Because alternatives exist for the full facelift (rhytidectomy), this procedure has become less popular overtime. In the past, forehead wrinkles were addressed with coronal^[1,2] and endoscopically assisted forehead lift^[3] procedures. Today, botulinum toxin and hyaluronic acid fillers are used for this purpose because they are more effective and result in less downtime. Lateral brow sag can be corrected by using the Fogli^[4] and Knize^[5] browlift techniques, Endotine® browlift^[6] or sub-brow fat augmentation.^[7] The pretrichial incision is occasionally chosen, typically in facial feminization surgery, which includes supraorbital rim contouring and scalp advancement.^[8] Although indications for facelift surgery remain, they are limited. A more recent approach to restoring a youthful appearance to the midface involves volume augmentation, although this is questionable.^[9] Facial aging is thought to be primarily due to gravitational sagging because of the loss of collagenous support [Figure 1]; however, fillers provide more predictable results than lifting in this area. Furthermore, hyaluronic acid fillers are more predictable than micro fat grafting^[10] and are safer to use around the eyes.^[11] The lifting of tissues is more useful in the lower face (caudal extension of nasolabial folds and grooves, labiomental folds and grooves and jowls disrupting the jaw line) and neck (platysmal bands, skin excess). Hence, “cheek and neck lift” or “buccocervical lift” may be more appropriate terms for this type of procedure.

This article describes important features of facelift surgery as performed by the author. All patients involved in this article agreed to have their facial pictures published and signed the consent form. The proper sequence of steps is explained in the last section.

For all patients, reduction of anxiety and mild hypnosis are achieved with the oral administration of 1 mg lorazepam, along with the 100 mg of diclofenac, 1 g of paracetamol, 2 g of penicillin and 32 mg of methylprednisolone given 1 h prior to the procedure. Lorazepam has a half-life of 9-16 h,^[12] which helps the patient to remain calm and normotensive postoperatively. Because pain occurs only with injection of the local anesthetic intravenously solution along the skin incision line, midazolam is given 2 min prior to the administration of local anesthetic for those patients who are anxious IV or agitated; oriented and calm patients may not require sedation. Midazolam is given by slow intravenous injection, starting with a test dose of 0.1 mg and slowly delivering a total dose of 2-6 mg (depending on body weight) over 2 min. During this time the skin is marked for the incision and prepping and draping are performed. The half-life of midazolam is 2-6 h.^[13] The goal is to achieve a co-operative, oriented and calm state (level 2 on the Ramsey Scale of Sedation).^[14] The patient should still be able to respond normally to verbal stimuli (i.e., minimal sedation on the American Society of Anesthesiologists scale of sedation); however, if moderate or conscious sedation is reached (i.e., purposeful response to verbal/tactile stimulation), this state will not last longer than 20 min.

The aim is to numb the area and provide a bloodless surgical field, defined by the marked dissection area, including the skin and superficial muscular aponeuroticsystem (SMAS). The first step is to achieve a superficial, cephalad cervical plexus block, aiming for the lesser occipital nerve, great auricular nerve and transverse cervical nerve rather than the inferiorly running nerves of the punctum nervosum. An aliquot of 3% lidocaine (one 1.8 mL carpule) with norepinephrine (1:100,000) is placed at the punctum nervosum, which is located at the posterior aspect of the sternocleidomastoid (SCM) muscle, midway between the mastoid process and the transverse process of C6 [Figure 2]. The second step is to infiltrate the periauricular incision line using 2 carpules of lidocaine and a serial puncture technique. The third step involves the infiltration of the dissection area using a Whitacre epidural cannula and the super wet technique with a modified Klein solution consisting of one 20 mL vial of lidocaine (2%) with epinephrine (1:100,000) and two vials of 0.9% sodium chloride (normal saline).^[15] The 25-gauge 3.5 inch Whitacre spinal needle (Becton, Dickinson and Company, NJ, USA) has a pencil tip and lateral opening, which spreads the subcutaneous tissues without cutting nerves and vessels. With a little pressure, it is inserted into the area infiltrated in step 2. The area can then be anesthetized painlessly by slowly sliding the cannula in the subcutaneous fat plane, continuously delivering the small amounts of the anesthetic solution [Video 1].

Whereas the tumescent technique uses a large volume of dilute solution to stretch the skin taut, the super wet technique injects less than half the volume required for the tumescent technique, 40 mL suffices to infiltrate both sides.

As we age, the loss of fibrous support, endocrine changes, a sedentary life style and excess caloric intake result in fat pockets in the cheek and the anterior neck becoming more voluminous and delineated. Disruption of the jaw line by jowling is often the first sign that leads patients to consider a cosmetic procedure, and submental lipodystrophy is hereditary in some individuals. Because a skin-only facelift cannot alter these signs of aging, submental liposuction is carried out prior to the lateral work, requiring another 20 mL of simplified Klein solution. Central lipodystrophy is accessed by a 2-mm incision with a number 11 blade anterior to the submental crease. A Becker grater round cannula (2.7 mm diameter, Wells Johnson Company, Tucson, AZ, USA) [Figure 3] is connected to a 10 mL disposable syringe with a luer lock and introduced without suction to dissect the subcutaneous plane at the supraplatysmal level. It is easy to inadvertently enter the subplatysmal plane, leading to disruption of the capsule of the submandibular gland with subsequent ptosis or injury to the marginal branch of the facial nerve. After determining the appropriate plane, the syringe plunger is withdrawn to create a 2-mL space. Just posterior to the central stab incision, a cannula with an open tip is used to maintain negative pressure in the syringe, with the tip close to the exit site. Rapid movements are required [Video 2].

Surgical removal of the jowl fat is essential for the lifting procedure. This may be performed by Metzenbaum scissors or by open liposuction with a Becker grater cannula, after elevating the skin flap [Figure 4]. However, closed liposuction through a 2-mm stab incision anterior to the earlobe can be used to avoid irregularities, hematomas and damage to the marginal branch of cranial nerve VII. Counter pressure is important, but also leaving a layer of fat on the undersurface of the dermis [Video 3].

Traction on low suspension sutures provides a stronglifting effect to the neck compared to the high suspension of the SMAS flap used in a classic facelift. The disadvantage is that the purse string formed by plication of the SMAS can result in preauricular fullness in heavier patients. The lateral SMAS ectomy^[16] offers a solution [Figure 5]. Excision of a portion of the SMAS overlying the anterior section of the parotid gland secures the mobile anterior SMAS to the fixed portion of the superficial fascia. The long axis of the lentoid incision is oriented such that the vectors of elevation following SMAS closure lie perpendicular to the nasolabial fold. This procedure avoids extensive SMAS flap dissection and elevation, which risks damage to the buccal branches of cranial nerve VII and tearing of the flap. In addition, lateral bulkiness is addressed.

Because the SMAS and platysma muscle are not elevated, and liposuction is preferred to lipectomy, there is no risk of injury to branches of the facial nerve. However, injury to the great auricular nerve can lead to a painful neuroma. Dissection of the skin flap overlying the mastoid fascia and under the earlobe should be confined to the reticular layer of the dermis. Sensation in the earlobe should return to normal or near normal by one week. In case of neuralgia, repeated injections with ropivacaine or betamethasone may be helpful.

Laceration of the facial vein [Figure 6] leads to bleeding, ecchymosis and sometimes hematoma. Coagula can lead to oozing because of fibrinolysis. They are difficult to remove because dissection of the tissue planes is required; following evacuation the epidermis appears lax and pigmented for a prolonged period. Vein laceration can be prevented by using Metzenbaum scissors, keeping the tips parallel to the skin surface and remaining in contact with the reticular dermis. Retrieving the vein stump after complete resection can be difficult as it retracts, and for this reason, bipolar coagulation is used. The vein may also be punctured by a suture needle when weaving the loops (the weaving is done with a sertix suture: suture and needle).

Scalp extension to create sideburns, which are beveled as described by Frechet^[17] and scalloped as described by Camirand and Doucet,^[18] opens the superior tunnel in a manner that allows for suspension of the SMAS to the temporalis fascia [Figure 7a].^[19] However, the result is a visible scar that cannot be erased [Figure 7b]. Attempts at correction will thin the sideburn hair and make the area less attractive. As mentioned in section one, the approach to the midface involves volume augmentation rather than lifting. The temporal extension does not improve the result.

The author recommends that the incision begins where the anterior helix separates from the preauricular skin and becomes the superior helix of the pinna. Depending upon the vector, the amount of lift and skin elasticity, the dog-ear may be small or substantial. Cephalad undermining is attempted first and is generally effective. Otherwise, an infra-sideburn incision, as described by Knize [Figure 8],^[5,20] or a 1-cm hockey stick extension can be used while keeping the scar hidden behind the sideburn.

The incision descends in front of the inferior crus and at the inner aspect of the tragus [Video 4]. The cartilage should not be notched as this will be visible after healing. The incision runs just anterior to the earlobe and curves around its attachment. After bipolar coagulation, thesuperior subcutaneous tunnel is prepared. The incision then runs behind the pinna in the cephalad direction to the conchal cartilage; the scar will contract and be pulled down into the groove. If the incision is inadvertently placed in the auriculomastoid groove, the scar will be pulled into the visible mastoid area. The incision becomes horizontal at the level of the external auditory canal and then is scalloped, curving cephalad [Figure 9]. It should generally not extend into the occipital hairline, but if it does, it curves caudally again. The scalloped incision is beveled according to the method of Frechet, in the area of hair-bearing skin. The scalloped incision developed by Camirand and Doucet^[18] aids tremendously in dealing with the retroauricular dog-ear. After removing excess skin, the straight long excision edge of the flap is sutured into the scalloped edge, from back to the front, keeping the hairline intact.

Patients often simulate the effects they wish to obtain in front of the bathroom mirror by manually pressing up the droopy skin, fat compartments and SMAS [Figure 10].

The 3 (sometimes 2 or 4) low suture suspension loops and 3 high suspension sutures are made of the resorbable material. The loops are woven in the SMAS layer and provide a mild purse string action that should be taken into clinical consideration [Video 5].

The inferior low reaching suspension suture picks up the posterior edge of the platysma at a point 1.5 cm anterior to the SCM muscle and 3 cm below the mandibular border, where the sliding plane between the platysma and deep cervical structures^[21] allows lifting without dissection [Figure 11].^[22] Labbé et al.^[22] suspend the platysma and SMAS to the temporoparotid fascia described by Lore,^[23] which is located immediately in the front of the intertragal incisura and at least 2 cm from the facial nerve trunk.^[24] The fascia is a highly resistant point of anchorage for the 2-0 polydioxanone (PDS) suspension suture. In heavy patients, the purse string plication of the platysma and SMAS obliterates the interval between the posterior mandibular border and SCM muscle, an aesthetically important zone [Figure 12]. The author proposes that a suspension suture be placed under the SCM muscle to suspend the platysma to the mastoid fascia. This can be achieved by lifting the SCM muscle with one hand and sliding a mandibular awl beneath it in an anterior direction [Video 6]. The PDS suture is picked up by the awl, pulled posteriorly and knotted to the mastoid fascia using a widow needle [Figure 13]. The PDS suture requires many knots to hold. The volume and ends of the suture may cause pain when they press on the skin, such as during sleep. In addition, the ends may pierce the skin and cause painful inflammation. Suturing the surrounding tissues on the top of the knots with a 4-0 Vicryl suture can prevent this problem.

The 2-0 PDS purse string suture that is woven into the SMAS and picks up the remaining fat in the jowl area is suspended to the temporoparotid fascia described by Lore. The same procedure is used for the 2-0 PDS suture loops picking up the lower side of the nasolabial fold, which smooth the nasolabial groove and provide a moderate lift to the malar prominence. However, this effect does not appear to be maintained over time.

The high suspension is achieved by suturing the dermis in the pretragal area down to the parotid fascia using 4-0 Vicryl, with one stitch above and one stitch below the level of the tragus. Another useful high suspension maneuver was demonstrated by Dr. Heinz Bull at during the 2006 meeting of the German Association for Aesthetic Surgery in Düsseldorf. Using this technique, the skin flap is fixed to the conchal cartilage under the earlobe to prevent a pixie ear deformity. The 4-0 Vicryl includes tissue from both the dermis and the cartilage [Figure 14].

In regard to low suspension sutures, Hoefflin^[25] observed that “pulling on the SMAS is like repositioning a living room sofa by pulling on the carpet. It’s easier to just pick up the sofa and position it where you want it”. Theprocedure described herein can therefore, be considered to be a repositioning of both the SMAS and fat.

The so-called “short scar” SMAS lift,^[19] with a strictly vertical vector, is not so short. The scar is quite long because it requires an extra skin excision in the lower eyelid [Figure 15a and c] and vertical pleating in the neck [Figure 15b] with difficult undermining in the retroauricular area and an extra posterior hairline incision. The total length of these “short scar” incisions averages 13 cm, whereas the currently proposed procedure uses an incision with an average length of 11 cm.

Trimming of the preauricular skin should be conservative because the pretragal high suture suspension creates tension on the tragal cartilage via the SMAS. Visibility of the external auditory canal is not aesthetically pleasing. The dermis overlying the tragal cartilage is trimmed over 1.5 cm to recreate the pretragal groove [Figure 16]. Otherwise, the flat appearance of the surface in front of the tragus can indicate that a facelift has been performed. In men, the hair follicles should be meticulously trimmed, taking into consideration the desired sideburn shape and the fact that shaving the tragus (and under the earlobe) is a nuisance and may lead to repeated bleeding. Two 4-0 Vicryl sutures in this location will support lifting and shaping of the pretragal fovea.

Trimming under the earlobe should also be conservative. The anterior skin flap created during the resection of excess skin can usually be pulled behind the earlobe to determine how much needs to be resected. Because the earlobe will be pulled forward and downward by gravity and collagen contraction during the first few weeks following surgery, the shape of the skin flap should push the earlobe upward and backward [Figure 14].

Skin closure with 5‑0 nylon starts at the superior end of the incision and continues down to the earlobe, stopping behind the earlobe and repositioning it upward and backward.

The use of vacuum drains and extensive bandaging is not recommended. Fibrin glue spray is preferred to prevent hematomas, ecchymosis, seromas and discharge [Video 7]. The sealant should be applied while the wound is still open (0.5 mL each side) to allow air to escape and prevent venous air embolism. The wound bed is dried by introducing a suction drain connected to the central vacuum system under the skin flap before skin suturing.

Whereas a turkey gobbler neck and lower eyelid bags are spotted quickly and addressed with blepharoplasty and liposuction, long upper lips and earlobes are often overlooked.^[26] A long upper lip (and low lower lip) expose the lower teeth when smiling, a typical sign of aging. Pendulous earlobes can result from wearing heavy jewelry over many decades.

Upper lip reduction and nasal tip lift are accomplished by a modification^[27] of the “double duck” procedure,^[28] which is a modification of Austin^[26] sub-nasal buffalo horn excision. This procedure involves a sub-alar crescent-shaped skin excision which continues into the membranous septum and which may be reduced in height if the nasolabial angle requires sharpening and a hanging columella is present. Otherwise, a full transfixion incision divides the medial crural footplates and the caudal septum. The dermis of the central lip is then suspended to it with a 4-0 PDS suture. The columella can then slide upward slightly with the footplates for the elevation of the nasal tip [Figure 17].

Earlobe reduction can be performed with marginal excision and fine sutures, although removal of a full-thickness medially based wedge produces better results. The facial skin flap is pulled up behind the newly formed earlobe to allow for proper cephalad repositioning [Figures 18 and 19].