Inferiorly Pedicled Tongue-Shaped Smas Flap During Facelift Surgery

JOSÉ M. SERRA-RENOM

JOSÉ M. SERRA-MESTRE^*

^*Neither author has a financial interest in any of the products, devices, or drugs mentioned in this chapter.

INDICATIONS

The concept of the facelift has evolved considerably over the years. The various techniques currently in use seek to obtain the most natural result possible without creating the stigmata associated with conventional facelifting techniques: the loss of the sideburns, the presence of scars in front of the hairline, or the distortion of the earlobe with anteroinferior displacement of the ear caused by cervical flap retraction. The popularization of the dissection of the SMAS in 1976 (1) allowed the abandonment of the “skin-only facelift” techniques, which achieved only short-lived results with a rapid loss of surgical effect.

ANATOMY

The SMASectomy technique described by Baker (2, 3) represented a step forward, as it permitted a more conservative approach without the need to elevate a wide SMAS flap in order to obtain consistent results. This technique is also safer because an ellipse of the SMAS is excised over the parotid gland and the facial nerve branches are protected. An anterior mobile SMAS, which is not separated from the deeper planes and thus maintains its vascularization and elasticity, is advanced along with a posterosuperior vector and sutured to the posterior SMAS fixed by the retaining ligaments; the clinical consequences are an improvement of the nasolabial folds and long-lasting results. Provided the SMAS vascularization is preserved, less atrophy will be induced and cheek emptiness is avoided. Our facelift technique (4) shares the rationale and anatomical benefits of lateral SMASectomy. What is more, instead of discarding the SMAS, we use it to create an inferiorly pedicle pointing tongue-shaped superficial fascia flap, which rotates and is transposed to the mastoid to improve neck contouring.

FLAP DESIGN AND DIMENSIONS

In our technique, we do not make an elliptical SMAS design, which allows maximal SMAS advancement at the midportion of the ellipse and provides proper correction of the nasolabial fold but does not satisfactorily correct the jowls. We make the base as wide as is necessary to reshape the cervicomandibular angle, while the width and length of the rest of the flap are tailored to ensure good correction of the nasolabial folds. By suturing the donor site and by rotating the flap in continuity with the platysma and suturing it at the level of the mastoid, we are also able to improve the neck contour. As we do not perform extensive dissection of the malar region, we can correct the facial negative vector with fat grafting (5).

FIGURE 118.1 Closed suction-assisted lipoplasty of the neck and jowls (left) and platysmaplasty (right).

OPERATIVE TECHNIQUE

Neck Contouring

The neck is infiltrated subcutaneously with a solution containing 1:200,000 epinephrine and lidocaine. To enhance the jaw line and neck contour, we dissect the cervical area without passing beyond the hyoid bone using nonaggressive lipoaspiration and undermining with a 3-mm flat cannula and attempt to leave a layer of subcutaneous fat attached to the skin. This maneuver is performed through three incisions: one incision that is 2 mm from the submental fold and two others at the insertions of the earlobes. In cases in which platysmal bands are active, the submental incision is extended about 3 cm and a midline plication is performed after myotomy at the level of the hyoid (Fig. 118.1).

Skin Flap Elevation and SMAS Flap

After infiltration of the tumescent solution, the skin flap is elevated through a preauricular incision that commences at the upper insertion of the ear without reaching the hairline and then descends behind the tragus and around the lobe. We proceed behind the ear with a 2-mm incision parallel to the retroauricular sulcus as far as the posterior auricular muscle, without reaching the hairline. The cutaneous dissection in the cheek is also limited above the parotid gland without undermining in the malar area and extends 4 to 5 cm below the angle of the mandible with an arc of about 4 to 5 cm behind the ear up to the hairline.

A pointing tongue-shaped inferiorly pedicled SMAS flap is designed (4), overlying the parotid fascia and extending from just below the lateral malar eminence to the angle of the mandible (2 cm below the inferior border of the mandible), parallel to the nasolabial fold (Fig. 118.2). The width of the flap, which
may vary between 2 and 4 cm, depends on the amount of tissue that must be removed in order to correct cheek flaccidity. This is assessed intraoperatively by a pulling test performed with a forceps. Especially in cases with wider flaps, care should be taken not to injure the marginal mandibular branch. To facilitate the dissection of the SMAS flap, it is infiltrated with the tumescent solution described above and then dissected from cephalic to caudal leaving its base attached to the platysma muscle. We then rotate the flap and close the donor site of the SMAS flap with absorbable 4-0 suture. We then apply traction to the flap in a posterosuperior direction under the angle of the mandible, suturing it behind the ear to the mastoid fascia. The redundant tip of the flap is excised and the remainder is fixed with interrupted 3-0 absorbable sutures (Fig. 118.3).

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