Shahidi, Shahram

Facelift continues to evolve over the past century. Initial surgical development probed into deeper layers of the SMAS to create a stronger lift of greater duration. Recently patients have requested smaller procedures which provide reduced risk and less time away from work in recovery. This article demonstrates how different facelift procedures were utilised to satisfy the varying needs of 4 patients. This range of procedures require a surgeon to understand the needs of the patient and have training and proficiency in the range of options available.

Key words: Facelift, SMAS, Facial Plastic Surgery, Rhytidectomy, aging face.


Facelift surgery has undergone a major evolution since Lexer performed the first face lift operation in 1906 and Hollander subsequently reported a case in 1912.1 These pioneering procedures simply involved removal of the excessive skin. A major step forward occurred when Skoog first described the treatment of superficial musculo-aponeurotic system (SMAS) as a way to enhance the result of the facelift in 1969(2). In 1976 Mitz and Peyronie carried out a series of anatomical studies of the SMAS layer in greater detail. Their work defined how to use the strength of the SMAS to increase the longevity and support of the procedure when compared to the skin only facelifts3.

In order to achieve a longer lasting result surgeons have probed deeper beyond the SMAS layer. The various procedures available for rhytidectomy can be classified anatomically according to the depth of dissection from skin down to periosteum4. A skin only facelift is the simplest procedure. The SMAS lift involves surgery to both the SMAS and the skin. This can be achieved by either reconstituting the SMAS after removing a strips or by SMAS plication alone6,7. The degree of the SMAS flap elevation is variable from none, to a small amount to extended sub SMAS elevation to the lateral edge of the zygomaticus major muscle in the face. In the mini-lift the skin incision is limited and the SMAS is plicated with a series of sutures at the lower face and neck area. In the deep plane facelift, the dissection is in a plane below the malar fat pad. Composite facelift described by Hamra8,9,10 adds the dissection of SMAS flap of the inferior portion of the orbicularis oculi to the dissection of the deep plane. The subperiosteal facelift elevates the periosteum off the zygomatic arch and the anterior face of the maxilla in order to reposition the whole unit superiorly4,9.

In this paper we will demonstrate how various procedures were utilized to satisfy different patient needs.


Case 1, Mrs KG 46 year old lady who presents for treatment of her minimal facial changes. She was concerned about early jowl formation and early drooping of the cervical angle. As her changes were minimal she underwent a minilift (small SMAS facelift). This procedure involved retrotragal and postauricular skin incision with subcutaneous undermining limited to 4 cm. SMAS plication was achieved in the preauricular and neck regions using multiple 3 PDS sutures to tighten the SMAS without SMAS excision. Submental skin incision and elevation permitted access to the medial platysmal bands which were plicated with 3 PDS to reduce submental banding. This lady also underwent lower eyelid blepharoplasty and laser skin resurfacing. Figures 1a,b and 2a,b.

Case 2, Mrs LS , 59 year old lady who presents with more advanced ageing changes. This lady underwent a long flap SMAS facelift. This invlolved retrotragal and postauricular skin incision, 8cm skin flap elevation around the ear, excision of a 1.5 cm strip of SMAS, SMAS elevation and resulure using 3 PDS and goretex sutures in the midface. She also underwent submentoplasty using 3 PDS to plicate the medial platysmal bands, upper and lower eyelid blepharoplasty and laser skin resurfacing under the eyes and over the upper lip. Figure 3a,b.

Case 3, Mrs MT 54 year old lady underwent a subperiosteal face lift to provide increased elevation of the sagging cheek tissues. This involved a retrotragal and postauricular skin incision, long subcutaneous flap elevation to 8 cm, 2 cm SMAS resection and suture as in the previous case using 3 PDS sutures. In addition a Caldwell Luc approach was carried out to elevate the periosteum over the anterior face of the maxilla to increase the release of the soft tissues. Goretex suture were used to suspend the mobilised soft tissues to the malar periosteum. This lady also underwent upper and lower eyelid blepharoplasty, dermabrasion to the upper lip, chin lift and removal of several naevi. Figure 4a,b and 5a,b.

Case 4, Mr KH, 62 year old gentleman who presented with left sided facial palsy. This occurred secondary to herpes infection of lower cranial nerves whilst being treated with chemotherapy for non Hodgkin’s lymphoma some 4 years previously. He had previously undergone insertion of a gold weight into the left upper eyelid. His problems related to alar collapse of the left nostril, and the habit of repeatedly biting into the soft tissues of his left cheek when chewing. He underwent a non cosmetic left sided deep plane facelift. In this procedure the elevation plane runs deep to the SMAS, over the zygomaticus major muscle. The deeper cheek tissues were suspended strongly to the zygoma using 3 PDS sutures. This procedure effectively pulled the left nostril out to control the alar collapse, and lifted the buccal tissues away from the oral cavity. Figure 6a,b.


Facelift surgery has evolved over the past century1. Skin only lifts have evolved toward a range of SMAS and deeper procedures. The overpulled windswept “surgical look” has given way to a more natural non surgical appearance. These cases demonstrate how the facial plastic surgeon can select from a range of facelift procedures to match the patients’ needs and the level of pathology. Contemporary trends have seen the development of smaller facelifts that result in faster recovery, less hospital stay and less risk. They are especially suitable for cases with lesser pathology. Deeper facelift techniques may provide a longer lasting mure effective result, at a price of increased time off work and activities, and possibly increased risk of complications. Deeper plane procedures arc ideal in patients with preexisting facial nerve palsy.

The development of a range of procedures has been driven by consumer demands at one end of the spectrum and surgical challenge at the other. Consumers have been interested in smaller facelift procedures. They accept that lesser results arc balanced by the reduced recovery, less time off work less cost and fewer risks. This smaller minimal lilt expands the indications to younger patients with earlier changes, such as in case 1(11). The deeper procedures were the result of surgical challenge to provide a longer lasting more effective result8. Surgeons probed beyond the skin to the SMAS, and then under the SMAS to the deeper planes to try to provide a more effective longer lasting lift, such as in case 4(12). However these procedures result in increased risk to the facial nerve, prolonged oedema and dysfunction affecting time off work, social and sporting activities. These outcomes are becoming less attractive to today’s consumer.

In this paper, case 4 demonstrates the use of deep plane facelift to provide a functional result in facial nerve palsy. Other options used to manage facial nerve palsy exist, and are beyond the scope of this paper. This procedure was not performed to change cosmesis in this patient, but merely to provide access to the deeper plane and demonstrate the versatility of facelift.

The range of options also provides the surgeon with challenges. The surgeon needs to understand and develop proficiency in multiple procedures and the indications, risks and recovery cycle of each. This range of options also introduces difficulties in surgeon education as the surgeon needs to understand the techniques and nuances of multiple procedures. It requires the surgeon to use judgment in deciding which operation to use for which patient based upon the level of pathology and patient acceptance of risk and recovery time. If a surgeon chooses to undertake only 1 or 2 types of facelift procedures he needs to understand the options and inform patients of alternate options as part of an informed consent.

The need for proficiency in a range of facelift procedures is an extra challenge with the current educated consumer and the modern era of increasing litigation risk. It may lean the surgeon toward the selection of safer and smaller procedures to reduce surgical risk.

Future directions seem to be trending towards developing more advanced results from smaller procedures. Despite the development of deeper procedures, the consumer is demanding smaller procedures with less risk, less swelling, less hospital stay, less time off normal activities and better results. This may be achieved with the development of suture suspension and endoscopic surgical techniques.


The range of operations for facelift surgery is now varied from minimal to more extensive deeper lifts. The surgeon needs to understand the benefits and limitations of each procedure in order to provide the best result for the particular patient. This variety in options provides challenges in training and experience.


1. TURPlN I.M. The modern rhytidectomy. Clin Plast Surg. 1992 Apr;19(2):383-400.

2. MERCANDETTI M. Facelift, SMAS Plication available at http://www.emedicine.com/plastic/topic50.htm

3. MITZ V., PEYRONIE M. The superficial musculo-aponeurotic system (SMAS) in the parotid and check area. Plast Reconstr Surg. 1976 Jul;58(1):80-8.

4. QUATELA V.C., SABINI P. Techniques in deep plane face lifting. Facial Plastic Surgery Clinic of North America 2000; 8 (2) 193-209.

5. MITTELMAN H., NEWMAN, J., Smasectomy and imbrication in face lift surgery. Facial Plastic Surgery Clinic of North America 2000; 8(2) 173-182.

6. HAMRA S.T. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990 Jul;86(1):53-61; discussion 62-3.

7. DE CASTRO C.C. The role of the superficial musculoaponeurotic system in face lift. Ann Plast Surf. 1986 Apr;16(4):279-86.

8. HAMRA S.T. Composite rhytidectomy. Plast Reconstr Surg. 1992 Jul;90(1):1-13.

9. HAMRA S.T. The tri-plane lace lift dissection. Ann Plast Surg. 1984 Mar; 12(3):268-74.

10. HAMRA S.T. Composite rhytidectomy. Finesse and refinements in technique. Clin Plast Surg. 1997 Apr;24(2):337-46.

11. DUMINY F., HUDSON D.A. The mini rhytidectomy. Aesthetic Plast Surg 1997 Jul-Aug; 21(4): 280-4.

12. ALSARRAF R., JOHNSON C.M. Jr. The face lift: technical considerations. Facial Plast Surg. 2000; 16(3):231-8.

13. ALSARRAF R., WYATT C.T., JOHNSON C. The dep plane facelift. Facial Plastic Surgery 2003 May; 19 (1): 95-105.


Sydney ENT and Facial Day Surgery Centre


New South Wales


Shahram Shahidi B.Sc.(Med.)(Hon.I.) M.B., B.S., F.R.A.C.S.

Marty Mendelsohn M.B., B.S., F.R.A.C.S.

Sydney ENT and Facial Day Surgery Centre, Chaiswood, New South Wales, Australia

Postal Address:

Dr Martyn Mendelsohn

Suite 4/12-14 Malveni Ave

Chatswood, 2067, New South Wales

Tel: (02) 9411 4288

Fax: (02) 9904 8787

Email: mm@face.au.com

Copyright Australian Society of Otolaryngology Head & Neck Surgery Ltd. Jun 2004

Provided by ProQuest Information and Learning Company. All rights Reserved

You May Also Like

Cocaine use in nasal surgery by ENT surgeons in Australia

Cocaine use in nasal surgery by ENT surgeons in Australia Irani, Danesh Objectives: To analyse the practices of Australian Otolaryng…



Functional and Selective Neck Dissection

Functional and Selective Neck Dissection Lewis, Richard Functional and Selective Neck Dissection Javier Gavilan Jesus Herranz Lawren…

A case report and proposed pathogenesis

Trilobed Zenker’s diverticulum: A case report and proposed pathogenesis Fahy, Colm Objectives/Hypothesis: To report the first descri…