Because modern facelift patients desire a less-invasive approach or minimally invasive approach to reduce visible scarring and decrease the recovery phase, achieving the surgeon’s goal of optimal, reliable, and long-term aesthetic results with few complications becomes a challenge. The authors use the terms minimal access and traditional access to describe rhytidectomy approaches based solely on incision size. A short-incision, minimal-access approach with a deep-plane extended dissection is presented. A preoperative physical examination maneuver to evaluate a patient’s candidacy for a minimal-access approach and guidelines for when to include platysmaplasty with the procedure to further improve cervicomental contour are described.
Key points
- •
Current trends in surgery are evolving towards less invasive techniques.
- •
Minimal access techniques should provide long-term aesthetic results with few complications.
- •
A short incision, minimal access approach with a deep plane extended dissection is described and guidelines for its use are discussed in detail.
Introduction
With the increasing popularity and societal acceptance of cosmetic surgery over the last 3 decades, several novel rhytidectomy techniques have emerged. Current trends in surgery are evolving toward less invasive techniques. Therefore, it is no surprise that subspecialties of minimally invasive surgery have evolved and patients actively seek surgeons trained in these methods. The authors think that, in rhytidectomy surgery, the term minimally invasive translates into patients’ desire for
- 1.
A smaller incision and, therefore, less scarring
- 2.
A shorter postoperative recovery
- 3.
Less risk
The result of this mindset is that patients are shying away from longer incision techniques. These techniques include approaches that enter into the temporal scalp with consequential hair loss and long posterior auricular/occipital scalp incisions that prevent patients from wearing their hair up in a ponytail. Some of the more recently popularized modifications promote the use of a vertical vector of lift, which limits the need for posterior auricular/occipital incisions and scars, such as that seen in the minimal-access cranial suspension (MACS) lift. Although the authors do not use the MACS lift, they incorporate the principal of lifting both the Superficial Musculo-Aponeurotic System (SMAS) and superficial tissues in a more vertical vector in their technique that is described in this article.
Misconceptions of Lunchtime Lifts
This patient mindset has also led to the popularization of terms, such as lunchtime facelifts , that lead the consumer to think that a procedure and recovery can occur over 1 hour. Full chains of surgical centers offer these procedures promoting a minimal recovery time. Unfortunately, there are several misconceptions that arise with buzzword marketing, and this may lead to patient dissatisfaction. Although less invasive procedures may have some component of decreased recovery time, the lunchtime facelift tends to understate the true extent of postoperative edema, ecchymosis, and overall recovery that is encountered. Even in a short skin-flap SMAS plication rhytidectomy, early recovery, including bruising and swelling, can extend for 1 to 2 weeks, which is hardly lunchtime.
The misconception is further compounded by the fact that, although patients want a minimal procedure, they do not want a minimal or subtle result or a result that lasts a minimal or short duration. Most patients expect results of a facelift to address the face, including the jawline (jowls) and drooping cheeks and neck. Also, they expect it to last 5 to 10 years. Patients anticipate the efficacy of a minimally invasive technique to be comparable with a more invasive technique. Although a surgeon can manage expectations and describe that a procedure will have a partial correction in certain areas or will have less longevity, it is the authors’ experience that patients are dissatisfied when they have residual facial ptosis, jowling, and neck redundancy.
Surgeons’ View of Minimally Invasive Facelifts
To most surgeons, a minimally invasive facelift is synonymous with a limited incision, short skin-flap elevation, and an SMAS plication or imbrication. The senior author (A.A.J.) has essentially abandoned this technique because the authors have experienced a high recurrence of facial ptosis over a 1- to 2-year period. A recent review of the plastic surgery literature has demonstrated a lack of consensus about whether more manipulation of the SMAS and deep facial tissues improves outcomes in rhytidectomy. There are a few studies suggesting no difference in outcomes at 1 year when comparing minimal SMAS manipulation techniques with more significant manipulation, but these studies only used subjective photographic analysis by physicians. They did not account for patient satisfaction with the procedure, and the cohorts had small treatment groups with only 20 patients. A study focusing on patient dissatisfaction after rhytidectomy caused by the recurrence of facial ptosis demonstrated that either the SMAS plication technique used in the MACS lift or the SMASectomy approach have a dissatisfaction rate requiring a tuck-up procedure in 50% of cases at 2 years. Others have demonstrated a 21.7% dissatisfaction rate at 1 year caused by persistent jowling after a short skin-flap SMAS plication facelift, which necessitated a tuck-up procedure. This finding is not surprising because the short-term efficacy of SMAS plication was noted by Aufrecht and Baker, who first described plicating the SMAS in the 1960s. Other studies demonstrated no benefit when plicating the SMAS versus a skin-only rhytidectomy at 1 year.
After Hamra’s description of the deep-plane rhytidectomy, Kamer and Frankel demonstrated a 97% patient satisfaction rate in a cohort of 335 patients undergoing the deep-plane technique, decreasing the tuck-up rate at 1 year to 3.3% when compared with a 11.4% tuck-up rate with an extended SMAS flap cohort of 279 patients. The greater longevity of rhytidectomy techniques that elevate an extended SMAS flap was also shown in another study whereby the average length of time from the primary to secondary facelift in patients repeating their rhytidectomy was 11.9 years.
MADE Lift
Because of the senior author’s (A.A.J.) experience, and supported by the aforementioned data, he has evolved to a rhytidectomy procedure that incorporates a shorter incision with an extended deep-plane dissection that has been described as a MADE facelift or minimal-access deep-plane extended vertical vector facelift. This technique is the subject of this article. The authors’ tuck-up rate on 153 patients at 1 year of 3.9% was published in its original description and has been consistent at 3.0% after the 1-year follow-up of 254 patients. The shorter incision is possible by incorporating a more vertical vector of skin excision as originally described in the MACS lift.
The MADE lift includes a more extensive dissection of the cheek, including the release of the zygomatic osseocutaneous ligaments with vertical elevation of the malar fat pad for midface improvement. This vertical elevation is not possible without the release of the zygomatico-cutaneous ligaments and more extensive midface dissection. It has been recently shown that the zygomatic ligament is the strongest of the facial retaining ligaments and has limited elasticity. This finding suggests that without the release of this region, superficial suturing techniques will have little effect on midface improvement. This release and vertical elevation creates a superior stacking of the malar fat pad, which adds volume to the cheek and recreates the heart-shape face of youth.
Recovery Time with the MADE Lift
The questions is whether this shorter-incision deep-plane approach, although potentially more efficacious, is commensurate with the patients’ desire for minimal surgery because it may create a longer recovery. Interestingly, it has been the authors’ experience that a deep-plane rhytidectomy, which involves the elevation of the skin and SMAS as a composite flap without delaminating them, is associated with a shorter recovery than when they performed a skin flap in rhytidectomy with a separate SMAS tightening. The authors think this decreased bruising is caused by the avascular nature of the deep-plane flap fascial dissection when compared with the highly vascular plane of dissection within the subdermal plexus during skin-flap elevation in traditional rhytidectomy. When a skin flap is elevated, any bruising is also more superficial and, therefore, more visible during recovery when compared with deep-plane dissection. The authors also have noticed more rapid resolution of bruising and faster healing of incision lines. The authors think that this is caused by the greater blood supply of the deep-plane flap. Deep-plane surgery preserves the transverse facial artery, which acts as an axial blood supply to the facelift lift flap, while this vessel is disconnected from the skin during skin flap elevation in standard rhytidectomy.
Edema and Lymphatic Drainage in Facelift
It is often suggested that either deep-plane dissection or elevation of an SMAS flap is associated with greater postoperative edema, but a recent study does not support this conclusion. Lymphoscintigraphy during the postoperative period shows that the depth of dissection disrupts lymphatic drainage of the face the same as simple skin-flap elevation. It is the length of flap elevation and not its depth that determines its effects on lymphatic drainage of the face. In fact, this study demonstrated that all approaches studied, which included a skin flap with SMAS plication and composite rhytidectomy, have a subtotal recovery of lymphatic pathways within 3 months and complete return-to-baseline drainage pattern after 6 months, regardless of the surgical technique. This finding also explains why patients typically like their results more at 3 months when their face has increased volumization as a result of some residual postoperative edema than after 6 months to a year when all edema has resolved.
Risks Involved in Facelift
Patients looking for a minimally invasive procedure often desire a procedure with less risk. All rhytidectomy approaches have 3 possible major complications:
- 1.
Hematoma
- 2.
Skin slough
- 3.
Facial nerve paresis
The incidence of hematoma is usually quoted between 1.8% and 9%, but higher or lower hematoma rates have not been identified in any particular approach.
The rate of skin slough in rhytidectomy is greater in techniques that require a long skin flap to be elevated because the main blood supply to the skin flap is random based on the subdermal plexus; the longer the flap, the greater the risk of necrosis. Because of this, shorter skin flaps do have a lower rate of necrosis. Although deep-plane flaps are longer flaps, they maintain a thicker flap with the preservation of the transverse facial artery as noted and, thus, have a theoretical lower rate of skin necrosis. This feature makes a long deep-plane flap more favorable than a long skin flap. The senior author has demonstrated a 0% skin slough rate in patients actively smoking during the preoperative and postoperative phase when undergoing deep-plane rhytidectomy. This finding supports the idea that the greater blood supply of the deep-plane flap reduces the risk of necrosis.
Facial nerve paresis is a concern for both the patients and surgeon. Although staying superficial to the nerves by performing plication of the SMAS implies less risk, facial nerves can be lassoed with suturing techniques creating nerve injury. Further, there have not been any studies showing increased rates of temporary or permanent facial nerve paresis related to more aggressive lifting of the SMAS in SMAS flap or deep-plane rhytidectomy with a careful and experienced technique. In fact, a series of 2500 consecutive deep-plane facelifts had no permanent facial nerve injury. The authors have reported a temporary facial nerve neuropraxia rate of 1.3% and no permanent facial nerve injuries, which is within the reported incidence of 2.1% temporary neuropraxia reported in a survey of more than 12 000 facelifts.
Surgical Approach Options
Because the MADE procedure results in a shorter incision, addresses the midface, jawline and neck, has a more rapid healing phase, and has a low rate of complications, it is the procedure the authors offer for their patients seeking a minimally invasive procedure. The authors offer primary surgical patients 2 approaches: a minimal-access (short incision) deep-plane vertical facelift (MADE) or a traditional-access (longer incision) deep-plane facelift. The key to the MADE approach’s shorter incision (not requiring a posterior auricular/occipital scalp limb) is the vertical vector of the lift. It is also less invasive because it does not require a separate midline platysmal tightening procedure because the deep plane is extended below the mandible and creates a widely undermined lateral platysmal flap, which corrects midline platysmal redundancy. This lack of a midline platysmoplasty makes the procedure duration shorter by obviating an additional platysmaplasty. It can be used in most aging face candidates with mild to moderate rhytidosis facialis, usually in the 40s to the 60s.
Poor candidates for this approach include those with more severe facial ptosis and poor anatomy, including retrognathia, low anterior hyoid, and severe platysmal redundancy. They require a traditional-access deep-plane facelift often combined with a midline platysmaplasty. The authors’ traditional-access approach incorporates a longer postauricular incision that extends into the occipital scalp and a submental incision for anterior platysmal plication.
The authors not only describe their short-incision, extended deep-plane, vertical vector facelift surgical technique but also a method to evaluate patients’ candidacy for a minimal-access approach based on a preoperative physical examination maneuver. The authors also provide guidelines to help the surgeon decide when to include Platysmaplasty with the procedure to further improve the cervicomental contour. The authors’ experience with 342 patients with this approach is presented.
Preoperative Evaluation and Candidacy
The authors have developed a basic decision algorithm for determining whether patients are candidates for minimal access or traditional access to a facelift. The preoperative physical examination of patients is the most decisive factor in the determination of candidacy for a short-incision deep-plane rhytidectomy. This examination includes observing how the face and neck redrapes when traction is placed on the skin along the vertical vectors of this facelift technique. The authors have had success with patients aged from 40 to 70 years, even if there is significant anterior platysmal cording and submental skin excess. Anatomic variants that may predispose to failures in the submental region with this technique include those with retrognathia, low anterior hyoid, and a short vertical height of the neck. In these cases, more aggressive submental surgery is required. The additional procedures that address unfavorable cervicomental contour issues include submental liposuction, platysmal plication, subplatysmal fat excision, and/or anterior digastric plication.
A physical examination technique that the authors use to determine candidacy for the MADE vertical facelift involves traction on the facial skin to evaluate the vertical and horizontal components of the neck; the authors call this the facial redraping capacity ( Fig. 1 ). This technique helps determine whether patients are candidates for sparing the posterior hairline incision of traditional facelifts. The deep-plane entry point is a line that courses from the angle of the mandible to the lateral canthus.
- •
The surgeon places 3 fingers at the deep-plane entry point on both sides of the face and moves the skin vertically to assess whether the submental and platysmal skin laxity is corrected.
- •
If the submental area is corrected, then there is no posterior hairline limb incision or any anterior platysmal surgery necessary.
- •
If patients still have significant horizontal neck skin excess with this maneuver, and platysmal cording exists, then an abbreviated incision is not advisable. The neck redundancy will exist and recur postoperatively. A posterior auricular hairline incision to remove the horizontal neck laxity and anterior platysma plication for midline platysmal redundancy would then be necessary.
Another guideline used when deciding whether to add a platysmaplasty to the facelift procedure or not is based on anatomic studies. Extending a traditional deep-plane rhytidectomy inferiorly to release the lateral platysma and cervical retaining ligaments of the platysma to the sternocleidomastoid muscle achieves greater lateral motion of the midline platysma, in fact 554% more than using lateral platysmal plication suturing. In this study, the average redraping of the midline platysma was 2.4 cm. Because of this, the authors are more likely to perform a midline platysmaplasty to resect excess medial platysma and plicate the two sides in the midline when the platysmal divergence approaches 3 cm.
Introduction
With the increasing popularity and societal acceptance of cosmetic surgery over the last 3 decades, several novel rhytidectomy techniques have emerged. Current trends in surgery are evolving toward less invasive techniques. Therefore, it is no surprise that subspecialties of minimally invasive surgery have evolved and patients actively seek surgeons trained in these methods. The authors think that, in rhytidectomy surgery, the term minimally invasive translates into patients’ desire for
- 1.
A smaller incision and, therefore, less scarring
- 2.
A shorter postoperative recovery
- 3.
Less risk
The result of this mindset is that patients are shying away from longer incision techniques. These techniques include approaches that enter into the temporal scalp with consequential hair loss and long posterior auricular/occipital scalp incisions that prevent patients from wearing their hair up in a ponytail. Some of the more recently popularized modifications promote the use of a vertical vector of lift, which limits the need for posterior auricular/occipital incisions and scars, such as that seen in the minimal-access cranial suspension (MACS) lift. Although the authors do not use the MACS lift, they incorporate the principal of lifting both the Superficial Musculo-Aponeurotic System (SMAS) and superficial tissues in a more vertical vector in their technique that is described in this article.
Misconceptions of Lunchtime Lifts
This patient mindset has also led to the popularization of terms, such as lunchtime facelifts , that lead the consumer to think that a procedure and recovery can occur over 1 hour. Full chains of surgical centers offer these procedures promoting a minimal recovery time. Unfortunately, there are several misconceptions that arise with buzzword marketing, and this may lead to patient dissatisfaction. Although less invasive procedures may have some component of decreased recovery time, the lunchtime facelift tends to understate the true extent of postoperative edema, ecchymosis, and overall recovery that is encountered. Even in a short skin-flap SMAS plication rhytidectomy, early recovery, including bruising and swelling, can extend for 1 to 2 weeks, which is hardly lunchtime.
The misconception is further compounded by the fact that, although patients want a minimal procedure, they do not want a minimal or subtle result or a result that lasts a minimal or short duration. Most patients expect results of a facelift to address the face, including the jawline (jowls) and drooping cheeks and neck. Also, they expect it to last 5 to 10 years. Patients anticipate the efficacy of a minimally invasive technique to be comparable with a more invasive technique. Although a surgeon can manage expectations and describe that a procedure will have a partial correction in certain areas or will have less longevity, it is the authors’ experience that patients are dissatisfied when they have residual facial ptosis, jowling, and neck redundancy.
Surgeons’ View of Minimally Invasive Facelifts
To most surgeons, a minimally invasive facelift is synonymous with a limited incision, short skin-flap elevation, and an SMAS plication or imbrication. The senior author (A.A.J.) has essentially abandoned this technique because the authors have experienced a high recurrence of facial ptosis over a 1- to 2-year period. A recent review of the plastic surgery literature has demonstrated a lack of consensus about whether more manipulation of the SMAS and deep facial tissues improves outcomes in rhytidectomy. There are a few studies suggesting no difference in outcomes at 1 year when comparing minimal SMAS manipulation techniques with more significant manipulation, but these studies only used subjective photographic analysis by physicians. They did not account for patient satisfaction with the procedure, and the cohorts had small treatment groups with only 20 patients. A study focusing on patient dissatisfaction after rhytidectomy caused by the recurrence of facial ptosis demonstrated that either the SMAS plication technique used in the MACS lift or the SMASectomy approach have a dissatisfaction rate requiring a tuck-up procedure in 50% of cases at 2 years. Others have demonstrated a 21.7% dissatisfaction rate at 1 year caused by persistent jowling after a short skin-flap SMAS plication facelift, which necessitated a tuck-up procedure. This finding is not surprising because the short-term efficacy of SMAS plication was noted by Aufrecht and Baker, who first described plicating the SMAS in the 1960s. Other studies demonstrated no benefit when plicating the SMAS versus a skin-only rhytidectomy at 1 year.
After Hamra’s description of the deep-plane rhytidectomy, Kamer and Frankel demonstrated a 97% patient satisfaction rate in a cohort of 335 patients undergoing the deep-plane technique, decreasing the tuck-up rate at 1 year to 3.3% when compared with a 11.4% tuck-up rate with an extended SMAS flap cohort of 279 patients. The greater longevity of rhytidectomy techniques that elevate an extended SMAS flap was also shown in another study whereby the average length of time from the primary to secondary facelift in patients repeating their rhytidectomy was 11.9 years.
MADE Lift
Because of the senior author’s (A.A.J.) experience, and supported by the aforementioned data, he has evolved to a rhytidectomy procedure that incorporates a shorter incision with an extended deep-plane dissection that has been described as a MADE facelift or minimal-access deep-plane extended vertical vector facelift. This technique is the subject of this article. The authors’ tuck-up rate on 153 patients at 1 year of 3.9% was published in its original description and has been consistent at 3.0% after the 1-year follow-up of 254 patients. The shorter incision is possible by incorporating a more vertical vector of skin excision as originally described in the MACS lift.
The MADE lift includes a more extensive dissection of the cheek, including the release of the zygomatic osseocutaneous ligaments with vertical elevation of the malar fat pad for midface improvement. This vertical elevation is not possible without the release of the zygomatico-cutaneous ligaments and more extensive midface dissection. It has been recently shown that the zygomatic ligament is the strongest of the facial retaining ligaments and has limited elasticity. This finding suggests that without the release of this region, superficial suturing techniques will have little effect on midface improvement. This release and vertical elevation creates a superior stacking of the malar fat pad, which adds volume to the cheek and recreates the heart-shape face of youth.
Recovery Time with the MADE Lift
The questions is whether this shorter-incision deep-plane approach, although potentially more efficacious, is commensurate with the patients’ desire for minimal surgery because it may create a longer recovery. Interestingly, it has been the authors’ experience that a deep-plane rhytidectomy, which involves the elevation of the skin and SMAS as a composite flap without delaminating them, is associated with a shorter recovery than when they performed a skin flap in rhytidectomy with a separate SMAS tightening. The authors think this decreased bruising is caused by the avascular nature of the deep-plane flap fascial dissection when compared with the highly vascular plane of dissection within the subdermal plexus during skin-flap elevation in traditional rhytidectomy. When a skin flap is elevated, any bruising is also more superficial and, therefore, more visible during recovery when compared with deep-plane dissection. The authors also have noticed more rapid resolution of bruising and faster healing of incision lines. The authors think that this is caused by the greater blood supply of the deep-plane flap. Deep-plane surgery preserves the transverse facial artery, which acts as an axial blood supply to the facelift lift flap, while this vessel is disconnected from the skin during skin flap elevation in standard rhytidectomy.
Edema and Lymphatic Drainage in Facelift
It is often suggested that either deep-plane dissection or elevation of an SMAS flap is associated with greater postoperative edema, but a recent study does not support this conclusion. Lymphoscintigraphy during the postoperative period shows that the depth of dissection disrupts lymphatic drainage of the face the same as simple skin-flap elevation. It is the length of flap elevation and not its depth that determines its effects on lymphatic drainage of the face. In fact, this study demonstrated that all approaches studied, which included a skin flap with SMAS plication and composite rhytidectomy, have a subtotal recovery of lymphatic pathways within 3 months and complete return-to-baseline drainage pattern after 6 months, regardless of the surgical technique. This finding also explains why patients typically like their results more at 3 months when their face has increased volumization as a result of some residual postoperative edema than after 6 months to a year when all edema has resolved.
Risks Involved in Facelift
Patients looking for a minimally invasive procedure often desire a procedure with less risk. All rhytidectomy approaches have 3 possible major complications:
- 1.
Hematoma
- 2.
Skin slough
- 3.
Facial nerve paresis
The incidence of hematoma is usually quoted between 1.8% and 9%, but higher or lower hematoma rates have not been identified in any particular approach.
The rate of skin slough in rhytidectomy is greater in techniques that require a long skin flap to be elevated because the main blood supply to the skin flap is random based on the subdermal plexus; the longer the flap, the greater the risk of necrosis. Because of this, shorter skin flaps do have a lower rate of necrosis. Although deep-plane flaps are longer flaps, they maintain a thicker flap with the preservation of the transverse facial artery as noted and, thus, have a theoretical lower rate of skin necrosis. This feature makes a long deep-plane flap more favorable than a long skin flap. The senior author has demonstrated a 0% skin slough rate in patients actively smoking during the preoperative and postoperative phase when undergoing deep-plane rhytidectomy. This finding supports the idea that the greater blood supply of the deep-plane flap reduces the risk of necrosis.
Facial nerve paresis is a concern for both the patients and surgeon. Although staying superficial to the nerves by performing plication of the SMAS implies less risk, facial nerves can be lassoed with suturing techniques creating nerve injury. Further, there have not been any studies showing increased rates of temporary or permanent facial nerve paresis related to more aggressive lifting of the SMAS in SMAS flap or deep-plane rhytidectomy with a careful and experienced technique. In fact, a series of 2500 consecutive deep-plane facelifts had no permanent facial nerve injury. The authors have reported a temporary facial nerve neuropraxia rate of 1.3% and no permanent facial nerve injuries, which is within the reported incidence of 2.1% temporary neuropraxia reported in a survey of more than 12 000 facelifts.
Surgical Approach Options
Because the MADE procedure results in a shorter incision, addresses the midface, jawline and neck, has a more rapid healing phase, and has a low rate of complications, it is the procedure the authors offer for their patients seeking a minimally invasive procedure. The authors offer primary surgical patients 2 approaches: a minimal-access (short incision) deep-plane vertical facelift (MADE) or a traditional-access (longer incision) deep-plane facelift. The key to the MADE approach’s shorter incision (not requiring a posterior auricular/occipital scalp limb) is the vertical vector of the lift. It is also less invasive because it does not require a separate midline platysmal tightening procedure because the deep plane is extended below the mandible and creates a widely undermined lateral platysmal flap, which corrects midline platysmal redundancy. This lack of a midline platysmoplasty makes the procedure duration shorter by obviating an additional platysmaplasty. It can be used in most aging face candidates with mild to moderate rhytidosis facialis, usually in the 40s to the 60s.
Poor candidates for this approach include those with more severe facial ptosis and poor anatomy, including retrognathia, low anterior hyoid, and severe platysmal redundancy. They require a traditional-access deep-plane facelift often combined with a midline platysmaplasty. The authors’ traditional-access approach incorporates a longer postauricular incision that extends into the occipital scalp and a submental incision for anterior platysmal plication.
The authors not only describe their short-incision, extended deep-plane, vertical vector facelift surgical technique but also a method to evaluate patients’ candidacy for a minimal-access approach based on a preoperative physical examination maneuver. The authors also provide guidelines to help the surgeon decide when to include Platysmaplasty with the procedure to further improve the cervicomental contour. The authors’ experience with 342 patients with this approach is presented.
Preoperative Evaluation and Candidacy
The authors have developed a basic decision algorithm for determining whether patients are candidates for minimal access or traditional access to a facelift. The preoperative physical examination of patients is the most decisive factor in the determination of candidacy for a short-incision deep-plane rhytidectomy. This examination includes observing how the face and neck redrapes when traction is placed on the skin along the vertical vectors of this facelift technique. The authors have had success with patients aged from 40 to 70 years, even if there is significant anterior platysmal cording and submental skin excess. Anatomic variants that may predispose to failures in the submental region with this technique include those with retrognathia, low anterior hyoid, and a short vertical height of the neck. In these cases, more aggressive submental surgery is required. The additional procedures that address unfavorable cervicomental contour issues include submental liposuction, platysmal plication, subplatysmal fat excision, and/or anterior digastric plication.
A physical examination technique that the authors use to determine candidacy for the MADE vertical facelift involves traction on the facial skin to evaluate the vertical and horizontal components of the neck; the authors call this the facial redraping capacity ( Fig. 1 ). This technique helps determine whether patients are candidates for sparing the posterior hairline incision of traditional facelifts. The deep-plane entry point is a line that courses from the angle of the mandible to the lateral canthus.
- •
The surgeon places 3 fingers at the deep-plane entry point on both sides of the face and moves the skin vertically to assess whether the submental and platysmal skin laxity is corrected.
- •
If the submental area is corrected, then there is no posterior hairline limb incision or any anterior platysmal surgery necessary.
- •
If patients still have significant horizontal neck skin excess with this maneuver, and platysmal cording exists, then an abbreviated incision is not advisable. The neck redundancy will exist and recur postoperatively. A posterior auricular hairline incision to remove the horizontal neck laxity and anterior platysma plication for midline platysmal redundancy would then be necessary.
