Clinical Evaluation of 225 Sub-SMAS Facelifts with No Temporal Incision

Abstract

Background: Despite their name, “short scar” procedures leave scars in the temples and the postauricular scar often requires extension. Redraping the orbicularis muscle for periorbital rejuvenation increases the risk of facial nerve injury. This retrospective cohort study was undertaken to clinically evaluate a surgical approach that eliminates the temporal incision. Methods: A sub-superficial musculoaponeurotic system (SMAS) facelift was used, incorporating a triple-vector platysmaplasty and fat injection for periorbital rejuvenation. From 2009 to 2019, 225 consecutive outpatients underwent a sub-SMAS facelift with a triple-vector (superior, lateral, medial) platysmaplasty, either alone or in combination with fat injection, laser resurfacing, blepharoplasties, endoscopic forehead lift, and other cosmetic procedures. Release of the retaining ligaments optimized SMAS mobilization. A temporal incision was not used. Fat (mean volume 32 ml) was injected into the undissected subcutaneous tissue plane. The mean follow-up time was 28 months. Results: The most frequent complication was a neuropraxia (7.6%), usually affecting a frontal nerve branch, and always temporary. Two deep venous thromboses were detected by ultrasound surveillance. No significant correlation was detected between complications and age, sex, body mass index, smoking history, or a previous facelift. Sixteen patients (7%) returned for a secondary facelift (mean interval, 3.5 years). Conclusions: A sub-SMAS facelift and triple-vector platysmaplasty with fat injection combine effective neckline rejuvenation with facial volume restoration. Avoiding a temporal incision eliminates a telltale scar. Orbicularis preservation avoids additional dissection, possibly reducing the risk of neuropraxia. Fat injection provides a net increase in facial volume. Long-term measurement studies are recommended.

Photographic Comparison of Malar Projection in 100 Facelift Patients Treated with and without Fat Injection

“…These patients were also the subject of a recently published clinical study. 18 An exemption from Institutional Review Board oversight was obtained from Advarra IRB (Columbia, Md.).…”

“…All patients underwent a subsuperficial musculoaponeurotic system (sub-SMAS) facelift, with no temporal incision. 18 The zygomatic 28 and masseteric 29 cutaneous retaining ligaments were released, and the SMAS flap was transposed superiorly and sutured to the deep temporalis fascia using 4-0 PDS sutures (Ethicon, Somerville, N.J.) (Vector 1). The lateral orbital thickening 30 was preserved.…”

“… 9 , 10 Over the last 2 decades, the importance of restoring facial volume at the time of a facelift by lipofilling has been well-recognized by plastic surgeons. 7 , 9 – 18 Indeed, any net increase is impossible without importing tissue. 18 Fat injection has been shown to provide a net increase in volume, 13 , 15 , 18 but its effect has not been quantitated in a large number of patients and compared with a control group to identify changes directly attributable to fat injection.…”

“… 18 Fat injection has been shown to provide a net increase in volume, 13 , 15 , 18 but its effect has not been quantitated in a large number of patients and compared with a control group to identify changes directly attributable to fat injection. 18 …”

“…Malar projection measured on matched photographs facilitates photographic comparisons and measurements. 9 , 10 , 18 , 24 This method allows comparison of a large number of patients treated with a facelift alone versus a facelift in combination with fat injection. By repeating measurements at subsequent time points, the longevity of injected fat may be evaluated.…”