Subscribe to RSS
DOI: 10.1055/s-0042-1756463
Essential Surgical Anatomy for Facelift
Abstract
It is crucial for a facelift surgeon to have a comprehensive understanding of ageing-related changes on the volume, elasticity, and relative position of various facial tissues and layers. These changes lead to an alteration in the surface topography, contour, and ultimately shape of the face. The depressions and sagging of tissues created as a result of ageing then has a bearing on one's perceived age. This article describes the various layers of the face and neck affected by ageing. The fat compartments, superficial musculoaponeurotic system (SMAS), potential facial spaces, facial ligaments, and facial nerve are discussed in detail. Safe and effective execution of facelift requires a thorough understanding of the intricate relationship between the various layers of face and neck, in particular the path of facial nerve, as it negotiates between these layers. The emphasis of this article is on integrating this knowledge to generate practical tips for safe dissection, effective tissue movement, and repositioning during various type of facelift procedures.
Publication History
Article published online:
23 December 2022
© 2022. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Foustanos A, Pantazi L, Zavrides H. Representations in plastic surgery: the impact of self-image and self-confidence in the work environment. Aesthetic Plast Surg 2007; 31 (05) 435-442 , discussion 443–444
- 2 Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek: facial layers, spaces, and the midcheek segments. Clin Plast Surg 2008; 35 (03) 395-404 , discussion 393
- 3 Mendelson B, Wong CH. Commentary on: modified composite-flap facelift combined with Finger-Assisted Malar Elevation (FAME): a cadaver Study. Aesthet Surg J 2018; 38 (12) 1284-1288
- 4 Raskin E, Latrenta GS. Why do we age in our cheeks?. Aesthet Surg J 2007; 27 (01) 19-28
- 5 Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007; 119 (07) 2219-2227
- 6 Hwang SH, Hwang K, Jin S, Kim DJ. Location and nature of retro-orbicularis oculus fat and suborbicularis oculi fat. J Craniofac Surg 2007; 18 (02) 387-390
- 7 Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989; 83 (01) 11-16
- 8 Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992; 89 (03) 441-449 , discussion 450–451
- 9 Kahn DM, Shaw RB. Overview of current thoughts on facial volume and aging. Facial Plast Surg 2010; 26 (05) 350-355
- 10 Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg 2008; 121 (06) 2107-2112
- 11 Swift A, Liew S, Weinkle S, Garcia JK, Silberberg MB. The Facial Aging Process From the “Inside Out”. Aesthet Surg J 2021; 41 (10) 1107-1119
- 12 Wan D, Amirlak B, Rohrich R, Davis K. The clinical importance of the fat compartments in midfacial aging. Plast Reconstr Surg Glob Open 2014; 1 (09) e92
- 13 Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plast Reconstr Surg 1979; 64 (06) 781-795
- 14 Hwang K, Kim JY, Lim JH. Anatomy of the Platysma Muscle. J Craniofac Surg 2017; 28 (02) 539-542
- 15 Cardoso de Castro C. The changing role of platysma in face lifting. Plast Reconstr Surg 2000; 105 (02) 764-775 , discussion 776–777
- 16 Zins JE, Menon N. Anterior approach to neck rejuvenation. Aesthet Surg J 2010; 30 (03) 477-484
- 17 Jacono AA, Talei B. Vertical neck lifting. Facial Plast Surg Clin North Am 2014; 22 (02) 285-316
- 18 Jacono AA, Malone MH. The effect of midline corset platysmaplasty on degree of face-lift flap elevation during concomitant deep-plane face-lift: a cadaveric study. JAMA Facial Plast Surg 2016; 18 (03) 183-187
- 19 Pelle-Ceravolo M, Angelini M, Silvi E. Complete platysma transection in neck rejuvenation: a critical appraisal. Plast Reconstr Surg 2016; 138 (04) 781-791
- 20 Mani M. Total composite flap facelift and the deep-plane transition zone: a critical consideration in SMAS-release midface lifting. Aesthet Surg J 2016; 36 (05) 533-545
- 21 Marten T, Elyassnia D. Management of the platysma in neck lift. Clin Plast Surg 2018; 45 (04) 555-570
- 22 Pelle-Ceravolo M, Angelini M, Silvi E. Treatment of anterior neck aging without a submental approach: lateral skin-platysma displacement, a new and proven technique for platysma bands and skin laxity. Plast Reconstr Surg 2017; 139 (02) 308-321
- 23 Jacono A, Bryant LM. Extended deep plane facelift: incorporating facial retaining ligament release and composite flap shifts to maximize midface, jawline and neck rejuvenation. Clin Plast Surg 2018; 45 (04) 527-554
- 24 Mendelson BC, Freeman ME, Wu W, Huggins RJ. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthetic Plast Surg 2008; 32 (02) 185-195
- 25 Mendelson BC, Muzaffar AR, Adams Jr WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002; 110 (03) 885-896 , discussion 897–911
- 26 Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 2000; 105 (04) 1475-1490 , discussion 1491–1498
- 27 Marten TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface. Clin Plast Surg 2008; 35 (04) 569-603 , vi–vii
- 28 Hu X, Wang Z, Wang Q, Zhang C, Hu G, Qin H. Are there differences between the upper and lower parts of the superficial musculoaponeurotic system? A preliminary biomechanical study. Aesthet Surg J 2014; 34 (05) 661-667
- 29 Gassner HG, Rafii A, Young A, Murakami C, Moe KS, Larrabee Jr WF. Surgical anatomy of the face: implications for modern face-lift techniques. Arch Facial Plast Surg 2008; 10 (01) 9-19
- 30 Hamra ST. Composite rhytidectomy. Plast Reconstr Surg 1992; 90 (01) 1-13
- 31 Gordon NAA, Adam SI. The deep-plane approach to neck rejuvenation. Facial Plast Surg Clin North Am 2014; 22 (02) 269-284
- 32 Jacono AA, Bryant LM, Alemi AS. Optimal facelift vector and its relation to zygomaticus major orientation. Aesthet Surg J 2020; 40 (04) 351-356
- 33 Mendelson BC, Wong CH. Surgical anatomy of the middle premasseter space and its application in sub-SMAS face lift surgery. Plast Reconstr Surg 2013; 132 (01) 57-64
- 34 Cakmak O, Özücer B, Aktekin M, Özkurt FE, Al-Salman R, Emre IE. Modified composite-flap facelift combined with Finger-Assisted Malar Elevation (FAME): a cadaver study. Aesthet Surg J 2018; 38 (12) 1269-1279
- 35 Mendelson BC. Anatomic study of the retaining ligaments of the face and applications for facial rejuvenation. Aesthetic Plast Surg 2013; 37 (03) 513-515
- 36 Reece EM, Pessa JE, Rohrich RJ. The mandibular septum: anatomical observations of the jowls in aging-implications for facial rejuvenation. Plast Reconstr Surg 2008; 121 (04) 1414-1420
- 37 Wong CH, Hsieh MKH, Mendelson B. Asian face lift with the composite face lift technique. Plast Reconstr Surg 2022; 149 (01) 59-69
- 38 Nagai K, Ichinose A, Kakizaki H. et al. Anatomical evaluation of facial nerve pathways and dissection of “premasseter space” for rhytidectomy in Asians. Aesthetic Plast Surg 2012; 36 (03) 534-539
- 39 Uppal S, Ashraf N, Raghavan U. Mid-Face Lift. Symptom Oriented Otolaryngology Head and Neck Surgery. Vol 2. 1st ed.. New Delhi, India: Jaypee Publishers; 2017: 259-277
- 40 Wong CH, Hsieh MKH, Mendelson B. The tear trough ligament: anatomical basis for the tear trough deformity. Plast Reconstr Surg 2012; 129 (06) 1392-1402
- 41 Ozdemir R, Kilinç H, Unlü RE, Uysal AC, Sensöz O, Baran CN. Anatomicohistologic study of the retaining ligaments of the face and use in face lift: retaining ligament correction and SMAS plication. Plast Reconstr Surg 2002; 110 (04) 1134-1147 , discussion 1148–1149
- 42 Muzaffar AR, Mendelson BC, Adams Jr WP. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002; 110 (03) 873-884 , discussion 897–911
- 43 Mendelson B, Wong CH. Commentary on: SMAS fusion zones determine the subfacial and subcutaneous anatomy of the human face: fascial spaces, fat compartments, and models of facial aging. Aesthet Surg J 2016; 36 (05) 529-532
- 44 Alghoul M, Codner MA. Retaining ligaments of the face: review of anatomy and clinical applications. Aesthet Surg J 2013; 33 (06) 769-782
- 45 Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast Reconstr Surg 1996; 12 (02) 77-88
- 46 Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg 2009; 124 (06) 2118-2126
- 47 Mendelson BC. Extended sub-SMAS dissection and cheek elevation. Clin Plast Surg 1995; 22 (02) 325-339
- 48 Mendelson BC. Correction of the nasolabial fold: extended SMAS dissection with periosteal fixation. Plast Reconstr Surg 1992; 89 (05) 822-833 , discussion 834–835
- 49 Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg 1995; 22 (02) 295-311
- 50 Owsley JQ, Roberts CL. Some anatomical observations on midface aging and long-term results of surgical treatment. Plast Reconstr Surg 2008; 121 (01) 258-268
- 51 Warren RJ, Aston SJ, Mendelson BC. Face lift. Plast Reconstr Surg 2011; 128 (06) 747e-764e
- 52 Knize DM. The importance of the retaining ligamentous attachments of the forehead for selective eyebrow reshaping and forehead rejuvenation. Plast Reconstr Surg 2007; 119 (03) 1119-1120
- 53 Wong CH, Mendelson B. Extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution. Plast Reconstr Surg 2017; 140 (02) 273-282
- 54 Hwang K, Nam YS, Kim DJ, Han SH. Surgical anatomy of retaining ligaments in the periorbital area. J Craniofac Surg 2008; 19 (03) 800-804
- 55 Botti G, Botti C, Cella A, Gualdi A. Correction of the naso-jugal groove. Orbit 2007; 26 (03) 193-202
- 56 Loeb R. Naso-jugal groove leveling with fat tissue. Clin Plast Surg 1993; 20 (02) 393-400 , discussion 401
- 57 Steinsapir KD, Steinsapir SM. Deep-fill hyaluronic acid for the temporary treatment of the naso-jugal groove: a report of 303 consecutive treatments. Ophthal Plast Reconstr Surg 2006; 22 (05) 344-348
- 58 Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg 2007; 120 (05) 1367-1376
- 59 Kpodzo DS, Nahai F, McCord CD. Malar mounds and festoons: review of current management. Aesthet Surg J 2014; 34 (02) 235-248
- 60 Hamra ST. The role of orbital fat preservation in facial aesthetic surgery. A new concept. Clin Plast Surg 1996; 23 (01) 17-28
- 61 McCord Jr. CD, Codner MA, Hester TR. Redraping the inferior orbicularis arc. Plast Reconstr Surg 1998; 102 (07) 2471-2479
- 62 Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg 1998; 102 (05) 1646-1657
- 63 Le Louarn C. The concentric malar lift: malar and lower eyelid rejuvenation. Aesthetic Plast Surg 2004; 28 (06) 359-372 , discussion 373–374
- 64 Le Louarn C. Concentric malar lift in the management of lower eyelid rejuvenation or retraction: a clinical retrospective study on 342 cases, 13 years after the first publication. Aesthetic Plast Surg 2018; 42 (03) 725-742
- 65 Wong CH, Mendelson BC. Reply: extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution. Plast Reconstr Surg 2018; 142 (02) 236e-237e
- 66 Uppal S. Brow Ptosis and its Management. Symptom Oriented Otolaryngology Head and Neck Surgery. Vol 2.. New Delhi, India: Jaypee Publishers; 2017: 240-258
- 67 Mendelson BC. SMAS fixation to the facial skeleton: rationale and results. Plast Reconstr Surg 1997; 100 (07) 1834-1842 , discussion 1843–1845
- 68 Mendelson BC. Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation. Plast Reconstr Surg 2001; 107 (06) 1545-1552 , discussion 1553–1555, 1556–1557, 1558–1561
- 69 Paul MD, Calvert JW, Evans GR. The evolution of the midface lift in aesthetic plastic surgery. Plast Reconstr Surg 2006; 117 (06) 1809-1827
- 70 Alghoul M, Bitik O, McBride J, Zins JE. Relationship of the zygomatic facial nerve to the retaining ligaments of the face: the Sub-SMAS danger zone. Plast Reconstr Surg 2013; 131 (02) 245e-252e
- 71 Owsley JQ, Agarwal CA. Safely navigating around the facial nerve in three dimensions. Clin Plast Surg 2008; 35 (04) 469-477 , v
- 72 Kaye BL. The extended face-lift with ancillary procedures. Ann Plast Surg 1981; 6 (05) 335-346
- 73 Langevin CJ, Engel S, Zins JE. Mandibular ligament revisited. Paper presented at: Ohio Valley Society of Plastic Surgery Annual Meeting; May 17, 2008; Cleveland, Ohio
- 74 Kang MS, Kang HG, Nam YS, Kim IB. Detailed anatomy of the retaining ligaments of the mandible for facial rejuvenation. J Craniomaxillofac Surg 2016; 44 (09) 1126-1130
- 75 Mustoe TA, Rawlani V, Zimmerman H. Modified deep plane rhytidectomy with a lateral approach to the neck: an alternative to submental incision and dissection. Plast Reconstr Surg 2011; 127 (01) 357-370
- 76 Jacono AA, Malone MH. Characterization of the cervical retaining ligaments during subplatysmal facelift dissection and its implications. Aesthet Surg J 2017; 37 (05) 495-501
- 77 Ozturk CN, Ozturk C, Huettner F, Drake RL, Zins JE. A failsafe method to avoid injury to the great auricular nerve. Aesthet Surg J 2014; 34 (01) 16-21
- 78 Rohrich RJ, Taylor NS, Ahmad J, Lu A, Pessa JE. Great auricular nerve injury, the “subauricular band” phenomenon, and the periauricular adipose compartments. Plast Reconstr Surg 2011; 127 (02) 835-843
- 79 Lefkowitz T, Hazani R, Chowdhry S, Elston J, Yaremchuk MJ, Wilhelmi BJ. Anatomical landmarks to avoid injury to the great auricular nerve during rhytidectomy. Aesthet Surg J 2013; 33 (01) 19-23
- 80 Sharma VS, Stephens RE, Wright BW, Surek CC. What Is the lobular branch of the great auricular nerve? Anatomical description and significance in rhytidectomy. Plast Reconstr Surg 2017; 139 (02) 371e-378e
- 81 Larson JD, Tierney WS, Ozturk CN, Zins JE. Defining the fat compartments in the neck: a cadaver study. Aesthet Surg J 2014; 34 (04) 499-506
- 82 Ramírez OM. Advanced considerations determining procedure selection in cervicoplasty. Part one: anatomy and aesthetics. Clin Plast Surg 2008; 35 (04) 679-690, viii viii.
- 83 Marten T, Elyassnia D. Neck lift: defining anatomic problems and choosing appropriate treatment strategies. Clin Plast Surg 2018; 45 (04) 455-484
- 84 Kim DI, Nam SH, Nam YS, Lee KS, Chung RH, Han SH. The marginal mandibular branch of the facial nerve in Koreans. Clin Anat 2009; 22 (02) 207-214
- 85 Tzafetta K, Terzis JK. Essays on the facial nerve: part I. Microanatomy. Plast Reconstr Surg 2010; 125 (03) 879-889
- 86 Zani R, Fadul Jr. R, Da Rocha MA, Santos RA, Alves MC, Ferreira LM. Facial nerve in rhytidoplasty: anatomic study of its trajectory in the overlying skin and the most common sites of injury. Ann Plast Surg 2003; 51 (03) 236-242
- 87 Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg 1966; 38 (04) 352-356
- 88 Trussler AP, Stephan P, Hatef D, Schaverien M, Meade R, Barton FE. The frontal branch of the facial nerve across the zygomatic arch: anatomical relevance of the high-SMAS technique. Plast Reconstr Surg 2010; 125 (04) 1221-1229
- 89 Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an important reference point for surgery in the temporal region. Plast Reconstr Surg 1998; 101 (01) 27-32
- 90 Hwang K, Cho HJ, Battuvshin D, Chung IH, Hwang SH. Interrelated buccal fat pad with facial buccal branches and parotid duct. J Craniofac Surg 2005; 16 (04) 658-660
- 91 Yang HM, Kim HJ, Park HW. et al. Revisiting the topographic anatomy of the marginal mandibular branch of facial nerve relating to the surgical approach. Aesthet Surg J 2016; 36 (09) 977-982
- 92 Woltmann M, Faveri Rd, Sgrott EA. Anatomosurgical study of the marginal mandibular branch of the facial nerve for submandibular surgical approach. Braz Dent J 2006; 17 (01) 71-74
- 93 Hwang K. Surgical anatomy of the facial nerve relating to facial rejuvenation surgery. J Craniofac Surg 2014; 25 (04) 1476-1481
- 94 Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg Transplant Bull 1962; 29: 266-272
- 95 Nelson DW, Gingrass RP. Anatomy of the mandibular branches of the facial nerve. Plast Reconstr Surg 1979; 64 (04) 479-482
- 96 Jacono AA, Parikh SS. The minimal access deep plane extended vertical facelift. Aesthet Surg J 2011; 31 (08) 874-890
- 97 Hazani R, Chowdhry S, Mowlavi A, Wilhelmi BJ. Bony anatomic landmarks to avoid injury to the marginal mandibular nerve. Aesthet Surg J 2011; 31 (03) 286-289
- 98 Salinas NL, Jackson O, Dunham B, Bartlett SP. Anatomical dissection and modified Sihler stain of the lower branches of the facial nerve. Plast Reconstr Surg 2009; 124 (06) 1905-1915
- 99 Daane SP, Owsley JQ. Incidence of cervical branch injury with “marginal mandibular nerve pseudo-paralysis” in patients undergoing face lift. Plast Reconstr Surg 2003; 111 (07) 2414-2418
- 100 Ellenbogen R. Pseudo-paralysis of the mandibular branch of the facial nerve after platysmal face-lift operation. Plast Reconstr Surg 1979; 63 (03) 364-368
- 101 Swift A, Remington K. BeautiPHIcation: a global approach to facial beauty. Clin Plast Surg 2011; 38 (03) 347-377, v v.
- 102 Richard MJ, Morris C, Deen BF, Gray L, Woodward JA. Analysis of the anatomic changes of the aging facial skeleton using computer-assisted tomography. Ophthal Plast Reconstr Surg 2009; 25 (05) 382-386
- 103 Farkas JP, Pessa JE, Hubbard B, Rohrich RJ. The Science and Theory behind Facial Aging. Plast Reconstr Surg Glob Open 2013; 1 (01) e8-e15
- 104 Wulc AE, Sharma P, Czyz CN. The Anatomic Basis of Midfacial Aging. New York, NY: Springer; 2012
- 105 Shaw Jr. RB, Katzel EB, Koltz PF. et al. Aging of the facial skeleton: aesthetic implications and rejuvenation strategies. Plast Reconstr Surg 2011; 127 (01) 374-383
- 106 Glaser DA, Lambros V, Kolodziejczyk J, Magyar A, Dorries K, Gallagher CJ. Relationship between midface volume deficits and the appearance of tear troughs and nasolabial folds. Dermatol Surg 2018; 44 (12) 1547-1554
- 107 Pessa JE, Garza PA, Love VM, Zadoo VP, Garza JR. The anatomy of the labiomandibular fold. Plast Reconstr Surg 1998; 101 (02) 482-486
- 108 Morales P. Repeating rhytidoplasty with SMAS, malar fat pad, and labiomandibular fold treatment: the NO primary procedure. Aesthetic Plast Surg 2000; 24 (05) 364-374