Anatomic Evaluation of the Vertical Face-lift in Cadavers

Abstract

arly face-lift surgery involved excision and redraping of lax skin. 1 Results were encouraging but often short-lived and not ideal because of widening of scars and other shortfalls. Skin-only techniques were the standard surgery for the aging face until 1968, when Tord Skoog, 2 of Sweden, realized the importance of repositioning the deeper structures of the face by shifting the platysma in the neck and lower face and the fascia in the cheek. The concept of incorporating the superficial musculoaponeurotic system (SMAS) rather than simply working on the skin has become widely accepted and serves as the foundation for modern face-lift surgery.Over time, surgical approaches have evolved and been refined, leading to different face-lift techniques, all of which incorporate treatment of the SMAS, including the deep plane face-lift, the composite face-lift, the "SMAS-flap," the "SMASectomy," and the "SMAS-plication." 3,4 Regardless of plane of dissection or technique chosen, most of the face-lifts performed until a few years ago had focused primarily on a superolateral vector of pull. In recent years, however, and prompted by a number of newer techniques, such as the minimal access cranial suspension and others, discussions have emerged about incorporating a more vertical vector of pull on the face. 5 IMPORTANCE This study investigates how different orientations of tension vectors affect the amount of soft-tissue lift in specific cervicofacial regions.OBJECTIVES To compare differences in cosmetic neck and face changes generated by 3 different face-lift techniques, to quantify the amount of lift across different points on the face, and to quantify changes in platysmal dehiscence in each of 3 standard superficial musculoaponeurotic system plication face-lift techniques applied to fresh-frozen cadaver heads. DESIGN, SETTING, AND PARTICIPANTSTen cadaver heads in an academic tertiary care center. INTERVENTION(S)Three different superficial musculoaponeurotic system plication rhytidectomy procedures were conducted in the following sequence: (1) vertical tension vector plication (vertical lift), (2) superolateral tension vector plication (superolateral lift), and (3) superolateral tension vector plication combined with midline platysmal plication (superolateral lift with platysmal plication). MAIN OUTCOMES AND MEASURESAfter completion of each technique, the amount of lift at 4 standard key points was measured and recorded, and differences in lift at the key points were analyzed.RESULTS Vertical lift was associated with greater total lift than superolateral lift alone or superolateral lift with platysmal plication (P < .001 for both). Platysmal dehiscence increased from baseline measurements after superolateral lift and decreased after vertical lift (P = .002 for both). CONCLUSIONS AND RELEVANCEOur findings establish how different orientations of tension vectors applied during face-lift surgery achieve different structural changes to various key points across the face. This study helps the face-lift surgeon and student understand...

The Effect of Midline Corset Platysmaplasty on Degree of Face-lift Flap Elevation During Concomitant Deep-Plane Face-lift

“…These findings are corroborated by data demonstrating similar effects in traditional SMAS plication techniques. 5 The opposing force created by midline platysmaplasty may compromise the aesthetic outcomes of rhytidectomy in 3 aspects, as represented by our data. First, it prevents vertical restoration of the cheek fat pad to its native youthful position, a hallmark of deep-plane rhytidectomy.…”

“…This reduces the amount of upward mobility of the jawline and neck tissues, and therefore decreases the effectiveness of treatment. 5 These undesireable outcomes perpetuate a substantial revision rate 6 and remain difficult to correct, warranting a thoughtful reevaluation of our indications for midline platysmaplasty to optimize our outcomes in the neck.…”

Deep Plane Facelift: An Evaluation of the High-SMAS versus Standard Incision Points

“…While the vertical elevation has been previously shown to have advantages in cadaver measurements, ours is the first study to compare standard deep plane entry point tissue movement to high-SMAS entry point tissue movement. [11][12][13] The high-SMAS entry for the deep plane lift above the zygomatic arch, rather than a subzygomatic diagonal one, allows for much improved vertical movement in the tissue. If a standard diagonal entry point is utilized, attempting significant vertical movement will often result in nonaesthetic skin bunching in the lateral orbital area.…”

Facelift Surgery: History, Anatomy, and Recent Innovations

“…While platysmaplasty provided a "hammock" or "corset" effect across the neck, it was also noted to work against and limit the upward and lateral pull on the neck associated with the traditional superolateral vectors of pull on the cheek SMAS above the mandibular line. 31,32 This tug-of-war between the downward and medial pull of platysma plication at the midline neck, and the upward and lateral pull on the SMAS has been noted to be counterproductive and to potentially limit the surgical results. Surgeons have at times turned to myotomy to more fully separate the platysmal fibers at the junction of the mandibular line and the neck to improve the appearance of the neck by creating a more visible transition from the mandibular line to the neck.…”

“…39,41 Cadaveric studies have shown that a more vertical pull avoids the distraction and dehiscence of the midline platysma commonly associated with a more superolateral vector of pull. 32 While previous rhytidectomy techniques describe releasing the retaining ligaments of the face and neck, the MACS vertical facelift only undermines a limited skin flap and, instead, uses purse-string sutures that are woven into the SMAS tissues (►Fig. 6).…”