Face Lift

Patients display individually unique crow’s feet lines, and deeply etched in wrinkles and treatment with botulinum toxin analogues must be tailored to each case. For the most part, lower botulinum toxin doses produce a more animated result, while higher doses of botox, xeomin, or dysport act to paralyze and relax wrinkles more completely. Low dosages for the most part deliver a more relaxed appearance. When rejuvenating with hyaluronic acid fillers, such as juvederm, restylane, or voluma, superficial, intermediate, and deep layers maybe injected in the periorbital region. Filling and correction of tear trough deformities should take place in the deeper layers when they had been present since early life, and deeper when they had been acquired through, tissue descent, thinning of skin, and other age associated changes. Finally, the entire region should be evaluated completely and treated with as many modalities as necessary to effect the necessary change.

 

This technique achieves the same effect as the SOOF lift in a deeper plane. By its design, it can only address the midface, but not the lower face/neck area, nor the outside of the midface with respect to sagging skin. Insofar as what it is designed to do, the technique is extraordinarily powerful, and produces fantastic results in the appropriately selected patient. A lower third face lift along with forehead lift, or brow lift technique, must be added to the subperiosteal face lift, or deep midface lift, however, if rejuvenation of the entire face is needed and desired.

Extending any face lift to involve the muscle found under the skin of the neck (the platysma muscle) results in lifting of the neck. In many cases a submental incision (an incision in the crease found on the underside of the chin) is added to address the fat found in this location, as well as platysma diastasis (banding of the neck that results from incomplete junction of the right and left neck muscles.

Unsatisfactory results may be divided into two categories, true surgical complications, and incongruence between patient expectations and achieved results. Depending on the severity of a true complication, it may or may not be significantly improved via further face lift surgery. Improper re-draping, inadequate tightening, poorly placed scars, and prominent scars may all be improved by revision rhytidectomy. You should discuss your dissatisfaction with your surgeon to see if he or she feels that the situation may be helped, prior to seeking the advice and intervention of another physician.

This SMAS layer is present in the face immediately deep to the subcutaneous fat. If you follow it anteromedially (toward the mouth and nose) it will invest (or wrap) around the musculature of the face. If you follow it inferiorly (down into the neck) it will merge with the platysma, the superficial neck muscle that can produce tents in the skin when contracted. If followed superiorly (up into the forehead) the SMAS will become contiguous (one) with the frontalis muscle, the muscle responsible for lifting the eyebrows. The significance of this layer is that most surgeons agree that mobilizing it, in some form, and using it to anchor the overlying skin in some fashion, will yield more durable results, and a heartier tissue flap more resistant to ischemia (oxygen deprivation). While this makes sense it has never been shown unequivocally to produce superior result to skin-only face lifts. It is however safer to do for smokers in whom tissue viability with skin only flaps would be questionable.

“SMAS” stands for sub muscular aponeurotic system. The fancy name is just a way to describe the layer found immediately beneath facial skin and fat. Closer to the ear this layer is a thin fibrous sheath, further in toward the nose it transitions to the muscles that move your face, mouth, nose, eyes, etc. and are essentially responsible for your facial expressions. Into the neck, the layer becomes a thin coat of muscle that can tent neck skin. Using this layer for suspension could potentially provide a more substantial lift, both in terms of result and longevity. The reasons some surgeons shy away from this type of lift is that it requires dissection under this layer. The problem with this is that the nerve that supplies the facial musculature, the facial nerve, with its many branches is at a considerably higher chance for injury. This can happen, albeit temporarily, even if the nerve is not cut, but only stretched or tugged. The result is paralysis of some of the muscles of facial expression, which could range from a purely cosmetic, temporary deficit, to more serious problems like oral incontinence, or the inability to close the eyes. A more limited dissection exposing only enough edge to sew without risking a deeper dissection can achieve similar results to a full SMAS lift. In conclusion, the full submuscular aponeurotic system (SMAS) lift should be reserved lift for smokers, while a variation of this deeper lift involving more limited dissection should be reserved for patients without and risk of devascularizing a thin muscular flap.