a smoker, the risk of increased skin flap necrosis and sloughing is explained and emphasized to the patient in every encounter with him or her pre- and postoperatively. Smokers need to stop smoking 1 week prior to the procedure and continue to abstain from smoking for at least 2 weeks postoperatively. Patients are also not allowed to use nicotine patches during this period. Frequently, Zyban (buproprion), Wellbutrin (buproprion) or a short course of Valium is prescribed during this interim to assist the patient with their “nerves.” Occasionally, these patients are referred to their primary physician to assist in the management of smoking cessation.

Patients who have had a full course of head and neck irradiation will have microvascular compromise, which can be more severe than in smokers. Individuals with active autoimmune diseases, such as scleroderma, lupus or Sjogren’s affecting specifically the face, are at higher risk of skin flap compromise. The decision to operate on these patients must be carefully considered and may be unwise because healing can be poor and unpredictable.

It is imperative to have a thorough knowledge of the patient’s allergies and the medications they are taking. Medicines, which may increase the tendency to bleed, such as non-steroidal anti-inflammatories, aspirin derivatives, health food or certain vitamin supplements, should be stopped a minimum of 2 weeks prior to surgery (Table I). Patients will occasionally under report their physical ailments. The senior author recommends that patients take vitamin C and Arnica Montana, an herbal medicine, to promote healing and to decrease postoperative edema and ecchymosis.


The objective of the consultation is for the patient to leave with an understanding of what can realistically be achieved with their underlying anatomy. The consult helps the patient understand that heredity, sun exposure, gravitational effects, underlying bony structure and prior history of smoking all have contributed to or sped up the aging process. Patients need to know what a facelift is, what it does, and what it does not do.

Physical habitus is important. It is not a contraindication for obese patients to undergo rhytidectomy, but they are not ideal patients. Results are not as predictable, and the duration of effect is shorter. Obese patients need to understand this. Patients with the heavy “bull” neck will often need a submental tuck-up within 12 to 18 months. If they are actively dieting or losing weight, patients are encouraged to wait and have the rhytidectomy when they are at their ideal weight. Emphasize to the patient that a healthy, well-balanced diet is important to the overall healing phase.

Certain facial and cervical characteristics make a patient a good candidate for rhytidectomy, while other physical traits make the patient a poor candidate. The traits which make a patient a good candidate for facelift are strong facial bony structures, such as a forward chin and strong cheek bones; fuller mid-face; shallow cheek/lip grooves; sharp cervicomental angle; a nonsmoker, and good skin tone with minimal photo-aging and few wrinkles (Table II). Traits which may lead to sub-optimal results are a weak or retrognathic chin; deep oral commissure grooves; thin skin; severely wrinkled and sun-damaged skin; a low hyoid producing an obtuse cervicomental angle; deep cheek/lip grooves; low, weak cheek bones; deficient mid-face tissues; and visible submandiblar glands.

Patients present with one of three main areas of concern relating to their mid-face, lower face, and neckline:

  1. Neck, skin, and fat ptosis with either a double chin and/or banding

Patients may specifically state, “I just want my neck tightened.” In the same breath, they may state, “…but I don’t want a facelift.” This may be true in a younger patient who may only need submental work performed, such as liposuction, but in most of the aging population, the skin has lost its elasticity and needs to be pulled back and trimmed. Educating the patient and alleviating fear and misconceptions about a facelift will go a long way toward preparing the patient for surgery.

  1. Increasing development of jowls with loss of definition of the submandibular jaw line and the increasing formation of the oral commissure-chin-cheek groove or “marionette line”

The facelift procedure does an excellent job in defining the jaw line.

  1. Deepening cheek/lip grooves

The patient may actually present to you, lift their mid-cheek tissues at the location of the malar eminence and lateral canthus, and state, “This is all I want, a little tuck.” Most SMAS facelift procedures do a poor job in this region. The procedure can improve the lower one-half of this groove, but the effect is often not long lasting, possibly six months to one year. The mid-facelift is the procedure of choice for this region. Patients need to understand this so they are not disappointed in the postoperative period.

The patient is thoroughly examined in front of a mirror, where the senior author specifically demonstrates what the facelift will and will not do. The vector of pull of the neck and jaw line is performed. Attention is now focused on the cheek/lip groove and the patient is made aware that this will be minimally effaced. The downward turn of the corner of the mouth, or oral commissure grooves, will also not be significantly improved. Facial rhytids or wrinkles may appear improved initially but, as the edema resolves and rebound relaxation occurs, the wrinkles will reappear. Palpation of the hyoid and neck angle is next performed. If a low hyoid is found, the patient is instructed that the cervicomental angle will be obtuse in angle. The temporal region is examined next. If there is mild dermatochalasis of the lateral upper eyelid, lateral brow ptosis or prominent crow’s feet, discussion regarding performing a temporal component of the cheek-neck facelift will be made. Discussions regarding additional procedures are now made depending on physical traits. (Refer to Tables IV-VII)

By the end of the initial visit, the patient leaves fully informed of the risks, benefits, alternatives, and limitations of the procedure. Adequate time should be allowed for specific concerns of the patient to be addressed and all questions fully answered at this point. Discussion of the postoperative course and anesthetic type should be covered and fees given.

Photodocumentation/Video Imaging

Standard facelift pictures are taken at this point. These include full-face frontal, left and right oblique, right and left lateral views. In addition, close-up views of the anterior neck and each ear with particular attention to the pre and postauricular hairlines are helpful. In our office, digital photographs are taken prior to the patient entering the consultations with the senior author. While discussions with the patient and surgeon are taking place in the consult room, the photographer is performing imaging alterations on the computer to show the effects of what the patient may look like after rhytidectomy. The patient is shown these images with the surgeon present to confirm that these are realistic possibilities.

The patient signs disclaimers explaining that the video imaging is not a guarantee of results after the operation, but merely a tool to illustrate what is possible and what the aesthetic goals are for that individual. Some have questioned whether video imaging should be used to show the risks of the operation.1 The senior author strongly believes it is a wonderful communication tool and actually assists in having a happier, more satisfied patient postoperatively.

Preoperative Work-up

Based on the review of the patient’s medical history and medications, we obtain certain lab tests and an EKG. Routinely, we obtain a CBC and a coagulation profile on those who are healthy. We do not hesitate to obtain a complete battery of liver, renal, and electrolyte panels as well. For patients older than 40, we obtain an EKG. Patients who have cardiac histories are asked to obtain cardiac clearance. The preoperative work-up is an important part to ensuring a safe and uneventful surgery for the patient.

Anatomic Considerations

Operating safely and efficiently demands an understanding of the different tissue planes in the head and neck. Beneath the skin and subcutaneous fat is a layer of fascia termed the SMAS layer by Mitz and Peyronie. This layer of fascia extends in continuity from the galea in the scalp, into the face surrounding the facial muscles, and into the neck wrapping around the platysma. The parotid fascia and masseteric muscle are deep to this layer. The deep plane, bi- or tri-planar, composite, and SMAS facelift procedures all depend on undermining this SMAS layer to some degree. The facial nerves exit the parotid gland and are beneath the parotid-masseteric fascia. It’s important to visualize these nerves when elevating the SMAS layer to avoid damaging them. (Figure 1) Depending on the inherent elasticities of the tissues, dehiscence of the platysma muscles in the neck, and fatty tissue in the submental or supraplatysmal region all contribute to the degree of submental fullness and banding.

Sensory innervation to the skin is temporarily interrupted by facelift surgery. Sensation returns to the ears and facelift flaps on the average of 8 to 12 weeks postoperatively. Occasionally, it may take 6 months to 1 year. The most commonly injured nerve in rhytidectomy is the greater auricular nerve. This nerve is contained within and above the superficial layer of the deep cervical fascia, which envelops the sternocleidomastoid muscle, parotid gland and masseter muscle. It is commonly located 6.5 cm below the mastoid tip and the angle of the mandible. This region contains the densest fibrous attachments between the SMAS/platysma and the enveloping muscular fascia. There is usually minimal subcutaneous fat, and dissection is tedious and difficult. When the greater auricular nerve is damaged, it needs to be repaired with microsurgical technique, but at best, return of sensation may take 1 to 2 years. 

In the temporal region, one needs to have a good understanding of the fascial planes. The temporal (frontal) nerve lies superficial to the temporalis fascia within the SMAS layer. The nerve stays within this fascia as it courses over and superior to the zygoma. Over the temporalis muscle, a safe plane of dissection is on the surface of the superficial layer of the deep temporal fascia. (Figure 2a and 2b) This layer allows one to stay deep to the nerve down to the zygoma. Staying superficial to this nerve over the zygoma requires the surgeon to be in a subcutaneous plane of dissection; the nerve lies within the superficial temporal fascia and periosteum of the zygoma before it exits more superficially to innervate the frontalis muscle from underneath. At the level of the zygoma one must be deep to the deep layer of the temporalis fascia and subperiosteum in order to avoid injury to the frontal branch. 

The orbicularis, zygomatic, and buccal nerves typically have a network of branches supplying innervation to their respective muscles. As a result of this redundancy of neural innervation, if small, distal branches of these nerves are damaged there likely will be return of function. This overlap is not seen with the temporal or marginal nerves, which explains why injury to these nerves may result in permanent paralysis.

Types of Facelifts

The type of facelift is dictated by the patient’s underlying anatomy. The facelift has three components: temporal, cheek and neck. Extending the facelift into the temporal region will help lateral hooding of the brows or severe crow’s feet. (Figure 3) The degree of jowling, submental fullness, platysmal banding and skin laxity next determine whether a type I, II, or III cheek/neck facelift should be performed.

A type I facelift patient has a minimum degree of laxity in the jowls and neck. (Figure 4) This requires a shorter elevation and undermining of the SMAS with imbrication. It is important to realize the difference between plication and imbrication. Imbrication is trimming the excess SMAS after it is repositioned and suturing it end to end. This involves undermining beneath the SMAS. Plication involves folding the SMAS upon itself by suturing it posteriorly without elevating. Liposuction is either not necessary or minimally performed in the submental region. (Figure 5a and 5b)

A type II facelift patient is a much more common group of patients. Skin laxity and fullness of the jowls and necks can be quite impressive. (Figure 6) A moderate degree of liposuction is required to thin the jowl and neck tissues. In addition, a type II facelift includes a moderate degree of platysma excision with plication and full neck skin undermining, a significant degree of SMAS undermining with imbrication, and release of the malar attachments in the midcheek. (Figure 7a and 7b)

A type III facelift patient is the male patient or the woman with the very heavy neck. (Figure 8) They often have a low positioned hyoid and significant laxity of submental skin. These patients often do not have a clear separation between where their jaw line ends and where their neck begins. Males are placed into this category because of their bearded, heavy, thick skin and their tendency to develop large skin wattles. (Figure 9a and 9b) Type III facelifts are for heavy-necked patients. Often, one can spend twice the usual amount of time contouring the neck by liposuction and plication of the platysma bands than for a type I or II patient. The focus of the operation is creating a “new,” defined neck angle. These patients also have a deep cheek/lip grooves and melolabial folds with loss of support of the midcheek tissues. The senior author attempts to obtain a good SMAS flap elevation with extension nearly to the midface if possible. Mid facelift procedures can often assist in these patients.

(Figure 10a and 10b)


Incision planning and marking for the facelift procedure are crucial to the long-term satisfaction and successful outcome for the patient. The surgeon who pays attention to the details of incision placement and planning can often build a reputation among hairdressers and other cosmeticians in the community as one who performs excellent work. A natural hairline, the freedom for the patient to style their hair without concerns of their scars showing, and the invisibility of the scar lines are what separates the good facelifting surgeon from the rest in the community. Postoperative changes in hairline and visible scars may leave a patient ultimately unsatisfied despite a good facelift result.

The three critical points to consider in planning facelift incisions are:

  1. Management of the Preauricular Tuft of Hair

The sideburn relationship with the insertion of the helical curvature is the key element in planning the incision in this region of the face. Postoperatively, the sideburn must not be lifted above the superior helix. If the preauricular sideburn is 1 to 2 cm below the insertion of the superior portion of the helical insertion, it can be very appropriate to design an incision that curves up into the temporal hair and allows some posterior superior lifting of the hairline. (Figure 11) A curved intratrichial incision is required to interrupt the forces of contracture and maintain a scar that will not widen or create alopecia. An incision that is straight up in this region usually results in a widened scar with alopecia. If the sideburn is at the level of the helical insertion, the incision needs to be drawn just inferior to the tuft of hair so one lifts the cheek skin and not the pretemporal hairline. (Figure 12) One should not carry the incision anteriorly so that it lies in front of the sideburn or temporal hairline. This will only result in a scar which is visible and difficult to camouflage.

  1. Management of the Preauricular Region

The incision must follow the curvature and creases of the auricle. The senior author highly prefers an incision that lies behind the posterior edge of the tragus so that it appears to lie “inside the ear.” (Figure 13) The only exceptions to making this posttragal incision are in patients with external auditory canal hearing aids and patients with very deep pretragal depressions and tall cartilaginous tragic. Patients who are particularly hirsute are also not good candidates. As a result, most men have the incision drawn in a preauricular crease; this prevents pulling the sideburn into the external ear canal. (Figure 14) A few women have preauricular hair as well.

  1. Management of the Postauricular Hairline

The incision must be directed up onto the posterior aspect of the auricle above the sulcus. Postoperatively this allows the incision to lie in the sulcus and not on the mastoid. A gentle sweeping curve at the level where the auricle meets the postauricular hairline is next drawn. (Figure 15) In the postauricular hairline, this gentle curve follows the hairline and gradually slopes inferiorly. In patients with a large amount of neck, the postauricular incision in the hairline is drawn differently. The large excess skin during the operation will distort the hairline and create a noticeable stepoff. The postauricular incision is drawn down the hairline itself; inferiorly, it is directed posteriorly back into the hairline. This prevents a noticeable scar as well.

Facelift procedure

Treatment of the Neck

Treatment of the neck is the first step of this operation. Liposuction is not always required in some type I facelifts, but for most aging faces, contouring of the neck is useful. We begin by making a 2-3 cm incision in the submental crease followed by 0.5 cm elevation of the subcutaneous flap. Contouring of the fatty tissues of the jowl, submental, submandibular and neck with liposuction is performed next.

A 3 mm round cannula with 3 rectangular holes is used to pretunnel in a fan-like fashion from the left jowl region to the right jowl region. The left hand elevates the fat and skin while the right hand easily advances the cannula in the subcutaneous plane. The suction holes are always placed against the deep layer of fat and soft tissue. Over reduction of the subcutaneous fat can lead to dimpling of the skin; this can be avoided by maintaining a moderately thick layer of adipose tissue on the undersurface of the skin. Once the entire neck is liposuctioned with the 3 mm cannula, a blunt, 4 mm cannula with a single rectangular hole is used to reduce the heavy neck, especially around the submandibular region. We finish the liposuction portion by contouring the neck with a 2 mm liposuction cannula. It is important to remember that we are judicious with our liposuction. Cicatricial banding can occur when only dermis is left on the fat; skeletization of the submandibular gland can leave a visible, ptotic submandibular gland, which can be a difficult aesthetic issue. Again, moderation is the key and leaving fat is better than removing too much.

For most necks, a sling is created with the anterior platysmal muscles. A conservative, but effective technique is the Kelly clamp platysmaplasty. Undermining of the neck skin with Kahn beveled facelift scissors extends from anterior sternocleidomastoid muscle to the other sternocleidomastoid muscle. Direct visualization of the submental region allows one to pick up the lax anterior platysmal bands and redundant subplatysmal fat. A large curved Kelly clamp is placed under the forceps to tighten the platysma. Sequential cauterization, excision, and suturing of the platysma with a buried mattress 3-0 vicryl are performed from the superior portion of the platysma down to the cervicomental angle and occasionally beyond. (Figure 16a, 16b, 16c, 16d, 16e and 16f) For heavier necks, the senior author prefers to use a permanent, 3-0 polydek suture in a figure-of-eight mattress.


Skin Flap Elevation

Degree of undermining depends upon laxity of mid-face tissues as well as history of smoking. In smokers, where skin flap viability is a concern, the senior author will typically perform a shorter skin flap elevation. Patients with significant laxity of the mid-face tissues, the sub-SMAS elevation and deep plane facelift technique typically have a shorter skin flap elevation. Besides improving skin flap vascularity and decreasing the incidence of venous congestion, the other benefit from a shorter region of skin flap undermining is less skin irregularities postoperatively, smaller incidence of seromas and hematomas.

Postauricularly, the plane of dissection is in the immediate subcutaneous plane. (Figure 17) The Kahn beveled facelift scissors, with their tips up, ensure the surgeon he is in the correct plane. The entire neck skin is undermined to connect with the submental and jowl flap performed earlier.

If a temporal-cheek-neck facelift is performed, dissection is performed in the subgaleal plane and directly over the superficial layer of the deep temporalis fascia down to the superior border of the zygoma. The temporal branch of the facial nerve is in the superficial temporalis fascia, in the plane immediately above your level of dissection. Releasing of the lateral orbital periosteum is necessary in most type II and III facelifts. This permits redraping of the tissues of the mid-face and lateral orbital region with less bunching of tissues lateral to the orbital rim. In those individuals in which an inferior sideburn incision is made, the temporal incision is disconnected and separate.

Preauricularly, elevation of the skin flap is performed initially underneath the hair follicles of the sideburns. This extends into the immediate subcutaneous plane to the lateral orbital “crow’s feet” region. (Figure 18) Again, the temporal branch is safe; the nerve is preserved in the layer below your level of dissection. Undermining is performed 3 to 4 cm and connected to the skin flaps in the neck.

SMAS undermining is performed by an incision that extends diagonally from the inferior border of the zygomatic arch, at the malar eminence, to 1 cm anterior to the sternocleidomastoid muscle at the level of the ear. Undermining is performed with scissors for the first 2 cm parallel to the parotidmasseteric fascia, then with vertical spreading motions of the scissors, dissection is carried over the masseter. One can often visualize the marginal mandibular nerve and safely dissect over it. Dissection is simultaneously performed 3 to 4 cm beneath the platysma muscle. In the malar region, a subcutaneous plan of dissection is next performed which extends just inferior to the orbicularis muscle. The objective is to release the strong dermal attachments to the malar eminence. Bleeding is frequently encountered which must be controlled. Superficial to the zygomatic muscle, dissection is easily carried out. Continuation of your sub-SMAS elevation in the mid-face is individualized for each patient and by modifying the extent of SMAS elevation medially, one lessens the risk to branches of the zygomatic and buccal nerves. By definition a full SMAS elevation is a deep plane facelift. Often, good mobilization of the jowl and malar eminence regions provides excellent redraping of skin and soft tissues of the cheek and neck.

A biplanar vector of suspension is created with the SMAS flap. A dramatic improvement is seen in the mid-face and jowl region with advancement and imbrication of the SMAS flap superiorly. A 0-vicryl anchors the flap superiorly at the helical region and when the tissues are heavy a 3-0 polydek is used. (Figure 19a, 19b and 19c) The lower portion of the SMAS is advanced posteriorly towards the mastoid tip. The Metzenbaum scissors make a cut on the SMAS at the level of the auricular lobule to facilitate advancement of this inferior slip of flap. Again, a 0-vicryl anchors the flap, this time on the mastoid periosteum. Advancement and imbrication of this portion of the SMAS creates a dramatic tightening of the jowl region, creating a corset of the neck. (Figure 20) Redundant preauricular and anterior sternocleidomastoid SMAS is trimmed at this point to eliminate lumpiness that may result from excess tissues. 3-0 polydioxanone sutures reinforce the SMAS-platysma and SMAS-preauricular contact points.

Baker’s “tri-plane” rhytidectomy is essentially accomplished with advancement and trimming of the skin-subcutaneous flap. The entire skin-subcutaneous flap is advanced over the auricle. Postauricularly, to avoid a hairline stepoff, the flap is advanced posteriorly and then superiorly to match up the hairline. The flap postauricularly is further advanced superiorly to the superior apex of the postauricular sulcus. The third attachment point is at the superior portion of the helical crus in the preauricular region. It is important to realize that the skin flap is advanced more posteriorly for the preauricular portion and not superiorly. The attached points have been performed with staples. The flap postauricularly is easily trimmed between the previous attachment points and staples align the scalp. A running interlocking 5-0 plain catgut approximates the skin and postauricular sulcus. To avoid a satyr or pixie ear deformity, the flap cradles the ear lobe superiorly. There is no tension on the ear lobe at this point. A 5-0 polyglycolic aid suture for the subcutaneous layer and two 6-0 nylon sutures approximate the skin at the lobule itself; the nylon sutures are taken out on postoperative day 10. The preauricular flap is trimmed judiciously and in incremental fashion. The tragal flap is designed to be redundant and pie crust sutured; this flap is also thinned carefully to avoid devascularization. The preauricular flap is next sewn with a running interlocking 5-0 plain catgut suture. 

Excising scalp incrementally closes the temporal region. One 3-0 vicryl closes the galea and staples approximate the scalp in the hair bearing skin. Prior to placement of the last sutures, a drain is placed postauricularly to decrease the incidence of seromas and hematomas.9 This drain is removed the next day. The remaining staples and catgut sutures are removed on postoperative day 7. The 6-0 nylon ear lobe sutures are removed on postoperative day 10.


A light compression dressing is placed using an abdominal dressing (ABD) and an elastic chin strap over the preauricular, cervical and submental regions. Pressure dressings can restrict venous outflow and lead to venous congestion. Venous congestion can lead to skin necrosis. Again, a light dressing is all that is needed. In individuals with a history of smoking, we occasionally do not apply any dressing.


Hematoma is the most common complication following rhytidectomy; the senior author’s experience is 1-2%. The incidence in the literature varies from 2% to 15%.9 Seromas occur in the senior author’s experience approximately 2% of the time. The low occurrence of seromas is attributed to the placement of active drains to bulb suction.

Infection can occur in approximately 4 to 5% of patients while on cephalosporin prophylaxis. Any signs of unilateral erythema in the pre- or postauricular regions, increasing pain, or delayed wound healing at the edges is treated with aggressive antibiotic coverage to cover Pseudomonas and other gram negative bacilli. Abscesses occur in less than 0.2% of patients and require immediate drainage and broad-spectrum antibiotic coverage.

Skin necrosis can be a serious issue in smokers. Smokers have a 12% higher risk of skin flap death compared with non-smokers.12 However if smokers have no nicotine in their system in the immediate perioperative period, the incidence of skin flap death drops to 2%. Using vacuum drainage and a noncompressive dressing reduces skin necrosis to a rare occurrence.

Facial nerve injury is a rare complication. The incidence in the literature ranges from 0.65% to 6%.3 Any facial nerve injury in the senior author’s experience has been a paresis lasting between 3 and 6 months; the frontal branch has been the most commonly involved, followed by the zygomatic branch and then the marginal branch with an occurrence of 0.005% (10 of 1,800 patients).

Alopecia or an artificially created hairline step-off can occur. Alopecia usually results from undue tension on flaps, while the hairline step-off is a result of poor pre-operative patient analysis and can be avoided.


Over the past twenty years, the senior author has performed over 1800 facelifts. Accurate analysis of the preoperative patient is imperative. Proper preoperative consultation is vitally important to assure a happy patient and meet the patient’s pre-existing expectations. The anatomical findings, preoperative condition of the patient and the patient’s expectations and lifestyle, dictate the extensiveness of the dissection, the placement of the incisions and may well predict the length that the operation will last for each individual. The goal of any rhytidectomy is a natural appearance, a happy patient, and a satisfied surgeon. As experience is gained, the level of surgical aggressiveness is increased to gain more and more improvements. However, complications begin to occur when more aggressive measures are undertaken. A safe, predictable facelift is the goal for the surgeon and the patient. The senior author has found that the aggressive techniques in the region of the neck have dramatically improved the overall initial, as well as long term, results for the neck portion of the rhytidectomy. However, it is equally true that more aggressive treatments to the midface do not necessarily improve the overall results and can significantly increase the complication rate.

Finally, the addition of adjunctive procedures, including combined resurfacing and mid-facelift, add to the overall improved results in rhytidectomy.


  1. Ashbell TS. Photographic Simulation: An Express Warranty. PlasticSurgeryProducts April, 2002.

  2. Baker SR. Tri-plane rhytidectomy. Arch Otol HNS 1997; 123:1167-1172.

  3. Castanares S. Facial nerve paralyses coincident with or subsequent to rhytidectomy.Plast Reconstr Surg 1974:54(6):637-643.

  4. Foment S. The Surgery of Injury and Plastic Repair. Balitmore: Williams & Wilkins; 1939:1344.

  5. Hamra ST. The deep plane rhytidectomy. Plast Reconstr Surg 1990;86:53.

  6. Kamer FM. One hundred consecutive deep plane face lifts. Arch Otolaryngol Head Neck Surg 1996; 122:17-22.

  7. Koch BB, Perkins SW. Simultaneous rhytidectomy and full-face carbon dioxide laser resurfacing a case series and meta-analysis. (submitted).

  8. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976;58:80-88.

  9. Perkins SW, Williams JD, MacDonald K, Robinson EB. Prevention of seromas and hematomas following facelift surgery with the use of postoperative vacuum drains. Arch Otolaryngol Head Neck Surg 1997;123:743-745.

  10. Ramirez OM. The Subperiosteal Rhytidectomy; The Third Generation Face Lift. Annals Plast Surg 28:218-232, 1992.

  11. Skoog T. Plastic surgery:the aging face. In:Plastic Surgery:New Methods and Refinements. Philadelphia: WB Saunders, 1974:300-330.

  12. Strath R, Raju D, Hipps C. The study of hematomas in 500 conservative face lifts. Plast Reconstr Surg 1983;52:694-698.

Legend for Drawings and Figures

Figure 1 – Branches of the facial nerve exiting the parotid gland and lying below the SMAS.

Figure 2a – Temporal branch of facial nerve with bifarcation of frontal and zygomatic branches.

Figure 2 b– Frontal branch of the facial nerve is safe in this plane of dissection.

Figure 3 – Lateral hooding of the brow and crow’s feet.

Figure 4 – Type I facelift candidate.

Figure 5a – Preoperative type I facelift patient.

Figure 5b – Postoperative type I facelift patient.

Figure 6 – Type II facelift candidate.

Figure 7a- Preoperative type II facelift patient.

Figure 7b- Postoperative type II facelift patient.

Figure 8 - Type III facelift candidate.

Figure 9a – Preoperative male facelift patient.

Figure 9b – Postoperative male facelift patient.

Figure 10a – Preoperative type III facelift patient.

Figure 10b – Postoperative type III facelift patient.

Figure 11 – Drawing depicting incision at inferior temporal hairline with sideburn below superior helical insertion.

Figure 12 – Drawing depicting incision into temporal hairline with sideburn above

superior helical insertion.

Figure 13 – Drawing depicting typical male preauricular facelift incision.

Figure 14 – Drawing depicting posterior tragal and preauricular facelift incision.

Figure 15 – Drawing depicting postauricular incision.

Figure 16a, b, c, d, e and f - Sequential cauterization, excision, and suturing of the platysma with a buried mattress 3-0 vicryl are performed from the superior portion of the platysma down to the cervicomental angle and occasionally beyond.

Figure 17 - Postauricularly, the plane of dissection is in the immediate subcutaneous plane.

Figure 18 - Preauricularly, elevation of the skin flap is performed initially underneath the hair follicles of the sideburns. This extends into the immediate subcutaneous plane to the lateral orbital “crow’s feet” region.

Figure 19a, b and c – Advancement and imbrication of the SMAS flap.

Figure 20 - Advancement and imbrication of this portion of the SMAS creates a dramatic tightening of the jowl region, creating a corset of the neck.

Table I

Medications Which Interfere with Blood Clotting

Health Food/Vitamin Supplements

St. John’s Wart Ginko Biloba Vitamin E (mega doses)

Non-Steroidal Anti-Inflammatory Drugs

Motrin (Ibuprofen) Indocin (Indomethacin) Naprosyn (Naproxen)

Advil (Ibuprofen) Celebrex Anaprox (Naprosyn-Na)


Anti-Inflammatory Medications

Tolectin (Tolmetrin) Persantine (Dipyridamole) Nalfon (Fenoprofen)

Aspirin-Containing Medications

Alka Seltzer (Christedyne) Anacin (Congestrin) Apa-Deine (Darvon w/ASA)

APC (Darvon compound) Arthritis Formula Arthritis Bufferin (Deproject)

Aspirin (Dristan, duradyne)

A.S.A. Compound (Dedacine)

Bayer Products (Dynosal) BC Tablets(Easprin, Ecotrin) Bufferin

Excedrin Fiornal (Protension) 4-way w/Codeine

Lanorinal (Sine-Aid) Marval (Sine-Off) Measurin (Sinex)

Mepragesic (Soma) Midol (Supac) Monacal (Talwin Compound)

Norgesic (Ten-Shun) Opasal (Triaminicin) Os-Cal-Gesic (Trigesic)

Pabrin (Ursinus) PAC Compound (Vanquish) Percodan



Table II

Favorable Characteristics for Facelift Candidates

  1. Strong forward chin

  1. Prominent cheek structure

  1. Good facial bone structure

  1. Fuller mid-face

  1. Sharp cervicomental angle

  1. Shallow cheek/lip grooves

  1. Nonsmoker

  1. Good skin tone

  1. Few wrinkles with minimal photo aging


Table III

Unfavorable Characteristics for Facelift Candidates

  1. Retrognathic or weak chin

  1. Deep oral commissure grooves

  1. Thin skin

  1. Severely wrinkled and sun damaged skin

  1. Low hyoid with obtuse cervicomental angle

  1. Deep cheek/lip grooves

  1. Weak cheek bones

  1. Deficient mid-face tissues

  1. Visible submandibular glands



Table IV

Algorithm for Aging Upper Face

Brow Ptosis

Lateral Brow Ptosis

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