Part I Face and Neck Lift

Thomas A. Mustoe, Eugene Park, and Sammy Sinno

Abstract

Facial aging is caused by atrophy and attenuation of deep layers of the face, including the subcutaneous fat and the underlying superficial fascial layers that encompass the superficial facial muscles and the skin. The deep plane facelift recognizes that all layers must be addressed with complete release, even tension and redraping, and excess tension on the skin must be avoided to achieve a natural appearance and longevity of result.

Facelift – deep plane – necklift – SMAS – retaining ligaments

10 Deep Plane Facelift

Key Points

Retaining ligaments must be released to allow for adequate mobilization of overlying tissues.
The extent of inferior dissection is determined by the degree of neck mobilization aimed to be achieved.
A superb understanding of facial anatomy is imperative to prevent damage to the branches of the facial nerve.

10.1 Preoperative Steps

10.1.1 Planning

It is critical to understand that the superficial musculoaponeurotic system (SMAS), a thin fascia layer just under the subcutaneous fat, is contiguous with and encloses the platysma muscle and inferior surface of the orbicularis oculi muscle, respectively.
The retaining ligaments are collagen attachments that pass through the skin to the SMAS and deeper tissues (Fig. 10.1).
The zygomatic retaining ligaments and masseteric retaining ligaments must be released in the face to allow adequate mobilization.
In the neck, the retaining ligaments are along the posterior border of the platysma just anterior to the great auricular nerve. They also run obliquely down the neck where they have attachments to the sternocleidomastoid muscle (SCM) and attachments to the anteroinferior portion of the parotid gland (Fig. 10.2). All of these attachments must be released for the neck to be mobile. The further inferiorly the attachments are released, the more inferior the pivot point, and the more the neck tissues (composite of SMAS-platysma and skin) can be mobilized and moved superiorly and posteriorly.
The SMAS-platysma is directly above the branches of the facial nerve:
- In the neck, the cervical branch enters the platysma anterior to the retaining ligaments.
- The marginal mandibular branch is protected by the parotidomasseteric fascia (Fig. 10.3).
- The buccal branch runs just above Stensen’s duct (Fig. 10.4).
- The zygomatic branch runs underneath the zygomaticus major muscle.
- The frontal branch becomes more superficial above the zygomatic arch.
Prior to surgery, routine labs and an electrocardiogram (EKG) should be obtained. Hypertension is managed with clonidine. Smoking must be stopped at least 3 weeks prior to surgery.
Risks including hematoma, facial nerve injury, skin necrosis, and limitations of skin elasticity are discussed with the patient.