(Short Scar Face Lift) with Lateral SMASectomy: Evolution and Application Daniel C. Baker, MD Background: The evolution of the author s technique for minimal incision rhytidectomy is reviewed. Objective: The purpose of this article is to outline the indications, advantages, and disadvantages of this technique. Methods: A total of 749 cases covering more than 10 years of clinical experience are reviewed. A classification of patient types is proposed that includes indications and surgical programs appropriate for each patient category. Results: In properly selected patients, the technique is safe, reliable, and reproducible. Complication rates are similar to those of other standard techniques. Conclusions: Minimal incision rhytidectomy with lateral SMASectomy is a useful technique that the plastic surgeon can add to his or her armamentarium. My first experience with rhytidectomy was during my plastic surgery residency in the late 1970s. At that time, a combination of extensive defatting of the neck with complete platysma muscle transection, plicating medial borders, and pulling laterally was presented as the only way to get the best result. 1,2 Many years of patient complaints, complications, and overoperated necks occurred before I abandoned most of these techniques. Evolution of the Technique When superficial musculoaponeurotic system (SMAS) dissection became popular after the work of Mitz and Peyronie 3 in 1976, it was fashionable to include a dissection of the lateral SMAS directly overlying the parotid gland. I initially performed this type of SMAS dissection in the late 1970s and continued to do so into the mid 1980s, but overall I was disappointed with the effects of a simple elevation and tightening of the lateral superficial fascia. Specifically, I saw little difference in overall facial contour regardless of whether I had performed a lateral SMAS dissection. As I gained greater experience with SMAS dissection, it became obvious that for the superficial fascia to produce any effective change in facial contour, it was necessary to elevate the mobile SMAS anterior to the parotid gland. The problem with this more exten- From the Department of Plastic Surgery, New York University Medical School, the Manhattan Eye, Ear, and Throat Hospital, and the Institute for Reconstructive Plastic Surgery, New York, NY. Accepted for publication December 8, 2000. Reprint requests: Daniel C. Baker, MD, 65 East 66th Street, New York, NY 10021. Copyright 2001 by The American Society for Aesthetic Plastic Surgery, Inc. 1084-0761/2001/$35.00 + 0 70/1/113557 doi:10.1067/maj.2001.113557 14 A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001
sive SMAS dissection is that facial nerve branches are placed in greater jeopardy. I also noted that the superficial fascia tends to thin out as it is dissected more anteriorly, making it easier for the SMAS to tear. All too often, I would note thinning and tears after elevating a SMAS flap. Any significant tension placed on the SMAS flap in suturing would result in further tears. For these reasons, I believed that an extensive SMAS dissection was not warranted in most patients and offered little long-term benefit in comparison with SMAS plication. The 1980s With the advent of lipoplasty in the 1980s, I found that I could obtain excellent neck contouring in many patients by performing lipoplasty combined with strong lateral platysmal suturing. Lipoplasty eliminated the need for a submental incision and extensive undermining in all but the most difficult necks. I also began to abandon medial platysma work (except when the bands were prominent on active animation), because the strong lateral pull obtained by suturing the platysma to the mastoid periosteum enabled me to obtain excellent neck contouring without medial plication. The 1990s In 1992, I realized that an alternative to formally elevating the superficial fascia was performing a lateral SMASectomy, removing a portion of the SMAS in the region directly overlying the anterior edge of the parotid gland. 4 Excision of the superficial fascia in this region secures mobile anterior SMAS to the fixed portion of the superficial fascia overlying the parotid. The direction in which the SMASectomy is performed is parallel to the nasolabial fold, so that the vectors of elevation after SMAS closure lie perpendicular to the nasolabial fold, thereby producing improvement not only of the nasolabial fold but also of the jowl and jawline. For the neck, a flap of the lateral platysma is developed in the region inferior to the mandibular border. After this lateral platysma flap is raised, the platysma is secured to the mastoid periosteum with figure-of-eight 2-0 Maxon sutures (United States Surgical Corp., Norwalk, CT) to help define the jawline and improve contouring in the submandibular region. This is the basic rhytidectomy operation that I have performed in more than 2000 patients since July 1992 (Figure 1). SMAS resection parallel to nasolabial fold Platysma flap sutured to periosteum of mastoid defining jaw line Width of SMAS resection depends on degree of laxity. In thin faces, plication only Vector of elevation perpendicular to nasolabial fold Figure 1. Classic retroauricular incisions in rhytidectomy with lateral SMASectomy. SMAS resection begins over the parotid gland and usually extends over the malar eminence. It runs parallel to the nasolabial fold. It is not unusual to see orbicularis oculi muscle fibers exposed at the superior limit of excision. It is essential to perform the SMAS resection in the same place where a SMAS flap superficial to the deep facial fascia was elevated. Blunt dissection in the plane between the SMAS and deep facial fascia to create a tunnel can be helpful. The width of SMAS resection depends on the laxity of tissues and the desired elevation. A platysma flap is elevated (usually 4 to 8 cm) until it is adequately mobilized to suture to the mastoid periosteum. This provides a fixed suspension of the platysma to contour the jaw line. It is reinforced with several sutures through platysma and fascia of the sternocleidomastoid muscle. Recent presentations on deep dissection rhytidectomies, subperiosteal lifts, and endoscopic approaches attest to the splendor of creative surgery. The contribution of these approaches is already evident: an increased and clearer knowledge of facial anatomy, muscle function, and human expression. I am certain that some aspect of these techniques will be incorporated by many plastic surgeons. What remains to be answered is: (1) What are the indications for these new techniques? (2) How great are the risks and complications? (3) Most important, do the benefits of these techniques outweigh their risks significantly enough to justify using them routinely? 5 The ultimate success of any rhytidectomy operation is a happy patient. That is where the best new referrals originate. Therefore each surgeon must adapt a technique that works best for his or her patients. A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 15 (Short Scar Face Lift): Evolution
Table 1. Evolution of minimal incision rhytidectomy No. of Year patients Procedure/type of patients 1990 1 Skin lift only 1991 4 SAL (neck) 1992 3 Type I patients 1992 3 1993 12 Plication or lateral SMASectomy 1994 15 SAL (neck) 1995 35 All type I and type II patients 1996 44 No platysma work 1997 45 1998 50 1998 25 SMASectomy with platysma resection 1999 245 SAL (neck) or open submental 2000 275 Patients of types I, II, III, and IV Total 749 SAL, Suction-assisted lipoplasty. Mini lifts have been around for almost a century; the first description of such a procedure was by Passot 6 in 1919. These operations were usually preauricular skin excisions with minimal undermining, resulting in minimal, short-lived improvement. More recently, the concept of the S-lift 7 with suspension sutures and SMAS plication has gained popularity. I am always hesitant to present a new surgical technique until I feel confident that it is safe, reliable, and reproducible by most trained plastic surgeons. The minimal incision rhytidectomy with lateral SMASectomy was developed out of a demand from younger female patients (aged mostly in their 40s) who sought facial rejuvenation but were adamantly opposed to any scarring behind the ears. They objected to the posterior hairline distortion, hypertrophic scars, and hypopigmentation that they often observed in their friends or mothers who had undergone face lifts. I performed my first limited incision rhytidectomy in 1990. The patient was 41 years old and had submental and submandibular fat and early jowls but good cervical skin elasticity. I performed lipoplasty of the neck and jowls with wide subcutaneous skin undermining in the face, detaching the malar and masseterocutaneous ligaments. A pure skin lift was done with no retroauricular scars. The result was superb, and I incorporated this procedure for all my younger patients with similar anatomies. In 1992, I began to add the lateral SMASectomy technique to the face lift operation for young women in their 40s. However, I noticed that vertical elevation of the face also affects the cervical skin to some degree; lax cervical skin was also tightened because the soft tissues of the face and neck are linked anatomically. Between 1990 and 1998, 204 young female patients underwent this operation without retroauricular scars (Table 1). As I became more confident about the results and the operation, I began to perform it in older patients with more progressive jowling and cervical laxity. In these patients, it was necessary to undermine further in the neck and over the sternomastoid and submandibular regions. This exposed the platysma muscle in the neck, which enabled resection of the posterior muscle continuous with the SMASectomy. By resecting platysma over the tail of the parotid gland and anterior border of the sternocleidomastoid, the facial nerves were protected and the platysma could be tightened with a lateral vector. Between 1998 and 2000, I performed 545 minimal incision rhytidectomies with lateral SMASectomy and platysma resection. Patients ranged in age from 40 to 74 years, all with a variety of facial aging signs and neck deformities. I now believe that the technique has progressed to the point where I can say that it is reliable, that it is as safe as other procedures, and that it should be reproducible for most plastic surgeons; in general, it produces consistent results in properly selected patients. Patient Categories On the basis of my surgical experience in more than 700 cases I have categorized candidates for this procedure into 4 types. Type I: The ideal candidate This patient is usually in her early to late 40s with aging primarily in the face (Figure 2 and Table 2). She may have slight cervical laxity, but elasticity is still good. There are early jowls and often submental and submandibular fat. Microgenia may be present. These patients do well with closed lipoplasty of the neck and jowls, wide subcutaneous skin undermining, and lateral SMASectomy with or without platysma resection. No retroauricular incision is necessary to improve the neck along with the face. If indicated, a chin implant enhances the result (Figure 3). 16 A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 Volume 21, Number 1
Figure 2. Presentation of a type I patient, an ideal candidate for minimal incision rhytidectomy. Table 2. Type I: Ideal candidate Presentation Aged early to late 40s Aging primarily facial Early jowls Slight cervical skin laxity May have submental fat May have microgenia Good cervical skin elasticity Surgical program SAL (neck) SMASectomy/platysma resection Plication only in thin face Chin implant if indicated A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 17 (Short Scar Face Lift): Evolution
A B Sept 1996 Aug 1997 C D Sept 1996 Aug 1997 E F Dec 1999 Dec 1999 Figure 3. A, C, Preoperative views of a 47-year-old type I patient. B, D, Postoperative views 11 months after minimal incision rhytidectomy. E, F, Postoperative views 39 months after minimal incision rhytidectomy. The patient had a septal cartilaginous graft placed at the nasal dorsum before these photographs were taken. 18 A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 Volume 21, Number 1
Figure 4. Presentation of a type II patient, a good candidate for minimal incision rhytidectomy. Table 3. Type II: Good candidate Presentation Aged late 40s to late 50s Moderate jowls Moderate cervical skin laxity Submental/submandibular fat May have microgenia No active platysma bands Surgical program SAL (neck) SMASectomy/platysma resection Plication only in thin face Chin implant if indicated Type II: The good candidate These patients are usually in their late 40s to late 50s with moderate jowls and moderate cervical skin laxity (Figure 4 and Table 3). Submandibular and submental fat are usually present, and they may have microgenia. Medial platysma bands are not present on normal animation (I do not evaluate the platysma on forced animation or on the basis of static photographs; often, what may appear to be significant platysma bands represents laxity only, which can be corrected with a lateral pull). Closed lipoplasty of the neck and jowls along with lateral SMASectomy and platysma resection produces a good result in these patients. Again, if indicated, a chin implant will enhance the result. Usually, no retroauricular incision is required, but if a dog-ear is present at the lobe, it can be corrected with a short retroauricular incision (Figure 5). A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 19 (Short Scar Face Lift): Evolution
A May 1995 B March 2000 C Oct 2000 D May 1995 E March 2000 F Oct 2000 G May 1995 H March 2000 I Oct 2000 J Oct 2000 K L Oct 2000 M Oct 2000 Oct 2000 Figure 5. A, D, G, Preoperative views of a 41-year-old type II patient. B, E, H, Postoperative views 5 years after SMASectomy only, with no lateral platysma tightening and no submental incision. The temporal incision was inside the hairline. C, F, I, Postoperative views 7 months after secondary minimal incision rhytidectomy with platysma resection and tightening with no submental incision. At the secondary operation, a temporal hairline incision was used to improve the temporal hairline. A modified brow lift was also performed. J, K, Appearance of right and left temporal hairline scars 7 months after secondary surgery. L, M, Right and left retroauricular areas show no scarring 7 months after secondary surgery. 20 A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 Volume 21, Number 1
Figure 6. Presentation of a type III patient, a fair candidate for minimal incision rhytidectomy. Table 4. Type III: Fair candidate Presentation Aged late 50s, 60s, early 70s Significant jowls Moderate cervical skin laxity Submental/submandibular fat Platysma bands on animation May have microgenia Some secondary rhytidectomy Surgical program Open submental SAL Platysma approximation at hyoid with wedge SMASectomy/platysma resection Removal of dog-ear in retroauricular sulcus Chin implant if indicated Type III: The fair candidate These patients are usually in their late 50s, 60s, or early 70s (Figure 6 and Table 4). They have significant jowls, moderate cervical laxity, and submental and submandibular fat. They may have significant medial platysma bands active on natural animation. The approach to type III patients is via an open submental incision connecting subcutaneous undermining with the face and lateral neck. Open lipoplasty of submental and submandibular fat is performed to expose the platysma muscle. A 4- to 5-cm wedge of platysma is removed at the level of the hyoid. The medial borders of the platysma muscle are approximated to define the cervicomental angle. Lateral suturing of platysma enhances the jawline. If redundant skin is present at the earlobe after redraping, it can be removed with a short retroauricular incision (Figure 7). A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 21 (Short Scar Face Lift): Evolution
A B 1 year postop C D 1 year postop E F 1 year postop Figure 7 A, C, E, Preoperative views of a 62-year-old type III patient. B, D, F, Postoperative views 1 year after surgery. 22 A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 Volume 21, Number 1
Figure 8. Presentation of a type IV patient, a poor candidate for minimal incision rhytidectomy. Table 5. Type IV: Poor candidate Presentation Aged late 60s and 70s Significant jowls Poor cervical skin elasticity Skin folds below cricoid Submental/submandibular fat Platysma bands on animation Deep cervical creases Surgical program A significant compromise Open submental SAL Platysma approximation at hyoid with wedge SMASectomy/platysma resection Chin implant if indicated Requires more extensive undermining for skin redraping Removal of dog-ear in retroauricular sulcus Retroauricular incision can always be extended Type IV: The poor candidate These patients are usually in their 60s and 70s with significant jowls and active lax platysma bands (Figure 8 and Table 5). Cervical skin elasticity is poor, and skin folds and deep creases below the cricoid are often present. These patients are not good candidates for minimal incision rhytidectomy. It can be presented to the patient as a compromise solution that keeps open the option of extending the retroauricular incision if necessary. Laterally and posteriorly, it is usually necessary to undermine over the mastoid and sternocleidomastoid to obtain proper skin redraping. Excess cervical skin must be tailored into the retroauricular sulcus (Figure 9). A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 23 (Short Scar Face Lift): Evolution
A B Oct 1999 Nov 2000 C D Oct 1999 Nov 2000 E F Oct 1999 Nov 2000 G H Nov 2000 Nov 2000 Figure 9. A, C, E, Preoperative views of a 60-year-old type IV patient. B, D, F, Postoperative views 1 year after minimal incision rhytidectomy with a temporal hairline incision. G, H, Retroauricular area shows no scarring 1 year after surgery. 24 A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 Volume 21, Number 1
Results Table 1 summarizes the minimal incision rhytidectomies that I performed from 1990 to 2000. During the past 2 years, I have used this technique in 75% of my rhytidectomies with gratifying results. All but 10 of the patients were women. Because the male neck has thicker skin and muscle, 8 few men are candidates for this procedure. Complications Table 6 summarizes the complications of this technique, which are consistent with other standard face lift operations. 9,10 Despite special attention to blood pressure control in the postoperative period, the hematoma rate is still 1.5%. The most common problems are minor revisions of earlobe and temporal hairline scars, but these are far less significant than when I was revising retroauricular scars or trying to repair posterior hairlines. Longevity The results and duration seem similar to those for my earlier rhytidectomies. A number of type I patients who returned at 5 to 8 years for secondary lifts were very pleased with the first operation. The secondary lifts were all done with the minimal incision technique. The longest follow-up on a type III patient is 3 years. Certainly, on type IV patients the result in the neck will not be as good as if retroauricular incisions were made. So far, I have 4 type III and type IV patients who would like some neck readjustment; this is the same number that I would expect to return after the classic operation. Discussion The primary advantage of minimal incision rhytidectomy accrues to the patient who prefers or often wears her hair pulled up or back (Table 7). Any retroauricular scarring or disruption of the posterior hairline makes such a patient very unhappy. In addition, the operation involves less dissection and is less invasive; presumably this results Table 6. Complications associated with minimal incision rhytidectomy Complication Incidence (%) Hematoma 1.5 Facial nerve weakness 0.1 Earlobe scar revision 2.0 Temporal hairline scar revision 3.0 Mini lift after 1 y 2.0 Pending neck revisions in 4.0 type II and type IV patients in less pain and a shorter healing time. In patients who develop a hematoma, the evacuation is easier with less morbidity. There are disadvantages as well. This is not a technique that is applicable to all patients, especially those with severe cervical skin laxity. Because the technique requires a significant vertical lift, strict attention must be given to minimizing temporal hairline shifts. In certain patients, an anterior hairline incision must be used. Fitting in dogears in the temporal and earlobe areas can be a challenge, and these areas take more time to soften and flatten. In general, I can say that in properly selected patients, minimal incision rhytidectomy with lateral SMASectomy is safe, consistent, and reliable. For the surgeon who desires to use this technique, I advise beginning with type I and type II patients to gain experience and confidence. Type III and type IV patients are more challenging, but in treating these cases it is always possible to extend the retroauricular incision if necessary. References 1. Connell B. Cervical lift: surgical correction of fat contour problems combined with full width platysma muscle flap. Aesthetic Plast Surg 1978;1:355-365. Table 7. Advantages and disadvantages of minimal incision rhytidectomy Advantages Requires less dissection Requires a less invasive procedure Is associated with less scarring Avoids posterior hairline distortion Makes for easier hematoma evacuation Limits neck exposure Disadvantages Requires more vertical skin lift Can make it difficult to fit in dog-ears in temporal and earlobe areas Requires time for temporal hairline scar to smooth Requires time for retro/earlobe scar to smooth Occasionally causes skin fold at base of earlobe Is not applicable to patients with severe cervical laxity A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 25 (Short Scar Face Lift): Evolution
2. Connell BF. Contouring the neck in rhytidectomy by lipectomy and a muscle sling. Plast Reconstr Surg 1978;61:376-383. 3. Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976;58: 80-88. 4. Baker DC. Lateral SMASectomy. Plast Reconstr Surg 1997;100:509-513. 5. Baker DC. Deep dissection rhytidectomy, a plea for caution. Plast Reconstr Surg 1994;93:1498-1499. 6. Passot R. La chirurgie esthetique des rides du visage. Presse Med 1919;27:258-262. 7. Saylan Z. The S-lift: less is more. Aesth Surg J 1999;19:406-409. 8. Baker DC, Aston SJ, Guy CJ, Rees TD. The male rhytidectomy. Plast Reconstr Surg 1977;4:514-522. 9. Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg 1983;10:543-562. 10. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Plast Reconstr Surg 1979;64:781-795. ON THE MOVE? Send us your new address at least six weeks ahead Don t miss a single issue of the journal! To ensure prompt service when you change your address, please photocopy and complete the form below. Please send your change of address notification at least six weeks before your move to ensure continued service. We regret we cannot guarantee replacement of issues missed due to late notification. JOURNAL TITLE: Fill in the title of the journal here. OLD ADDRESS: Affix the address label from a recent issue of the journal here. NEW ADDRESS: Clearly print your new address here. Name Address City/State/ZIP COPY AND MAIL THIS FORM TO: OR FAX TO: OR PHONE: Mosby 407-363-9661 800-654-2452 Subscription Customer Service Outside the USA, call 6277 Sea Harbor Dr 407-345-4000 Orlando, FL 32887 26 A ESTHETIC S URGERY J OURNAL ~ JANUARY/FEBRUARY 2001 Volume 21, Number 1