Foundation facelift

CHAPTER 10 Foundation facelift

Patient evaluation

Foundation facelift is particularly useful in certain classes of patients.

Patient evaluation is directed towards identifying anatomical features which will be particularly well treated with the foundation facelift. Conversely, some anatomical features are better treated with other techniques. Evaluation proceeds as follows.

Evaluate the skin of the face and neck and underlying soft tissues for laxity and loss of elasticity. Laxity is characterized by excess and redundant skin. Loss of elasticity means that the skin does not easily snap back after being put under stretch, and mitigates against a superior and long-lasting result. These patients should be warned that an early secondary operation may be necessary.

Severe sun damage, as evidenced by rhytids, thinning of the skin, and pigmentary changes, should also be noted and pointed out to the patient. These actinic changes are little improved by facelifting, and the patient should be aware of the limitations imposed by solar damage to the skin.

Ptosis of the platysma, evidenced by vertical bands in the anterior neck, will almost always require anterior platysma plication for correction.

Note presence of excess fat in the neck, as removal of this excess is a sine qua non for creating a youthful neck and jaw line.

Jowling and deep nasolabial folds should be noted. These hallmarks of facial aging are well-treated with foundation facelift.

Descent of the malar fat pad is also a cardinal sign of aging. Its correction requires movement of the fat pad and skin in a vertical, cephalic direction.

The quality and thickness of the preauricular skin and the presence of fine hairs on the skin should be noted in women and men. Thick, hair-bearing skin in either sex is a relative contraindication to using a retrotragal incision, since transposing the thickened, hair-bearing skin to cover the tragus will obscure the fine detail of this important anatomic landmark.


From its origin in the lower neck, the platysma muscle extends to the lower cheek, covering a portion of the lower parotid gland before inserting into the perioral muscles at the corner of the mouth (Fig. 10.1). The investing fascia of the platysma continues cephalad in the cheek as the SMAS (superficial musculo-aponeurotic system). The SMAS lies superficial to the masseter muscle and the buccal fat pad, before continuing in a cephalic direction to invest the deep and superficial layers of the zygomatic major and minor.

The defining feature of the foundation facelift is elevation of the SMAS-platysma, subcutaneous fat, and overlying skin as a unified flap. The SMAS-platysma is the integrated foundation of this musculo-cutaneous, composite flap. In the upper neck and lower cheek, the platysma is the deepest layer of the flap (Fig. 10.2); in the mid and upper cheek, the platysma continues as the SMAS and forms the deepest layer of the flap (Fig. 10.3).

Safe and facile performance of the foundation lift requires the surgeon to possess an intimate knowledge of the three-dimensional course of the facial nerve as its branches traverse the musculo-fascial planes of the cheek and upper neck.

As the nerve branches exit the parotid gland, they lie deep to two important fascial planes:

The more superficial and thicker plane is the SMAS-platysma.

Just deep to the SMAS-platysma is a thin layer of fascia lying just superficial to the nerve branches.

As the zygomatic and buccal branches course in a cephalad direction, they are covered by the zygomaticus major and minor muscles (Figs 10.3 and 10.4).

A more complete understanding of the anatomy of the foundation facelift is obtained by studying an artist’s representation of the surgeon’s view when the flap is elevated (Fig. 10.5). The platysma is elevated with the subcutaneous fat and skin in the lower cheek. In the mid and upper cheek, the platysma becomes the SMAS and is also elevated with the subcutaneous fat and skin. The malar fat pad in the upper cheek also remains attached to the skin and is elevated as the skin is mobilized and repositioned. Note the course of the branches of the facial nerve as they exit the anterior border of the parotid gland, but remain covered by masseteric fascia, buccal fascia, and the zygomaticus major.

Technical steps

Mar 4, 2016 | Posted by in Aesthetic plastic surgery | Comments Off on Foundation facelift
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