8. Fifty Years of Progression in Facelifting and Neck Lifting

10.1055/b-0036-141956

8. Fifty Years of Progression in Facelifting and Neck Lifting

Steve M. Hamilton and Bruce Connell

The search for perfection in facial rejuvenation continues. Dr. Connell’s pursuit of improved results in facelift surgery represents a classic, informed, and pragmatic approach to surgical design. His underlying compulsion to accurately diagnose and ask why has shaped his career.

The facelift technique that was universally used when he was in residency in the 1950s at the Mayo Clinic involved deep-layer plication and excision of excessive skin. Fig. 8.1 shows work by Dr. Connell typical of his early practice (1952–1960) in which a facelift was accomplished by precise plication at multiple points of the investing fascia and neck defatting. The result is notable for its absence of the later, more successful jowl and neck correction. The brow lacks successful rejuvenation; however, using the techniques current in that era, he delivered not only a respectable result but also one lacking the surgical stigmata sometimes common to that period of surgical plication. No distortion of hairline or preauricular anatomy is present, and the skin rests naturally over the face.

Fig. 8.1 Early Connell **(a)** preoperative and **(b)** postoperative facelift. (1) Postoperative results demonstrate jowl laxity improved but lacks full correction seen in later work. (2) Cheeck ptosis is partially improved. (3) Infraorbital hollowing is not fully corrected. (4) Periorbital and brow correction incomplete. (5) Submental fullness not as corrected as seen in later years. (Courtesy of Dr. Bruce Connell, Santa Ana, CA.)

Not satisfied with then-current techniques, the younger Dr. Connell began tackling the surgical incisional stigmata typified by hairline shift and poor skin-color matches. His intuitive skill at limiting an observer’s ability to detect evidence of surgery would become the hallmark of his early work and reputation.

8.1 Preservation: Incision Design

Connell’s good results followed redesign of incision placement, closure technique, and preservation of normal anatomical facial boundaries, proportions, and relationships. He was inspired by the writing of Dr. Raul Loeb of Brazil, who published observations that identified natural-appearing surgical earlobe reattachment. The normal-appearing earlobe was determined to be approximately 10 to 15 degrees posterior to the long axis of the ear. Re-creation of this earlobe angle avoided the tethered, forward-swept, elflike ear often caused by surgically induced skin tension with conventional facial suspension and closure. ¹ ^, ² ^, ³ ^, ⁴ ^, ⁵ ^, ⁶ By preserving inclination of earlobe attachment, along with producing improved neck contours, his early evolution from the 1950s to the 1970s permitted maximal rejuvenation with minimal detectability of surgery.

8.1.1 Details and Planning of Incisions

Temporal Incision

While riding the Paris Metro as a young surgeon, Connell observed that a hairless gap of greater than 3 or 4 cm from the lateral orbit to the temporal hairline imbued an additional 10 years of age to any face, young or old. Similarly, he noted that surgical elevation of the sideburn above the root of the helix results in an aging appearance. ¹ ^, ³ ^, ⁴ ^, ⁶

He believes that preoperative, precise evaluation of expected skin shift should guide the choice of either a temporal incision into a hair-bearing temporal scalp location if a minimal shift in hairline superior or posterior is expected, or a hairline or intertrichial incision if the hairless space would be surgically expanded beyond 4 cm. Often one sees swept-back hair in preoperative pictures and swept-forward hair in postoperative photographs that intentionally obscure temporal hairline and ear details. Regrettably, these patients can never comfortably wear their hair back or up. Entire lifestyles that are active and outdoor based may be impacted by the visible stigmata of this hairline shift. A “pinch test” perpendicular to the temporal hairline and sideburn along the axes of expected skin shift (Fig. 8.2) will quickly predict the temporal expansion of hairless facial skin or the probability of overelevation of the preauricular sideburn above the base of the helix. ³ ^, ⁴ ^, ⁶

Fig. 8.2 Pinch test. **(a)** Estimate of preauricular/temporal skin redundancy by pinch test and the predicted skin and hairline shift measured. A 4-cm lateral-canthus-to-temporal-hairline distance is the maximum allowed for natural-looking results. A hairline incision is indicated if the redundancy present will result in greater than a 4-cm lateral-canthus-to-temporal-hairline distance. The skin shift measurement is added to the existing preoperative lateral canthal–temporal distance for determination. W-Lateral cathus to hairline displacement. X-Sideburn upward displacement looks old. Y-Cheek to tragus displacement.(b) Occipital skin pinch test. If there is a 2-cm or greater expected occipital skin redundancy (and thus an unacceptable hairline shift expected), a hairline incision is indicated. Both images show hairline incision design chosen and marked already. Z-Neck to occipital hairline displacement. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

Connell modified the classic temporal hair-bearing scalp incision at its origin in the prehelical hairline with a small semicircular anterior deflection, or prehelical flap (Fig. 8.3 and Fig. 8.4). The flap originates at the origin of the sideburn, beginning at the root of the helix, then continuing its arc in the temporal hair-bearing scalp. This “rescue” flap mitigates the formation of an unsightly notch, or hairless zone, intruding into the temporal hairline just at or above the root of the helix (Fig. 8.5). ⁴ ^, ⁵ ^, ⁶ The alternative incision follows the anterior temporal hairline or intertrichial approach and is used when an expected skin shift would expand the orbitotemporal open area beyond 3.5 to 4 cm and terminates superiorly in a small posterior incisional deflection placed before the temporal hair thins to wispy hair at the frontotemporal boundary (Fig. 8.6). The posterior deflection allows for later inset into a recipient bed created just posterior to it during closure to direct the terminus of the incision away from the sparse zone of the upper temple and reduce detectability. ¹ ^, ⁶ A fine hairline incision will preserve more ideal facial ratios and add to minimizing detectability and maximizing natural-appearing rejuvenation, ⁶ ⁷ (Fig. 8.7).

Fig. 8.3 Planning the temporal and occipital incisions. The temporal and occipital hairline incisions are shown in green. The traditional temporal and occipital scalp incision placement is shown in red (with an anterior extension in the temporal area as described by Connell). The periauricular incision is orange. Vertical skin pinch redundancy estimates are performed at points X and Y. W is the maximum lateral-canthal-to-temporal-hairline distance of 4-cm width allowed following a skin shift with a facelift. If the lateral-canthal-to-temporal-hairline distance is 4 cm or less as predicted by the pinch test exam, then a traditional temporal scalp incision *(red line)* is chosen. If the distance is greater than 4 cm, a temporal hairline incision design is chosen *(green line)*. Z is a similar pinch test for potential occipital skin advancement. If there is greater than 2 cm of redundancy and analogous skin shift predicted, a hairline incision design is recommended. If there is less than a 2-cm skin shift, a traditional hair-bearing occipital scalp incision is allowable. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

Fig. 8.4 Temporal, retroauricular, and occipital incision planning. W is the measurement of maximum recommended hairless skin distance (4 cm) from lateral canthus to temporal hairline. If pinch test skin shift measurements X and Y, added to existing distance W does not exceed 4 cm, then traditional temporal scalp incision *(A—red line)* is safe to use. A small anterior deflection in the lower temporal scalp incision *(point B)* is the prehelical flap (or “rescue” flap). This prevents the unanticipated intrusion of hairless facial skin into the sideburn and temporal scalp. If the temporal hairline displaced by skin advancement is more than 4 cm from canthus, a temporal hairline (*C—green line*) incision design is recommended. The incision stops short (superiorly) of the frontotemporal hairline *(indicated by arrow)* to avoid visibility in this sparse area. The retroauricular incision *(orange dashed line)* should fall into the postauricular crease. For occipital incision planning, expected occipital skin shift (Z) is measured assuming ideal tangential redrape as shown. If the skin shift is less than 2 cm, the retroauricular incision traverses the bare mastoid area at level of superior auditory meatus to form occipital scalp incision *(D—red line)*. If the skin shift is greater than 2 cm, the retroauricular incision follows same path and then follows the occipital hairline *(E—green line)*. The incision stops short of the sparse nape of the neck. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

Fig. 8.5 Common errors with hair-bearing scalp incisions. Both images show a facelift with traditional hair-bearing scalp incisions planned. Failure to consider the maximum canthal-to-temporal distance *(W)* of 4 cm with expected shift indicated by pinch test measurements X and Y results in temporal hairline recession along indicated advancement vector U. Similar error in not utilizing estimate Z (2 cm maximum) to guide incision design, or similar outcome due to obligatory forward and vertical flap shift vector *(V)* required to close an incision designed onto the posterior aspect of the concha. Both result in intrusion of bare neck skin into the mastoid-occipital scalp and hairline notching seen below. Retroauricular flap shift should be ideally oriented tangentially to anterior neckline to avoid this problem, and preserves important vertical neck skin length. Recognition of magnitude of anticipated centimeters of skin advancement is extremely important to incision planning. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

Fig. 8.6 Proper hairline incision design utilized when large temporal and occipital skin shifts are expected. Same scenario as seen in Fig. 8.5. Hairline incisions *(green line)* are shown as an alternative to prevent recession and notching. Proper tangential redrape skin vectors A, C, and D is demonstrated. Theoretical vertical retroauricular redrape vector B results in potential occipital hairline disturbance and bunching at earlobe inset point *(F)* due to converging vectors A and B. Vertical vector E results from incision design too high on the mastoid requiring forward rotation of flap to close, compromising redrape and potential for hairline notching. Proper tangential vectors C and D are demonstrated as ideal alternative skin shift direction. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

Fig. 8.7 Results of common incision planning errors. **(a)** Large temporal hairline shift posteriorly with small mastoid-occipital notch due to inappropriate vertical vector of redrape. **(b)** Reconstruction with hair transplants. **(c)** Large mastoid-occipital notch from vertical shift incision design onto concha and failure to plan for excess redundancy. Note that the retroauricular hypopigmentation is evidence of flap stress due to increased tension caused by vertical neck skin shortening with this incision design. **(d)** Reconstruction with hair transplants. To avoid these outcomes, strict adherence to pre-op redundancy/shift measurements and choice of hairline incisions with large shifts is essential. (Courtesy of Dr. Alphonso Barrera, Houston, TX.)

Preauricular Incision

As part of his reevaluation of the status quo in the 1960 to 1970s, Connell broke the preauricular anatomy into subunits. He determined that helix width, pretragal hollow, tragal height, superior and inferior intertragal notches, and the earlobe–cheek junction were subunits of the preauricular aesthetics that would require preservation in incision design. He reduced the number of color shifts from face to ear by careful placement of the incision within the distances defined by the simple observation of the patient’s ear anatomy and pigmentation pattern (Fig. 8.8). Incisions anterior to the natural facial and ear color shift can create multiple color shifts and become an emblem of surgery and the operated look. ⁵ ^, ⁶

Fig. 8.8 Incision design error. **(a)** Secondary facelift patient from elsewhere who sought a facelift and correction of ear deformity seen preoperatively. Prehelical facelift incision was placed two helical cartilage widths in front of posterior helical border. This appears to double helical visual width. Ear lobule and lobe–facial junction are rotated forward (tethered). **(b)** Same patient after revision/secondary facelift. Note the prehelical incision is now one helical cartilage width from posterior helical margin, and normal-appearing width restored. Ear lobule and lobe–cheek junction rotated posteriorly to “de-tether” earlobe. X-Appropriate incision placement following the visual curve of the helical rim. Y-Correction of anterior displacement of earlobe.(Courtesy of Dr. Steven Hamilton, Houston, TX.)

As shown in Fig. 8.9, the uppermost portion of the incision begins one helix width (Fig. 8.9) anterior to the posterior border of the helix beginning at the facial–helical junction. The incision then gently curves into the superior intertragal notch to the edge of the tragus.

Fig. 8.9 Incision planning: the preauricular incision. The superior portion of the preauricular incision is designed as a soft parallel curve to the posterior helical margin and designed to mimic the visual transverse width *(X)* of the helical cartilage *(bordered by arrows)*. The resulting hypopigmented preauricular incision will later mimic an ear highlight and suggest a normal, delicate helical margin and anatomical proportion. If placed further anterior, the helical width will appear exaggerated. The incision follows the depression superior to tragus and continues along the posterior tragal border. It is not placed retrotragal. A small perpendicular incision of deflection *(Y)* travels anterior to the facial–lobular sulcus and is necessary to preserve the inferior intertragal notch and tragal definition; otherwise, the natural inferior notch disappears and the tragus appears “chopped off” and too long. The incision turns 90 degrees again at the facial–anterior lobule crease and descends to harvest the earlobe–cheek junction *(Z)*, which is a natural sulcus that will help reproduce this delicate landmark during closure. Raul Loeb’s angle of dangle is illustrated. The earlobe maximum deflection point should be 10 to 15 degrees posterior to the long axis of the ear. The blue arrow denotes the slight earlobe rotation necessary to re-create this ideal relationship during closure. A hairline temporal incision is shown and diagrammed. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

In the lower one-fifth of the tragus, Connell devised a transverse flap (Fig. 8.9 y, point Y), which exits at 90 degrees from the posterior tragal edge and moves anterior across the tragus. Once it reaches the crease between the anterior lobule and the cheek, the incision turns 90 degrees again to liberate the earlobe while preserving a 2- to 3-mm cuff of facial skin to avoid closure of the earlobe to the face. ⁶ (Fig. 8.9). Failure to preserve the earlobe–cheek junction frequently results in a “stuck-on” appearance of the ear. Later, this hairless, thin cuff of tissue will provide a more natural transition and point of union with the advanced thicker, pigmented, sometimes hair-bearing facial skin and the thin, delicate ear skin closure. Without preservation of the delicate earlobe facial sulcus, no technique exists that will re-create this aesthetic, visible landmark of normalcy.

The Retroauricular Incision

Some teaching advocates a retroauricular incision onto the concha with the intended goal of prevention of a downward and posterior drift of the retroauricular incision postoperatively into the visible mastoid area. Unfortunately, placement of the incision more anterior on the concha makes it likely that downward tension will occur, as a result of greater obligatory vertical neck skin excision inherent with this approach. Connell chose to place the incision directly into the auriculomastoid groove and preserve rather than obliterate it (Fig. 8.5). He also thought that placement of the incision over the concha might lead to an unnatural webbing deformity across the auriculomastoid groove and risk the loss of another attractive landmark and delicate sulcus often appreciated when observing an individual from behind. ⁶ As stated, placement onto the concha throws the incision anterior and creates an obligatory vertical shift of neck skin to close. In contrast, the ideal shift of neck–retroauricular skin is tangential to the anterior neckline region to obtain the best redrape of redundant anterior tissue, to correct horizontal excess, and to reduce unwanted vertical skin excision. Significantly excessive vertical shift of neck skin will create an unplanned vertical skin deficit with resultant postoperative tension. Postoperatively, when the patient sits up, tension at the auriculomastoid incision will increase as the neck undergoes flexion and the shoulders naturally drop. While on the operating table, patients’ shoulders are relatively higher, and their neck is positioned commonly in some degree of extension, which gives a false impression of excess vertical skin to many surgeons. Thus, maintaining neutral head position and avoidance of an incision design that promotes vertical shifts of the neck skin are the keys to avoiding excessive vertical skin excision, incisional tension with poor scarring, and unsightly hair shifts. ⁶ ^, ⁷

The earlobe should be an attachment point, not a pivot point. Unnatural infralobular fullness can occur when the preauricular facial flap is rotated toward the ear anteriorly and the postauricular flap is also rotated toward the ear posteriorly. The convergence effect of these flaps creates fullness at the earlobe attachment and is detectable as a facelift with unnatural infralobular fullness (Fig. 8.6, point F). With a precise shift of neck skin 90 degrees to the neckline, almost no neck-flap skin will require trimming along the anterior flap edge as it moves up along the auriculomastoid groove for closure behind the ear. ⁶

Occipital Incision

This region is similar to the temporal incision design. As in the temple, if greater than 2 cm of hair shift is measured and expected to be advanced, then a hairline occipital incision should be used(Fig. 8.3 and Fig. 8.4). The incision terminates with a curved posterior deflection above the sparser occipital hair at the nape. As in the temple, the terminal post/superior deflection of the occipital incision is inset into the scalp by creation of a recipient site. Failure to anticipate a significant skin shift with an incision in the hair of the masto-occipital scalp will guarantee movement of hairless neck skin into the occipital hairline with masto-occipital hairline notching and posterior occipital hairline elevation (Fig. 8.7 a, c). ¹ ^, ⁵ ^, ⁶ ^, ⁷

Connell advocates no singular approach, but instead one based on clinical assessment, expected shift, and preservation of a normal hairline.

Submental Incision

Many “traditional” approaches have long advocated placing this incision in the submental crease (Fig. 8.10 a). ⁶ ^, ⁸

The submental incision should be placed posterior to the crease 1 to 2 cm, and its length generally is 2.5 cm (Fig. 8.10 b). ⁵ ^, ⁶ Lengthening the incision requires manual elevation of the cheek skin bilaterally to test whether planned incision length would move onto visible territory. Connell’s posterior incision placement, rather than placement at the submental crease, makes attention to these deeper, lower structures easier.

8.2 SMAS Flap Design—History

During the 1960s, Connell focused on incisional improvements and redesign. All too often the plicated investing fascia flattened cheek contours and widened the intermalar distance by gathering tissue laterally. Fixed suturing to plicate the superficial musculoaponeurotic system (SMAS) from orbit to ear also placed important permanent and supportive sutures in visible areas of the face rather than the facial boundaries he used later. Visible lumpiness, puckering, and distortion across these load-bearing plication sutures were additional stigmata Connell designed his SMAS technique to bypass by moving important points of SMAS tension and fixation sutures (Fig. 8.11).

Fig. 8.11 Planning modification of superficial musculoaponeurotic system (SMAS): the high-SMAS flap. **(a)** Design of the classic high-SMAS flap.The incision begins at a point roughly 1cm anterior and superior to the tragus above zygoma *(X)*. The incision travels medially just above the zygoma to the malar high point *(Y)*. The vertical limb travels along the preauricular sulcus over the parotid. At the inferior parotid border, the incision turns slightly posterior and travels along the anterior border of the sternocleidomastoid muscle and divides a small portion of the posterior edge of the platysma *(Z)*. **(b)** The flap is released and advanced. Shown sewn to the superficial temporal fascia superiorly. Excess posterior margin is excised and end-to-end closure accomplished. Malar overlap of SMAS flap creates a subtle augmentation to the cheek helpful in restoring youthful fullness. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

He observed that lateral platysmal attachment to the sternocleidomastoid (SCM) fascia exerted a corrective force on the submental anatomy, but correction of submental laxity was additionally improved by direct submental platysmal invagination (Fig. 8.12, Fig. 8.13, and Fig. 8.14). Connell and others, such as Dr. Rex Peterson and Dr. Jose Guerrerosantos, began dynamically releasing the platysma by complete or partial division to create a permanent and clear aesthetically pleasing release of a tight or tethered platysma. The added benefit of platysma transection was the permanent release of anterior or lateral platysmal banding and increased mobilization for improved suspension (Fig. 8.12, Fig. 8.15, Fig. 8.16, and Fig. 8.17). With age, the platysma will bowstring away from the angular submental contour that in youth is close to 90 degrees and in midlife can elongate or dehisce to a straight line from menton to sternal notch, effectively bowstrung into a 45-degree profile from chin to lower neck. Without division, any corrective suturing and tension will be overcome eventually.

Fig. 8.12 Planning modification of the superficial musculoaponeurotic system (SMAS) and platysma. Anterior platysmaplasty with full-width platysma transection. In cases of poor submental support and platysmal redundancy, a multilayered invagination of the medial platysma edges from menton to hyoid improves definition and support. If platysma too redundant, medial edges trimmed and edge-to-edge repair performed. The important caveat: Suspend the SMAS first, and then repair the anterior platysma, or a block to upward facial rotation will be created and compromise the facelift results. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

Fig. 8.13 Clinical use of retroauricular and temporal transposition flap. **(a)** Pre- and postoperative view of patient with significant neck fullness and redundancy. Use of the retroauricular transposition flap helps significantly evaluate and define submental and mandibular contour. **(b)** Diagram of actual deep methods used. Note transposition flap, platysma myotomy, and significant deep submental compartment reductions in fat, muscle, and gland volume. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

Fig. 8.14 Planning modification of the superficial musculoaponeurotic system (SMAS) and platysma: anterior platysmaplasty. The majority of aging necks require anterior platysmaplasty to achieve superior results. The key to avoiding a compromised result is to always suspend the SMAS flap first before suturing the anterior platysma. If you do not, a block to upper-face SMAS rotation will be created and reduce jowl and midface correction. **(a)** The SMAS is suspended and the medial edges of the anterior platysma can be seen. Anterior and lateral bands are seen transected. **(b)** The platysma is seen sutured either by process of multilayer invagination or, if redundancy great, medial edges trimmed and an edge-to-edge repair performed. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

Fig. 8.15 Planning modification of the superficial musculoaponeurotic system (SMAS) and platysma. **(a)** Treatment of dynamic platysmal anterior bands requires transverse platysmal myotomy from jugular vein to jugular vein at the level of the cricoid cartilage. **(b)** The SMAS is suspended first (1), then the platysma is divided low at the cricoid level (2) to avoid a step-off and loss of a gentle cervicomental transition. Performed through the submental incision. Patients treated in this minimal way typically have good preexisting lateral mandibular border definition and lack generalized platysma laxity. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

Fig. 8.16 Planning modification of the superficial musculoaponeurotic system (SMAS) and platysma. **(a)** Design of a low platysma myotomy to lyse the anterior and lateral dynamic platysmal bands planned preoperatively. **(b)** The SMAS flap is shown suspended with division of anterior and lateral platysmal bands at the level of the cricoid with extended release along anterior border of sternocleidomastoid muscle. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

Fig. 8.17 Planning modification of the superficial musculoaponeurotic system (SMAS) and platysma: “full- width” platysma myotomy. **(a)** Diagram of further extension of platysma release beyond the lateral bands superiorly along anterior border of sternocleidomastoid muscle to join the SMAS-flap incision. Used in cases of a tight, tethered platysma with an obtuse neck, marked platysmal redundancy, and poor definition over the lateral mandibular border. The lateral portion of the release is generally performed through the facelift incision approach superiorly and laterally coursing inferiorly to join with transverse myotomy performed through submental incision. **(b)** The SMAS flap has been suspended and fixed into position. The divided platysma opens up inferiorly. (Courtesy of Dr. Steven Hamilton, Houston, TX.)

Curiously, it was likely his early awareness of the powerful corrective force of platysma release that led Connell to release its fascial projection across the anterior face. This layer was identified incidentally by many surgical innovators of that time, including Tessier and Connell, and was immortalized in the classic article by Mitz and Peyronie, who worked with Tessier and coined its eponymous name. The term SMAS, rather than investing fascia, entered the lexicon of facelift surgeons everywhere. ⁹

Connell’s early elevations of the facial SMAS in continuity with the platysma reached no higher than a line parallel to and just below the lower border of the zygoma (Fig. 8.18). Results from that period show improved jowl and submental correction, but little or no midface rotation or periorbital correction is evident. From the 1970s to the 2000s, he reasoned through these limitations and, with an uncanny knowledge of facial microanatomy, redesigned his SMAS release to occur above the zygoma, where most literature warned of a high risk of frontal branch injury. As the era of midface elevation and lower eyelid filling populated the podiums of meetings in the 1980s and 1990s, Connell offered an effective solution to provide midface rotation, elevation of the depressed lid–cheek junction, and correction of infraorbital hollowing with the higher vector of SMAS supportive force associated with division of this layer above the zygoma. He further refined the high-SMAS release to include a crow’s-foot correction, or lateral orbicularis oculi myotomy. Similar to platysma division, his concept of dynamic release was applied to an obstacle to further refinement and restoration of a more youthful periorbital appearance. By dynamically releasing the orbicularis oculi, along with greater eyelid skin undermining, greater periorbital rotation and shortening of the perceived lower eyelid length occurred by a pleasing elevation of the lid–cheek junction. Realizing that the lateral orbicularis oculi frequently functioned as a depressor of the lateral brow (or depressor lateralis), his design of dynamic release of the sometimes powerful lateral orbicularis helps elevate the temporal brow, reduce crow’s feet, and shorten the vertically depressed aging lower eyelid (Fig. 8.19). What follows is a description of his final flap design to resuspend ptotic facial tissue and structures without any assistance from pulling on the thin, aged facial skin flaps as had been advocated in Connell’s day and persists in current times. Instead, he chose to observe that in his opinion the sole function of the skin was to cover, never support, the face; and any deviation from that truth would invite creation of a pulled, artificial appearance.