Indication and Technique for Skin-Only Face- and Neck Lifting

James E. Zins

Gehaan D’Souza

DEFINITION

Modern face and neck rejuvenation no longer focuses only on skin tightening but also may include fat contouring and volume restoration.
Skin-only face-lift techniques avoid superficial musculoaponeurotic system (SMAS) manipulation. When combined with the release of major ligaments of the face, a skin-only face-lift may produce results equal to a more invasive technique.
Knowledge of anatomical planes, three-dimensional relationship of the facial nerves, and location of the retaining ligaments is imperative.
Procedures range from skin-only manipulation to alterations of the SMAS including minimal access cranial suspension (MACS) lift, lateral SMASectomy, extended SMAS, and the composite rhytidectomy.

ANATOMY

Skin/fascial relationship
- The facial soft tissue architecture can be described as being arranged in a series of concentric layers: skin, subcutaneous fat, superficial fascia, mimetic muscle, deep facial fascia (parotidomasseteric fascia), and the plane containing the facial nerve, parotid duct, and buccal fat pad.
- Superficial fascial system invests mimetic muscles of facial expression, whereas deep fascial system covers and protects the facial nerve branches.¹
Ligaments and zones of adhesion
- Retaining ligaments buttress the facial soft tissues against downward forces. These ligaments are in a constant location in relation to the facial nerve branches.²^,³
- Ligaments act as sentinels to the facial nerve branches.
  - True ligaments such as zygomatic and mandibular ligaments fixate the bone to the dermis and pass through SMAS.
  - False ligaments such as parotid and masseteric ligaments fixate fascial layers to superficial soft tissue.
- Recent writings have emphasized the concept of adhesions rather than retaining ligaments. Adhesions such as the masseteric temporal and supraorbital ligaments are fibrous or fibrofatty attachments between superficial and deep tissue.
Neck
- Factors that provide a youthful and aesthetically pleasing neck include distinct mandibular border, subhyoid depression, thyroid bulge, a distinct border to the sternocleidomastoid muscle, and a cervicomental angle of 105 to 120 degrees.
Facial nerve—five groups of branches are identified
- Frontal (temporal) branches: Pitanguy delineated the course that extends from 0.5 cm below the tragus to 1.5 cm above the lateral eyebrow.⁴ At the level of the zygomatic arch, the branches run 1.8 cm anterior to the helical crus, and 2 cm posterior to the lateral orbital rim deep to the SMAS and parotid masseteric fascia. Superior to the arch, the nerves travel in the innominate fascia—a fusion plane between superficial and deep fascia. One should remain superficial to the superficial layer of the deep temporal fascia or deep to the layer.⁴
- Zygomatic and buccal branches: Interconnections between these branches account for natural recovery. The most commonly injured facial nerve is the buccal ramus.
- Mandibular branches: The mandibular branch consists of a single nerve with few interconnections with other facial nerves that results in a risk of permanent injury. Posterior to the facial vessels, the mandibular rami travel within 1 cm cephalad to the mandibular border. Anterior to the facial vessels, the branches are always cranial to the border. The nerve travels deep to the parotid masseteric fascia and under the platysma by crossing superficial to the facial vessels.
- Cervical branches: The nerve travels in close proximity to the gonial angle at the 1.74 mm inferior to the mandibular border.

PATHOGENESIS

There is controversy between descent of soft tissue and volume loss in relation to facial aging. One camp suggests laxity of malar soft tissues as an etiology. The other side suggests that volume loss is the key factor leading toward facial aging.¹^,⁵
Malar soft tissue migrates distal to the zygomatic cutaneous ligaments. This leads to soft tissue ptosis directly adjacent to the fixation of the nasolabial fold.
Masseteric cutaneous ligaments support the cheek soft tissues that migrate downward inferior to the mandibular border to forming jowls.
Jowling and loss of mandibular definition occurs by laxity of masseteric ligaments or deflation of the fat compartments of the face (submandibular).

NATURAL HISTORY

Upper third

Aging is associated with
- Eyebrow ptosis
- Transverse forehead rhytides
- Vertical glabellar lines
- Hairline recession

Middle third

Aging is associated with
- Blepharochalasis
- Ptosis of malar soft tissue
- Laxity of lateral canthus and lid lead to rounding of palpebral fissure and ectropion
- Lower lid fat bulge
- Crow’s feet
- Tear trough deformity
- Palpebromalar groove
- Malar mound

The lower third and neck

Aging is associated with
- Bulge superior to the nasolabial crease
- Nasolabial crease deepening
- Marionette lines
- Exaggeration of the labiomental fold
- Perioral wrinkles
- Loss of the cervicomental angle secondary to skin ptosis, fat accumulation, and muscling banding
- Platysmal bands

PATIENT HISTORY AND PHYSICAL FINDINGS

Patients with medical comorbidities including cardiac and respiratory conditions should be excluded from surgery. Screening of bleeding complications should be undertaken.
Antiplatelet medication must be ceased 2 weeks prior to surgery.
Smoking must be stopped at least 4 weeks prior to operation.
Patients with body dysmorphic disorder, unrealistic expectations, or psychiatric illness should also be excluded.
Elderly patients (older than 65 years) are not at higher risk for complications compared to those younger than 65 years old when properly screened.