Skin is elastic and accommodates changes in the shape of our faces during movement and expression. It cannot provide sustained support for sagging deeper facial tissues (Fig. 38.1). Skin is a covering, not a support.
The superficial musculoaponeurotic system (SMAS) is closely connected to sagging facial tissues and is a logical vehicle to reposition them. The SMAS
is /«elastic and can provide a strong and sustained support of the midface, cheek and jowl and periorbital area (Figs. 38.2-38.4). Pulling on the skin flattens facial contours, whereas pulling on the SMAS enhances contours.
Using the SMAS to reposition sagging deep facial tissue allows skin to be redraped under normal tension, which preserves normal skin function and results in a natural appearance (Figs. 38.1, 38.5). Healing of skin incisions is without tension. Preauricular natural contours are preserved. In addition, using the SMAS extends the longevity of a facelift.
Fig. 38.1. a Detailed knowledge of the anatomy including frontal and zygomatic branches of the facial nerve is required for high superficial musculo-aponeurotic system (SMAS) transection at the top of the zygomatic arch, which permits a more cephalad vector for midface, lid-cheek junction, nasojugal groove, elevation at the angles of the mouth and eversion of upper-lip vermilion. b One year postoperatively with improvement by SMAS support and release of the crow's-feet, which enabled the skin to shift the nasojugal groove from diagonal of old age to horizontal of youth and give the appearance of youthful shorter lower eyelids
Fig. 38.2. a Preoperative view of a 19-year-old patient whose neck contour was interfering with her modeling career. A necklift can be performed without a facelift by utilizing a submental incision, combined with an incision above the occipital hair so that the short platysma muscle could be transected along the anterior border of the sterno-cleidomastoid and across the neck at the cricoid. b One year later showing improvement made by removal of subcutaneous cervical fat by open liposuction, removal of subplatysmal submental fat by scissor dissection along with transection of the platysma muscle along the anterior border of the sternocleidomas-toid and across at the cricoid. The pla-tysma muscle was shifted laterally over the fascia of the sternocleidomastoid in the upper neck. No skin was excised and no chin implant was used
Fig. 38.3. a The two circles show the point of rotation of the SMAS at the malar bone and the attachment of the osseocu-taneous mandibular ligament, which is to be released for the SMAS to have a supportive affect across the midline of the chin. The markings locate the crow's-feet to be freed from the attachment to the orbicularis oculi muscle so that the facelift skin shift can extend across the entire lower eyelid. The dotted line on the neck is the location of the incision of SMAS and
platysma muscle and follows the anterior border of the ster-nocleidomastoid and crosses at the cricoid. b Only one Allis clamp pulling on the SMAS flap shows shortening of the appearance of the lower eyelid, shift of the skin past the crow's-feet into the lower eyelid, elevation of the angle of the mouth, eversion of the lateral vermilion of the upper lip, shifting of the skin beyond the malar ligament and beyond the mandibular ligament along with a slinglike submental support
Fig. 38.5. a, c The release of osseocuta-neous submental creases along with transection of the short platysma muscles, correction of sagging skin of the face and neck and lateral brow pto-sis are corrected by utilizing deep-layer SMAS support and appropriate vectors for both the SMAS and the skin. b, d One year later the improvement has been accomplished by releasing the crow's-feet attachment to permit shifting of the skin across the entire lower eyelid and redirection of the nasojugal groove from diagonal to horizontal, high SMAS incision at the top of the zygomatic arch along with complete transection of the platysma muscle along the anterior border of the sterno-cleidomastoid and across at the cricoid for correction of the short playtsma. In addition, there has been release of the osseocutaneous malar ligament and the submental creases. No chin implant was used
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